A 12-year-old boy is brought to the office by his mother for follow-up of behavioral problems. The patient has had poor attention, difficulty listening, and hyperactivity since kindergarten. Despite ongoing behavioral therapy, he continues to have problems at school and at home. He is easily distracted in the classroom and has difficulty sitting still and following instructions. His schoolwork is disorganized and sloppy and his grades are below his academic potential. At home, he annoys family members with his intrusive behavior, forgets his chores, and becomes moody and irritable when reprimanded. Pharmacological treatment options are discussed. The mother is opposed to stimulant medication and would like to consider alternatives. Which of the following is the most appropriate medication to recommend at this time?

Question

A 12-year-old boy is brought to the office by his mother for follow-up of behavioral problems.  The patient has had poor attention, difficulty listening, and hyperactivity since kindergarten.  Despite ongoing behavioral therapy, he continues to have problems at school and at home.  He is easily distracted in the classroom and has difficulty sitting still and following instructions.  His schoolwork is disorganized and sloppy and his grades are below his academic potential.  At home, he annoys family members with his intrusive behavior, forgets his chores, and becomes moody and irritable when reprimanded.  Pharmacological treatment options are discussed.  The mother is opposed to stimulant medication and would like to consider alternatives.  Which of the following is the most appropriate medication to recommend at this time?

Quizplus · Accepted Answer

Medication options for attention-deficit hyperactivity disorder (ADHD) in children and adolescents include stimulants (eg, dextroamphetamine, methylphenidate), atomoxetine, alpha-2 adrenergic agonists, and certain antidepressants. Although stimulants are commonly recommended as initial pharmacotherapy due to their rapid onset and larger treatment effect size compared to nonstimulants, family preferences should be considered when choosing treatment. Atomoxetine is a first-line alternative to stimulants for child and adolescent ADHD. It is a selective norepinephrine reuptake inhibitor and is not a controlled substance. Atomoxetine may also be preferred to stimulants when there is concern for abuse or diversion due to a personal or family history of illicit substance use. Alpha-2 adrenergic agonists (eg, clonidine, guanfacine) and certain antidepressants (eg, bupropion, tricyclic antidepressants) are other nonstimulant options, but these are usually reserved for children who respond poorly to a trial of stimulants or atomoxetine (Choices B and D). (Choices C and E) Dextroamphetamine and methylphenidate are stimulant medications. (Choice F) Modafinil is a wakefulness-promoting agent used to treat narcolepsy. (Choice G) Valproate is an anticonvulsant that has been used as a mood stabilizer in bipolar disorder. Educational objective: The nonstimulant atomoxetine is an appropriate treatment for child and adolescent attention-deficit hyperactivity disorder when parents prefer a nonstimulant medication. References: A critical appraisal of atomoxetine in the management of ADHD. (http://www.ncbi.nlm.nih.gov/pubmed/26730199) Systematic review of atomoxetine data in childhood and adolescent attention-deficit hyperactivity disorder 2009-2011: focus on clinical efficacy and safety. (http://www.ncbi.nlm.nih.gov/pubmed/23438503)

A 12-Year-Old Boy Is Brought to the Office by His