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"HEADDS" Up on Talking With Teenagers

September 1, 2007
Consultant for Pediatricians, Consultant for Pediatricians Vol 6 No 9, Volume 6, Issue 9

Perhaps some aspects of this scenario sound familiar? Many pediatricians feel ill-equipped to meet the often complex
needs of adolescents. Some physicians have a challenging time convincing teenagers to talk to them about anything.
Others worry about opening a Pandora's box of issues that cannot fully be addressed. Given the time and reimbursement
constraints facing primary care providers, the wish to avoid time-intensive patients is understandable.

Fifteen-year-old Matthew comes to your office for his annual examination. You last saw him a year ago, when his
stepmother brought him in for his physical. For the first 10 minutes of that visit, the stepmother told you about Matthew's
"attitude" toward--and "bad influence" on--the rest of the family. She reported that Matthew refused to talk to her or his
father, alleged that he was spending all his time "instant messaging," and worried that he was watching pornography online.

Throughout that conversation, Matthew sat on the examination table in his boxer shorts, arms tightly folded, staring at the
floor.

During the remaining 5 minutes left for the physical examination, Matthew refused to make eye contact and offered
monosyllabic responses. Given the time limitations, you had asked Matthew whether he was using drugs, whether he had a
girlfriend, and whether he was sexually active. His response was a firm "no." During the physical, Matthew refused to allow a
genital examination.

As Matthew was leaving, you said: "Everything looks fine. Don't do drugs and stop drinking alcohol--they're bad for you. And
always use a condom." You haven't heard from him again until today.

Having reviewed his chart, you brace yourself for another forced interaction with this teenager. You think, "I went into
pediatrics to take care of babies, not to take care of obnoxious teenagers. What am I really supposed to talk about with this
adolescent?"

Perhaps some aspects of this scenario sound familiar? Many pediatricians feel ill-equipped to meet the often complex
needs of adolescents. Some physicians have a challenging time convincing teenagers to talk to them about anything.
Others worry about opening a Pandora's box of issues that cannot fully be addressed. Given the time and
reimbursement constraints facing primary care providers, the wish to avoid time-intensive patients is understandable.

Quality adolescent health care requires that the clinician address a myriad of social and emotional issues that can affect
an adolescent's physical and mental well-being. This goes beyond simply ensuring that immunizations are current,
listening for heart murmurs, and providing clearance for sports participation.

While time with patients is limited, pediatricians need to build a rapport that permits a glimpse into the adolescent's real
concerns. In general, if a teen is treated with respect and addressed nonjudgmentally, he or she will learn to regard the
physician as an ally.

Here I present a basic framework for obtaining the relevant psychosocial information that is important for maintaining a
teenager's well-being.
BUILDING RAPPORT

The opening vignette underscores the importance of the following measures in establishing rapport with a teenager:

•When you enter the examination room, introduce yourself to the teenager first and shake hands before addressing the
parent (if present).

•Take the history while the teenager is dressed and ask him to disrobe only for the examination.

•Face the adolescent and maintain eye contact as much as possible while listening to the parent. If the teenager
perceives that he is the central person in the doctor- patient relationship, he will feel respected and will be more likely to
trust you.

•When the parent has a laundry list of concerns, make sure to interject occasionally and politely ask the adolescent
whether he shares those concerns, which can be addressed one-on-one with the teenager later in the visit.

With a new patient and family, I find it invaluable to discuss confidentiality up front. I usually say, "At this office, we
encourage teens be honest with their doctor. It helps ensure that health concerns and questions are addressed. It also
helps teens prepare for a rapidly approaching adulthood, when they will have to know how to discuss health concerns
with their physician. Occasionally, we discuss sensitive issues such as sexuality and drugs and, for the most part, we
agree to keep these conversations private. We expect teens to ask questions that will ultimately keep them healthy and
safe."

I also discuss the contingencies of when confidentiality must be broken. Specifically, I explain that when there are issues
that may put the teen's (or someone else's) life or health at risk, confidentiality must be broken and adults must be
brought in who can help keep him/her safe. I tell the adolescent that I never break confidentiality without telling him first.
The teen always has the option to decide how he would like the parent to find out.

THE "HEADDS" SCREENING TOOL

The "HEADDS" mnemonic reminds clinicians about the psychosocial factors that influence the physical and emotional
well-being of teenagers. This is a helpful screening tool for identifying potential problems and risk factors.

Home

•Try to get a general picture . . . Who lives with the patient? Does the family live in a house? Cramped quarters? Does the
adolescent have any privacy?

•Do the parents live together? If not, is the out-of-house parent involved with the patient--and to what extent?

•Have there been recent changes in the family dynamic--a new sibling, the death of a close grandparent, a parental
separation or divorce? Is a family member sick? If so, how is this affecting the patient?

•How many siblings live at home and where in the birth order is the patient? In some large families, the responsibilities
for younger children may fall on the oldest child. This level of responsibility may seem appropriate or it may overwhelm
the teen.

These questions are best asked when the parent is present so that objective information (that can be discussed with the
teen alone) can be obtained.

Education

Many busy practitioners hesitate to explore issues about education because they believe that this is outside their
domain. I would argue that avoiding a discussion about school performance prevents a real understanding of any
underlying issues facing the teen. School is the adolescent's primary job, and almost all teens want to succeed. When
things are going poorly in school, I see this as a manifestation of some other process that is inhibiting success. Such
processes frequently include ADHD, learning disabilities, depression, anxiety, bullying, or school phobia.

It can be immensely helpful to ask the teen how well school is going while the parent is in the room. Teens often report
that everything is "fine"; parents may counter that the adolescent has been skipping classes or is earning poor grades.

Some other key issues to inquire about:

•Have there been any changes (for better or worse) in the teen's academic progress during the past year?

•If the teen is doing poorly, find out why. Does he have difficulty paying attention in class or during homework time? Do
homework assignments take forever to complete? Positive answers suggest the possibility of ADHD.

•Have teachers mentioned any problems with the student's ability to learn, digest, and understand information? Positive
answers suggest possible learning disabilities. In this situation, the student might benefit from psychoeducational
testing and/or the development of an individualized education plan.

•Is the student skipping classes? Has he joined a new peer group? Do the parents suspect any drug or alcohol use? Any
significant mood changes recently? Could there be an underlying mood disorder (depression, anxiety) that prevents the
student from focusing?
•Is the student having trouble waking up to get to school on time? Is he falling asleep in class? Are homework
assignments incomplete because the student sleeps for hours each afternoon or early evening? The duration and
quality of sleep can profoundly influence an adolescent's academic performance and should be addressed whenever
academic concerns arise.

•What are the student's life plans and goals? Younger teenagers may simply want to be a "pro basketball player," a
developmentally appropriate goal. By high school, there should be some discussions about the teen's post-high school
plans. If the student is planning on going to college, is he pursuing the academics and activities necessary to meet this
goal?

Be on the lookout for the adolescent with strong cognitive abilities who is faltering academically. An evaluation for
mood disorders, substance abuse, ADHD, or learning disabilities is usually warranted.

Activities

After-school activities (or lack thereof) can profoundly affect an adolescent's physical well-being. I generally obtain this
history without the parent in the room because the teen usually answers more honestly. If the history suggests
participation in an activity that could be detrimental to the patient's health, this may warrant a private or a 3-way
discussion with the parent.

Other key points to ask about:

•What activities does the teen participate in after school? Most adolescents need to be involved with some activity in
addition to academics. Watching TV or Internet chatting all afternoon does not count as a healthy activity. The American
Academy of Pediatrics recommends no more than 1 to 2 hours each day of "screen time."

•Simple "chilling" and "hanging out" generally spell trouble. With whom does the adolescent spend time? Is he home
alone with a girlfriend or out on the street with peers? If an adolescent spends afternoons alone every day, some
investigation of possible mood disorder or social issues is warranted.

The adolescent who naps for 2 to 3 hours every afternoon may require an evaluation for depression, substance use, or
sleep cycle disorders.

Overactivity also needs to be identified. Teenagers (like everyone else) need time to relax and have fun. Some teens (or
their parents) may require a friendly "prescription" from the doctor instructing them to incorporate this into their busy
schedules.

Drugs and Drinking

There is no one "right" way to approach the topic, but the following tactics can be helpful:

•Start with a generalized conversation and open-ended questions: eg, "Many of my teenage patients tell me their friends
sometimes try drugs and alcohol. What kinds of things have your friends talked about trying?"

•As the adolescent answers, start bringing the conversation closer to home. "It must be a challenge for you to be at a
party where your friends are drinking and getting drunk. How do you deal with it when they offer you (or pressure you
with) something to drink?"

•Congratulate the teen who continually insists that he has never indulged in any of these substances for making good,
mature decisions for his health.

•If the teen admits to trying various substances, be careful not to sound judgmental. Explore the benefits (and
consequences) the teen gets from the substance use, how it makes him feel the next day, how often he is using the
substance.

•When you identify a substance use problem, encourage a follow-up appointment. Let the teen know that you can see
why he is attracted to the substance, but that you have concerns for his safety.

•Suspected habitual substance use by a teenager who will not follow up with you constitutes a safety issue that requires
breaking confidentiality.

Sex and Sexuality

Addressing sexual development can help prevent unplanned pregnancies, sexually transmitted infections, and HIV/AIDS.
Data consistently indicate that adolescents frequently begin sexual experimentation during middle school. Providers
who wait until high school before discussing sex with teenagers may be doing their patients a great disservice.

Teenagers can usually tell if their physician is uncomfortable talking about sex and they typically withhold information if
they suspect that the disclosure of sexual activity will lead to a judgmental reaction. If the practitioner has strong moral,
ethical, or personal objections about talking with teenagers about sex, referral to a colleague more comfortable with the
topic is appropriate.

A few personal pointers on talking about sex:

•Try to talk about the patient's friends' sexual experimentation before asking the patient about personal experiences.
•Consider the possibility that the patient may have same-gender attractions or experiences. Many adolescents who are
unsure of their sexual orientation tend to avoid labels such as "gay," "lesbian," or "bisexual." A good way to broach this
topic with a male teenager might be: "I see lots of teenagers, and we frequently talk about sex. Some like girls, some like
guys, some like both, and some are just not sure. When you think about dating or having sex, do you think about guys,
girls, or both?"

•Patients frequently use slang to describe genitalia or different kinds of sexual activity. If you are unsure, ask for
clarification.

•Teens hate lectures. Rather than lecturing on safer sex, involve the teen in a discussion on how he would approach
various situations. For example, ask a female patient how she would negotiate not having sex with a partner who did not
have a condom. Ask a teenage boy how he might behave if he was about to have intercourse and his girlfriend changed
her mind.

Suicidality and Mental Health

The following approach can help you quickly assess the patient's mood and mental health status:

•Explain that many teenagers deal with strong emotions during adolescence that can sometimes make them feel "out of
control."

•Ask about mood-related symptoms. Does the teen feel "down" more often than his friends do? How many days a week
is he happy? Sad? Inquire about persistent irritability--a presenting symptom of depression in teens.

•Ask about fatigue and/or inability to fall asleep. Does the patient wake early in the morning, unable to get back to sleep?
Has his appetite changed recently?

•Does the teen feel worthless or guilt-ridden? Has there been any change in the teen's ability to enjoy activities as
before?

•Have there been changes in relationships with friends, family, teachers? Does the patient care about the future?

•If the patient admits to any of these things, you must ask about thoughts of hurting or killing himself or anyone else. An
affirmative response requires emergency psychiatric consultation.

WRAP-UP

As a physician who specializes in taking care of teenagers, I have learned that a comprehensive psychosocial evaluation
cannot be done in a 20- or 30-minute annual visit. However, by touching on some of these issues, one can at least start
to identify real problems facing a teen and, perhaps, provide some intervention in the form of follow-up appointments or
(when indicated) referral. The hope is that by talking about these sensitive issues, the adolescent comes to regard you
as a trustworthy resource. *

References:
FOR MORE INFORMATION:

• Neinstein LS, ed.

Adolescent Health Care: A Practical Guide.

4th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:59-78.

• Pratt H. Office counseling for the adolescent. In:

Primary Care: Clinics in Office Practice.

Philadelphia: WB Saunders & Co; 2006;32:349-371.

• Reif C, Warford A. Office practice of adolescent medicine. In:

Primary Care: Clinics in Office Practice.

Philadelphia: WB Saunders & Co; 2006;33:269-284.

The youth mental health crisis: supporting patients with

ASD and ADHD
June 14, 2022
Erin O'Brien
How can we help this unique patient population thrive? Experts weigh in at the 2022 APA Annual Meeting.

“One-third of kids in middle school and high school in North America are struggling socially—one-third,” Elizabeth
Laugeson, PsyD, told attendees of the 2022 American Psychiatric Association Annual Meeting. “Do you think they’re all
getting services? Probably not. And if you think about the consequences of this, it’s pretty disturbing.”

Laugeson is the founder and director of the University of California, Los Angeles (UCLA) PEERS Clinic; training director
of the Tarjan Center for Developmental Disabilities and Health Sciences; and clinical assistant professor of psychiatry
and biobehavioral sciences at the Semel Institute for Neuroscience and Human Behavior, David Geffen School of
Medicine, at UCLA. She is also the author of The Science of Making Friends: Helping Socially Challenged Teens and Young
Adults.

The estimated 1 in 54 US children diagnosed with autism spectrum disorder (ASD) may especially experience social
difficulties, according to Thomas E. Brown, PhD, of the Brown Clinic for ADHD and Related Disorders and the University
of California-Riverside School of Medicine. Brown added that about 50% to 75% of individuals on the autism spectrum
also have attention-deficit/hyperactivity disorder (ADHD).

Youth with ASD who exhibit symptoms of ADHD tend to have more difficulty with adaptive behaviors at home, in school,
and in their community, and may fall behind in a wide variety of executive functions, including activation, focus, effort,
emotion, memory, and action. They also experience several social challenges, including poor social communication,
poor social awareness, poor social cognition, less constructive social engagement, and few close meaningful
(reciprocal) friendships, according to Laugeson. Youth may experience any or all of these challenges even if they do not
meet full DSM criteria for an ADHD diagnosis.

Teaching targeted social skills can help youth with ASD and ADHD, Laugeson added, noting the impact of common
issues such as rejection and bullying on mental health, self-esteem, academic performance, and beyond even in youth
who are not neurodivergent. “What we know is that peer rejection is one of the strongest predictors of mental health
problems,” she said, noting a connection between rejection and depression, anxiety, loneliness, substance abuse, early
withdrawal from school, and suicidal ideation and attempts.

Laugeson explained that evidence-based programs teaching targeted social skills, such as the PEERS Clinic at UCLA,
can help youth with ASD and ADHD improve in common challenge areas such as social communication, awareness,
engagement, and cognition. At PEERS, they work with preschoolers, adolescents, and young adults by teaching them
targeted strategies for building friendship and relationship skills, managing conflict, and handling rejection through
training, teleconferences, virtual boot camps, and role-play videos and exercises.

They also help all age groups deal with both direct (verbal, physical) and indirect (cyberbullying, gossip) forms of
bullying. “The reality is that every kid gets teased. Even adults get teased. What matters is how you react to it,” Laugeson
said, noting that the most common advice youth receive for handling bullies is often ineffective.

“What are most young people told to do in response to teasing? Ignore it, walk away, tell an adult. But these are not
ecologically valid strategies—and yet, this is what adults tell kids to do... It’s an epidemic of bad advice.”

PEERS shows youth the effects of these strategies in comparison to more effective techniques through role-play
exercises and videos.

Based on the research, the PEERS approach works. Laugeson shared a recent study on outcomes of PEERS treatment in
individuals with ASD, ADHD, and with both ASD and ADHD. All groups demonstrated significant improvements in social
skills (ASD: t[58]=6.07, p<.001; ADHD: t[43]=3.45, p=.001; ASD and ADHD: t[42]=3.83, p<.001) and decreases in features
of autism (ASD: t[59]=5.97, p<.001; ADHD: t[43]=3.45, p=.001; ASD and ADHD: t[31]=6.47, p<.001).

“Even though the groups started differently at baseline,” she said, “they all improved after this treatment at the same
rate.”

Overall, teaching targeted social skills can be helpful to youth who have ASD, ADHD, or both ASD and ADHD, as well as
those who are not neurodivergent. “What if conversational skills—and more broadly, social skills—were not an art, but a
science? Our research in social skills training for teens and young adults with social difficulties is based on this
premise,” Laugeson wrote in The Science of Making Friends.

“We believe that social skills can be taught, much in the way we might teach math or science. By breaking down
complex, seemingly sophisticated social skills into concrete rules and steps of social behavior, we can demystify and to
some extent decode the ‘art form’ that is social skills.”

Originally published on our sister brand, Psychiatric Times.

ADHD and the COVID-19 pandemic

May 12, 2022
Jaclyn Halpern, PsyD, Gonzalo Laje, MD, FAPA
What are the unique challenges for individuals with ADHD?

Although we have all been challenged by the COVID-19 pandemic, those with underlying mental health and
neurodevelopmental diagnoses have faced particular hardship. Individuals with attention-deficit/hyperactivity disorder
(ADHD) especially seem to have struggled to effectively adapt to the pandemic, showing more vulnerability to its many
challenges.

Individuals with ADHD have showed a higher level of mental health concerns, difficulty adhering to preventive measures,
and less economic success during the pandemic, as well as negative impacts on behavioral, emotional, and perceptual
skills.1 Other challenges reported by adults with ADHD and caregivers of children with ADHD during the pandemic
included social isolation, motivation difficulties, managing boredom, and difficulty engaging with online learning.
Individuals with ADHD also reported increased symptom severity with higher risk factors for both major depression and
school dropout.2 As the pandemic eases, these individuals are likely to require a high level of support, including therapy,
psychiatry, and school and workplace accommodations to attain optimal functioning.

Accommodating Students With ADHD

The COVID-19 pandemic forced most students to engage in virtual learning. During that time, caregivers of children with
ADHD reported significant changes in the children’s behaviors, suggesting a higher level of underlying emotional
dysregulation.3 After returning to school, many children with ADHD have found it harder to adapt. They have required a
higher level of support in reacclimating to a set schedule and have needed to rely on executive functioning skills that
they may not have had support for during the period of virtual learning.4

Due to the combination of online learning, increased access to devices, and, for many, increased hours spent on digital
media, it is not surprising to see struggles increase among children with ADHD. It has been suggested that ADHD
symptoms, behavioral concerns, executive functioning difficulties, and family struggles all increased as digital media
use increased during the pandemic.5 For many, the combination of these challenges and the challenges faced by
exhausted parents has caused ongoing conflict even as the pandemic has begun to calm. Families continue to require
mental health support for children and coaching for parents to manage these concerns.

Work Challenges for Adults With ADHD

The routine changes caused by the COVID-19 pandemic also presented a particular challenge for adults with ADHD.
These individuals tend to require a higher level of structure than neurotypical peers and colleagues and are more likely to
struggle when changes to routine occur. Creating a new schedule requires the ability to plan, organize, and initiate
independently, which can be particularly challenging for those with ADHD, many of whom reported experiencing
decreases in motivation and increases in distractions during the pandemic.

The constant access to media and electronics created a difficult distraction for many. The stimuli of “in-person” work
was lost, and the ability to “body double”—that is, to work beside another person while completing a nonpreferred task to
support engagement and accountability—was diminished. Individuals with ADHD are easily distracted and prone to
missing social and environmental cues. The impact of both masking guidelines and frequent changes to these
guidelines and other rules have likely increased these challenges and related stress, as well. It is important to support
individuals with ADHD as they continue to adapt to changing guidelines, including changes to masking requirements.

Diagnosis

Accurate diagnosis of ADHD has also become more challenging because of the COVID-19 pandemic. Now more than
ever, it is imperative to explore neurodevelopmental history to determine early signs and traits of ADHD. Even
neurotypical individuals have found themselves more distracted and distressed during the COVID-19 pandemic,
including those who have not struggled with attention, executive functioning, or related emotional or behavioral
dysregulation in the past. As a result, more people sought care for potential ADHD as evidenced by increased inquires to
CHADD.4 In some cases, caregivers began noticing their children’s attentional concerns for the first time while virtual
learning was in effect. In other cases, caregivers found their child’s ADHD easier to manage without the restrictions of
the pandemic. With increasing calls for diagnosis, practitioners have had to take great care to avoid misdiagnosis. It has
been imperative to recognize that children may display ADHD symptoms when preferred distractions are nearby, when
anxiety is high, when social opportunities are limited, when children are sitting on a screen and exercising infrequently,
and when children are internalizing their caregivers’ anxiety.

Concluding Thoughts

A final concern related to ADHD during the COVID-19 pandemic has been the response to infection itself. Research
shows that individuals with ADHD are at increased risk of acquiring COVID-19, experiencing greater severity of COVID-19
symptoms, and being hospitalized for COVID-19. The same study noted the need for more research on whether
individuals with ADHD are at higher risk for long COVID or for neuropsychiatric symptoms resulting from COVID
infection.6 Long COVID is an emerging challenge that is in need of additional study. For some, long COVID symptoms
include cognitive impairment and memory loss, as well as disturbed sleep and increased anxiety.7 These symptoms
mirror those of ADHD and will require accurate diagnosis and treatment.

Dr Halpern is a licensed psychologist with Washington Behavioral Medicine Associates, LLC, and director/co-founder of
The SOAR Program for Psychotherapy and Testing at WBMA. Dr Laje is a psychiatrist and the director of Washington
Behavioral Medicine Associates, LLC, and the co-founder of The SOAR Program.

Originally published on our sister brand, Psychiatric Times.

References:

1. Pollak Y, Shoham R, Dayan H, et al. Symptoms of ADHD predict lower adaptation to the COVID-19 outbreak: financial
decline, low adherence to preventive measures, psychological distress, and illness-related negative perceptions. J Atten
Disord. 2022;26(5):735-746.

2. Sibley MH, Ortiz M, Gaias LM, et al. Top problems of adolescents and young adults with ADHD during the COVID-19
pandemic. J Psychiatr Res. 2021;136:190-197.

3. Zhang J, Shuai L, Yu H, et al. Acute stress, behavioural symptoms and mood states among school-age children with
attention-deficit/hyperactive disorder during the COVID-19 outbreak. Asian J Psychiatr. 2020;51:102077.

4. Abrams Z. Helping adults and children with ADHD in a pandemic world. Monitor on Psychology. 2022;53(2):68.

5. Shuai L, He S, Zheng H, et al. Influences of digital media use on children and adolescents with ADHD during COVID-19
pandemic. Global Health. 2021;17(1):48.

6. Merzon E, Weiss MD, Cortese S, et al. The association between ADHD and the severity of COVID-19 infection. J Atten
Disord. 2022;26(4):491-501.

7. Raveendran AV, Jayadevan R, Sashidharan S. Long COVID: an overview. Diabetes Metab Syndr. 2021;15(3):869-875.

Do preschool children with ADHD get the behavioral therapy

they need?
April 25, 2022
Lois Levine

Conference | Pediatric
Academic Societies

At the 2022 Pediatric Academic Societies meeting, Shruti Mittal, MD, FAAP, looked at how many children with attention-
deficit/hyperactivity disorder get started on behavioral therapy before medication in the preschool years.

With existing guidelines from the American Academy of Pediatrics and the Society for Developmental and Behavioral
Pediatrics recommending behavioral therapy (BT) as a first-line treatment for preschool-age children with attention-
deficit/hyperactivity disorder (ADHD), Shruti Mittal, MD, FAAP, assistant professor and developmental and behavioral
pediatrician at Levine Children’s Hospital in Matthews, North Carolina, set out to present the frequency of, and factors
associated with, physician-documented receipt of BT in preschool-age children with ADHD. “To our knowledge, no
studies have examined this receipt of BT from physicians, prior to medication initiation,” she explained. There is also
limited research with provided details about specific types of behavioral therapy received in these children.

The DBPnet (Developmental Behavioral Pediatrics Research Network) study included a review of 497 manual charts of
children aged less than 6 years who were seen by a developmental-behavioral pediatrician at 7 different sites, and were
started on an alpha 2 agonist or stimulant. Most (82.9%) also had coexisting conditions, such as autism spectrum
disorder or disruptive behavioral disorder. Of the group, the number of children documented to have received any BT was
low (45% did; the majority of children, 55% did not). Receipt of BT varied across sites, as did coexisting conditions, and
although published guidelines do specify the need for evidence-based behavior interventions, the receipt of parent
training in behavior management and applied behavioral analysis was low.

“Given the significant variability in receipt of BT…further research is needed to identify factors that improve BT access
and delivery,” observed Mittal. Additionally, more research is needed on availability of therapy in each state, as well as
insurance reimbursement for specific types of behavioral therapy, which may be a factor in why the majority of
preschoolers with ADHD are not getting BT.

Reference

Mittal S, Bax A, Blum NJ, et al. Receipt of behavioral therapy in preschool-age children with ADHD initiated on
medications: a DBPNet study. Pediatric Academic Societies 2022; April 24, 2022. Denver, Colorado.

Newest medications for ADHD

March 24, 2022
Lois Levine
Conference | National
Association of Pediatric Nurse
Practitioners

At the 43rd National Conference on Pediatric Health Care for nurse practitioners in Dallas, Texas, a look at the newest
medications for children with attention-deficit/hyperactivity disorder.
Erin O’Connor Prange, MSN, CRNP, from Children’s Hospital Philadelphia in Pennsylvania, began her session by
explaining, “Drugs for [attention-deficity/hyperactivity disorder] ADHD have been in the market for more than 45 years,
beginning with Ritalin, which was approved in 1955. For the purposes of this discussion, however, we are going to focus
on medications that have been approved in the past 5 years.”

According to a national survey in 2016, roughly 6 million children in the United States have been diagnosed with ADHD.
Boys are diagnosed twice as frequently as girls. Also in this survey, it was reported that 77% of these children were
receiving some form of treatment, and roughly 32% of that group received both behavioral and medication treatment.

When discussing what ADHD looks like, Prange explained that the main component is poor executive functioning in
tasks that include planning, time management, attention, organization, self-control, and others. Additionally, during the
months that children were learning remotely due to the COVID-19 pandemic, impaired communication, eye strain,
distractions, and anxiety were also reported, largely as a result of the struggle with virtual and hybrid learning.

Nonmedication treatment for ADHD includes cognitive behavioral therapy, extra time on tests, creating lists (what to put
in the school backpack, for example), bouncy bands and wiggle seats for desks.

When it comes to medications for ADHD, the newest drugs of note are viloxazine (Qelbree), a nonstimulant. Stimulants
include methylphenidate extended-release orally disintegrating tables (Cotempla), methylphenidate hydrochloride
(Adhansia), methylphenidate hydrochloride extended release (Aptensio, Jornay), amphetamine extended-release oral
suspension (Dyanavel), Adzenys, and mixed-salts of a single-entity amphetamine product (Mydayis).

Prange reminded the audience, "Before starting a patient on stimulants, the American Academy of Pediatrics
recommend a thorough cardiovascular assessment, including patient and family health histories; evaluation of all
medications currently being used; and a physical exam focused on cardiovascular disease risk factors." Prange also
reviewed the side effects for stimulant medications, which include, but is not limited to, decreased appetite, trouble
sleeping, headache, weight loss, and mood swings. Prange also encouraged audience members to seek out a copy of
the ADHD medication guide, which can be found on the addwarehouse.

Reference

Prange EO. ADHD treatment explosion: new meds are here! 43rd National Conference on Pediatric Health Care. March
23, 2022; Dallas, Texas.

ADHD highlights from the 2022 ASPARD meeting

February 23, 2022
Heidi Anne Duerr, MPH, Leah Kuntz, Erin O'Brien

Catch up on all the latest in ADHD from the The American Professional Society of ADHD (attention-deficit/hyperactivity
disorder) and Related Disorders (APSARD) virtual 2022 Annual Meeting.

APSARD CONFERENCE REPORTER

Steven Pliszka, MD, chair of The American Professional Society of ADHD [attention-deficit/hyperactivity disorder] and
Related Disorders (APSARD) annual program committee, joined Jeffrey Newcorn, MD, APSARD president, in welcoming
attendees to their virtual 2022 Annual Meeting, noting the conference was putting attendees “on the ground floor of
exciting developments in the field.” Pliszka said the conference would highlight issues in genetics, neuroimaging,
psychological variables, and environmental variables. “I think we’re moving to really integrating all these different
aspects so we can think much more broadly about where ADHD fits into psychopathology in general,” he added. “And it
will get us thinking more about new ways to intervene and to treat people.”

The 4-day meeting was held January 13 to 16, 2022. In-depth coverage can be found online at
www.psychiatrictimes.com/conferences/apsard.

SGM College Students

Leah Kuntz

As separate groups, college students with ADHD and college students who identify as a sexuality and gender minority
(SGM) have increased risk for functional impairments, psychiatric comorbidities, and risky behaviors.1 According to
Destiny Orantes, PhD, from Syracuse University, and colleagues, previous research had not considered if these outcomes
are further increased in SGM students who have ADHD. Orantes shared findings from their recent research in a poster
presentation.

The study assessed functional impairments, psychiatric comorbidities, and engagement in risky behaviors in 4 groups:
(1) SGM students with ADHD, (2) SGM students without ADHD, (3) non-SGM students with ADHD, and (4) non-SGM
students without ADHD. Data from the American College Health Association-National College Health Assessment 2019-
2021 III were used. The researchers also sought to examine the prevalence of ADHD in SGM college students.
They found ADHD prevalence increased in SGM populations: 15% compared with 8% in non-SGM individuals.
Additionally, SGM students with ADHD reported the highest levels of functional impairments, substance use, and
psychiatric comorbidities.

The research results suggest, Orantes said, that future studies should consider the underlying reasons for SGM students
having high rates of ADHD, and how best to reduce these negative outcomes. Specifically, treatment plans should take
into account the separate difficulties students face from their ADHD diagnosis and their SGM identities, as well as how
best to target the risky behaviors and comorbidities.

Reference

1. Auerbach RP, Mortier P, Bruffaerts R, et al; WHO WMH-ICS Collaborators. Mental disorder comorbidity and suicidal
thoughts and behaviors in the World Health Organization World Mental Health Surveys International College Student
initiative. Int J Methods Psychiatr Res. 2019;28(2):e1752.

The APSARD Health Equity Task Force

Erin O'Brien

“The [APSARD] task force was launched in relation to the amazing societal changes that are happening...in association
with the awareness that equity means creating fair, equitable opportunities for all of us,” Martin Katzman, MD, FRCP(C),
APSARD Health Equity Task Force chair, told attendees. “We’re hoping to build connections within the APSARD
community, to enhance diversity of the organization, and to reach out across boundaries as well as to partner within all
of our communities to raise awareness and to increase opportunities for treatment for populations that may not get the
same access to treatment.”

Amy Glasofer, DPN, RN, nurse scientist with Virtua, shared an analysis of 41 studies relating to ADHD, race, ethnicity, and
disparity; Catherine Dingley, PhD, RN, FNP, FAAN, associate professor in the Nursing Department of the University of Las
Vegas, Nevada, also worked on the project.

They found 66.7% of studies noted Black children were significantly less likely than white children to be diagnosed with
ADHD, and 65% of Black children with ADHD were significantly less likely than white children to receive medication. In
addition, compared to white children, she noted Black children were more likely to discontinue medication and more
likely to experience gaps in treatment; less likely to receive an α2 agonist alone; and more likely to receive significantly
lower doses of stimulant. The findings suggest that, although diagnostic disparities have been reduced over time,
treatment disparities still exist for minority children with ADHD.1

Reference

1. Katzman M, Higgins N, Glasofer A, et al. Introducing the APSARD Health Equity Task Force. Presented at 2022
APSARD Conference. January 14, 2022.

Preschool-Aged Patients
Heidi Anne Duerr, MPH

“ADHD in preschool children is a valid and reliable condition,” reported Ann Childress, MD, president of the Center for
Psychiatry and Behavioral Medicine, Inc, in Las Vegas, Nevada.

According to the 2014 National Survey of Diagnosis and Treatment of ADHD and Tourette’s, 30% of children diagnosed
with ADHD receive their diagnosis before age 6; 16% receive the diagnosis at 4 years or younger.1 Impairment can be
great for these patients, Childress said. For example, an epidemiological review of preschoolers diagnosed with ADHD
found more than 40% had been suspended from school or daycare and about 16% had been expelled.2 In comparison,
less than 1% of young children without ADHD were suspended.

The actions of young children with ADHD pose safety risks to themselves due the higher levels of hyperactive
impulsivity, she said. “These are kids who are running out in traffic. They’re jumping off of things and breaking bones.
They’re doing things that are dangerous, and they really need treatment for their safety,” she explained.

Childress reviewed efficacy and safety data for a number of common medications, noting some small behavior
improvements as a result of the study medications. However, medications were associated with adverse events,
including insomnia, gastrointestinal issues, irritability, sedation, and repetitive behaviors and thoughts. She also noted
not all of these medications have been approved for the youngest patients.

Fortunately, there is good evidence for the efficacy of nonpharmacological interventions for preschoolers with ADHD,
Childress reported. The New Forest Therapy, Helping the Noncompliant Child, and the Incredible Years series were
among the programs she noted that have demonstrated efficacy. Furthermore, she spoke highly of parent training
models that foster the implementation of positive reinforcement to promote positive behaviors; ignoring low-level
provocative behaviors; and responding in a clear, consistent, and safe manner to unacceptable behaviors.

“You have to carefully consider both developmental aspects and comorbidity when you’re establishing a diagnosis, and
the medication efficacy and tolerability profile may not look as good in the little guys as it does in older children,” she
concluded.

References
1. Visser SN, Zablotsky B, Holbrook JR, et al. Diagnostic experiences of children with attention-deficit/hyperactivity
disorder. Natl Health Stat Report. 2015;(81):1-7.

2. Egger HL, Kondo D, Angold A. The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity
disorder: a review. Infants and Young Children. 2006;19(2):109-122.

This article was originally published by sister publication Psychiatric Times.