Medicate or Not?
As pediatric practitioners, we often hear about medication and ways to help with symptoms for psychiatric diagnoses, in combination with our treatment. But how safe is medication? Do they have an affect on their health? As a focus of a previous blog, we looked into the prevalence and symptoms of ADHD…
“Symptoms are often noticed during the early childhood years before 3 years of age. However, caution is advised on early diagnosis and will most often be made during elementary school years when behavior is interfering with school performance. Some other notes on symptoms:
Occurs in 5%-8% of elementary school aged children.
Prevalence in boys to girls is a 3:1 ratio, most common in first born boys.
Partial remission may occur in ages 12-20. Hyperactivity may disappear during these years to allow for a productive adolescence but distractibility and impulsivity can persist.
Symptoms persist into adulthood in 60% of cases.”
In reference to treatment of something like ADHD, Oppositional Defiant Disorder, Conduct Disorder, Disruptive Behavior Disorder, there are usually a combination of treatments. Behavioral techniques, and medications. But most importantly, before your doctor gives you a script for a prescribed medication- there should be a thorough process to make sure that your child is diagnosed appropriately.
It’s true, that medication for ADHD can be overused, but the under-diagnosed and under-treated factor for ADHD is more often than over treatment. Your child should not be diagnosed as having ADHD after a 10 minute exam. There should be behavior reports from multiple sources, surveys, medical history, and a clinical interview with your child.
After a thorough evaluation, you can discuss options with your doctor. The most common medication is Methylphenidate (Ritalin, Concerta, Metadate, Daytrana, Quillivant), and has been used for over 50 years for symptom management of inattention, impulsivity, and hyperactivity. If symptoms are affecting your child's quality of life and learning, it’s something to consider with the supervision of your doctor. Side effects seem to be not life threatening according to research, there may be problems with sleeping, or decreased appetite, but you can always discuss adjusting the dosing with your doctor to get a better fit.
Other treatment options:
Occupational Therapy is one of the specialized treatments that can help your child perform in school and at home. When I treat in schools, there were often times that I would go into the classroom with the child to help learn different coping strategies and techniques to facilitate his or her attention. We also took time to educate the teacher on the strategies we were working on in order to facilitate learning. Also, as an occupational therapist I encourage participation in functional activities and extracurricular activities (at their pace), to help with time management, organizational skills, positive social interaction, and an outlet to feel successful in.
References:
https://www.bmj.com/content/351/bmj.h5203
https://www.health.harvard.edu/blog/adhd-medication-for-kids-is-it-safe-does-it-help-201603049235
A Video Game for ADHD?
After hearing about a new FDA approved prescription video game for ADHD, I had to read the research myself to believe it. At first thought, it seemed counterproductive to me. How can something that typically has been known to be a distractor help ADHD? Don’t get me wrong, technology has its pros, such as increased productivity for the workplace, convenience of shopping from home, even working from home thanks to COVID but it still makes me question the effectiveness of a video game to improve your attention.
In today’s day and age, technology is such a large part of our lives. Screen time on our phones increase, and our threshold for the amount of “multitasking” for the first hour of our work day has drastically increased over the past 20 years. Below is part of the research study that I found. I hope you find this useful!
ADHD is a widely known diagnosis that children struggle with, it accounts for about 5% of US children, and is the most commonly diagnosed pediatric mental health disorder. As we learn more about mental health in the US, we want to find the safest treatment - especially for children who are still developing and growing. Medication has it’s side-effects, and has short-term efficacy. I was especially surprised to hear that the trials used for pharmacological efficacy for ADHD typically used parent rated or clinician rated symptom measures! This means the research to back these drugs used for ADHD are mostly based on the parent or clinicians subjective opinion. Having alternate methods outside of pharmacological intervention is important, especially if it has limited improvements that become outweighed by side effects.
Participants: 8-12 years old with ADHD, No Medication even if regularly taken, 348 kids
About the Study Design: Randomized, Double-Blind, Parallel-group, Controlled Trial
The video game trial would be an alternative method that would be engaging, but also reduces adverse effects (negative side effects). The novel digital therapeutic. AKL-T01 (Akili Interactive Labs, Boston, MA, USA), was made to engage children with ADHD but also targets attentional control to improve completion of tasks and shift attention more efficiently between tasks. What makes this trial unique to research for the ADHD population, is that it uses objective cognitive assessments to measure outcomes. So, findings are not based on a parent or clinician opinion of the results, but tests administered to the child. The trial showed significant improvement in attention-related measures with children that used the video game AKL-T01, compared to the group that did not. It also reduces negative side effects for the child. The only reported adverse effects included 7% of children using AKL-T01 were frustration and headache, versus 40-60% of children in trials of commonly used stimulant medications (which has a lengthy list depending on the medication). Specifically, trials done for stimulant medications don't have research on the functional improvement on a validated measure that this study has. There definitely needs more research done to see the long term effects of this video game, but it’s a novel treatment technique that may be safer and more accessible to families in the future.
References
Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol 2014; 43: 434–42.
Catalá-López F, Hutton B, Núñez-Beltrán A, et al. The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: a systematic review with network meta-analyses of randomised trials. PLoS One 2017; 12: e0180355.
Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry 2018; 5: 727–38.
Shams TA, Foussias G, Zawadzki JA, et al. The effects of video games on cognition and brain structure: potential implications for neuropsychiatric disorders. Curr Psychiatry Rep 2015; 17: 71.
Kollins SH. Moving beyond symptom remission to optimize long-term treatment of attention-deficit/hyperactivity disorder. JAMA Pediatr 2018; 172: 901–02.
Kollins SH, DeLoss DJ, et al. A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomized controlled trial. Lancet Digital Health 2020: Volume 2, Issue 4, E168-e178.
Wolraich ML, Greenhill LL, Pelham W, et al. Randomized, controlled trial of oros methylphenidate once a day in children with attention-deficit/hyperactivity disorder. Pediatrics 2001; 108: 883–92.
The Real Deal with ADHD
We often hear people say that they think they may have ADHD if they are having trouble focusing on school or work. ADHD is a well known diagnosis that people may misinterpret or misdiagnose.
If you have ever wondered if you may have ADHD, it’s always best to speak to a doctor. However, here is some background on the topic in order to help those that are curious.
Etiology is unknown, however there are suggested contributing factors including:
Genetic factors - higher occurrence in monozygotic twins than in dizygotic twins, 2X the occurance in siblings of hyperactive children. This leads us to believe there’s a correlation in passing it down in families.
Neurological factors - possibility of minimal brain damage due to circulatory, toxic, metabolic, or mechanical effects during fetal development, and infection inflammation, and/or trauma during early childhood.
Neurochemical dysfunction related to neurotransmitters in the adrenergic and the dopaminergic systems.
Psychosocial factors - stress, anxiety, or predisposing factors such as temperament.
According to the American Psychiatric Association (APA) there are three types of ADHD as defined by Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). There are three subtypes of ADHD; Predominantly Inattentive type, Predominantly hyperactive-impulsive type, and Combined type. Depending on the symptoms, your doctor will be able to diagnose your subtype.
Symptoms
Symptoms are often noticed during the early childhood years before 3 years of age. However, caution is advised on early diagnosis and will most often be made during elementary school years when behavior is interfering with school performance. Some other notes on symptoms:
Occurs in 5%-8% of elementary school aged children.
Prevalence in boys to girls is a 3:1 ratio, most common in first born boys.
Partial remission may occur in ages 12-20. Hyperactivity may disappear during these years to allow for a productive adolescence but distractibility and impulsivity can persist.
Symptoms persist into adulthood in 60% of cases.
Diagnostic Criteria
Presence of 6 or more symptoms are required in three Domains (or subcategories).
Symptoms in the inattention/hyperactivity domain that interfere with occupational activities are present for at least 6 months.
Inattention Domain Symptoms may include: lack of attention to detail, poor listening, limited follow through of tasks, difficulty with organization, and avoidance of tasks that require sustained attention, tendency to lose things, distractibility, and forgetfulness.
Hyperactivity Domain Symptoms may include: fidgeting, inability to remain seated, inappropriate activity level for a given situation, difficulty with quiet sedentary activities, frequent movement and excessive talking.
Impulsivity Domain Symptoms may include: answering questions before they are fully stated, difficulty with turn taking, and interrupting the conversations of activities of others.
Other symptoms that may be present: Visual-perceptual, auditory-perceptual, language, cognitive problems.
Some of the symptoms presented were evident before the age of 7.
Symptoms result in difficulty in 2 of these settings: school, home, and/or work.
Symptom management
Medication as prescribed and monitored by a doctor, Psychotherapy, behavior modification, parent and individual counseling may be indicated.
Impacts on function
Infants may be overactive, difficult to soothe when crying, and demonstrate poor sleeping habits.
You may see defensiveness to environmental stimuli, frequent irritability, aggressive behavior, emotional lability, and unpredictable performance. These are all in response to difficulty with attention, it creates a barrier to learning and performance.
There may also be disorders in school related tasks or learning disabilities, which can be assisted with a team approach to your child’s care at school.
Caregivers may also see an increased risk for depression due to frustration and difficulty with learning. Checking up and addressing your child’s self esteem is important during this time to avoid progression. Those with symptoms remaining in adolescence and adulthood are at an increased risk of antisocial personality disorders, and substance-related disorders.
Considerations for Occupational Therapy
Occupational Therapists will work with children and their families on behaviors that may contribute to difficulty in school, play/leisure, and social participation. This may include environmental modification for facilitated learning, training in social skills/self-management, promotion of sensory modulation. Consultations to family, teachers, and employees regarding strategies are also implemented for treatment.
If you have any questions, please feel free to reach out to me directly smplytherapy@gmail.ccom
References
Glanzman, M. M., & Nathan J. Blum. (2007). Attention deficits and hyperactivity. In M. L. Bathshaw, L. Pellegrino, & N. J. Roizen (Eds.), Children with Disabilities, 6th ed. (ppp. 345-365). Baltimore, MD: Paul H. Brooks
American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and statistical manual of mental disorders, text revision, 4th ed. Washington, DC: Author.