Diagnosing ADHD in Children and Teens Following a Failure in First-line Medications

The diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) in children and teens can be a complex and unique challenge for primary care providers.

At the 2020 Virtual Conference on Pediatric Health Care, Dawn Garzon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN, the immediate past president of the National Association of Pediatric Nurse Practitioners and an associate professor at the University of Portland in the School of Nursing, discussed the complexities when approaching the diagnosis and treatment of ADHD in a pediatric population, especially in light of ADHD’s similarities with other diseases and its common comorbidities.

Maaks explained that although parents and teachers may be more familiar with ADHD and may identify a child’s symptoms as such, this does not necessarily mean that ADHD is the underlying issue. Anxiety, depression, tics, or complex ADHD may be occurring, in which case treatment with ADHD medication may not be the correct approach and could also cause harmful adverse effects.

“In primary care, part of the reason we see failures in medication is that it’s very hard to get the developmental history we need to rule out symptoms of other diseases in a brief 20-minute appointment,” Maaks said during her lecture at the virtual conference.

In order to diagnose a child with ADHD, symptoms must cause significant impairment in more than 1 domain. Also, symptoms must be developmentally inappropriate for the child and must present before the age of 12. If the symptoms begin after age 12, then the child does not have ADHD, and something else is occurring that requires further investigation.

Maaks explained that there are risk factors that may support the correct diagnosis of a child. These risk factors include family history, trauma, lead exposure, premature birth/low birth weight, prenatal and intrapartum complications, maternal substance use (especially alcohol and tobacco), maternal pregnancy illness, maternal depression and/or psychosocial stress, parenting stress, socioeconomics, and prefrontal cortex and subcortical brain changes.

The problem in diagnosis lies in how the symptoms of ADHD often occur with issues such as depression. For example, people who are depressed have difficulty concentrating and staying on task. This may cause such individuals to read and re-read the same thing multiple times. Additionally, children suffering from depression may also be fidgety. These are all symptoms that often can get identified by parents and teachers as ADHD.

“When I get kids who have failed first-line medications, I go back and I do a thorough history,” Maaks said. “I find out that, for example, their mom used substances or alcohol during pregnancy, and what we might have is a child who has inter-uterine exposure to neurotoxic substances that don’t manifest themselves until later on. This is because that higher executive functioning has been impaired by the damage that’s been done.”

Additionally, a child with anxiety may present with some similar symptoms as a child with ADHD. For example, people who are anxious may appear impulsive, hyperactive, or fidgety due to their anxiety.

According to Maaks, it is very common that anxiety may get initially labeled as ADHD because parents and teachers are more aware of ADHD. The signs and symptoms of anxiety can include somatic complaints; crying, irritability, and anger; and some OCD behaviors. Common sources of anxiety can include academic performance, athletic performance, timeliness, and fear of bad things happening.

Maaks explained that what is important in the diagnosis of anxiety or ADHD is establishing that the functioning is not developmentally appropriate, as many kids may be a little hyperactive if they’re bored. So being hyperactive does not mean a child has ADHD or anxiety.

“Sticking children in the backyard, going out on a bike ride with them, or letting them run around a park and burn off energy—those can be as effective as a medication for some children,” Maaks said in an interview with Pharmacy Times®.

However, for cases in which medication has been pursued and a child has responded poorly to it, complex ADHD may also be a possibility. This is defined as ADHD that is co-occurring with 1 or more learning, neurodevelopmental, or psychiatric disorders. For example, if a child has both ADHD and anxiety, then the child has complex ADHD.

Complex ADHD is applicable if the child is under 4 or over 12 years old; has coexisting, impairing conditions (neurodevelopmental, mental health, medical, or psychosocial factors); and moderate to severe functional impairment. Additionally, complex ADHD may be the correct diagnosis if there has been diagnostic uncertainty and the child has had an inadequate response to treatment.

“When you have a kid with complex ADHD, such as a kid who has both anxiety and ADHD, then your non-pharmacologic interventions have to include teaching them about those conditions,” Maaks said in the lecture. “The child is still going to be a human with good days and bad days, and ADHD can be their superpower because of their ability to hyper focus in on material.”

Maaks noted that it remains important to refer patients to psychologists who can work with children through appropriate therapeutic methods. She mentioned both cognitive behavioral therapy training and Koch’s training have proven effective in the treatment of children with complex ADHD. These treatments can help the child become aware of early warning signs of symptoms in order to not be as overwhelmed when they occur.

REFERENCE
Maaks DG. ADHD 300: Beyond the Basics. Paper presented at: 2020 Virtual Conference on Pediatric Health Care; June 4 – June 5, 2020; virtual. event.vconferenceonline.com/vconference/odplayer_flash.aspx?id=16559. Accessed July 2, 2020.