How Caring for Children with ADHD Has Changed, May Progress in the Future

Alana Hippensteele: Hi, I'm Alana Hippensteele from Pharmacy Times. Before we get started, one of our top articles today discusses how a recent study that is the first of its kind demonstrated that there has been a decline in cancer-related deaths following the adoption of the Affordable Care Act in states that adopted it. There’s more of that on PharmacyTimes.com.

Today, I’m speaking with Dr. Dawn Garcon Maaks, the Immediate Past President of NAPNAP and the Associate Professor at the University of Portland in the School of Nursing, on caring for children with ADHD in advance of her presentation on the subject at the 2020 Virtual Conference on Pediatric Health Care.

How has caring for children with ADHD changed over the years?

Dawn Garcon Maaks: I think it was just like I said when I was in my NP school. I remember, you know, Oh my gosh, we're gonna talk about ADHD now. That's mental health! We’re peeds people, we don't do that. So I think we've kind of gone from this stigma of not knowing what it is to the flip side, and now people come in and say, Well my teacher said she can’t tell me my kid has ADHD, but she thinks he does and he needs medicine. And I start saying, Okay, have they done any school testing, have they figured out if this is a learning disorder? You know, Is this in fact happening in 2 domains because if it's just happening at school and it's not happening outside of school, that to me sounds like an intellectual or learning disorder and not an attention deficit disorder. Is it just happening at home and the kid does fine at school? In which case, there might be some interplay between the adults and the child in the home that might be contributing to some of those behaviors.

So, I think we've gone from not wanting to talk about it, talking about it like it’s a dirty word. I vividly remember the first couple of times I talked to parents about putting them on stimulants, they were like, I don't want my kid to be addicted, and he's gonna be a junkie. I don't think we feel that way now. I do feel like people are, and rightly so, a little concerned about what are the long-term effects, and I don't know that I want to subject my child to taking medication every day for the rest of their lives, and that's where I think having conversations around if we can set them up with behavioral modification, as this child developmentally gets better, he may be able to get off medication for this isn't necessarily something they have to do their whole life. But if a child is not doing well socially, if their grades are poor, they're not learning what they need to learn, and we know they have increased injury risk and all the other comorbidities that we know of untreated ADHD, to me it sounds like if we can use a little bit of medication—and I am of the start low and go slow crew, I openly admit to that—if we can start with a low dose and a teeny amount, like you know 18 milligrams of extended-release methylphenidate, and it changes this kid's world, well that's the kind of kid that probably will grow up to the point that they may not need medication in the future, and we should celebrate that. We should celebrate that they develop the skills that they needed to be successful, and that they didn't have to be managed by medications.

Alana Hippensteele: Yeah, absolutely. How do you see caring for children with ADHD progressing in the future?

Dawn Garcon Maaks: That's a question! There's a part of me that goes, you know, artificial intelligence is going to dramatically change health care in the next 5 to 10 years. Some of us are going to be replaced, honestly, and given the fact that in some instances, computers do better jobs at diagnosing in some circumstances, that may or may not be a bad thing. That's a coffee talk, Discuss amongst yourselves. You can have that conversation on your own, and whatever your belief is on that.

So, I do see that happening, I could see better diagnostic precision, maybe over time as we do more of the psychiatric epidemiologic studies of really looking at the population level because anytime you just deal with people that are seen in clinic, you're getting the worst cut of any condition, you know, when you go out and you look at symptoms in the general population, then you see the full spectrum.

So, a lot of our recommendations and evidence are based on the worst of the worst that show up at an academic medical center because the majority of kids never step foot in an academic medical center their entire childhood. And so all of our recommendations are based on that population, so I could certainly see, you know, with like big data and data analytics starting to get a better idea of what that spectrum looks like and maybe identifying kids better. You know, I would love to see something that is as efficacious as the stimulants without the side effect profiles that come with them.

I think there is a financial incentive to the development of drugs that people will be on for a long time, and so I wouldn't be surprised that there aren't some exceptionally smart people that are working on that as we speak. So, I'm sure there will be different approaches. I just don't see human development evolving to the point that kids in 50 years are that much different than kids are today. So, I mean I think this always going to be an issue. In 50 years from now, are they gonna look back and go, You filled out a piece of paper and looked at what the teacher said and the parent said, and then you did this 20 minute interview, and that's how you figure it out? I think some of that probably will be different, but I will tell your readers, I have made many a prediction in the 30 years I've been a nurse, and I'm rarely right. So, I certainly wouldn't go hedging any bets on what my opinion is today.

Alana Hippensteele: It can be very hard to make accurate predictions about the future, specifically in relation to understanding mental health or AI or technology because we really have no idea.

Dawn Garcon Maaks: No we don’t. And I think, you know, there's a big push on psychogenomic analysis, and, as many of us are aware, there was testing for ADHD and then that proved not to be evidence-based, and so we got rid of that, and so we're not doing that anymore, but I'm pretty sure there's a company that's working on that right now. But I do have full faith and confidence that we're still gonna have kids with ADHD, we're still gonna have adults with ADHD, we're still gonna have companies that are trying to figure out a way to help us identify them, and help us figure out which medication works because, as we all know, this is not, you know, amoxicillin is a first-line for upper respiratory tract infections that 90% of the time is going to knock it out. There's a lot more personal variability as far as tolerance, as far as response to our psychoactive drugs. And so, I think 10 years ago we never would have talked about the prefrontal cortex, the amygdala, the nerves in the patients, this pathway and that pathway, and how this medication affects the GABA receptor versus the serotonin receptor. We never would have had that conversation 10 years ago because we've grown leaps and bounds in our understanding of the central nervous system and how it functions, and therefore understanding why these medications work.

But what I what I can guarantee is it's still going to be an issue. I think we're going to have a better understanding of how the brain works and why the brain works, and I think as we develop, we're going to do better and not have as much failure with our first lines as we do now because I think we'll be able to have more targeted approaches to that individual’s biology, if that makes sense. It would be a cool, like a Jetsons moment.

Alana Hippensteele: I'm looking forward to getting some, I don't know, little tech thing to be able to tell me what's wrong and what needs to be fixed.

Dawn Garcon Maaks: That and I need Rosie to clean my house.

Alana Hippensteele: I'm all for that. Alright well, thank you, Dr. Maaks, so much for taking the time out to speak with me today. Now, let's hear from some of our other MJH Life Sciences brands on their latest headlines.