What is the best treatment approach for a 14-year-old female with Attention Deficit Hyperactivity Disorder (ADHD) and dermatillomania (skin picking disorder) with pica (eating disorder)?

Treatment Approach for Skin Picking and Pica in a 14-Year-Old Female with ADHD

For a 14-year-old female with ADHD, dermatillomania (skin picking), and pica, the most effective treatment approach is a combination of FDA-approved ADHD medication (preferably a stimulant) along with cognitive-behavioral therapy targeting both the skin picking and eating behaviors.

Understanding the Condition

This adolescent presents with a complex clinical picture involving:

• ADHD (primary neurodevelopmental disorder)
• Dermatillomania (skin picking disorder) - classified as an obsessive-compulsive related disorder
• Pica (eating disorder involving consumption of non-nutritive substances)

Treatment Algorithm

Step 1: ADHD Treatment

• First-line medication: FDA-approved stimulant medication (methylphenidate or amphetamine-based) 1
  • Stimulants have the strongest evidence base for ADHD treatment in adolescents
  • Recent evidence suggests methylphenidate may directly improve skin picking behaviors 2
  • Initial dosing for adolescents >70kg: Start at 40mg daily for atomoxetine or appropriate weight-based dosing for stimulants 3
  • Titrate to effective dose over 2-4 weeks

Step 2: Targeted Treatment for Skin Picking

• Cognitive-behavioral therapy (CBT) with specific focus on:
  • Habit reversal training
  • Acceptance and commitment therapy components 4, 5
• If skin picking persists despite ADHD treatment and CBT:
  • Consider adding an SSRI (selective serotonin reuptake inhibitor) 4
  • Alternative: N-acetylcysteine has shown efficacy for skin picking 4

Step 3: Address Pica Behaviors

• Nutritional assessment to identify any deficiencies
• Behavioral therapy specifically targeting pica behaviors
• Monitor for medical complications of pica (intestinal obstruction, toxic ingestion)

Important Clinical Considerations

Medication Selection Factors

1. Stimulant medications should be first-line for ADHD in this age group 1

   • There is direct evidence that methylphenidate can improve skin picking in ADHD 2
   • However, be aware that in rare cases, stimulants may exacerbate or trigger skin picking 6

2. If stimulants are contraindicated or ineffective:

   • Atomoxetine has shown efficacy for both ADHD and skin picking in case reports 7
   • Starting dose: 0.5 mg/kg/day, target dose: 1.2 mg/kg/day 3

Monitoring and Follow-up

• Assess medication effectiveness for ADHD symptoms every 3-4 weeks initially
• Monitor for improvement in skin picking and pica behaviors
• Screen regularly for other comorbid conditions that may emerge (anxiety, depression) 1
• Evaluate for medication side effects at each visit

Comorbidity Considerations

• The presence of multiple conditions (ADHD, dermatillomania, pica) suggests possible underlying anxiety or obsessive-compulsive features
• Screen for other potential comorbidities that may affect treatment approach 1
• Consider specialized referral if symptoms are severe or treatment-resistant 1

Pitfalls to Avoid

1. Treating only the ADHD while ignoring the skin picking and pica behaviors
2. Focusing only on behavioral interventions without addressing the underlying ADHD
3. Failing to monitor for medical complications of skin picking (infections) and pica (intestinal issues)
4. Not involving parents/caregivers in the treatment plan, especially since ADHD is a chronic condition requiring consistent management 1
5. Discontinuing treatment prematurely - ADHD treatment needs to be maintained long-term 1

School Considerations

• Educational interventions and individualized instructional supports are necessary components of the treatment plan 1
• Consider implementing a 504 plan or IEP (Individualized Education Program) to address academic needs

This comprehensive approach addresses all three conditions while recognizing their potential interrelationships, with the primary focus on improving the patient's quality of life and reducing morbidity associated with these conditions.