Prakash Chandran: Children with attention deficit hyperactivity disorder or ADHD may have difficulties concentrating on a single task or sitting still. Early diagnosis and treatment of ADHD can help a child manage symptoms. We'll be exploring what to look for, the different types of ADHD, diagnosis, treatment methods and more.

This is Children's Health Checkup, where we answer parents' most common questions about raising healthy and happy kids. Let's talk about it with our expert, Dr. Angela Canas, a neuropsychologist at Children's Health and Assistant Professor at UT Southwestern. This is Children's Health Checkup, the podcast from Children's Health. My name is Prakash Chandran. So Dr. Canas, really great to have you here today. Thank you so much for your time. I wanted to get started by asking what exactly is ADHD and how common is it?

Dr Angela Canas: absolutely. So ADHD is a medical condition characterized by a pattern of inattention, hyperactivity and/or impulsivity that has persisted for at least six months and interferes with an individual's functioning.

Now, across resources, ADHD is classified as a neurodevelopmental, neurobehavioral or neurological condition, which can be confusing for parents trying to gain a clear understanding of ADHD. But essentially, all of these terms are used to indicate that ADHD is a brain-based condition that manifests in childhood and is characterized by differences in mental processes and behaviors that lead to difficulties in everyday settings or situations, including at home, school, work or even with friends.

Now, as far as prevalence, ADHD is one of the most common disorders of childhood affecting anywhere between 5% to 7% of children worldwide, and about 10% of children within the US. Now, parents may encounter variations in prevalence rates, depending on which sources they reference. And unfortunately, exact prevalence rates are just sometimes hard to pinpoint and can vary widely across states and countries due to differences and diagnostic methods and practice guidelines as well as access to specialized healthcare services.

Prakash Chandran: So one of the things that you mentioned is that ADHD manifests in childhood. What exactly do symptoms of ADHD present in children?

Dr Angela Canas: Yeah. So parents may first observe concerning behaviors such as excessive motor activity, problems delaying gratification, difficulty completing daily tasks and routines between toddlerhood and preschool. But it's often difficult to distinguish atypical symptoms from highly variable behaviors that are normal prior to four years of age. ADHD becomes more identifiable during the elementary school years when problems with attention and self-regulation become more pervasive and problematic. And it is during this period of time that ADHD is most frequently diagnosed.

I also want to point out that the age of symptom onset is an important component in the diagnosis of ADHD because current criteria for this condition requires that several symptoms be present prior to 12 years of age. So when ADHD-type symptoms first appear after that time point, they're most often associated with other mental health disorders, such as anxiety or substance use.

Prakash Chandran: So ADHD sounds very nuanced based on what you were just saying. Are there different types of ADHD that people should know about?

Dr Angela Canas: Yes. So there are three different ways in which ADHD can present itself, depending on which symptoms a child is exhibiting most frequently. So the predominantly inattentive presentation is used to describe a child who has difficulty focusing, filtering distractors, sustaining attention, attending to details or staying organized. The predominantly hyperactive impulsive presentation is used to describe a child who has difficulty with things like sitting still, waiting their turn, regulating their motor activity and quietly engaging in activities. So a child with this presentation might fidget or talk excessively. They might interrupt others or run around constantly.

The third presentation is the combined presentation and, as indicated by its name, this one is used to describe a who presents with sufficient symptoms from both the inattentive and the hyperactive impulsive presentations. I'd also like to add that it's not uncommon for children who present primarily with issues related to inattention to also exhibit some problems with behavior regulation, even if they do not meet criteria for the combined presentation.

The presentation of symptoms can also change over time. And so while a child may initially meet criteria for the predominantly hyperactive impulsive presentation, they may later meet criteria for the combined presentation. So I have personally found this to be particularly true for kids diagnosed at an early age when attention issues are not as prominent.

Prakash Chandran: Okay. So you mentioned some of the different presentations there. So it leads me to ask the question, if a parent is witnessing some of those presentations or signs in their child, what should they do?

Dr Angela Canas: That's a really great question. So a lot of parents are inclined to reach out to their child's teacher for guidance. You know, teachers are often the first to detect signs of ADHD and to communicate concerns. They have experience working with many children and managing an array of behaviors. And so they tend to have larger comparison sample than most parents. However Most teachers are not formally trained in the diagnosis of ADHD. So while teachers are a great source of information, parents should discuss their concerns with their child's medical provider. A primary care provider, such as a pediatrician, may want to conduct a medical exam, including things like vision and hearing testing to rule out other possible reasons for the behaviors. Also, as you mentioned, it is nuanced, and it can be particularly helpful to see a provider with specialized training in the diagnosis of ADHD. So, many pediatricians often refer children suspected of presenting with this condition to a neuropsychologist or psychiatrist for further evaluation.

Prakash Chandran: Okay, that makes a lot of sense. So can you talk to us a little bit about how ADHD is actually diagnosed?

Dr Angela Canas: Yes. So basically, the diagnosis is based on the presence of a number of symptoms, again that have persisted over a six-month period and they really have to be present in at least two or more settings, such as the home and at school. The determination process itself is pretty multifaceted and involves the collection and integration of information and data from multiple sources. So a provider trained in the assessment of ADHD, such as a neuropsychologist, would typically want to obtain a thorough history of the child as well as information about the frequency of the behaviors, which can be accomplished through parent and teacher questionnaires or rating scales.

There are also objective measures of attention and impulsivity that can be used to obtain additional information regarding the likelihood that a child presents with ADHD. So these measures allow for a comparison between the child and a normative sample, thus providing some sense for the developmental normalcy or appropriateness of that child's behavior. So all of these data in combination with the provider's own observation of the child, as well as additional cognitive testing can really help to ensure that other conditions such as anxiety, depression, and learning disabilities, which can share similar features, are considered or ruled out, and that ADHD is in fact a source of the difficulties.

Prakash Chandran: So Dr. Canas, tell me, is ADHD actually treatable? And if so, how is it treated?

Dr Angela Canas: Absolutely. ADHD treatment usually encompasses a combination of medication management and therapeutic intervention, the literature suggests that medication alone may be most effective in treating core symptoms, although a combined approach is best for addressing all of the difficulties that children with ADHD may experience.

This differs for preschool-aged children or children under six years of age. A large follow-up study on children within this age group actually revealed improvements in core symptoms with medication, but the effect size or the strength of the relationship was smaller and adverse side effects were more common. So for preschool-aged children, behavioral intervention with a parent training component is the recommended first-line approach. As for medication management, psychostimulants, are first-line treatments for ADHD. These medications have the largest effects and greatest frequency of response. There are also some non-stimulant medication options, but their effects tend to be smaller. And in my experience, these are typically tried in children who cannot tolerate stimulant side effects or who have comorbid mood or behavioral problems, or as an additive for children with more severe ADHD symptoms.

In terms of behavior therapy, parent training focuses on cultivating positive and adaptive behaviors and reducing some of those unwanted or problematic ones by really training primary caregivers and contingency management strategies, things that target cues, consequences and reward systems.

Now, as children get older, they can begin working more one-on-one with their therapists to develop effective strategies for managing their own behaviors and strengthening their executive functions. Now, executive functions are a set of cognitive processes that are needed to select, monitor and accomplish tasks and include things like task initiation, organization, and emotion regulation. Most children with ADHD also exhibit difficulties in some aspects of executive functioning. And because executive functioning becomes increasingly important to academic and daily success, targeting these skills in therapy can be quite valuable.

Lastly, I'll mention that social skills training, especially in combination with other types of behavioral interventions, can also be quite valuable for children who have problems related to peer relations and social problem solving. Now, outside the home children whose symptoms affect their functioning, you know, at school can also qualify for educational supports, including section 504 accommodations or special education services, and really determining the best educational programming for a child will largely depend on the extent of the symptoms, the level of support they need and the presence of any comorbid conditions. So some children will benefit from accommodations to their environment, such as preferential seating, while others may require academic intervention or even modifications to their curriculum. And in many cases, behavioral classroom interventions will need to be implemented to reward on task and other positive behaviors.

Prakash Chandran: It's really great to hear about all of the different treatment options and also all of the different studies that are being done around ADHD treatment. But from a practical standpoint, are you able to share how parents might support their children with ADHD?

Dr Angela Canas: Sure. Well, in addition to initiating recommended medical treatment and educational services, there are lots of things that parents can do at home to support their children. Now, these things are typically helpful for children in general, but they're particularly relevant to children with ADHD because they can help promote self-esteem and organization and decrease inattention and behavioral dysregulation.

So, my first recommendation is to establish structure and routines. Most children with ADHD do best when they know what to expect and what is expected of them. Using checklists and reward charts can be great tools for increasing motivation and task completion while also reinforcing routines. Focusing on your child's strengths, rewarding positive behavior and delivering expectations and consequences in a firm, but warm and respectful manner, can also go a long way in terms of fostering self-esteem and promoting healthy relationship patterns.

Listen, ADHD symptoms can certainly be a challenge. So it's okay to take a breather or a few minutes to decompress before addressing your child. Also, rewards do not always have to come in the form of tangibles. So words of encouragement, quality time with a parent, extra time on a preferred task. These are all great ways to reinforce and reward without breaking the bank. Improving decision-making and reducing overstimulation are also important. And one of the best ways to accomplish this is by limiting choices. So instead of three breakfast options, give two. Also, if something is important, take the time to ensure that your child is attending by getting down to their level, use clear and concise language and ensure eye contact. Shouting directions across the house or from one room to another is likely to result in a lack of follow through.

Promote a healthy lifestyle through nutritious food options, physical activity, and good sleep habits. While sugar doesn't cause ADHD, it can lead to bursts of energy that can amplify your child's symptoms. Free play is also a great way to redirect and release that excess energy. Structured activities are good for promoting self-discipline while team sports can help foster peer relationships.

Lastly, sleep can affect concentration, learning, and mood. So setting boundaries around screen time and ensuring that your child gets sufficient sleep are key. I'll point out that unlike adults, most children require more than eight hours of sleep. In fact, children between three to five years of age require 10 to 13 hours while children who are between six and 12 years of age require between nine to 12 hours. Some teenagers do well with eight hours, while others need 10.

Prakash Chandran: Yeah, those are some really helpful tips. Are there any final pieces of advice that you can offer to parents whose children have ADHD or are showing symptoms?

Dr Angela Canas: Well, my number one recommendation is just to seek help. You know, even if your child does not meet criteria for ADHD, consulting with experts can lead to helpful resources, strategies that can be implemented to help alleviate problematic behaviors. Addressing issues later, can also have long term consequences on your child's self-esteem social relationships and academic achievement.

Along the same lines, I recommend that parents ask all the questions when they consult with experts. As with many other things, knowledge truly is power when it comes to making medical and educational decisions and advocating for your child.

I'll end with saying that it is also absolutely normal to have questions or concerns about medication. Although the field of pharmacology has come a pretty long way in terms of treatment options for ADHD, parents need to feel comfortable and well-informed about all options for helping their child.

Prakash Chandran: Well, Dr. Canas, I think that is the perfect place to end. Thank you so much for your time today.

Dr Angela Canas: Absolutely. Thanks for having me.

Prakash Chandran: That was Dr. Angela Canas, a neuropsychologist at Children's Health and Assistant Professor at UT Southwestern. Thank you for listening to Children's Health Checkup. You can head to childrens.com for more information. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. My name's Prakash Chandran. Thanks so much for listening and be well.