ADHD adolescents children CME Continuum diagnosis education eLearning online treatment

Continuum satellite symposium Q&A

Q

What does psychoeducation entail?

Psychoeducation is the process of educating patients and their families about:1,2

  • The nature of ADHD, including recognising symptoms and the effects on everyday life
  • What to expect from ADHD treatment, whether it is psychosocial or pharmacological
  • Managing expectations and preventing unrealistic hopes of instant benefits
  • The impact and benefits of treatment to promote adherence
  • Coping strategies for the effects of ADHD or any treatment side effects
  • How to take medication correctly, what side effects they may experience, and how to mitigate them

Psychoeducation is a crucial component of treatment, and experts recommend that it should begin immediately following diagnosis. While materials such as leaflets, websites and DVDs can be a useful supplement, psychoeducation should be based on direct clinician-to-patient contact, either individually or in groups.2

1. Taylor E et al. Eur Child Adolesc Psychiatry. 2004; 13(1):17–30.
2. Ferrin M and Taylor E. Future Neurol. 2011; 6(3):399–413. Montoya A et al. Eur Psychiatry. 2011; 26(3):166–175.

 
Q

The panel reported 60% of adult ADHD patients have comorbid conditions, but I have heard it is higher (up to 80% in some studies)

While some studies based on clinical samples have shown as high as 80%, data from epidemiological studies tends to be lower. However, in a recent study of a Swedish psychiatric patient registry, 60% of adult ADHD patients also had a psychiatric comorbidity.1

1. Nylander L et al. Nord J Psychiatry. 2012. [Epub ahead of print.]

 
Q

How do you manage adolescents who respond well to treatment during the day but have significant symptoms in the evenings?

Where the renewed evening symptoms cause impairment, experts recommend advising the parents to establish an evening routine that fits the patient’s needs. For example, if increased impulsiveness or hyperactivity make doing homework in the evenings difficult, getting the patient to start it earlier in the day may help. Evening routines are ideally based around soothing activities (eg bathing, reading).

Changing to a longer-acting medication or adding a small dose of a short-acting formulation later in the day may help, although this may also lead to sleep problems in some patients.1

1. National Institute for Health and Clinical Excellence. ADHD: National Clinical Practice Guideline Number 72. NICE. 2009.

 
Q

If there is syndromatic remission in adulthood, is it possible to diagnose ADHD in adulthood, and, if so, how?

ADHD is a childhood-onset disorder; ICD-10 criteria require symptoms and impairments to be present by age 7 years, and DSM 5 symptoms by age 12 years. Diagnosis in adulthood therefore focuses on:

  • Retrospectively determining the presence of symptoms in childhood
  • Assessing whether symptoms persist and continue to produce impairment in adulthood

In many adults, ADHD manifests predominantly with inattentive symptoms1, although combined subtype is still a common diagnosis in adulthood. Due to the likelihood of other conditions manifesting overlapping symptoms, clinicians should take particular care to determine whether any mood instability, impulsive behaviour and anger outbursts are linked specifically to ADHD. The Diagnostic Interview for ADHD in Adults (DIVA) is a useful instrument in aiding diagnosis in adults by systematically reviewing the symptoms and other criteria for ADHD.2

1. Biederman J. Am J Psychiatry. 2000; 157:816−818.
2. Kooij JJS. Adult ADHD. Diagnostic assessment and treatment (3rd Edition). Springer: London, UK. 2012.

 
Q

Lana’s adult doctor opted for citalopram, but can citalopram worsen inattention?

There is no evidence that citalopram specifically worsens the inattentive symptoms of ADHD. However, patients starting on citalopram or other SSRIs may experience an initial increase in anxiety in the first 1–2 weeks, before subsequent improvement, and this may affect any ongoing ADHD treatment.

 
Q

The evidence for SSRIs in depression with comorbid ADHD is weak. Do you think nortriptyline would be a better option?

While tricyclic antidepressants (TCAs) have been used as third-line treatments for ADHD, they have historically been associated with safety concerns. Although nortriptyline is less toxic than other TCAs, many would still not consider it a line treatment for depression in patients with ADHD.1

In a recent study, ADHD patients with depression who did not respond to an initial SSRI benefited as much from changing to a different SSRI as they did from changing to a TCA (venlafaxine).2

1. Bond DJ et al. Ann Clin Psychiatry. 2012; 24(1):23–37.
2. Hilton RC et al. J Am Acad Child Adolesc Psychiatry. 2013; 52(5):482–492.

 
Q

What is the risk of adult patients becoming dependent on stimulant medications?

Oral stimulant medications are very unlikely to induce euphoria when used as prescribed (taken orally), and published research has not shown a link between stimulant prescription and long-term dependence on either stimulant medications specifically or substance use disorder generally.1–3 Indeed, stimulant treatment may have a protective effect against substance use disorders in adolescence by decreasing impulsivity.1 It is also noted that children who have been on medication for several years do not have any difficulty stopping stimulant medications as they enter the adolescent years. However, some patient groups may be at increased risk of stimulant misuse, particularly those who already have substance use problems.4,5 Intravenous or intranasal use of stimulant medications may lead to a reinforcing effect.

Part of the risk assessment before prescribing stimulants should include any risk factors for substance use, such as the presence of drug-misusing relatives or peers. During treatment, clinicians should look out for potential signs of misuse: requests for dose increases despite no effect, excessive prescription requests according to clinical records, and repeated claims of lost tablets may indicate potential substance misuse.4 If misuse of medication is suspected, atomoxetine, long-acting formulations of methylphenidate or lisdexamfetamine* should be considered.

* Currently available in the UK only

1. Wilens TE et al. Curr Opin Psychiatry. 2011; 24(4):280–285.
2. Biederman J et al. Am J Psychiatry. 2008; 165(5):597–603.
3. Mannuzza S et al. Am J Psychiatry. 2008; 165(5):604–609.
4. National Institute for Health and Clinical Excellence. ADHD: National Clinical Practice Guideline Number 72. NICE. 2009. 5. Sepúlveda DR. J Pharm Pract. 2011; 24(6):551–560.

 
Q

Why are short-acting stimulants still used given the frequent rebounds and low compliance?

For young patients who have a short school day and whose impairment is concentrated in that domain, a short-acting stimulant may be the most appropriate option. Experts recommend that short-acting formulations may also be used in a two-dose strategy to avoid insomnia due to persistent medication effects in the evening. In addition, small doses of short-acting medication can help patients whose rebound symptoms from their long-acting daytime medication cause significant impairment at home.

Some parents may be unduly anxious about extended medication for their child and insist on the shortest-acting mediation; clinicians should educate families on the properties of the different formulations and come to a joint decision.1

Finally, rebound effects are not inevitably greater in all cases; some patients who can manage frequent dosing regimens prefer the greater control they experience over their symptoms with short-acting medications. Immediate-release medications may be more cost-effective in the absence of rebound or compliance problems.1

1. Banaschewski T et al. Eur Child Adolesc Psychiatry. 2006; 15(8):476–495.

 
Q

Can dissociative disorders be a severe case of ADHD?

While dissociative disorders can include symptoms of inattention that may mimic those found in ADHD,1 and the conditions can co-occur, they also differ in other respects. Dissociative disorders are not normally associated with hyperactivity or impulsivity, and age of onset is usually higher. Furthermore, dissociative states generally occur in discrete episodes and do not follow the sustained trait-like course of ADHD symptoms. An in-depth clinical interview, including full patient case history, physical examination, patient and family interviews, structured assessment instruments and psychological assessment, should be able to clearly disentangle the two conditions.

1. Endo T et al. Psychiatry Clin Neurosci. 2006; 60(4):434–438.

 
Q

If a young adult presents with ADHD at age 20, how high is the risk that ADHD will persist when they are older?

Among adults with a previous diagnosis of ADHD in childhood, 50–60% continue to experience some degree of impairment from their symptoms at age 25, and 15% or more still meet the full diagnostic criteria for ADHD.1,2 In another study, patients diagnosed at a mean age of 8 years continued to experience occupational, economic and social impairments at age 41, and 22% of this group still had ongoing ADHD symptoms.3

1. Young et al. BMC Psychiatry. 2011; 11:174.
2. Kessler et al. Psychol Med. 2005; 35(2):245−256.
3. Klein RG et al. Arch Gen Psychiatry. 2012; 69(12):1295–1303.

 
Q

Is neurofeedback useful in ADHD treatment?

There is currently no evidence that neurofeedback is an effective treatment for core ADHD symptoms.1 While some studies have shown a positive effect of neurofeedback on ADHD symptoms, this has not been consistently replicated in randomised controlled trials.1,2

1. Sonuga-Barke EJ et al. Am J Psychiatry. 2013; 170(3):275–289.
2. Moriyama TS et al. Neurotherapeutics. 2012; 9(3):588–598.

 
Q

What medications should be used for pregnant or lactating patients with ADHD?

Most experts and treatment guidelines do not recommend using ADHD medication with pregnant or breastfeeding patients.1 The safety of stimulant and non-stimulant medications has not been systematically established in pregnant or breastfeeding women, and little research data are available.

1. Kooij et al. BMC Psychiatry. 2010; 10:67.

When do you think medication should be restarted for postpartum female patients?
Experts recommend that medication should be restarted after the child has finished breastfeeding.