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Updates in the Management of Pediatric ADHD - Episode 2

Risk Factors Associated With Pediatric ADHD

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Robert L. Findling, MD, MBA, and Timothy Wilens, MD, review specific risk factors of pediatric ADHD, focusing on family history.

Robert L. Findling, MD, MBA: A lot of folks are given this diagnosis, and the risk factors extend beyond genetics. Tim, from your perspective and from what the data show, what’s the greatest risk factor for a child to develop ADHD [attention-deficit/hyperactivity disorder]?

Timothy Wilens, MD: It’s family history. Heritability is derived from looking at twins. If 1 has ADHD, we determine the likelihood that the other one does. That gives you an estimate of the genetics. It’s about three-quarters. If a parent has ADHD, that’s unequivocally the biggest risk factor that their child is going to have ADHD. One thing we talk about with young parents with ADHD is that we watch their children very closely. You should be screening for it. When you pick up concerns that one of the younger children may have ADHD, start with things like behavioral interventions and environmental structure changes.

Robert L. Findling, MD, MBA: That goes back to another related question. You talked about screening and being vigilant. Is ADHD an easy and simple diagnosis to make, considering how prevalent it is?

Timothy Wilens, MD: That’s a great question. If you look at the core symptoms of ADHD—the 18 symptoms or derivations of symptoms—it isn’t that difficult to diagnose. It’s a clinical diagnosis. It’s sitting across from a pediatrician, a child psychiatrist, or a developmental psychologist. That part is going through the symptoms systematically and looking for a longitudinal track, looking for impairment within the entire cluster of symptoms, and being sure that what you’re looking at isn’t accounted for by an anxiety disorder, autism, a mood disorder, etc. The core diagnosis isn’t that difficult.

It gets a little more difficult because you can’t do a diagnosis of ADHD in isolation. You have to see what’s going on in the environment, developmentally with the child, educationally, and with peers in the family. Then you have to look at comorbidity or co-occurring issues, such as depression, anxiety, oppositional disorder, or conduct disorder. If they’re older, look at cigarette smoking and substance use. Do they have a learning disability? Do they have cognitive executive function deficits? You have to [look at] all of that. Before you think you’re done, you have to look at all the medical issues. Is there a tick disorder? Or is there a cardiovascular disorder or a neurological issue?

The core ADHD symptoms aren’t that difficult. It’s a clinical diagnosis, so you don’t need neuropsychological testing. Don’t order neuropsychological testing just to make a diagnosis of ADHD. But that’s what it comes with. That’s what’s taking a lot of your time, because you’re obligated to do a comprehensive evaluation.

Robert L. Findling, MD, MBA: To your point, it’s one thing I spend a lot of time talking with folks about. Any of the 1, 2, or 3 symptoms are very nonspecific. It’s about the big picture of whether this is a pervasive issue across certain key domains that the symptoms come into play. Finding the symptoms is easy but making an accurate diagnosis and taking good care of a patient might not be.

Timothy Wilens, MD: Case in point, if you look at distraction—one of the big symptoms—you can be distracted because you have obsessive thoughts because of anxiety or a trauma occurring at home. I absolutely agree. Any 1, 2, or even 3 symptoms in isolation aren’t helpful. You have to see a comprehensive picture. That’s why it takes time to do an evaluation.

Transcript edited for clarity