Massachusetts Child Psychiatry Access Project Clinical Conversations

Recognizing and Treating Attention Deficit Hyperactivity Disorder

in the Pediatric Population

April 26th, 2016Michele Casoli Reardon, MD

MCPAP Medical DirectorMassachusetts General Hospital for Children

at North Shore Medical Center

JL is a 6 year old male who was referred to MCPAP for evaluation of his hyperactivity and mood. The PCP raised a question of Bipolar disorder.

Presented in care of foster mother after being removed from biological mother for neglect and physical abuse.

Prior diagnosis of ADHD and per foster mom had been treated with Adderall and Risperidone when with biological family but family was noncompliant with treatment.

Birth and development was unknown but JL was otherwise healthy and foster mom denied any known concussions or seizures.

Symptoms at time of presentation included issues with focus, concentration, distractibility and impulsivity that had partially responded to Regular Adderall 5mg a day. However, foster mother had noted the onset of facial tics with Adderall and increased irritability.

There was no history of aggression, mood or sleep issues, anxiety, or mania and JL was described by foster mom as a “happy” and “bright” child who was doing well academically in public school.

FH was positive for mom with “mental health issues” and dad with DV history.

CAPS questionnaire filled out at time of MCPAP exam was notable for Severe ADHD and mild to moderate ODD.

JL referred for mood issues and to help with medication management.

History complicated by neglect and trauma. Was on amphetamine but affecting mood and contributing to tics. Off stimulants, noted to be aggressive, impulsive and disruptive

behaviors – noted by foster mom to push peers, cry easily and tantrum with limits.

Although foster mom described JL as a “happy child” she worried that he “had no fear” and would get hurt.

Foster family denied any mood, self injurious or anxiety issues for JL, however it was noted that JL struggled with “night terrors” around 10-11pm which he had no memory of the next day.

Neuropsychiatric testing had not been done in past but was pending through school and DCF. Additionally, JL had both in home and mentoring services through local mental health center.

Incidence is 5-10% of children Exist across all cultures, genders and societies although M>F. Strong genetics/FH but also environmental role [i.e. lead, cannabis]. Important to remember that ADHD is a developmental disorder. Children exist and present along a spectrum. Frontal lobe makes up 1/3rd of brain and is responsible for much

more than just attention and concentration. Therefore, it is not uncommon to see variety of symptoms and co

morbidity that exist in children with ADHD including issues with mood and anxiety.

Important to differentiate those children who are “moody” and reactive ADHD kids so they are not mislabeled.

DSM5 now helped clarified with addition of DMDD [Disruptive Mood Dysregulation Disorder] diagnosis.

Persistent pattern of inattention and impulsivity that interferes with functioning.

Six or more of the symptoms have to be present for at least 6 months and are not developmentally appropriate [5 for adolescents]:

Symptoms of inattention/impulsivity occur prior to age of 12 although patient doesn’t have to present for treatment prior to 12.

Symptoms are presents in two or more settings. There is clear evidence that symptoms reduce quality of functioning

socially, academically, and/or occupationally. The symptoms do not occur exclusively during the course of

another illness [i.e. schizophrenia, substance use]. Changes from DSM-IV include adolescents and adults only need 5

symptoms and age of onset increased from 7 to 12.

Understanding Frontal Lobe function allows for better recognition of ADHD across the spectrum.

Frontal lobe includes parts of premotor cortex, frontal eye fields, language [Broca’s area] and mood.

Functionally, our frontal lobe is arguably among the most underappreciated but most important parts of our brain.

Frontal lobe functions include: attention, processing [PS], working memory [WMI], sensory discrimination, reasoning, organization, motivation, impulsivity, novelty seeking behavior, shifting attention, frustration, fine motor and mood.

This results in children who can present with not only symptoms of ADHD but meeting criteria for sensory integration disorder, mood disorders, oppositional, pragmatic, language and learning disorders.

Anterior orbital portions of our frontal lobe has connections with our limbic system [nucleus accumbens/amydala] which is responsible for fear response, risking and emotional decision making. In children with ADHD these areas are underdeveloped often placing them at risk for high risk taking behaviors including substance abuse.

Studies have shown association between anterior/orbital portions of frontal lobe and disorders such as schizophrenia, bipolar disorder and OCD.

Three predominate types: Hyperactive, inattentive or combined. Females tend to have more inattentive ADHD than males. DSM5 also allows for whether disorder is in remission and the severity. Children may present at any age with variety of complaints and

symptoms including academic failure, oppositional/aggressive behaviors, mood issues, anxiety and social/peer issues.

Being mindful that ADHD is a developmental disorder can help differentiate with other mood and anxiety disorders.

Even in absence of mood disorder, parents often describe their children as “moody”, easily frustrated, and unpredictable.

Unlike a mood disorder, parents describe these symptoms being present from early childhood and may even describe their child as being “colicky” or having history of temper tantrums from the time they were toddlers.

Kids who can’t “self soothe”. Moods don’t take form of discrete periods of days to weeks but are described as “moment to moment” and reactive to environmental cues.

Variety of rating scales to evaluate both with parents and teachers: Connors, ADHD Rating scales, Vanderbilt's etc . . .

Obtain detailed developmental history of mood and behavioral symptoms. Remember episodic nature of mood disorder vs. Neurodevelopmental of ADHD.

Use Rating scales to help in diagnosis

Remember rule is comorbidity and expect children will likely meet criteria for more than one diagnosis

Treatment should be bio psychosocial and involve school accommodations, social skills development, parent training and medication. Do not get

frustrated if having difficulty finding right medication.

Re evaluate using scales during visit to assess need to adjust meds and treatment.

Co morbidity is high for children with ADHD. Important to screen for co morbidity as it contributes to dysfunction in

ADHD. Estimated 40% have another LD. 30-40% anxiety disorder including OCD, Social Phobia, Panic and GAD. 20-30% estimated to have tic disorder. Up to half at risk of a mood disorder [depression or bipolar disorder]. Oppositional defiant disorder and conduct disorders can occur in up to half

of [untreated] children. Increased rates of substance abuse. School truancy*, retention*, failure and drop out. Early marriage, pregnancy, issues with bullying, higher rates of divorce, DV,

accidents/head injuries/MVAs and job loss. Higher risk of suicide and attempt. Half struggle with sleep disorders.

Treatment should be bio-psychosocial.

Important to help psycho educate family regarding ADHD, treatment and course.

Support parents in difficulty of parenting. Refer to support groups.

Social and pragmatic skills groups can be beneficial for many and prevent later issues with bullying.

Special education plans [504/IEP] to allow for accommodations, extended time and help with communication.

Consideration of additional referral/testing to rule out other Learning disabilities may be warranted.

Mainstay psychopharmacological treatment are stimulants.

Consideration of using Methylphenidate preparations for younger children [under age of 12].

Remember that Amphetamines are twice as potent as Methylphenidates when converting.

May need to try more than one stimulant in order to find “right fit”. If child can’t tolerate or becomes irritable with one stimulant, does

not preclude use of other stimulants. Be careful to differentiate between medication rebound and

irritability secondary to meds. Many children with ADHD also require augmentation as stimulants

may not get them through day. Choices include alpha adrenergic [clonidine/tenex],Wellbutrin, and Strattera.

Remember that kids will metabolize and brain able to access meds at different rates. Focus less on dose and more on response and tolerability.

Monitor efficacy and need for adjustment using rating scales.

Diagnosis for JL: Felt that given developmental history issues with attention, behavior met criteria for ADHD, not for mood disorder.

Given history of neglect and abuse, recognized that JL was at risk for Post Traumatic Stress Disorder.

Felt that given young age, amphetamines were likely affecting his mood even though they were helping with focus and impulsivity.

Sleep disorder as well. Recommendations included: Changing Adderall to long acting Methylphenidate preparation [i.e.

Concerta/Metadate] to help with mood issues. Adding alpha adrenergic [clonidine] during day and at bedtime to

help with sleep and potentially persistent tics. Reinforced recommendation for neuropsychological testing and

recommended that JL continue with his services through MHC.

Important to remember that children with ADHD can present doing well academically but struggling in other areas.

Not all moodiness in children is a symptom of an underlying Mood disorder.

Likewise, kids with ADHD can present as “anxious” because of disorganization .

Therefore, don’t equate symptoms to diagnosis.

Being mindful that ADHD is a developmental disorder when screening can be helpful in making diagnosis.

Important to screen for co morbidity, especially in adolescents.

Finding right medication or stimulant for given child can be process and take time.

Questions?