Dr Childress Discusses Treatment of Pediatric ADHD

Ann Childress, PhD, discusses the next steps in the attention-deficit/hyperactivity disorder (ADHD) treatment of 13-year-old female who presented for an evaluation of anxiety and depression.

Read the transcript:

Hi. I'm Dr Ann Childress. I'm a child, adolescent, and adult psychiatrist in Las Vegas, Nevada. I do predominantly clinical research and follow my patients after they finish research trials.

Today, I'd like to talk to you a little bit about diagnosing ADHD when the presentation might be a little bit more complex. I'm going to talk to you about a 13-year-old Asian girl who came in to see me. I was doing an anxiety study. She came in to see me for anxiety and depression. We started talking.

I'm going to read a little bit from my notes, so I don't miss anything important. She was in public middle school. She had recently been in a private school, but it was too difficult so her parents transferred her. She reported feeling overwhelmed and that it was hard for her to talk in front of the class. It was also difficult for her to make friends.

That had gotten worse during the pandemic, although she did play soccer. She was able to get out with folks doing that. She worried a lot about her grades, especially math. She felt panic when she talked about her grades. She had multiple missing assignments and had a lot of conflict with her parents over her schoolwork and not getting things done.

Then, she was depressed. She said she was only sad for part of the day. She didn't have any difficulty with sleep or eating. Her weight hadn't changed. She felt guilty, and it was harder to concentrate when she felt depressed.

Starting about age 10, she had thoughts about hurting herself. She had done some superficial cutting. The last time was a couple of months prior to the visit. When I did some inspection of her arm where she had been cutting, I couldn't see any scars. She denied any suicidal ideations at the visit.

Most of her depressive and anxiety symptoms we've talked about stem from that conflict with her parents over those missing assignments and her school performance. She reported making careless mistakes, having trouble staying focused, having to reread an assignment frequently, being easily distracted, and forgetting or misplacing her soccer gear frequently.

Additionally, her mother reported that she was very disorganized. Her room was a mess. It was hard for her to complete tasks, especially her chores. She'd get started, would get off track, and not do them or wash the dishes in the sink and then forget the ones that were on top of the counter.

She also avoided difficult schoolwork. Sometimes, she'd even do her work and forget to submit the assignments. She was very fidgety in my office. She reported that she bit her nails and tapped her foot frequently. She denied any other hyperactive or impulsive symptoms.

Thinking about this, what should the clinician do at this point? Refer for psychotherapy to treat that depression and anxiety? Start on an antidepressant to treat depression and anxiety? Further explore her ADHD symptoms and her family history, whether there's a family history of ADHD?

Consider medication treatment for ADHD symptoms? Consider psychotherapy to improve ADHD, depressive, and anxiety symptoms? I'll let you think about that for a second.

There actually is more than one right answer for folks who thought about more than one thing. I decided to further explore her ADHD symptoms and her family history of ADHD. I thought about medication treatment. We'll talk about that in a minute.

Also, considered psychotherapy. I talked to her about seeing a therapist to help her with organization and some executive functioning with her ADHD and also, to work on the depression, anxiety, and relationship with her parents. There is a lot to unpack and a lot to do with this visit that was for an anxiety study.

I told the patient she was making a good case for attention deficit hyperactivity disorder. I asked if anybody else in the family had symptoms of ADHD. The patient's mother reported she had been treated for ADHD for the past several years when she was completing her doctorate in nursing.

The mother reported she had been diagnosed with depression previously and treated with multiple different antidepressants, but she continued to struggle with depression and struggle academically. None of the antidepressants relieved her symptoms with those prominent difficulties in concentration.

The mother reported she was finally diagnosed with ADHD and treated with a stimulant. Once that happened, her depressive symptoms improved dramatically. She was able to pursue her graduate education. She was just about to graduate and become a nurse practitioner.

What did I do with the patient? I recommended therapy. We got a good history for ADHD and a good family history for ADHD. Remember, ADHD is as heritable as height. If the child's got it, chances are, there's probably somebody, one of the parents or somebody in the immediate or extended family who's going to have ADHD.

The patient started on stimulant treatment. Six months later, she's not feeling depressed. Her grades are improved and so is her relationship with her parents. She's happy in school. I will be seeing her every few months to make sure that we're at a good dose of medication, that she's dose-optimized.

We will continue to follow her height, weight, blood pressure, and pulse to make sure that she is not having any significant medical side effects from her medication.

I want to thank you for listening to this case. I hope it's going to be helpful in your practice.