Providing the Best Quality Care for Your Child

Why Finding an Experienced Paediatrician Matters When Your Child Is Being Assessed for ADHD and Behavioural Difficulties?

When your child is struggling with attention, impulsivity, hyperactivity, emotional outbursts, learning or challenging behaviour, it can be difficult to know where to start.

Many parents first speak with their GP. This is often a very good place to begin, and GPs play an important role in children’s health.

When ADHD or behavioural difficulties are affecting several areas of your child’s life, an assessment by an experienced Paediatrician can provide a broader view of what is happening.

The important question is not simply:

“Does my child have ADHD?” It is: “Why is my child struggling, and what are the underlying causes/diagnosis, and what is the best way to help them?”

It is important to have your child assessed from a 360-degree perspective to look beyond ADHD (association comorbid conditions such as Anxiety, Learning difficulties and Autism) by an experienced Paediatrician, as this can make a significant and life-changing difference for your child’s future.

ADHD is not just about being unable to concentrate

ADHD is a neurodevelopmental condition. It can affect attention, impulse control, activity levels, organisation and the ability to manage everyday tasks.

But children do not all experience ADHD in the same way. Some children are very active and impulsive. Some are mainly inattentive. They may be quiet and easily distracted and therefore can be missed, particularly at school. Others have a combination of difficulties.

ADHD symptoms also need to be considered in the context of a child’s age and development. Symptoms should occur in more than one setting, such as home and school, and they need to cause meaningful difficulties in everyday functioning. This is why a good ADHD assessment involves much more than completing a questionnaire.

At Paediatric Care Clinic, ADHD assessment is approached as a comprehensive developmental assessment, including consideration of common conditions that may occur alongside ADHD or sometimes look like ADHD.

Why experience with child development and behaviours matters?

Children are constantly developing. What is normal behaviour for a four-year-old may be very different from what we would expect from an eight-year-old. A child who cannot sit still, for example, does not automatically have ADHD. What matters is that preschooler executive function is dramatically improving from age 3 to 5.

Similarly, a quiet child who is struggling to concentrate may have ADHD even though they are not disruptive. For instance, typically girls with inattentive type ADHD (previously known as Attention Deficit Disorder) are often being late diagnosed or missed during primary school, and classically this group of girls starts to struggle when transitioning to high school as the expectations of school of being self-independent, complexity of subjects, and general demands increase.year by year.

An experienced Paediatrician looks at behaviour in the context of the child’s:

• Development (History of global developmental delay means at risk of learning difficulties, ADHD and Intellectual disability)
• Learning (History of lack of preschool also puts your child at risk of learning difficulties)
• Language (History of any degree of Language delay also can increase risk of academic difficulties – Specific Learning disorder or dyslexia)
• Social communication (Persistent problems of social skills, friendship and communication issues may indicate Autism)
• Emotional development (Emotional dysregulation is very common in children with ADHD and Autism)
• Sleep (Sleep deprivation can impact daytime concentration and emotional regulation)
• Family environment (Children thrive with consistent routine, rules, expectation but can impact family life due to untreated ADHD)
• School environment (Being bullied or social conflicts are common, and the most concerning is the academic impact or decline in significant cases from accumulated lack of attention from ADHD)
• Physical health (Being a preterm baby, history of epilepsy and hypothyroidism increased risk of ADHD)
• Strengths and abilities (Last but not the least, this is the area to foster to develop a future career of interest)

to help decide whether ADHD is really the main problem or whether something else may be contributing.

Most of the time ADHD is not the whole story (Majority of the children with ADHD has another comorbidity)

One of the most important reasons for a comprehensive assessment is that children with ADHD can also have other difficulties.

For example, a child who cannot concentrate or pay attention or listen may have ADHD. But they may also have:

• Anxiety
• Autism Spectrum Disorder
• Learning difficulties
• Language difficulties
• Sleep problems
• Emotional difficulties
• Developmental delay and/or Intellectual disability
• Hearing or vision problems
• Difficulties at school, e.g., being bullied
• Significant family or social stress

Sometimes there are several conditions at the same time. For example, a child may have ADHD and anxiety, or ADHD and autism. These combinations can change how the child behaves and will also change the best treatment approach. This is why the assessment needs to look beyond ADHD symptoms alone.

Behaviour tells us something, but we need to understand why (the triggers)

Parents may describe a child as: “He doesn’t listen,” or “She is always arguing,” or “He is aggressive,” or “She refuses to do her homework,” or “He has huge meltdowns.” These behaviours are real but behaviour is often the end result of an underlying difficulty.

For example, a child who refuses to do homework may not simply be “lazy” or “oppositional”.

They may have difficulty reading.

They may not understand the instructions.

They may have ADHD and struggle to organise themselves.

They may become anxious when they cannot do the work.

They may be overwhelmed by the amount of work.

The behaviour can look similar, but the reason can be completely different.

A comprehensive assessment is often warranted to investigate and find out the reasons.

Is it so called AuADHD – ADHD and Autism together?

ADHD and Autism Spectrum Disorder can sometimes be difficult to distinguish.

Some children have ADHD. Some have autism. Some have both. When there are concerns about both, we need to look at more than attention and activity levels. Important behaviours need to consider included:

• Social communication
• Reciprocal interaction
• Friendships
• Eye contact and non-verbal communication
• Play
• Flexibility
• Repetitive behaviours
• Strong or restricted interests
• Sensory sensitivities
• Difficulty with changes and transitions

This broader neurodevelopmental approach is particularly important when a child has challenging behaviour or emotional outbursts.

A questionnaire is helpful, but it is not the diagnosis

ADHD questionnaires completed by parents and teachers can be very useful. They help us understand what is happening in different environments, but questionnaires do not tell the whole story. A child may have a high ADHD score because they are anxious, struggling academically, having poor sleep or experiencing another developmental difficulty. The assessment therefore needs to combine questionnaires with a detailed developmental and behavioural history and information from different settings.

At Paediatric Care Clinic, the ADHD assessment approach includes a multi-informant neurodevelopmental behavioural evaluation together with consideration of mental health and educational difficulties.

What happens after the diagnosis?

This is where a good assessment should lead to a treatment plan.

The approach should be beyond a single treatment and should always be combined with behavioural strategies. Parents play a central role in improving the children’s behaviours and training their executive function, including organisational skills in conjunction with teachers who work to improve their learning at school.. Every child with ADHD has their strength and challenges; therefore, the treatment plan needs to be individualised.

Depending on the child’s age, severity and circumstances, treatment may include Parenting and Behaviour Strategies, School Base Support and medication when appropriate.

1. Parenting and Behaviour Strategies

Medication is not the only treatment for ADHD. Parents often need practical strategies to help their child manage everyday life. This can include:

• Establishing predictable routines
• Giving short and clear instructions
• Using visual reminders
• Breaking large tasks into smaller steps
• Using positive reinforcement eg reward system
• Providing consistent consequences
• Helping the child develop organisational skills
• Supporting emotional regulation
• Managing transitions
• Developing consistent morning and bedtime routines
• Limiting the screen time
• Increase physical activities

At Paediatric Care Clinic, behavioural management is viewed as an important part of ongoing ADHD treatment, including a three-prong approach involving parents, the child and teachers.

Parenting a child with ADHD can be very challenging. Empowering parents with practical tools that are more likely to work with the way their child’s behaviours and responses to rewards, consequences and expectations, such as the ADHD Parenting Course.

2. School-based support

Children spend a large part of their day at school. Therefore, strategies should not stop at home. To accommodate and support students depending on their needs, implement classroom strategies such as:

• Clear and simple instructions
• Breaking tasks into smaller sections
• Extra time where appropriate
• Movement breaks
• Seating arrangements
• Visual schedules
• Organisational support
• Positive reinforcement
• Assistance with planning and completing work

Working together with teachers and other professionals can make a significant difference.

3. Psychological and behavioural support

Some children need more than ADHD strategies alone.

A psychologist or behavioural therapist may be particularly helpful when there are significant:

• Anxiety symptoms
• Emotional difficulties
• Anger
• Aggression
• Trauma-related difficulties
• Social difficulties
• Family stress

At Paediatric Care Clinic, multidisciplinary care and collaboration with allied health professionals are part of the approach to supporting children with neurodevelopmental and behavioural difficulties.

4. Medication when appropriate

Medication can be an important part of ADHD management but should not be considered as the sole treatment. For a significant group of children, medication can make a substantial difference to attention, impulsivity and daily functioning.

Stimulant medications such as methylphenidate and lisdexamfetamine are commonly used. Non-stimulant options may also be considered, including medications such as atomoxetine and guanfacine. Other medications may sometimes have a role depending on the child’s individual circumstances.

The choice is not simply: “Does my child need medication?” It is: “Which treatment is most appropriate for your child with specific associated conditions?”

Factors such as age, symptoms, severity, anxiety, autism, sleep, appetite, growth, blood pressure, tics and previous medication responses can all influence the decision.

Paediatric Care Clinic provides information on a range of ADHD medications, including Ritalin, Ritalin LA, Concerta, Vyvanse, Strattera and Intuniv, as well as information about medication side effects and management.

How effective is ADHD medication?

One of the reasons the medication is commonly considered is that stimulants can be highly effective for the core symptoms of ADHD. One of the randomic control trials noted that stimulant medication may improve ADHD symptoms in most (73–88%) children who took Ritalin, for example. The majority of children respond very well. Some respond partially. Some experience side effects. To minimise the side effects, at Paediatric Care Clinic, using the lowest dose of medication while achieving the best response to get the balance right. Some do not respond adequately to a particular medication; therefore, it can be a trial and error for some cases. Sometimes a child appears to be “worse” because of the significant rebound symptoms of ADHD, depending on the types and severity of ADHD and whether they have comorbid Autism Spectrum Disorder or Anxiety disorder. This is why treatment often needs careful adjustment.

Zakia Alavi, MD, Assistant Professor reviewed that “Stimulants may “not work” due to incorrect ADHD diagnoses or undiagnosed comorbid conditions in patients with ADHD. Estimates of comorbid psychiatric diagnoses in children with ADHD are 50% to 90%,^15,16 emphasizing the high prevalence of complex patients labeled with ADHD. Many of these complex patients may be misdiagnosed or their comorbidities may be undiagnosed at the onset of stimulant therapy. Naguy offers an excellent comprehensive review on ADHD medications interacting with comorbidities including depression and oppositional defiant disorder.¹⁷“

An important example is having comoribid “Autism spectrum disorder (ASD). There are instances when stimulants might actually increase irritability; the stimulant response rate for those with concomitant ADHD and ASD is lower and the rate of discontinuation higher than for those with ADHD alone.” This again highlights that a comprehensive assessment is very important to look into comorbidities/ associated conditions present in a child with ADHD.

Finding the right medication is a journey, and aiming to make it as smooth as possible

At Paediatric Care Clinic, informed choices of medications will be provided to parents, helping them choose the best one for their children with ADHD. This will involve discussing how the medication works, how long it starts to work and lasts, how many times it has to be taken, and what is expected or how to monitor the response as well as side effects. It is also important to discuss the untreated consequences of severe ADHD.

There is no “one-size-fits-all” ADHD medication. For some children, methylphenidate works very well. For others, a Dexamphetamine-based medication such as lisdexamfetamine may provide better symptom control. For some children, a non-stimulant may be more appropriate. Sometimes the timing of medication needs to be adjusted to match the child’s severity and timing of the behavioural issues.

The goal is to improve attention, self-control, learning and everyday functioning while preserving the child’s personality and strengths at the same time, avoiding making a child quiet or so-called “not themselves”.

Side effects need to be taken seriously

Medication can be very helpful, but it is not completely free of side effects. Depending on the medication, we need to monitor:

• Reduced in Appetite
• Weight, Height and growth
• Sleep
• Headache and Abdominal discomfort
• Mood and Anxiety
• Irritability
• Tics
• Behavioural changes
• Heart rate and Blood pressure

Most children may experience minor side effects. For example, a child may become unusually quiet, emotionally flat, irritable or withdrawn. Another may lose too much appetite during the day. These changes should not simply be ignored. They should be discussed with the treating doctor so that the dose, timing or medication can be reviewed.

Paediatric Care Clinic also provides specific medication information and advises families to seek medical review for significant or concerning side effects.

Avoiding common ADHD treatment pitfalls

One of the advantages of having an experienced clinician involved is being able to recognise when treatment is not going as expected.

Some common problems include:

Treating the behaviour instead of the cause

Not every difficult behaviour is caused by ADHD. The underlying cause needs to be considered.

Treating ADHD but not the co-existing condition

If a child also has anxiety, autism, learning difficulties or sleep problems, these issues may need their own treatment.

Stopping behavioural strategies once medication works

Medication can improve the child’s ability to focus and control impulses. It does not automatically teach organisational skills, emotional regulation, social skills or parenting strategies. Behavioural strategies should therefore continue.

The bottom line

An ADHD/ Behavioural assessment for your child should be a comprehensive assessment of their development, behaviour, learning, emotions, relationships and environment. An experienced Paediatrician can help identify ADHD while also looking for conditions that may occur alongside it or explain similar symptoms. Treatment should then be tailored to your child. This usually includes parenting strategies, behavioural support, school-based strategies, psychological or allied health support, medication, or a combination of these approaches. Medication can be very effective, but finding the right treatment may require adjustment and monitoring. The important thing is to look at the whole child, understand the reasons behind their difficulties, monitor treatment carefully and make changes when needed. The goal is to understand your child and develop an individualised treatment that helps them learn, develop and reach their potential.

Learn more: Paediatric Care Clinic – ADHD Information · Paediatric Care Clinic – Medications

Paediatric Conditions Consulted (both Clinical assessment and Treatment) commonly but not limited to: