Balancing Efficacy and Risk in ADHD Pharmacotherapy

Helen Alphonso, DO, discussed current challenges in the diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD), with particular attention to illness severity, stimulant prescribing, and considerations for special populations. Alphonso emphasized the need for improved tools to distinguish severe ADHD from milder presentations, noting ongoing efforts at her institution to develop and validate a severity assessment scale. She argued that more precise characterization of ADHD severity could improve treatment decision-making and risk-benefit evaluations.

Alphonso also highlighted the need for continued innovation in ADHD pharmacotherapy. While acknowledging the efficacy of stimulant medications, she advocated for expanded development of nonstimulant treatments with novel mechanisms of action. She stated, “I do want there to be more interest in developing nonstimulant treatments for ADHD,” reflecting concerns about the limitations of currently available options. Alphonso noted that stimulants remain highly effective in reducing ADHD symptom burden but cautioned that they are associated with potentially serious adverse outcomes.¹

A major focus of the discussion involved the risks associated with stimulant treatment. Alphonso cited concerns regarding cardiovascular disease, psychosis, and Parkinson disease and emphasized the inability of clinicians to reliably predict which patients may experience these complications. She explained, “For us as providers, we have no way of telling which patients will experience these and when,” underscoring the uncertainty that often accompanies prescribing decisions.

Alphonso also addressed ADHD treatment during pregnancy. Drawing on discussions with colleagues specializing in perinatal psychiatry, she noted the limited evidence base, which relies largely on animal and observational studies. She stressed that treatment decisions should be individualized and guided by illness severity, with severe ADHD potentially warranting pharmacologic intervention despite potential risks.²

The intersection of ADHD and substance use disorders is also important to watch, Alphonso noted. As an addiction psychiatrist, she observed that addiction affects patients across socioeconomic groups and diagnostic categories. She concluded that clinicians currently lack reliable methods for predicting who will develop stimulant-related addiction, reinforcing the importance of careful monitoring and informed consent.

Dr Alphonso is a psychiatrist at John Peter Smith Hospital in Fort Worth, Texas, and board-certified in both addiction medicine and lifestyle medicine.

References

1. Nanda A, Janga LSN, Sambe HG, et al. Adverse effects of stimulant interventions for attention deficit hyperactivity disorder (ADHD): a comprehensive systematic review. Cureus. 2023;15(9):e45995.

2. Scoten O, Tabi K, Paquette V, et al. Attention-deficit/hyperactivity disorder in pregnancy and the postpartum period. Am J Obst Gyn. 2024;231(1):19-35.