Support, Accommodation May Reduce Pediatric ADHD Severity

Pediatric attention-deficient/hyperactivity disorder (ADHD) can be “largely reversed” with the proper support, accommodation, and treatment, says Timothy E. Wilens, MD, chief, Division of Child and Adolescent Psychiatry, Harvard Medical School, Boston, Massachusetts. 

In this Q&A, Dr Wilens, who is also the co-director at the Center for Addiction Medicine, Massachusetts General Hospital, Boston, answers questions about his session at Psych Congress 2021 titled “What’s new in adult and pediatric ADHD: A 2021 psychopharmacology update."

Question: What are the main developmental impacts of untreated pediatric ADHD?
Answer: Negative self-esteem/self-image, difficulty with peer relationships, academic underachievement (and all that goes with that), behavioral difficulties, injuries/accidents, driving mishaps; higher risk for addictions: nicotine, internet/internet gaming, marijuana, alcohol [use].

Q: What tips do you have for clinicians to better integrate caregivers and school administrators into the patient’s treatment plan?
A: To work with the school psychologist, special ed program, and/or guidance counselor to: 

• initiate an educational/behavioral plan,
• implement the plan and 
• ensure that teachers and others are adhering to the plan. 

I recommend that parents act as a conduit with treatment providers, and if necessary, set up a Zoom with the treatment team and the child's school team (note, it doesn't have to be a long call for most situations). 

Q: What do you recommend as a “first-line” treatment in pediatric ADHD?
A: In most cases, medications are first line and include both stimulants and nonstimulants. In preschoolers and those in whom medications are not indicated or desired, behavioral, and cognitive-behavioral therapies for the youth and/or parents (parent training) may be the first line. At some point, many children receive both medications and [cognitive behavioral therapy] which some studies note adds to the overall wellness of the child and family.

Q: What should clinicians look out for when monitoring that treatment’s success?
A: It is important to monitor the symptoms of ADHD—whereas we previously thought that a 30% reduction was adequate for a response, the field is moving more toward 50%. At 50% the data show clear evidence of functional improvement. Practitioners should also monitor for functional improvements (eg, academics, peers, driving, etc.).  

Along with monitoring for ADHD, practitioners need to examine side effects, including monitoring vital signs and growth (weight and height) and any other potential problems due to the medication.

I think it is also important to gauge the child's maturation and fund of knowledge over time to ensure they are maturing—often these kids are 1 to 2 years behind and you want to ensure that they do not fall further behind. Since co-occurring issues including learning, psychiatric, and substance use comorbidities are so common in ADHD. I also advise carefully monitoring for the presence of these potential issues.

Q: Are there any misconceptions in this area that you would like to clear up?
A: 

• Long-term treatment of ADHD with nonstimulants/stimulants results in brain damage or bad outcomes. Conversely, the data show improved longer-term functional outcomes and a lack of evidence of deleterious persistent brain changes.
• ADHD is a cosmetic disorder.  
• ADHD is a moderately severe disorder that brings with it a multitude of difficulties, suffering, and struggling that can be largely reversed with support, accommodation, and treatment.

Timothy E Wilens, MD, is the Chief of Child and Adolescent Psychiatry, and Co-Director of the Center for Addiction Medicine at the Massachusetts General Hospital, Boston. He is a Professor of Psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Wilens specializes in the diagnosis and treatment of ADHD, substance use disorders, and bipolar disorder.