Diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) are associated with a variety of practical and clinical challenges. In a recent 

 video series, available at Contemporary Pediatrics.com, 

 a child and adolescent psychiatrist at Massachusetts General Hospital in Boston, Massachusetts, led a discussion regarding the multidisciplinary management of ADHD, the diagnostic and treatment obstacles during the coronavirus disease 19 (COVID-19) pandemic, and the effect of medication abuse. This article recaps the key clinical pearls and takeaways from the conversation.

To view the video series associated with this 

ADHD is the most common presenting neurobehavioral disorder that pediatricians and child psychiatrists will see in their course of practice and is second only to asthma when ranked among all chronic pediatric illnesses, Wilens explained as he opened the discussion. The prevalence of ADHD among children is between 6% to 9%, regardless of country of origin.

Diagnosis can be made as young as age 4, and stimulant medications are the first-line choice for pharmacotherapy, according to the 2019 American Academy of Pediatrics guidelines for the care of ADHD.

A key challenge associated with ADHD is making an accurate diagnosis, Robert L. Findling, MD, MBA said, noting that a countless number of things may make a child appear inattentive or fidgety.

“[Diagnosis] can only be done by a careful assessment, both cross-sectionally and over time, [and] pediatricians are particularly well-equipped to do such a thing because [they] have the benefit of watching children grow up,” Findling explained. He added that comorbidities, such as oppositional defiant disorder, anxiety, depression, and bipolarity, are the rule and not the exception in the setting of ADHD. These can complicate the clinical picture and, when left undiagnosed or untreated, can mask the benefits from ADHD medication. “You have to know the whole child,” he said. “There are many things … that will not respond to ADHD treatment.”

Probably 70% to 75% of kids [with ADHD] have a comorbid or coexisting medical or psychiatric disorder, Harlan R. Gephart, MD added. “Autistic Spectrum Disorder, family issues, divorce, [a] parent’s separation, [the] death of a parent … [can] look like ADHD [and] would give you a positive Vanderbilt Rating Scale for ADHD,” he said. “[They can] make you inattentive and distractable. That all has to be sorted out.”

To help manage ADHD, pediatricians and child psychiatrists would benefit through collaboration, Findling said. “Sometimes it just takes a bunch of people working together, putting the kid right in the center,” he explained.

However, Mark Wolraich, MD explained that communication between all players remains an issue. Information asymmetry between parents, schools, pediatricians, child psychiatrists, and therapists is common in ADHD management. “Some [of these barriers] are there for protection of health information, but they [can] really decrease the communication,” he said.

ADHD management during the COVID-19 pandemic

In addition to these challenges, the panelists discussed several downstream consequences of the COVID-19 pandemic and ADHD management; some of them have been positive, others have not.

For years, telemedicine was not a reimbursable intervention for physicians, Wolraich pointed out. However, that changed during the pandemic when delivery of goods and services shifted to a more contactless approach. Telemedicine, Wolraich noted, is beneficial for ADHD management because it allows for better observation of the child in their more natural home environment and is more conducive to the shorter follow-up intervals required during rapid dose titration of ADHD medication.

“Patients can come to appointments much easier,” Wilens said. “[Parents] don’t have to drive far distances, [they] don’t have to take off a half day of work, kids don’t have to miss sports [or] school. Our no-show rates [have] dropped precipitously.”

In addition, as ADHD stimulant medications are scheduled drugs, Wilens also observed that the relaxing of regulatory oversight during the pandemic for prescribing controlled substances via telehealth visit has proven helpful.

The downside of increased telemedicine include access to adequate internet bandwidth, technical glitches, and a loss of in-person human connection, the panelists noted.

Another challenge associated with a more virtual world in the wake of the COVID-19 pandemic, is not all children are back to in-person learning at schools. This can be problematic for patients with ADHD, the panelists noted. “For many kids and families, it’s an absolute disaster,” Ann Childress, MD said. “[Kids with ADHD] can’t sit [still] in front of the camera … they are getting in trouble … they can’t figure out what link they’re supposed to [click on for] the next class … they’re running around the house.” Parents fear their kids are falling behind and are considering quitting their jobs until in-person school resumes, she added.

But it’s not just concerns over learning, children with ADHD have strengths that can’t be observed virtually, Findling said. “[So] now they have lost the chance to succeed in domains that they might have been successful at when [school] was in person and not via screen,” he explained.

COVID-19 has also made for supply chain issues that have created access barriers for stimulant medications. “We’re dealing with distribution problems, [and] people are having more problems finding stimulants … they may have to go to 3 or 4 different pharmacies,” Wilens said.

Because pharmacies will not always tell someone over the phone if they have a particular stimulant medication in stock over robbery concerns, a parent may drive there only to learn the medication isn’t available. “Then I have to … go back and send [the e-script] to another pharmacy, [and] it takes up a lot of time just to try and get somebody their medicine,” Childress said.

Unfortunately, COVID-19 has forced many people out of work and that has also meant loss of health insurance for families, making it difficult to afford brand-name ADHD medications that they have already been taking. “I’m having to do things that I don’t like to do, and that’s switch people to immediate-release [agents] that they can afford,” Childress said.

The last big challenge in the management of ADHD that the panelists discussed is the misuse of prescription stimulant drugs.

Nonmedical use of prescription stimulants—using the drug differently than was prescribed or using the drug without a prescription—has now outpaced opioid [use] among teens and young adults, Wilens explained, with the highest rates of abuse aggregating at colleges and universities.

“It turns out that about 40% of stimulant misuse is intranasal,” Wilens said. “This is a huge concern … [because] if you use [it] intranasal[ly] or intravenous[ly], you have [a] 20-fold [higher] likelihood of serious medical morbidity or even death.”

The panelists offered several suggestions for curbing nonmedical use of prescription stimulants: prescribe extended-release formulations, monitor pill counts, and write [scripts] for the number of tablets the patient needs. Extended-release formulations have less intranasal abuse potential versus their immediate release counterparts, while pill counting and not writing for extra tablets helps prevent stockpiling.

Several stimulant drugs in development may also help control medication abuse because they are being made with manipulation-resistant technology, Childress explained. “There are about 40 drugs in the pipeline in various places,” she said. For instance, one product is a capsule containing crush-resistant pellets of an immediate-release amphetamine. The difficulty of grinding the pellets down into a powder for snorting prevents misuse intranasally. Other products in development use prodrugs which must undergo conversion in the gastrointestinal tract before becoming active. Nonstimulant drugs currently being investigated for use in ADHD have mechanisms similar to antidepressants.

“[It’s] really exciting to hear that we have new potential alternatives [for use in ADHD] … [and that] they are trying to make them safer,” Wilens said.


Chief, Division of Child and Adolescent Psychiatry
Co-Director, Center for Addiction Medicine
Director, Substance Abuse Services in Pediatric Psychopharmacology
Massachusetts General Hospital
Boston, Massachusetts


Clinical Associate Professor
University of Nevada School of Medicine
Las Vegas, Nevada


Chair, Department of Psychiatry
Virginia Commonwealth School of Medicine
Richmond, Virginia

ADHD Complex: Practicing Mental Health in Primary Care


Professor
University of Health Sciences
Oklahoma City, Oklahoma

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