Sai Iyer, MD
The immediate clinical concern is the management of stimulant medication. Decreasing or discontinuing the stimulant medication due to the weight loss could be detrimental to the improvement made in her school performance. Alternatively, Nicole may have a primary eating disorder or disordered eating behavior coexisting with Attention-Deficit/Hyperactivity Disorder (ADHD). Was the clinician being manipulated into prescribing stimulants and accentuating weight loss based on a factitious diagnosis of ADHD?
Attention-Deficit/Hyperactivity Disorder is the most prevalent neurodevelopmental disorder among children, with an estimated prevalence of 7.2%.1 Eating disorders have a prevalence varying from 0.1 to 3.5%.2 A number of studies addressed an association between eating disorders and ADHD. Most studies describe a relationship between ADHD and binge eating behaviors and bulimia nervosa. A case-control, longitudinal family study of girls with ADHD found that those with ADHD were 3.6 times more likely to develop a clinical or subclinical eating disorder and 5.6 times more likely to develop clinical or subclinical bulimia nervosa compared with controls.3 Davis et al4 found an association between ADHD symptoms and binge eating.
There is less information about the relationship between ADHD and restrictive eating behaviors (limiting caloric intake and lack of interest in eating but without a fear of gaining weight or a disturbance in perception of their body shape). This relationship is important in understanding Nicole's situation, considering the common side effect of appetite suppression and weight loss with psychostimulants. Psychostimulants have been shown to be effective in treatment of bulimia nervosa and binge eating disorder.5,6 However, the effect of these medications on patients with anorexia nervosa and other restrictive behaviors is unclear.
Bleck et al7 explored the coexistence of clinical and subclinical ADHD and eating disorders in a nationally representative sample of US residents (18–27 years of age). Participants with ADHD were more likely to experience eating disorders, binge and/or purge eating behaviors, and restrictive eating behaviors. The authors recommended monitoring for binging/purging behaviors and restrictive eating behaviors in children and adolescents with ADHD. These studies point to the need to actively look for disordered eating behaviors, especially binge eating and restrictive eating behaviors, in all adolescents with ADHD.
Nicole's stimulant medication was continued as it significantly improved targeted ADHD behaviors. In addition, she was referred for psychotherapy and a psychiatric consultation for depression. She was also referred to a dietitian with expertise in adolescents with eating disorders. At subsequent follow-up visits, Nicole's weight remained stable at 50 kg, ADHD symptoms continued to improve, and her depressed mood was responsive to psychotherapy with a focus on cognitive behavioral therapy.
1. Thomas R, Sanders S, Doust J, et al Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics. 2015;135:e994–e1001.
2. Swanson SA, Crow SJ, Le Grange D, et al Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68:714–723.
3. Biederman J, Ball SW, Monuteaux MC, et al Are girls with ADHD at risk for eating disorders? Results from a controlled, five-year prospective study. J Dev Behav Pediatr. 2007;28:302–307.
4. Davis C, Levitan RD, Smith M, et al Associations among overeating, overweight, and attention deficit/hyperactivity disorder: a structural equation modelling approach. Eat Behav. 2006;7:266–274.
5. Kooij JJ, Burger H, Boonstra AM, et al Efficacy and safety of methylphenidate in 45 adults with attention-deficit/hyperactivity disorder. A randomized placebo-controlled double-blind cross-over trial. Psychol Med. 2004;34:973–982.
6. McElroy SL, Hudson JI, Mitchell JE, et al Efficacy and safety of lisdexamfetamine for treatment of adults with moderate to severe binge-eating disorder: a randomized clinical trial. JAMA Psychiatry. 2015;72:235–246.
Bleck JR, DeBate RD, Olivardia R. The comorbidity of ADHD and eating disorders in a nationally representative sample. J Behav Health Serv Res. [published online ahead of print July 10, 2014]. doi: .
Maya Kumar, MD
This challenging case raises a number of important issues. First, before starting medication, it is critical for the primary care pediatric clinician to ensure that the patient meets DSM-5 criteria for Attention-Deficit/Hyperactivity Disorder (ADHD) including symptoms in more than 1 setting and onset before the age of 12 years.1 Eating disorders and weight loss themselves can cause significant neurocognitive impairment, including problems with memory, learning, and executive function,2,3 which may present as ADHD. A study of low-weight adult women with restrictive eating disorders demonstrated that 21% met at least 6 criteria in at least 1 ADHD domain (inattention or hyperactivity/impulsivity); however, only one-tenth of these women had met criteria in childhood.4 If Nicole did not have childhood symptoms (i.e., before 12-year-old) of inattention or did not meet other DSM-5 criteria for ADHD, the pediatrician must consider whether her inattention is attributable to poor nutrition rather than true ADHD; first-line treatment would be nutritional rehabilitation and weight restoration rather than stimulant medication.
Second, pediatricians should be aware that adolescents and young adults commonly seek stimulant medication for a variety of purposes such as recreational substance abuse, to stay awake, or to “enhance” concentration even if ADHD is not present. A common reason for misuse of stimulant medication is the desire for weight loss. In a survey of college students, 4.4% reported nonmedical use of prescription stimulants for weight loss; this behavior was also associated with vomiting for weight loss, laxative use, diuretic use, and diet pill use.5 This is another reason to ensure that the patient meets ADHD criteria before prescribing stimulant medication. In addition, the assessment should include a confidential discussion with the adolescent exploring possible motives for seeking stimulant medication.
Assuming that Nicole met the criteria for ADHD with a good response to stimulant medication but subsequently developed weight loss, it would be important for the pediatrician to look for specific behaviors of an eating disorder. Examples include frequent weighing oneself, skipping meals, or reducing portion sizes despite encouragement to eat, calorie counting, or frequently reading nutrition labels, secretive behaviors such as throwing away food or hiding food, or fear of what the adolescent perceives to be “unhealthy” foods. The adolescent should be explicitly asked about these behaviors, as well as exercise frequency and intensity, self-induced vomiting, and the use of laxatives, diuretics, or diet pills.
There is no published evidence to guide the management of an eating disorder that exists concurrently with ADHD. However, given the potentially life-threatening medical complications, severe socioemotional dysfunction, and cognitive impairment (including worsening ADHD symptoms) that could arise from the eating disorder, I would recommend prioritizing treatment of the eating disorder and weight loss over the ADHD. I would recommend discontinuation of the stimulant medication, which if continued would interfere with weight recovery. If the patient's ADHD was so severe that she had significantly impaired function without any medications, a trial of guanfacine or clonidine may be considered; these medications improve core ADHD symptoms but are much less likely than stimulants to interfere with weight restoration.6 If the primary care clinician did not have experience with these alpha-2 agonist medications, it would be reasonable to focus on weight restoration and refer the patient to a psychiatrist for medication management.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Chui HT, Christensen BK, Zipursky RB, et al Cognitive function and brain structure in females with a history of adolescent-onset anorexia nervosa. Pediatrics. 2008;122:e426–e437.
3. Weider S, Indredavik MS, Lydersen S, et al Neuropsychological function in patients with anorexia nervosa or bulimia nervosa. Int J Eat Disord. 2015;48:397–405.
4. Yates WR, Lund BC, Johnson C, et al Attention-deficit hyperactivity symptoms and disorder in eating disorder inpatients. Int J Eat Disord. 2009;42:375–378.
5. Jeffers AJ, Benotsch EG. Non-medical use of prescription stimulants for weight loss, disordered eating, and body image. Eat Behav. 2014;15:414–418.
6. Hasnain M, Vieweg WV. Weight considerations in psychotropic drug prescribing and switching. Postgrad Med. 2013;125:117–129.
Michael I. Reiff, MD
Nicole's history is not that unusual. The impact of the DSM-5 age of onset criteria for Attention-Deficit/Hyperactivity Disorder (ADHD) has resulted in 3.46% increase in children meeting criteria for ADHD; the greatest impact is in the inattentive subtype.1 The statement that Nicole met DSM-5 criteria for the diagnosis of ADHD assumes that there were some signs of ADHD identified before age 12. The decline in school performance especially over the past year could certainly be due to the increased demands for work production, higher order thinking, greater independence, and an increasing importance of social activities in the high school years.
The case presentation suggests that Nicole's depressive symptoms were at least associated with if not caused by her parents' decision to withdraw privileges. However, they are as likely to be a result of the increased demands already mentioned. In addition, coexisting depression and depressive symptoms are quite common in children who demonstrate the predominantly inattentive ADHD presentation. These symptoms become more prevalent in adolescents, and, overall, the cumulative incidence of mood disorders (major depression, depressive disorder, dysthymia, and bipolar disorders) in individuals with ADHD by age 10 is 22.9% as opposed to 7.2% individuals not diagnosed with ADHD.2
Weight loss can certainly be a sign of depression, but in this case, it is more likely due to the initiation of stimulant medication, where weight loss is a well-known collateral effect, especially in the first 6 months of treatment. Nicole's continuing low mood could possibly be related to adjusting to stimulant medication but may also suggest a coexisting problem with depressive symptoms. Depending on duration and degree of impairment, evidence-based interventions for depression include cognitive behavioral therapy (only if Nicole would buy into it) or antidepressant medication. Her continued daily weighing suggests an additional anxiety component (also frequently coexisting in individuals diagnosed with ADHD). Selective serotonin reuptake inhibitor medications could also address this.
Anorexia nervosa seems unlikely due to the hints in the case presentation that Nicole is healthy, is having regular menstrual cycles, and is not obsessed with exercise, in addition to which the associations between ADHD, depression, and side effects to stimulant medications are common and seem like a much more feasible explanation.
Finally, it is important to keep in mind that we are treating Nicole rather than her “diagnoses.” It is much more practical to look at a treatment plan prioritized by Nicole's major impairments in functioning rather than her DSM diagnoses, which are sensitive but generally lack specificity and have no externally validating biological markers.3 A treatment approach will also be most effective at Nicole's age if it also has her buy-in. We often forget to look at our patient's strengths, and in this challenging case, strengths are not indicated. Looking at strengths can lead to successful interventions that can result in optimal outcomes.
1. Vande Voort JL, He JP, Kathleen ND, et al Impact of the DSM-5 attention Deficit/Hyperactivity disorder age-of-onset Criterion in the US adolescent population. J Am Acad Child Adoles Psychiatry. 2014;53:736–744.
2. Yoshimasu K, Barbaresi WJ, Colligan RC, et al Childhood ADHD is strongly associated with a broad range of psychiatric disorders during adolescence: a population-based birth cohort study. J Child Psychol Psychiatry. 2012;53:1036–1043.
3. Reiff MI, Feldman HM. Commentary: Diagnostic and Statistical Manual of Mental disorders: the Solution or the problem? J Dev Behav Pediatr. 2014;35:68–70.
Martin T. Stein, MD
The case presentation that led to a concern about the potential to enable an eating disorder in an adolescent girl with Attention-Deficit/Hyperactivity Disorder may not be an infrequent occurrence. The commentaries emphasized the importance of considering an eating disorder with a detailed medical and psychosocial history. After a few clinical mishaps, I learned to engage the help of a specialist in eating disorders at an early stage in the disease whenever faced with a moderate to severe eating disorder—before the development of cardiovascular instability and hospitalization. Finally, Dr. Reiff's reminder to treat the patient (and her impairments) and not the diagnosis is elaborated in the third reference in his commentary.