Take-home points

ADHD comorbidity in children is less prevalent than noted in adult patients

Comorbidity does, however, occur sometimes and this case emphasized the overlap of ADHD, anxiety disorders, and ASD

Like adults, adequate doses of psychotropics are generally needed to obtain good clinical responses

Like adults, children develop side effects with the added complication that the medication may hinder normal growth potential

These longer-term side effects must be monitored in collaboration with primary care clinicians

Performance in practice: confessions of a psychopharmacologist

What could have been done better here?

• – The SSRI was effective for anxiety but problematic for inducing weight loss and enuresis; are there other options for anxiolysis in this patient?

  • Atomoxetine (Strattera) is an ADHD-approved agent that is an NRI. Agents with this property sometimes act as anxiolytics

  • BZ sedative–anxiolytics are frowned upon in children due to paradoxical agitation effects and addiction

  • SNRIs have no approvals in this age group and possess SRI properties equivalent to those of SSRIs and are likely to have similar side effects, while the NRI properties might help the ADHD symptoms

  • Buspirone (BuSpar) is a 5-HT1A receptor partial agonist that is approved for adults with GAD and it might be utilized off-label in children with anxiety

  • The antihypertensive agents guanfacine (Tenex) and clonidine (Catapres) are sometimes used off-label to treat adults with agitation, anxiety, and insomnia as both are alpha-2a noradrenergic agonists

• Slow-release preparations exist for both Intuniv and Kapvay, respectively, and are approved for treating childhood ADHD

• In the future, it might be possible to discontinue this patient’s SSRI to determine if guanfacine-ER (Intuniv) alone will treat his anxiety without enuresis or weight loss

Possible action items for improvement in practice

• – Research the risks of stimulant use with regard to height and weight loss

• – Research the risks of stimulant use with regard to cardiac side effects and monitoring

• – Research nonstimulant options available for treating ADHD as they may carry less risk for short stature or weight loss

• – Research strategies where polypharmacy may be rational and warranted to improve effectiveness while diminishing side effects

Tips and pearls

When dosing stimulants in children and adolescents

• – Collaborate with primary care

• – Monitor height and weight

• – Monitor blood pressure

• – Monitor for abnormal movements such as tic disorders

• – Monitor for affective dyscontrol and acute onset of suicidal symptoms

• – Monitor for switches into mania if the patient has comorbid bipolar disorder

• – Monitor for substance abuse and drug diversion

  • Evidence suggests children and teenagers treated with stimulants often have better symptom control and less risk of addiction to drugs later in life

  • However, teenagers and young adults may divert and share their medications more often

• – Consider an EKG or further cardiac workup in patients with a severe family history of cardiac illness or early myocardial infarctions, or those with any current cardiorespiratory symptoms noted upon their own exertion

  • The American Heart Association issued a warning that all children should have EKGs prior to stimulant use

  • The American Association of Pediatricians has made similar comments but has since modified them, suggesting EKGs are needed only on a case-by-case basis

  • The FDA has issued warnings regarding the possibility of sudden cardiac death with stimulant use

  • The most current longitudinal studies suggest no added cardiac risk with stimulant use compared to that in children not taking stimulants

Two-minute tutorial