ORLANDO -- You should assess inattentive-and hyperactive-impulsive-type ADHD based on a patient's developmental age rather than their biological age, said David O. Childers, MD, chief of the division of developmental pediatrics at the University of Florida in Jacksonville.
"That is a huge consideration, and the vast majority of pediatricians don't understand that," Dr. Childers said at the annual meeting of the American Academy of Pediatrics.
A diagnosis of ADHD in children should be reserved for situations in which the symptoms clearly interfere with how they function in social, academic, and occupational settings. ADHD should not be diagnosed in children who exhibit hostility, defiance, a failure to understand, or who have oppositional defiant disorder (ODD). In addition, ADHD in children often overlaps with other conditions, such as learning disabilities, ODD, anxiety, depression, poor self-esteem, conduct disorder, motor coordination problems, and encopresis and enuresis.
One mistake you can make is starting the medication too young in patients who exhibit symptoms of ADHD. Receptive language relative to developmental age should be taken into consideration when deciding whether to treat very young patients. "If the voice in your head is at a 3-year-old level, that's going to be your behavior picture regardless of your chronological age," Dr. Childers said.
You also can misdiagnose ADHD in young patients because you don't recognize behavioral phenotypes and diagnoses that are similar to ADHD. Extreme prematurity, global developmental delay, fetal alcohol syndrome, spina bifida, genetic syndrome, intellectual and learning disabilities, closed head injuries, and depression all can mimic ADHD symptoms. "Everything that wheezes is not asthma, and everything that is 'hyper' or 'drifty' is not ADHD," he noted.
Another mistake is considering mixed amphetamine salts (MAS) the same as methylphenidate (MPH), Dr. Childers said. MAS has 5 mg of active isomer versus 2.5 mg in MPH doses, and patients could see side effects from the increased potency in MAS in the form of appetite suppression and tics. You should start with a low dose of the medication and titrate up until patients get the most out of the medication to avoid situations in which patients report a change in personality or that the treatment is not effective.
"The medicine should never change a kid's personality," Dr. Childers said. "We are not here to treat the kid to the point of hyperactivity management; we're here to treat for attention."
In cases where patients ask for the short-acting medication rather than long-acting stimulant, remember that short-acting medication for ADHD has a higher potential for abuse. "Medication diversion is real. It does occur," he said.
Establishing a basal sleep history and whether the child has insomnia is important before prescribing ADHD medication. Dr. Childers noted he uses a short-acting stimulant as an off-label treatment to treat some of his patients with insomnia, but he said to be aware of side effects like headache, abdominal pain, anorexia, and tics, as well as cardiac issues.
You also should rethink your diagnosis if the medication is not having an effect after two trials of a stimulant, Dr. Childers noted, and when a child has conditions like anxiety and depression that can mimic ADHD symptoms, a stimulant will increase irritability and have a paradoxical response to the medication. Inattentive ADHD can be missed in adolescent patients who struggle academically until they fall behind their peers, which can result in developing depression that complicates treatment, he said.
Bipolar disorder can be over-diagnosed in children; in these patients, the most likely diagnoses are ADHD and ODD, he said. According to a 2004 National Alliance of Mental Illness fact sheet, approximately 7% of patients in caseloads for federally funded studies in psychiatric facilities met the criteria for bipolar disorder, but the lifelong prevalence of the disease is between 1% and 1.6%.
"Bipolar disorder is frequently oppositional defiant disorder, and the word 'no' can be a trigger," he said.
Dr. Childers reported no relevant conflicts of interest.
BY JEFF CRAVEN
EXPERT ANALYSIS FROM AAP 18