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ADHD continued from page 1
to an initial treatment trial of firstline
medication or when the patient’s
condition is more complicated.
“The published response rate for
stimulants when you try a single
stimulant is estimated at about 70
percent. So approximately 30 percent
of the time, clinicians will need to try
a different stimulant or try a different
medication altogether. I will provide
some suggestions or guidance
on how to optimize medication
response,” said Dr Adesman, who is
Chief, Developmental & Behavioral
Pediatrics at Steven & Alexandra
Cohen Children’s Medical Center of
New York in New Hyde Park, NY.
His presentation will include some
discussion of alternative therapies
and what place – if any – treatments
like fish oil have in the treatment
approach of children with ADHD
as well as provide information about the
effectiveness of dietary and nutritional
formulations currently available.
According to Dr Adesman,
pediatricians should be comfortable
understanding the many different
medication options and some of
their nuanced differences in terms of
choosing the right medicine. That
comfort should extend to developing
and implementing a second line of
treatment when the initial treatment
plan doesn’t appear to be adequate.
Second-line therapy should include
non-stimulants and alternative
stimulant formulations.
“I’ll also talk about the use of non
stimulants, either as a first-line or
second-line medication, or as an adjunct
treatment,” he said.
One of the major challenges for a
pediatrician dealing with patients with
ADHD involves setting appropriate
family expectations in terms of benefits
and side effects. The pediatrician has to
be sensitive and responsive to parental
concerns, requiring the pediatrician to
consider the different potential areas of
functional improvements one hopes to
see from medication and that the right
outcome criteria measures medication
“Setting the right expectations is
always important. If parents expect
too much or if they are looking
for improvement in the wrong
domains of function, they may be
disappointed.”
effectiveness. It is also important to
consider possible comorbid conditions
that affect the medication choice, the
medication response or the child’s
overall function.
Dr Adesman noted that challenging
issues of communication with families
can be time consuming. “I’ve written
that I believe it is easier for my oncology
colleagues to give their patients strong
chemotherapy than it is for us to give
our patients a prescription for Ritalin
just because there is so much hesitation
and misinformation.” Resistance,
anxiety, doubt and unrealistic
expectations can plague the parent of
a newly diagnosed child. “Setting the
right expectations is always important.
If parents expect too much or if they are
looking for improvement in the wrong
domains of function, they may be
disappointed,” he said.
There are also possible logistical
challenges for families such as availability
of preferred medications and dealing
with prescription plan formularies.
“Choosing the best medicine is
not always an option because we as
pediatricians need to be mindful of what
is available and affordable for families in
formulary options,” he said.
Dr Adesman will review the
major revisions to the AAP
treatment guides for ADHD,
including the expansion of
the guidelines from preschool
through adolescence. He plans to
address medication management
in the preschool population with
attention to patient friendly
formulations and issues specific to
the young child.
“We have to recognize that
preschool kids can’t swallow pills and
thus consider what that means in terms
of treatment options,” he said. “I’ll
also talk about some of the sensitive
issues with adolescents in terms of
diversion, potential misuse, and some
of the specific challenges of meeting
the individual needs of an adolescent
and college student in terms of their
longer academic days and more variable
schedules.”
In the end, it is important that
pediatricians can comfortably optimize
the response of children and adolescents
to medication for ADHD. “That can
translate into making sure pediatricians
are able to adjust the medications and
pick the right formulation so that
benefits are maximized and side effects
are minimized.”