All About ADHD
ADHD is a significantly more common topic discussed in schools in recent decades. It is being recognized more commonly in children. Due to this, there are always a lot of questions surrounding this diagnosis. What is it? How do I know if my child has signs of this? How does it get diagnosed? What are the treatment options? What can I expect at Pediatrician visits related to this? I hope to give insight into these questions to help you better understand this subject. Some of this information may be more detailed than what you are looking for. Still, I hope to provide enough information for everyone to get the answers they want. At the end of this discussion, there will be references that can be helpful as well.
What is ADHD?
In short, it stands for Attention Deficit Hyperactivity Disorder. The longer answer is that it is a neurodevelopmental disorder that presents itself as inappropriate levels of inattention, hyperactivity, and impulsivity. There is no exact known pathophysiology behind this disorder. However, there is a thought of the dopamine and serotonin receptor dysregulation at the frontosubcortical area being involved. There are varying degrees of inattention and distractibility for most people, but when it starts to negatively impact someone’s learning ability, working ability, or surrounding people’s ability to function daily, then it becomes something that needs to be discussed.
Epidemiology of ADHD
Approximately 9% of the population from 3-17 years of age have a diagnosis of ADHD. It is twice as common in boys than it is in girls. There does seem to be some component of inheritability seen (meaning coming from parents), but it is not fully understood. There is also the suggestion that the environment (how we are raised and what we are exposed to) can also play a part in this disorder. There are higher rates in certain medical conditions, such as Fragile X Syndrome, Autism, Williams Syndrome, Tuberous Sclerosis, Cerebral Palsy, and Learning Disabilities, among others.
Signs of ADHD
The American Academy of Pediatrics suggests undergoing an evaluation for ADHD for 4-18-year-olds who demonstrate academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. These symptoms include not completing tasks when asked, talking out of turn or during inappropriate times, problems organizing themselves for tasks, always getting up or fidgeting during tasks, and not being able to sit for tasks appropriately. Sometimes, these can be harder to see at home as there is less of a structured setting than there is at school, especially for younger ages. Due to this, the consideration of this diagnosis is often brought up by teachers to the parents through observation at school.
Evaluation and Diagnosis of ADHD
According to DSM 5, the diagnosis of ADHD must meet the following criteria: A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by having at least six or more(5 if older than 17 years old) symptoms of inattention or hyperactivity. These must also be present in two or more environments (home, school, after-school program, work, etc.) and have occurred for at least six months. With the diagnosis of ADHD, there will also be a distinction of whether it is inattentive, hyperactive, or combined type. With this in mind, this is a “clinical diagnosis.” That means there is no blood test or imaging that can help with making this diagnosis. There are a few different questionnaires that can help us to make this diagnosis, and most likely, you and the teacher will be asked to fill this form out. These forms can also help us as clinicians to see if other diagnoses could present similarly, and we can address those as well. Our evaluation will also include questions to consider whether things such as learning disabilities could be a part of the symptoms. Due to the complexity of these evaluations, you will have a visit solely to address ADHD.
Treatment Options for ADHD
The two main options for treatment are behavioral therapy and medications. Behavioral therapy can potentially help at any age but has the best evidence in children less than six years of age.
When discussing medication options, you can split the medications into two categories: stimulants and non-stimulants.
Stimulants: This is the most common medication used for ADHD and can work well in both inattentive and hyperactive subtypes. The mechanism of this medication is theorized to help with the dysregulation of the frontal lobe. There are both short-acting (typically 4-6 hours) and long-acting (up to 12 hours) options available. We would start with short-acting to see the effects, as some patients can take a short-acting and have it work for them all day. Potential side effects include appetite suppressant, trouble falling asleep, headache(typically will resolve within 1-2 weeks of starting new medication or dose), and abdominal pain(typically will resolve within 1-2 weeks of starting new medication or dose).
Non-stimulants: Work best for hyperactive subtype, but can potentially work for both. The mechanism of this medication is basically to slow down the hyperactive brain. Again, there are both short-acting and long-acting options available. We would start with short-acting first to see what effects can be seen, then consider long-acting if needed. Potential side effects include drowsiness (this will typically wane away after a few weeks of starting medication or increasing doses), fatigue( this will typically wane away after a few weeks of beginning medication or increasing doses), decreased heart rate, and headache(this will typically wane away after a few weeks of starting medication or increasing doses),
Stimulants and non-stimulants can potentially be used together to help augment each other.
There is an educational component that can be a part of treatment that would include 504 plans or Individualized Educational Plans, in which schools can help accommodate this disorder in different ways.
Substance Abuse and Stimulant Medication
I feel this is important to mention in this discussion as this is likely one of the biggest worries for parents, and appropriately so. Stimulant medications are controlled substances secondary to the possibility of abuse if not used appropriately and how they are prescribed. There are multiple long-term studies related to this that all show that untreated ADHD does have an increased risk of substance abuse but that treated ADHD has a decreased likelihood of substance use disorder compared to the general population. The thought is that the inherent impulsivity that is a portion of ADHD would put them at increased risk of substance use, but if controlled appropriately with medication, it would reduce that risk. This is addressed in a few resource websites at the end.
What to expect at the initial consultation visit for ADHD
The first visit will take the longest in order to sort things out. As discussed, completing forms before the visit will also be important. The most common form we will use will be called the Vanderbilt form. These can be easily found online and can also be found on the Parkside Pediatric website under ADHD forms. We will ask questions about the behaviors you, as the parent, and the teacher are seeing. We will ask questions about grades at school and how well your little one does with certain subjects. We will ask for past family history, not only for ADHD diagnosis but for other relevant medical problems as well. We will then do a pertinent physical exam.
At the end of the visit, we will discuss our conclusions as to whether the symptoms meet the criteria for ADHD. If a diagnosis of ADHD is made, then a discussion of therapy and medication will be next. The discussion with medication will include what type of medication, how they will take it, when they will take it, and potential side effects. If a new medication is started, we typically will follow up with you within a month to see how the medication is working and note side effects.
What to expect at subsequent visits for ADHD
On follow-up visits, you will fill out a short form about how things are going. The clinician will discuss how things have been going in regards to school (teacher perspective) and home, but will also discuss potential side effects that have been noted (change in appetite, aggression, headache, sleep disturbances, etc.). We will also discuss when the medicine seems to be wearing off. Changes can be made at that time if they are needed. If medication changes are made, we typically ask you to follow up in one month for a recheck. If things are going well and no change in dosages is needed, we can follow up every three months.
