Treating Children Diagnosed with ADHD: Q&A with Dr. Mark Stein
Mark A. Stein, PhD, ABPP
Dr. Mark Stein, a clinical researcher and attention-deficit/hyperactivity disorder (ADHD) expert who joined Seattle Children’s this spring, addresses questions about treatment choices and other issues related to helping children with this diagnosis.
Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Children’s medical staff and author of the Seattle Mama Doc blog, for submitting these questions.
Q. What is your first-line stimulant medication and why?
A: My first-line medication is usually an intermediate or long-acting methylphenidate- or amphetamine-class stimulant.
In studies where the data is combined for groups of children, about a quarter of individuals tolerate or respond to one formulation more than the other. Identifying the optimally effective and tolerated medication is key for a disorder such as ADHD that often persists through adolescence and young adulthood.
Children’s is among a number of places trying to identify biological and clinical predictors of differential response, which we hope will lead to more personalized care.
Other factors to consider when making medication decisions include the severity and duration of the impairment related to ADHD symptoms – which is very different for a 6-year-old in half-day kindergarten versus a 16-year-old who is driving – availability to the family and whether the child can swallow a pill or capsule.
Q. Are there any new medications primary care physicians (PCPs) should know about?
A: The ADHD formulary has increased dramatically. There are new formulations, delivery systems and treatment strategies that can be individualized, which is where the field appears to be going.
There are also several new ADHD medications in the pipeline. We hope to study some of them at Children’s this year.
Q. Over the last year there have been numerous editorials (in the New York Times, for example) about the overmedication of American children. It has left many of our patients feeling ashamed that they are on stimulant meds. What would you say to PCPs about this?
A: It is very unusual to hear this from patients or their parents. Often, they see the benefits of medication compared to the chronic academic, social and emotional failures associated with untreated ADHD.
It is far more common to hear parents express guilt for not seeking medical attention earlier for their child’s difficulties, especially if they waited until the teen years when their self-esteem is at an all-time low and they are far behind academically.
The overmedication issue is more a symptom of our limited healthcare service delivery system, which artificially distinguishes “mental health” from “health” and is not well coordinated with primary care and with our educational system.
As a society, we need to commit more resources to improving identification and treatment strategies for the broad range of factors that contribute to school failure and behavioral difficulties above and beyond ADHD that are not addressed solely by ADHD treatment.
Q. We often talk about diet changes. What are your top three tips for children with a new ADHD diagnosis?
A: 1. Make sure to eat a good breakfast that includes protein.
2. Focus on exercise and activity as much as food.
3. If taking a stimulant medication, allow small snacks and supplements like protein bars or fruit when they are hungry.
Q. We often talk about sleep as a necessity for attention. What number-one sleep issue do you see that is frequently forgotten or missed during an initial work-up?
A: The initial work-up should include screening for primary sleep problems and obtaining a baseline measure of sleep amount and variability in sleep onset and duration.
Drs. Mindell and Owens suggest screening for BEARS (bedtime problems, excessive daytime sleepiness, awakenings, regularity/duration of sleep and snoring).1
Q. What specific advice can you give on teens with ADHD? When is a good time to try a trial off medications?
A: My advice is that you can be very successful with ADHD. We now have many examples of adults who have done extremely well despite ADHD.
The key is to focus on your strengths and minimize ADHD-related weaknesses. Although this is difficult, especially in school and during key life transitions, there is definitely much to be optimistic about.
For many patients, it is a good idea to plan for a one- or two-week trial off medication to see if they still benefit. This should not be during a high-stress or transition time.
- Source: A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems by Jodi A. Mindell and Judith A. Owens; Lippincott Williams & Wilkins
Seattle Children’s Dermatology and TeleDerm Services
The dermatology team at Seattle Children’s treats many different skin conditions in children, teens and young adults up to age 21.
We see patients with common problems like acne, eczema and warts, as well as less common disorders like morphea and lichen sclerosis. We provide services adult dermatologists may not offer for pediatric patients, like pulse dye laser treatment, surgical procedures and excisions.
The dermatology team is experienced at making complex diagnoses and dealing with conditions that persist despite treatment.
Dr. Robert Sidbury, division chief, noted that quality of life is important when deciding whether or not to refer a child to the dermatology team.
For example, a persistent case of eczema may not be medically urgent, but the constant itching can cause sleep loss and the rashes can be stigmatizing. “We would probably be able to help in a case like that,” Sidbury says.
A comprehensive set of pediatric dermatology referral informaion (PDF) is available. It covers these 10 conditions:
- Herpes simplex, herpes zoster and varicella
- Impetigo and pyoderma
- Inflammatory dermatoses
- Keloids/hypertrophic scars
- Molluscum contagiosum
- Pre-cancerous skin lesions and skin cancers
- Vascular lesions
In some cases, families who live in the south Puget Sound region can consult with the dermatology team without traveling to Seattle.
Seattle Children’s Olympia Clinic offers a TeleDerm service. High-definition TV screens and microphones at the hospital and at the clinic enable doctors to see and communicate with patients and families, and vice versa.
“TeleDerm is very useful for follow-up appointments when we have a known diagnosis and we just need to check how the patient is doing,” Sidbury says. “We also use TeleDerm to see new patients if they have a common condition like acne. In some cases, we see children being treated by adult dermatologists who want to confirm that the medications they’ve prescribed are appropriate for the child.”
TeleDerm is not, however, an option for patients with an unknown diagnosis.
“We need to see those patients in person to make the most clear visual assessment possible and to touch and manipulate the patient as needed,” says Sidbury.
The dermatology team collaborates with radiologists, plastic surgeons, orthopedists, otolaryngologists and other experts at Children’s to treat conditions that require multiple specialties.
Children’s holds three weekly clinics – dermatology/rheumatology, dermatology/plastic surgery and dermatology/vascular anomalies – where patients can see more than one specialist during the same visit.
For additional information, visit Dermatology, Telemedicine and Children's Olympia.
Bellevue CME: Interactive Discussion with Dr. Dennis Christie, GI Specialist
Seattle Children’s Gastroenterology Department presents an interactive discussion with Dr. Dennis Christie. The presentation will cover several cases and offer discussion around each case. Providers may claim category 2 CME.
Location: Seattle Children’s Bellevue Clinic and Surgery Center, 1500 116th Ave NE, Bellevue, WA 98004
Date: July 9 from 6 to 7 p.m.
Appetizers will be served.
RSVP: Please reply by Friday, July 5 to Kristy Dobrauc or by calling 509-834-0222.
Register Now for the 2013 Pediatric Bioethics Conference – Cases That Keep Us Awake at Night: Challenges in Pediatric Bioethics
July 19 and 20 at the Bell Harbor International Conference Center, Seattle.
There are cases that test our moral values, raising complicated ethical issues in our day-to-day care of patients. Frequently, as they search for the proper course of action, clinicians and families seek advice from ethics committees or consultants. Yet, even when these situations are resolved, they may leave us feeling unsettled and uncertain. Did we do the right thing? Did we act in the best interests of all concerned? Could we have done more?
- Should a teenager be allowed to refuse a lifesaving blood transfusion on religious grounds?
- Should an organ transplant be performed over a family’s objections?
- Should Child Protective Services be encouraged to intervene when a family fails to address the eating habits of a morbidly obese child?
- Should healthcare professionals withdraw medical interventions against the wishes of a family?
Renowned leaders in the field of pediatric bioethics will discuss these issues. Join us and add your voice and perspective as we grapple with these ethical questions through presentations and panel discussions.
Learn more and register online.
Upcoming PALS and PEARS Courses for Providers
Pediatric providers and their nursing staff can improve their team-approach model for best outcomes by practicing the American Heart Association (AHA) systems of assessment and team-approach management of respiratory failure and shock in infants and children.
The AHA Pediatric Advanced Life Support (PALS) and Pediatric Emergency Assessment Recognition & Stabilization (PEARS) curricula are building blocks for success with in-class practical management of simulated cases.
Upcoming 2013 classes offered at Seattle Children’s are as follows:
- June 29 to 30 and Nov. 2 to 3: Regular PALS provider courses
- June 29, Sept. 7 and Nov. 2: PALS renewal option, which now includes online plus in-class AHA Heart Code PALS
- Sept. 7: A one-day PALS provider course for physicians and advanced practitioners
- Oct. 4 and 22: PEARS courses for acute care and ambulatory care nurses
For course descriptions and registration information, visit PEARS and PALS.
New Medical Staff and Allied Health Professionals, June 2013
Flavia Consens, MD, University of Washington, Pulmonary and Sleep Medicine
Allied Health Professionals
Michele Frame, ARNP, Providence Regional Medical Center – Everett, Neonatology
Jennifer Patano, ARNP, Seattle Children's, Pulmonary and Sleep Medicine
Jaime Ralston-Wilson, MSTOM, Seattle Children's, Anesthesiology and Pain Medicine