Despite some methodological limitations, recent reviews of cardiovascular event data from a large number of healthy ADHD medication users versus nonusers show that in the absence of cardiovascular illness, ADHD agents are safe. Conversely, the presence of cardiovascular symptoms or history requires consultation with a specialist to determine a further course of action. Thus, it is recommended that clinicians take a detailed family and personal history to rule out cardiac illness and potential risk factors. The absence of cardiovascular information does not mean that there is a negative history. Clinicians should not feel pressured to prescribe until they feel comfortable that the data gathered are sufficient to establish a negative history.
Healthy individuals, in particular children and young adults, do not require specific cardiac testing before initiating treatment, and routine age-appropriate follow-up appears sufficient in the absence of symptoms. Since patients are now taking ADHD medications for extended periods, it is prudent to routinely reassess cardiac history status and to obtain consultation should any cardiovascular symptoms develop.
ADHD and co-administration of antipsychotics
There has been increasing off-label use of a combination of stimulants and antipsychotics, possibly in response to the challenge of having to treat complex cases and the paucity of effective monotherapy for symptoms.10 Few studies have examined this combination strategy, but an article just published suggests that there may be industry interest in exploring the role of molindone(Drug information on molindone) in children with comorbid conduct problems.11
A poster presented at the 2012 APA annual meeting compared outcome data on children treated with a stimulant/antipsychotic combination or switched to antipsychotics with outcome data on children who received treatments other than antipsychotics.12 The children who received antipsychotics were more likely to visit emergency departments and to be hospitalized; the researchers concluded that this combination approach resulted in an increased economic burden.
Practical tip: ADHD is highly comorbid with conditions that result in anger and aggression, such as affective and conduct disorders. For patients who have comorbid affective disorder and ADHD, the addition of an antipsychotic may be indicated to address comorbid core symptoms. For most other concurrent disorders, particularly in youths, there is less evidence for the use of antipsychotics. Thus, the decision to recommend these agents for patients without affective disorders but who nonetheless show high impulsivity and aggression must take into account a careful benefit-risk assessment of the potential severe adverse effects of antipsychotics.13 In fact, experts support the use of psychosocial interventions and parent education and training before the use of a medication for maladaptive aggression at every stage of treatment, from diagnosis to maintenance to medication discontinuation.14
ADHD and DSM-5
Revisions to the ADHD diagnostic criteria in DSM were discussed at the 2012 APA annual meeting.15 According to the task force, the following changes are likely but have not been finalized16:
• Change the age from onset of impairing symptoms by age 7 to onset by age 12
• Change the 3 subtypes to 3 current presentations and add a fourth presentation for restrictive inattentive
• Change the examples in the items, without changing the exact wording of DSM-IV, to accommodate a life span relevance of each symptom and to improve clarity
• Remove pervasive developmental disorder from the exclusion criteria
• Modify preamble A1 and A2 to indicate that information must be obtained from 2 informants (parents and teachers for children and third part/significant other for adults) whenever possible
• Still under consideration: adjust the cut-off point for diagnosis in adults
Practical tip: Overall, the proposed DSM-5 changes in diagnostic criteria do not appear to be significant enough to have great impact on the day-to-day practice of child psychiatry. However, for those colleagues who had strictly followed DSM-IV and had been reluctant to diagnose the condition in patients with little evidence of dysfunction before age 7 despite other criteria being met, the proposed revisions will resolve this conflict.