Caring and Prescribing for Children With ADHD Who Have Other Comorbidities

Dawn Lee Garzon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN, the Immediate Past President of NAPNAP and the Associate Professor at the University of Portland in the School of Nursing, discusses caring and prescribing for children with ADHD who have other comorbidities.

Alana Hippensteele: Hi, I'm Alana Hippensteele from Pharmacy Times. Before we get started, one of our top articles today discusses how a recent study that is the first of its kind demonstrated that there has been a decline in cancer-related deaths following the adoption of the Affordable Care Act in states that adopted it. There’s more of that on PharmacyTimes.com.

Today, I’m speaking with Dr. Dawn Garzon Maaks, the Immediate Past President of NAPNAP and the Associate Professor at the University of Portland in the School of Nursing, on caring for children with ADHD in advance of her presentation on the subject at the 2020 Virtual Conference on Pediatric Health Care.

Dr. Maaks would you mind briefly discussing the scope of your research into caring for children

with ADHD?

Dr. Dawn Garzon Maaks: So, I have had done research in the past on the roles of specific symptoms of oppositionality in inattention, hyperactivity, and impulsivity, and I did a case control study looking at children who presented to an emergency room for an injury or a non-injury related reason, and looked at in a preschool population, so largely four-year-old children, was there a difference in those symptoms between two groups. But the majority of my work in this space hasn't necessary been research related.

I'm a pediatric nurse practitioner and a primary care mental health specialist. Obviously, an academic, I educate nurses and nurse practitioners, and in addition I practice in behavioral health and a federally qualified health center in Southwest Washington, and so a lot of my work has been more translational about helping to take research that's been done on ADHD, on oppositionality, and translating that to make it usable and digestible by clinicians. Because, in my opinion, it's wonderful that we do research, but unless we get it in the hands of the people that are doing the work, it's not being used, and so I really am very passionate about that translational piece, and so that's where I've spent the majority of my time.

Alana Hippensteele: Great. Could you explain why it is important to increase primary care provider confidence in caring for children with ADHD symptoms who have other comorbidities?

Dr. Dawn Garzon Maaks: I think this is a great question. You know, I've been a nurse practitioner, I probably shouldn't admit this on video, but now for 25 years, and you know, when I went to my MP program, we talked about ADHD, we talked about how we gave kids stimulants, we talked about how there was some paradoxical reason why they worked in the brain and we didn't understand why. There was still an incredible amount of stigma around the diagnosis and kids weren't getting diagnosed, and then the pendulum kind of swung a little bit, that it for a little bit, it was a very popular diagnosis, and there were a lot of people that were diagnosed with ADHD that might have had just developmental normal variations of behavior, but the reality is that when you look at utilization data, ADHD is definitely consistently in the top 3 of the mental health issues that are seen in primary care pediatrics.

So our primary care folks are seeing this all the time, and we are often the ones who do the first-line prescribing around caring for kids that need medication for ADHD, and so helping them to understand, you know, what do you do when you give a kid let's say methylphenidate, and it doesn't work. Is it that they were in that 40% that don't respond to methylphenidate? You know we're just switching them to an amphetamine salt, or is there something else that's going on? Because unfortunately, there are a lot of comorbidities of things like autism or ADHD that are significantly more common, or conditions like anxiety or depression that mimic a lot of the symptoms of ADHD, and if you aren't careful, you're going to get people that endure certain symptoms but they don't necessarily have ADHD. So is some of that drug, and I'm going to use air quotes, failure due to someone who's been treated for ADHD symptoms, but has another condition and doesn't actually have ADHD. So is it really a drug failure or was it a diagnostic imprecision that caused that to happen.

Alana Hippensteele: Right, so I feel like you're kind of adding to this next question helping to clarify it. Why is it important for primary care providers to be acquainted with the diagnostic criteria for comorbidities like anxiety, autism, and explosive anger disorder when caring for children with ADHD symptoms?

Dr. Dawn Garzon Maaks: I feel like for many of us in primary care, we do not feel a depth and comfort with treating mental health conditions. I think a lot of us feel like, and I hear it from physicians as well as nurse practitioners, I hear it from PAs, I certainly even hear it from some pharmacists that maybe didn't have as wide of an exposure to pediatrics or to mental health, and that they're not as comfortable in this space. And I often tell my students you're never going to diagnose something that you don't consider as a differential, and so if you're not aware that there are other conditions that mimic the symptoms of ADHD, then you're not going to consider them when you see a child who presents with symptoms of inattention, impulsivity, externalizing behaviors, it's not necessarily that it's ADHD. I think because we're comfortable with ADHD, we always think of that as a possibility, but we have to consider other conditions in the mix.

Alana Hippensteele: Absolutely, so why is it important to increase primary care provider confidence in caring for children with ADHD symptoms who do not have a successful clinical response to first medication use?

Dr. Dawn Garzon Maaks: Another great question. So, I think the bottom line is we have a dearth of mental health providers in this country overall. We have an extreme dearth of those who care for children and youth. So there are, I believe, approximately 8000 child psychiatrists in the entire United States. There are nurse practitioners that are prepared at the psych mental health level as a lifespan, so they learn about children through geriatrics, and even though they're educated about caring for children, the overwhelming majority of them choose not to work in this space, and so it is not uncommon when there's an open pediatric behavioral health specialist to see these positions go unfilled for months. I live outside of a major metro area there's a local organization, I think it took them six to seven months to place the correct person. And so, what happens is I'm in primary care and I see a child with ADHD, and I treat them again, I'm just pulling the drug name but methylphenidate because I think that's everybody's go-to as a first-line. If I have a child who fails on that medication, then being comfortable with stopping and thinking about what else could be going on and maybe I'm not comfortable with anxiety, maybe I'm not comfortable with explosive anger disorder, but I'm able to recognize what's going on in it, so that we can get them somewhere, but in the United States right now, it's not unusual for kids to go 6 to 12 months from the time that they are referred to a pediatric mental health person to actually be seen, and so if we can increase primary care providers’ comfort around these issues like ADHD, then we're going to decrease the burden on the pipeline so that those specialists can care for the sicker kids that really need to be there.

Alana Hippensteele: Absolutely. So, what are some of the controversies in prescribing for children with ADHD symptoms?

Dr. Dawn Garzon Maaks: You know, I kind of feel like we could we could probably spend an hour on this one, and it depends on who you talk to. There's always this oh it's just overdiagnosed, and it's just developmentally normal. Yes, it is developmentally normal, and no you can't diagnose ADHD in a ten-minute visit, it takes time, and our system really isn't set up to reward that. And so I can see where some diagnostic difficulties might come from that. I think people say, you know, use of medication psychotropics in kids are controversial. Yeah, I can give you that one, and certainly, I happen to be of the belief that ADHD can be somebody's superpower. You take somebody with ADHD and that hyper-ability to focus, they become fantastic experts in these areas that are of interest to them. We see people who have been hugely successful in the tech world, but clearly are ADHD because they found something that's of interest and they zone in on it, and so when parents come in and say like yeah he has ADHD, but I don't think he needs medication, I'm of the belief that not everybody does need medication. I think things like learning behavioral modification learning, how to do organizations, things that we would learn in therapy or in psycho-education are probably as important as the stimulants. But the argument that I make is, you know, in an adolescent or an adult where impulsivity, blurting out answers, or fidgeting in my seat is not an expected thing, and we develop the ability to control that, then in some ways medications, at least externally from what other people are able to see, may not be as needed. But because all kids struggle with these issues, and it's hard for all kids to stay focused, sometimes when you have a child whose brain is wired to be like looking for that next zip line, and we don't treat that, then that puts them at a disadvantage socially because they're difficult to be around, let's just be honest about that. It's not fun to have somebody you tell them something and you say don't, you know, like this is our pinkie-swear moment, and then they turn around and they blurt it out because they're impulsive, or a kid who is running around in the classroom and constantly having to be admonished for that, and what that does to that child's self-esteem, and what that does to that child's ability to learn. That yes, these are normal behaviors, but when they happen at those developmentally excessive amounts, they really do impact how that child feels about themselves, and how their families function, and how their relationships with other people function, and so, you know, not everybody needs medication. Mild to moderate cases really probably don't ever need to be medicated. But I would argue that if you're 8 years old and you're showing up in my office, you're probably already in the moderate to severe category because those mild to moderate cases just get included within that developmental expectation of these symptoms occurring.

Alana Hippensteele: Right well, thank you Dr. Maaks, so much for taking the time out to speak with me today. Now, let's hear from some of our other MJH Life Sciences brands on their latest headlines.