Pediatric ADHD: Proper Diagnosis, Stimulant Therapy

Manpreet K Singh, MD, MS, director, Pediatric Mood Disorders Program, Stanford University School of Medicine, California, discusses introducing stimulant therapy for attention-deficit/hyperactivity disorder (ADHD) management, differentiating pediatric ADHD from mood disorders, and gender or ethnic bias during diagnosis. Dr Singh, who is also an associate professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, says "It's just very important to check your biases and make sure that you, if you're questioning yourself, and you're not sure, to get a second opinion. Call a friend."

In Part 1 of this video, Dr Singh offers "clinical clues" to clinicians on how to distinguish ADHD from primary mood disorders or other conditions and discusses comorbid conditions in pediatric ADHD.

Read the transcript:

Heather:  When you're talking a little bit about treatment and you're talking about adding medications to a stimulant, are there any things that are kind of contraindicated for a mood disorder that would really countereffect the ADHD pharmacologically that could manifest into an even worse situation or more dangerous situation for children?

Dr. Manpreet Singh:  It's a complicated question, Heather, because there are some studies that suggest that stimulants have no effect on triggering mania, whereas other case reports suggests they have.

There was a randomized controlled trial done many years ago that suggested that really there wasn't any difference between a stimulant and placebo arms for adjunctive ADHD treatment in use with bipolar disorder.

The general consensus is that if there are very clearly presentations of first-rate mania symptoms at cardinal symptoms of mania, that mood stabilization ought to be prioritized before adding a stimulant so that you can get the benefit of mood stabilization and perhaps even address the attention problems that very much go alongside having a manic episode, which helps you understand whether ADHD is running alongside it or the attention problems are just part of the primary condition.

It's also useful to be sensitive to the dosing and to use, for example, kids who may show, for example, pretty high sensitivity to like side effects to stimulants or may have a family history of side effects to stimulants or have had very significant bipolar family history to maybe start with short-acting stimulants as a way to introduce the agent to the child.

Start low, go slow and see how things go and reevaluate very frequently. It's not a monolithic approach but it at least gets you safely understanding whether stimulants would be tolerated and also allows you to cut bait because stimulants have such a short half-life to be able to try something else or maybe reconsider the diagnosis.

Heather:  No, no, I appreciate bringing to light the fact that it's really important to get the mood stabilized before treating ADHD. Have you found in certain cases that maybe ADHD really isn't the problem? Maybe it was the mood disorder and there was a misdiagnosis. Going back to the basics seems to work more.

Dr. Singh:  You bet. ADHD is a common prodrome to the development of bipolar disorder. A lot of kids who have bipolar disorder classic mania has had a protracted period of attention dysfunction. We've seen that too, in kids, for example, who have a family history of bipolar disorder might start off with some attention problems that develop over time and then sometimes they adapt to it really well.

When they develop their classic manic symptoms, they tend to do better in school. It's useful to be curious and hold mania as a differential diagnosis. A child may not meet criteria for bipolar disorder, but having it on your mind as a possible differential diagnosis can be very helpful, especially if stimulants aren't working.

Heather:  Switching gears just a little bit when you're diagnosing. Recently we've talked to several clinicians that have talked about differences in diagnosing ADHD between genders, ethnicities.

Do you find that there are certain misdiagnoses because of it being a boy or a girl, there's a socioeconomic background relationship? Can you just speak a little bit to that to clinicians as far as what you would suggest, not falling into that rabbit hole of, "It's a boy. It must be ADHD. It's a girl. It must be anxiety." We've heard a lot about that recently.

Dr. Singh:  You bet. You know what? We're human. Let's acknowledge that we're all susceptible to bias. Our general impressions when we hear about the epidemiology, which is often limited by whoever was studied or responded to a particular survey.

We have to be thoughtful about how we get our information and whether it's truly representative of the population that we're treating. It's very important for us to have some sensitivity to that, and also to be thoughtful about understanding when common things are common. I call them horses versus zebras.

It's OK for us to at least at first blush, leverage what we know, and utilize the common things as common, recognizing that ADHD does tend to more commonly occur in boys than girls.

It's also likely that we're probably going to attribute bad behavior to certain subgroups of individuals that we probably shouldn't be. Making sure that we're doing an earnest job of doing a thorough and comprehensive diagnostic interview on every child that comes to your door, no matter who they are, will certainly help you in the long run.

Again, as I said, epidemiology is our friend. It helps us hedge our bets. No, I think this is probably more likely ADHD. It seems like a horse rather than something more rare. It's just very important to check your biases and make sure that you, if you're questioning yourself, and you're not sure, to get a second opinion. Call a friend.

Heather:  Phone a friend. I love that. We talked a lot about that at Psych Congress about working together, collaborative efforts between providers, health care general practitions. I love that you brought that up because that was a big deal for a lot of folks talking about that.

With that, I will say we are so thankful that you had time to sit down with us. We hope that you'll sit down with us again in the future and discuss more on these important topics.

Dr. Singh:  I would be delighted. Thank you so much, Heather.

Heather:  Thank you.

Dr Singh is Associate Professor of Psychiatry and Behavioral Sciences and leads a program aimed to accelerate understanding and treatment of youth with or at high risk for developing lifelong mood disorders. Dr. Singh earned her MD at Michigan State University and her MS at the University of Michigan. She completed her combined residency training in Pediatrics, Psychiatry, and Child and Adolescent Psychiatry at Cincinnati Children’s Hospital Medical Center. Dr Singh leads a multidisciplinary team that evaluates and treats youth with a spectrum of mood disorders as young as age 2 and well into their 20s. Her research examines mechanisms underlying mood disorders and applies cutting-edge strategies to directly modulate the brain using transcranial magnetic stimulation and real-time neurofeedback. She also investigates the efficacy and safety of pharmacotherapies and psychotherapies, such as family-focused psychotherapy and mindfulness meditation, to reduce mood symptoms and family stress. All of these areas of research aim to elucidate core mechanisms underlying mood disorders and how timely evaluation and treatment early in life can pave the path to more adaptive long-term outcomes.