Transcription:

Melanie Cole (Host): ADHD is the most commonly diagnosed behavior disorder of childhood. And my guest today is Dr. Mini Tandon. She’s a Washington University Pediatric Child and Adolescent Psychiatrist at St. Louis Children’s Hospital. Welcome to the show Dr. Tandon. Explain a little bit about ADHD and what are some of the challenges in diagnosing it?

Dr. Mini Tandon, DO (Guest): Thanks for having me today. Thank you. So, ADHD is one our most commonly diagnosed disorders in child psychiatry and of course, it often is – the primary care physicians are responsible for diagnosing it the large majority of the time. And I think some of the challenges include how they can get that done and all the other things they have to do in a short office visit comprehensively. It’s a neurodevelopmental disorder as you know, and it’s characteristically defined as a problem that occurs usually with the symptoms that begin before the age of 12 and typically in more than one setting and usually, there is a predominance of either hyperactivity impulsivity or inattention or a combination of both.

Melanie: So, you basically stated that the best place for a parent to start that process is with their primary care giver; so, do pediatricians have a history that they take? What’s involved in their first initial diagnosis before a child would be referred to a specialist?

Dr. Tandon: Well I think it would be important for them to ask history. After all, there is no one test for ADHD. And so, asking them about symptoms in several settings and the impairment that’s involved is a first step. Getting short measures in the office and getting that done from the school and from home and getting that collected prior to sending them to a specialist can be very helpful.

Melanie: Dr. Tandon: Is there a standardized group of questions that the pediatrician has if a parent brings in some of these red flags or talks about some symptoms of hyperactivity or attentional issues? Is there a standardized set of questions?

Dr. Tandon: Well there are many standardized measures and I think that they are all very good for use in pediatrics offices. It depends on what the pediatrician is comfortable with. Many pediatricians seem to like the Vanderbilt scales and that can be a helpful screening tool covering ADHD symptoms and they are often pretty classic questions across scales. Things like does your child resist tests that require sustained efforts? Is your kid acting as if run by a motor? These are very classically asked questions across scales regardless of what the brand of the scale is.

Melanie: Before treatment begins, and maybe a child has been referred to a specialist such as yourself; what’s the immediate goal as far as working with parents and caregivers to get them to understand what the process is about to be?

Dr. Tandon: Well, I think it’s important to do – to have the parents understand that this is a comprehensive evaluation. We don’t want to jump to conclusions. We want to be thorough. We want to have the parents understand that it’s a highly treatable disorder and that getting this done in a slow and steady way will probably lead to a better assessment and treatment plan. So, while the parents might have some frustration in having to get paperwork done, I think it’s very important to know how impacted the child is in the school setting and in the home setting.

Melanie: When would a pediatrician refer to someone such as yourself?

Dr. Tandon: I think if they feel that they can’t manage with straightforward ADHD medications or when they feel that there’s more going on than just ADHD in the complex of other psychiatric illnesses; I think that’s when we start getting referred to as specialists. Now many pediatricians are still very comfortable with that and we are happy to collaborate with them and talk them through that. But ADHD is one of these disorders that rarely occurs alone. And so what happens is then you can diagnose ADHD but then find out there is also learning disorder, oppositional defiant disorder, anxiety, depression, and that becomes a little bit complicated as some meds become helpful for some symptomology and then worse in other symptomology and that’s when sometimes I feel like we get more calls at the specialist office.

Melanie: Speak about the implementation of behavior strategies that you begin with when you’re working with a child?

Dr. Tandon: So, I think first thing starts with education for the parents. Parents are the crux of treatment here and helping them understand what the disorder is and to keep a structure and routine in the household, keep backpack in the same place; is actually sounds clique, but it is actually quite helpful. I think educating them on national websites like CHADD or organizations that can be of support to them is helpful. I think talking to them about and telling them about advocating for their child’s needs at school through either educational plans, sitting in the front of the classroom so some real basic things can be done, but also higher level individualized educational plans can be obtained and I think guiding them through this process is important and letting them know it may not happen overnight, but that’s it’s worth being persistent to get the services needed is also very important.

Melanie: And you said some pediatricians are definitely very comfortable treating these children without referral. Speak about prescribing medications; when it come to that point; what do you want pediatricians to know about the medications available out there and how to explain to their parents who are probably pretty afraid of that zombie effect, what these medications are intended to do?

Dr. Tandon: Well, the idea is that the gold standard of treatment for a school aged kid with ADHD is medication and has like 80% will respond to a medication, so they are highly useful, but they also become controversial because they are abused and misused and whatever. But, I think the real crux of the matter is that it is one of the medication classes on all of psychiatry for which we have an excellent response. We want to wait until kids are at least six, however, there are times when indicated when the earlier ages are indicated but that needs to be done carefully. Once you get under the age of six; then you may need to really consult with a specialist to make sure that that’s what needs to be done. Because there are other things that happen. If a preschool kid has ADHD; you start with parent behavioral training and support and educational support before you go right to a medication. In the school aged kid; you may go to a medication, but you need to also have behavioral training and school wrap around services.

Melanie: Are these medications studied in children younger than six?

Dr. Tandon: Less so. Less so and they have more side effects in kids less than six, which is part of the trouble.

Melanie: So, where do you see this field going in the next ten years Dr. Tandon, because it certainly is more in the media now, pediatricians are seeing it more often, parents are complaining, schools are noticing some of these red flags even as young as kindergarten, which kids can be a little attentional issued anyway in kindergarten, first time sitting in class. But it’s different and the red flags are certainly different. So, what do you see changing in the field or do you see anything changing?

Dr. Tandon: Well I think we continue to make better pharmacologic agents that have less side effects over time. I think that probably will happen and continues to happen regularly. I think being comprehensive is still very important to make sure that you are utilizing medications for those that do need them and not just want them. I think that imaging studies may become more useful, however right now; that’s not the case. That’s just more of an academic matter right now. But a comprehensive evaluation that is done at a pediatric office or a specialist’s office is still probably going to be the way we want to go.

Melanie: Can children grow out of ADHD?

Dr. Tandon: Well, the literature suggests that symptoms may fuse over time for a lot of kids, but about half to three quarters of kids will still continue to have adolescent ADHD symptoms as adolescents and half to three quarters will also have it in adulthood. Those that were properly comprehensively diagnosed either in pre school age or school age will continue to have many of the features of
ADHD on into adolescence and on into adulthood. But many of the children may fuse out of some of the hyperactive impulsive symptoms that are more characteristic of childhood ADHD.

Melanie: Are there any Washington University studies taking place that you can reference that you’d like pediatricians to know about?

Dr. Tandon: Right now, I don’t have an active study to refer, but this could be changing at any moment; given the nature of research studies. But I think 454 KIDS is a good resource at Children’s, should there be any active enrolling studies.

Melanie: And what can a referring pediatrician expect from your team in so far as communication with the referring physician?

Dr. Tandon: Well, we – for ADHD or any disorder, I hope that the idea is that when a pediatrician sends a specialist a referral that we can communicate our general ideas from the assessment and ongoing treatment strategies and stay in touch with the pediatrician. As you know, there are less child psychiatrics available and so we don’t – we really do need to collaborate better and more effectively with our pediatrician partners. They are doing a large burden of the work, but we are happy to try to help.

Melanie: So, wrap it up for us. What else would you like pediatricians and other physicians to know about ADHD from a pediatric psychiatrist’s point of view and really when to refer, when those red flags signal an issue?

Dr. Tandon: I think if they are uncomfortable, I think it’s important to get in touch with their specialist, but I think one of the things that I see commonly is the under dosing of medication. I think it’s important to go slowly and steadily up on the medication dosages. But sometimes it is important to use the medication at a dose that’s appropriate for weight and in general, not everybody, but in general there are stimulants that are needed at a milligram per kilogram of body weight, there are stimulants that are needed at a half a milligram per kilogram body weight and until you reach that general number; it seems that the medicines don’t help and then what we have is a person on medicine and exposed but without the actual help. So, one of the issues would be medication dosage management as the child continues to grow and then frequent measuring of growth and vital signs which of course is done very well at the pediatric offices and then finally communicating with the schools, having repetitive and comprehensive input from the schools is very important because sometimes we are missing key disorders. So, the ADHD I want them to know that the ADHD never – it’s rare to have it alone. And I think once you have that in your mind; you start to get more astute about looking at disorders that are missed like anxiety, depression, oppositional defiant disorder. We don’t want that school aged kid or any aged kid to be missed for other key disorders and ADHD is one of those disorders that rarely occurs alone.

Melanie: Thank you so much Dr. Tandon, for being with us today. A physician can refer a patient by calling Children’s direct physician access line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital you can go to www.stlouischildrens.org that’s www.stlouischildrens.org . This is Melanie Cole. Thanks so much for listening.