What doctors wish patients knew about ADHD in children

With distractions just a click away, some minds struggle to tune out the noise. For children, teens or adults who are inclined to race ahead, juggle thoughts and wrestle with focus, the problem is more than just dealing with everyday distractions. This restlessness and impulsivity are part of a condition that affects millions in the U.S. and often goes unnoticed or is misunderstood: Attention-deficit/hyperactivity disorder (ADHD).

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Jonathan Shook, MD, a pediatrician and medical director at Hattiesburg Clinic Connections, took time to discuss what patients need to know about ADHD. Hattiesburg Clinic is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“ADHD is a neurodevelopmental condition that has many risk factors or contributing factors that can affect individuals at different times in life in different ways,” Dr. Shook said. “It was first thought to be mainly a pediatric condition or present mainly in children and teens.

“But in the last few decades, we’ve been learning a lot more about adult ADHD and that many adults have ADHD,” he added. “That’s an expanding field and we’re excited to be trying to help more adults with ADHD right now.”

“There are different types of ADHD and in children it’s more common to see more levels of hyperactivity and impulsiveness,” Dr. Shook said. For example, “trouble staying seated, trouble remaining quiet during activities, interrupting conversations or trouble sitting still. That’s more common in the pediatric population.”

“The symptoms that are most common as we get into older children, teens and adults are more related to attention and trouble focusing, trouble staying on task, trouble organizing and trouble with time management,” he said. “We don’t see as much overt hyperactivity in adults, but we do see sometimes it can turn into more of an inward restlessness that adults can describe.”

Additionally, “they may have some more fidgeting or small movements that they do, but they sometimes can have a racing mind that feels more like inner restlessness rather than a lot of movements,” Dr. Shook explained, noting that “in children, boys are more likely to be diagnosed than girls, but as we go up the lifespan into adulthood, the ratio is closer to one-to-one. 

“So there's not a big difference with men and women, but in childhood we do see that more boys are diagnosed in girls,” he added.

“Other conditions we have more objective tests for, but for ADHD it is more of a clinical diagnosis that’s made by getting information from the patient as well as from family members, teachers or other support people who know the person as well,” Dr. Shook said. That means “establishing that they’ve had symptoms of ADHD for longer than six months and the symptoms have caused some impairment and difficulty functioning and evidence that there’s no other medical or psychological conditions that are causing those symptoms.”

“When we say symptoms of ADHD, we have a list of defining symptoms related to hyperactivity and impulsivity,” he said. “Then another list of symptoms related to focus and attention.”

“There are many contributing factors or risk factors that can contribute to ADHD, but we know the biggest player looks to be more genetics,” Dr. Shook said, noting ADHD “definitely tends to cluster in families and be transmitted pretty strongly in the gene. So, we know there’s a big genetic component.”

“We don’t know of one specific gene, but it’s more polygenetic, which means there are lots of genetic regions that are being looked at,” he said. “Then there are other things such as intrauterine conditions or pregnancy and birth history. Maybe certain exposures in pregnancy or complications of pregnancy and labor might increase chances of ADHD.”

“When we come to childhood, certain types of brain conditions or brain injuries can also contribute to or make ADHD worse as well,” Dr. Shook explained. 

“Children who have an underlying tendency for ADHD or have that trait or genes, we know that going through certain environments or stressors are more likely to cause symptoms to be noticeable or come out,” Dr. Shook said. 

For example, “children who come from difficult socioeconomic statuses are more likely to be diagnosed with ADHD and struggle with ADHD,” he said.

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For a person with ADHD, it “can have a huge impact on their daily life, no matter their age,” Dr. Shook said. “It can cause kids to be easily distracted, have a hard time focusing on instruction or on details and they may make careless mistakes when trying to do their schoolwork or take a test. So, it can impact learning.

“So, they may not be able to learn as well and then they—even when they do learn well—may not represent that well when it comes to what we call executive functioning on a test,” he added. “They may not be able to represent that well because they make more mistakes in the execution of the test.”

“A lot of kids with ADHD might be more impulsive and have disruptive behaviors,” Dr. Shook said. “If they’re not able to finish their work, they miss out on things such as recess because they have to stay in and do their work, so that can affect their daily experience.”

“And then it can show up socially as well. A lot of people with ADHD may have trouble listening whenever there are conversations going on, especially with multiple people and so they may feel left out of conversations or not participate as much and not be able to participate as much in groups,” he explained. “A lot of times we find that because of their ADHD that they are left out of some friend groups at school. So, we have to look at the social impact on people.”

“Because of all these things, then we see self-esteem come into play. If a student with ADHD is not performing as well as they want to or as well as they feel like they should academically, behaviorally or socially, that affects self-esteem,” Dr. Shook said. “And then you have higher incidence of anxiety and depression and other mental health conditions as we get older due to those effects.”

“Adults with ADHD have a harder time on daily functions with organization, losing things, trouble at work and time management,” he said. “The details that do matter and add up are sometimes a lot harder for people with ADHD.”

“For children and students, we think of treatment in three baskets. We have behavioral, academic and medical or medicine treatments,” Dr. Shook said. “When it comes to behavioral treatment, the thing that’s been shown to be the most effective for younger kids is called parent behavior management training and it’s where we help the parents learn the strategies that will help children thrive and develop through their ADHD and have better coping skills.”

“When we’re talking about young ages—anywhere from preschool age up to adolescents—parent-behavior management has been shown to be the most effective behavioral therapy,” he said. “Once we get older, to adolescence, then therapy with the adolescent is more beneficial, which includes doing organizational skills training, working explicitly on ways to use our time better, ways to be more organized with our daily routines and responsibilities.”

“Also on the behavior front is behavioral therapy for coexisting conditions such as anxiety or depression that can be very helpful because we see those often,” Dr. Shook said. “A lot of times, the therapist will work with the individual on some of the coexisting conditions such as anxiety, depression or sleep problems that can really help with their daily functioning.”

This means “making sure that the school can get medical records or any sort of psychological records of the child,” Dr. Shook said. This ensures “that the school understands what struggles or difficulties the child may have or what strengths the child has. 

“A lot of times, interventions the school can do—whether that’s tutoring, a separate area to take a test or extra time to take tests, or having questions read aloud—can often be helpful, so it’s always good for families to meet with school officials to talk about those options for the academic side of things as well,” he added.

“When it comes to children who are school age—6 years or older—the American Academy of Pediatrics” recommends combining medication treatment with behavior therapy, Dr. Shook said. “Medicine should be considered more first line, early on after diagnosis in children 6 or older along with the other treatments.”

These are Food and Drug Administration-approved medications for ADHD and should be used along with parent training in behavior management and behavioral classroom interventions. The preference is using both parent training in behavior management and behavioral classroom interventions in addition to medication treatment for ADHD.

“We still want to do our behavioral interventions and educational interventions, but medicine should be considered early on,” he said, noting “there’s not a good reason to wait on medicine if we see that the ADHD is causing impairment because medicines have been shown to be the most effective intervention in children for ADHD and have been shown to be very safe as well.”

Because there are different types of ADHD medicines on the market, “the family needs to look at the options with the medical provider and talk about the benefits of specific medicine as well as the potential side effects,” Dr. Shook said. “Then look at the goals for the specific child or person and decide on which medicine might be the best fit for that person.”

“The most common side effect with our stimulant ADHD medicines would be decrease in appetite during the day when the medicine is active,” he said. That is why “we always talk about the importance of nutrition and appetite and ways to manage that.”

“More rare side effects that sometimes come up would be disruptions in sleep or trouble falling asleep and sometimes mood side effects,” Dr. Shook said. “Those sometimes pop up too and need to be addressed.”

“The other kinds of medicines are nonstimulants and they also can have side effects, but they’re a little bit different. They may affect sleep or have gastrointestinal side effects, but usually do not suppress appetite as much as the stimulants do,” he said.

Families, friends and other loved ones play an important role too, starting with “understanding. There are so many myths, stigmas or misconceptions about ADHD, but if someone in our family has ADHD or a close contact or friend, learning about ADHD and that person is important because it can look different from person to person,” Dr. Shook said. “Everyone does not have the same struggles, so knowing how that individual’s ADHD may affect them can be helpful.’

“Once we know that, then we can know more of how to form a more solid relationship and maintain that relationship with the person, whether that’s planning more one-on-one time, sending a reminder about an appointment or about something that we’re scheduling together to help prompt the person might be helpful,” he said. “But also, being understanding and supportive that when maybe things are forgotten or missed, having some grace and forgiveness can go a long way as well.”

“We know that ADHD goes undiagnosed often in children and adults and even when it’s diagnosed, it goes untreated often,” Dr. Shook said. “We know that untreated ADHD increases the risk of lots of negative outcomes, such as an increase in automobile accidents, dropping out of school, less likely to get jobs, more likely to be in the justice system and so on.

“And then people with untreated ADHD are more likely to have depression, anxiety and suicidal ideation,” he said. “All those risks are higher in a person with ADHD than the general population, so treating ADHD can decrease those risks and make life better for people with ADHD.”