Mental Health Series: ADHD

In this episode—the second in our series on mental health in children & teens—Children’s behavioral health experts weigh in on Attention Deficit Hyperactivity Disorder, better known as ADHD. How does this disorder impact children—and what should parents know?

Topic Breakdown

1:15 – ADHD basics
3:55 – Evaluating children and diagnosing ADHD
6:38 – How ADHD can manifest across the ages
8:24 – ADHD signs to look for
11:23 – The long-term prognosis of ADHD
14:38 – Treatment for ADHD
18:51 – Adapting the environment to help children with ADHD
20:05 – About ADHD medications
22:44 – Communicating with your child’s school


Transcript

Here at Children’s Hospital & Medical Center in Omaha, Nebraska, it’s all kids — all day, every day. Our pediatric experts are here to answer your questions and weigh in on hot topics, helping you keep your child healthy, safe, and strong. We’re here for you. Listen in.

In this episode, the second in our series on mental health in children and teens, Children’s Behavioral Health experts weigh in on attention deficit hyperactivity disorder, better known as ADHD. How does this disorder impact children, and what should parents know?

Dr. McWilliams: Hey, I’m Dr. Jennifer McWilliams. I’m one of the Child and Adolescent Psychiatrists here at Children’s Behavioral Health. Along with my partner in crime, today we’re going to be talking about ADHD.

Dr. Akers: I’m Dr. Sean Akers. I’m a Clinical Psychologist here at Children’s Hospital & Medical Center in the Behavioral Health Department, and as Dr. McWilliams said, we’re going to talk today about ADHD. And I think, Dr. McWilliams, why don’t we start with just the basics. Just let’s maybe talk about the signs and symptoms and diagnosis of it.

ADHD basics

Dr. McWilliams: Yeah, absolutely. So, one of the first questions that I get is, you know, what is ADHD? And a lot of people grew up with the terms ADHD and ADD and other things. And just to be kind of clear at first, those diagnoses are all actually kind of lumped together now, so it’s all ADHD, but with different subtypes. So right now there are three types of ADHD that we recognize and diagnose.

The first is the inattentive type of ADHD, where people have difficulty with focus and staying on task. The second is a hyperactive and impulsive type of ADHD, so kids that are running, jumping, and talking. And the third is a combination of the two of those.

So, there are a list of different criteria for each type of ADHD that we look for to try to determine if somebody meets the criteria for one or the other. Often, it’s pretty easy to recognize the hyperactive type of ADHD, but being able to pick up on the inattentive type can be more challenging.

Dr. Akers: So, you know, what I’ll add to that is when we diagnose somebody, we often have to wait until they are close to school age. You know, so one of the things that we do is take a pretty extensive history, and there is a difference between seeing a 6-year-old in your office versus starting a diagnostic evaluation with a 12-year-old with, you know, with concerns about that. So, what do you see about the difference between that evaluation process Dr. McWilliams?

Dr. McWilliams: Yeah, absolutely. So one of the key criteria for ADHD is that you have to have difficulties in multiple settings. So it’s not just a matter of having trouble focusing at school. You also have to have difficulties at home and so that kind of goes back to why it’s hard to diagnose ADHD for preschool age kids— because if you’re really just in one environment all day, it’s hard to really get that picture of if things are challenging and multiple areas of your life when we’re doing the evaluation.

We’ll sit down and talk to the kiddo, of course, and also talk to their parents and get information from them. But then, oftentimes we also wanna get collateral information from school — talking to teachers or daycare providers — to make sure that we’re getting the full picture of how kids are doing across all the different areas of their life.

Evaluating children and diagnosing ADHD

Dr. Akers: Yeah, that’s a really good point. I do want to emphasize that — that it’s a little bit of a different process when we evaluate kids for ADHD than some of the other things. And the reason is that kids can be different depending on the context. So, you know, we know that it’s not uncommon for ADHD kids to do really well. If somebody is sitting next to them, sort of on a one-on-one basis, or if they’re really highly monitored, or if they’re in a new situation. So somebody coming into our office for the very first time might show very little impulsivity that very first day. And then when you get to know them, it may change a little bit and so it’s really important to get a sense of the context, and we want that collateral information.

So we want input from main caretakers, we want input from the teachers — hopefully multiple teachers — because there’s a real difference between if somebody is exhibiting a behavior just in the home setting but not in school, and they’re making great grades, and they’re behaving well, and there’s no issues. That might be a different picture that we want to look at.

Dr. McWilliams: Or conversely, sometimes kids will do really well at home and really struggle at school, and so we also want to look at — is there possibly something else that’s going on? Sometimes, if a child is struggling with anxiety, for example, that can be very distracting for them if they’re so busy worrying about everything that’s going on around them, and then they’re not always able to pay attention. Or if they have a learning disability. If they, you know, really struggle with math.

You know, I always joke that there are entire lectures about nephrology and kidney disease that is spaced off on completely because I just didn’t get it. It’s hard to stay focused on something if you don’t understand it.

Dr. Akers: And so here, we do have a few different levels of evaluation. You know, there are times, as you said, Dr. McWilliams, that it’s pretty clear. And what we have and the history is pretty understandable and, you know, we have good collateral information, and we really get a good sense of what’s going on. Sometimes it does get more complicated. Not only could it be something else, but you could have multiple things happening at the same time? You know, do you have anxiety and ADHD? One thing I will say is that here at Children’s Behavioral Health, we have Dr. Levering who does our ADHD clinic, and if we do feel, especially if it’s a little bit potentially more complicated, or we want to rule out of a number of different areas, she might do a little bit more of an extensive evaluation to make sure that we’re picking up on everything.

How ADHD can manifest across the ages

Dr. McWilliams: Exactly. So a quick note about the statistics. So ADHD is actually really common, and so it isn’t unreasonable that there is a lot of overlap with other things like anxiety and depression and stuff like that. So some estimates are up to 7% of kids would meet criteria for ADHD. Typically, again, like you mentioned, we see it, you know, starting to be recognized around that early grade school age, but it’s also not unheard of for people to start really getting symptoms as they get older.

A lot of times, kids who are bright are able to compensate and do well and control their ADHD symptoms, until they get to a certain level in school, where it’s harder for them to be able to manage those symptoms while also juggling calculus or more complex subjects. So, typically we look for it in younger kids, and we want to look for a history of ADHD that’s been going on for a long time, but it can be recognized later in life, as well.

Dr. Akers: Yeah, that’s a good point, and it is a little bit harder to diagnose a little bit later. Again, we want to make sure that we’re catching the right things. But the trends that I see — there are just some classes, some grades, that tend to push kids more. And in some schools that may be fourth or fifth grade and other schools, maybe middle school, and other kids, it’s high school where they’ve been able to do pretty well. But then, suddenly they have to study a whole lot more, they’re off task a whole lot more, and it just taxes their ability to sustain their attention. And that’s when you’re going to see that uptick, a little bit.

ADHD signs to look for

Dr. McWilliams: Exactly. I always talk about the, you know, when you’re transitioning from learning to read and learning to write, from learning to doing math to learning subjects in that third to fourth-grade time when you actually start learning, you know, material is when we can see a lot of difficulties arise. So some things that parents can look for the obvious ones are again, like I said, the hyperactivity — you know, talking all the time, blurting out, forgetting to raise your hand in a class, being really impatient, interrupting. The little kid that’s climbing every bookcase and trying to jump off the roof with their blankey tied around their neck as a cape.

You know, those are some pretty obvious signs of the hyperactive and impulsive subtype. The inattentive subtype can be a little bit more difficult to recognize, again this is a lot of times — kids that tend to daydream and space off, kids who might start one thing and then get distracted and wander off and start something else and never come back and finish the original task. One question that I often ask parents is, “If you give your child multiple requests like, ‘Hey, Sean, I want you to go put your shoes away, wash your hands, and then come set the table for dinner,’ is your child able to do all three steps, or do they get lost somewhere in the middle and forget what they were supposed to be doing?”

What are some of the other symptoms that you tell parents to be on the lookout for

Dr. Akers: Those are absolutely right on with the first things that we’re going to look at. I’m also gonna look at organizational skills and how are they doing with, you know, keeping up with their homework.

I also, I want to ask about what their morning routine is like. Are they able to get up and go through their typical tasks? Or does a parent more or less need to walk them through their morning routine every single day — they’re not getting the ability to do something as a habit as easily as some of the other kids. Are they easily sort of forgetting things, you know, just very forgetful and easily distracted? You know where they’re doing a task, and they see the TV on, and they veer toward the TV, and they just sit down.

Now, you know, again, a lot of the things that we’re talking about, Dr. McWilliams are…I think we’ve all heard, “Well, I do that too.” Or, you know, and we have to make sure that we understand that, a couple of things. That this is a continuum, you know, there are mild and moderate and severe forms. And it’s not all or nothing that we really are going to be looking at — are these issues affecting functioning when they’re in our office? Typically, they’re saying they are, we have concerns about that. But we’re not necessarily going to diagnose something if somebody is occasionally spacey or somewhat disorganized, but they do well in all aspects of their life. It is a matter of looking at how that’s affecting their lives.

The long-term prognosis of ADHD

Dr. McWilliams: Exactly. I would say every morning between 6 a.m. and 7 a.m., I would meet the criteria for ADHD, and then I get some caffeine, and I’m good.

So, another question that parents often ask is kind of, what’s the long term prognosis for ADHD? And when I was in school, we were always kind of taught the rule of thirds — that we know that ADHD is a really inherently biological condition where certain parts of the brain just mature at different rates than others. So, about a third of kids will go ahead, and as their brain continues to develop and mature, and it may even be into their early 20s those signs of ADHD will disappear. And if they sat down with Dr. Levering and did some of her testing, there wouldn’t be any indication that they still had ADHD symptoms.

About a third of kids will continue to have those signs that would show up on formal testing would have adopted different coping skills and strategies so that the ADHD symptoms actually are a strength for them. I always joke that I’ve never met a single ER doctor that doesn’t have a touch of ADHD — being able to think on their feet and shift from one thing to the next is really a strength for them.

And then about a third of people will continue to always have some struggles. They’ll need to keep their sticky notes in their day planners and everything to keep themselves organized, but they may be a little bit more spacey as life goes on.

Oftentimes, we see those hyperactive symptoms, if they’re present, kind of burnout as kids get older, and it’s shifting more into the inattentive type.

Dr. Akers: One question that I often get from parents when we first sit down, is, they’ll say, “Well, but my child can attend to something if he’s really interested in it. So, I don’t think he has it.” Or, you know, “This is something that if I see him really interested in video games or television or his videos on his phone, he can pay attention for hours.”

And so we do have to sit down and make that distinction that there is an under focus in certain areas, but we do often see an over-focus, right? We see — because what we have to explain is that, with ADHD, the brain is searching for stimulation. And they don’t tolerate the things that are, I don’t want to say boring, but a little bit less stimulating. But, when I was a kid, I could sit in a more boring class and I could say, “Come on, Sean, pay attention,” and “It’s not that hard.” But some of these kids, or most of these kids, who are especially inattentive — they may say and have the same motivation and want to pay attention, but their brain is seeking out stimulation. And that’s where it becomes difficult, is that they will continue the same behaviors over and over again because it overrides that motivation to sit still, that their brain goes in other areas.

Dr. McWilliams: Exactly. One of the criteria, actually, for inattentive type ADHD is that hyper-focus — that you’re able to just completely put blinders on and go into a little tunnel and ignore everything else around you. So certainly, it’s almost like there are gas pedals and brake pedals in your brain, and some get stuck one way and some get stuck the other way.

Treatment for ADHD

Dr. Akers: So let’s go with, when somebody is diagnosed, Dr. McWilliams. So, we have an accurate diagnosis, and we’re really primarily dealing with ADHD, and it’s not super complicated with a lot of other issues. Let’s talk a little bit about treatments and what directions we go with that because it’s a little bit unique compared to some of the other areas.

Dr. McWilliams: Absolutely. So, several years ago there was actually a big research study that was done that looked at a number of kids who’ve been diagnosed with ADHD and compared them taking medication, to being in therapy, to being in therapy and taking medication, and just kind of living life on their own. And what we found pretty clearly is that because, again, it’s such a biological disorder that medication really is very, very helpful for kids who have ADHD. Therapy certainly helps and adds to, you know, developing coping skills and organizational skills, but a lot of those are really difficult to attain if you don’t have the medication piece to help out.

There are two types of medications that we use for ADHD. There is one group called the stimulants and another group called the non-stimulants. The stimulants are the ones that you’ve probably heard of the most — things like Ritalin and Adderall and Vyvanse. And those medications are really nice because they’re very fast-acting. They work as soon as you start taking them, but they’re also very short-acting. So on the plus side, you can take them just on school days, if you need to, and take summers or weekends off. On the downside, if you forget your medicine, then you’re kind of out of luck for that day. And the biggest side effects for those medicines is that they can make it hard for you to fall asleep at night if you take it too late in the day, and sometimes, they can suppress your appetite and make people not very hungry. But those medicines have been around the longest and probably been the most well researched.

The non-stimulant medicines are kind of a hodgepodge of different types of medicine, and the advantages of those medicines is that they work 24 hours a day, seven days a week. The disadvantage is you have to take it every day, and it can take several weeks for them to build up and start to work. They tend to be a little bit gentler medicine, so sometimes they’re not as effective for kids that have a lot of ADHD symptoms or have tasks that they really have to be very focused on. But they can be a good option, too, especially in some of the younger kids, where, you know, they’re so impulsive that, you know, they might hurt themselves if they don’t have something helping them out 24 hours a day, seven days a week.

So that’s kind of the medicine piece and, as a psychiatrist, just and, you know, a lot of my friends are pediatricians and family practice doctors — we kind of manage that. But we also look really closely at working with our friends in psychologies to help with the other skills. How do you present or work with kids with ADHD?

Dr. Akers: The first part is really getting that good diagnosis and formulating that treatment plan based on the diagnosis, and part of that’s going to be age. Certainly, you’re gonna have a different treatment plan, if you’re looking at a preschooler, or a 6-year-old, a first-grader versus a high schooler.

But one thing that we do emphasize is not only explaining the whole ADHD model, then it’s also understanding that working on ADHD in treatment is really about managing symptoms. We’re not, we don’t have a cure, kind of outlook. We don’t have — we’re going to eliminate this through therapy or meds. How are we going to manage these symptoms as best we can, so that their frustration is less, they’re able to learn as well as possible, they’re able to socialize, you know, as appropriately as possible? And we’re addressing all of the things that may be affecting their functioning, but it really is a management, kind of focus. And so a lot of times, we start with more of a behavioral focus because, you know, we’re not going to — it doesn’t help to just tell an impulsive child to stop doing that.

Adapting the environment to help children with ADHD

Dr. McWilliams: Knock that off!

Dr. Akers: Yeah, just knock it off. A lot of the behavioral things are going to be — how do we help the environment? How do we, you know, whether that’s helping with monitoring a little bit more, or we know that a very reinforcing environment can be really helpful for a lot of kids, and making it as stimulating as possible. So there’s a lot of techniques and behavioral suggestions, whether that’s for the parent or the teacher, to try to manage these as much as possible. And even something as simple as sitting in the front of the classroom as opposed to the back of the classroom, or making sure that the teacher does regular check-ins one-on-one to make sure that they’re staying on task versus just hoping for the best or, doing, thinking that they can sit down for four hours doing homework with no break, as opposed to breaking tasks up into small bits.

So it really comes down to, first, getting to know people because there’s no one-size-fits-all — not everything works for everybody. So we want to get to know them, but we also want to make sure that we’re giving them as many techniques and coping skills as possible to manage this.

About ADHD medications

Dr. McWilliams: Absolutely. So, one question that I get asked a lot from parents is that they come and see me and really have heard a lot of awful things about medications for ADHD and are very hesitant to have their kids take those medicines. And that’s perfectly understandable — I actually applaud anybody who wants their kid to be on less medicine rather than more medicine.

One thing, though, that I do always want to clarify with the medications, is that they can be very effective, especially if they’re used in combination with those skills and strategies that you just outlined, and also that the medications have become a lot more refined as we’ve gotten more advanced in treating.

So a lot of the medicines and the side effects that we, as now adults, remember from our childhood, have been refined so that there are fewer side effects, and that they’re more tolerated. You know, parents often talk to me that they feel like their kids are afraid their kids are gonna be zombies on the medicine. And I think that’s a big red flag — if your child is ever on so much medicine that it kind of blunts their whole personality, then they’re on too much medicine, and we need to take a good look at if they’re on the right medicine and if what we’re doing is helping or hurting more.

So I always encourage people to, you know, work with, you know, therapy and look at all the different options. Like you said, schools, there are a lot of great, you know, tools — different fidgets, and, you know, stress balls, and things like that that can help kids release some of that kinetic energy can be really helpful. But recognizing that medications can be a very safe option, but you have to have a good open dialogue about what you’re seeing with your kid and what your goals are for each individual patient.

Dr. Akers: And one thing that I emphasize also is the therapist side of this, Dr. McWilliams, that, especially here in behavioral health, we do really pretty close monitoring, and we want that good communication. I think a lot of parents sometimes worry that their child is going to be just placed on a lot of meds, and then we just sort of wave goodbye — call us if you need us. And that’s really not the way we do it. We really want to make sure we’re on the right meds with the right dosage, and that we’re monitoring this consistently. We often even get teacher input and parent input as they’re on these medications to make sure that it’s effective and that we’re not kind of changing personality and so forth. I think that does set some ease.

Communicating with your child’s school

Dr. McWilliams: Absolutely. One of the other questions that I often get, I’m not sure if you do, is whether or not parents should even tell school about their child’s diagnosis once we make it. Some people are really worried that their child will be stigmatized and, you know, set apart from the other kids if their teacher and the other school personnel know that they have ADHD.

And certainly, every circumstance is different, and there may be some situations where it is more appropriate to not share that information, but in general, I think it’s more important that we all are working together collaboratively as a team and getting information from the teachers and having them be aware so that they can help, you know, provide appropriate accommodations, can be very helpful.

So, that’s my recommendation. Do you have any different thoughts on that?

Dr. Akers: Yeah, I would totally reiterate that, maybe even stronger — that in a perfect world, we have, say it’s both parents working together, right, there are the same goals and same rules and have at least a relatively similar approach to things. And we want that in the school as well, so in a perfect world, we want that collaboration. That teacher is going to see that your child for seven hours typically if they’re in elementary school, and they’re going to have a lot of information, and what we know is that, when there’s really good communication between parents and school, then we just have so much more rich ability to treat them well.

So whether that’s a weekly email or very regular check-in — some teachers are willing to do a daily, you know, kind of thing where they hand it back and forth between the home and the school. So everybody is aware they’re on the same page. And we’re working towards this child, making sure that the child is learning appropriately and doing well in school. It always worries me when, you know, when the parent is unaware of what’s happening in school and I really, I think the best-case scenario is that there’s a good positive collaboration.

Dr. McWilliams: Absolutely. Well, I’m just — I know that we get a lot of questions about ADHD, and I think we’ve kind of hit on some of the biggest topics that have come up. Of course, you know, we are never able to address every question that people have. So I would encourage listeners, if you do have additional questions about ADHD or concerns about your child, to reach out to either your primary care provider, your child’s pediatrician or reach out to our department or any other mental health provider, and we’d be more than happy to talk to you and answer any further questions.

Dr. Akers: Absolutely. And I think that’s going to be about it for today, so I sure appreciate everyone listening,

Dr. McWilliams: Yep, thanks so much. Have a great day.


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