With the foregoing discussion in mind, it is important to approach each patient in a systematic and comprehensive fashion and to reassess the patient's diagnosis. Comorbid conditions such as learning disorders, anxiety and mood disorders, and executive dysfunction (including deficient working memory, organizational skills, and time perception) can reduce treatment efficacy. These require careful consideration by the clinician and will probably necessitate a revision of treatment goals and approaches. Patient and family educational sessions are useful for clarifying new information about the patient's condition, and for placing these findings in a broader context. For instance, the presence of learning disabilities might shift the focus of treatment to school-based interventions. Likewise, the appearance of anxiety or mood disorders, in either the child or the parents, might indicate the need to focus more on intensive family therapy approaches.
Medication nonadherence is a major source of treatment resistance and should be addressed in a nonjudgmental and balanced fashion. If nonadherence is because of ambivalence on the part of the patient and his parents, it is worthwhile to conduct motivational enhancement interviews to determine whether they are ready to accept responsibility for undertaking a medication regimen. It is valuable to find out the precise reasons why the patient and family are not willing to comply with treatment, and to learn about their views of the consequences (both positive and negative) of taking or not taking the prescribed medication.
The primary reason for nonadherence is often the appearance of adverse effects, especially in the face of equivocal clinical results. If this is so, it is vital that the clinician make adjustments to improve the cost-benefit ratio of treatment. This may be achieved by increasing the current dose of medication (to achieve greater symptom control), switching to a different class of medication, combining the current medication with another agent, or stopping medications altogether. More frequent visits to enable closer monitoring of pharmacotherapy may also promote greater adherence.
If initial treatment with a stimulant medication has not been successful, the Texas Children's Medication Algorithm for ADHD (Figure),34 introduced in 1998 and revised in 2004, recommends starting treatment with either methylphenidate(Drug information on methylphenidate) or amphetamine and increasing the dosage to optimal levels as needed. If partial or nonresponse to medication results, a switch to another stimulant medication is advised. If this does not work, atomoxetine(Drug information on atomoxetine) is used in place of a stimulant. If the response is not satisfactory, combining atomoxetine with a stimulant is recommended. Following this, bupropion or a tricyclic antidepressant is substituted for atomoxetine. As a last step, the addition of an a-agonist (guanfacine or clonidine(Drug information on clonidine)) is advised. If there is still no satisfactory clinical response, a consultation with a specialist in ADHD pharmacology may be in order.
Other medication combinations have been beneficial for some patients. For instance, the combination of an SSRI and a stimulant can be quite effective for patients with ADHD and comorbid anxiety disorders, including generalized anxiety disorder, social phobia, and obsessive-compulsive disorder. Atomoxetine is also useful for ADHD patients with these conditions.35 Patients who experience adverse effects with stimulants seem to tolerate modafinil(Drug information on modafinil) quite well, although the absence of FDA approval for ADHD has created an economic barrier for many families who cannot afford to pay out-of-pocket for this medication. Venlafaxine appears to be helpful in adolescents and adults with ADHD and comorbid anxiety and/or depression. With cautious dosing, stimulant medication can be safely added to venlafaxine, although careful cardiovascular monitoring is recommended. Finally, small open-label studies and case series have shown a modest benefit with monoamine oxidase inhibitors, the an- ticholinesterase inhibitor donepezil(Drug information on donepezil), and the combination of stimulant and a-agonist.36
Turning to the issue of inadequate response to psychosocial interventions, one of the most important findings from the MTA study is the strongly negative impact that parental depression has on treatment outcomes. Considering this, along with the fact that many parents of ADHD children have ADHD themselves, it is important that the astute clinician pay attention to how parents are faring. If there is evidence of excess stress or burnout (as evidenced by direct and indirect statements, nonverbal cues, or inconsistent attendance at office visits), it makes sense to schedule a separate session to discuss the parents' issues. Severe parental psychopathology (eg, substance abuse, major mood disorders, psychosis) can be especially difficult to address and might require enlisting other family members to help the individual obtain treatment.
Above all else, it is vital that the clinician maintain respect for the significance of the parent's role in the life of his or her child or adolescent. The vulnerabilities, needs, resources, and capacities of each parent must be taken into consideration whenever a psychosocial intervention is attempted. The demands of family-oriented treatment (eg, completing homework assignments between sessions, changing one's habitual responses to the child's negative behavior, making time, and paying for sessions) should not be overlooked and, when appropriate, genuine appreciation for the parent's dedication and involvement in the process of helping the child who has ADHD should be generously provided.
Attempts must be made to work with the child's educational setting, especially if there are serious conflicts between family members and the school staff. Even the best efforts to assist patient and family cope with ADHD are neutralized by intransigent or antagonistic school personnel, especially the child's teachers. It is especially important to talk directly with school staff to reduce misunderstandings and promote a collaborative approach to help the child succeed in school. When an individualized education program or a Section 504 plan is not being effectively implemented, it is helpful to alert the school, and to offer to meet in person to discuss ways to put needed accommodations into place. As much as possible, the clinician should act as an advocate for the child while maintaining a pragmatic appraisal of the resources of the school and the school district. Unrealistic expectations on the part of the child or family about the capacity of the school to meet every aspect of the child's academic and social needs should be gently but firmly confronted and educational options (including approved private schools or home schooling) should be discussed if family-school conflicts appear insurmountable.Case Vignette
Tommy's presentation at the office visit suggested that his anxiety about school was extremely high and that he had a depressed mood. Further exploration revealed that he truly felt worse when he was taking the medication, and that his ability and motivation to complete his homework assignments were virtually nonexistent. His medication was switched to atomoxetine, which resulted in moderate improvement in concentration and a marked reduction in anxiety symptoms.
A telephone call to the school led to an immediate reduction in homework and an increase in resource-room time to make up for missing assignments. The school guidance counselor made time to speak to Tommy on a regular basis about his negative views toward school, and over the ensuing month, his attitude began to shift in a more positive direction.
Family therapy sessions were geared toward changing unrealistic parental expectations and anxiety about academics and de-escalating their preoccupations with Tommy's homework in favor of developing more positive interactions with him. During the next few months, Tommy started taking more responsibility for homework and began spending more time socializing with family and friends.