Kids will be kids. Getting them to sit still or focus on anything for more than a few minutes can regularly be a monumental task. But when is it something more? Most kids grow out of this as they grow up, but children with Attention Deficit Hyperactivity Disorder (ADHD) don’t just grow out of it. And if they have severe symptoms, it can make school and home life hard for them and for everyone around them.
So when is it ADHD, and what can we do to help them learn and grow? Pharmacogenomics can play a significant role in eventual medication therapy for ADHD, helping find the most effective medication and avoiding serious side effects, but there are a few questions to answer first, and other strategies to consider.
To hear first-hand how one child struggled with medications, and how PGx turned his life around (and his family’s lives), click here: Glenn and Reese’s Story
ADHD can present itself in three different ways, and can be classified by what behaviors or symptoms are present and strongest:
In a Predominantly Inattentive individual, they may struggle with simple organizational tasks, or maintaining focus on tasks, instructions, or listening. They may get distracted easily or just get lost in the flow of what they’re doing.
When it comes to the Predominantly Hyperactive-Impulsive, it’s easier to see an outward manifestation. They have a hard time sitting still compared to others during usual activities (eating, sitting in class, etc), they may fidget and they may be more talkative. Young children tend to be very active and mobile, but some may display even higher levels of constant activity – running, jumping and climbing. They may also lack impulse control, which leads to interrupting conversations and even accidents and injuries.
Finally, the two can manifest in a Combined presentation where elements of both of the above are true.
There is no definitive and uniform cause of ADHD, but recent research shows that genetics do play a significant role. There is speculation that sleep schedules, too much sugar and a poor diet contribute directly to ADHD, but they are likely just exacerbating the issues caused by ADHD rather than causing the ADHD primarily.
For the youngest children diagnosed, medication therapy for ADHD is rarely the first line of treatment. Behavior therapy, especially in teaching strategies to the parents, is the first thing that should happen before medication therapy is considered.
According to the Centers for Disease Control, approximately 6 million children aged 2-17 have ever been diagnosed with ADHD, with boys outnumbering girls at a rate of about 2:1. Among those diagnosed:
So, when it becomes time for the parents of a child with ADHD to talk with their child’s pediatrician about medication therapy, multiple conditions could make finding the right medication very complex. While just finding the right ADHD medication can be a challenge, there is also a significant chance they’ll be dealing with anxiety, depression or other disorders. This is where pharmacogenomics can play a significant role.
When it comes to prescribing, there are several genetic bio-markers that may affect the way an individual responds to a particular medication, and the side effects it may cause. Variations in the CYP450 genes, especially, can impact a wide range of medications that are FDA-approved for the treatment of ADHD, including:
The FDA has also created a Table of Pharmacogenetic Associations where “there is sufficient scientific evidence to suggest that subgroups of patients with certain genetic variants, or genetic variant-inferred phenotypes are likely to have altered drug metabolism, and in certain cases, differential therapeutic effects, including differences in risks of adverse events”. Other resources for additional evidence for use in prescribing include the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Dutch Pharmacogenetics Working Group (DPWG).
When considering medication therapy for multiple conditions, PGx testing would almost certainly prove to be essential to minimizing time to effective therapy and reducing office visits. PGx testing has proven to be significantly effective in selecting a medication that is genetically appropriate for an individual at the outset of medication therapy for depression and/or anxiety.
In the group of CYP450 genes that impact the effectiveness of ADHD medications, the same genes and others also affect the effectiveness of the most common antidepressants, including SSRIs, tri-cyclic antidepressants and SNRIs. And since approximately 50% of people have a hidden genetic mutation that will affect prescribing, not starting with a PGx test could prove costly. Without PGx, a full HALF of patients will need trial-and-error prescribing rather than getting it right the first time. Not starting with a PGx test means effective treatment will likely take up to four months longer, including about eight extra visits to the doctor in that time.
Parenting is hard enough on a good day. Navigating medication therapy for a child with ADHD can be really difficult, even more so with multiple conditions to manage. Should you or your patients find that it may be time for medication therapy for ADHD, don’t waste time getting to what’s best. Start by giving the child’s pediatrician, and the child, the best chance to succeed with the results of a PGx test. You’ll be glad you did, and they’ll thank you for it.
