The combined treatment and medication management groups showed significantly greater symptom improvement compared with the intensive behavioral treatment and community care. Compared with the community care arm, participants in the intervention groups receiving medication generally received higher doses of medication. The first effective dose was not always the most effective dose. Dosing in the intervention groups was as much as 50% higher than community-treated participants.6
Because children in community treatment only saw providers 2 to 3 times per year compared with monthly in the intervention groups, they may have been at risk for a “honeymoon effect” in which they initially responded to a low dose of medication, but then required a higher dose after a few weeks or months. Because of the nature of the intervention, this was more likely to be addressed.
Parents may also describe their child as “spacey” or “zombie-like” after starting ADHD treatment. This can be thought of as hyperfocus from a dose that is too high. In most instances, this is due to too high a dose and treatment should be reduced. If ADHD symptoms return, the pediatrician can consider a different stimulant or nonstimulant therapy.
The purpose of stimulants is to increase ability to focus on 1 item, not decrease hyperkinesis. Decreased hyperactivity is a frequent benefit but targeting hyperkinesis as a treatment goal is not appropriate and can lead to overdosing.
Unfortunately, it is often the teacher report that drives medication dosing, and the teacher-targeted behavior goal may not be attention but may be hyperactivity The stimulant medication should never alter the child’s personality.
Stimulants come from either methylphenidate or amphetamine categories. If a stimulant trial is not effective at an appropriate dose, then a medication from the other category is indicated. A failure to manage targeted attention issues in ADHD after trials at an appropriate dose of both a methylphenidate and an amphetamine product should raise a diagnostic concern. If the pediatrician finds the patient on multiple stimulants or treatments for ADHD, it is important to step back and rethink the diagnosis. Could the patient have a different diagnosis?
Mistake #4: Masked or coexistent mental health issues.
In children, the presentation of ADHD symptoms may also be the presenting symptoms of a mood disorder or a learning disability (LD) (after 3rd grade).
After beginning ADHD treatment in a patient, the pediatrician may be occasionally faced with a call from a parent stating that “my child has been crying every day since starting the stimulant medication!”
Whereas the prevalence of ADHD is estimated to be nearly 10%, childhood mood disorders are estimated to occur in 5% of the pediatric population. More than 7% of children have been diagnosed with anxiety and more than 3% have been diagnosed with depression.7 Among children with ADHD, 33% may have coexistent anxiety and 17% may have coexistent depression.3 While comorbid, if the mood issue is the primary diagnosis, a stimulant trial may exacerbate the presenting symptoms, resulting in the parent phone call.
The inability to understand/comprehend academic material can result in the child not paying attention or in acting out behavior (unconsciously, getting into trouble may be better than feeling academically inadequate as the classroom work demands are generally removed when the consequences for poor behavioral actions in the classroom are instituted).
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2. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management; Wolraich M, Brown L, Brown RT, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.
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