All 3 conditions (ADHD, mood disorders, and LD) present with similar symptoms and can be comorbid. A high index of suspicion for a primary mood disorder should be maintained if there is a paradoxical response early in stimulant treatment.
The pediatrician must consider if the patient has another condition that needs treatment in addition to his/her ADHD. It is important to realize that even if the pediatrician feels there is a comorbid diagnosis, symptoms will often resolve with stimulant treatment. The addition of a second agent such as a selective serotonin reuptake inhibitor (SSRI) may be considered if monotherapy does not produce adequate symptom relief.2,8,9
Although stimulants are effective in treating ADHD, they can sometimes exacerbate a patient’s symptoms. It is important for the pediatrician to identify the timing of when emotional lability occurs. Stimulant-induced emotional lability may need to be treated by discontinuing or switching medicines. The pediatrician would expect this to occur as blood levels of the stimulant are peaking.9
Conversely, some patients may be actually experiencing “rebound irritability” as the stimulant blood levels begin to decline. This is an important distinction to make as this can be treated with adding a short-acting dose of medication as the morning dose begins to wane.9
Finally, inattentive ADHD is much more common in females and may present as depression in early/mid-adolescence when the ADHD results in academic struggles relative to peers. Until the DSM-5 age expansion of ADHD symptom presentation, these young women often were diagnosed with only a mood disorder, and the ADHD was never even considered.
Mistake #5: Failure to identify learning disabilities.
The pediatrician is likely to have heard one of the following from parents or caregivers: “She’s not a behavior problem at school, just lazy”; “The teacher said if she would just pay attention better, she could get it”; or “He just started to have problems with school—it must be this 3rd- (4th-) grade teacher!”
All these statements point to the significant overlap of ADHD with LD. In fact, 31% to 45% of children with ADHD have an LD.10 Girls with ADHD are nearly 10 times more likely to have a written-language disorder compared with girls without ADHD whereas boys are nearly 5 times as likely.11 When the LD presents itself will depend on the age when a child begins to struggle in the school system. Brighter children will compensate early and present later.
Learning disabilities are the most common chronic condition in most pediatric practices. One area of concern is that 2 in 5 pediatricians do not feel that identifying LDs is their responsibility.12 In fact, periodic surveys of membership conducted in 2004 and 2013 by the AAP demonstrated that fewer pediatricians (62% vs 51%) were screening for learning disabilities in their practice, but the percentage treating or comanaging LDs increased (8% vs 18%).13 If the pediatrician fails to identify at least the need for referral for LD, screening many children may go undetected until school issues develop.
Mistake #6: Misuse, abuse, and diversion.
The pediatrician may also occasionally encounter patients or parents asking to be switched from long-acting to short-acting formulations or frequently running out of medication. The pediatrician needs to begin by asking why.
Reports of the misuse of stimulants have been increasing for some time.14 Estimates of misuse (use of ADHD medication not prescribed to an individual or taking differently than prescribed) among grade and high school students range from 5% to 9%, and from 5% to 35% for college students. Estimates of diversion (selling, trading, or giving medication to a person without a prescription) occurred in 16% of grade school and high school students and 23% of college students. High school students reported giving ADHD medications away (15%), selling (7%), or having their medications stolen (4%). Among college students with a prescription for ADHD medication, 30% reported selling their medication and more than 50% said they were approached by another student to give or sell their medication.15
Reasons for misuse vary by age. In grade school and high school students, the primary motivation is generally social and recreational where- as improving cognitive performance is the main factor for college-aged students. Among all children misusing stimulants, the most common source is friends and family members followed by physicians.14,15
Parents also have been noted to divert ADHD for themselves or another family member. In 1 study, 16% of parents admitted to self-administering their child’s medication and 13% had considered it.16 This is not commonly diagnosed, but parents may see a benefit to self-administering their child’s medication for their own use as there can be a high rate of undiagnosed ADHD in parents of children with ADHD.
If there is a suspicion that a parent is also manifesting adult ADHD, a recommendation to discuss the symptoms with the parent’s primary care provider is not only appropriate, but good medical care. If the parent’s ADHD is managed, the child’s outcome can be improved.
Pediatricians need to emphasize to their patients that it is inappropriate and illegal to share, sell, or distribute their stimulant medication. The pediatric office should have clear procedures and policies about refills and what to do if medication is lost or stolen. Parents and patients need to be educated about the importance of safe storage and what to do if they are pressured into sharing their medication with someone else.
Likewise, the pediatrician should consider use of long-acting formulations as these have less potential for abuse compared with the short-acting formulations. Finally, the pediatrician needs to be aware that some parents and patients may seek a diagnosis of ADHD in order to obtain a stimulant prescription. In fact, adults are highly successful in obtaining stimulant medication when coached about ADHD symptoms.17
Attention-deficit/hyperactivity disorder and its comorbid conditions represent a significant problem to the children in a pediatric practice. Pediatricians need to be not only cognizant of the diagnostic criteria, comorbidities, and complications of ADHD, but also comfortable with addressing other issues such as stimulant abuse and diversion.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association Publishing; 2013.
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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11. Yoshimasu K, Barbaresi WJ, Colligan RC, et al. Written-language disorder among children with and without ADHD in a population-based birth cohort. Pediatrics. 2011;128(3):e605-e612.
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16. Pham T, Milanaik R, Kaplan A, Papaioannou H, Adesman A. Household diversion of prescription stimulants: medication misuse by parents of children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2017;27(8):741-746.
17. Edmundson M, Berry DTR, Combs HL, et al. The effects of symptom information coaching on the feigning of adult ADHD. Psychol Assess. 2017;29(12):1429-1436.