ADHD Experts Podcast #571: Combined Treatment Options for Pediatric ADHD – Sequencing Your Child’s Care

Date: September 2, 2025
Guest: Dr. Mark A. Stein, Professor of Psychiatry and Behavioral Sciences, University of Washington
Host: Annie Rogers, ADDitude Magazine

Episode Overview

This episode, led by leading ADHD researcher and clinician Dr. Mark A. Stein, dives into the evolving landscape of pediatric ADHD treatment. Dr. Stein addresses myths and realities around ADHD management, particularly the importance of combining treatment options ("multimodal treatment") and sequencing interventions to suit each child's unique needs. The discussion distinguishes between medication and behavioral approaches, highlights real-world cases, and responds to parent questions about side effects, long-term outcomes, and the critical role of individualized care.

Key Discussion Points & Insights

1. ADHD: Background and Myths Debunked

[02:54-09:55]

• ADHD is Not New:
  ADHD is a longstanding, highly heritable neurodevelopmental disorder affecting not only children but entire families.
  • ”ADHD doesn't occur in isolation, and it’s not new.” – Dr. Stein [03:55]
• Medication is Not the Only Treatment:
  Despite public controversies, relying solely on medication and minimizing multimodal approaches ignores the complexities of ADHD and the harms of untreated cases.
• ADHD Runs in Families:
  Twin studies confirm ADHD's genetic links, "approaching that of height" in heritability.
• Comorbidities are the Norm:
  Only about 20% of cases have "ADHD simplex;" most children have co-occurring learning, psychiatric, or behavioral problems.
• 24-Hour Impact:
  ADHD symptoms and impairments often extend beyond the school day, affecting evening, sleep, and family routines.
  • “Nights affect days, and days affect nights...we really have to pay attention to the 24-hour clock in treating ADHD.” – Dr. Stein [09:00]

2. Overview of Core Treatments and Evidence

[11:18-20:14]

• Stimulants Remain Highly Effective:
  Medications like methylphenidate (Ritalin, Concerta) and amphetamines (Adderall) yield large, rapid improvements in core ADHD symptoms for about 75% of children.
  • “Medications have what we call a large effect on core ADHD symptoms, especially the stimulant medications...about 75% of the time.” – Dr. Stein [13:37]
• Importance of Dose Titration:
  Response varies: 39% of children may respond better to one stimulant class versus another. If one fails, try another.
• Side Effects and Sleep:
  Higher doses are linearly related to appetite suppression and insomnia; 25% on high doses take >30 minutes to fall asleep.
  • “We should be assessing sleep before starting a medication trial.” – Dr. Stein [18:35]
• Non-stimulants:
  Considered when stimulants fail, cause intolerable side effects, or in cases of comorbid conditions (e.g., substance abuse, tics, sleep problems). Evidence is still emerging about when to start with non-stimulants first.

3. Combination and Sequencing of Treatment Modalities

[20:14-34:16]

• Medication Alone is Rarely Enough Long-Term:
  ADHD is not a simple disorder; treatment needs change with development and comorbidities.
• Multimodal Treatment Best for Functioning:
  The MTA (Multimodal Treatment Study—landmark research) showed medication works best for core symptoms, but combinations of medication and behavioral interventions provided higher parent satisfaction and broader functioning improvements.
  • “Combination treatment rated the highest…gives us an idea of the range of treatments and treatment intensities.” – Dr. Stein [23:45]
• Sequencing Matters:
  Dr. William Pelham's research found starting with behavioral therapy may increase engagement, but many still need to add or switch to medication.
• Current Challenges:
  ADHD treatment remains fragmented—access and sequencing often depend on geography and initial provider.

4. Case Studies Illustrating Personalized Care

[24:30-30:40]

• Joe (age 7, combined type):
  Moderate severity; start with parent training and school-home behavioral supports, consider medication if impairments persist.
• Tim (age 5, very severe, behavioral problems, complex background):
  Due to severity, initiate medication (possibly starting with alpha-2 agonist), refer parents for support, address comorbidities—especially parental depression.
• Jazz (age 13, inattentive type, adolescence):
  Best addressed with multimodal approach; stimulant medication plus executive function supports at school.

5. Tailoring Treatment Intensity and Sequence

[31:00-32:00]

• Milder Cases:
  Begin with behavioral interventions.
• More Severe/Complex Cases:
  Combine approaches earlier; phase in treatments to assess what works best.

6. Q&A Highlights

Medication Duration, Side Effects, Access to Resources
[34:16-59:30]

a. Medication’s Long-Term Benefits

• The MTA study’s findings after 36 months are often misrepresented; follow-up data is confounded because participants changed treatments post-study.
  • “The data that we have most confidence in is from those first 14 weeks. The follow up studies don’t really tell us the impact of the treatments.” – Dr. Stein [35:31]
• Stimulant medications have data supporting long-term benefits, including lowering accident and comorbidity risks.

b. Managing Appetite and Growth Concerns

• Appetite suppression is common but usually self-limiting; monitor growth, consider medication breaks, dietary strategies.
  • “One of the most common side effects is decreased appetite…We worry about weight loss, not so much decreased appetite because usually they catch up.” – Dr. Stein [38:48]

c. Sleep—Not Always a Simple Side Effect

• While stimulants often delay sleep, a minority of children paradoxically sleep better due to increased organization.
  • “For most of the time stimulants…make it take longer to fall asleep. But there are some children who…are more organized and able to get to sleep.” – Dr. Stein [40:32]
• Combination treatments—stimulant plus alpha-2 agonist—may help (lower stimulant dose + improved sleep).

d. When Treatment Seems to Fail

• Revisit thorough titration and diagnostic evaluation; try different classes; involve a second opinion.
  • “Always reconsider the diagnosis…sometimes it helps to get a fresh look from someone else.” – Dr. Stein [43:43]

e. How Many Medication/Dose Trials?

• Most kids respond to the first or second stimulant; up to 90% if you try both classes and titrate doses.

f. Executive Function and Emotional Dysregulation

• Medication has moderate effects; skill-building and emotion regulation benefit from behavioral interventions—especially with parent involvement.

g. Younger Children—Behavior Therapy First?

• Yes, except in cases of life-threatening behavior or severe disruption.
  • “After an evaluation and a diagnosis there needs to be a discussion about…using a shared decision making approach with the families coming up with a plan.” – Dr. Stein [49:12]

h. Addressing Fears About Medication Addiction

• No evidence stimulants are addictive in ADHD treatment; in fact, treatment reduces risk of future substance abuse.
  • “Treatment of ADHD with medications lowers the risk of later substance abuse…untreated ADHD is associated with substance abuse.” – Dr. Stein [53:17]

i. Barriers to Parent Behavior Training

• Acknowledges resource gaps, especially post-COVID. Recommends seeking university psychology clinics, telehealth, and online options. Group parent training can be as effective as individual.
  • “It’s easier to say it than to do it and to find someone…technology is kind of coming to the rescue.” – Dr. Stein [55:06]

j. When Parents Disagree on Medication

• Meet together to discuss rationale, process, and implications for the child; a trial is not a lifelong commitment.
  • “What I like to do…is to bring everybody together and have a meeting to talk about how a trial is done and what the benefits of a trial to determine if they respond…” – Dr. Stein [58:30]

Notable Quotes & Memorable Moments

• “ADHD is not new and doesn’t occur in isolation…It’s extremely variable, and the evaluation highlights that variability.” – Dr. Stein [05:10]
• “Medication alone usually isn’t enough and most people need multimodal treatment…the question is how to personalize it.” – Dr. Stein [21:45]
• “It’s best to phase in treatments and evaluate…You want to objectively measure until you’re able to treat ADHD as best as you can without making sleep worse.” – Dr. Stein [19:19]
• “Untreated ADHD is not a benign disorder…Treatment begins with a diagnostic evaluation and psychoeducation…” – Dr. Stein [33:50]
• “You don’t just give up on ADHD treatment because of side effects. You try to find what works best with the least impairment.” – Dr. Stein [39:40]
• “No, stimulant medication for ADHD is not addictive. In fact, treatment lowers the risk of future substance use disorders.” – Dr. Stein [53:17]

Timestamps for Key Segments

• ADHD background, family impact: [02:54–09:55]
• Medication effects, dosing, and side effects: [11:18–20:14]
• When to use non-stimulants; real-world application (cases): [20:14–32:00]
• Summary and clinical pearls: [32:00–34:16]
• Long-term medication efficacy (Q&A): [34:16–36:56]
• Appetite, sleep, side effects (Q&A): [37:32–42:47]
• When treatment isn’t working (Q&A): [43:43–45:49]
• Executive function and emotion regulation (Q&A): [45:49–48:28]
• Young children treatment approach (Q&A): [48:28–50:34]
• Concerns about “addictive” properties of medication (Q&A): [53:00–54:32]
• Access to behavioral parent training (Q&A): [54:33–56:47]
• Parental disagreement on medication (Q&A): [58:03–59:30]

Takeaways

• Every Child’s Course is Unique:
  Treatment must be personalized, stepped, and reassessed regularly as symptoms, impairments, and needs evolve.
• Combination Care is Optimal:
  While stimulant medications are effective for core symptoms, most children need multimodal interventions to improve functioning, address comorbidities, and teach skills.
• Early, Ongoing Partnership:
  Successful ADHD care demands collaborative, informed decision-making among clinicians, families, and schools.

For slides or resources related to this episode, search “Podcast 571” on attitudemag.com.