Approaching ADHD Treatment Selection in Children and Adults

Rakesh Jain, MD, MPH: Let’s address the issue of the evidence-based recommendation hierarchy in the choice of medications for adult patients who have ADHD [attention-deficit/hyperactivity disorder]. The treatment guidelines are elegant and helpful. They recommend, I think appropriately so, that a stimulant might be the appropriate first choice for the vast majority of patients.

However, there may be some patients for whom such an approach might be reserved as second- or third-line therapy. Those patients may have significant anxiety, significant depression, significant sleep difficulties, or significant and worrisome substance misuse disorders. In such situations, a nonstimulant may be the preferred first therapy. But it does appear that the greatest efficacy and appropriateness for most patients does tend to be with the use of stimulants. 

I will add 1 further word of advice for you. If you don’t receive all that your patient deserves from that intervention, it’s OK. Let’s not get frustrated. It’s OK to sometimes switch to another release mechanism, or maybe another medication of the same class of stimulants, or maybe switch to a nonstimulant medication. It’s OK to consider a long-acting version there. Of course, as I said before, let’s always combine our medication interventions with other interventions—the nonpharmacological interventions. That is what is recommended by our treatment guidelines, and I very much follow that in my own clinical practice.

Let’s now talk about the pediatric population and treatment paradigms for addressing ADHD. Very similar to adult ADHD, stimulants do tend to be recommended as first-line treatment by the vast majority of guidelines. I fully support that approach. Let’s never, however, ignore the specific populations for which nonstimulants may well be first-line options. For example, maybe a patient has a tic disorder, or the patient has significant anxiety or comorbidity. You know for a fact that’s rather common. What if the patient is significantly underweight to begin with and can’t afford to lose much weight right off the bat? Those may all be reasons to consider nonstimulants.

It’s better not to put it as a stimulant versus nonstimulant. It’s better to think of it as we have 2 different classes. Each class has many members in it, and I need to know their strengths. It’s not a matter of, “It must be this. It must be that.” It’s more a matter of customizing treatment to the patient. The patient might be pretty complex or might be highly comorbid or might be relatively straightforward. You may have a family member who responded very well to a certain class of medications. All those factors should influence our final decision as to what medication to choose to help our pediatric patients.

Transcript Edited for Clarity