What is the treatment approach for a child with Attention Deficit Hyperactivity Disorder (ADHD) and a mood disorder?

Treatment Approach for Children with ADHD and Mood Disorders

For children with both ADHD and mood disorders, treatment should include FDA-approved medications for ADHD combined with evidence-based behavioral therapy, with careful assessment and treatment of the mood disorder as a critical component of the management plan. 1

Assessment and Diagnosis

• Comprehensive evaluation must include screening for comorbid conditions, particularly mood disorders (depression, anxiety, bipolar disorder) 1
• Use validated rating scales to document baseline symptoms from multiple sources (parents, teachers)
• Assess for other potential comorbidities:
  • Behavioral: oppositional defiant disorder, conduct disorders, substance use
  • Developmental: learning/language disorders, autism spectrum disorders
  • Physical: tics, sleep apnea 1

Treatment Algorithm

Step 1: Determine Age and Prioritize Treatment Targets

• Ages 4-5 years:

  • First-line: Evidence-based parent/teacher-administered behavior therapy
  • Second-line: Consider methylphenidate if behavior therapy is insufficient 1

• Ages 6-11 years:

  • Combination of FDA-approved ADHD medications AND evidence-based behavioral therapy 1
  • Address mood symptoms concurrently

• Ages 12-18 years:

  • FDA-approved medications for ADHD with adolescent assent
  • Behavioral therapy recommended 1
  • Screen for substance use before initiating treatment

Step 2: Medication Selection

For ADHD Component:

1. First-line medications (strongest evidence):

   • Stimulants (methylphenidate, amphetamine-based medications) 1
   • Titrate doses to achieve maximum benefit with minimum side effects

2. Second-line medications (if stimulants contraindicated or ineffective):

   • Atomoxetine - may be particularly beneficial in children with comorbid mood disorders 2
   • Extended-release guanfacine
   • Extended-release clonidine 1

For Mood Component:

• For depression/anxiety with ADHD:
  • Consider atomoxetine as it may improve both ADHD symptoms and depressive symptoms 2
  • For more severe mood symptoms, specific treatment for the mood disorder may be necessary

Step 3: Behavioral Interventions

• Parent training in behavior management
• Classroom behavioral interventions
• Educational supports (IEPs or 504 plans)
• Skills development targeting organization and time management 3

Monitoring and Follow-up

• Regular monitoring of:
  • Vital signs, weight, appetite, sleep quality
  • Height (in children)
  • Emergence of tics or psychiatric adverse reactions
  • Response to treatment for both ADHD and mood symptoms

Important Considerations and Pitfalls

• Children with anxiety and ADHD respond well to both behavioral and pharmacological ADHD treatments 4
• Treatment of ADHD may help prevent development of future psychiatric disorders 4
• Common pitfalls to avoid:
  • Inadequate dose titration
  • Ignoring timing of medication administration
  • Overlooking behavioral interventions
  • Neglecting comorbid mood disorders
  • Discontinuing treatment prematurely 3
  • Treating only the ADHD while ignoring mood symptoms

Special Considerations

• Children with ADHD and mood disorders may show slower improvement with atomoxetine compared to those with ADHD only, but can still achieve significant benefit 2
• The presence of comorbid mood disorders complicates diagnosis, treatment, and prognosis of ADHD, requiring careful monitoring and adjustment of the treatment plan 4
• Fluoxetine monotherapy has shown promise in some children with ADHD and comorbid non-bipolar mood disorders, improving both depressive symptoms and ADHD symptoms 5

Remember that ADHD is a chronic condition requiring ongoing management following principles of the chronic care model, with regular follow-up and treatment adjustments as needed 1.