An 8-year-old boy is brought to the office by his mother for evaluation of behavioral concerns. The patient has had poor attention, difficulty listening, and hyperactivity since kindergarten. Despite ongoing behavioral therapy, he continues to have problems at school and at home. He is easily distracted in the classroom and has difficulty sitting still and following instructions. His schoolwork is disorganized and sloppy, and his grades are below his academic potential. At home, he annoys family members with his intrusive behavior, forgets his chores, and becomes moody and irritable when reprimanded. Vital signs are normal. Physical examination shows no abnormalities. Treatment options are discussed, and the mother shares that she would like to try a medication for her son. She states that her older son has been taking pills at parties "for fun," and she does not want addictive medications at home. Which of the following is the most appropriate pharmacotherapy for this patient?
Attention deficit hyperactivity disorder | |
Clinical |
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Treatment |
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This child's symptoms of inattention (eg, difficulty listening, sloppy schoolwork, forgetfulness of chores) and hyperactivity/impulsivity (eg, difficulty sitting still, intrusive behavior) are concerning for attention deficit hyperactivity disorder (ADHD).
Medications for ADHD variably increase norepinephrine and/or dopamine in the prefrontal cortex to manage symptoms. The most effective treatment is with methylphenidate or amphetamine salts (ie, stimulants), which inhibit dopamine/norepinephrine reuptake transporters and promote neuronal dopamine/norepinephrine release. However, stimulants also act within the mesolimbic reward pathway, especially the nucleus accumbens (NAcc), which poses risk for substance abuse. Therefore, when there is a personal or family history of drug use or parent preference against medications with abuse potential, alternates should be offered. In this case, because the older brother "has been taking pills at parties 'for fun'" and the mother prefers no "addictive medications" in the home, atomoxetine is an appropriate alternate to stimulants (Choice D).
In contrast to stimulants, atomoxetine is a selective norepinephrine reuptake inhibitor, does not have significant action in the NAcc, and has comparatively little dopaminergic effect that is limited to the prefrontal cortex. Alpha-2 adrenergic agonists (eg, clonidine, guanfacine) and certain antidepressants (eg, bupropion, tricyclic antidepressants [eg, imipramine]) are other nonstimulant options, but these are usually reserved for children who respond poorly to a trial of stimulants or atomoxetine (Choices B and C).
(Choice E) Modafinil acts as a weak dopamine transporter inhibitor and is sometimes used off-label for the treatment of ADHD; however, it is a controlled substance with low, but real, abuse potential.
(Choice F) Valproate is an anticonvulsant that is commonly used as a mood stabilizer in bipolar disorder.
Educational objective:
The nonstimulant atomoxetine is an appropriate treatment for child and adolescent attention deficit hyperactivity disorder when parents prefer a nonstimulant medication.