MIAMI BEACH – To avoid mistakes in the management of a child with attention-deficit/hyperactivity disorder, consider the patient's receptive language age, comorbidities such as depression, and medication to protect a young child when a parent is very intolerant of the child's behavior, Dr. David O. Childers recommended.
Attention-deficit/hyperactivity disorder (ADHD) is complex and not a stand-alone diagnosis, said Dr. Childers, a neurodevelopmental pediatrician. Look for a grouping of social, behavioral, and attention issues, as well as immaturity of fine and gross motor skills, judgment, and/or learning.
Errors in stimulant dosing, untreated insomnia, and missing ADHD inattentive type in an adolescent are other pitfalls to avoid, Dr. Childers said at the annual Masters of Pediatrics conference sponsored by the University of Miami.
Begin with assessment of receptive language age. “Our receptive language defines our behavior. We all have conversations in our heads. If the conversation in your head is at the 3-year-old level, your behavior will be like a 3-year-old,” said Dr. Childers, who serves as chief of the section of developmental pediatrics, University of Florida College of Medicine in Jacksonville.
Medications make a difference, he said, “But they are a Band-Aid approach–they do not make the problem go away.”
Dr. Childers outlined the following possible mistakes in management of ADHD:
▸ Mistake 1: Automatic prescription of stimulants for a hyperactive 3-year-old. A physician might want to dose “the hyperactive child who is jumping off the chair and up on the exam table … but is it the right thing to do?” Dr. Childers asked. The medication will allow the young child to focus their attention where they want to, and “a 3-year-old is nothing but a walking 'id.' They want it, they want it, they want it now,” he said, whether it's a toy or their own personal needs met.
▸ Mistake 2: Not dosing a young child for protection. A possible exception to the first mistake is the scenario of a “really, really hyperactive 3-year-old with a really intolerant parent. There is a subset of children who have a desperate need for protection,” he said. “Sometimes the stimulant is important at this age” in such cases.
▸ Mistake 3: Inappropriate initial dosing. There can be, for example, a 5-year-old who is extremely emotional, a zombie, or absolutely intolerable after starting a particular medication. “I get a lot of these referrals,” Dr. Childers said.
A prescription of 5 mg of methylphenidate is 2.5 mg of the L isomer and 2.5 mg D isomer, or 2.5 mg total of active isomer.
“Part of the problem is we start frequently with the mixed amphetamine salts 5 mg,” he said. This is 5 mg of active isomer. “So starting them on mixed salts is double the dose [we give with methylphenidate]. This is not the ideal [starting] dose for the average 4- to 6-year-old. I'm not saying you're not going to get there, anyway, but do you want to start there?”
▸ Mistake 4: Confusing the first effective dose with an ideal dose. “We find a dose that is effective, and we leave it there. We make the mistake of settling for lowest effective dose, not the best dose,” Dr. Childers said. Parents in this situation might say, “He tried the medicine–it didn't work” or “The medicine worked for a little while, but then his body got used to it.”
▸ Mistake 5: Neglecting comorbidities. “This is where some people start to make mistakes,” he noted. ADHD might be primary, and it might be secondary. Learning disabilities, oppositional defiant disorder, conduct disorder, anxiety, depression, encopresis/enuresis, and poor self-esteem are among possible comorbidities.
Parents will ask, “What did you do to my kid? He is crying all day, upset all the time since starting the medication.”
“Many times I diagnose childhood depression,” Dr. Childers said. “Childhood depression can look like ADHD in many cases.” ADHD incidence is 6%–10%, childhood depression incidence is 10%, and they can be comorbid. “You think it's hard to talk to a parent about putting a child on a stimulant, try to talk to them about putting a child on Prozac.”
▸ Mistake 6: Not detecting drug diversion. “ADHD is inherited. It is one of the most heritable conditions we know of,” Dr. Childers said. “You find a child with ADHD, the likelihood you'll find a parent with ADHD is 0.8.”
He added that there are exceptions, but sometimes “my goal is to see how fast I can make the diagnosis in the parent.”
Keep in mind that maybe the child is not the only one who sees the value of the medication. “Parents can divert.” A drug-seeking parent might say, “I need to change my child from the long-acting to the short-acting.” Long-acting agents, in general, have much less abuse potential. In contrast, short-acting stimulants can be divided, and there can be enough to get a child through school and a parent through work.