I'm Dr. Rachel Lynch.
I'm a general pediatrician at
the Mayo Clinic in Rochester,
Minnesota, and I'm really excited
today to have the opportunity to
talk with you about ADHD.
I'll talk specifically about the
treatment of ADHD in
children and the long-term follow-up
of ADHD.
During our time together, I will
focus on these learning objectives
that include learning to identify
treatments that are available to
treat the symptoms and impairments
of ADHD in children.
I also want to take time to
recognize the mental health
conditions that children and
adolescents with ADHD
are at risk to develop.
And then we'll review
recommendations for long-term
management in children and
adolescents with ADHD.
The first thing that I want to make
sure is that we're all on the same
page when we talk about ADHD
treatment recommendations.
And in 2011,
the American Academy of Pediatrics
put out treatment guidelines that
go by children's age,
and they recently revised
these and they continue to be
set up by age.
So for school-agedchildren
and adolescents, the recommendation
is for children to be treated with
FDA-approvedmedication for
ADHD, and
the recommendation is that that will
be part of multimodal treatment
for that child or
adolescent.
When it comes to preschool-aged
children, the recommendations
are for parent behavior management
training to be the first-line
treatment.
There may be times we need to
consider treatment with
ADHD medications for these
younger children, but for the most
part, the recommendation is that
their symptoms are managed by parent
behavior management training.
And of course, it's important to
think about the goals of treatment,
and the goal for treatment in
children with ADHD is
that we help decrease
the symptoms and decrease the
impairment that they're experiencing
from their ADHD symptoms.
And then we want to really get
them to the point of remission,
which we would consider to be, you
know, getting them to a place that's
subclinical or sub-diagnostic,
or they would no longer meet
criteria for the diagnosis of
ADHD.
I want to give you more specifics
about what I mean when I say
parent behavior management training.
So a lot of people are not quite
sure what we mean when we say
behavior therapy or
parent behavior management training,
and what the goal is with this,
especially for preschool aged
children, is that we help
parents understand ways
to interact with their child, ways
that they can be warm
in their interactions with their
child, and they can have positive
interactions with their child.
This can be difficult
in families when children are
struggling with ADHD symptoms
because parents need to give
constant and frequent reminders
about what they would like their
child to do.
We want to reduce negative
parent interactions, parent-child
interactions, and we
want to teach them ways that they
can more effectively communicate
with their child about what they
need or want them to do.
And so that means teaching them
techniques like giving effective
commands, or using reward
systems like token economy,
or using timeouts in a positive
way with their child.
And we know if parents can learn
these techniques that there can be
improvement in disruptive behavior,
and
then that helps the whole family, it
helps the child and it helps the
parents.
If you have families that say
we want to do the very best
behavior management training there
is, we want to do the gold standard,
we want to do the best,
then what I recommend, and what's
recommended in the literature, is
something called parent-child
interaction therapy.
And this is evidence-based
intervention for preschool children
or children up through age six,
that have disruptive behaviors,
and their parents are struggling.
This provides additional training
for the parents in behavior
management.
This is a very sophisticated
way for parents to get
parent behavior management training
that involves multiple sessions
where they initially learn the
techniques about behavior
management, and then they get to
practice or have real-life
interactions with their child,
and a therapist who is trained
and has the equipment to do this
is on the other side of a
window or a
one-way mirror that allows
them to see and hear the
interactions with the parent and
child in real-time
and give the parent feedback through
a sound device in their ear.
And this type of
parent interaction training is
shown in the literature to
reduce hyperactivity, to reduce
disruptive behavior, and
improve compliance in children.
And the gains
that children make through this
interaction training are maintained
up to at least six years later in
evidence-based studies.
So when parents can access this,
this is the best way
for them to do parent behavior
management training.
For older school-age children, it
can be
more challenging to do behavior
management training,
and it's harder to impact the
child's behavior as they get older.
But there are things we know that
can be helpful, especially for
common things that happen with ADHD,
like battles that they have over
homework, if
they're having a lot of defiance
around being asked to do chores,
or if they're showing aggression
towards family members.
And what the focus of
parent behavior management training
for school-agedchildren and their
family focuses
on, is helping to correct parenting
that is not warm or consistent.
So again, we want to look for
opportunities for positive
interactions with children
and their parents.
And we know kids spend a lot
of their time at school,
and so interventions that are just
based at home may not have
as much impact as we would like as
kids are older and school age.
So it's important to know what are
things that can be helpful at
school. What can we expect
of schools and teachers?
And here are some examples
of things that we hope will
be helpful to decrease
disruptive behavior and
off-task behavior,
to decrease aggression,
and improve completion of
academic work, and what we can hope
for is that teachers can learn
to use proactive use of cues
and prompts when they're giving
directions, so making
sure that they make eye contact with
a child who has ADHD
when directions are given to assure
that their attention is focused.
Also giving
rewards in the classroom setting
for good behavior,
as opposed to always just giving
negative consequences for
unwanted behavior.
Another thing that's really helpful
is a way of daily communication
about the child's behavior, so daily
report cards, and it can be
as simple as a smiley face or
a sad face, depending on the child's
overall behavior that day,
or a number system, or a red
light, yellow light, green light
system, and this is very helpful
for parents and teachers to work
together. Behavior management
training is not enough
for most kids to take care of their
ADHD symptoms, and so
we also need to think about
medications, as I said earlier,
for school-age and adolescent
children, medications are
highly recommended and really
first-linetreatment.
And there are two different types
of medications, two big classes
of medications we use in treatment
of ADHD.
So the most common, the one that
people have heard of the most, are
stimulant medications that
are methylphenidate or amphetamine
derivatives.
And non-stimulant medications
are also available, and those
include Guanfacine, Atomoxetine,
and Clonidine.
As you see on this table, there
are some guidelines
for daily dosing based on mg
per kg dosing.
But generally, our approach is to
start with the lowest dose, no
matter how old or the size
of the child. But what I'd like you
to pay attention to on this slide
is the age for FDA approval,
it's interesting that you can see
the Dextroamphetamine and mixed
amphetamine salts are approved
down to age three.
However, we don't actually recommend
using the mixed amphetamine
salts or Dextroamphetamine for
children under age six.
The recommendation is for use of
methylphenidate, and it
is not FDA approved in children
down to age three, but has
sufficient evidence in well-done
studies for us to
confidently be able to prescribe
it safely in children when it's
needed at an age younger than six.
As I said, generally with the
stimulant medications, we always
start with the lowest dose,
but the titration of the medications
when treating ADHD
is very important, and
as a provider, having a plan
for frequent follow-up during
titration is really important,
and then setting that expectation
for families, is also very
important. What the goal is overall,
is to titrate the stimulant
medication to the most effective
dose without significant
side effects, and the medications
start to work quickly, so this is a
really good thing about ADHD
medications, and you can
tell within a week is this
dose going to work well for this
child, or do we need to make an
adjustment?
And so making a plan to
follow-up with them weekly,
or at minimum biweekly
in the first month is really
important. We know this can't always
be done in the office, and
so we do a lot of this by online
messages, or telephone
when that's needed.
Another aspect of follow-up
that I feel is really important is
getting rating
scales or other objective
ways to follow their improvement
in their ADHD symptoms and
impairment.
And this is especially important
to get this information from
teachers because
we don't usually get the chance to
talk with them face to face like we
get to talk to the parents.
On this slide, you can see one
way that we are able to track
children's improvement in their ADHD
symptoms and impairment,
and this shows for a particular
child over time that
initially they had a high total
ADHD score, the total ADHD
score was 38 initially,
they're inattentive rating was
positive, and then you can see along
the bottom of the slide that there
was a point in time that medication
was started, they were started on
methylphenidate 18 milligrams,
and then the dose was increased to
27 milligrams,
and then after being on that 27
mg dose, we retested
the Vanderbilt scoring and
found significant improvement, where
now the inattentive rating is
negative, and their total
ADHD score has gone all
the way down to 11.
And this can be really encouraging
for families to see,
to see how much improvement that has
been noticed and this was completed
by a teacher, so again, getting
that feedback is especially
helpful.
Sometimes I think we wonder,
is there really proof that this
titration, that all this work
to follow them frequently is worth
it? Is it really important?
And this slide, I feel like, really
demonstrates how important
this is, and how much better we
can do to help children and families
if we are doing this titration
carefully.
This slide reviews results from
the MTA study, the initial
landmark study for ADHD
treatment, and that compared
children who were being treated
with medication in the study.
It looked at children who were
treated with behavior management in
the study, and then children who
received a combination of medication
management and behavior management.
This was all compared to
children getting ADHD care in
the community.
And what we want to see is that at
baseline, no one's in remission,
but at the end of the study, we'd
like to see everyone achieving
remission. The classroom controls
are the white bar.
And the red bar shows for children
that received a combination of
medication management and behavior
management in the study, the
most improvement.
Then medication management in the
study (yellow), significant
improvement.
Behavior management (green), not
quite as much improvement.
And then community care was much
lower in the gray bar.
And I found this really
perplexing at first because children
in the community care arm could
receive medication, they could
receive behavior management
training, but what was found
was that it was not done with the
same level of intensity.
We can see that the total daily
dose of methylphenidate that was
given in the study, in the
community care was much lower
than in the medication management
arm of the study, and so
those children had significantly
improved remission rates with
a higher dose of medication.
This chart further shows
that their functional recovery
is significantly improved if
we can get children to remission
with their ADHD symptoms.
So you can see on the chart
that for normalized social
functioning, normalized emotional
functioning, and school functioning,
children who had persistent
ADHD symptoms in the orange
bars were not functioning
nearly as well as the children who
had remission of their ADHD symptoms
in the red bars.
Now there are times we need to think
about non-stimulant medication,
and the reasons we think about that
is when a child or a family
member has a substance abuse
disorder,
or if the child has a tic disorder,
or if they've experienced side
effects that are significant on both
classes of stimulants or the
stimulants have not been adequately
effective.
When we're at a point we need to
consider non-stimulant
medications, we
have the options, as I mentioned
before, of atomoxetine,
clonidine, and guanfacine.
And they can be quite helpful,
they're FDA approved for treatment
of ADHD, but also
are not quite as effective as the
stimulant medications.
So that's why we usually start with
the stimulants.
I do get questions from families
about new treatment modalities
that are out there, and those
include trigeminal nerve stimulation
and game-based digital
therapeutics.
These are both have achieved FDA
approval, and
a nice thing about them is they have
few side effects.
However, they're just not nearly as
effective as treatments that
are proven like ADHD medications
and parent behavior management
training. So these now exist
and families are interested in them,
but our message really is they're
not adequately effective to replace
standard treatments at this time.
Once we've started treatment for
children with ADHD, it's important
to decide how closely are
we going to follow them and how are
we going to know if they're really
getting better?
So children that are ages 6
to 12 and start
on a medication for ADHD
with their first prescription, they
need to see a prescribing provider
within 30 days of their first
prescription for ADHD medication.
This is followed closely by
many monitoring groups, including
Minnesota community measures in our
area, and
insurance companies are now often
sending families information
about this to know and expect
a follow-up visit within the first
30 days.
Once they've been on a medication
dose for more than a month,
there is a period that they call
continuation and maintenance phase,
where kids need to have two or more
visits during this next nine
months while they're on a medication
for ADHD.
And beyond that, it's really
recommended we see children about
every three months, or certainly
every six months while they're on
treatment for ADHD, or
while we know they're struggling
with symptoms of ADHD.
And I certainly hear from providers
who wonder, do we really need
to see them that frequently?
And what is it that we need to do?
And of course, we need to follow up
on their ADHD symptoms.
But what we also need to be aware of
and monitoring for is that these
children and adolescents are at risk
for other psychiatric disorders,
and those include substance use
disorder, anxiety disorder,
and major depressive disorder.
So having a formal way to
screen for these things when kids
come in is important,
and that can include questionnaires
like the CRAFFT for substance
use disorder, the SCARED
questionnaire for children with
possible anxiety, and
the PHQ9 for children that
potentially have depression.
We have good evidence from the
literature that as
children become adults,
they are at increased risk
for developing other psychiatric
conditions when they have
been diagnosed with ADHD in
childhood.
So one study
with this was done in 2013
and looked at a group of 232
kids who were diagnosed in childhood
with ADHD, and it followed
them all the way to adulthood.
And it found that
a majority of children, as
they became adults, developed
another psychiatric disorder
or had persistent ADHD symptoms,
or had both persistent
ADHD symptoms plus
the development of another
psychiatric disorder.
And for these people
into adulthood, this certainly
affected their quality of life,
and for some even
experiencing death by
suicide being more likely
in people who had another
psychiatric disorder and
a diagnosis of ADHD in
childhood. So our
recommendations are clearly
to do the best treatment we can for
children with ADHD to
help them avoid these outcomes
that can be can be tragic
or difficult.
And so I want to review that
parent behavior management training
is very important in the treatment,
especially of young children with
ADHD.
Medication treatment is also
important and supports
that can be given at school are
necessary as well.
Once we put these treatments in
place, we need to monitor for
improvement and monitor
for the emergence of co-occurring
mental health conditions.
And this really means that we treat
children who have ADHD
as children with special health care
needs, and
we have guidance from the American
Academy of Pediatrics as
far as how do we do this.
And as they transition to adulthood,
how do we make sure this is
successful for them?
So as you can see on this slide,
there are expectations
for us to introduce
the things that children need as
they begin to transition into
adulthood with their health care.
And that means starting as early as
age 12 to 14,
and then tracking progress over
time, and coming up with a formal
plan for them to be transitioned
to adult medical care
as they reach ages 18
to their early 20s.
So in conclusion, I want
to share with you that ADHD
is a chronic condition.
It has onset in childhood
and can persist for most patients
or some patients into their adult
years. We know there are
evidence-based treatments available,
and we want to deliver those in the
best way that we can to help these
children and their families.
We want to help them because they're
at risk for other psychiatric
disorders.
So careful monitoring, coordination
of care, and guidance during their
health care transition into
adulthood is important while
we're caring for patients with ADHD.
Thank you.
