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Attention Deficit Hyperactivity Disorder (ADHD) in Children

Melanie Cole (Host): ADHD is the most commonly diagnosed behavior disorder of childhood and here to tell us what that means is my guest Dr. Jose Ferreira. He’s the Chief of Pediatric Neurology Division at St. Joseph’s Children’s Hospital, part of BayCare Health. Dr. Ferreira tell us a little bit about ADHD and what’s the difference? People hear ADHD and they hear ADD. What’s the difference between those two?

Jose A. Ferreira, MD (Guest): ADHD stands for Attention Deficit Hyperactivity Disorder. ADD is Attention Deficit Disorder. And there is a difference in terms of quantitative and qualitative symptoms so that some children with ADHD may have predominantly inattentive type and some can have the more impulsive type and then some can have the combination of both. So, the ADHD in general, gets treated similarly with similar medications when medications are prescribed whether it is ADD or ADHD. So, the definition doesn’t necessarily change the management. It’s mostly a descriptive way for the – to describe the symptoms whether they are more hyperactive or an impulsive or mostly inattentive.

Host: Then let’s talk about those symptoms and red flags that parents might be on the lookout for because sometimes they say oh boys will be boys, he’s just hyperactive, that’s how he is. But what should they be on the lookout for that would signal a visit to their primary care provider for an assessment and an evaluation?

Dr. Ferreira: The importance of evaluating and treating ADHD is number one; whether or not ADHD affects daily activities in the home environment and the school environment or socially so that intervention may be necessary. Some children may have obvious symptoms of ADHD that are not necessarily affecting quality of life significantly and not very likely to require treatments, but I think this is something to be determined based on a very comprehensive history, examining the child and then if any other disorder is suspected to be contributing to the difficulties behaviorally or academically; those need to be addressed first before we can say well it is ADHD and start treating it. So, there are other conditions to look for and also there are children with symptoms that may not have significant affect on their quality of life to be treated. So, it depends on the severity of the symptoms.

Host: So, I mean what would a parent be looking for whether it’s affecting the quality of their life? Are they hearing from the school your child is acting up? Are they noticing that children can’t sit still? Give us some specifics Dr. Ferreira if you would, so that parents know what they are looking for.

Dr. Ferreira: Yes, so let’s say that a child is preschool, kindergarten and early elementary school; children with ADHD usually are going to start having symptoms early on and they may have difficulties keeping up with the schoolwork. They also require more supervision than expected for their age to be able to complete routine activities and schoolwork. They also have difficulties with compliance, getting ready to go to places, and when they require so much supervision and disciplining if you will; then it may start to affect their self-esteem, self-confidence, may start to cause some feelings of anxiety about not being able to get things done, not being able to participate in activities because of having difficulties keeping up with their schoolwork. And that may be a source of frustration and some children may even start to develop some symptoms of oppositional defiant disorder when the ADHD symptoms are persistent and not treated. So, it is important to realize as early as possible that children are having some difficulties associated with it so that the evaluation can be completed to make sure it is not any other disorder but if it’s ADHD, that it is going to be treated.

Host: And I really appreciate how you have reinforced the importance of that evaluation and the consequences of not treating ADHD. So, tell us a little bit about what treatment looks like because some parents are wary. They hear about medications. They hear about possible side effects of those medications. So, doctor, tell us a little bit about treatment and explain some of the medications or cognitive behavioral therapy, some things and modalities that you might use to help a child with ADHD as early as possible.

Dr. Ferreira: Yes, so generally, we expect that parents and teachers are already doing most of what they can do in terms of schedule and organizing activities and by the time a child gets referred to a neurologist for evaluation because of suspected ADHD, it is because it is becoming an issue at home and at school. The decision to treat is based on what I mentioned before and the treatment, usually in the neurology office, we don’t necessarily do any specific therapy, but cognitive behavioral therapy may be helpful with children especially when they are starting to develop some symptoms of anxiety, oppositional defiance disorder that the medications may help with when you treat ADHD adequately, but they still may need some more help than just medications.

There are different types of medications that are prescribed. Some are the so-called stimulants and some non-stimulants. Within the stimulants are those that are derived from methylphenidate and those from amphetamines so there are many different brands that are prescribed based on the specific patient needs such as whether they can take liquid, tablets, capsules, or chewables depending which is the best way to administer the medication and also depending on the duration of effect of medication that we are looking for.

So, some medications for immediate release only last three or four hours, sometimes a little bit longer. Some may go for six or eight hours and some can go as much as 15 or 16 hours and so it depends on the child’s age, what they can take and the duration of effect that we are looking for. And also keeping in mind, other conditions that may be aggravated by side effects of medications especially the stimulants such as insomnia, decreased appetite, weight loss, sometimes they have anxiety, it may be exacerbated, it may be worsened when the stimulant is wearing off so that it may appear the medications are making things worse when in fact, it’s that when it starts to wear off in the afternoon and the evening; some children get some rebound effect and they require a longer acting medication or some other nonstimulant medication to help to get through the rest of the day.

The sleep disorder which is more common in children with ADHD to have comorbidity of sleep disorder, can also be aggravated by the long acting medications that may keep them awake and for that, sometimes they need a separate prescription, something as simple as over-the-counter sleep aids like melatonin or sometimes clonidine, guaifenesin and some children may have decreased appetite enough that they may not be able to stay on the stimulant medication so may need to take something to improve the appetite and sometimes they don’t take the medications when they are not in school if they can be without it on non-school days to improve the appetite. But that is another concern in many children. They may lose weight as a result of their loss of appetite.

Within the nonstimulant medications like I mentioned, clonidine and guaifenesin can be used during the daytime also to help with the symptoms especially in children who tend to get more anxiety as a result of the rebound affect of stimulants sometimes. And then there is also atomoxetine which is Strattera the brand name. It’s a nonstimulant that can be prescribed with or without another medication such as nonstimulant. Strattera may not have as much of a rebound affect because you take it daily to maintain a certain level. And it may have less of withdrawal affects as well as – as far as anxiety or some children may have some tic disorder also that may be aggravated by stimulants which the nonstimulants either help to reduce or to not exacerbate them.

So, we think about all of these other factors that may affect the treatment decisions with ADHD when we prescribe the medications. The first thing is to decide whether or not the treatment is needed and if medications need to be prescribed. Because once you make the decision, then we just have to try to find whatever is best tolerated and effective. We look at the other conditions that may be also overlooked sometimes to make sure that the child doesn’t need to be referred to another specialist, psychiatrist or a therapist, if they have anxiety, if they have some mood disorder. So, it is a very comprehensive evaluation that needs to be done in terms of history taking and examining the child and making sure there is no history of congenital heart disease or any other condition that may be aggravated or may even contraindicate prescribing certain medications sometimes.

Host: Dr. Ferreira what about the family members, as a child with ADHD may be hard to handle for all the members of the family including other siblings? What do you want parents to know about helping their child and helping themselves to overcome some negative feelings or resentment of a child that may be a little bit more difficult to handle? What resources are available? What help is available for the family members?

Dr. Ferreira: Yes, and that is when the therapists can have the most input, helping the family to cope with it because ADHD is not only about academic performance. That is very important because children do get anxious like I said, and it affects the self-esteem where they cannot keep up with things and in addition, children with ADHD may not be able to participate in extracurricular activities as much if they are struggling to keep up.

So, another factor to consider with ADHD is also one of the most genetically determined conditions that we treat. So, whatever I see children diagnosed with ADHD, I also like to remind a family member, the parents especially that it is very common and around 50% of children with ADHD have another relative with ADHD. Could it be another sibling, a parent? And so, if let’s say a child has ADHD, but the parent has ADHD, one of them or both; then it is also important to recognize that, because the entire family dynamics can be affected by having another sibling or parent with ADHD if they are not treated as well. And so, that’ something to keep in mind.

And another is that organizing activities in a certain way, being supportive to the child and obviously communicating with their school is very important to make sure that children are being evaluated in the school to see what special needs they may have in the classroom setting. So, there are some ways to get children help in the school to be able to get through their schoolwork and to take examinations. And so, they do a lot of times, require an individual educational plan and so forth to be able to avoid children getting more anxious and frustrated about not being able to keep up with things.

And even with the treatment with prescription medications, sometimes children do require some extra attention by the teachers and parents to keep up with things. Because ADHD is a daily thing and it doesn’t go away with the treatment. The treatment helps the symptoms, but if you are not being treated or the treatment is not adequate; they are still going to persist. And as they get older, if they are not treated, then all of the other potential complications may take place.

And another fear the parents have which is appropriately brought up during the visit by most parents that they have concerns about potential dependence on medications, addiction and the fear that if you prescribe a controlled medication for ADHD the child may become addicted. So, it’s true that we have to be careful. These are controlled medications. But it is also true that untreated ADHD has more potential for self-medicating later on in life than the risk of addiction when the treatment is needed and is prescribed appropriately.

So, those are very reasonable fears that the parents bring up at consultation and some of the fears they have to initiate treatment. So, understanding the fact that ADHD, when it’s not treated, may end up causing more complications. Children with ADHD are more likely to have accidents, to have more difficulties keeping up with their driving privileges because of impulse control issues and so risky behaviors are more common. Emergency rooms are more common in children with ADHD that are untreated.

Host: Dr. Ferreira as we wrap up here in just the last minute, please give the parents listening, your best advice about recognizing and getting evaluated, their child, that may have ADHD and some hope that they can have as the child grows into teen years that this is a situation that can be managed.

Dr. Ferreira: Yes, so it is important to get over the uncertainty as to whether or not the child should be evaluated because missing the diagnosis and treatment can have consequences as we mentioned. As simple as initially having the primary care physician become aware that there are concerns at home and at school and doing some screening procedures in the primary care office and then they can determine whether the child should be referred to either a child psychiatrist or neurologist, developmental specialist, depending on what the symptoms are.

And that first step is very important and there are some – diagnosing ADHD is not – it doesn’t require specific procedures, like an MRI and EEG, bloodwork. When those procedures are done are because there may be some symptoms that suggest that something else may be going on, sleep disorders, seizures, other not so common disorders may also aggravate the symptoms of ADHD by themselves or appear as if ADHD – first the children who have frequent staring episodes, sometimes they come because they have attention deficit hyperactivity symptoms but sometimes they do have absent seizures. And so, making sure that the evaluation is done in the right place and bringing up the symptoms of concern so that we can determine whether or not it should be a presumed more as another disease process or disorder rather than ADHD.

But once ADHD is diagnosed; then the treatment should follow and the other thing about diagnosing ADHD is that the symptoms may be different in some children. It is not necessarily that the child has to be running around, jumping, constantly on the go, impulsive and in fact, I think the children who are not diagnosed early on are those who don’t show those symptoms of ADHD but have attention deficit symptoms more prominent without the impulsivity and hyperactivity. But the affect can be similar, and the treatment is similar, and the outcome can be similar.

It may be some children who tend to be more hyper and impulsive get treated earlier because of the behavior concerns. Some children who have mostly the academic difficulties and the self-esteem issues and anxiety may not be anxious – I mean may not be extremely impulsive and hyperactive, get treated later because maybe there was not so much concern behaviorally. But the affect can be similar in their quality of life. And I think the evaluation is just as important.

Host: Thank you so much Dr. Ferreira for joining us today and for sharing your expertise for parents about attention deficit hyperactivity disorder in their children and what they can expect as far as evaluation and treatment. Thank you again. You’re listening to BayCare HealthChat. For more information please visit www.baycare.org, that’s www.baycare.org. This is Melanie Cole. Thanks so much for listening.