ADHD: Strategies for Developing a Further Dialogue - Episode 8
Experts in the management of ADHD (attention deficit hyperactivity disorder) consider various unmet needs in the treatment of pediatric patients.
Tim Wilens, MD: COVID-19 [coronavirus disease 2019] hopefully will end one of these days, and what will persist is ADHD [attention-deficit/hyperactivity disorder]. It does bring up some of the things that we’ve talked about with COVID-19 and highlights some of the issues we’re dealing with medicines and shortages. There is a lot of need still yet to be unveiled in ADHD in terms of treating it.
Ann, you’ve been at the forefront of a lot of clinical research in this area, you know what the needs are. Can you give us a lay of the land of what you think are some of the major areas where we need to do better?
Ann Childress, MD: If we could come up with a medication that worked as well as a stimulant and had low abuse potential and didn’t affect growth, we’d have a home run. I don’t see anything like that in the pipeline.
Tim Wilens, MD: How about some other things? What other needs do you think about? Should whatever we have treat comorbidities?
Ann Childress, MD: It would be nice, because as we talked about, I do clinical trials, and I’m trying to find kids with just ADHD, and that’s only about 25% of the kids out there. It would be nice if we can have a medication that will help with ADHD and may treat some of the mood and some of the anxiety symptoms that are comorbid. There is something coming that was used as an antidepressant for about 3 decades in Europe, that also is effective in ADHD. It’s a nonstimulant, it doesn’t work as well as the stimulants do, but doesn’t have that abuse potential. It hasn’t been studied with comorbidity here yet, but I have hope. I have hope for it, since it was used as an antidepressant.
Tim Wilens, MD: What’s your sense about through the day coverage? Where do you think we are now, and where do we need to go?
Ann Childress, MD: Some of the medications, for example, extended-release guanfacine and atomoxetine, we know do help with some of those bookend times.. The kids have so much trouble before they get off to school in the morning, and then the medication lasts into the evening. None of the stimulants have 24-hour coverage, and I don’t know that we would want a stimulant that had 24-hour coverage, because I don’t know what it means when we’re blocking dopamine 24 hours a day. There probably needs to be some downtime with that.
Tim Wilens, MD: Harlan, you’ve thought a lot about this. Your book and everything about what works and what’s not working in ADHD. What are some of the things that you also see from a pediatric standpoint that we need to do better?
Harlan R. Gephart, MD: I’d like to get away from the medicine thing. I don’t disagree with any of that. Schools are not properly, what should I say, they’re not user-friendly for kids with ADHD, and there’s very little that’s been done. The best you get is just sit near the teacher, or that sort of thing. Moving into middle school and high school, class sizes are huge, 30, 40 kids in a class. There’s very little time to do homework in the class; the teacher barely can collect yesterday’s homework and explain tomorrow’s, and then they’re out the door. The kids come home with 2 or 3 hours of homework, which is just killing for a kid with ADHD.
I remember 60 years ago being in high school, and homework was like an hour a night. Of course, I didn’t have a learning problem, but it was not a big chore. We’ve just got to do something different. Sitting in a row of kids drives a kid with ADHD crazy. The whole school system, I think, needs to change. That’s one thing I wrote down. We’ve got to do better about vocational counseling. I tell parents all the time, “Your kid’s smart enough to be a doctor, but he wants to be a plumber, so for goodness sake, let him be a plumber. Don’t get hung up there.” I see every once in a while an ex-doctor who now works finally as a plumber, or something like that.
Mark Wolraich, MD: One of the big issues is communication between all the players. It is not yet a good system. There are some out there that work well but are not supported enough to do, where the information from the school, to and from, can be in the process, the better communication with parents, and as we talked about with the telemedicine. Communication between the pediatricians and the child psychiatrists, the communication between the pediatricians and if there’s a therapist or a psychiatrist, are really not there. And there are a lot of barriers there for protection of health information, but they decrease the communication.
In the case conference calls we have, the pediatricians…still have relatively little contact, either if the child has a therapist, or if they’ve sent them to a child psychiatrist for help.
-Dr. Findling receives or has received research support, acted as a consultant and/or has received honoraria from Acadia, Adamas, Aevi, Afecta, Akili, Alkermes, Allergan, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, Axsome, Daiichi-Sankyo, Emelex, Gedeon Richter, Genentech, Idorsia, Intra-Cellular Therapies, Kempharm, Luminopia, Lundbeck, MedAvante-ProPhase, Merck, MJH Life Sciences,NIH, Neurim, Otsuka, PaxMedica, PCORI, Pfizer, Physicians Postgraduate Press, Q BioMed, Receptor Life Sciences, Roche, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Syneurx, Takeda, Teva, Tris, and Validus.
-Dr Gephart is retired from the practice of medicine. He is on the faculty of the REACH Institute for a course entitled “Patient Centered Mental Health in Primary Care.” He receives a stipend for serving as a virtual consultant to Course graduates who call in and present difficult cases. He has no other financial contracts to report.
-Dr Childress reports receipt of research or writing support, participation on advisory boards, and service as a consultant or speaker for Adlon Therapeutics, Aevi Genomic Medicine, Akili Interactive, Allergan, Arbor Pharmaceuticals, Cingulate Therapeutics, Emalex Biosciences, Ironshore Pharmaceuticals, Jazz Pharmaceuticals, KemPharm, Lundbeck, Neos Therapeutics, Neurovance, NLS Pharma, Otsuka, Pearson, Pfizer, Purdue Pharma, Rhodes Pharmaceuticals, Sunovion, Supernus Pharmaceuticals, Takeda, and Tris Pharma.
-Dr Wolraich is professor emeritus from the University of Oklahoma Health Sciences Center. He is on the steering committee and a faculty member of the REACH Institute, a non-profit organization providing CME training on mental health to primary care physicians. He has no affiliations or investments where he receives any compensation, and he is no longer in any clinical practice.
-Dr Wilens is Chief, Division of Child and Adolescent Psychiatry and Co-Director of the Center for Addiction Medicine at Massachusetts General Hospital. He receives or has received grant support from NIH(NIDA). He is or has been a consultant for Arbor, Otsuka, Ironshore, KemPharm and Vallon. He is the author of Straight Talk About Psychiatric Medications for Kids (Guilford Press). He is co-editor of ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier); and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). He is co-owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire) and has a licensing agreement with Ironshore (BSFQ Questionnaire). He serves as a clinical consultant to the US National Football League (ERM Associates), U.S. Minor/Major League Baseball; Gavin Foundation and Bay Cove Human Services.