Mental-Health 30 Oct, 2022 Read Time: 3 mins

A child psychiatrist’s perspective on current treatment options

During the third multidisciplinary South African congress for ADHD, Dr Brendan Belsham, a child and adolescent psychiatrist from Johannesburg, delved into treatment options focusing on children with ADHD. The three main themes of his presentation addressed:

 

  • What nonpharmacological treatments are evidence based?
  • Where do amphetamines fit in?
  • What is the role of precision medicines and pharmacogenetics?

Nonpharmacological treatments include the following:

Psychoeducation

  • Educate and empower the patients and their families by providing information on ADHD
  • Look at lifestyle factors such as sleep, diet, and exercise
  • Examine modifications that can be made in both the school and home setting

This mostly occurs in a group setting and has shown to be effective in reducing symptoms of ADHD and disruptive behaviour disorders.

Parent management training

This mostly occurs in a group setting and has shown to be effective in reducing symptoms of ADHD and disruptive behaviour disorders. All training of this nature shares similar behavioural principles, which consist mostly of reinforcing positive behaviours, ignoring low level provocative behaviours, and providing clear, consistent, and safe responses to unacceptable behaviour. Parents should be engaged as partners. This is the first line treatment for pre-schoolers under five years of age.

 

Other interventions

These include social skills training, CBT, mindfulness training and digital therapeutics. The recent trend towards ‘gamification’ tries to train working memory via a computerised intervention, considering that those with ADHD are likely to choose ‘smaller, sooner’ than ‘larger, later’ rewards. However, digital interventions cannot currently be recommended for ADHD due to inconsistent findings.

However, digital interventions cannot currently be recommended for ADHD due to inconsistent findings.

Pharmacological treatments include the following:

  • Psychostimulants, including methylphenidate (MPH) and the amphetamines
  • Non stimulants, such as atomoxetine
  • Other medications, which are used off label

It is important to remember that although medications have similar efficacy and tolerability at population level, individual response to certain agents will vary. A combination of a stimulant and a non-stimulant can be combined as augmentation for suboptimal responders.

 

How to decide on which medication to use?

Age

For pre-schoolers (less than five years of age):

  • Check which medications are indicated
  • Look at the potential for titration
  • Assess the ability to swallow the medication

Previous medication history
  • Different MPH preparations may give very different results
  • Patients may respond differently to the same medication years later
  • Interestingly, 70% will respond to MPH and 70% will respond to amphetamines, but if the classes are switched then 90% will respond

Pattern of impairment
  • At what time of the day are the symptoms most problematic?

 

Are there family members who have received treatment for ADHD either currently or in the past?

 
  • Response between family members may be similar
  • The family may trust a medication more if it has helped someone else in the family

Comorbidities and side effects
  • Consider anxiety, tics, insomnia
  • The comorbid disorder may need to be treated first
  • Start one medication at a time
  • Document pre-existing symptoms

It is important to remember that although medications have similar efficacy and tolerability at population level, individual response to certain agents will vary.

Pharmacogenetics

There is genetic variability in medication response and in drug metabolism, although only small effect sizes when shown in trials. Adverse effects are also related to various genetic variants, and this is important as it may affect adherence. However, in 2018, the Canadian ADHD Resource Alliance (CADDRA) said there was insufficient evidence to recommend the routine use of pharmacogenetics.