Evaluating and managing ADHD in children

ADHD is a neurobiological disorder that significantly affects executive functions, including inhibition, vigilance, working memory, and planning. Functional neuroimaging has shown differences in brain volume, particularly in the cortical white and gray matter, as well as in the frontal and temporal lobes of individuals with ADHD. While brain imaging is not used for diagnosing ADHD, it is useful for understanding neurobiological differences.

Genetic factors play a substantial role in ADHD, with research indicating the involvement of at least seven chromosomes and eight gene loci. Dopamine receptors, transporters, and serotonin receptors also contribute to ADHD's genetic component. Non-genetic factors include perinatal stress, low birth weight, prematurity, traumatic brain injury, maternal smoking, and severe early deprivation.

The DSM-V now includes guidelines for managing ADHD in adults, reflecting a broader understanding of the disorder’s persistence into adulthood.

SCREENING AND DIAGNOSIS

Screening for ADHD can be integrated into routine check-ups of children in primary care by inquiring about symptoms like impulsivity and hyperactivity. Tools such as the Paediatric Symptom Checklist are useful for screening children aged 4 to 16. ADHD symptoms often become apparent through challenges at school or in other settings.

The DSM-V criteria for ADHD include both inattentive and hyperactive-impulsive symptoms. For a diagnosis, symptoms must be present before age 12 and be evident in at least two settings (such as the home and school).

The symptoms must persist for more than six months and cause significant impairment in social, academic, or occupational functioning. The DSM-V has increased the age threshold from 7 to 12 years to accommodate cases where symptoms are recognised later.

TYPICAL SYMPTOMS

The classic symptoms are:

Inattentiveness: Difficulty sustaining attention, not listening, not following through on tasks, disorganisation, losing things, distractibility, and forgetfulness.

Hyperactive-Impulsive: Excessive talking, interrupting others, difficulty waiting for turns, and being constantly on the go.

EVALUATION

Evaluation for ADHD involves a thorough history, including parent and teacher reports, and using validated screening tests like the Vanderbilt Assessment Scales. The process often takes several visits and includes assessing whether other psychiatric disorders and developmental conditions are present.

It is important to rule out other conditions such as anxiety, depression, trauma, and sensory impairments. Comorbidities may include oppositional defiant disorder, learning disorders, anxiety, and depression. Use specific screeners to assess these conditions.

TREATMENT APPROACHES

Behavioral interventions: For preschoolers (ages 3-5), parent training in behaviour management is a grade A recommendation. Medication, such as methylphenidate, is recommended if behavioural interventions are insufficient, particularly in severe cases.

Medications: For older children (ages 6-12) and adolescents (ages 12-18), evidence supports the use of FDA-approved medications combined with behavioural therapies. Medications like stimulants and non-stimulants can be effective, and they should be prescribed based on the patient’s assent and in conjunction with behavioral therapies.

Behavioral strategies: Implementing classroom adaptations and behavioral interventions can significantly aid children with ADHD. This includes strategies like preferential seating, modified assignments, and frequent breaks. Resources such as those from CHADD (Children and Adults with ADHD) provide valuable information on managing ADHD.

Practical, freely available resources are invaluable for managing ADHD effectively. The Vanderbilt Assessment Scales are validated instruments designed to evaluate ADHD symptoms and comorbid conditions. The second edition of these scales is available for free, while the third edition is included in the American Academy of Pediatrics (AAP) toolkit.

TOKEN ECONOMIES

Token economies are a structured method of reinforcing desired behaviors, particularly effective for children with ADHD and younger kids. This approach involves awarding tokens, such as stickers or points, immediately after a child exhibits a desired behavior. These tokens can then be exchanged for rewards. The system needs to be immediate and concrete, making it particularly beneficial for children with ADHD, who thrive on quick reinforcement.

To implement a token economy, you can use simple tools at home or in school. For example, you might use a chart where children earn stars for positive behaviors. Accumulating a set number of stars (e.g., five) could result in a small reward. This method is also applicable for managing behavior in classrooms and at home, as children quickly become invested in the system and often remind adults if they haven't received their tokens.

COMBINING THERAPY AND MEDICATION

When treating ADHD, a combination of therapy and medication is often the most effective approach. Therapy, which focuses on behavioural strategies and skill-building, complements medication, which helps manage the neurological symptoms of ADHD. Sometimes, appropriate use of medication can reduce the need for intensive therapy, and vice versa. However, genetic factors, such as a family history of ADHD, can impact treatment efficacy. Parents with untreated ADHD may inadvertently affect their child's treatment success.

MEDICATIONS FOR ADHD

Stimulants: Stimulants are commonly used to treat ADHD and are effective for about 75% to 90% of children. They are categorised into two main types: amphetamines and methylphenidates. Amphetamines come in both short-acting and long-acting forms, with long-acting formulations often preferred in children with a risk of substance abuse due to their lower potential for misuse.

Methylphenidates, which are also available in short-acting and long-acting forms, work by increasing the levels of certain neurotransmitters in the brain, thereby improving attention and reducing impulsive behaviors.

When starting stimulant medication, it's best to begin with a low dose and gradually increase it, monitoring for side effects. Common side effects include headaches, abdominal pain, decreased appetite, sleep issues, and mood swings. These usually improve over time, but if they persist, adjustments might be necessary. Short-acting medications are often preferred for younger children as they wear off within 4-6 hours, minimising the duration of any adverse effects.

Atomoxetine: This non-stimulant is effective for about 55% of children with ADHD. It usually takes about 6 weeks to see full effects. Atomoxetine has a potential risk of suicidal thoughts in children, though such cases are rare. Side effects may include gastrointestinal issues and sedation.

Alpha-2 adrenergic agonists (guanfacine and clonidine): These can be useful for children with mood lability or tics exacerbated by stimulants. They should be tapered off slowly to avoid rebound hypertension and can cause side effects like sedation and dry mouth.

ADJUSTING TREATMENT

If stimulant medications fail to improve symptoms or cause intolerable side effects, it might be necessary to reconsider the diagnosis or switch medications. For example, if increasing doses of stimulant medications does not reduce core symptoms, a consultation with a mental health specialist might be warranted. Sometimes, trying a combination of stimulant medications or switching to non-stimulant options might be necessary.

For children with persistent issues despite medication adjustments, a comprehensive reevaluation is essential. This could involve considering other diagnoses or exploring alternative treatments.

CONCLUSION

Effectively managing ADHD involves a combination of behavioural strategies like token economies and appropriate medication management. By understanding the types of medications available, their effects, and potential side effects, as well as utilising resources like CPAN, caregivers and professionals can better support children with ADHD. Regular assessment and adjustment of treatment plans ensure the most effective management of ADHD symptoms, leading to improved outcomes for affected children.

Images: Shutterstock.com

REFERENCES

Chang, JG, et al, 2020. ADHD in Children: Common Questions and Answers. American Family Physician, Volume 102, Number 10.

Coelho, LF, et al, 2015. Use of Cognitive Behavioral Therapy and Token Economy to Alleviate Dysfunctional Behavior in Children with Attention-Deficit Hyperactivity Disorder. Front Psychiatry. 2015 Nov 25;6:167.

Coghill, D, et al, 2023. The management of ADHD in children and adolescents: Bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). European Child & Adolescent Psychiatry (2023) 32:1337–1361.