HOUSTON – “When I am asked whether I think [attention-deficit hyperactivity disorder] is overdiagnosed, I say that kids are underfoot now more than they used to be,” Saundra Gilfillan, D.O., said at the annual meeting of the American Society for Adolescent Psychiatry.
“Did we miss ADHD before? No, the hyperactive kids wore themselves out,” said Dr. Gilfillan, a child and adolescent psychiatrist at the University of Texas Southwestern Medical Center at Dallas, which cosponsored the meeting.
Comorbidities are common with ADHD: As many as 80% of children and adolescents with ADHD meet criteria for a related category disorder, particularly conduct disorder, oppositional defiant disorder, and bipolar disorder. When evaluating a child or adolescent for ADHD, it is important to consider other conditions as well.
When Dr. Gilfillan assesses children and adolescents for ADHD, with or without comorbidities, she starts by asking parents about the child's behavior as an infant.
Hyperactive children were often very active in utero and active as infants; they didn't sleep well and were distracted when eating, she said. In addition, children with ADHD often skipped the crawling stage or spent very little time crawling. Dr. Gilfillan also asks whether the child or adolescent is invited to birthday parties.
“It's a very big developmental thing on the social side,” and parents who recognize a “hyper,” aggressive child may not want the child in their house, she noted. She also asks about emergency department visits and car accidents.
“I like to look at report cards, to see what teachers wrote about behavior,” she said. Another question is who babysits. “If the grandmother won't babysit the child, then that's a problem.”
People do not truly outgrow ADHD; the symptoms simply evolve. Motor hyperactivity in childhood evolves into internal feelings of restlessness in adolescence and adulthood. They often have problems in classes where they have to sit or take notes, she said.
Children with ADHD who do not have comorbid conditions generally exhibit less severe symptoms. Their carelessness and inattention may lead to destructiveness and misbehavior, but it appears to be unintentional. Children with ADHD who also have conduct disorder, oppositional defiant disorder, and bipolar disorder are more likely to have social problems, to require hospitalization, and to develop other problems such as depression and anxiety. Here are more specific observations on the comorbidities:
▸ Conduct disorder. “I call these the thugs and 'thugettes,'” Dr. Gilfillan said. These children or teens have no respect for societal norms–they genuinely do not care about the rights of others. The majority of child-onset cases of conduct disorder are in males, but by adolescence the numbers are approximately equal. Children with conduct disorder don't always make it to the psychiatrist because they go into the legal system first.
▸ Oppositional defiant disorder. By contrast, children with oppositional defiant disorders tend to be argumentative, but usually only within their immediate network of family and friends. Some kids negotiate that way; some derive satisfaction from engaging their parents in an argument.
▸ Bipolar disorder. More than 50% of adolescents with bipolar disorder have at least one coexisting psychiatric disorder. “In many areas, to get a child some time in a psychiatric hospital, you must have a diagnosis of bipolar disorder,” Dr. Gilfillan noted. As a result, many clinicians lead with the bipolar diagnosis because they know the child needs to spend some time in an inpatient facility, she said. Features of bipolar disorder in children and adults are similar to characteristics of ADHD. The prolonged outbursts, which she described as “affective storms,” are bipolar rather than hyperactive.
Early symptoms of childhood-onset bipolar disorder include oversensitivity to sensory stimulation and night terrors as an infant, and high levels of anxiety and difficulty controlling anger as a school-aged child. Reports from family members might suggest that the child has a difficult temperament.
Treatment options for children and adolescents with ADHD and other conditions include Strattera (atomoxetine), Adderall (amphetamine mixed salts), and Concerta (methylphenidate), as well as Ritalin (methylphenidate HCl) and Dexedrine (dextroamphetamine sulfate).
Underdosing is one of the most common reasons for discontinuing medication, Dr. Gilfillan said. Parents often are not used to titration for their children's medications, since it is not used for ear infections or urinary tract infections. Families become impatient and say that the medication is not working; they may want to switch drugs instead of increasing the dose. “Medication can do some things, but other things must be done at the same time,” she said. Nonmedication therapies for ADHD and comorbid problems include hobbies, sports that channel excess energy, and strategies for better academic performance, said Dr. Gilfillan, a consultant and member of the speakers' bureau for Pfizer, Ortho-McNeil, and Abbott, and a member of the speakers' bureau for AstraZeneca.