Learning Objectives

After the webinar, you should be able to:

1. Identify common co-occurring conditions associated with ADHD.
2. Describe key components of a comprehensive ADHD assessment.
3. Discuss effective strategies for environmental, psychological, and biological management of ADHD symptoms.
4. Summarize some of the current research findings on psychiatric treatment

Transcript edited for clarity.

Hi, I'm Josh Feder, and welcome to another Carlat webinar. Today, it's another webinar from the Child and Adolescent Psychiatry team on the comprehensive assessment and treatment of ADHD, attention deficit hyperactivity disorder (ADHD). I'm the Editor-in-Chief at The Carlat Child Psychiatry Report, and I have no conflicts or disclosures relevant to this activity.

Faces of ADHD

 If you've seen people with ADHD, you'll know what I mean. You might have a very active child who is prone to accidents—constantly falling, breaking things, climbing walls, or diving into bushes because they saw something they wanted. These kids are incredibly active and impulsive. Sometimes, they are referred to child welfare teams, with people wondering if they've been mistreated or neglected. It can be challenging to monitor and manage some of these kids, so you may encounter many with this combined type of ADHD. They're inattentive but also extremely overactive.

Then, there are kids who are more inattentive, daydreaming in class, not completing their work, and sometimes becoming depressed because they can't keep up. They’d rather think about something else, but they get in trouble for not paying attention. This can impact their self-esteem. They may start to feel like they're not smart, when in reality, they have an inattentive form of ADHD. This type of ADHD is complicated in terms of treatment and differential diagnosis, which we’ll discuss more later.

Many people with ADHD misinterpret social cues. They might see a neutral face or hear someone calling out to them and perceive it as an attack. They may think they’re disliked or being scolded. This often happens because kids with ADHD are frequently corrected for doing something wrong or not doing enough. They also tend to have an elevated level of internal arousal, making them more likely to be on guard and react negatively, even when the situation is neutral.

Teenagers with ADHD may be impulsive in their daily lives. They might drive recklessly, accept dares from friends, or be more inclined to experiment with substances. These days, being offered street drugs, including pills and marijuana, carries a much higher risk because of fentanyl, which can be deadly. So, we must consider the increased risks impulsive teens with ADHD face in today's world. While we expect teenagers to be active and experiment, those experiments are now even more dangerous.

Irony of ADHD

The irony of ADHD is that the diagnosis isn’t always clear. Many conditions mimic ADHD, and developmentally, things can look different in a differential diagnosis. However, clear cases of ADHD usually improve significantly with treatment.

Let’s dive deeper. Think about a toddler who's overactive. If a young child is referred to you, it may just be a case of a tired parent dealing with a typical child, not necessarily ADHD. But what else could be happening? The child may be under stress from mistreatment or neglect, which can cause hyperactivity. This isn’t necessarily biological ADHD but a response to environmental issues.

It’s rare to diagnose a child as manic in early childhood, but as they get older, especially into their teenage years, it becomes part of the differential diagnosis. Other conditions to consider with school-age kids include anxiety, which can cause overactivity or inattention, and depression, which can also cause inattention. Trauma or bullying may also make a child inattentive. Many kids with ADHD also have learning difficulties. For instance, if a child struggles with reading, they may avoid it, and this can be mistaken for ADHD, though both can co-occur. Similar issues arise with math and writing difficulties.

For teenagers, bipolar disorder might also be in the differential diagnosis, as could substance use, particularly stimulant abuse. One of my fellows at UCSD recently asked me, “What about eating disorders?” My mind went to avoidant/restrictive food intake disorder (ARFID) because I see a lot of it in autistic kids, but we also see anorexia nervosa. Kids with anorexia may be very active and constantly exercising, which could be mistaken for ADHD.

This highlights the importance of conducting a thorough assessment. The key is to carefully consider the differential diagnosis, particularly with inattentive ADHD.

Now, what about treatment? Well, as Russ Barkley would say, you get many more years of quality life if you treat ADHD symptoms. It’s one of the most effective treatments we have in medicine when it comes to using stimulant medications. When they work, people take better care of themselves. They are less likely to suffer from conditions like obesity, diabetes, and heart disease because they can focus better on their health. In addition, there are improvements in academic performance, social relationships, and overall functioning. This is why it’s so important to be careful with your differential diagnosis and to get the treatment right.

In terms of demographics, when good studies are conducted, the prevalence of ADHD is relatively similar across cultures globally, ranging from 5% to 10% of kids continuing into adulthood. Diagnosing adults is a bit harder. ADHD is common. Many people now refer to it as a form of neurodiversity, emphasizing acceptance rather than labeling it a disorder. But that doesn’t mean we shouldn’t offer treatment to those who need it.

Demographics also show that people from minoritized communities—Black, Indigenous, and people of color (BIPOC)—tend to have more ADHD diagnoses, but they also experience more missed diagnoses. For example, ADHD may be misdiagnosed as conduct disorder, or a learning disability may be missed altogether. So, it’s essential to be especially careful when working with people from minoritized communities to ensure you’re not overlooking anything important.

Comorbidities

We’ve touched on this, but ADHD often co-occurs with other conditions. Learning disorders like dyslexia (reading), dysgraphia (writing), and dyscalculia (math) often appear alongside ADHD. In these cases, kids may struggle with those subjects partly because they can’t focus, which can be misinterpreted as a lack of attention rather than a specific learning difficulty.

Oppositional defiant disorder (ODD) frequently co-occurs with ADHD. Personally, I try to avoid labeling kids with ODD because it can be a pejorative diagnosis. Usually, the child is struggling with something internally, which leads to oppositional behaviors. Labeling them as "defiant" biases people against the child. If we address their unmet needs, we may see those behaviors disappear.

Conduct disorder is also often diagnosed alongside ADHD. Impulsivity can lead a child to act out or violate the rights of others. But if you treat the ADHD, those symptoms may diminish. Do we still call it conduct disorder, or is it ADHD with aggressive tendencies that needed treatment? We’ll explore that later.

Substance use disorders are common in people with ADHD, often due to impulsivity or the usual reasons people use substances—to feel better or fit in with others. ADHD also frequently co-occurs with mood disorders. Kids with ADHD often feel like everything they do is wrong. They’re constantly being told to "pay attention" or "stop doing this or that," which can contribute to depression or anxiety. Being depressed also makes it harder to focus, complicating the diagnosis. Some medications used for ADHD can help with depression, including stimulants and certain nonstimulants, which we’ll discuss further.

There are high rates of ADHD in people with autism. Over half of autistic individuals exhibit ADHD symptoms, and many carry a concurrent diagnosis. Bipolar disorder often includes ADHD as well. Treating both conditions together generally improves the outcomes for each.

Post-traumatic stress disorder (PTSD) can also co-occur with ADHD, partly because individuals with ADHD may end up in risky situations that lead to trauma. They might get injured in accidents or find themselves in situations where they’re mistreated because they didn’t anticipate the risks. While mistreatment is never the fault of the person, it’s harder for people with ADHD to navigate and prevent these situations.Poor executive function can look like ADHD, especially in conditions like schizophrenia or even after certain illnesses, like COVID, which can affect cognitive function. Similarly, head injuries can lead to ADHD-like symptoms for six months or more. In those cases, treating the symptoms like ADHD can be effective, but it’s important to consider the underlying cause and adjust the approach accordingly.

Assessment

A thorough history should include a family history of neuropsychiatric and medical problems, including ADHD, as there’s a strong genetic component. You’ll also want to look for co-occurring symptoms and consider any family history of cardiac issues, particularly when considering stimulant medications. A significant cardiac history might necessitate getting an EKG or a cardiac consultation before starting stimulants. Endocrine problems like thyroid issues and infections can also play a role.

As for the physical exam, I like to take my own vital signs. I have a scale and measure height, and I take blood pressure myself. These are important to track for nearly all the medications we use for ADHD. It’s also essential to perform a general physical exam to rule out any other illnesses that might be affecting the child’s ability to pay attention.

Next, we consider nutrition. If a child has food insecurity or a poor diet, this can affect their ability to focus. There’s some discussion about whether a high-sugar diet or high-salicylate foods—like purple grapes or red apples—contribute to ADHD symptoms. Vitamin D deficiency is another consideration, especially in kids who spend a lot of time indoors. Addressing sleep is crucial too. Sleep apnea or poor sleep can lead to symptoms of inattention, impulsivity, and difficulty focusing. Improving sleep can sometimes alleviate ADHD-like symptoms altogether.

I always get collateral information from teachers when I can. I often use a simple rating scale, like the Child Attention Profile, because it’s easy for teachers to complete and gives you a sense of where the child falls compared to their peers. You can also ask teachers or others who know the child outside of the home about their attention, focus, and activity levels. Direct observation is ideal, when possible, whether by video from the parents or a home visit. School visits can also be helpful, though privacy concerns usually prevent recording. Seeing the child in their environment can give you valuable insights.

Computerized tests can be useful, but they don’t make the diagnosis. They support or challenge what you already know. These tests can include measures like the Conners Continuous Performance Test (CPT), which looks at attention and impulsivity. But keep in mind that they are tools, not diagnostic criteria.

In terms of treatment, you’ll need to start by establishing rapport and discussing ADHD, its symptoms, and treatment options with both the child and their parents. When parents understand what’s happening, they are more likely to follow through with treatment, and the child feels more supported. Addressing the emotional impact of ADHD, including any co-occurring conditions, is key to improving their overall well-being.

Diet is also important. Avoiding ultra-processed foods and considering dietary factors like sugar or salicylates can be helpful. Ensuring a balanced diet with a variety of foods is essential. For kids with restricted diets, food chaining—a technique to gradually expand the range of foods a child will eat—can be useful. Treating co-occurring conditions, such as anxiety or depression, before starting ADHD medication can also significantly reduce ADHD-like symptoms.

Medications

Now, let’s discuss medications, which many of you have been anticipating. Stimulants are the gold standard for treating ADHD. There are two main types: methylphenidate and dextroamphetamine. Methylphenidate typically has fewer side effects in children, making it often the first-line treatment. Dextroamphetamine is about twice as potent as methylphenidate, so dosing needs adjustment when switching between the two.

When starting stimulants, I begin with a low dose and increase gradually. For methylphenidate, the typical dose is around 0.8 to 1.2 milligrams per kilogram, but I usually start with 5 mg of immediate release to gauge the child's response before increasing the dose. If given too much, the child might become over-focused, which may seem like good behavior but can hinder learning and engagement. The goal is to reduce ADHD symptoms without affecting the child's spontaneity and personality.

Stimulant dosing should be adjusted based on the situation. For example, a child may need a different dose on weekends or families might choose to skip doses to help with appetite and sleep.

Immediate-release stimulants offer flexibility for adjusting doses throughout the day but last only about 4 to 6 hours, requiring redosing during school hours, which can be inconvenient. Kids often need to visit the nurse's office, and since stimulants are controlled substances, they cannot carry them in their backpacks. Extended-release stimulants are more convenient as they last 10 to 12 hours, covering the entire school day. However, I often start with immediate-release forms to fine-tune the dose before switching to extended-release.

As children grow, they may outgrow their dose, necessitating frequent reassessments.

Nonstimulant medications for ADHD include guanfacine and clonidine, which are central alpha-agonists. These are milder than stimulants but can still be effective, especially for specific profiles. Guanfacine lasts about 12 hours (extended-release), while clonidine works for about 4 hours (immediate-release) but is also available in an extended-release version. Clonidine tends to be more sedating and is often used at night to help with sleep if the stimulant causes insomnia.

Nonstimulants generally have a calming effect and do not affect appetite like stimulants, but they can cause sleepiness or lower blood pressure, leading to dizziness, particularly in hot weather or if the child isn’t well-hydrated. These medications can be used in combination with stimulants, often to help with sleep or to smooth out stimulant effects.

Medications like atomoxetine and viloxazine are norepinephrine reuptake inhibitors. Atomoxetine often doesn’t work as well in my experience, though some benefit from it. Viloxazine is newer, originally developed for other uses, and later found to be somewhat effective for ADHD, though the criteria for efficacy may have been adjusted. These medications, like antidepressants, can have side effects such as increased blood pressure, agitation, or even suicidal ideation in a small percentage of people, so I use them infrequently but they can be helpful in certain cases.

Recent research has shown that autistic kids respond similarly to stimulant medications as their nonautistic peers with ADHD, which has increased my confidence in prescribing stimulants to autistic children. I still frequently use guanfacine for managing irritability in autistic children.

One interesting observation is that some children, particularly those who become irritable when coming down with a cold, may be crankier on guanfacine. I always ask families about this as part of my assessment to decide if guanfacine is the right choice.

Regarding aggression in ADHD, a study by Blader showed that a thorough stimulant trial can manage aggression in 60 to 80% of cases. If this doesn’t work, medications like valproate or risperidone might be used, though these have more side effects but are often effective for treating aggression.

When talking to kids about ADHD, emphasize neurodiversity. ADHD is common—about 5 to 10% of the population has it—and traits associated with ADHD might have been beneficial historically for spotting danger or responding quickly. Frame ADHD as a difference with value, while helping kids manage its challenges.

Discuss different learning styles with kids. Some learn better through movement or hands-on activities, which our educational system doesn’t always support. Allowing experiential learning helps children with ADHD internalize lessons better.

When talking with parents, minimize extra reading and homework, as they can get frustrated helping their children with ADHD. Provide supportive guidance and encourage parents not to lose their cool or get angry, as children with ADHD often feel they’re always doing something wrong. Help parents embrace their child’s energy and understand that ADHD is part of who they are.

Offer a long-term perspective. Many children with ADHD improve in their late teens or early 20s as their prefrontal cortex develops. This knowledge can give parents hope and help them stay calm during tough times. Building daily habits early, like knowing where their backpack and lunch are, and maintaining routines, helps as children become more independent.

Remember parents’ well-being too. Parenting a child with ADHD can be exhausting. Ensure parents address their own mental health needs and seek treatment if necessary.In summary, ADHD cases vary widely. Some are straightforward, while others are diagnostic puzzles. If treatment isn’t working, reassess and continue exploring the diagnosis. ADHD can be complex, and solving it may require addressing multiple factors.

CARLAT TAKE

References
Fiske A et al, Annu Rev Clin Psychol 2009;5:363-89
Husain-Krautter S, Ellison JM, Focus (Am Psychiatr Publ) 2021;19(3):282-293
Reynolds CF 3rd et al, World Psychiatry 2022;21(3):336-363
Blader JC, et. al J Am Acad Child Adolesc Psychiatry. 2021 Feb;60(2):236-251

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