Transcription:
Diagnosis: ADHD. Now What

Anne Walters, PhD (Host 1): Impulsive, distracted, overactive, unfocused. It's hard to walk into a child's parent-teacher conference and hear those words describing a child. It may be somewhat of a shock or perhaps it's confirming a suspicion that's come up first in preschool. Either way, these are potential symptoms of a child who may have attention deficit hyperactivity disorder. Some children may present with classic symptoms where they are fidgety, always hopping up from their seat, distracting themselves and their peers, or maybe they're presenting as unfocused, appearing as if they're miles away or even unmotivated.

We're here to learn more about ADHD with Dr. Brian Kavanaugh, a Neuropsychologist at Bradley Hospital who spends his time researching evidence-based treatments and treating children who have been diagnosed with ADHD. This is Mind Cast, Healthy Mind, Healthy Child, a podcast from the Mental Health Experts at Bradley Hospital, leaders in mental health care for children.

I'm Dr. Anne Walters with my colleague, Dr. Gregory Fritz.

Greg Fritz, MD (Host 2): Brian. So good to see you.

Brian Kavanaugh, PsyD (Guest): Likewise, thank you so much for having me.

Host 2: The diagnosis of ADHD has come a long way hasn't it?

Dr. Kavanaugh: Certainly.

Host 2: I remember back in the 70s when I was in training, what was called a paradoxical response to stimulants was used as a diagnostic test. So, if a child calmed down and attended better to a dose of a stimulant, he had ADHD. Of course, that was all blown up when a researcher at the NIMH gave stimulants to normal children, including her own and found that they responded the same way, with greater focus on cognitive tests. So thankfully diagnosis and treatment are much more sophisticated and scientific today.

Or at least they should be. But most of all, we know that a diagnosis of ADHD is not the end of the road for a child. With good treatment, even a child with serious ADHD symptoms can thrive at school and in the big world. So let's get started with your explaining what ADHD is.

Dr. Kavanaugh: Yes. So to start off, we know that ADHD is a brain-based neurodevelopmental disorder that emerges in development or in childhood, and it manifests with clinical symptoms of distractability, hyperactivity and or impulsivity. And we know, and we'll talk about this today, of course, but we know that these symptoms interfere with the child's ability to succeed in their environment. And that is in part, part of the, the reason why we are so focused on identifying and in treating kids who have this, clinical disorder.

Host 1: Well, I'm curious, Brian, when you say, clinical symptoms, can you tell us how we would know what's clinical versus what's out of the range, I guess, of what we'd say is typical.

Dr. Kavanaugh: Yeah. So I think that's in part, one of the reasons why there's misconceptions out there about ADHD. Outside of the hospital setting, in the community, we still hear a lot well, you know, he's just being a five-year old or that's a boy being a boy. Right. And that's what families hear or they say it to us and at first I used to say, just dismiss it and say, you know, that's just not true or that, that's a misconception that has no truth to it. I think there is a reason why that misconception is out there. And I think it's in part because of the symptoms of ADHD. In many ways we look through the symptoms and they could be normal in younger kids. Having trouble remembering. Being, having trouble sitting in your seat, being too impulsive. In many ways, these symptoms can be a delay or a disruption to development that may be okay for a younger kid.

But when they persist in older kids is when it starts to be a problem. And as opposed to other disorders that we're used to where a sign, a symptom, or a behavior, regardless of the age would be considered atypical or unusual. In ADHD, it's more of a developmental trajectory type of symptom or difficulty that can create problems.

And so we look at it really with our tests and our assessments and our procedures in psychology and psychiatry as what's normal versus what's atypical for the child's age. So, age and development in context are really the overarching components to any accurate or appropriate assessment and treatment process.

Host 2: So some of the symptoms that get diagnosed as ADHD on a superficial evaluation, if they're pursued more in depth, can be a sign of a different disorder or a different problem, I think. And you're in agreement with that?

Dr. Kavanaugh: Yeah, absolutely.

Host 2: What are some of the things that can be mistaken for ADHD if the evaluation is not as thorough and as comprehensive as it needs to be?

Dr. Kavanaugh: So really, you know, we can get into the specifics, but almost any type of brain-based disruption can start to mimic features that would look like an attentional problem. Attention is really the canary in the coal mine. If something is going wrong in a brain, attention is probably the most sensitive brain function to disruption. So in that we have some functions like intelligence or language or vision where they can take a hit and keep on functioning in a normal way. But our attention is so vulnerable that any types of things, as you said, Dr. Fritz, like sleep for sure, stress, even appetite or diet issues, changes in routine. So all these types of normal, daily activities or daily health activities can disrupt our attentional functions and certainly disorders too, that we're familiar with in mental health. Certainly attention can be a component to many mental health disorders.

It's a primary feature of ADHD, but depression and anxiety can have significant attentional disruption. Certainly autism, PTSD, disruptive mood dysregulation disorder. All of these are always on the table for us when we're meeting with a family and looking through what is the actual set of symptoms that we're trying to identify and describe in the most parsimonious way.

Host 1: I'm curious if you have any thoughts about whether ADHD looks different in girls.

Dr. Kavanaugh: Yeah. So this is a really important topic that I think is, thankfully getting a lot more traction now in ADHD actually, and also in autism, it seems like both conversations are occurring in parallel. And this is thankfully driven by a lot of NIMH regulations and encouragement to include both sexes in scientific research studies to advance our understanding of female phenotypes in different brain based disorders.

And so I think that the research would suggest, the literature at least to date, is that our prevalence rates still suggest that boys are about twice as likely to be diagnosed with ADHD. I think it's 12 versus six and the most stable estimates that I've seen, although that you're always out of date with the estimates, because they change so quickly.

But I think 12 versus six is, a common one. And at the same time, we know that ADHD was first described based on a male phenotype or a probate who was a boy who had ADHD and most of the boys, most of the initial cohorts from Dr. Hoffman in the 1800s and Dr. Still in the 1900s were really boys who had ADHD and this kind of classic phenotype.

And so I think because the, I think in many ways, boys in healthies and in ADHD are going to have more externalizing symptoms. This is more part of their presentation. And, and so I think that boys who have ADHD compared to girls, the research has shown that boys are likely to have more externalizing symptoms.

I think that's one concrete finding is that boys are going to have...

Host 2: By externalizing. Do you mean. What sort of symptoms?

Dr. Kavanaugh: Yes. I apologize. I believe it's going to characterize the hyperactivity and impulsivity as well as some of those co-morbid kind of noncompliance symptoms, as opposed to in your more classic distractability. And the other really solid finding in the research in sex differences is that, females tend to have a later age of symptom onset. So boys in the literature, that's done a really nice longitudinal studies have found it's more like that four to 10 range, more your classic textbook type. While females are more likely to have a 10, 11, 12 type of burst of symptom worsening or at least exacerbation.

And so there's some researchers to suggest that it almost takes a little bit more symptom presentation to get a diagnosis if you are a female. And I mean that could be because we have inherent biases as clinicians and diagnosticians, and we may think about the male presentation of a disorder and possibly be vulnerable to missing some milder cases from when females present in this way.

Host 1: One of the things I've noticed clinically is that it seems to me as though there are times that for girls, the social characteristics or I guess the impact of ADHD symptoms on social development and on social relationships is so prominent. You know, I think for a girl who is acting silly without being able to monitor when maybe they've crossed the line with a peer, that's much less tolerable in that sex stereotyped group, I guess if you will, than it is for boys. So I'm curious if you've had that experience and what you think about that.

Dr. Kavanaugh: Yeah, I think you said it, the stereotypes that we have, right. For sex differences in terms of what's normal and not for a boy and a girl growing up, I think that that is part of that reason is that it's almost okay for some boys to kind of break the rules or be a comic or kind of get in trouble or they're cool in some early grades, they actually may be a somewhat of a positive characteristic to some kids and how they feel about their disorder while I think for females and for girls, they have a different set of expectations from people and how they're told to behave and how they're expected to behave. And so I do think it crosses that line of what's appropriate and not appropriate. And that is a, I think, a direct reflection of these stereotypes that we have created and we're trying to change now.

Host 2: So, think about the etiology with us. What causes ADHD? That's a simple question. You're going to have a simple answer.

Dr. Kavanaugh: Yes. If only, as you know, and as we all know, it's a brain based disorder, right. And we've known about the brain basis of ADHD for two decades now, it's not new to us in clinical and research practice. I think families are still sometimes surprised to hear that we've known about that for so long. In terms of etiology, there's a few different pathways. I think the most common is familial. Right? I think that most research has suggested about 74, 75% of the variance in ADHD is solely attributed to familial factors. Right? So being passed down throughout a family. If you have ADHD and you have a child with ADHD, there's a more likely chance than not maybe 50 to 60% that your child will also have ADHD. And same if you have a sibling. And so we know that these run in families and oftentimes ADHD, many people who have ADHD and becoming very successful and they have their own families and procreate.

And so the actual rates of ADHD increase, in many ways that don't occur in more severe disorders that don't allow for procreation independence. And, in terms of brain mechanisms, we tend to, I think the most common research has shown it's these frontal striatal pathways that are the most disrupted or most consistently disrupted in ADHD with some cerebellar involvement as well.

And these, when I say frontal striatal, these are the pathways in the brain that are critical for things like control, motor activity, emotional control, all of these aspects. And so when these motor cognitive and emotional networks or highways are disrupted, they're going to lead to subsequent problems in these areas.

And that is in part how we see some of this ADHD presentation. And so certainly frontal is what's called the prefrontal cortex, but we also know it's these medial white matter and striatal pathways that are really critical for control, for attention, for motor activity.

Host 1: Would you describe ADHD as a mental illness or would you describe it as a disruption in development? You know, what's your thought on that?

Dr. Kavanaugh: That's good question. I do think it is a mental health disorder alongside all the other disorders that we think about and treat, a neuropsychiatric disorder, a mental health disorder, any term in that sense that captures these disorders, that effect emotional, behavioral and cognitive development. I do like the categorization of a neurodevelopmental disorder within the mental health. I think that DSM-V, I liked that approach to moving these things outside of a behavioral domain was a little bit pejorative and misleading, I think. And now that it's described as a neurodevelopmental disorder, I do think it helps us understand the etiology of it.

And so, I tend to think of it as neurodevelopmental and or psychiatric, that can persist into adulthood for sure. With all of our, disorders in the DSM, we could go on for a while, but the DSM I'm sure. But, in many ways are syndromes, right? I mean, we know the etiology as clinicians and researchers, but the diagnosis itself doesn't imply an etiology.

It's more of a set of co-occurring symptoms, which would be considered a syndrome by definition. So I do think that ADHD is a brain-based neurodevelopmental disorder. I think that we, and at the same time, kind of like a yes and right. Yes and, but we are going to get better at diagnosis in the future.

Host 1: What do you think about sharing a diagnosis with a child, especially, you know, kids with ADHD are often aware that there's differences in the way that they're responding to learning opportunities in the classroom. And they may know this pretty early on what do you think is a way to talk to them about it?

Dr. Kavanaugh: It depends on every kid for sure. I do think that there is utility in helping them to understand why they're acting the way they're acting. A lot of times when we see kids, if it's kind of later in the process or they haven't gotten earlier treatments, they tend to have negative self-esteem about these things, right? They've been blamed perhaps or felt it's their fault or it's caused them issues. And they may tend to internalize these things. And so by assigning an explanation or a medical explanation for their difficulties, I think it helps to reduce some of that guilt and blame.

At the same time, we want to be mindful of a label for a child. Of course, that can be a whole different level of difficulties perhaps. And so, what we do in neuropsychology, we have the advantage of focusing on assessment and having time with the families to go over this. But to put it in as normalizing of a way as possible. Strengths and weaknesses. We use the terms learning style or our blind spots or areas of weakness so that we can just be mindful of these things that are harder for us while also trying to magnify our strengths in gravitating towards our strengths.

Host 2: So let's talk about treatment, a big topic that we could spend the entire podcast on, but what are your thoughts about treatments?

Dr. Kavanaugh: So, our psychiatry colleagues, such as yourself, have fantastic options for ADHD. I think to start, the medication options are really strong in ADHD. We know that stimulants have response rates, 70 to 80% of kids who have ADHD can respond to a stimulant. We would be hard pressed to find other disciplines in medicine and other disorders in medicine that have such a strong response to a medication for their primary disorder. So I think that there are many strengths, even the next generation of medications, non-stimulants or alpha 2 agonist, even those have similarly strong or medium to large effect size, responses to their medications. So I think that for many kids, that medication option and that psychiatric treatment is fantastic. I think that there's still stigma out there about ADHD treatments, ADHD medications, especially in society and always is unfortunate because these medications are actually extremely effective for kids. But with that being said, we also, as a psychologist, we also think about the more the behavioral or emotional interventions. And we know that when the other first line treatments for ADHD are parents trainings and behavioral modification, these different types of psychological interventions where we're targeting behaviors in looking at the causes of behavior and the reinforcers of behavior and being able to help the child to make different choices and succeed in their environment in different ways and teach these new skills about control and about attention and about making the right choices and these things also have really strong effects. One thing about ADHD that I'm sure we'll talk about is that, most kids with ADHD has something else that's been diagnosed.

Right? And so we think about things that anxiety or autism or learning disorders, all these other disorders need treatments as well. And so I think that that's why these psychological interventions can also be so necessary to help wrap around and support the primary medication treating the primary ADHD symptoms and then helping to treat these other social academic, emotional, and behavioral symptoms or weaknesses that the child is likely experiencing.

Host 1: So it sounds like you're really recommending that parents find a good team of professionals that can address both the psychopharmacological needs, as well as what we'd call more the psychosocial treatments. The treatments are going to be about kind of everyday life as the parent of a child with ADHD. And that, that doesn't have to be an end in any way, but that there's a path forward and that we can also look a little bit at some of the strengths of kids that have ADHD.

Dr. Kavanaugh: Exactly. I think that the multi treatment provider team is a fantastic approach. And it depends on the child. We know that some kids who never really make it to us at Bradley, cause they can go to their pediatrician and they have a mild presentation and they're able to take a stimulant and that actually works. And they're actually well managed by their pediatrician and that is wonderful. We're used to seeing kids who have more of a complex presentation, who have other disorders or symptoms that are getting in their way. And so that's really, when we love to see a psychiatrist, a psychologist, educational specialists, other care providers that are helping them to succeed in navigate their environment despite these symptoms that they're experiencing.

Other things that are, that can be useful are academic tutors. And so we know that learning disorders can co-occur in ADHD a lot. And so making sure we're supporting them, not only with primary academic interventions, like reading and math, but also these study skills type of interventions, organizational approaches. There's a term that executive functioning coaching is getting some traction out there. And these types of things can really help kids who have ADHD with the organization, the independent components of schoolwork to help them really show all they know and meet their potential and thrive in that sense.

Host 2: So not only are you involved in the treatment process and in a very comprehensive way. I understand that you're working on a clinical research project. Tell us a little bit about that.

Dr. Kavanaugh: Yes, of course. So, we have started a new clinical trial at Bradley Hospital for a teenagers who have ADHD and it's a magnetic brain stimulation trial where the idea behind it is as you know, and as we know in psychiatry, there's a big wave to move towards brain-based treatments. We're still certainly in the research phase, but we hope that that can be a new or a supplemental component to treatment in the future. And in, so in this study we've identified a component, a brain component of ADHD that we're interested in, in our prior work, this neural oscillation is what we call it and we're using this type of brain stimulation to activate the brain activity in the prefrontal cortex in teenagers who have ADHD to hopefully increase their brain activity and subsequently improve their ADHD symptoms. And the type of TM or brain stimulation we're using is called TMS or transcranial magnetic stimulation. And it's been around since 1985.

And when we're using a three minute protocol. So the kids just get their TMS for three minutes and as part of study participation, they do it every day for two weeks. And we ask because every kid is guaranteed the actual full therapeutic dose of the TMS, that they also complete a fake or placebo two week phase of the study.

So it's a crossover design where every kid gets both. That allows us to, one to hopefully allow kids to get better and have symptom improvement as part of their study participation, but also allows us to mean scientific rigor, and really provide some really nice steps to propel us towards this option in the future where our hope is that with this study and future studies, we eventually have brain-based treatments for disorders like ADHD here at Bradley Hospital.

Host 2: Wow. That's really exciting. It could be a huge breakthrough and maybe there are some listeners of the podcast whose children might be interested in participating. If that were the case, how would they get in touch with you?

Dr. Kavanaugh: Yeah, of course. So they could always reach out to me at Bradley. My number is 401-432-1359 and my email as well which is bkavanah@lifespan.org. And we'd love to have anybody who would like to learn more about this study, learn more about our research and our goals et cetera.

Host 2: Very exciting.

Host 1: Brian, thanks so much. This was a great discussion and really enjoyed talking with you today.

Dr. Kavanaugh: This was really fun. I think it's a really wonderful topic to dive into and thank you all.

Host 1: If you found this podcast helpful, please share it on your social channels and check out our entire podcast library at bradleyhospital.org/podcast for topics of interest to you. This is Mind Cast, Healthy Mind, Healthy Child, a podcast from the experts at Bradley Hospital. I'm Dr. Anne Walters with Dr. Gregory Fritz. Thanks for listening.