Alana Hippensteele, Editor

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 

.

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.




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.


Articles

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

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

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 the associate professor at the University of Portland in the School of Nursing, discussed the treatment of anxiety in a pediatric population.

Maaks explained in her lecture that many children have normal fears for their age that are not a sign of anxiety, such as the fear of going down the drain when a drain plug is pulled after a bath. In order for anxiety to be a problem, the anxiety should be impairing their lives.

In the management and treatment of anxiety symptoms by providers, Maaks noted that the child’s own fears should never be used for any form of discipline or behavioral control, as there have been many studies that have shown this to be harmful and ineffective.

Instead, there are treatments available that have proven highly efficacious, such as behavioral modification, CBT, and mindfulness therapy. These treatments can help the child become aware of early warning signs of symptoms in order to not be as overwhelmed when they occur.

Other successful treatment methods include desensitization therapy, which entails exposing the child to their fears in a therapeutic environment. However, desensitization therapy is not generally used in a primary care setting. The reason for this is that if it’s done incorrectly, it can be harmful.

Additionally, Maaks noted that since the classroom environment may be triggering for children, classroom modification and an individualized education program may be necessary for treatment to be successful. Such modification can include extra time for assignments and alternate testing sites, which can help to support the patient in those environments.

In regard to appropriate medication for anxiety, a meta-analysis of 9 randomized clinical trials assessed sertraline, fluoxetine, fluvoxamine, venlafaxine, paroxetine, duloxetine, and atomoxetine for their efficacy and safety in a pediatric population.

The researchers found that both selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors improved symptoms at 2 weeks. However, at week 2 there were class differences that showed that SSRIs worked better with significant differences for the next 10 weeks. Additionally, half of the treatment response for both groups occurred by week 4.

The research also showed that the SSRI treatment response was not different over time for high versus low SSRI doses, but high doses resulted in improved symptoms at 2 weeks.

Maaks noted that duloxetine is the only FDA approved medicine that is specifically used for generalized anxiety disorder. Medications such as fluoxetine, sertraline, and escitalopram have been FDA approved for OCD in children and are also widely used for treatment of anxiety. However, these medications have not been approved by the FDA for anxiety specifically.

There are also other medications that are available for treatment of anxiety that have not been approved by the FDA for anxiety. These include busipirone, buproprione, venlafaxine ER, clomipramine, and atomoxetine.

One area to be cautious of when giving SSRIs to a child is serotonin syndrome, Maaks explained. Serotonin syndrome can be fatal, and may present as agitation, pressured speech, tachycardia, diarrhea, shivering, diaphoresis, mydriasis, clonus, hyperreflexia, tremor, and seizure.

Serotonin syndrome can occur if an SSRI is taken with St. John’s Worst, and it can be stopped with medications such as serotonin-production blocking agents. If this syndrome is occurring, stopping the medication will be necessary, which should also, in turn, stop the symptoms.

Maaks also made note that during treatment with an SSRI, if an SSRI is stopped abruptly without tapering, a condition can develop called discontinuation syndrome. This syndrome occurs more commonly with SSRIs that have a longer half-life, such as fluoxetine, and it can appear like the flu.

Symptoms of discontinuation syndrome can include dizziness, fatigue, irritability, insomnia, diarrhea, chills, paresthesias, and vivid dreams. In some rare cases, psychosis, suicidality, and a feeling of being removed from oneself can also occur.




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.

Although many children have normal fears for their age that are not a sign of anxiety, fears become anxiety when they are impairing a child's life.

Approaching the Treatment of Anxiety in a Pediatric Population

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 the Associate Professor at the University of Portland in the School of Nursing, discussed important elements in the diagnosis and treatment of tics in children with attention deficit hyperactivity disorder (ADHD).

Maaks explained in her lecture that tics and ADHD are commonly comorbid, with certain fears precipitating tics in children. These tics commonly begin between the ages of 4 and 8 years old.

In order to be considered tics, the behaviors must begin by age 18, be present for at least 1 year, and consist of at least 2 motor tics and 1 vocal tic during the course of the disease.

However, Maaks noted that ADHD and tics do not need to present concurrently, although tics should be present during the course of a child’s experience with ADHD. Some patients report that they can initially tell when a tic is coming on, and they can express relief and comfort when they do engage in them. For many children, tics are started by an action that moves from a conscious act to a semi-conscious movement.

Tic symptoms can be treated with methylphenidate, clonidine, methylphenidate and clonidine, guanfacine, and desipramine. Studies have shown that of stimulants used to treat ADHD, a high dose of dextroamphetamine worsen occurrences of tics in one study investigating its use in children.

In the management of tics, a psychotherapy treatment called comprehensive behavioral intervention for tics (CBIT) has the best supporting evidence available. This therapy teaches patients to recognize when the tic is coming on in order to make the movements conscious again. This treatment also aims to help patients identify situations in which triggers for tics occur, develop techniques that promote relaxation, and identify replacement activities.

The clinical practice guidelines from the American Academy of Neurology states that if a patients has tics with functionally impairing ADHD, ADHD treatment should be the main focus for treatment.

However, CBIT and alpha-adrenergics like clonidine and guanfacine can also help, if necessary, following ADHD treatment. Botulism toxin injections for adolescents with simple motor tics or topiramate may also be helpful, while antipsychotics would only be used when benefits outweigh the risks.

Maaks added in her presentation that it is also important to rule out non-tic behaviors, such as fidgeting, compulsions, and stereotypies, before diagnosing a child with tics and pursuing any treatment for it. These other behaviors can resemble tics but have a different source. For this reason, it is important to investigate the cause for tics in order to ascertain whether the behavior is a tic or something else.

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.

At the 2020 Virtual Conference on Pediatric Health Care, Dawn Garzon Maaks, discussed important elements in the diagnosis and treatment of tics in children with ADHD.

Identifying and Treating Tics in Children with ADHD

At the 2020 Virtual Conference on Pediatric Health Care, Susan Van Cleve, DNP, RN, CPNP-PC, PMHS, FAANP, FAAN, discussed identifying and treating anxiety in children and teens, especially in relation to the high incidence of comorbidity in that population.

According to Van Cleve, approximately 15% to 20% of children and teens in the United States suffer from either a mental, emotional, or behavioral disorder. Of that population, 3 of 4 children aged 3 to 17 years who have depression also have anxiety (73.8%), while approximately 1 of 3 children in that age range have behavior problems (37.9%), and depression (32.3%).

“There's so much comorbidity in terms of children and teens who have either depression with anxiety or ADHD, mostly inattentive ADHD, and anxiety, that it really requires that the clinician conduct a comprehensive assessment and evaluation for all these different disorders so that we don't miss a disorder,” said Van Cleve, in an interview with 

Van Cleve explained that since anxiety often exists alongside other comorbidities, it can make diagnosis a difficult process.

“Diagnosis of anxiety requires a fair amount of time. It requires asking a lot of questions and getting information from teachers, parents, kids, the children themselves, as well as looking at their symptoms, and how much those symptoms are interfering with the child’s functioning. We then need to come up with an appropriate diagnosis and treatment plan,” Van Cleve said.

Van Cleve explained that a key term in this evaluation process is the functional impairment of the child in relation to their symptoms. Functional impairment, which occurs when a child does not function in a typical way for his or her age, is a major criteria when considering whether to look into an issue that a child or teen may be having because without that element, a diagnosis of anxiety may not be helpful or relevant.

“So, if a child comes to us with a complaint of inattention in school and we go through our whole evaluation process and determine that the child may have inattentive ADHD but also anxiety, we have to decide what treatment is going to be appropriate because that diagnosis will affect the treatment, and so by doing a thorough evaluation and really looking at the symptoms that are interfering with that child's level of functioning, we can choose the appropriate treatment plan,” Van Cleve said.

She explained further that many times in her practice, she will sit down with parents and children to see what is causing the most harm in the child’s life right now: Is it the anxiety, or is it the inattentive ADHD? Once those needs are made clear by the parent and the child, they are able to determine an appropriate treatment plan based on the right diagnosis.

Screening tools also are a critical tool available for diagnosis of children and teens due to the tools’ ability to provide objectivity, according to Van Cleve. They allow providers the opportunity to hear from people that are not present during the visit, such as a teacher, a daycare worker, a counselor, or a therapist. Furthermore, screening tools allow children to self-report their symptoms in order to inform the provider of exactly what their feeling and their struggles.

“The use of screening tools when diagnosing a child is invaluable, and I really think that we should recommend their use for every practice when screening for depression and anxiety. We screen for all kinds of behavioral issues with our patients; it's very important.”

From this point of diagnosis, since children’s brains are more pliable than adults, Van Cleve explained that children often respond very well to treatment. She added that currently, the strongest evidence-based treatment option available is cognitive behavioral therapy (CBT). CBT is able to act as a method for cognitive restructuring that allows children to change how they think about their lives, how they behave, and how they feel about themselves and their behaviors.

“It's very interesting. Cognitive behavioral therapy does work and children's brains are very pliable, so it's a wonderful thing to see when children can learn these skills and really reframe how they think about things,” Van Cleve said.

Since the FDA has not yet approved any drugs for anxiety in children and teens, CBT is the first option when treating patients, as any pharmaceutical treatments available for children are off-label, according to Van Cleve. She explained that CBT acts either as an adjunct to be used with medication or a treatment before medication is considered.

Van Cleve added that one of the benefits of approaching medication cautiously is the opportunity to build trust with the parents of the child, as they will feel that the provider is not just throwing a medication at a child’s issue.

“I think we have to use medication really carefully,” Van Cleve said. “We have to start at low doses, we have to go slowly, and we need to include the family as part of the decision-making, and as we progress with dosages.”

Van Cleve S. Worrying, Fear and Angst: How to Identify and Treat Anxiety in Children and Teens. Presented at: 2020 Virtual Conference on Pediatric Health Care; June 4 – 6, 2020; virtual. Accessed June 11, 2020.

Since anxiety often exists alongside other comorbidities, it can make diagnosis a difficult process.

Author | Alana Hippensteele, Editor

Articles

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

Approaching the Treatment of Anxiety in a Pediatric Population

Identifying and Treating Tics in Children with ADHD

Management of Anxiety in the Pediatric Population