ADHD: Primary Care Perspectives

Table of Contents

1. "My Child is Hyper": How Can My Pediatrician Help?
2. DIAGNOSIS
3. CO-MORBIDITIES
4. DEPRESSIVE DISORDERS
5. ANXIETY DISORDERS
6. OPPOSITIONAL DEFIANT DISORDER
7. AUTISM
8. PHARMACOLOGIC TREATMENT: STIMULANT MEDICATIONS
9. PHARMACOLOGIC TREATMENT: OTHER MEDICATIONS
   1. Nonstimulants
   2. Antidepressants
   3. Mood Stabilizers
10. NON-PHARMACOLOGIC MANAGEMENT OF ADHD
11. POST-TEST
12. USEFUL RESOURCES
13. SELECTED REFERENCES
14. THE AUTHORS

Antidepressants

Many primary care physicians now manage the pharmacotherapy of their patients with diagnosed depressive disorders, particularly when that patient is also being seen by a qualified child psychologist and/or after a consultation with a psychiatrist. Current regulations mandate that pharmacists dispense antidepressants with warnings about potential increased suicidality. The American Academy of Child Psychiatry states that insufficient evidence exists to confirm this risk, though in general, severely depressed individuals are at increased risk of suicide. Depressed patients who are placed on antidepressants should be closely monitored.

Most clinicians perceive that antidepressants (with the exception of imipramine or bupropion) have little or no direct effect on core ADHD symptoms. Imipramine or bupropion are prescribed for treatment of ADHD as adjuncts to stimulants, or instead of them when stimulants are contraindicated.

The physician should remember that any antidepressant has the potential to induce mania in patients with underlying bipolar disorder. Thus, a child who experiences extreme behavioral activation on any of these medications should be evaluated promptly for bipolar disorder .

The SSRIs

Selective serotonin reuptake inhibitors appear to have excellent safety profiles in children, rarely cause sedation, and thus are generally used as first-line antidepressants in children. One note of caution: Fluoxetine (Prozac^R) can cause "behavioral activation"-i.e., worsening of anxiety or hyperactivity--in some children, particularly boys, with ADHD and related disorders. Sertraline (Zoloft^R) is less likely to do so. These medications are also used to treat anxiety, with some suggestions that fluoxetine or citalopram are more effective than some other agents.

Tricyclic antidepressants (TCA's)

Imipramine (Tofranil^R) and amitryptyline (Elavil^R), have a long history of use for depression in children. Although these medications have been generally safe, electrocardiograms should be obtained at the initiation of therapy and with major dosage changes. Imipramine may have a direct effect on attention span as well as mood.

Bupropion

Bupropion (Wellbutrin^R) is an antidepressant that also appears to directly affect attention span. Chemically unrelated to TCA's or SSRI's, bupropion can be a helpful adjunct to stimulants in some adolescents with combined ADHD and mood symptoms, although it often exacerbates underlying anxiety symptoms.