What is the recommended workup and treatment for a 12-year-old with Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and depression?

Workup and Treatment for a 12-Year-Old with ADHD, ODD, and Depression

Initial Diagnostic Workup

Begin with structured diagnostic assessment using DSM-5 criteria for all three conditions, obtaining information from multiple sources including parents, teachers, and the adolescent. 1

ADHD Assessment

• Confirm presence of at least 6 symptoms from either inattentive or hyperactive-impulsive criteria (or both for combined presentation) persisting for at least 6 months 1
• Document impairment in at least two settings (home, school, social) 1
• Verify symptom onset before age 12 1
• Use standardized rating scales from parents and teachers to quantify symptom severity 1

ODD and Depression Screening

• Screen systematically for comorbid conditions including ODD (pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness) and depression (persistent sad mood, anhedonia, neurovegetative symptoms) 1
• Rule out alternative causes including psychosocial stressors, learning disorders, autism spectrum disorders, and physical conditions like sleep apnea 1

Medical Screening

• Screen for bipolar disorder or family history of bipolar disorder, mania, or hypomania before initiating ADHD medication 2
• Assess cardiovascular risk factors and obtain baseline vital signs 3
• Screen for substance use given the age and comorbidities 1

Treatment Approach

For this 12-year-old with ADHD, ODD, and depression, initiate FDA-approved stimulant medication with the adolescent's assent as first-line treatment for ADHD, combined with parent management training for ODD, and consider adding individual cognitive-behavioral therapy for depression. 1, 3

Pharmacological Treatment for ADHD

• Prescribe extended-release methylphenidate or amphetamine as first-line treatment (Grade A evidence), as stimulants demonstrate the highest efficacy for adolescent ADHD 3
• Extended-release formulations provide once-daily dosing with symptom coverage throughout the school day and evening, which is critical for adolescents 3
• Obtain the adolescent's assent for medication, as adolescent preference strongly predicts treatment engagement and persistence 3
• Titrate to maximum benefit with tolerable side effects 1, 3

Alternative if stimulants are contraindicated or not tolerated:

• Atomoxetine is the primary non-stimulant option with Grade A evidence 3, 2
• For adolescents over 70 kg, initiate atomoxetine at 40 mg daily, increase after minimum 3 days to target dose of 80 mg daily, with maximum of 100 mg daily if needed after 2-4 weeks 2
• Extended-release guanfacine or clonidine are additional options with less robust evidence 3

Behavioral Interventions for ADHD and ODD

Parent management training is the most substantiated treatment for ODD (Grade A evidence) and should be implemented concurrently with ADHD medication. 1

Parent Management Training Components:

• Reduce positive reinforcement of disruptive behavior 1
• Increase reinforcement of prosocial and compliant behavior through contingency management 1
• Apply consistent, predictable, contingent, and immediate consequences for disruptive behavior 1
• Training typically requires several months with potential booster sessions 1

Individual Approaches for the Adolescent:

• Problem-solving skills training targeting specific behavioral problems encountered 1
• Cognitive-behavioral interventions to address functional impairments and executive function deficits that medication alone does not resolve 3
• Training interventions focusing on organization, time management, and skill development through repeated practice 3

Treatment for Comorbid Depression

• If the primary care clinician is trained in treating depression, initiate appropriate treatment (typically CBT and/or antidepressant medication depending on severity) 1
• If not trained or experienced in managing adolescent depression, refer to an appropriate subspecialist (child psychiatrist or psychologist) 1
• Critical caveat: Depression may improve with effective ADHD treatment, so reassess depressive symptoms after ADHD stabilization before adding antidepressants 1

Educational Interventions

Educational supports are a necessary component of any treatment plan and should be formalized through an Individualized Education Program (IEP) or 504 Rehabilitation Plan. 1, 3

• Accommodations may include extended time for tests, reduced homework demands, ability to keep study materials in class, and provision of teacher's notes 3
• Establish bidirectional communication with school personnel to monitor treatment response across settings 1

Treatment Sequencing and Monitoring

Initial Phase (First 4-8 Weeks):

• Start stimulant medication with dose titration 3
• Initiate parent management training 1
• Implement school accommodations 1, 3
• Monitor for medication side effects and treatment response 1

Ongoing Management:

• Manage ADHD as a chronic condition requiring ongoing care following principles of the chronic care model and medical home 1, 3
• Reassess diagnostic formulation if response to adequate treatment is poor, considering unrecognized comorbidities, psychosocial stressors, or poor treatment adherence 3
• Add individual CBT for the adolescent if behavioral problems persist despite parent training and medication 1, 3
• Begin transition planning to adult care around age 14 3

Critical Implementation Considerations

• Combined treatment (medication plus behavioral therapy) provides complementary benefits: medication addresses core ADHD symptoms while behavioral interventions improve functional impairments 3
• Combined treatment allows for lower stimulant dosages, potentially reducing adverse effects 3
• Parents and teachers report significantly higher satisfaction with combined treatment approaches 3
• Family preference, including the adolescent's own preference, is essential in determining the treatment plan and enhancing adherence 3

Common Pitfalls to Avoid

• Do not delay ADHD treatment while waiting for behavioral interventions to become available, as inadequate treatment leads to poor long-term outcomes 3
• Do not assume depression is primary without treating ADHD first, as mood symptoms often improve with effective ADHD management 1
• Do not use short-acting stimulants as first-line in adolescents due to increased diversion risk and rebound symptoms 3
• Do not implement medication without concurrent behavioral and educational supports, as medication alone does not address all functional impairments 1, 3
• Ensure atomoxetine capsules are taken whole and not opened 2