Treatment and Management of Pediatric ADHD Over the Summer

In this video, Psych Congress Steering Committee member and ADHD Section Editor Vladimir Maletic, MD, MS, discusses living with, treating, and managing pediatric attention-deficit hyperactivity disorder (ADHD) over the summer months. Dr Maletic gives practical advice for clinicians treating these patients and knowledge to share with caretakers.

Read the transcript:

Meagan Thistle, Managing Editor, Psych Congress Network: Hi Psych Congress Network family. Thank you so much for joining us today. We are here again with Dr. Vladimir Maletic and today we'll be discussing pediatric ADHD treatment over the summer. If you'd like to introduce yourself, Vlad.

Vladimir Maletic, MD: Yes, Meagan. My name is Vladimir Maletic. I'm clinical professor of psychiatry at USC School of Medicine in Greenville, South Carolina.

Thistle: Thanks again for joining us. I'm really excited to talk with you about this today and I think our audience will be really interested as well. So, I guess, we'll just get started off with the first thing, what are the pros and cons of treating pediatric ADHD over the summer?

Dr Maletic: Meagan, it's a very interesting question and, frankly, very clinically important question because as the summer unfolds, and it's usually within the first weeks or the first month of vacation, it is not uncommon that during our fall off visits, we will have family members inquire about, potentially, stopping ADHD treatment during the summer. Sometimes there are justifiable reasons as in they have concerns that ADHD medicines, while really necessary during the school year, are also associated with changes in sleep.

The child has a harder time falling asleep or is waking up more during the night. Or they're noticing that there is suppression in appetite. Children don't seem to be gaining weight as would be expected given their growth charts. So, all of these are, indeed, concerning issues.

Indeed, there are longitudinal studies indicating that some of these observations are accurate. So, stimulants are associated with suppression of appetite as well as sleep disturbance. Stimulants have a negative impact on vertical growth. Stimulants can have a negative impact on change in weight, on appropriate weight gain for children who are developing. So, these are valid concerns.

In terms of what influences growth, vertical growth, in children taking particular stimulant medications, it's not clear that it is closely linked to decrease the appetite and caloric intake. It is also possible that stimulants can, in some instances, influence change in sleep architecture. And particularly concerning ramification would be if there is decrease in quantity of slow-wave sleep. Why would that be so important? Because it is during slow-wave sleep when growth hormones are secreted.

So, one on one hand, we would want to address all these concerns, but on the other hand, we have to realize that ADHD does not remit during the summer. So, ADHD is still there. Unfortunately, there are studies that looked at the impact of ADHD and mortality, and there is very significant increase in mortality in child and adolescent population that is affected by ADHD. It is not only, at least, 50% increased in risk of dying, very significant number, but if there are comorbidities, that risk progressively builds. So, if the child, in addition to ADHD, has an anxiety disorder, a mood disorder, oppositional defiant disorder, all that builds on the risk of mortality.

Why might that be the case? Well, youngsters who have ADHD have greater risk of head injury, have greater risk of ending up in ER. If they are adolescents, if they're are 15 and 16 and have permit and are driving, there's a greater risk of motor vehicle accidents. There's a greater risk, again, in teenagers, of substance use if they're not treated. So, we have to take into account... And, frankly, even suicidal behavior risk increases if ADHD is not treated. So, we have to take into account that while there may be gains, there may be also substantial risks. Ultimately, we are not the ones who are going to decide, but as clinicians, I believe it is our duty to bring it to parents' attention.

The other issue is that presence of ADHD, as many families have realized, has an important impact, not only on grades in school, but on the quality of family life. In families where kids have ADHD, divorce rates are substantially increased. So, during the summer, many times, this is not particularly fair to moms, but many times mom will shorten their work schedule in order to spend more time with kids. If families have several children, siblings are at home at the same time. Kids who have ADHD have greater propensity towards having negative affect. And they don't like not being in focus of attention many times.

So they will try to, either politely, maybe initially, engage their siblings, or if their siblings are not interested in having an intrusion in their activities, they'll be pissed off, when, at that point, the child with ADHD may become a bit more intrusive, a little bit more assertive and a little bit more disruptive. And what that causes is fights and then parents have to manage these fights. And it's really not a fun day for parents and it's not a fun day for siblings. It's not a fun day for anybody in the family. And families that have kids with ADHD know exactly what I'm talking about. Well, with appropriate treatment, that can be addressed. It doesn't have to be so. So, there are some pros in, at least, temporarily stopping treatments or having these treatment holidays, but there's also a big question mark in thinking about what may be the risk involved in doing so.

Thistle: So, let's say a parent comes in and says, "We're really looking to stop the treatment over the summer." What would you say to them? How would you have the conversation, "Yes, that sounds like a good idea. Maybe not." What would that look like?

Dr Maletic: Well, some of the factors that we have just discussed would be part of that conversation, right. But one thing that I would also want to know is why. So, it may be because there are some concerns about medicine, but there may be something else. Parents may note that now that they are having a chance to observe children for a longer period of time, because during the school year, kids were in school for most of the day, now they're at home most of the day. And now they're all of the sudden wondering if the child that has ADHD and is being treated is having a little bit more irritability on these medicines. Or are they having more anxiety? Or are they having more moodiness? Those are all valid concerns. And there are long-term observational studies that have recognized a phenomenon that is very intriguing and it actually has to do with genetics of ADHD.

So, while we have naively thought that psychiatric diagnosis reflect homogeneous pathophysiology for the entire group of these patients, now we are finding that it is far from accurate. So, children, indeed, may have risk genes for ADHD, which may translate into maybe earlier onset of condition, maybe more symptomatic expression of ADHD, but they also may have genetic risks for other psychiatric conditions.

So, children who have ADHD may also have genetic risk for bipolar disorder, or they may have genetic risk for anxiety disorders, or they may have genetic risk for major depressive disorder. And if that is so, they will have a little bit different response to stimulants than a child with maybe more typical ADHD without having genetic risks for these comorbid conditions. If they have risk for these comorbid conditions, guess what's going to happen? ADHD medicines will not behave like expected. And then we get a call during the summer saying, "I want to change the medicine."

While the longitudinal studies that I've mentioned to you are the ones that have ascertained, it is exactly in those scenarios when the medicines are most frequently switched. So, many times during the summer, if there is a request for switch of medication, let's say going from non-stimulant to stimulant, or stopping the medicine, it is a signal to us as clinicians to hit a pause button and start wondering, "Why is all of the sudden this child more irritable? Why is this child having more mood swings? Why is this child having change in sleep-wakefulness patterns? Why is this child all of the sudden, they've been treated for a long time, but they're now having a more pronounced anxiety symptoms.”

Getting a good family history, getting a good longitudinal history, can sometimes help us identify either a fully present comorbidity or, at least, gain some awareness that there may be genetic risk for comorbid conditions, which may then inform our treatment choices. So, these are some of the challenges that may occur during the summer where we have to really rethink our diagnosis and be more careful, not just have knee-jerk reaction, say, "Okay, let's just stop the treatment." It's easy thing to do, right? Because the problems don't go away when we stop the treatment, that is the concern.

Thistle: So, that's a good indicator to look out for parent calls and says, "I'd like to pause." That's when you even pause-

Dr Maletic: "I'd like to pause. I'd like to change the treatment." And treatment has all these effects that we have not noticed during the... One, maybe the child was having some of these manifestations, but they were in school and these manifestations were not interfering with school performance. The other is, again, if they have a genetic risk for these comorbid conditions, that these manifestations just became apparent during the summer. They were not really there. Because one thing that we need to realize about ADHD, ADHD is not a static condition.

There have been, now, longitudinal studies that came out of multimodal treatment project of ADHD that went on for years. And here's an interesting conclusion, of all the children in this large national study that were treated with stimulants, this was a standard treatment, they could also receive various forms of psychotherapy and family therapy, but stimulants were one of the major treatment arms in this large project. Here's the finding, "80% of these children going on to becoming adolescents and going on to becoming adults did not have stable course of ADHD."

"Only 10% were sick throughout this period and having clear presence of disease. 10% only got better to the point where they would no longer meet the criteria for diagnosis." So, 10 sick all the time, 10 in recovery. 80%, it shifts between these states. Sometimes doing well, sometimes not doing well, right? So, we have to realize that treatment of ADHD is dealing with a moving target. And the fact that child may be doing better now does not necessarily mean that they'll never need treatment, that they're done. So, this is of particular concern in adolescents, because leaving it untreated can be associated with significant risks, not only in terms of their social activity and driving and substance use and risky behaviors, it can translate, I hate to say it, into lethal outcomes. So, we have to be very, very careful about that.

And the more we know about that natural course of ADHD, I think, the more effective we can be as clinicians and better advice we can give to parents and adolescents and even younger children. They very much understand what ADHD is like. And I can tell you that I've had patients who were treated, now, some summers, they were without medicine, and then parents came in and we started treatment. And the follow-up appointment, the child is saying, "I'm not really seeing much of a difference. I'm the same way I was. I don't even know if I need to be taking the medicine. But I've noticed that since I've been on medicine, my parents and my siblings are treating me much more nicely."

Dr Maletic:

They had little insight that they're picking and intruding and interrupting and doing all these things and tearing apart a sibling's toy or doing things to get attention, that they would evoke an emotional response in family members. And, of course, it's all internalized and they end up not feeling very good about themselves, right? And now that stimulants are in place, and some of these negative behaviors that were intended to engage their family members are no longer there, all of the sudden everybody's being nicer to them. So, unintended consequence of treatment of ADHD, people become much nicer to you, right. But it's good to follow and it's good to spend time with patients and elicit this information.

Thistle: So, is there anything else that a child or an adolescent might say to you, aside from, "People are being nice to me," because that's a really good thing for clinicians to know to look out for that, right. Obviously, something's working. Is there anything else that clinicians should know to look out for, whether that's good or bad, when we're thinking, "Are we going to continue treatment, stop treatment, change things up." What does that look like from a child's perspective?

Dr Maletic: They get invited for more play dates, because one of the reasons, again, that they're not getting invited for birthdays and play dates is that manifestations of their illness tend to be disruptive. So, unfortunately, these kids end up not being very popular with parents of their peers and that is all hard. And I don't think it really has the attention that it deserves. Having ADHD is associated with a lot of emotional suffering and internalization of self image that is not the best. And it takes a long time to fix that. I don't think that it has deserved enough attention in the literature. What is life of a child that has ADHD like, and what kind of self image it produces? So, I think that these are all things that, unless we ask and unless we spend time with our patients and unless we spend time with their parents, we will just not know about these things.

Thistle: So, over the summer, these things, obviously, exacerbated, right? The self image, the fighting with the family. And they don't have the reinforcement of maybe teachers at school, right? And maybe harder-

Dr Maletic: No school structure, right? No school structure, because structure doesn't go-

Thistle:

Dr Maletic: Those are boxes that contain some of these behaviors. Now they're gone. I'm sorry, I you.

Thistle: No, you're good!

Dr Maletic: You know, you have begun answering that question. You are absolutely right. As we transition from school year to summertime, many times there isn't a structure there. But having in mind some camp-like activities during the summer, kids enjoy that. Sports activities are really good from both socialization perspective and the need to be more engaged and moving all the time. So, all these things are really good. So, as school structure is removed, I think that one needs to plan ahead and then not just make it up as we go on, but rather have a plan for the summer, have a plan for several days that would have some structured activities and also pay attention, especially in adolescents, to sleep-wakefulness cycle.

So, one of the developments related to COVID-19 pandemic is that circadian rhythm, especially in adolescents, has changed quite a bit. So, not only are they using their computers for school, at least that was the case until a few months ago, they were using them to communicate with their peers because many of them were spending time within their families and not socializing. Well, not all of that has changed since COVID-19 related restrictions have been largely lifted. So, kids are still spending much more time with screen time. They're communicating via screens.

Unfortunately, some of this is happening in the evening hours and disturbances in circadian rhythm for kids who have ADHD do have ramifications. It's not important they get enough sleep in terms of quantity, it's also important that they get the right quality of sleep. What I mean is if one sleeps during the night, one is more likely to have richer, slow-wave sleep phases. Slow-wave sleep, I've mentioned before, is the time when most of the growth hormones are released. But slow-wave sleep is also the most restorative phase of sleep. And, therefore, children who have had good restorative sleep are less likely to be stressed the next day.

Why might that be relevant? Because there are studies that have looked at the impact of stress. Children who have ADHD, when stressed, are more likely to be irritable. They're more likely to be anxious. They're more likely to be moody. So, all of these may not necessarily be reflection of comorbidities. They may be reflection of stress. And vulnerability of stress is related to getting a good night's sleep.

Thistle: So, how could a clinician or even a parent investigate this? How do I know my child's getting adequate sleep? What can I do to make sure that this is happening? Anything that they can do to make sure that a child's maybe putting their phone down a certain time of night. What does that look like and how can a clinician guide a caretaker to do that?

Dr Maletic: I hate to say it, but there apps...

Thistle: Of course.

Dr Maletic: There apps for everything.

Thistle: Fix tech with tech!

Dr Maletic: This was a little bit uneasy situation that I've just gone through during the last week. And, sadly enough, this is a scenario where parents are no longer together. And one of the parents was under impression that child was sleeping well. And the other parent is like, "Well, I'm tracking the activity on their phone and I'm tracking the activity on their laptop, and they were using it at one o'clock in the morning."

Thistle: Sounds like me. I'm up too late. I mean, we all do it.

Dr Maletic: Yeah. Kids can be sneaky, right?

Thistle: Yeah.

Dr Maletic: So, it's a good idea to have some way of tracking their screen time and not taking it at face value if they say, "I'm going to sleep at 10 o'clock." Especially in adolescents, that may not be quite accurate.

Thistle: Right. Right. So, is there any sort of eye -wear Fitbit, for example. Would you suggest something like this to a parents or caretaker, anything like that?

Dr Maletic: I think that wearable devices are helpful because it's another way of doing two things. On one hand, making sure some of the more sophisticated programs will actually give you an idea of what the quality of the sleep, duration of the sleep, number of awakenings, these are all important to take into consideration. But they'll also give you an idea of the activity level during the day. And this is equally important because, again, it's good for kids who have ADHD to be physically active.

And if one sees that wearable device that conducts actimetry during the day, is showing that the child has been sedentary for extended period of times, most likely there are screens involved in that phenomenon too. It's probably not the best way to spend the summer. So, parking a kid in front of TV screen is not the best way to help child that has ADHD.

Thistle: Right. So, just to summarize your suggestions for lifestyle, right? So, we want adequate sleep. We want physical activity and we want structure in general, right? So, summer camps and making sure maybe some sports, things like that. Anything else that we're maybe missing?

Dr Maletic: Nutritionally, these studies are not always the most consistent ones, but there are research studies, research papers, published that have suggested that red and orange dyes may be problematic. These are not unequivocal. There is many studies showing that they really do not have significant effect. But there is some indication that there may be a neuro-inflammatory component in ADHD, in which case anti-inflammatory diets would be helpful. And these anti-inflammatory diets are very similar to Mediterranean diets.

So, meaning more lean protein in diet, nuts, those are good and healthy snacks, avoiding simple sugars, avoiding carbohydrates. During the summer, having fresh fruit and vegetables is not difficult to do. So, all of these things that are assumed to be healthy eating habits for adults actually may contribute quite a bit when it comes to ADHD. In the past, there was some conversation about omega-3 fatty acids and polyunsaturated fats as being helpful in ADHD. I must admit that it's not the most consistent dataset. If the benefits are there, they're relatively minor. But on the other hand, having healthy diet is not going to hurt things.

Thistle: So, you shared a lot of really great pearls for clinicians to take, to share with parents. And if parents are watching and caretakers are watching this, that they can maybe implement in the summer. Is there anything else that we didn't touch on that you'd like to share, in general, about treating pediatric ADHD during the summer months?

Dr Maletic: Yes. Summer is not the time to, if you are a clinician, to take things easily and to take information at face value. Summertime is actually the time to be extra thoughtful and to use this time to establish a better relationship with your patient that has ADHD and maybe get a little bit more richer information about what their life is really like because during the school, it is all about doing well in school. This is a time to really get to know your patients well, and to get a better understanding of their lives and also to get better understanding what life is like for their parents.

Thistle: Right. Yeah, because this does impact the whole family and parents and familiar relationships, so it is, probably, a good idea to get that insight.

Dr Maletic: And I hate to say it but studies that looked into parental history of ADHD, about 40% of dads of kids who have ADHD also have ADHD.

Thistle: Wow.

Dr Maletic: Lesser percentage of moms, it's more like 25 to 30%. But 40 to 45% of dads of kids who have ADHD also have ADHD. So, our identified patient may not be the only family member with ADHD and that's always good to keep in mind too.

Thistle: Well, thank you so much, Vlad. Did we cover everything? Anything else you'd like to share?

Dr Maletic: I think for now we did. I'm sure that there will be time for a next conversation and other topics that we can address in the future.

Thistle: Of course. And Psych Congress Network family, if you thought this was interesting, please check back. Go through our pediatric ADHD center of excellence, our micro resource center. There is a plethora of information there for you to check out and get even more information on pediatric ADHD. And thank you so much, Vlad, for joining me again. It's always such a pleasure to talk with you. Always a good time. Thank you.

Dr Maletic: Thank you, Meagan. Likewise, and I wish happy spring and summer to all of our audience members.

Thistle: Yes. Thank you so much.

Dr Maletic: Thank you.