Stimulants work by increasing the levels of norepinephrine and dopamine in the frontal cortex. They also stimulate adrenergic receptors in the heart and blood vessels, leading to small increases in resting heart rate and blood pressure—on average, an increase of <10 beats per minute for heart rate and <5 mm Hg for both systolic and diastolic blood pressure. A minority (5-15%) of patients experience larger increases. The existing evidence on long-term cardiovascular risks of stimulants is mixed. Some studies have shown no increased risk, while others have cited an increased risk for arrhythmias, cerebrovascular disease, hypertension, ischemic heart disease, heart failure, pulmonary hypertension, and/or sudden cardiac death. Overall, existing studies are of limited quality and relatively short duration.

A 2024 case-control study by Zhang et al. examined the long-term (up to 14 years) cardiovascular effects of stimulants in 278, 027 individuals aged 6–64 years in Sweden. The results suggested that long-term use of ADHD medications was associated with an increased risk of hypertension and arterial disease. Each additional year of medication use was associated with an average of 4% increased risk of cardiovascular disease. The increase in risk was highest during the first three years of treatment and thereafter stabilized. Reassuringly, the study did not observe any statistically significant increases in the risk for arrhythmias, heart failure, ischemic heart disease, thromboembolic disease, or cerebrovascular disease.

When determining whether a stimulant is the right course of action for a particular patient with ADHD, providers must balance the potential benefits against these risks. Proper treatment of ADHD can improve educational, occupational, and social outcomes. Additionally, stimulants are associated with a decrease in unintentional physical injuries and deaths, substance use disorders, and criminal acts. These medications are highly effective, with response rates of 65-75% and an effect size of 1.0. Therefore, in a generally healthy child or adolescent without cardiac risk factors, stimulant medication should still be considered the first-line treatment for ADHD, and no routine cardiac evaluation is necessary. Consultation with cardiology may be warranted prior to stimulant initiation in cases of complex congenital heart disease or symptoms suggesting significant cardiovascular issues, such as severe palpitations, fainting, exercise intolerance (not accounted for by obesity), or a strong family history of sudden death.

To improve the cardiovascular safety of stimulant use, providers should have an extensive discussion with patients and parents about the risks, including cardiovascular risks, benefits, and alternatives of the medication. Screening each child for factors that increase cardiovascular risk, including personal and family cardiovascular history, is essential. Additionally, monitoring pulse and blood pressure at baseline and regularly throughout treatment is recommended. Psychopharmacology should be just one part of a comprehensive treatment plan, which may also include psychoeducation, behavioral therapy, lifestyle modifications including diet and exercise, linkage with community supports, and school resources. If stimulants are not an option, providers can explore alternative treatment options, such as nonstimulant medications (though selective norepinephrine receptor inhibitors and alpha 2 agonists also have cardiovascular risks to consider) or behavioral therapy without medications. Omega-3 fatty acids, video game treatment (e.g., Endeavor Rx), trigeminal nerve stimulation, or biofeedback also have some evidence for the treatment of ADHD.

References

Cortese S, Fava C. Long-term cardiovascular effects of medications for attention-deficit/hyperactivity disorder-Balancing benefits and risks of treatment. JAMA Psychiatry. 2024;81(2):123–24. https://doi.org/10.1001/jamapsychiatry.2023.4126

Dopheide JA, Stutzman DL. Five steps to improve cardiac safety of attention deficit hyperactivity disorder treatment. The Journal of Pediatric Pharmacology and Therapeutics. 2024;29.6:670-673.

Pliszka S. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2007;46(7):894-921.

Torres-Acosta N, O’Keefe J, O’Keefe C. et al. Cardiovascular effects of ADHD therapies: JACC review topic of the week. JACC. 2020;76(7): 858–866. https://doi.org/10.1016/j.jacc.2020.05.081

Wolraich, Mark L., et al. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4).

Zhang L, Li L, Andell P, et al. Attention-deficit/hyperactivity disorder medications and long-term risk of cardiovascular diseases. JAMA Psychiatry. 2024;81(2):178–187. doi:10.1001/jamapsychiatry.2023.4294

AUTHOR:

Dr. Kristen Kim, MD

Child, Adolescent and Adult Psychiatrist

Vista Hill Foundation

1. Includes at least six or more inattentive and/or 6 or more hyperactive symptoms, lasting at least 6 months.
2. Several of the symptoms were present prior to age 12.
3. Several of the symptoms are present both at school and at home.

Today’s newsletter discusses the findings of the same research group as regards the validity of the notion of “late onset ADHD”.   The group’s data was developed from psychiatric assessments administered longitudinally to a normative comparison group involved in the seminal Multimodal Treatment Study of ADHD.   The concept of “late onset” ADHD has been an area of interest and concern, in part, in consequence of the modification of the age of onset criteria in DSM 5 for diagnosing ADHD in children – now with an extension of the required date of onset from mid-elementary school years (~age 7, as per DSM IV) out to the middle school years (~ age 12).  Does a broader age range make sense?

The question of “late onset” ADHD is of practical concern as data suggests an increasing number of older adolescents and young adults are presenting with complaints of inattentiveness beyond the new DSM cutoff age.   Some estimates of the prevalence of this later onset presentation have been reported to range from 2.5% up to 10% of the population.  The majority of these individuals do not have a history of childhood onset of symptoms.

Findings from the referenced study suggest that a number of factors are involved in the relatively high prevalence data.   The following subgroups bear consideration:

1)    Some of these patents may represent individuals with undetected childhood ADHD– i.e., they are “identified” late but have had some signs or symptoms since earlier in childhood.   Others in this group may have been high functioning in spite of their handicap— only running into performance challenges as they advance to higher grades in school or face more demanding work challenges.  For this population, with appropriate confirmation of a past history from the patient and family and, as feasible, from prior providers (educational and medical), and, with a clear presentation of relevant symptomatology and no evidence of contraindications (i.e., no current substance use issues and a clean CURES check), judicious initiation of treatment, with close follow up with the patient and relevant collaterals, may be indicated and appropriate.  Concurrent participation in psychotherapy and/or other support activities (tutoring, psycho-education, etc.) would be clearly appropriate for most of these “late-identified” individuals.

2)   Another group, accounting for the majority of the “late-onset” cohort, are described in the study as typically-developing individuals without core ADHD symptoms who seek stimulant medication for cognitive enhancement during their late high school, college and post graduate first years in the workforce.  Requests for treatment may come from parents or the young adult patients themselves.  In general, this is not the type of patient for whom prescribing would be recommended.  While it may be difficult to ‘just say no’ to those presenting in this manner, saying ‘yes’ presents an ethical dilemma — artificially supporting the achievement of someone seeking credentialing as a lawyer, physician or ‘whatever’ thru medication that offers short term cognitive enhancement is ultimately not fair to the individual nor to their prospective clients or patients.   The risk of harm to the individual if they continue to take a medication that is not needed is one concern and the possibility that they will not be fully capable of performing their work adequately after credentialing is another concern.

3)   Finally, and perhaps the most challenging patients are those who have developed an ADHD profile consequent to a health or psychosocial condition occurring during their childhood or adolescence.  Individuals in these categories would not typically be appropriate for treatment within a primary care setting, though once evaluated and if well stabilized and supported, some might be able to be maintained on appropriate medication regimens in primary care with availability for consultation as needed.

a) For example, individuals who’ve suffered a significant traumatic brain injury or other major medical or neurological insult may present with a secondary form of ADHD for which medication may be of great benefit.

b) Even more complex may be those who have had significant substance abuse exposure but who are now in recovery status with strong support systems and oversight. These individuals may sometimes need treatment, but clearly would need to be monitored and tracked intensively with multimodal therapeutic interventions and ongoing drug screening activities beyond the capacity of a primary care provider.

c) Also quite complex, are those with other psychiatric conditions who may present with significant impairment in their cognitive and executive functioning as might be seen in an individual with ADHD. Individuals in this category would most appropriately be treated by a psychiatrist or psychiatric team to address all aspects of their illness(es) so that any and all co-morbidities and risk could be addressed.

The bottom line take home message from the data is that “late-onset ADHD” is not a valid diagnostic category but that for a small minority of individuals other considerations may support initiation of treatment for ADHD.   Careful assessment and management of such individuals by specialty mental health providers with close monitoring of treatment interventions would be the most appropriate approach to care.

The following SmartCare newsletters contain further information relevant to treatment of ADHD.

https://www.vistahillccyp.org/adhd-treatment-concerns-in-adolescents-6-6-2019/

https://www.vistahillccyp.org/assessment-treatment-of-adhd-in-adults-2-19-2021/

https://www.vistahillccyp.org/comorbidity-of-adhd-and-ptsd-diagnostic-and-treatment-implications-5-8-2020/

https://www.vistahillccyp.org/co-morbid-depression-and-adhd-assessment-and-treatment-strategies-10-11-2018/

https://www.vistahillccyp.org/psychiatric-sequelae-of-concussions-2-1-2018/

Reference:

Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25; Margaret H. Sibley, Ph.D., et al.; American Journal of Psychiatry; Published Online: 20 Oct 2017   https://doi.org/10.1176/appi.ajp.2017.17030298

While medication for ADHD is often the first line treatment for older children and adolescents with ADHD, it is not the recommended first line treatment for young children with ADHD symptoms. Both the CDC and AAP urges healthcare providers to refer parents of young children with ADHD for behavioral therapy training before prescribing medication to treat the symptoms. Research shows that behavioral therapy can be as effective as medication, being 70-80% effective for treating the core symptoms of ADHD in young children.

Where the problem lies is that less than 50% of young children are referred to parent behavioral therapy training. While behavior therapy can take more time, effort, and resources than medication, the effects last much longer past when the treatment ends, unlike medication. Another concern is that stimulant medication in young children can have problematic side effects, including irritability, increased agitation, appetite suppression, growth delay, and sleep disturbance.

In clinical practice, psychotropic medication for ADHD symptoms has been shown to not work as reliably and robustly in younger children as they do in older children. This could occur when ADHD is not the correct diagnosis, as children with trauma or anxiety or sensory challenges can also present with hyperactivity and impulsivity, but would respond poorly to a stimulant medication. The other major reason is that the commonly seen side effects with stimulant medications (sleep and appetite disturbance, moodiness) can have more impact on young children, who are physically growing at a faster pace and are still developing core social/emotional and behavioral processes, as compared to older children, who are typically more mature in all of these areas.

Of course, there are situations where medication interventions may be warranted for preschool children, such as when a young child is so persistently hyperactive, agitated and/or aggressive throughout the day such that placements in preschool or recreational programs become threatened, but even in these situations, the use of medication should be best seen as a provisional supplemental intervention that will enable behavioral and parent training interventions to be applied.  Careful consideration as to whether a stimulant medication or an alpha-agonist preparation should be administered is warranted, with the goal of reducing the extreme disruptive behaviors that impair engagement and functioning at home and in community settings.  Reconsideration of the need for ongoing treatment in these cases is appropriate as the impact of behavioral therapies and the normative developmental process may improve their clinical profile.

In summary, when considering the diagnosis of ADHD in a young child, it is important to conduct a careful assessment, looking for other mood/anxiety, developmental, and medical symptoms, prior to confirming the diagnosis and initiating pharmacologic treatment.  If a young child does meet criteria for ADHD, the first-line recommended treatment is parent training for behavioral therapy, before considering medication. Because we know it is hard to help families find resources, parents can be referred to the SmartCare Parent Line to help find an appropriate program to meet their needs.

References:

1)    Preschoolers and ADHD: Recommended treatment for children under 5 is behavioral therapy, not stimulant medication, Caroline Miller   https://childmind.org/article/preschoolers-and-adhd/

2) ADHD in preschool children: parent‐rated psychosocial correlates, Nadine A De Wolfe PhD,

Joseph M Byrne PhD, Harry N Bawden PhD; 13 February 2007   https://doi.org/10.1111/j.1469-8749.2000.tb00696.x

There is evidence that the diagnostic features of ADHD take a different form in adults compared to children. The DSM criteria are geared towards diagnosing ADHD in children. For example, adults (and even adolescents) with ADHD typically do not present with hyperactivity the way that children with ADHD do. Instead they may quite often present with restlessness, difficulty relaxing and a feeling of chronically being “on edge”.  In adults behavioral impulsivity often takes on the form of socially inappropriate behavior.  Inattention is of course commonly seen in adult ADHD, with symptoms that may include forgetfulness, disorganization, poor concentration, and difficulty prioritizing—not dissimilar from the profile seen in children. In addition, adults with ADHD and those around them report related mood symptoms, like mood lability and stress intolerance. Under conditions of increased emotional arousal from external demands, the individual can become more disorganized and distractible.

Wender developed a set of ADHD criteria, referred to as the Utah criteria, for diagnosing ADHD in adults:

1. Childhood history consistent with ADHD (symptoms of inattention, hyperactivity, impulsivity starting before age 7 and causing impairment in two or more settings.
2. Adult symptoms
   1. Hyperactivity and poor concentration
   2. Two of the following:
      1. Affective lability
      2. Hot temper
      3. Inability to complete tasks and disorganization
      4. Stress intolerance
      5. Impulsivity

Assessment for ADHD in adults should include: (1) obtaining a developmental history, to determine if symptoms were present since childhood, including attempting to corroborate information with other sources, (2) inquiring about the impact of core ADHD symptoms on current occupational, school and relationship functioning, (3) having the patient perform screening tasks in the office setting to assess attention, concentration, distractibility and short-term memory, and (4) assessing for the presence of other psychiatric disorders and substance abuse. Self-report instruments, like the Wender Utah Rating Scale and the Brown Adult Attention Deficit Disorder Scale, can be useful for initial screening but should not be used alone to diagnose ADHD in adults.

Here is a chart that can help with the Differential Diagnosis for ADHD in adults:

Adapted from Adult ADHD: Evaluation and Treatment in Family Medicine, AAFP, November 1, 2000, Table 5

Though it is less commonly seen, some medical conditions can mimic ADHD in adults. These include hyperthyroidism, petit and partial complex seizures, hearing deficits, hepatic disease, sleep apnea, head injury, and lead toxicity. If there are concerning findings on physical exam, then these should be evaluated further.

Once a provider is comfortable that other psychiatric conditions are not in evidence or have been addressed through appropriate treatment, consideration of an ADHD diagnosis for an adult patient may lead to targeted treatment options. Non-pharmacologic therapeutic are an appropriate first step, with counseling and other interventions to enhance organizational skills, optimize concentration, and develop strategies to deal with restlessness.

Providers are often hesitant to consider medication treatment because of the concern of the abuse potential for stimulant medication, but with involvement of others in the patient’s life, routine review of a patient’s CURES data and periodic toxicology screening for stimulants and other substances of abuse can contain risks. When managed appropriately, careful pharmacologic treatment of patients who truly have ADHD can decrease their higher risk for self-medicating with illicit drugs and of other risks to their safety and optimal functionality. When treating ADHD in an adult, a conservative approach would be to consider a non-stimulant approach (Strattera, Intuniv, or Wellbutrin) as a first line of intervention, and if prescribing a stimulant, to focus on extended-release preparations and to avoid short-acting stimulants, which have a greater misuse and abuse potential.

Ongoing monitoring to include information from others in the patient’s life, regular checks in CURES and prompt referral for consultation with trusted and experienced colleagues are appropriate strategies to utilize.

Reference: Adult ADHD: Evaluation and Treatment in Family Medicine; H. Russell Searight, PhD et al; Am Fam Physician; November 1, 2000; 2077-208

Decreased appetite:
If your patient’s appetite decreases after taking ADHD medicine, advise the parent to give the morning dose after breakfast so that the youth will eat better in the morning. Also advise them to serve a large dinner in the evening when the medication is beginning to wear off. Have them keep healthy, high-calorie, protein snacks on hand for whenever a child asks for food, even if it is before bedtime. Discuss with parents that it is more important to monitor the child’s weight than his day-to-day appetite. Advise them to let you know if the child’s poor appetite lasts for a long period, and consider reducing the dose or stopping the drug on weekends or summer breaks to allow appetite and food intake to return to normal.

Stomach pain or upset:
Advise parents not to give the medication on an empty stomach. Taking the medication with or immediately after food can be helpful for this side effect.

Sleep problems:
Parents should set up a regular bedtime routine that includes calming activities, such as bathing or reading.  Makes sure that a long-acting stimulant is only given in the mornings, typically no later than 10am, and an afternoon dose of a short-acting stimulant should typically not be given later than 3pm. If the sleep disturbance persists, the provider could consider switching from a long-acting to a shorter-acting form or reducing the dose or stopping an afternoon dose.

Daytime drowsiness:
If a child is taking atomoxetine (Strattera) or guanfacine (Tenex/Intuniv) or clonidine (Catapres/Kapvay) and experiences daytime sleepiness, consider giving the medication at bedtime instead of in the morning.  The provider could also consider lowering the dose or dividing the dose and giving it twice a day. 

Rebounding effects:
When an ADHD medication wears off in the afternoon or evening, some children have a period of more ADHD symptoms or irritability and moodiness.  This is more common with the stimulant medications than the non-stimulant medications. To prevent this “rebounding” consider using a longer-lasting medication or prescribing a small dose of fast-acting stimulant later in the day.

Mood Changes:
Make sure the parents are keeping an eye out for changes in the child’s mood and anxiety.  Stimulant medications can negatively affect mood symptoms and anxiety. If that does occur, consider using a non-stimulant medication instead to address the ADHD symptoms.

Finally, it is often advisable to schedule medication initiation or dosage changes to occur on weekends when parents can better monitor for side effect emergence

It is our hope that this practical primer on addressing the common side effects for ADHD medications is helpful to address problems that may arise in the primary care office. And remember providers can contact is at SmartCare for real-time consultation on particular cases.

When assessing inattention, it is important to consider all possible causes, including: depression, anxiety, reaction to trauma, family or psychosocial stressor, a learning disability, a sensory processing issue, mental retardation, poor educational fit, brain injury, substance abuse, and rarely psychosis. If these other causes have been considered and ruled out, the inattention symptoms are impairing in both the home and school settings and the symptoms began before age 7, then a diagnosis of ADHD is likely. A treatment course involving a stimulant medication will likely be helpful. Likewise if a diagnosis of ADHD has been made but a child does not respond to multiple medication trials including stimulants and non-stimulants, then the treating clinician should reconsider the diagnosis.

Here are two case examples to illustrate the point:

1. 14yo female presents with a chief complaint of “trouble focusing”. She previously maintained good grades and did not have concerns of inattention, hyperactivity or impulsivity in early childhood. She now has failing grades. Associated symptoms include: irritability, poor sleep, isolation including from friends and non-suicidal self-injury for the last 2 months. She has a family history of depression in her mother and maternal GM and older sister.

-This presentation is more consistent with a diagnosis of Major Depression than ADHD. Patients with depression commonly report poor concentration and trouble with attention. A diagnosis of ADHD would not be consistent with this presentation because the patient did not have symptoms begin before age 7. A good treatment plan would be to consider an SSRI and individual therapy. While a stimulant may have helped with her inattention, it would not have helped with her other depressive symptoms.

2. 6yo boy presents with a chief complaint of  “inattention and impulsivity” primarily in the school setting. This child is in protective custody after being removed from bio parents because of physical abuse and neglect. He was not in school prior to the removal and was mostly isolated at home. He also presents with delays in speech and cognitive development as well as anxiety and aggression.

-This case example is more complicated because there are factors related to trauma, as well as developmental and educational delays. It would be important to fully evaluate those delays (including a speech evaluation and cognitive evaluation) and to ensure that he is in an appropriate educational placement prior to considering a diagnosis of ADHD. Also because of the co-morbid anxiety, a stimulant may not be the best medication choice as stimulants can make anxiety worse. Other options might be atomoxetine or guanfacine. Until a more thorough assessment can be completed, a more appropriate diagnosis might be Adjustment Disorder with Disturbance of Conduct and Emotion.

Hopefully this discussion and these case examples help illustrate the importance of a thorough assessment when a child presents with a chief complaint of “trouble focusing”, prior to beginning treatment. Since most patients will first present to their primary care provider with this concern, it is important for primary care providers to be comfortable beginning that assessment process .

In the past, OCD was categorized diagnostically as an anxiety disorder, but in the DSM V it has been separated into its own category. This is largely because research has shown that the genetics of OCD is different from the genetics of other anxiety disorder. OCD is defined as obsessions (intrusive, unwanted and excessive worries) and compulsions (rituals to relieve the anxiety) that are impairing to everyday life. The impairment can be defined by the amount of time spent on the obsessions and compulsions, its effect on preventing a patient from carrying out activities of daily living and work responsibilities, and its effect on alienating important people in the patient’s life. The obsessions and compulsions can involve the following: preoccupation with contamination, cleaning, checking, symmetry and order, preoccupation with sexual, violent or religious thoughts, and hoarding.

The diagnosis of OCD is primarily a clinical one. Two good screening questions to determine if further assessment is indicated are:

1. “Are bothered by unpleasant worries that repeatedly come into your mind about contamination, ordering things, etc?
2. “Are driven to perform certain acts over and over again like checking locks or washing your hands excessively?”

The YBOCs is a good diagnostic tool for delineating specific symptoms and determining the level of severity and the patient’s level of insight. The patient is typically aware that the obsessions and compulsions are irrational and excessive but are compelled to do them anyways. This egodystonic nature of the illness is partly what leads to the suffering from OCD and can lead to an increased risk of suicide.  In rare cases, when patients are not aware that their obsessions and compulsions are irrational and excessive, they are said to have “poor insight” and their OCD is typically more treatment-resistant. These cases can often be difficult to differentiate from true psychotic delusions.

OCD is frequently co-morbid with other anxiety disorders, depressive disorders, and eating disorders in adults and ADHD and tic disorders in children. Treatment options include exposure response prevention (a CBT specifically geared for OCD) and psychotropic medications. ERP involves repeated exposure to situations that trigger the obsessive thoughts and having the patient gradually learn to tolerate the anxiety and resist the urge to perform the compulsions. Medication options include the SSRIs (Prozac, Paxil, Lexapro, Celexa, Zoloft, Luvox) and Anafranil (an older tricyclic antidepressant, used primarily for treatment resistant cases). Medication treatment involves slow titration to avoid worsening the anxiety, and patients often need higher doses for longer periods of time for a full effect. It is important to make sure patients are aware that it can take up to 3 months to get to a full effective dose. Most patients do better with a combination of medication and ERP. There are adjunctive medication options available if full symptom relief is not achieved with an SSRI alone. These include the second-generation antipsychotic medications. Surgery and ECT vs deep brain stimulation can be used for refractory cases.

Given that OCD is more prevalent than previously thought, it is important that first line providers are comfortable with knowing when to assess for OCD and how to pursue with treatment recommendations.

7 year old boy with chief complaint of “frequent meltdowns”. Additional history: daily meltdowns (crying, hitting) with loud sounds or when asked to wear certain clothing; wants to make friends but poor boundaries and accidentally hurts peers at school when he is playing with them; hard time sitting during seat work at school and prefers to move around when doing his work. There is no known language delay or cognitive delay.

It is thought that the prevalence of Sensory Processing Disorder (SPD) is from 5-15% of school-aged children. SPD is commonly misunderstood and either under-diagnosed or misdiagnosed as Autism or Attention Deficit Hyperactivity Disorder (ADHD). While children with Autism commonly have sensory processing difficulties, it is different than for children with SPD.

Sensory processing is how the nervous system manages incoming sensory information and generates responses. Sensory integration is how the body’s eight senses work together to create the body’s responses. The eight senses include:

A child is diagnosed with a SPD when there is difficulty taking in and interpreting sensory information so that an appropriate response can be generated. Here are some indicators that there might be a concern for SPD.

1. Hyper-acute hearing
2. Hypersensitive hearing
3. Touch aversion
4. Poor motor coordination
5. Poor sense of boundaries
6. High pain tolerance
7. Aggression
8. Distractibility
9. Delayed language development
10. Difficulty learning new things

It is not hard to see how these children can be misdiagnosed with Autism or ADHD. Children with Autism also have impairments in communication, social interactions and present with repetitive behaviors and restricted interests, symptoms that are not seen in SPD alone. Children with ADHD present with hyperactivity, impulsivity and inattention without other sensory processing difficulties.

The behavioral symptoms that are seen with SPD (namely aggression, distractibility, difficulty learning new things) occur as a result of the sensory processing difficulties. Sensory input is organized in a manner that enables an individual to establish a sense of where the body is in time and space, to feel safe in one’s own body and to accurately perceive the body’s relationship to the environment. When this doesn’t happen, it can lead to poor arousal regulation. One significant problem is that SPD is not identified as a diagnosis in the DSM, making it difficult to diagnose. Another barrier is that psychiatrists and medical professionals in general are not well trained in diagnosing SPD.

The goal of this e-Weekly article is not to make all of us experts in SPD and other sensory challenges, but to help us to be better aware when the concern might be there and refer for an appropriate evaluation, most likely with an occupational therapist, who are trained to diagnosis SPD and other sensory challenges and make recommendations for the appropriate treatment.      

Depression is highly co-morbid with other psychiatric disorders, like anxiety disorders, substance abuse disorders and disruptive behavior disorders. If an adolescent is presenting with depressive symptoms, it is important to take a careful history of bipolar symptoms, including current and past manic, hypomanic or psychotic symptoms, family history of bipolar disorders, and history of medication-induced manic or hypomanic symptoms. Twenty percent of young patients with depression go on to develop bipolar disorder as adults. The typical timeline is that adults with bipolar disorder will report they first experienced depressive symptoms starting in childhood or adolescence.

Adolescents will sometimes turn to drugs, like alcohol and marijuana, to self-medicate. If they are using on a regular basis, the use can be contributing to their depressive symptoms, and psychoeducation about that interaction will be important. Ongoing regular drug use can also limit the efficacy of a medication treatment for depression, if that is being considered, and it is important to talk with teens about limiting their drug use if they are interested in a medication intervention.

In terms of general treatment guidelines, consider therapy alone for mild-moderate symptoms and consider combination therapy and medication treatment for moderate-severe symptoms, particularly if there is a significant impairment from their symptoms. Fluoxetine is the medication that has been studied the most for MDD in children and adolescents but the other SSRIs, like citalopram, escitalopram and sertraline, can also be utilized. Other options to consider are bupropion and mirtazapine. The antidepressants to consider avoiding include: paroxetine and venlafaxine (because of their short half-lives, there is a higher risk of side effects and discontinuation symptoms with inconsistent use), and duloxetine (because of limited data in children and adolescents). It is important to consider a slower titration, starting with ½ the usual starting dose, to minimize the risk of side effects including akathisia (internal restlessness), behavioral activation and increased anxiety. So for example if considering fluoxetine, a starting dose of 10mg qday would be appropriate with a plan to increase to 20mg after 1-2 weeks if tolerated and needed. It is important to discuss the length of time it can take for a patient to see a full positive result, so that the teen and family is realistic with their expectations. It is also important to carefully discuss with the teen and family the FDA black box warning about the increase in risk of spontaneous reporting of suicidal thinking and have close monitoring (follow-up in 1-2 weeks either in person or by phone), particularly when medication is started or when the dose is being increased.  With open disclosure and judicious monitoring this relatively infrequent side effect can comfortably managed, typically without having to terminate the medication trial.

It is our hope that this e-Weekly is helpful for primary care providers to develop comfort with assessing and treating adolescents with depression, as it is a fairly common presenting concern in the primary care office.