Melanie Cole, MS (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. I'm Melanie Cole, and today we are demystifying and destigmatizing ADHD. Joining me is Dr. Alex Tan. He's a Board Certified Clinical Neuropsychologist at Children's Hospital of Orange County, and he's an Adjunct Assistant Professor at the University of California, Irvine with a distinguished expertise in the assessment of neurobehavioral and neurodevelopmental disorders in children and adolescents. Dr. Tan, thank you so much for being with us today. People hear these terms, ADD, ADHD. They hear these things, but they don't really know what that means. I'd like you to tell us what ADHD really is and how is it different than Attention Deficit Disorder or ADD.

Alexander (Alex) Tan, Ph.D., ABPP-CN: Yeah. Well, thank you for so much for having me. I think the ADD and ADHD is, actually kind of a side effect of how they've updated the labels that we use to characterize these kinds of deficits. But at its core, I think ADHD is the term that's now used to describe a spectrum of symptoms that can include attention deficit as well as hyperactivity. So we're talking about difficulties with attention with hyperactivity in the context of a slower rate of maturation in what we call the executive control center of the brain. And sometimes we hear the term executive functioning to describe that. So that's, you know, primarily associated with the frontal lobes of the brain.

And so in younger ages that might look like how we control our attention, how we control our behavioral activity. So, can we sustain focus on tasks? Can we do things without getting easily distracted? Can we regulate our impulses? Right? Can we inhibit our inappropriate behaviors?

And then sometimes that can look like regulation of emotional functioning as well. So, for some kiddos I say, or to some families that sometimes, you know, or do they have a more difficult time tolerating frustration, right? Are they a little bit quicker to get upset? Sometimes that's a sign as well of that kind of executive control center.

And then once they get older, it looks like things like maybe poor planning, poor organization, procrastination, maybe carelessness or forgetfulness. And, a couple I guess myths that I always like to dispel. One is ADHD is not related to bad parenting or lazy behavior. So this is something that's related to brain development and as we mentioned, most commonly kind of the slower maturation in the frontal lobes of the brain as opposed to, something that parents are doing wrong or something that the child is doing wrong. All the time, you know, I hear sometimes children that get diagnosed with ADHD later.

Before they get diagnosed, it's those comments about, why aren't you trying harder? Why can't you pay more attention? And it gets kind of characterized as this kind of laziness or, bad behavior, when it's really something that's happening in the brain.

Another myth I want to dispel is that I hear parents say all the time, well, how can my child have an attention deficit? They actually can pay attention to, for example, they like to read, they can pay attention to reading for four or five, six hours and there's no problem.

And so, I think, the term attention deficit hyperactivity disorder, you know, ADHD, sometimes is a little bit of a misnomer because it's not always that you can't pay attention, it's that you have a hard time regulating or controlling that attention. And so, we also have in the brain the basal ganglia and associated pathways that have to do with kind of the neurotransmitters, like dopamine response. And so those pathways in the brain sometimes are a little bit under activated or sometimes are a little overactivated. So sometimes we have children, that are focusing, an extraordinary amount of time on something that they prefer.

And so we say, that's actually kind of a less known sign that this kind of control of attention, this hyper focus, might be a sign of ADHD as well. And of course the opposite is true. Children with ADHD really difficult time, sustaining their attention on non-preferred tasks, right?

So, think of an example, no one likes doing a major cleaning out the closet, kind of overhaul, right? That's kind of a non-preferred activity, I think, for most people. But for children, maybe just cleaning their room, or, doing the dishes or taking out the trash. That might be just as, insurmountable or monumental of a task as something that most of us find really insurmountable, like cleaning out the whole house. So, those are just some, ways that we describe what ADHD is.

Host: Thank you for that comprehensive answer. And I mean, I guess the big question Doctor, that everybody has is, do we know what causes these things? Are we seeing more of these spectrum disorders or are we able to diagnose them better now?

Alexander (Alex) Tan, Ph.D., ABPP-CN: That's actually more loaded of a question than one might think. There are some medical conditions that we diagnose based on cause, right? So I'm thinking, for example, an epilepsy disorder we diagnose based on the presence of seizures that are happening, or cancer, we might diagnose based on an identified tumor, right? So those are kind of diagnosed based on cause. There are some medical diagnoses like ADHD that we diagnose based on criteria, and for ADHD especially, you know, we might see symptoms at home, we might see symptoms in social context, but really you're going to see the ADHD symptoms the most prominently in a learning environment. So when the COVID pandemic happened, children were suddenly all at school, but at home, right? And so they're with their parents so parents are just kind of observing them in a learning environment much more closely than ever before. And so suddenly it's like we had this huge influx of parents, being concerned like why is there so much functional impact here in the learning environment? Is this like an ADHD that we never saw before or what's going on? So I would say that a lot of times, ADHD is being recognized more because we might have experts around like teachers or, those that are observing the child that really have this understanding of what ADHD might look like. But we also sometimes, miss the diagnoses if there aren't those around them, that are kind of really seeing how much they're being impacted in that learning environment.

But because they can be diagnosed based on criteria, its almost like the causes are less important. And the reason why I say that, not that they're not important, but that when we diagnose it, it's because there could be a lot of different reasons. We see associations with all kinds of things. With certain kinds of genetic factors, with certain kinds of environmental factors, maybe exposure to things like prenatal exposure to alcohol or tobacco. We have certain kinds of medical conditions that can increase risk for ADHD, for example, epilepsy or congenital heart disease, which is what I personally work with. And then like I mentioned, there's genetic factors too. There are all these different kinds of factors that together can result in the brain developing in this trajectory or in this way, that results in it having enough difficulties in a learning environment, enough severity of their symptoms, enough impact, like interfering with their learning that now we say, okay, this is truly an ADHD diagnosis.

One problem of course is that, sometimes there can be an overdiagnosis of ADHD as well, right? And so as neuropsychologists, we like to take a comprehensive approach, but, sometimes on paper, it can be a really short evaluation that some families experience that are purely checking off whether or not they have those symptoms, but not necessarily ruling out other possible explanations for that behavior, right?

So there's a lot of things that can cause children to have trouble paying attention or staying focused that don't just relate to ADHD. Some of our kiddos with learning disabilities, it's really hard to pay attention if you really have a difficult time learning certain things like math. It's going to be really difficult to focus in math class. Or some of our kiddos have a language disorder, they have delays in their ability to communicate, their ability to understand other people's language. And so, how can we pay attention if we can't even understand, what the other person, what the teacher is saying.

Some of our kiddos, it's actually these kinds of difficulties are more in the context of a global developmental delay or an intellectual disability where all of their cognitive development is actually below what we expect for their age and attention just has to be one of those components. So I always do like to take a comprehensive approach because you know, we want to make sure that this is truly an ADHD diagnosis and not necessarily something that might be related to other kinds of diagnoses or conditions which might overlap in their symptoms.

Host: So it's really such a complex issue, Dr. Tan. Let's talk about treatments, things that you can do that you can tell parents, working with the school system, working with their medical home, their pediatrician, and indeed counselors and neuropsychologists such as yourself. Tell us what are some of the treatment options out there?

I know that many parents are afraid of medications. You know, they have questions about what those medications are going to do, but I'd like you to speak sort of briefly if you can, because I know there's a lot of tools in your toolbox, but briefly if you can, about some of those tools and what you find are some of the most helpful for parents.

Alexander (Alex) Tan, Ph.D., ABPP-CN: I always like to go back to what the research shows. And so research does show that in younger children that behavioral support is the best treatment. And then, once children hit school age, you know, 6, 7, 8, that does combination of behavioral support and medication, can be most helpful.

So I'll talk about both of those. You know, the first thing I'll talk about is behavioral intervention. So in the school environment, we can actually put supports in place, to help give them the structure and the tools that they need to be successful. And so sometimes that looks like what we call a section 504 plan, which can provide accommodations in the classroom, so that children have a more successful learning environment and outcome.

We have a higher level of services called the Individualized Education Plan, IEP, that's special education services, if there's enough functional impairment to warrant additional focus and intervention. In the community, sometimes we might recommend something like behavioral intervention, behavioral therapy, you know, to really help with increasing their focus, to really help with regulating their behaviors, maybe to help with those tantrums or the poor frustration tolerance, and if the parents are open to it, sometimes parent training is a really helpful aspect, or parent coaching is a really helpful aspect of that kind of treatment.

I always tell parents, at home, there are things that you can do as well. A child with ADHD, it's just these executive functioning strategies are just not going to come as naturally to them. Right. They have to be taught. And so I actually have a family member that has kind of an executive functioning weakness.

They were born prematurely and, we see that that has also a possible impact on executive functioning long term, and she's an adult now, a very successful adult. But, she has learned over time the kinds of tools and strategies that she needs. So, she has post-it notes everywhere that she uses.

She sets timers for herself. She can't go anywhere without a planner and a calendar. Those are the kinds of things that we need to help our executive functioning when they might be an underlying weakness. And so I always tell parents, you know, those are skills that we can teach at home as well. How to kind of organize our schedule, how to organize our tasks, right? How to check over our work. Those are the kinds of strategies at home that can be helpful.

Now, I know medication is kind of an elephant in the room, just because there's so much stigma around ADHD medication.

So, the first thing that I have to say is first of all, don't let that stop you from getting an evaluation. Because we know that the earlier that we can identify these kinds of disorders, the earlier we can help them get the support they need, which results in the best outcomes.

And medication is not the only thing that's going to be recommended. And especially in younger children, it's actually not supported by the literature, to be the first line of intervention. But with that said, another thing we have to dispel is that ADHD medication, really, there's a lot of different ones.

 But I think a lot of parents are just scared of the negative side effects and, long-term side effects. And so the literature does show that we don't really see long-term side effects to ADHD medication. They typically tend to be very, fast acting in and out of our system.

And so, sometimes there's side effects that parents, find uncomfortable or children find uncomfortable, and, that just means that we might need to find one that's a better fit. But I always tell parents, if the ADHD is impacting them in the classroom so much that they can't learn, we're kind of making their educational and long-term outcomes much worse; then we have to weigh, what's more important to us, their future success or, these side effects that we can talk to psychiatrists about, we can talk to pediatrician about. I always tell families, finding the right medication is kind of like speed dating, or dating.

 There's one that's going to be a good fit and maybe you go through a few tries and, we find ones that aren't good fits. But eventually it just takes the right fit to really find something that works well for our child, has the tolerable side effects or doesn't have the side effects, that we might find uncomfortable and really makes that much of a difference in their success in the classroom and in the learning environment.

Host: Dr. Tan, you've given us a lot to think about and so much great information. As we wrap up, how does the diagnosis and treatment change for a child as they're growing up with ADHD into their teen years and their adult years? Tell us how, when you've seen families, siblings of this child, how does this all come together as they become teenagers and young adults?

Alexander (Alex) Tan, Ph.D., ABPP-CN: There's a lot of different trajectories. And so there's not necessarily a one size fits all kind of answer, and I think this is why sometimes it can be a little bit confusing for parents because different children with ADHD can look very differently. Some of them have more of those attentional deficit symptoms. Some of them have more of the hyperactivity symptoms. Some of them have more of a combination. But we typically see, again, just remembering that this is really about maturation of certain parts of the brain, and so as children get older, the brain does mature.

And so we sometimes will see a lot of times as they get older, that maybe those earlier childhood kind of hyperactive symptoms or impulsive symptoms sometimes, they just, get expressed in a different way. And similar to the attention and the focus. So, when they're younger, maybe they just have a more difficult time just paying attention or getting distracted.

But when they're older, and some executive functioning that is coming more online in the brain; we see things like, oh, more difficult time getting started on tasks. Once they start getting those projects, like, kind of a more overwhelm or difficulty breaking those things down step by step.

Sometimes it's like more about difficulty planning ahead or problem solving. So, you know, as they get older, there's more structure, but higher expectations, and more of a expectation for them to be independent. Same thing with the hyperactivity, when they're younger, maybe it just looks like, they're running around constantly or, they really kind of like to interrupt other kids or, things like that. But as they get older, we also kind of can see it be expressed in different ways. Like, a difficulty with just checking over our work. And so we're making a lot of careless mistakes. Or maybe a penchant to just make poor decisions or exercise poor judgment in the moment, because of those reward systems in our brain. So, things can look different as they get older. I will say that, just the message for families that I always want to make sure to emphasize is that the brain matures over time.

And so sometimes, we do grow out of certain symptoms that are more difficult and, there's a lot of adults out there with ADHD that live very successful and productive lives. And sometimes, the ADHD has its strengths too. You know, that ability to hyper focus, that ability to really find what they are passionate about and to spend the time to really focus on that can also help them be very successful, as they go to college, as they develop careers. So, we find the tools and the strategies that that work for us. So, over time it can look very different, but I always want to say it doesn't always have to be a negative picture. There's a lot of people out there that live very successful and productive lives with ADHD.

Host: Thank you so much, Dr. Tan, for joining us and sharing your incredible expertise and take on ADHD for parents. There's so many questions and you've gotten through so many of them today, so thank you again for joining us and for more mental health tips and information, please visit choc.org/programservices/mentalhealth/ADHD.

 aAnd you can get so much great information there. Thank you so much for listening to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. Together we can keep kids happy and healthy. Please also remember to subscribe, rate, and review Long Live Childhood on Apple Podcast, Spotify, iHeart and Pandora.

I'm Melanie Cole. Thanks so much for joining us today.