Attention Deficit Hyperactivity Disorder (ADHD): TIPS for Pediatricians

Children and adolescents with attention deficit hyperactivity disorder (ADHD) have difficulty regulating their attention and emotions. Concerns about ADHD, as well as about learning disorders, behavioral, and social problems are all on the rise. Parents are looking for answers and for ways to help their children, but are confronting months-long wait lists for evaluations, and deep difficulties in accessing care. Find out more about our services for children with ADHD here, and hear from a panel of Columbia ADHD experts on our webinar, linked to above. At the bottom of this page is a list of resources to share with parents.

What is ADHD?

ADHD is one of the most common neurodevelopmental disorders of childhood, and often lasts into adulthood. Children with ADHD may have trouble paying attention, controlling impulsive behaviors, or be overly active. ADHD symptoms can be severe enough to cause difficulty at school, at home, or with friends.

There are three distinctive categories of attention deficit hyperactivity disorder (ADHD):

Inattentive

• Difficulty focusing and paying attention
• Difficulty with executive function
• Difficulty completing tasks

Hyperactive

• Increased level of motor activity, impulsivity

Combined

• Both inattention and hyperactivity are present in a significant way.

ADHD is difficult to diagnose in children younger than four, and its presentation often changes over time. In younger children, especially boys, hyperactivity is more prominent, while in older children hyperactivity is often less of a problem. Difficulties with executive function may become much more problematic as a child gets older. Girls with ADHD tend to be less hyperactive and have more difficulty with attention, focusing, and executive function. They are often “well behaved” and their condition may get less notice.

Impact of COVID-19

Elementary and middle-school age children who had to attend school virtually missed out on critical social learning opportunities and academic instruction. About 200,000 children have lost at least one parent or other primary caregivers to COVID, which has had a devastating effect on many families.

Other effects of the pandemic include:

• Difficulty distinguishing between an increase in ADHD versus difficult family situations
• Increased severity of symptoms
• Behavioral, social, and psychiatric concerns

Testing for ADHD

The proper age to accurately evaluate and diagnose ADHD is between 6-7 years of age. Some types of testing are more available and easier to access than others.

Psychoeducational testing, usually provided by the local boards of education, is widely available, and often provides sufficient information to delineate needed educational supports. Testing typically includes:

• IQ (Intelligence testing)
• Assessment of adaptive learning skills
• Language screening
• Academic attainment
• Assessment of vision and hearing

Neuropsychological testing is important if a child appears to have complex or significant issues with learning, which could present at any age. This form of testing identifies a child's learning style and any significant emotional and other barriers to learning. Testing usually involves three to four sessions:

• A parent intake to:
  • Obtain developmental and academic history
  • Identify parental concerns
• Testing of the child to measure skills including:
  • Verbal thinking     
  • Problem solving skills
  • Non-verbal thinking
  • Memory
  • Language comprehension
• Assessment of executive functioning including:
  • Attention regulation
  • Impulse control
  • Cognitive flexibility
  • Academic and social skills
• Psychiatric interview, when appropriate
• Consultation with relevant providers including teachers, pediatrician, and others

During a session with the family to review the findings, the evaluating provider will explain the child’s diagnoses and help formulate specific recommendations for the patient, family, and school. Support could include:

• 504 Plan: some modifications and supports that do not require significant school-based resources.
• Individual Education Plan (IEP): a higher level of support services that could include smaller classes; speech/language, occupational, physical, hearing, vision, and behavioral therapies; and assistive technologies

The report may need to be update periodically, depending upon how the child is doing in school and/or if new issues arise.

Management of ADHD

ADHD can be very well managed in a primary care setting by providers who are comfortable with the condition. The most important components of ADHD management are the parents’ (and child’s) understanding of the condition, a close, trusting relationship between the patient, family, and the treating physician, and open communication between the family and the school system. Ongoing feedback from the family and teachers is essential.

Components of a successful treatment plan include:

• Identification of learning, social, behavioral problems
• Identification of significant co-morbidities including:
  • Depression
  • Anxiety
  • Anger management
  • Oppositionality
• Identification of other disorders such as:
  • Tourette syndrome
  • Tics
  • Sleep disorders
  • Restless leg syndrome

Non-pharmacological approaches to treatment

A major component of care of children with ADHD is making sure that they receive appropriate behavioral accommodations within the school setting:

• Preferential seating in the classroom
• Smaller classes with a lower student to teacher ratio
• Teacher cues when child is “off-target”
• Extended time for test taking and completion of work
• Quieter areas for test taking
• Outside tutoring

Behavioral strategies at home, such as:

• Brief and clear instructions for tasks (avoid giving more than 2 tasks at once)
• Behavioral charts with pictures and words (especially for younger children)Work with psychologist and family therapist
• Regular exercise
• Sleep hygiene
  • Elementary school children need 9-10 hours of sleep
  • Adolescents need 9-9.5 hours of sleep
  • Develop a consistent bedtime routine
  • Discontinue all screens an hour before lights off
  • Bed is for sleep only
• Promotion of socialization with peers           

Medication for ADHD

When a child is profoundly struggling with behavioral, social, and academic problems, it may be worth trying medication. Parents may initially have significant resistance to a recommendation to medicate, and it’s important to accept their hesitation and concern. The goals of treatment is not to change a child’s personality or sedate him/her, but to reduce distractibility and improve the child’s ability to focus and learn. It’s important to discuss the treatment, goals, and potential side effects with the child.

When selecting a medication:

• Psychostimulants are usually the first choice, and there is no significant difference between the methylphenidate and dextroamphetamine in efficacy or adverse effects.
• Start with a low dose; the child will probably need dosage adjustments to obtain the optimal result with minimal adverse effects
• While the goal is for a dramatic response that is evident to parent and teachers, the child may not be aware of a change
• Adverse effects may include:
  • Decreased appetite
  • Sleep onset insomnia
  • Headache
  • GI upset
  • Mood change
  • Irritability / aggression
  • Flatness
  • Tachycardia

Second line therapies are used when psychostimulants have intolerable adverse effects, produce an incomplete response, or are contraindicated. These therapies include:

• Alpha 2 agonists
  • Guanfacine – generally preferred as has fewer cardiovascular adverse effects
  • Clonidine
• Norepinephrine reuptake inhibitor (NRI, NERI)
  • Atomoxetine (Strattera)

Prognosis and Outcome of Childhood ADHD

Most children have a good response when they receive pharmacological and behavioral treatment for their ADHD. Adolescents are significantly undertreated for ADHD and may have continuing symptoms into early adulthood.

Children with untreated ADHD:

• Are less likely to complete high school and to continue to university or vocational training
• Go on to have lower lifetime income and economic attainment
• Have increased likelihood of involvement with the legal system
• Have increased risk of automobile, bicycle, motorcycle injury / death

Contributors

Jay E. Selman, MD, MS, Professor of Neurology and Pediatrics, Columbia University
Gabriella Paskin, MD, Assistant Professor of Pediatrics, Developmental Behavioral Pediatrics, Columbia University
Katelyn Selver, PsyD, Instructor of Medical Psychology (in Psychiatry), Pediatric Neuropsychologist, Columbia University.

Resources