Advances in the Management of Complex ADHD in Pediatric Patients - Episode 4
Theresa Cerulli, MD: With ADHD [attention-deficit/hyperactivity disorder], we’ve been talking about the core symptoms. But 75% of the time, in addition to ADHD, the individual meets full criteria for another comorbid psychiatric condition—75% of the time, think about that. And 60% of the time, it’s 2 or more coexisting conditions with ADHD.
So the challenge in how this presents isn’t just the ADHD, but the 75% of the time you’re also having to look for, screen out, or screen in an additional psychiatric condition. With that, I know Frank, I’m so excited about this, you have been looking into diagnostic and treatment guidelines for ADHD, which I think are well needed. Please, share with us what are the new AAP—American Academy of Pediatrics—and the SDBP [the Society for Developmental and Behavioral Pediatrics] updated guidelines for diagnosis and treatment?
Frank Lopez, MD: Absolutely. As you were mentioning, back in September of 2019, Mark Wolraich, MD, and the American Academy of Pediatrics put forth the updated guidelines for ADHD. And in particular, they have action statements that have been updated, but I’m going to read to you action statement number 7, which for me, really stands out. And that is that the primary care provider, if trained or experience in diagnosing comorbid conditions, may initiate treatments of such conditions or make referral to an appropriate subspecialist for treatment. After detecting the possible comorbid conditions, if the primary care provider is not trained or experienced in making the diagnosis or initiating treatment, the patient should be referred to an appropriate subspecialist to make the diagnosis and initiate treatment.
This is critical because it’s no sin not to be trained in certain areas. Not all of us are trained in all areas. So if our primary care pediatricians, family physicians, general practitioners are able and comfortable to identify and treat, please do so. But if you have some concern, or you’re not very confident that you have identified all the parts and pieces, it’s best to move them forward.
And that initiates part of what’s coming next, which is more of a team treatment approach rather than just a solitary practitioner.
The effect of comorbid conditions on ADHD treatment is very variable. So treatment of the ADHD may resolve or improve the comorbid condition, such as coexisting oppositional defiant disorder, depression, or anxiety, but it may not. Many times parents will come back and say, “Hey, the symptoms of the inattention, the symptoms of the hyperactivity, have improved. But we’re still challenged. We’re still having struggles in school.” If the teacher reports improved attention, you may think, “Oh, I’m a miracle worker, we’ve done this.” But you really haven‘t treated the entire problem.
This allows for us to expand. And then in January of this year, the SDBP under William Barbaresi, MD’s guidance came up with some new and expanded guidelines, more specific. I’ll read part of this to you because I want to make sure that it comes out correctly.
“The clinician with specialized training or expertise should initiate a comprehensive assessment and develop,” here’s the team approach, “an interprofessional, multimodal treatment plan for any child or adolescent through age 18, with suspected or diagnosed complex ADHD.” What is complex ADHD? Well it is ADHD that has other comorbid conditions.
“Treatment of complex ADHD should include evidence-based approaches to address the ADHD, and account for the coexisting conditions while respecting family background and preferences.”
That’s critical because here’s the piece that I find really exciting. There’s more compassion. This guideline opens it up to say, “Look, you’re human.” Because we all read guidelines. They’re available for every major disease and disorder. But they lack that personal, that human touch. This does not. This actually says, “with respect for the family and their preferences.”
We’re humanizing this disorder. I think that’s the first time I’ve actually seen it written this way. Complex ADHD, the definition is: “presence or suspicion of coexisting disorders or complicating factors, moderate to severe functional impairment, diagnostic uncertainty on the part of the primary care provider, and inadequate response to treatment, or uncertainty about treatment planning.” And this holds true for children under the age of 4, or greater than the age of 12, at initial symptom presentation.
Now this opens the door for us not to be limited to those children 6 years of age and older as it was back before the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, 5th edition], and now actually start thinking about the preschool presentations, which we do see. We do see a lot of really high levels of activity that are beyond the expectation for their developmental stage.
Theresa Cerulli, MD: We’ve expanded beyond the DSM criteria, right?
Frank Lopez, MD: Exactly.
Theresa Cerulli, MD: Which is what’s exciting to me. It’s not cookie cutter. These are highly individualized patients needing individualized treatment. And the comorbidities, to me the fact that the guidelines now include the importance of recognizing the comorbidities is essential. I’m really glad we’ve seen the guidelines evolve over the many years we’ve both been involved in treating these patients.
Frank Lopez, MD: Yes. Along those lines, if you remember, we were taught, treat the worst thing first.
Theresa Cerulli, MD: Right.
Frank Lopez, MD: Now we are actually looking at treating everything that’s present.
Theresa Cerulli, MD: Absolutely.
Frank Lopez, MD: So that we can get the best effect. That requires a patient approach—not a human being approach—but a patient approach on our part, for them.
Transcript Edited for Clarity