Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Lauren Ferguson, and I am a Pediatrics Resident at University of Virginia with an interest in general pediatrics.
Today, we will be reviewing what you need to know before your first Pediatric appointment with a patient who either has been diagnosed with or who is being seen to rule out attention deficit-hyperactivity disorder, or ADHD.
Straight from the American Academy of Pediatrics “ADHD is the most common neurobiological disorder in the United States and more than 9 percent of children aged 2-17 receive an ADHD diagnosis during their childhood” so you are very likely to encounter it during your Pediatrics rotation.
First, let’s define ADHD.
There are 3 major different subtypes of ADHD, and so children may present differently. There is the inattentive subtype, the hyperactive/impulsive subtype, and the combined subtype, in which the child has both inattention and physical hyperactivity. In general, symptoms should be present in 2 or more settings (such as home and school), and these symptoms interfere with functioning at home, school, or in social settings. Also, we want to rule out other problems that could cause these symptoms. Because symptoms have to be in 2 or more settings, ADHD is usually not diagnosed until the child has started school or is spending a significant amount of time outside the home setting such as in daycare.. You also have to remember what is developmentally normal at different ages. A 2 or 3 year old is often not going to be able to sit still and pay attention for long periods, and that is developmentally normal. So we would generally not diagnose ADHD in a 2 or 3 year old.
There are multiple kinds of visits for ADHD that you might see on a typical general pediatrics schedule. So before the visit, it’s important to look in the EMR to find out what kind of workup or treatment, if any, has already been done for this patient.
If this patient has already been diagnosed with ADHD and started on medication, they might be presenting for a “med check.” We’ll cover what to know for these visits near the end of our discussion. If your patient is still in the process of working up a possible ADHD diagnosis, it’s important to know where you are in that conversation.
Sometimes, a family’s concern for ADHD in their child may come up in the setting of a well child check, or it could be the sole topic of conversation at a visit scheduled specifically for that purpose. It comes up in all sorts of different ways because children with ADHD can present so differently, and it is usually a concern that grows over time rather than something that happens acutely. We often see patients for concerns surrounding attention or hyperactivity when they first enter school, or toward the beginning of middle school - both times when there may be new or increased demands on their skills in attention, organization, or cooperation.
If this is the first conversation this family has had with their pediatrician about concern for ADHD in their child, it is important to collect a very thorough history. Remember that one of the components of a diagnosis of ADHD is that it affects the child in at least two different environments - most frequently we assess their home environment, and school environment. In many cases, the conversation will be prompted by conversations with teachers about disruptive behaviors, though it can also present at school as poor performance, forgetting assignments, taking a long time on assignments or tests, or distracting other students. Collect a thorough history of any concerns brought up by teachers.
Because the home environment is often more open and requires less focus, the symptoms to look for can be very different. Frequently kids with hyperactive or inattentive symptoms will have trouble focusing on one activity at a time, and will bounce from toy to toy quickly without being able to sit with one for a while. It can also present as difficulty to focus on meal times, taking longer to finish a meal than other family members. Another common finding is difficulty listening to instruction, and can result in frequent conflict with caregivers or siblings. It is also important to assess for patient safety if they’re an elopement risk - a child that wanders off in public could be inattentive to where their caregiver is, and become lost easily. Similarly, a child with difficulty controlling their impulses may see something they’re interested in and wander off from the family in a public setting. And finally, difficulties with sleep and bedtime can be a problem for children with either inattentive or hyperactive subtype ADHD.
One more important piece of the history to collect is when these symptoms started. ADHD typically comes on gradually. Any behavior symptoms that start suddenly should always be concerning for emotional or physical trauma, or family stress, and a thorough social history is warranted - both from the parent and the child!
It’s important to remember that ADHD can present in many different ways. Some families may have the impression that because their child gets good grades, they can’t have ADHD. There are some children whose symptoms may prevent them from performing well in school, and some children who are able to complete assignments and therefore reportedly do well in school, and then, out of boredom, may distract other children and all the in between. So, there is a broad spectrum of the way the symptoms of ADHD may look. Even if a child with ADHD has adequate performance, they may still benefit from treatment for ADHD, and ignoring it puts them at risk of becoming an adult without appropriate treatment - when it is much harder to be diagnosed. And remember, inattentive ADHD and hyperactive/impulsive ADHD have different symptoms, and explaining this may help a family understand why their child may seem different than their impression of what ADHD looks like.
It may be tempting to decide on a diagnosis of ADHD after a convincing history, however it is very important to conduct a thorough physical exam and consider other causes for a child’s behavior. Your physical exam starts the moment you enter the room, and often, children with either inattentive or hyperactive/impulsive ADHD will struggle to sit patiently in the exam room while their parent and the doctor do all that talking. They will frequently be disruptive, struggle to stick to one form of entertainment during the history, or even be very physically active in the exam room while the history is being discussed. These observations are all important to your diagnosis and important to document.
It’s also important to use your history and physical exam as a chance to rule out other diagnoses that can commonly be misdiagnosed as ADHD. While mood disorders like anxiety and depression will likely be elucidated in the history, depression can be accompanied by exhaustion, psychomotor slowing, and weight changes. A child with anxiety may have tachycardia, elevated blood pressure, or be visibly anxious during your exam. A child with autism spectrum disorder may have communication differences, trouble making eye contact with you, or may use their body in unexpected ways like with unusual gestures. Obstructive sleep apnea (OSA) - or lack of sleep for other reasons - can be confused with ADHD because both can present with poor sleep and “overtired” energy during the day. For this reason, checking tonsil size on the oropharyngeal exam is important to remember. Lastly, any child with difficulties in school should be thoroughly evaluated for hearing and vision difficulties as these can affect both performance and behavior. These are all just examples of the importance of paying close attention to your physical exam, even when you’re feeling fairly confident about a diagnosis of ADHD.
If you and the pediatrics residents and attendings you’re seeing the patient with are concerned about ADHD, you will likely send the family home with Vanderbilt forms to complete. The Vanderbilt diagnostic rating scale is used to diagnose severity of ADHD symptoms in children ages 6-12yo. They are validated and reliable in studies so they are the most often used assessment tool for this diagnosis. These are validated scales used to assess symptoms of the different subtypes of ADHD, as well as other conditions that often co-exist with or can mimic ADHD, such as anxiety, depression, oppositional defiant disorder or ODD, and conduct disorder. Most children with ADHD have at least one other co-morbidity and many have several. There are two versions of Vanderbilts, one for parents, and one for teachers, because remember that symptoms need to be in at least 2 different settings. The teacher form can be completed by a tutor, a coach in addition but in general should be another adult who knows the child well and interacts with them frequently. It is also beneficial to have multiple parents or care providers who help to care for the child complete the Vanderbilt rating scale so you can look for discrepancies or patterns. In addition to being a tool to assist with diagnosis of ADHD, there are also “follow-up” Vanderbilt forms that can help assess how a child’s symptoms have changed after starting therapy and/or medication.
In some cases, Vanderbilts may have been sent home with the child after a previous conversation about ADHD, in which case you can use those scores in this visit to inform your discussion about the child’s symptoms. It is important to remember that the Vanderbilt forms are a tool to assist you in your evaluation, but don’t make or break a diagnosis of ADHD if they don’t correlate with your impression from the history and exam!
The Vanderbilt forms are scored in sections that are not noted on the form, so make sure to look up the appropriate scoring rubric as you evaluate your patient’s forms. In general, the symptom questions are divided into sections assessing Inattentive symptoms, hyperactive/impulsive symptoms, ODD, Conduct disorder, and Anxiety/depression. The last section assesses the child’s performance, to help us understand how these symptoms impact the child’s ability to function. This section can also help diagnose or rule out learning disorders. Remember that a child’s functioning needs to be affected by their symptoms to support a diagnosis of ADHD. In some cases, these forms have already been sent to the clinic prior to the visit and are already entered into the EMR, so you may be able to go into the visit knowing the scores.
So, you’ve taken a thorough history, scored some Vanderbilt forms, and paid close attention to your physical exam. Now it’s time to make a plan. It’s important to ask the family what their goals are for their child and the visit today. Many families know that it is frequently treated with medication and they may already have a strong opinion in favor of or against medication. Once you’ve heard their thoughts on how to manage their child’s ADHD, it’s important to ensure they’re fully aware of both behavioral and pharmacologic interventions so they can make an informed decision.
Behavioral interventions have sometimes been pursued at least in part by families when they present to clinic, because often these behaviors have been present for some time. Even so, it’s a good idea to discuss them with parents, because even if you decide to pursue pharmacological management, these changes are very important to supplement the benefits of medication. The younger the child, the more beneficial and important the non pharmacologic interventions are. Some helpful changes for home or school to manage a child’s inattentive or impulsive behaviors include:
Maintaining a daily schedule
Minimizing environmental distractions (such as background noise, etc)
Deciding on specific and intuitive places to keep their belongings
Setting small goals
Positive reinforcement
Not rewarding negative behaviors with attention
Using checklists or visual guides to help kids stay on task
Finding activities well suited to the child such as sports
Limiting choices
There is also formal training in enhanced parenting techniques aimed at strengthening the parent-child relationship that is frequently used for children with ADHD, called Parent (or caregiver) training in behavior management (PTBM).
For some children, these interventions may be sufficient to limit the impact of their behavioral differences on their performance. However, many families will have already tried those with inadequate improvement, or may find these interventions unrealistic. In that case, it is 100% ok to try pharmacologic management.
Medications for ADHD are generally divided into stimulants and non-stimulants. Stimulants are first line agents and achieve benefit in about 80% of cases. However, there are certain circumstances in which a non-stimulant may be more appropriate, or if parents favor non-stimulants after adequate education.
Stimulants are divided into amphetamines and methylphenidate. Some studies suggest that amphetamines tend to be more effective, while methylphenidate is better tolerated, however, every child is different and it’s common to need to try several doses or different medications before arriving at a long-term plan. Some things that may affect your choice are whether a parent has been on medication for ADHD and what worked well for them, or, on the flip side, avoid a medication they didn’t tolerate, because there are genetic differences in how people respond to these medications. Sometimes a coexisting condition may push you more towards a non-stimulant that can address both, which we’ll discuss next.
Whichever stimulant you choose, it is always a good idea to start at a low dose of a short acting medication, and titrate up once we make sure the patient tolerates it initially, ideally after several weeks on the medication in the school and home environment. Look at the dosing range per kilogram for the medication, and start on the lower end. Side effects to watch for that may signal poor tolerance of a medication are gastrointestinal upset, headaches, poor mood or feeling like a “zombie” while on the medication, or mood problems or even symptom rebound as the medication wears off. Some symptoms, such as decreased appetite, are expected but can be worked around: many families have to make some adjustments in order to take advantage of the times a child on stimulant medication DOES have an appetite, such as eating breakfast before the medication, and a late dinner after the medication has worn off. Feeling grumpy or even having rebound of their hyperactivity or inattention as the stimulant wears off is also very common and can be tolerated by some families when it’s expected, though some families may find this a deal breaker.
It’s important to keep in mind that the initial dose of a stimulant may not resolve their ADHD symptoms to a satisfying degree. As long as they aren’t having side effects that the family can’t tolerate on this initial dose, don’t call it a medication failure until you’re at treatment dose.
There are also short and long acting doses of both amphetamines and methylphenidate. Depending on the child’s schedule, they may only need a short acting dose such as if they’re a younger school aged child with a half day of school. Older children will often need a long acting dose eventually in order to get through a whole school day, or in some cases they may take two doses of a short acting stimulant, with the second administered at school. For some children, a second dose is ok, but others find that it is stigmatizing to be called out of class to go to the nurse’s office every day. It’s important to keep working with the family until you achieve the right schedule that works for them.
Non-stimulants include atomoxetine, which is a serotonin and norepinephrine reuptake inhibitor, and is typically less effective than stimulants but is often tolerated well. Alpha 2 adrenergic agonists like guanfacine and clonidine are non-stimulants that are also frequently used for ADHD. These are also generally less effective than stimulants but may be helpful when there are coexisting conditions or as adjunctive treatment with a stimulant. For example, guanfacine can be used in children who also have Tourette syndrome , and clonidine can be useful for children who also have emotional dysregulation or sleep difficulties.
One aspect of stimulants that many families find convenient is the ability to give or withhold doses on different days. Some families only use stimulants on school days because home behaviors are tolerable on the weekends. It is important to note that this is NOT appropriate for alpha 2 adrenergic agonists because they affect blood pressure. Families being prescribed these medications need to be reminded that they must be given every day.
Once you’ve prescribed a medication, you will want them to make a follow-up appointment. Titrating the stimulant or non-stimulant medication typically happens at visits 2 weeks to 1 month apart so intolerances can be addressed quickly, while still giving enough time to see how the medication affects the child at school and at home. Once at a steady state dose that the family is happy with, “med checks” should be done every 3 months to keep a close eye on symptoms, and because stimulants are controlled substances. So you can only give the family 3 prescriptions, each with a 30 day supply. If a patient develops symptoms they can’t tolerate with a medication they are already at treatment dose for, you can switch to a new medication at a conversion dose, without necessarily having to titrate up from a starting dose again. Up To Date has a very helpful conversion chart titled “Dosing guidelines when switching from one stimulant to another in the treatment of attention deficit hyperactivity disorder in children and adolescents”. We’ve provided that link in the Show Notes.
At med checks, it is important to take note of the vitals, especially blood pressure and weight. You are worried if there are increases in the blood pressure, or if the child is not sustaining adequate weight gain. Ensure that the medication is still achieving the desired effects - ask how school is doing, and consider sending Vanderbilts for reassessment of how things are going so you can track a child’s improvement with medication. If the medication continues to benefit the patient, make sure they’re tolerating the side effects - is the weight plateauing? Are they able to find meal times that work with the medication schedule? And ask both the patient and the family how the medication seems to be affecting their mood. And for non-stimulants that affect blood pressure like Alpha 2 adrenergic agonists, make sure to check and reiterate that these need to be taken every day to avoid rebound hypertension.
ADHD that is poorly controlled can feel debilitating for some families. While managing stimulant or non-stimulant medications can be intimidating and time intensive, it can change families lives and is an important skill in outpatient pediatrics!
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