#13 All That Fidgets is Not ADHD

November 25, 2020 | By Justin Berk

Diagnosis, Management, and Social Implications of Attention Deficit Hyperactivity Disorder, with Dr. Sarah Vinson

Summary

Ever gotten overwhelmed by all the categories of ADHD, or interpreter the scores on a Vanderbilt form? Join us with Dr. Sarah Vinson, a triple-boarded clinician in adult psychiatry, child psychiatry, and pediatrics who helps us optimize a diagnosis and management process of ADHD. What other conditions can masquerade as ADHD? Which type of stimulant should you use? Listen to find out more!

Credits

• Writer, Producer, Infographic: Angela Zhang
• Cover Art: Chris Chiu
• Hosts: Justin Berk, Chris Chiu
• Editor:Justin Berk; Clair Morgan of nodderly.com
• Guest(s): Dr. Sarah Y. Vinson

Time Stamps

• 5:30 Diagnosis of ADHD
• 6:53 Considering a differential diagnosis of ADHD
• 8:43 Categories of ADHD
• 15:02 Ancillary Supports
• 18:27 Consequences of Misdiagnosis
• 19:53 Parent Counseling
• 22:08 Behavioral Interventions Treatment
• 25:56 Gender Differences in ADHD
• 28:00 Anaphylaxis Promo
• 28:39 Alternative Treatments
• 30:54 Pharmacotherapy for ADHD
• 37:29 Side Effects of Medical Treatments
• 44:33 Monitoring Progress
• 46:19 Treating concurrent mood disorders
• 49:21 ADHD in Young Adults
• 55:29 ADHD and Race
• 1:08:13 Future of ADHD

ADHD Pearls

1. Not all that fidgets is ADHD – all that the Vanderbilt forms tell you is that a patient has symptoms of ADHD. 
2. Significant health and racial disparities exist within the context of ADHD diagnoses. 
3. Optimal treatment includes both behavioral modifications and pharmacotherapy
4. Schools are legally required to provide Individual Education Plans (IEPs) which may include behavioral modifications that can help treat children with ADHD.
5. Methylphenidates are typically better tolerated than amphetamines.

Sponsors

VCU Health CE

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Diagnosis

Misdiagnosis is Common

• The Vanderbilt forms tell you only that a child has symptoms of ADHD (inattentive, hyperactive, and/or impulsive behaviors in more than one setting, as defined by the DSM-V); it does not tell you why. 
• Symptoms of ADHD can also be caused by other underlying etiologies: lack of sleep, anxiety, depression, vitamin deficiencies (iron, though more research needed (Millichap 2008)), and trauma (Jimenez 2017).
• ADHD is much less likely if the symptoms are acute or only happen in one setting. If it’s the latter, ask yourself what is being asked of the child in other scenarios (e.g. a certain relationship, unstimulating activities, etc.).
• Expert Opinion: ADHD symptoms often look like other behavioral conditions, like oppositional defiant disorder. But, once you treat ADHD, these other conditions will often disappear.

When ADHD is the Underlying Cause

• Expert Opinion: Hyperactivity is much easier to see earlier on than inattention.
• Expert Opinion: Patients can move in and out of subcategories of ADHD and won’t necessarily always be hyperactive or inattentive. 

ADHD in Adults

• For adults who don’t yet have a diagnosis, a careful history should reveal symptoms going all the way back to childhood (Cooper 2018). They may have found ways to scrape by or function in childhood.

An Anti-Racist Approach 

Health Inequities…

• Children of color are underdiagnosed with ADHD (Moody 2018). For instance, Black boys are more likely to be (erroneously) diagnosed more with oppositional defiant and conduct disorder instead of ADHD (expert opinion).
• Expert opinion: Because ADHD is so often diagnosed in childhood, the adults in someone’s life act as the gatekeeper for that patient to show up in the clinic. If someone has barriers to get to either a primary care clinic or a mental health provider, they may experience diagnosis or management delays. 
• Socially defined boys may be more likely to be diagnosed with ADHD based on social acceptability of certain gendered behaviors (Rucklidge 2010). If boys are allowed to interrupt and be loud, and girls learn to internalize their symptoms, then they may fall under the radar. 
• The risk of not treating a Black boy with ADHD means that down the road, they may act in a way that society deems dangerous; society already has less room for error for Black boys (Moody 2018).  

…And What We Can Do About Them

• Look at what happens in your clinic. Are more Black boys diagnosed with ODD and more white boys with ADHD? Are you or your hospital going back into your charts at all to review retrospective data? 

• Allow bandwidth for reflection and change. Acknowledge your biases and look for information that goes against it. 

Management

Educating the Family

• The symptoms will not be new to the family – what’s new will be helping them understand why their child is acting that way, and that it’s not volitional. (Expert Opinion)

Behavioral

• The MAT Study showed that behavioral therapy combined with medication management were superior than either one alone. Thus, experts recommend that psychosocial support should always be offered as an adjunct to medications to your patients with ADHD, especially if they have a history of trauma or Adverse Childhood Events.
• Part of the conversation with parents will be to restructure how they interact with their kid at home. For instance, you can emphasize eye contact, have the child repeat the task back to you, set sleep curfews without electronics, etc. Parents will need to teach their kids to bring structure to their world through prioritization and organization. The three key things to keep in mind: expectations, framing, and consistency. 

Pharmacological

• There are 4 main types of ADHD medications you can consider as a primary care provider: methylphenidates, amphetamines, alpha 2 agonists, and atomoxetine (which doesn’t work as well as the other 3 and also takes longer to work). 
  • Methylphenidates are typically better tolerated than amphetamines. (AAP ADHD Guidelines 2019)
  • Stimulants have greater effect sizes to improve ADHD over alpha-2 agonists. (AAP ADHD Guidelines 2019)
  • Short-acting vs. Long-acting: Short acting stimulants are off-label, but you can start with these to alleviate any parent/child anxiety about starting medications (expert opinion). 
• Treat what the patient identifies as their most impairing issue. For instance, if it’s a concurrent mood disorder, consider treating that first. Dr. Vinson: the best treatment plan is one that the patient is able and willing to follow.
• Don’t forget to follow up on learning or intellectual disability issues that the patient struggles with! They may fall off the radar if their hyperactivity is treated. 

• About considering concurrent substance use disorder: Untreated ADHD is a risk factor for SUD (Harstad 2017).

Advocating With Your Patients Outside the Clinic

• Use resources like Wrights Law, which has information about special education law, to educate yourselves and your patients about their rights in a school.
• Schools are legally required to follow Individualized Education Plans (IEPs). Sometimes, a school will be willing to accommodate without a formalized plan.
• Refer parents and patients to support groups like CHADD (ADHD-specific) or NAMI (on mental health in general).

Links

• How to Be an Anti-Racist by Ibram X. Kendi

1. ADDitude – Inside the ADHD Brain: ADD Symptom Tests, Treatment, Support 
2. Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
3. Home | NAMI: National Alliance on Mental Illness 

Goal

Listeners will explain the process of accurate diagnosis and responsible management of ADHD to improve health equity outcomes and patient education. 

Learning objectives

After listening to this episode listeners will…  

1. Utilize appropriate work-up in the diagnosis of ADHD
2. Choose evidence-based therapies in the management of ADHD
3. Identify the role of structural, institutional, and interpersonal racism in the misdiagnoses of ADHD in racially minoritized children, and the impacts in education and carceral probability.

Disclosures

Dr. Sarah Y. Vinson reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Vinson SY, Zhang AY, Chiu C, Berk J. “#13: All That Fidgets is not ADHD”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ Nov 25, 2020.