571- Combined Treatment Options for Pediatric ADHD: Sequencing Your Child’s Care

Summary

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

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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.

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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]

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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]

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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]

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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.

Transcript

[Annie Rogers]

Welcome to the Attention Deficit Disorder Expert Podcast series by Attitude Magazine.

Everyone. My name is Annie Rogers. On behalf of the Attitude team, I'm so pleased to welcome you to today's ADHD Experts presentation titled Combine treatment options for Pediatric Sequencing your child's care. Leading Today's presentation is Dr. Mark A. Stein. Dr. Stein is a Professor of Psychiatry and Behavioral Sciences and an Adjunct professor of Pediatrics at the University of Washington. He is also the founder of the Program to Enhance Attention, Regulation and Learning or Pearl at Seattle Children's Hospital. Previously, Dr. Stein was professor of Psychiatry and Pediatrics at the University of Illinois at Chicago. He was Chair of Psychology and Developmental Pediatrics at the Children's National Medical center in Washington, DC. Dr. Stein is a Fellow of the American Psychological association and the past President of the American professional Society for ADHD and Related Disorders or APSARD. In 2017, he received the Lifetime Achievement Award from Chad. Dr. Stein has written more than 150 peer reviewed articles and conducted numerous studies regarding ADHD treatment in children, adolescents and adults. His interests are in the relationship between ADHD and sleep and in personalizing ADHD treatment. He has also very recently started a private practice for focused on adult adhd. Finally, the sponsor for today's webinar is Play Attention. Play Attention, inspired by NASA technology and backed by Tufts University research helps strengthen executive function, a key piece of the puzzle for kids with adhd. It works well with other treatments like therapy or medication and helps improve focus, self regulation and follow through. Each family gets unlimited support from a personal focused career coach so you're never on your own. Click the links on your screen to schedule a consultation to discuss your specific needs or visit www.playattention.com to take the ADHD test home and professional programs are available. Attitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content. Okay, without any further ado, I am so pleased to welcome Dr. Mark Stein. Dr. Stein, thank you so much for joining us today and for leading this discussion.

[Dr. Mark A. Stein]

Great. All right, thank you so much for Annie and thank everyone in the audience for joining the webcast. Just wanted to mention that and disclose that I do consult for several companies, but that doesn't have any influence on what I'm going to be talking about today. Recently there was an article in the Sunday New York Times on rethinking ADHD which has generated a lot of controversy and I know there's been a response to motivated me though to kind of want to summarize, I guess My feelings about ADHD and kind of what we've learned, because I felt like the article was kind of missing the point. In several areas, it tended to say that medication was the main treatment for ADHD and kind of minimize the impact of multimodal treatment and combination treatment and also minimize the harms associated with untreated adhd. I thought I'd start off with summarizing what I think are pretty clearly established facts about ADHD and then get to the point of how we develop personalized treatment for ADHD and and address what we know so far about sequencing and combining treatments. So fact number one, ADHD is not a new disorder. And it's a disorder that doesn't just affect children, but affects whole families. This is an illustration from a children's book from 1845. And you see the little boy in red that's falling off the chair because he can't sit still. He's fidgety, Phil, and he can't sit still. He probably would have what we say is ADHD combined type and maybe developmental coordination disorder. But as he's falling, look at the faces of his parents, and you can imagine that maybe his father with the red face maybe has developed a drinking problem. Maybe he had attention problems as a child. And mom is just very sad and just very worried what's going to happen when he falls and bumps his head. ADHD doesn't occur in isolation, and it's not new. Second fact, also not new, is that stimulant medication really has a dramatic effect on ADHD symptoms. Dr. Charles Bradley, in 1937, surreptitiously administered Benzedrine. Not surreptitiously, but accidentally discovered that the administration of Benzedrine in children who we would say now have ADHD and oppositional defiant disorder had a dramatic effect in their behavior. Their hyperactivity decreased, their attention improved. The kids called them arithmetic pills because they were able to do their arithmetic. And about 25% of them had side effects like difficulty falling asleep. So this is really the birth of pediatric psychopharmacology and the birth of stimulant medication treatment of ADHD. So now we're 90 years later, and we've learned a lot. And I'm going to talk about what we've learned since then. So I mentioned in the case of fidgety Phil, how ADHD tends to run in families. What you see now is a bar graph from various twin studies. And this is a way that we use to calculate heritability or how much the variance is due to genetic factors. Where you look at the difference between twins and other relatives and what it shows is that the trait of ADHD symptoms, thinking of it as a dimension. So everyone is somewhere on that dimension. But the trait of ADHD is pretty high in terms of the heritability approaching that of height. So think about that. Now this is a busy slide and the way to think about this slide is if you look in the center, there are two clusters of symptoms, the hyperactivity impulsivity symptoms and the inattention symptoms. So these are core ADHD symptoms in the center. And what this is a slide. It represents what I call targets of treatment. What I want to emphasize is that ADHD usually doesn't come by itself. ADHD simplex or someone that just has ADHD pretty rare. Like 20% of the time, 80% of the time, ADHD CO occurs with another psychiatric or learning or behavioral disorder, psychiatric disorders like depression or anxiety or substance use in children, problems like learning problems or behavior problems. And deciding what to treat is a process that is done after the evaluation and we can talk about what goes into that decision. For me, a lot of it is patient preference after getting psychoeducation on what treatments are available and what are the benefits and what can we expect. Slide also highlights the different causes of adhd. Most of the time there's not one single cause, but a variety of factors. Usually genetics plays a role, but there are other factors that contribute to the disorder and also to the ability to seek treatment in general. I guess what this says is that ADHD is extremely variable in terms of how different it is, how it presents from mild to severe, what's associated with it and what the causes are. And the evaluation kind of highlights that and leads to the decisions about treatment. The last point, and this is really kind of evolved in 40 years ago when I was starting to treat ADHD. We thought of it as a school disorder and the treatment at that time was immediate release methylphenidate or Ritalin twice a day to help children get through school. Later we discovered that it wasn't just a school disorder, but after school is important. Thinking about the impact of ADHD on social functioning, other people realized that ADHD affects sleep and affects nighttime behaviors. I love this comment from Laufer and Denhoff. Generally the parents of hyperkinetic children are so desperate over the night problems that the daytime ones pale in significance. So what this means is that nights affect days and days affect nights. And we really have to pay attention to the 24 hour clock in treating ADHD.

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[Dr. Mark A. Stein]

Finally, it's not just ADHD is associated with sleep problems and we tend to think of these as mutually exacerbating conditions. They frequently co occur and they make the other problem worse. But also treatment of ADHD influences sleep. So this is an earlier study, I had done an observational study where we just surveyed parents with ADHD seeking treatment, taking stimulant medications, children not taking stimulant medications and psychiatric controls. What it shows is that if you're taking a stimulant medication, almost 30% have nightly insomnia, meaning it takes them more than 30 minutes to fall asleep. That may not sound like a lot, but if you're a parent and your child can't fall asleep, it is a lot and it influences lots of things. So the five facts are it's not new and it's increasingly common as awareness has increased and as we have changed our definition of ADHD to include those with inattentive type and people of different ages. Number two, stimulants rapidly improve core symptoms of ADHD and behavioral interventions really address impairments and teach skills. Number three, it's extremely heterogeneous in severity. What's associated with it and the causes certainly runs in families. And you should expect when you have one person with adhd, there might be others in the family with it and we want to have a 24 hour perspective in looking at ADHD. So I always like to besides talking about research, as a clinician, I think it helps to talk about individual cases. Let's talk about Joe, a seven year old boy who's in second grade and he's referred from his pediatrician for evaluation because he's struggling in school, he's struggling at home with behavior. He doesn't like reading at home, he doesn't listen to his parents at school, kids laugh at him, he's the class clown. But no one really wants to play with him. After school, parents are unsure what to do. They've heard about adhd, they wonder if he has adhd. So this is someone that would probably say has ADHD combined type and maybe oppositional defiant disorder, which is a common comorbidity of adhd. So this is the type of ADHD that we know the most about. The farther you get from a seven year old boy with these symptoms, it's a little bit more challenging to diagnose. But this group we really know a lot about. So how do we treat Joe? Well, you could first address the behavioral issues and what that would involve would be working with the parents, teaching them to focus on positive behaviors, to use rewards to target challenging behaviors, working with the school, connecting school with home with a daily report card. And the behavioral interventions vary in intensity, but they would really address some of the oppositional symptoms. Or you could try to address the core symptoms of ADHD with medication. So this is what a meta analysis, which is really a summary of many, many studies and there have been many studies of ADHD medications, especially in the short term. And what the studies indicate is that medications have what we call a large effect on core ADHD symptoms, especially the stimulant medications, either immediate release or long acting. They have an effect size of almost one, which is a whole standard deviation, moving someone from pretty significant problems to minor or mild problems most of the time, about 75% of the time. The meta analysis studies also show the non stimulants work, but maybe to a lesser degree on those core ADHD symptoms. So this gives us a lot of confidence in using these medicines to treat ADHD symptoms. As a clinician and researcher, it's always easiest for me to talk about my own studies. This is a study that I did a few years back looking at a long acting stimulant, Oros, methylphenidate or Concerta in children with ADHD combined type. This is what's called a dose response study where children are treated with different medications and every week different doses, every week they get a different dose. So one week they get 18, one week 36, one week 54 and one week placebo. And what you can see is this is a linear dose response effect. So by the time they got to 36mg dose, the majority their ADHD symptoms were markedly improved. They improved a little bit with placebo, a little bit more with 18, but really 36 was the sweet spot for most of these children in the study. Just another dose response study to ask the question, is there a difference between treatment with mixed amphetamine salts or an amphetamine product and dexmethylphenidate, a sustained release methylphenidate product? And what this study shows is really the same linear dose response. In this study, the cutoff for having normal ADHD was 20, and they got there at around 20 milligrams. And you can see there's really no difference at the group level between mixed amphetamine salts and dexmethylphenidate. In other words, there was marked improvement when you got to the higher doses for both medications. The significant finding was that although at the group level they both worked, 39% had a preferential response for one medication over the other. What this means is that if you don't have a good response to one type of stimulant, you might respond better to another formulation. So far, we've showed a linear dose response for ADHD symptoms. Unfortunately, there's also a linear dose response for some side effects, what we call dose related side effects, especially effects like decreased appetite and insomnia or difficulty falling asleep. This study shows that when you get to the higher doses, about 25% of children took more than 30 minutes to fall asleep or had insignificant insomnia. About 10% had it at baseline. And low doses affected a little bit. But when you got to high doses, you're more likely to have insomnia. So what we've learned over time, and as we're treating ADHD kind of more aggressively for longer periods of time, we're finding that sleep problems are even more common. So the importance of this is that we should be assessing sleep before starting a medication trial. And the reason for that is that some children have a primary sleep disorder, like obstructive sleep apnea or restless legs, and you want to rule that out and treat that first. You also want to get a baseline about their sleep and are they achieving adequate sleep because medication and treatment can affect that. And then you want to monitor it. Throughout treatment, you always want to do sleep hygiene or behavioral interventions. And if someone develops a worsening of sleep as their ADHD is getting better, you want to have a treatment strategy which may involve switching formulations, changing doses, adding melatonin or another intervention. Unfortunately, we're not able to predict in advance which intervention is going to be helpful. And so I think the message is you don't want to give up. You want to keep trying things and objectively measure them until you're able to treat ADHD as best as you can without making sleep worse.

[Annie Rogers]

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[Dr. Mark A. Stein]

So what are the situations when you want to consider using a non stimulus? And this is a slide by one of my colleagues, Dr. Newcorn, who has shared with me and the reason to consider a non stimulant? Well, certainly if someone doesn't respond to a stimulant, that's a reason. Another reason would be if there's a limited response like the stimulant wears off and you're trying to get either longer coverage or stimulants associated with some adverse effects that might be improved by a non stimulant, for example tics or difficulty falling asleep, which may improve with an Alpha 2 Agonist, which is a type of non stimulant. If you're concerned about substance abuse, a nonstimulant is always a good choice. Now, an area of research which hasn't been adequately researched is is it actually better to start on a non stimulant? There's some evidence to suggest nonstimulants work best if tried first, and this is an area that I think is being actively investigated currently. Nonstimulants tend to be used with younger children or with children that have had a poor response to stimulants. And we may not know like the group that responds best to the non stimulants. So let's talk about combination treatments. And one of the issues about ADHD research is that we know a lot about acute treatment effects and we know a lot about monotherapy. But monotherapy or one treatment isn't real life in that it doesn't work for most people over time. And the reason is that ADHD is not an infectious disease. It's not like you take one medicine and then it's better. It changes through development and the symptoms change and the impairments change. So a treatment, for example, a medication that might be helpful for a kindergartner, is not going to be helpful for a college student who studies at 7pm it's also maybe not the best treatment for someone that has multiple symptom clusters or multiple comorbidities. So finding the right combination to treat ADHD and what comes with it, if it's anxiety, if it's bedwetting, and if it's sleep problems. So coming up with the best combination. So I think we've come a long way clinically from treating ADHD with monotherapy to the realization that medication alone usually isn't enough and that most people need multimodal treatment. The question is how to personalize it and how to deliver it in terms of what's best. Multimodal therapy, or combining medication with psychosocial interventions, is a concept that's about 25 years old. The best study of multimodal treatment is this MTA study. It's a very famous study that was started about 20 years ago. It was really designed to compare behavioral interventions with medication treatment and. And the combination. And so this was a study where children, the mostly combined type of ADHD, were randomized to different treatment arms for 14 months. One group received medication only, and it was pretty intensive medication every day, individually titrated. One group received really intensive behavioral interventions, summer treatment program, parent training, teacher training, and then one group received a combination, and then one group was the community control group. And really many articles have been written on the MTA study. My takeaway is that when you look at core ADHD symptoms, certainly the medications, those that received stimulant medications did the best. But when you look at overall impairment or functioning, and when you look at satisfaction of parents, the combination, those that got combination treatment rated it the highest. Now, the treatments that they received are unique and expensive and intense and not what most people get or what most people need. But this gives us an idea of kind of the range of treatments and treatment intensities. So one of the MTA investigators and a real pioneer in ADHD research who died this past year is Dr. William Penn Pelham. Dr. Pelham really pioneered many areas. One was the summer treatment program for adhd, which I think of as the Cadillac for ADHD treatment. But he also was proponent and really the first to study sequencing treatment. Dr. Pelham has done studies with ADHD combined type, showing that we were trying to answer the question, what's best to start with, in one of the studies that he did, where he compared low intensity behavioral interventions like eight weeks of parent training and a daily report card with low intensity medication, which would be a stimulant medication given on school days, both worked, by the way, at least for many of the patients, although many of them still had adhd. And needed treatment and after the initial treatment. But there was a benefit to starting with behavioral interventions, especially in terms of being engaged in treatment and following through. But really, this was a pioneering study just showing how important it is, how we sequence treatment. Unfortunately, right now there's no rhyme or reason to how treatments are sequenced or how they're delivered. ADHD treatment is very fragmented. It depends a lot on when it's identified and where you seek it, and kind of what door you go into, what provider you see, what services are available. It's not a logic based system, which is a problem. The result of that is that many people with ADHD are undertreated. Some of the people with most severe ADHD are the least likely to be treated, unfortunately. And figuring out again how best to deliver treatment is an ambitious undertaking that many people are looking at now. So I talked a little bit about Joe ADHD combined type. But let's talk about some other treatment scenarios. Let's talk about young children with ADHD symptoms. Tim, a five year old who just got kicked out of preschool for being aggressive, biting other kids and not listening to teachers, running out of the class. He has a history, he was premature, had low birth weight, was delayed in his speech, had speech therapy, saw an occupational therapist who said he had sensory integration issues, and now has these really continuing behavior problems at school and at home. And the psychosocial situation is this. Parents have separated, his mother is overwhelmed and depressed, father who he sees occasionally has a substance abuse problem, and father had ADHD as a child. So put yourself in the clinician standpoint. What do you treat first and how do you treat them? So Tim is an example of. Of. Sorry, Tim is an example of a very challenging case and difficult to treat. Then let's talk about Jazz. Jazz is a 13 year old with ADHD who would now say has the inattentive presentation. And Jazz was recently concerned about ADHD because she's struggling in middle school, struggles with completing work, is quiet, socially anxious, has low self esteem. Her older brother has ADHD combined type. And her parents are now divorcing. And her pediatrician referred her and wondered, does she have adhd? What to do about it? Again, we know most about ADHD in the childhood age range, less about it in preschool, less about it in adolescence. But there's more and more that we're learning. This is a study that was recently done by my colleague Maggie Sibley, looking at the adolescent treatment studies and summarizing them. And what this study found was that medications dramatically improved core ADHD symptoms and Behavior therapy and cognitive therapy addressed some of the impairments. And I think the conclusion is if you see ADHD in an adolescent, it's best to utilize multimodal treatment. But how do you obtain it? It's not always easy. So let's think about the three cases. Joe with adhd, combined type and odd, moderately severe. Tim with very severe hyperactivity and behavior problems, just starting school, and then Jazz, who has the inattentive type presentation. So one of the things Dr. Pelham talked about is the need for stepped care. In other words, not using the most intensive treatment right away. Certainly with Jazz, you might consider using the. You might start with a medication trial with a stimulant and you might want to get some services at school focusing on executive functioning. With Tim, you might want to refer the parents for support, help mother get treatment for depression due to severity. Even though Tim is 5, you would want to initiate a medication trial. And the question is whether to start with an Alpha 2 Agonist or a stimulant. Either way you want to evaluate sleep and if they don't respond to one, you want to try another. Joe is an example of the combined type who would probably be best to start with a psychosocial intervention like parent training and consider medication at some point. So to summarize, what have we learned? Well, ADHD is common in all age groups and increasingly common. We know about most about the core symptoms and the short term treatment effects, but we know that that's insufficient for many, many people. In terms of the etiology, there are multiple factors that contribute with strong familial and neurodevelopmental correlates. ADHD is highly heterogeneous in terms of the severity from mild to moderate to severe. That's a determinant of how you combine treatments and when to initiate them. For milder cases, you can start with behavioral interventions, but when it's severe, you want to combine as much as possible. But it gets complicated because the more things you do at once, the harder it is to evaluate what's contributing to improvement. It's best to phase them in and evaluate. Then again, ADHD is a 24 hour disorder. We want to have that framework. Certainly untreated ADHD is not a benign disorder and the recognition that that it fluctuates over time. So treatment begins with a diagnostic evaluation and psychoeducation in terms of the results of the diagnostic evaluation. And it's not just do they have adhd, yes or no. But what else do they have and are there mimics that need to be targeted? Are there psychiatric comorbidities? What are the strengths? Stimulant medications have the largest effect on core ADHD symptoms, but monotherapy is seldom effective beyond the short term. Multimodal treatment is optimal, but few receive it in younger children. We recommend behavioral approaches initially unless it's severe. And then overall, we want to work toward developing personalized stepped measurement based care of ADHD that includes psychoeducation, behavioral interventions and pharmacological interventions targeting impairment. I'm going to turn it over to Annie and I guess there have been a few questions.

[Annie Rogers]

Yes, Dr. Stein, thank you so much. That was just thorough overview. And before we launch into the Q and A, I would like to thank Play Attention once more for sponsoring today's webinar. And I'll go right into your questions. So you mentioned at the outset of the presentation, the New York Times magazine piece and also the MTA study on adhd. And there was a piece of information in that magazine piece. The author said that the relative benefits of stimulant medication were shown to fade after 36 months according to the MTA. But Dr. Russell Barkley and others have come out and said this interpretation of the MTA is incorrect. So I wonder if you could just help us understand kind of the bottom line, what we know about medication efficacy over time and whether we can feel confident that it will continue to have a positive impact on adhd symptoms after 36 months.

[Dr. Mark A. Stein]

Yeah, well, I think, I guess I agree with Dr. Barkley. The issue with the MTA study is that it was a study for 14 months, but then after that people could do what they wanted to. In other words, the first 14 months they received very specific treatments and suggestions about how to treat their ADHD. But after 14 months, people did what they wanted. And so lots of things kind of can influence that. Certainly if you're more severe, you're gonna probably want certain treatments. If you're better, you're gonna not need certain treatments. And it just makes it really hard to evaluate the impact of the initial treatments. But clearly all the treatments worked. Everyone got a little bit better at the end of 14 weeks. But 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. So I'm sorry, my screen keeps moving. Sorry.

[Annie Rogers]

Oh, no problem. Right? Yes. Basically that after, after 14 months, the folks in the control group were free to try medication and the folks in the medication group were free to stop taking medication. So you really can't say much about that, just based on mta.

[Dr. Mark A. Stein]

The article really ignores the experience of people with ADHD and people who treat adhd, who knows that treating it really can be life changing. I also thought the New York Times article ignored the many studies that showed the benefits of stimulant treatment not just on the child, but how they interact with others, the impact in the classroom, the impact on families. And now we have more data in terms of long term effect, in terms of reducing risk of significant negative outcomes, psychiatric outcomes and medical outcomes.

[Annie Rogers]

Right? Yes. I mean, the data just on how use of stimulant medication lowers the risk of car accidents was for the parent of a teenager, a critical piece of information for me. But there are plenty of others regarding preventative benefits of ADHD medication that I think are important for people to know about. That, as you said, were not mentioned in that New York Times piece. And that really comes, you know, parents, concerns are prevalent in the questions that we're receiving today. And you talked a bit about the side effects that are kind of most common and certainly the sleep side effects with ADHD medication. Another one that I'm hearing a lot today is regarding appetite suppression. And I wonder what we know about the impact of stimulant use on appetite and then on growth. And at what point should parents be concerned that what they're seeing is a sign that their child should try a different treatment strategy?

[Dr. Mark A. Stein]

Yeah, well, it's well known that one of the most common side effects is decreased appetite. And especially when you start an ADHD medication, that tends to occur. And I think the important thing is to pay attention to that. We worry about weight loss, not so much decreased appetite because usually they catch up. But there are different strategies. And Dr. Waksmanski has done some really great work showing that different strategies, such as giving supplements, monitoring weight, and if necessary, medication, holidays on weekends can help mitigate that effect. But one of the physical aspects of stimulant treatment that are important is monitoring weight and, and monitoring cardiovascular effects. And that's why it's important to work closely with your child's primary care physician to monitor those. And again, if they occur, if they start losing weight, then there are options much like sleep in terms of trying a different medication or changing the dose. Those sorts of strategies can be helpful, but you don't just give up on ADHD treatment because of that.

[Annie Rogers]

Okay. And onto the sleep side effect. Number of people saying that they've read recent research suggesting that a low dose of a stimulant may actually be shown to Improve sleep, especially among children. Just wondering if you could speak to that. And that we shouldn't assume necessarily that the stimulant is having a negative effect.

[Dr. Mark A. Stein]

Yeah. So this is an area that there's been some recent research on it, but there's more that's needed. But I think my read of that research is that for most of the time stimulants decrease. They have an effect of making it take longer to fall asleep. But there are some children who, if they take medication later in the afternoon, are more organized and are able to get to sleep. Now the question is what percentage of children and can we identify them somehow in advance? But there are definitely cases like that. Now, whether it's 20% or 30%, I'm not sure, but that's certainly something worth trying. But again, we need more research to identify the predictors. But for most children, the later you take a stimulant in the day or the higher the dose, the more likely you are to have problems like insomnia. Now the other aspect of it though is that you're likely to sleep more soundly, so it changes your sleep pattern. But one of the common problems children with ADHD have is waking up in the morning then. So again, paying attention to that and developing a strategy is really important.

[Annie Rogers]

Okay. And there are some clinicians, in my understanding, that are using the combination therapy and specifically sort of long acting stimulant early in the day followed by a non stimulant later in the day that could actually promote sleep.

[Dr. Mark A. Stein]

Yes. We don't have that many studies of combination treatment, but we have some, especially combining a stimulant with an alpha 2 agonist like clonidine and guanfacine. And studies that have been done actually show improved tolerability. And you can use a lower dose of a stimulant when you combine it with an alpha 2 agonist. And the alpha 2 agonists have been shown to make it easier to fall asleep. So that's a very common combination that has been used.

[Annie Rogers]

Great. Okay. So something to. And again, I should preface and say these are all talking points for. We hope the parents and adults with ADHD listening will bring to their doctors. And a number of questions from parents who said that, one in particular, that her son has tried a number of different stimulants, also CBT and executive function training, and is still really struggling, wondering if this is a sign that the diagnosis is incomplete or perhaps that they just maybe need to try a different kind of stimulant, a methylphenidate versus amphetamine or vice versa? What about these folks who feel like they've tried quite a few solutions and the combinations aren't paying off?

[Dr. Mark A. Stein]

Yeah. Yeah. So Dr. Sam Cortese has recently written on these types of cases that are refractory to several medications. And one of the questions the provider should answer is, well, first of all, have I done adequate titrations? I mean, have I evaluated several different doses to see if the dose is the issue? And then have they tried different classes of medication? So if they tried the stimulants, have they tried the non stimulants? You should always reconsider the diagnosis. Although medication response is not a way that we evaluate if you have ADHD or not. But in cases like that, it often helps to get like a second opinion or a fresh look as well from someone else. So those are all the things that I would suggest too.

[Annie Rogers]

Yeah, very tricky. Okay. And is there any rule of thumb for parents for their expectations of how many medications and dosage variations they should expect to try before they, you know, go a different path? How long does this take?

[Dr. Mark A. Stein]

Okay, well, most of the time it doesn't take long, at least in children. The data suggests that if you individually titrate on a methylphenidate, about 75% will respond initially. And if they don't respond and you try an amphetamine, you'll get to 90%. Those might be a little bit high, but I think if you add in trying a stimulant and a non stimulant and they're well titrated. The other aspect that I think is often missing is what is the psychosocial treatment and are we expecting too much from medication? You always want to look at the complete picture and what are the services they're getting at school and what's at home.

[Annie Rogers]

Right. And that's a segue to some questions we've been getting about the impact of medication versus CBT and or parent behavior training on specifically executive function and emotional dysregulation. Are those two facets of adhd? Do they benefit more from medication? Do we know? And. Or do they benefit more from the psychosocial interventions?

[Dr. Mark A. Stein]

Yeah, that's actually a hard question to answer. There are some meta analysis that have looked at medication effects on emotion regulation and executive function, and they are helpful. It's not a large effect. It's a medium to small effect size. So you would expect medication to help a little bit. But again, medication doesn't teach skills. So the question is how to teach these skills. But the Other aspect is development. And this is something that executive functioning that continues to develop as children age. We used to think that teenagers had good executive functioning and now we realize that the parts of the brain that really involve executive advanced executive functioning are still developing. Age 18, 19 and 20. So there's just a lot of variability. But you have to take age into account. The interventions like teaching executive function skills, they're challenging. I think they work better in adolescents. I haven't seen strong evidence of them in young children, so that's not something that I would emphasize.

[Annie Rogers]

Gotcha. Yeah, we hear that a lot that the medication is helpful for getting the child to attend to the psychosocial interventions. As you said, the skills themselves don't teach the skills, but perhaps they create the time and the space to work on that skill building.

[Dr. Mark A. Stein]

Yes, emotion regulation though, is something that does tend to respond to behavioral interventions. Especially because many times the emotion dysregulation comes about due to non compliance or due to rapid behavioral escalations or due to lack of structure and increasing those things. And those skills often does affect that in a positive way.

[Annie Rogers]

Wonderful. Okay, so a few questions from parents of younger children. There's a parent here of a five year old who has, whose doctor is hesitant to diagnose and even more hesitant to talk about treatment with medication. For parents of young children, generally speaking, do you recommend that they start with the parent behavior training prior to medication or is that an outdated way of thinking?

[Dr. Mark A. Stein]

No, I agree with that. Unless the symptoms are so severe. I guess the two things that matter to me is the child's life in danger. I remember hearing of a case where like a five year old with hyperactivity darted out to the street and you know, got hit by a pickup truck. I mean in that case it's really life and death. And then I think the more challenging cases are someone that is really struggling in school, getting kicked out of school and that really is having a significant negative effect. And depending on how comfortable the parent is that something maybe to consider. I think after an evaluation and a diagnosis there needs to be a discussion about what are the benefits versus the risks of each of the treatments and what we know about and what works best. And sort of using a shared decision making approach with the families coming up with a plan. I think that's often what's helpful and putting it in perspective. But what you don't want is you don't want the parent kind of abandoning all treatment or doing something that we know nothing about. And there are a lot of non evidence Based treatments that people are very vulnerable to.

[Annie Rogers]

Yes, indeed, that is a great point. And to that point, someone wrote in to say that there pediatrician said she doesn't recommend medication until the child is quote, unquote, in crisis. They're looking for a new pediatrician. But sadly, it seems that this is not uncommon.

[Dr. Mark A. Stein]

Yeah, so medication isn't a crisis medication, and it is not a disorder like that. I mean, that's not the best time to evaluate medication. It's also not the best time to evaluate when there's a marked change in their environment. So it's best to, you know, to figure out a good time to do it. But again, when there is a crisis, there's always the impetus to do something quickly. But you want to make sure that you're doing something that makes sense.

[Annie Rogers]

And, you know, many parents are eager to sort of try everything else before medication. We did a editorial survey here at Attitude that showed that on average, parents were waiting six to nine months before even considering medication post diagnosis. Would you offer any caution to trying, for example, improving daily physical exercise, clean diet with fewer processed foods, that sort of thing as a first step for parents of newly diagnosed.

[Dr. Mark A. Stein]

Yeah, no, I love that question. I guess the way I think about it is that you want to have a floor in terms of interventions. And this would be actually primary prevention, not when children are diagnosed, but before they're diagnosed. And that is to make sure that the child is getting adequate nutrition and make sure that they have good sleep patterns. And that's something all children should be trying to establish. For adhd, though, you're already having significant symptoms, and so certainly you want to target. You want to do what you can to improve sleep and appetite. But depending on the severity, you're going to want to initiate treatment. But you. But you might want to start with behavioral interventions first.

[Annie Rogers]

Okay. And one concern that I'm seeing among parents is a worry that stimulant medication itself may be addictive. Is there any evidence?

[Dr. Mark A. Stein]

Yeah, I mean, no. On the contrary, there are these evidence, especially from the Scandinavian studies where they have these registries where they're able to track health care and they also have universal access to medications. What they show in general is that treatment of ADHD with medications lowers the risk of later substance abuse. It's actually the opposite. We know that untreated ADHD is associated with substance abuse, but treating it actually in most of the studies actually lowers the risk. That doesn't mean you shouldn't be cautious and you shouldn't go carefully, do a careful trial but that's not something to worry about. I wanted to get back to the parent that says, I want to do everything other than medication. And that's certainly important to hear that and then to understand where that's coming from and what the reasons are. And you know, my job as a clinician is to kind of give them the knowledge from the research in terms of what we know, like explaining about those studies. And then again, it's the parent feeling confident and understanding that makes that decision.

[Brain FM Representative]

Gotcha.

[Annie Rogers]

Now that's an important point. Okay, so someone wrote in to say that they're having trouble finding a parent behavior training specialist and that in fact their doctor has really not introduced parent behavior training as an intervention early on for their child. Are there any resources that you're aware of, places that parents can go to get more familiar?

[Dr. Mark A. Stein]

Yeah, well, this has become a very significant problem, especially post Covid, as more people have been diagnosed with ADHD and there are fewer providers. It's fine to say everyone should have multimodal treatment with strong evidence based behavior therapy, but it's easier to say it than to do it and to find someone that can provide that and someone that takes your insurance, for example. So I guess I have two thoughts. One is universities are usually a good resource. And if you contact a local university and if they have a psychology department or a clinical psychology department, they may have a training clinic that offers those services. And then the other answer is that technology is kind of coming to the rescue. And now there are online behavioral parent training services that are available. And I think also services like chad, the nimh, cdc, all have links to behavioral parent training services that people can seek out and they may be able to try. So there's more of those all the time, but it is a challenge. The other advantage post Covid is with telehealth, though the parent doesn't have to come in and geographically be next to the clinic. There are a number of telehealth providers that do it. And there's more evidence now that group parent training is as effective as individual parent training for many cases.

[Annie Rogers]

Oh, interesting. Okay, that's very helpful. I wanted to go back, if I could, to the comment about that stimulant medication not being addictive. It was mentioned in your slide regarding when to consider non stimulants that it might be appropriate when there is the presence of substance abuse. And so I wonder if you could just clarify when that would be the case. If an individual has a history of substance abuse, perhaps they shouldn't try a Stimulant medication or am I reading that incorrectly?

[Dr. Mark A. Stein]

Yeah, I think those are the cases that it's just highly individualized and really depends on the relationship of the provider with the patient. But people with comorbid substance abuse and ADHD are really challenging to treat. There is some evidence Dr. Willins has done some studies and others showing you can treat them for ADHD and it's beneficial without exacerbating the substance abuse. But certainly if the patient is worried about stimulant abuse, that might be an easier lift to start with a non stimulant.

[Annie Rogers]

Okay, got you. Okay. And for those who we have a few people here who say that they and their child's other parents are not on the same page regarding ADHD medication use. Any words of advice for those people who would like their co parent to consider adhd.

[Dr. Mark A. Stein]

So this is a very frequent challenge where one parent wants to try medicine, the other parent doesn't, that the child is caught in the middle. What I like to do in those cases 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 and talk about the harms done by parents not being together for the child and then hearing what are the reasons that the parent is against a trial. Is it because of their own personal use or is it their own adhd, in which case it's important to highlight the struggles that they went through because of untreated adhd. But again, it depends on the relationship of the parent to the provider and their understanding of what a trial is and what's involved. That it doesn't mean your child's going to be in medicine for the rest of their life. But that at this time that might be a consideration to see if that would help things.

[Annie Rogers]

Wonderful. Thank you so much, Dr. Stein. Unfortunately, that has to be our last question because we are just about out of time. But thank you so much for joining us today, contributing your voice and sharing all of this really valuable insight and research.

[Dr. Mark A. Stein]

My pleasure.

[Annie Rogers]

Thank you and thanks to all the listeners today as well. If you would like to access the event resources, you can visit attitudemag.com and search for Podcast571. The slides and recording are posted a few hours after each live webinar. If you're listening in replay mode, you can simply click on the episode description description. And I hope you'll know that our full library of Attitude webinars is available as a podcast. It is called the ADHD Experts Podcast and it's available in most streaming platforms. Make sure you don't miss any future Attitude webinars, articles, research updates, etc by signing up to receive our free email [e-mail] newsletters thank you so much again, Dr. Stein, and we hope everyone has a wonderful day.

For more Attitude Podcast and information on living well with attention deficit, visit attitudemag.com that's a D D I T U D E mag.com.

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