Gabriel Kaplan, MD

To view the slides in PDF format, click here.

1. Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, et al. American Academy of Pediatrics. 

Clinical Practice Guideline. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

 2011;128:1007-1022. 
2. American Academy of Child and Adolescent Psychiatry. Atypical Antipsychotic Medication. 

http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf

.
3. Olfson M, King M, Schoenbaum M. Treatment of young people with antipsychotic medications in the United States. 

 2015;72:867-874.
4. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. 

 2012;60:616-631.
5. Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings. GAO-15-211: Published: Jan 30, 2015. See: 

.
6. Pacchiarotti I, Bond DJ, Baldessarini RJ, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. 

 2013;170:1249-1262.
7. Viktorin A, Lichtenstein P, Thase ME, et al. The risk of switch to mania in patients with bipolar disorder during treatment with an antidepressant alone and in combination with a mood stabilizer. 

 2014;171:1067-1073.
8.  Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. 

Slideshows

Recent data show that widespread discrepancy exists between clinical guidelines and practice patterns for ADHD, dementia, and bipolar disorders.

Practice Patterns for ADHD and Other Disorders Collide

There are countless examples of long-lasting ongoing rivalries that most likely will never be totally settled, such as Coke versus Pepsi. No one would think that these 2 could ever work together for the common good. But what about therapy versus medication? Is there a conflict between these 2 treatment approaches? Uncompromising proponents exist for the solo use of either methodology: one camp argues that the risk of adverse effects is not acceptable, and the other that psychosocial interventions have very little benefit compared with their expense. Since no single remedy exists that is 100% successful, clinicians often recommend a combined approach.

Clinical studies and surveys of whether to use one or the other approach, or a combination of both abound. Huhn and colleagues

 undertook a large review of 61 meta-analyses containing 852 trials and 137,126 participants to assess the efficacy of pharmacotherapies and psychotherapies for major psychiatric disorders. In head-to-head comparisons, they found that pharmacotherapy was more effective for dysthymia and schizophrenia, but psychotherapy was better for bulimia and prevention of depression relapse. A combination of pharmacotherapy and psychotherapy was significantly more effective than psychotherapy alone as treatment for MDD, social phobia, and bulimia. And a combination of psychotherapy and pharmacotherapy was superior to pharmacotherapy alone for depressive disorder, schizophrenia, panic disorder, and bulimia.

[[{"type":"media","view_mode":"media_crop","fid":"41276","attributes":{"alt":"Â© Emilio100/shutterstock.com","class":"media-image media-image-right","id":"media_crop_6642594294089","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4333","media_crop_rotate":"0","media_crop_scale_h":"143","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â©Emilio100/shutterstock.com","typeof":"foaf:Image"}}]]In the lay press, according to a survey of 3079 of its readers, 

 found that a combination of talk therapy and drugs often worked best. “Mostly talk” therapy was almost as effective if it lasted for 13 or more visits. “Mostly drug” therapy was also effective for many individuals. Drugs had a more rapid impact on symptoms than talk therapy, but it took time to find the right medication.

Official government communications such as those issued by the National Institutes of Health assert that “sometimes medications are used with other treatments such as psychotherapy and that psychotherapy alone may be the best treatment for a person, depending on the illness and its severity.”

In ADHD, the issue of medication versus therapy remains, and it is not surprising that this issue is still not resolved. Almost 80 years have passed since the publication of the seminal paper by Bradley

that marked the beginning of psychopharmacology for children and adolescents with ADHD. Since then, a very large body of literature has validated that pharmacology is a first-line, safe, and effective treatment for ADHD in youths. Consequently, after a diagnosis of moderate to severe ADHD, clinicians feel comfortable recommending medication and explaining to families the risks and benefits of the proposed treatment.

Pediatricians and child psychiatrists are, most often, treatment providers to youths who have ADHD. Their professional associations have issued somewhat different practice guidelines regarding the medication versus therapy dilemma. In 2011, the American Academy of Pediatrics (AAP) took an inclusive, age-dependent approach

• For preschoolers, behavioral therapy is favored

• For children aged 6 to 11 years, the AAP recommends medication or behavior therapy and preferably both

• For adolescents, the clinician should prescribe medication and may prescribe behavioral therapy; a combination of both is preferable

On the other hand, the American Academy of Child and Adolescent Psychiatry’s (AACAP) 2007 parameters tend to favor medication: “It seems established that a pharmacological intervention for ADHD is more effective than a behavioral treatment alone. Behavioral therapy may be recommended as an initial treatment if the patient’s ADHD symptoms are mild with minimal impairment, the diagnosis of ADHD is uncertain, parents reject medication treatment, or there is marked disagreement about the diagnosis between parents or between parents and teachers.”

A 2015 report suggests that the AACAP guidelines are followed more closely than those of the AAP.

 The authors analyzed the responses of a very large US Centers for Disease Control and Prevention parental survey regarding children aged 4 to 17 years about the presence of an ADHD diagnosis and its treatment. It was found that, of those youths with ADHD, 43.3% received medication only, 30.7% received a combination of medication plus therapy, 13.3% received therapy only, and 12.7% were not treated.

Randomized clinical trials (RCT) for pharmacology have been used for years; in contrast, psychotherapy research only began using RCTs very recently. Although RCTs are a gold standard, they are more difficult to employ in psychosocial research for several reasons: double-blind conditions are not practical, intensive investigator training using treatment manuals has to be implemented in order to guarantee treatment fidelity, and the duration of treatment has to be of significant length to demonstrate change. An extraneous factor that has played an important role in influencing psychotherapy outcome studies is that the “same” therapy performs better in studies conducted by researchers who are committed to the approach than it does in studies conducted by others, a factor also known as “therapist allegiance.”

 Therapist allegiance affects outcomes and needs to be considered when interpreting results.

While the role of the physician is to guide, counsel, and advise, ultimately it is the family’s responsibility to decide which treatment should be pursued. The issues of whether medication is more effective than therapy or whether therapy is effective as a single modality are not addressed in this article; instead, the article aims to provide psychiatrists with practical tips on how to proceed with the treatment recommendation process with families who prefer therapy alone.

To remain true to evidence-based principles, the psychiatrist must follow a path that goes beyond simply recommending “therapy.” In other words, once a family declines medication (patient preference), the psychiatrist has to select the type of psychotherapy with the best research results (evidence) that they are skilled in (expertise). Since it appears that more than half of psychiatrists no longer practice psychotherapy, the recommendation process will also likely involve a referral to an outside therapist with expertise in the suggested approach.

 The psychiatrist must be familiar not only with the most effective therapies for ADHD but also with how to find an appropriate therapist if he or she will not be the treating clinician.

A number of psychotherapy approaches for ADHD demonstrate evidence-based effectiveness. It is generally accepted that stimulants reach an effect size of about 1.0 for the treatment of ADHD core symptoms. Less agreement exists regarding the effect size of behavioral interventions: some meta-analyses propose an effect size approximately as high as 0.83 for between-group studies while others show no efficacy.

 This large gap in findings probably results from methodological differences in how the meta-analyses were conducted. For instance, inclusion of non-RCTs favors an increase in effect size. Another consideration is that behavioral interventions have tended to show better efficacy for overall functional improvements (parents are more pleased) rather than improvements in specific core ADHD symptoms (attention, hyperactivity, impulsivity).

 lists the types of psychotherapies with the best chances of success; each is linked to a review paper that the reader can consult for a comprehensive appraisal, and to a manual that can be used to develop expertise in the technique.

Behavioral modification and social skills training (SST) approaches have been the most studied and utilized modalities for decades. The most common behavioral intervention involves training parents for 8 to 12 sessions in contingency theory, during which they learn basic principles of how to reward good and extinguish undesired behaviors. Once proficient with a home approach, parents can extend and coordinate their efforts with cooperative teachers to institute daily report cards that link improvement in school behaviors to rewards at home, thereby extending the reach of the approach to the school setting without having to demand a change in school processes. Specific school-based behavioral interventions are effective but much more difficult to implement given the lack of educational resources.

Another fairly successful approach is centered on having patients improve the manner in which they relate to peers, which is significantly deteriorated in ADHD. SST teaches children to overcome deficits in sharing, making conversation, meeting new friends, taking turns when playing, following game rules, and walking away when upset. These skills are best taught in group settings so that children can practice with peers. Faraone and Antshel

 provide information on SST as well as other therapies such as cognitive therapy, neuropsychologically informed therapy, and others.

For those psychiatrists who are not proficient in effective therapies and do not have the time to learn the methodologies of the therapies, the next step is to find an expert clinician they can refer their patient to. The previously mentioned therapist allegiance effect is relevant not only to better understanding of research results.

 Predictably, therapists with specific expertise and investment in the modalities they profess will be more effective; thus, the treating clinician needs to be invested in the modality being used and have experience with it.

Many psychiatrists have already established ongoing referral relationships with able therapists, but for those who have not, the search engines of several websites can quickly help find a suitable therapist. The Association for Behavioral and Cognitive Therapies (ABCT) is an interest group of mental health professionals (it is not a certifying organization).

 The association makes its list of members and specialties available via a search page to help locate a therapist. Query parameters include location, patient age, individual versus family, and over 100 clinical conditions, among which ADHD can be found. The type of insurance accepted can also be checked, which is very helpful because a clinician may have opted out of the insurance system or does not accept whatever insurance the patient has. When parameters of zip code 10028, within a 20-mile radius, for children with ADHD, and family therapy were entered, the search engine yielded the names of 3 therapists. There is a detailed profile associated with each therapist, including contact information.

Members of the American Psychological Association (APA)must have a doctoral degree in psychology or a related field from a regionally accredited graduate or professional school or a school that achieved such accreditation within 5 years of the doctoral degree.

 The APA does not certify that the therapist is qualified in specific treatment modalities, but it offers a search engine (although it does not list insurance status). Using the same parameters as for ABCT, the query yielded 131 therapist profiles. In some cases, there was a brief summary with varying degrees of information attached to the profile.

According to its website, the National Association of Cognitive-Behavioral Therapists (NACBT)is the leading organization dedicated exclusively to supporting, promoting, teaching, and developing cognitive-behavioral therapy and those who practice it.

In contrast to the other organizations, NACBT lists only therapists who have obtained certification with the association. The criteria for certification are listed on the website. The search engine allows searching for therapists by state only. The state of New York had 8 therapists listed, each one accompanied by a brief profile.

 has a therapist search engine that finds professionals from various backgrounds who specialize in treating ADHD.

 According to the publication, it verifies the name and contact details of the professional; that the professional’s license, if applicable, is valid within the state in which he or she practices; and that the professional is not subject to any license strictures preventing practice. However, the site cautions that the integrity of the directory relies on its professional membership and that professionals pay a fixed monthly fee to participate.

Despite the significant safety and effectiveness of pharmaceutical agents for the treatment of ADHD, many families decline this recommendation and request psychotherapeutic alternatives. There are several evidence-based psychotherapeutic approaches that may prove effective; however, outcomes depend on the experience of the treatment provider.

Dr Kaplan is Clinical Associate Professor of Psychiatry at the Rutgers New Jersey Medical School, Newark, NJ, and Medical Director, Behavioral Health Services at the Bergen Regional Medical Center, Paramus, NJ. He reports no conflicts of interest concerning the subject matter of this article.

 Huhn M, Tardy M, Spinelli M, et al. Efficacy of pharmacotherapy and psychotherapy for adult psychiatric disorders: a systematic overview of meta-analyses. 

 Consumer Reports. Drug vs talk therapy. 

http://www.consumerreports.org/health/free-highlights/manage-your-health/depression/talktherapy.htm

. Published October 2004. Accessed August 24, 2015.

 National Institute of Mental Health. Transforming the understanding and treatment of mental illness. 

http://www.nimh.nih.gov/health/topics/mental-health-medications/mental-health-medications.shtml

 Bradley C. The behavior of children receiving benzedrine. 

 American Academy of Pediatrics. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. 

 Pliszka S, for the AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. 

 Visser SN, Bitsko RH, Danielson ML, et al. Treatment of attention deficit/hyperactivity disorder among children with special health care needs. 

 Shean G. Limitations of randomized control designs in psychotherapy research. 

http://www.hindawi.com/journals/apsy/2014/561452/

 Zoler ML. Percentage of psychiatrists doing psychotherapy dwindles. 

www.clinicalpsychiatrynews.com/practice-economics/health-reform/single-article/percentage-of- psychiatrists-doing-psychotherapy-dwindles/ccd0a6e32f3727cfb77f8b69ce433ab1.html

 Fabiano G, Pelham WE, Coles EK, et al. A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder. 

 Sonuga-Barke EJS, Brandeis D, Cortese S, et al. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. 

 Faraone SV, Antshel KM. Towards an evidence-based taxonomy of nonpharmacologic treatments for ADHD. 

 Faraone SV, Antshel KM. ADHD: non-pharmacologic interventions. 

 The Association for Behavioral and Cognitive Therapies. 

 Practice Central. Psychologist Locator. 

 National Association of Cognitive-Behavioral Therapists. 

https:// therapists.psychologytoday.com/rms//

 Pfiffner LJ, Haack LM. Behavior management for school-aged children with ADHD. 

Defiant Children: A Clinician’s Manual for Assessment and Parent Training

 Robin AL. Family therapy for adolescents with ADHD. 

Defiant Teens: A Clinician’s Manual for Assessment and Family Intervention

 Mikami AY, Jia M, Na JJ. Social skills training. 

Organizational Skills Training for Children With ADHD: An Empirically Supported Treatment

Articles

Here: practical tips on how to proceed with the treatment recommendation process with families who prefer therapy alone.

Nonpharmacological ADHD Treatments for Youths: How to Implement Evidence-Based Practice Recommendations

That clinicians practice in an ever-changing, more complex environment that increasingly exposes them to multiple factors that may influence care is a clichÃ©-and an understatement. A clinician’s behavior can be influenced by many factors that range from indirect approaches to direct financial compensation.

At a very basic level, patients attempt to influence our behavior. For instance, strong patient preferences and the right to refuse treatment are conscious efforts directed at changing a recommendation that may not be liked. Transference, a psychodynamic construct generated by unconscious forces, may also result in patient attempts to change the physician’s behavior. Clinicians are familiar with these doctor-patient forces in the relationship.

External forces also exist. For example, doctors view advertisements, navigate financially sensitive formularies, and try to manage insurance requirements. These tactics do not involve direct monetary arrangements, but they influence physicians’ decisions and may have macroeconomic consequences. Moreover, some clinicians receive direct compensation from the medical industry for participating in activities such as advisory boards, research trials, and promotional talks.

By nature, physicians are strong-willed and make recommendations based on the Hippocratic principle and with their patients’ best interests at heart. Despite this, payments to physicians have been a concern because the doctor’s judgment may be biased toward the source of remuneration.

 The field of ADHD has been singled out in the controversy, in particular as it relates to whether the condition is being overdiagnosed and consequently overtreated.

 A regulatory response to this issue, applicable to all physicians and conditions, is the Sunshine Act, which mandates that the industry post a list with the names of doctors who receive payments and the amounts paid.

Physicians wield great power over individual lives as well as the financial outcome of medical products. The following case vignettes illustrate potential challenges that physicians confront in day-to-day practice and offer a rationale to help resolve influencing forces.

Married to a public school teacher, Mrs B, a 46-year-old stay-at-home mom, complained of lifelong distractibility. Her husband was emotionally supportive, calm, and well organized. The couple had 2 boys, aged 8 and 5. Mrs B explained that she had had a very successful career and had done very well financially. This money allowed her to stop working when her first son was born and for the family to enjoy a very comfortable lifestyle. She reported having concentration problems since early childhood and that she had been accident prone until she reached puberty. Her school performance was poor, but with a lot of effort she managed to graduate from high school. She was often referred to as “being in her own world.”

Her father experienced alcohol-induced violent episodes. Both her brothers had been treated for ADHD during childhood and did not do well as adults. Despite her difficult upbringing, Mrs B was very ambitious and completed an associate’s degree. A bubbly personality and a desire to advance helped her land a job with an Internet start-up. Her work required frequent travel. Mrs B’s contributions were instrumental to the success of the start-up, and she made a small fortune by selling her stock after the company went public.

Although she had never received a formal diagnosis of ADHD, several features point to the condition. As a child, she had problems with concentration and was overactive. A career in sales, working in the field rather than in an office setting, and a spouse who could help her set complex schedules are typical examples of compensating strategies for adults with ADHD.

 A strong family history of ADHD further validated that Mrs B met criteria for the condition.

Mrs B was not looking for diagnostic accuracy when she requested a consultation. After all, she had known that there was something wrong with her cognition for a long time and she was aware of her brothers’ diagnoses. She had successfully dealt with her problems on her own up until now, but a change in circumstances motivated her to seek treatment. Because a recent financial crisis had depleted the family’s savings, Mrs B needed to begin earning income again. She wanted to remain very involved with child care, so she decided to start a business locally to avoid traveling. She attempted to write a plan, put together financials, and study the relevant regulations, but she found it impossible. She could not concentrate on the many documents she needed to review and had difficulty in keeping a schedule without her husband’s help. She was getting confused about appointment times, was unable to help her sons with schoolwork, and was leaving pans on the lit stove. She had tried to improve her organization by using scheduling software and getting help from friends, but these methods had only minimal impact.

Her older son had recently received a diagnosis of ADHD and was doing well with medication. Her goal was to receive the same medication to help her get organized so that she could manage both her career goals and her family life. She had no doubt that she wanted to take the same medication that had helped her son.

Although in Mrs B’s mind this was a fairly simple logical request, there were many factors that tilted the risk-benefit ratio toward risk, possibly making medication not advisable. She unquestionably had ADHD, but her adaptive skills had served her very well over the years so that fine-tuning with an experienced coach could improve her performance.

 In addition, while stimulants are generally considered safe in younger patients without a history of cardiac symptoms, their growing use in middle-aged adults has been cause for concern.

 The patient also seemed to lack significant need for medication.

A strong history of substance abuse in the patient’s family cautioned that a high genetic vulnerability might trigger chemical dependence. The controversy over the relationship between use of stimulants and substance abuse in ADHD is still unresolved.

 Finally, given all of the considerations against medication, would a recommendation to use stimulants in this case validate the accusation that doctors succumb to industry’s heavy marketing?

When confronted with so many confounding variables, it is helpful to take a back-to-basics approach, such as the one outlined in the following questions:

• Does the patient experience significant problems related to the condition?

• Are there nonpharmacological options?

• Is there an evidence-based treatment available?

• Is the patient able to give informed consent?

• Is the patient willing to cooperate with the physician?

Following this approach yielded more facts (endorsed by her husband) that illuminated the negative effects of the illness on Mrs B’s daily functioning as well as the difficulties she encountered trying to move forward with her career plans.

Nonpharmacological options attempted by the patient were not helpful, and abundant published data exist on the effectiveness of stimulant medication in adults.

 Besides a need for caution because of her family’s history of substance abuse, there were no absolute contraindications for use of stimulants.

Mrs B understood the risks and benefits of treatment and was willing to undergo follow-up routine cardiac examinations. She also learned about the early warning signs of substance abuse and agreed that dose changes would only be recommended by her physician. It was determined that contrary to initial impression, pharmacotherapy was indeed a reasonable option in Mrs B’s case.

A year later, Mrs B was the proud owner of a lucrative business and was an effective manager of her household. She had achieved her goals with minimal adverse effects, so she continued treatment for several more years.

Sam, a 16-year-old, had recently developed attention problems that were mainly noticeable while playing golf. Sam’s concentration problem interfered with his game performance. To improve his skills, he attended golf camp over the summer. There he made friends with a teenager being treated with stimulants, which had been very helpful with both schoolwork and sports. Sam’s friend offered his medication: after taking the pills for a few days, Sam noticed that his game improved. He was happier and more relaxed than he had been in recent months. Sam’s parents felt the changes were beneficial, and the family talked to Sam’s pediatrician about formally prescribing medication. The pediatrician referred them to a psychiatrist.

As political refugees, the family had endured considerable hardship in their early years in the US. Despite the family’s tradition of high education achievements in their native country, neither parent had had time or money to pursue a college education. Eventually, they started their own business and became successful and wealthy. Their hope was for Sam to go to an Ivy League school, since he excelled academically. Being a top high school athlete was part of the strategy to increase Sam’s chances of entrance to an elite school.

Sam was articulate and engaged easily in conversation. He was popular, respectful, and had no behavior problems. His teachers raved about him. He denied using illicit drugs and was generally healthy. There was no family history of psychiatric illness. Sam described his parents as strict but loving. He was aware of his parents’ hopes for him and felt pressured to do everything he could to fulfill their expectations.

Although he denied major psychiatric symptoms, he reported recent onset of anxiety and poor appetite. He attributed this to the stress incumbent with college applications. While psychological testing is not essential to the usual ADHD diagnostic process, in this case it was obtained to help the decision-making process.

 A comprehensive evaluation concluded that Sam was an adolescent of high average intelligence without psychiatric impairment but who was undergoing situational stress. Therefore, medication was not recommended.

Sam’s parents were conflicted: on the one hand, they were happy that Sam did not suffer from a severe illness, yet they were very upset that medication was denied when they had seen proof of its effectiveness. A back-to-basics approach was used to reassure the parents that medication should not be pursued. It was explained that the comprehensive evaluation showed no signs of ADHD as determined by the history and objective testing.

 A review of the neuropharmacology clarified that healthy individuals can experience gains on attention induced by stimulants, and this is why these agents are frequently abused by otherwise healthy students.

 Sam’s concentration improved not because he had ADHD but because of the inherent properties of the medication. Moreover, stimulants in the absence of convincing therapeutic need could lead to unnecessary adverse effects and, in fact, Sam was already experiencing medication-induced anxiety and anorexia. The additional risk of substance abuse was mentioned as well.

Sam suffered from a mild attention problem and other situational symptoms that were not due to ADHD; he had an adjustment disorder. The symptoms were related to his preoccupation with the family’s tradition of high academic achievements and the possibility that underperforming would disappoint his parents. His distress could best be addressed by giving him more freedom to decide what he wanted to do instead of imposing a predetermined goal. Research supports the use of various psychotherapies for adjustment disorders.

 In this case, family psychotherapy to realign goals and individual psychotherapy to cope with stress were advised. After reviewing all the information yielded by a back-to-basics approach, Sam and his parents were very pleased that Sam was accepted to a non–Ivy League top level school from which he ultimately graduated with high honors.

There is no question that physicians are exposed to multiple forces that attempt to change their behavior. These forces can be clinical and inherent to the physician-patient relationship or external to this relationship. While clinicians have become more aware of the potential conflicts these influences may present, difficult cases, in particular, can make the sorting out of such influences more challenging. In these cases, taking a back-to-basics approach may bring clarity to both diagnostic and therapeutic clinical processes.

http://www.psychiatrictimes.com/adhd/co-occurring-mania-and-adhd-youths

Infographic: Men With Versus Men Without ADHD in Childhood

http://www.psychiatrictimes.com/adhd/infographic-men-versus-men-without-adhd-childhood

Conduct Disorder, ADHD-or Something Else Altogether? 

http://www.psychiatrictimes.com/adhd/conduct-disorder-adhd-or-something-else-altogether

Dr Kaplan is Clinical Associate Professor of Psychiatry at Rutgers New Jersey Medical School in Newark. He is a consultant for Ogilvy CommonHealth.

 Harris G, Carey B. Researchers fail to reveal full drug pay. 

June 8, 2008. http://www.nytimes.com/2008/06/08/us/08conflict.html?pagewanted=all&_r=0. Accessed May 13, 2014.

 Carey B, Harris G. Psychiatric group faces scrutiny over drug industry ties. 

 July 12, 2008. http://www.nytimes.com/2008/07/12/washington/12psych.html?pagewanted=print. Accessed May 13, 2014.

 Rosenthal A, Tang T, Semple RB Jr, et al. Worry over attention deficit cases. 

 April 9, 2013. http://www.nytimes.com/2013/04/10/opinion/worry-over-attention-deficit-hyperactivity-disorder.html. Accessed May 13, 2014.

 Sciutto MJ, Eisenberg M. Evaluating the evidence for and against the overdiagnosis of ADHD. 

 Centers for Medicare & Medicaid Services. Fact Sheet for Physicians. 2013. http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment-Transparency-Program/Downloads/Physician-fact-sheet.pdf. Accessed May 13, 2014.

 Loftus P. Doctors face new scrutiny over gifts. 

 August 22, 2013. http://online.wsj.com/article/SB10001424127887323455104579014812178937016.html?mod=WSJ_hpp_LEFTTopStories. Accessed May 13, 2014.

 Adler LA. From childhood into adulthood: the changing face of ADHD. 

 Kubik JA. Efficacy of ADHD coaching for adults with ADHD. 

 Kaplan G. What is new in adolescent psychiatry? Literature review and clinical implications. 

 Ivanov I, Pearson A, Kaplan G, Newcorn JH. Attention deficit hyperactivity disorder and comorbid substance abuse. In: Greydanus DE, Calles JL Jr, Patel DR, et al, eds. 

Clinical Aspects of Psychopharmacology in Childhood and Adolescence.

 Bitter I, Angyalosi A, Czobor P. Pharmacological treatment of adult ADHD. 

 Kaplan G, Newcorn JH. Pharmacotherapy for child and adolescent attention-deficit hyperactivity disorder. 

 Johnson B, Newcorn JH. Prescription stimulant and other substance abuse in college students. In: Greydanus DE, Kaplan G, Patel DR, Merrick J, eds. 

Substance Abuse in Adolescents and Young Adults: A Manual for Pediatric and Primary Care Clinicians

. Boston: Walter de Gruyter; 2013:273-287.

 Katzman G, Geppert C. Adjustment disorders. In: Sadock BJ, Sadock VA, Ruiz P, Kaplan HI, eds. 

. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:2187-2196.

What forces influence your decision to treat ADHD? Case vignettes and a back-to-basics approach may bring clarity to the diagnostic and therapeutic clinical processes that surround the decision.

A Back-to-Basics Approach to Managing ADHD?

Research over the past 2 decades has demonstrated that ADHD occurs frequently and causes considerable suffering in patients and their families. ADHD begins in early childhood and persists through adolescence and into adulthood in 70% of those affected. Two large epidemiological studies in the US have placed its prevalence at 8.7% in children and 4.4% in adults.

In addition to the well-known, emotionally costly symptomatology at the individual level, a review paper just presented at the 2012 American Psychiatric Association (APA) meeting found that ADHD was also associated with a substantial impact on education costs among children and adolescents and on income and productivity losses among adults, ranging from approximately $86 billion to $138 billion dollars.

 Therefore, not surprisingly, there is an increased interest in all aspects of the illness, and the number of papers being published has grown every year for the past decade (

Such a large body of literature makes it challenging for busy clinicians to discern which of the hundreds of articles they should read to keep current with relevant, clinically applicable findings. In that spirit, this article reviews the most recently published ADHD literature as well as some of the presentations from the May 2012 APA meeting in Philadelphia and provides a clinical perspective on how findings may apply to everyday practice.

ADHD and cardiovascular risk of medication

The effects of stimulants on the cardiovascular system of healthy individuals are established. In therapeutic dosages, these agents increase blood pressure and heart rate, but such changes are not clinically meaningful.

 The rise in stimulant prescriptions and a renewed examination of sudden death case reports provided the stimulus for the FDA and its Canadian counterpart and the American Heart Association to review concerns about potential stimulant cardiotoxicity. In response to concerns, these agencies issued clinical guidance recommendations that were not universally accepted and became controversial. Following discussions with professional associations of physicians, these guidelines were ultimately reversed.

A 2009 large case-control study by Gould and colleagues

 found an association between the use of stimulants and sudden unexplained death among children and adolescents. Given the level of uncertainty in the field, several investigators launched a number of studies with varied methodological approaches geared toward generating additional data to clarify the issue.

 The resulting reports were published in 2011 and 2012 and are outlined in the 

 
Variation in the number of articles published in 2001 versus 2011 obtained by searching by year in PubMed using keyword "ADHD" 
Figure 2


 
Effect sizes of diet, omega-3, and stimulants in children with ADHD 

Gould and colleagues reported a significant association, or “signal,” between sudden unexplained death and the use of stimulant medication, specifically methylphenidate. They acknowledged that the data had limitations that precluded a definitive conclusion, but their findings drew attention to the potential risks of stimulant medications. Since the publication of this study, other researchers have pointed to additional methodological issues that may have biased results away from the null.

 Furthermore, a number of well-designed large studies have not replicated this signal.

 Psychotropics in general should not be prescribed for patients with current or past cardiac illness without obtaining medical clearance and coordinating follow-up care with a specialist. In such patients, a benefit-risk assessment determines whether medications should be recommended. Is there, however, a risk of significant cardiotoxicity when stimulants are prescribed in usual therapeutic doses for otherwise normal individuals?

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.

 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 in children with comorbid conduct problems.

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.

 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.

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.

 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.

Revisions to the ADHD diagnostic criteria in DSM were discussed at the 2012 APA annual meeting.

 According to the task force, the following changes are likely but have not been finalized

• 	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

 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.

All child and adolescent psychiatrists have interviewed at least 1 parent who strongly asserted that this or that type of food caused their offspring to become more acutely symptomatic, while eating other types of foods improved symptoms. The therapeutic and pathogenic theoretical roles of foods in ADHD, however, have fallen into disfavor since the 1980s, and most clinicians have tended to take parental reports regarding dietary effects with a certain degree of skepticism.

The results of 2 recent analyses may validate such previously discredited parental reports to some extent. Bloch and Qawasmi

 found that omega-3 fatty acid supplementation, particularly with higher doses of eicosapentaenoic acid, was modestly effective for treating ADHD. Nigg and colleagues

studied the role of diet and food colors and found that restriction diets reduced ADHD symptoms and that an estimated 8% of children who have ADHD may have symptoms related to synthetic food colors.

 An emerging body of evidence has concluded that certain artificial dyes used in food seem to increase hyperactivity and their elimination from the diet of children may improve behavior and attention, although the effect sizes of these approaches are much lower than those of stimulants (

). These data are intriguing but do not yet support routine dietary assessments.

On the other hand, clinicians should not dismiss unsolicited parental reports of food effects as invalid; explore these reports further and consider recommending a diet that excludes the posited offending agent. Furthermore, since fatty acids have a benign adverse-effect profile, they could be used to supplement/augment usual medications or they could be recommended in cases in which families are averse to prescription drugs but not opposed to over-the-counter options.

 
Recently published articles on the cardiovascular safety of ADHD agents 

Obtaining the first driving license generally causes exhilaration in teenagers and anxiety in parents. For ADHD patients, the newly acquired independence that driving brings can also carry additional risks, because there is evidence that ADHD may impair motor vehicle operation. Stimulant medication, however, appears to improve driving skills in persons with ADHD.

 conducted a randomized, double-blind, 6-week, placebo-controlled, parallel-design study to determine the effect of lisdexamfetamine (LDX) on driving performance in a validated driving simulation paradigm. Sixty-one 18- to 26-year-old outpatients of both sexes with ADHD were randomized to receive LDX or placebo after a baseline driving simulation. They completed a second driving simulation 6 weeks after beginning the drug or placebo. LDX treatment was associated with significantly faster reaction times and a lower rate of simulated driving collisions.

 investigated whether methylphenidate delivered through a long-acting transdermal system (MTS) would reduce collision rates of young adult drivers with ADHD. Seventeen young adults completed this open-label, crossover design study in which drivers were randomly assigned either to no medication for 3 months and then MTS for 3 months or to the reverse sequence. In-car video monitoring of routine driving occurred during these 6 months. Participants who were receiving MTS had fewer video-recorded collisions and other problematic driving events.

 Distracted driving has become a public health concern, eliciting comments from federal officials such as Secretary of Trans­portation Ray LaHood, who has called it “an epidemic on America’s roadways.” Psychiatrists have not routinely addressed the issue of driving with their ADHD patients. Given the compelling evidence, however, families who are considering medication for their adolescent should be made aware of these data because they could offer improved reassurance that the risk to bene-fit ratio for symptomatic driving-age youths favors the use of ADHD medication.

The overwhelming number of articles published about ADHD every year necessitates that clinicians rely on aggregators to highlight the most significant articles in their quest to improve the quality and options of care offered to patients. This article outlines the latest research on topics of high importance to the field. Nothing can replace, however, a direct examination of the data, so readers are encouraged to review the original reports for those topics they have found most interesting.

1. Kaplan G, Newcorn JH. Pharmacotherapy for child and adolescent attention-deficit hyperactivity dis­order. 

Research over the past 2 decades has demonstrated that ADHD occurs frequently and causes considerable suffering in patients and their families. ADHD begins in early childhood and persists through adolescence and into adulthood in 70% of those affected.

Author | Gabriel Kaplan, MD

Articles

Practice Patterns for ADHD and Other Disorders Collide

Nonpharmacological ADHD Treatments for Youths: How to Implement Evidence-Based Practice Recommendations

A Back-to-Basics Approach to Managing ADHD?

Practical Tips From New Research on ADHD

Strategies to Improve Medication Adherence in Youths