Starting ADHD Treatment in Adolescents, With Ann Childress, MD

Ann Childress, MD, discussed clinical approaches to medication sequencing in attention-deficit hyperactivity disorder (ADHD) and management of comorbid insomnia in pediatric and adult patients with ADHD, in an interview with Gus Alva, MD, previewing her upcoming sessions at the Southern California Psychiatry meeting.

Childress described her approach to stimulant versus non-stimulant sequencing in children, noting that American Academy of Pediatrics guidelines recommend starting with an FDA-approved medication. She typically initiates a stimulant after discussing options with parents, defaulting to alpha-2 agonists or the non-stimulants atomoxetine or viloxazine when families have concerns about controlled substances, such as a family history of substance use disorder. In younger children, she preferentially starts with methylphenidate, citing response rates of approximately 80% to methylphenidate or amphetamine-based stimulants, and switches to the alternative stimulant class if response or tolerability is inadequate. Childress noted the current absence of formal US treatment guidelines for adult ADHD, but reported that guidelines developed under her tenure as past president of the American Professional Society of ADHD and Related Disorders are expected to be published imminently.

On durability of treatment effect, Childress drew an analogy to diabetes, emphasizing that ADHD symptoms typically return upon medication discontinuation, but that symptom control is reliably restored upon resumption of treatment.

Addressing comorbid sleep disturbance, which Childress noted is common in both pediatric and adult ADHD, she emphasized that no medications are FDA-approved for pediatric insomnia, making behavioral interventions (like structured bedtime routines, removal of evening electronics, and cognitive behavioral strategies) first-line treatment. For children who do not respond to behavioral intervention alone, Childress cited supportive double-blind, placebo-controlled evidence for melatonin, referencing a study by Margaret Weiss in which children with ADHD and insomnia first underwent sleep hygiene intervention, with melatonin reserved for behavioral nonresponders.¹ She noted that the over-the-counter status of melatonin introduces variability in product content and dosing as a practical limitation.²

Want to see more from Dr Childress at the Southern California Psychiatry Conference? Register to attend here!

Dr Alva is a board-certified psychiatrist and the Mood Disorders Section Editor for Psychiatric Times.

Dr Childress is a psychiatrist practicing in the Las Vegas, Nevada area and is past president of the American Professional Society of ADHD and Related Disorders.

References

1. Weiss MD, Wasdell MB, Bomben MM, et al. Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry. 2006;45(5):512-519.

2. Erland L, Saxena P. Melatonin natural health products and supplements: presence of serotonin and significant variability of melatonin content. J Clin Sleep Med. 2017;13:275–281.