The Quarterly Consult is a quarterly publication highlighting pediatric clinical expertise. If you would like to submit questions for a specialist at Children's to address in the Quarterly Consult, contact Kim Arthur, editor.

December 2011: Implementing the New ADHD Guideline in Primary Care

Dr. Robert Hilt, a psychiatrist at Seattle Children's, addresses questions about the new American Academy of Pediatrics (AAP) guideline for managing attention-deficit/hyperactivity disorder (ADHD). Thank you to Dr. Ben Danielson, a pediatrician at Odessa Brown Children's Clinic and member of Children's medical staff, who submitted these questions.

Q. What would you say are the most important changes in the new guideline?

A. The new guideline talks about managing ADHD in young children and older adolescents instead of limiting the age range to 6 to 12 years. Treatment of 4- to 6-year-olds has been the most controversial. Concerns have been raised about why the guideline recommends methylphenidate, which is not approved by the Food and Drug Administration (FDA) for children under 6 years old, when dextroamphetamine is the stimulant with a FDA indication down to age 3.

However, there isn't research evidence that dextroamphetamine is safe and effective in 3- to 6-year-olds. Its approval by the FDA for preschoolers was a non-data-based decision a long time ago, before we had modern criteria about the quality of evidence required for approval.

The best research evidence about treatment of ADHD in preschool children is for using methylphenidate, not dextroamphetamine. A large, well-designed trial called the Preschool ADHD Treatment Study (PATS) showed that methylphenidate can be used safely and effectively, although there is a tendency for more frequent side effects when given to preschool children compared to older children.

Q. The guideline speaks more strongly about using validated rating tools for evaluation. What rating tools would you recommend for the youngest age groups?

A. Rating scales are very helpful because they help the provider learn about the presence or absence of ADHD symptoms in settings other than when the child is with the parent. It is actually a key diagnostic criterion for ADHD that symptoms must be present in more than one setting.

There is very little research on preschool ADHD rating scales. Most validated scales are for children age 5 or 6 and up. One scale in the public domain has been published with normative data, called Rating Scale IV - Preschool Version (McGoey KE, DuPaul GJ, Haley E, Shelton TL, Journal of Psychopathology and Behavioral Assessment, 2007). It takes the ADHD DSM-IV diagnostic criteria and makes some wording changes to fit preschool children. The Conners Comprehensive Behavior Rating Scale, which is available for purchase, also includes preschool children. The Conners Scale is longer, so it takes longer to score.

Q. Are there any rating tools you would recommend for the adolescent age group?

A. The Vanderbilt, which is arguably the most commonly used ADHD rating scale, has only been tested up to age 12, but most of us use it for older adolescents as well. The 18 items on the Vanderbilt about ADHD symptoms are actually the verbatim wording of diagnostic criteria from the DSM-IV. From a practical standpoint, it's easy to have just one scale that you use for many different populations.

The Vanderbilt is available for free in our ADHD Care Guide (PDF) at the Partnership Access Line site, as well as through the Bright Futures (PDF) program. The Swanson, Nolan and Pelham-IV (SNAP-IV) Teacher and Parent Rating Scale and the Attention Deficit Disorders Evaluation Scale (ADDES-3) have both been tested in patients up to age 18. The ADHD Rating Scale-IV is tested up to age 17.

Q. The new guideline talks more about identifying comorbidities like anxiety, oppositional or depressive disorders, as well as learning disabilities. What are the best tools for identifying these?

A. First of all, it's important to be open to the possibility that there are other comorbidities, and to ask the parent if there's anything else going on with their child. For example, a provider could ask if their child has any worries or fears, or if their child ever appears down, sad or depressed.

The PSC-17 (PDF) is a free rating scale we recommend for other symptoms. It's a brief questionnaire to evaluate the likelihood of an internalizing disorder (depression or anxiety), an externalizing disorder (conduct disorder or oppositional defiant disorder) or an attention disorder (ADHD). It's not perfect, but it's a way to ask some of the questions you might forget otherwise. The Vanderbilt also has other question categories that can help identify the likelihood of a comorbidity like oppositional defiant disorder.

In-office rating scales don't pick up learning disabilities very well. Diagnostically, a provider needs to inquire about details of how the child does with reading and school assignments. If there are particular areas of concern where they are having difficulty, the next step is to request a more detailed assessment.

Uneven academic performance could be a sign of a learning disability, such as if the child does very well in math but can't read, or vice versa. Or, if you think the child has ADHD and treat it but the child's learning doesn't improve, you might want to reconsider if they have a learning disability.

Q. What are some of the best strategies behavioral specialists utilize to help parents overcome reluctance to medication when it clearly seems indicated?

A. Parents are often reluctant to use medicine, and I can understand where they are coming from, given the type of information on the Web about psychiatric medications, and ADHD medications in particular. The first strategy we use is education about what's true and what isn't about these medicines.

It's helpful to ask what parents' concerns are about medications and to point them to information sources that you trust. The site is a good resource with factual information about child psychiatric medications.

It's also important for parents to know that medications can be stopped right away if any negative side effects do occur. Too often parents approach using medications as a long-term commitment rather than as a trial to decide if they want to continue with that strategy.

Q. What's the best way to maintain good communication between teachers and healthcare providers (with parental permission) to ensure progress is well monitored?

A. Practically speaking, I think repeated use of the rating scales is the best way to communicate, since it's hard for a busy practitioner to have phone conversations with teachers. It's also important to encourage parents to interact regularly with teachers and to use attention aids like homework binders going back and forth.

Q. What is a behaviorist's preferred starting medication (s) and dose (s)?

A. The new guideline affirms that stimulant medications (methylphenidate and dextroamphetamine) are more effective than the other ADHD medications, so they should be the preferred starting medications by most providers.

Initial dosage depends on the age of the child. As a rule of thumb, an elementary school child will start on the smallest pill size, and an older adolescent would have a higher starting dose at perhaps twice that amount. The ADHD Care Guide (PDF) on the PAL site has additional dosing advice.

Q. The guidelines say that special testing, like electroencephalograms (EEGs), thyroid tests and cardiac workups, are not necessary unless a specific reason to be concerned arises in the initial workup. When should you worry about seizures, thyroid disorders or heart complications?

A. Some people say hyperthyroidism could be confused with ADHD, but it looks very different; it involves such things as tremors, weight loss and jitteriness. The AAP and the American Heart Association (AHA) have said that routine electrocardiograms (EKGs) are not recommended unless there's a family history of a congenital cardiac condition, or a history in the child of cardiac concerns, such as unexplained fainting.

The one time where I recommend considering an EKG during ADHD treatment is if you end up prescribing very high doses (higher than the FDA maximum level) of a stimulant or other ADHD medicine like atomoxetine - which also stimulates the adrenaline system - because we don't have clinical trial data above the FDA maximum to assure safety.

As for EEGs, the hallmark of a seizure behaviorally is an acute onset of symptoms that typically isn't precipitated by something occurring in the child's environment. There is also a definable offset with seizures, whereas ADHD is a continuous condition.

Q. The guidelines speak about the greater benefit of parenting support in young children who have ADHD, compared to older kids and compared to using medications. Could you comment on that?

A. Behavior management training is useful for parents with young kids, because parents' ability to deal with a tantrum or willful misbehavior has a big impact on a young child. By the time children are in their late teenage years, parent interaction with their child has a relatively lower impact.

Behavior management strategies don't change ADHD, but they can alter some of the problems that result from it. A child with ADHD is more frustrating than other children to parent, and can set parents up for negative management strategies such as yelling, intense arguments or corporal punishment.

As far as how medications compare to behavior management, the large study in preschool children assumed in their study design you shouldn't use a medication right off the bat. You should first try to change the parenting response to the child through behavior management. In part, that's because ADHD diagnostic certainty is poorer in preschoolers than in children who are age 6 or older. I typically tell the parents of preschoolers that I can't be 100% certain of an ongoing ADHD diagnosis until children have entered school.

In terms of treatment effect size in a child with true ADHD, behavior management strategies do not improve core ADHD symptoms very much. They have a mild effect compared to medications, which have a much larger impact. Although we recommend behavior management strategies, they are often intended to deal with the ramifications of having a child with ADHD rather than actually curing the ADHD.

Q. How many visits should it take to complete the initial workup for ADHD? If medications are prescribed, how long after initial dosing should a follow-up visit occur?

A. If the provider has background information from multiple sources (teacher, parent, etc.) at the first diagnostic visit, they may make the diagnosis at that first visit. Otherwise, it takes two visits just to gather the necessary data.

If a medication is prescribed, it takes about a week to observe the pattern for a stimulant medication (which works immediately) and a month before full effect is achieved for a nonstimulant ADHD medication. There's no build-up phase required with a stimulant medication.

If I think a patient has very severe symptoms and I prescribe a stimulant, I may decide to see them within a couple weeks so I can quickly make any necessary adjustments. With atomoxetine, I still want to check in with them after just a few weeks (at least by phone) because atomoxetine has the same suicidality black box warning as selective serotonin reuptake inhibitors (SSRIs). So it's important not to wait a full month when prescribing atomoxetine, but rather to check in sooner to ensure there's no agitation or suicidality side effect.

Q. How do you proceed when two parents, or parents and teachers, significantly disagree about the severity or range of symptoms?

A. Disagreements come up fairly often, but there's no easy answer. When you have parents who cannot agree on a parenting plan, such as if there's a contested divorce situation, it's not uncommon that the two parents will have strong opposing opinions.

If you know there's a disagreement, it's important to ask the parent who brings in the child how they are planning to deal with it. If the child is going from one home to the next, and one parent will give the medicine and the other won't, that factor can guide your medication choices as to which are safe and appropriate to use.

For instance, the alpha agonists, which are clonidine and guanfacine, are medicines I would not use if the child is repeatedly going on and off the medicine. Stimulant medications would actually be preferable, since a child essentially weans on and off the medicine each day it is used and no build-up is required for clinical benefits.

Q. Could you comment on continuing treatment in adolescence?

A. The reason to continue to treat is not only to ensure success in school and in social relationships if they are continuing to have dysfunction, but also to decrease some of the other adolescent health risks. For instance, an adolescent with ADHD who is driving is at significantly higher risk of a motor vehicle accident, and the risk goes down if they are appropriately medicated.

There is a significantly higher risk of substance abuse in adolescents with ADHD compared to other adolescents, potentially because of their impulsivity. Studies have looked at the impact of stimulant treatment on substance abuse, and it doesn't look like stimulants cause more substance abuse than would otherwise occur. Some research suggests that stimulants actually reduce the risk of substance abuse.

However, there's another risk to be aware of when prescribing stimulants for adolescents: when adolescents are asked if they have ever given one of their stimulant pills to someone else, 20 to 30% of adolescents taking stimulants will respond that they have. They most often give their pills to other family members.

Q. What is the Partnership Access Line (PAL), and what kinds of questions are appropriate?

A. Any Washington primary care provider is welcome to call the PAL line Monday through Friday from 8 a.m. to 5 p.m. with any mental health question at all, whether it's a general question or a question about specific patients. You can usually reach one of our child psychiatrists immediately. We also have social workers who can help with resource coordination.

After we talk with a provider, we send a faxed note the next day that summarizes all the recommendations we discussed. Providers are also encouraged to follow up with us regarding past patients discussed. We can do some ongoing co-management, but we don't take over prescribing from the primary care provider.

For Medicaid or Healthy Options-insured children, we offer rapid access consult appointments where we actually see the patient in person or use telemedicine. We schedule appointments at the request of the primary care provider, or when the PAL consultant needs an appointment in order to know what advice to give.

You can visit the PAL website for more information. The PAL phone line is 866-599-PALS (866-599-7257).