Dr. Chad Perlyn (Host): Welcome to the For Peds Sake podcast, a Nicklaus Children's Hospital podcast that is all about putting children at the heart of healthcare. I'm your host, Dr. Chad Perlyn, a pediatric plastic surgeon here at Nicklaus Children's and also a father of two boys. And I am so excited to welcome you to today's episode.

Today, we have a very special guest with us. Joining me is Dr. Agenia Delouche, a child and adolescent psychologist. And today, we're diving into an important topic that affects so many families, attention deficit hyperactivity disorder, or ADHD for short. Now, ADHD is a condition that can significantly impact a child's daily life, and we'll be covering signs to look out for, common misconceptions, and how parents and caregivers can best support their children. And before we start, I wanted to extend a warm welcome to Dr. Delouche. Doctor, thank you for joining us today.

Dr. Agenia Delouche: Thank you so much for having me. I'm excited to be here.

Host: It's great you're here and this is such an important topic as so many kids are affected by this. Let's start with the basics. What exactly is ADHD and how is it different from ADD?

Dr. Agenia Delouche: So, that's a great question. Because oftentimes I'll have parents come to me and they'll say, "You know, I had a previous diagnosis of ADD or attention deficit disorder" or they say, "You know, I think my child might have ADD." And right now, ADD is actually an older term, so we now categorize the disorder as ADHD, or attention deficit hyperactivity disorder. There are three types, so you have ADHD inattentive presentation, ADHD hyperactive impulsive presentation, and then ADHD combined. So, there are three different subtypes of ADHD, so ADD is now an outdated term.

Host: And I think the important thing for parents to understand for that is you do not have to have hyperactivity to be diagnosed with this condition. Is that right? Even though it's in the name today and the nomenclature is what we use, being hyperactive is not necessarily a need to be able to have this diagnosis. Is that correct for our families to understand?

Dr. Agenia Delouche: Absolutely. So, that's just one set of symptoms. There's actually, again, those three subtypes. So, you might have a child who presents predominantly as inattentive. They have that difficulty focusing, they can't sustain their attention, and they're not really hyperactive at all. And they would still be categorized potentially as having ADHD, but just with that inattentive presentation.

Host: Got it. What are some of the signs for parents to look out for should they suspect their child might have ADHD?

Dr. Agenia Delouche: Sure. So, I'll talk about the three different presentations and the symptoms within each one. So, common signs of the ADHD inattentive presentation might include things like having difficulty sustaining their attention in tasks or play, not only at home, but also at school, not following through on instructions, often losing things necessary for a task to even be completed. Often, these children and teens are very easily distracted or forgetful in daily activities. So, this could be forgetfulness not only for homework completion. "I don't know where my homework is," or even things at home, right? So, a lot of times parents will say, "I told them to do these three things and they didn't even get one done," right? So, you see that forgetfulness at home as well. Common signs of ADHD hyperactive impulsive include things like fidgeting, being super restless, having difficulty remaining seated, being an excessive talker. So, sometimes I like to say they're like an energizer bunny. It's as if they're running on a motor, if you will, or they're running or climbing inappropriately. So, those are the things that are more of that hyperactive and impulsive presentation. And then, you have the combined type, right? So, this would consider symptoms in both of these presentations. Not only the inattention, but also they may have those hyperactive, impulsive symptoms as well.

In terms of all of these symptoms, you'd want to see them for at least six months across settings. So, we would want to see functional impairments, for example, at home and at school. And you want to make sure that when you're looking at these symptoms, how much is it impacting their functioning in terms of how appropriate it is for them to be behaviorally this way, developmentally, right? So, you want to look at all of these factors and also their age. Typically, these symptoms present before the age of 12.

Host: I think it's wonderful how you describe the different symptoms to look for in the different groups. I want to talk about some of the misconceptions around this, and I want to focus on a second on Legos. So, why do I bring up Legos? I once heard mother describe something fascinating to me about watching her child with Legos. And she described that when she would buy a new Lego set, an age-appropriate Lego set for the child, the child would play with the Legos and build Legos for an hour, very focused, very detail-oriented. And the mother was saying, "But how could my child have ADHD? Because he focuses so well, he's so attentive to the Legos." And the question that came up was, "But is he following the instructions and actually building the set as it was meant to be built? Or is he essentially free play with the Legos and building to his own decide, i. e., not following the detailed instructions?" And that was sort of an eye-opener to me to think a little bit differently about this, that notion of the ability to follow a set of instructions for a period of time in a multi-step, organized fashion versus being simply focused on a task or a love for something that this child had, which was building Legos. So, talk to us about this and some of these common misconceptions around ADHD.

Dr. Agenia Delouche: That's such a great anecdote and story. I get that so many times too. Parents will be like, "Well, when they're interested, I see them paying attention. I see them focusing." But there's so many layers to it. And a lot of the misconceptions are really important to debunk. So, one major misconception is that children with ADHD are just not trying hard. They're lazy. They're deliberately being disobedient or defiant. And in reality, these children are often really wanting to do well. You know, I have a lot of patients who will tell me that. They'll say, "I really would love to do well in this class, but I just can't focus. I don't know how to keep myself organized." So, they want to do well, but they're really struggling due to their neurological differences.

Another big misconception is that ADHD is caused by poor parenting. So, that's another thing that, you know, I work with a lot of families and sometimes parents will put that onus on them. Like, "Maybe it's something I did. Maybe it's me. Maybe I'm the reason that these symptoms are occurring." This is not true. It's a very complex condition and it's influenced by genetic and environmental factors. So, we know that ADHD is heritable. So oftentimes, when I'm talking to families, I like to ask them what it was like for them when they were kids and teens, and if they had some of these similar struggles. But at the same time, your environment can influence how these symptoms present, right? So, we know that kids and teens with ADHD, they really strive to do well in structured settings, right? So if there's an environmental factor such as a setting that's unstructured, you might see those symptoms present even more.

Host: Yeah. I think that's so important. And I'm glad you brought up the piece about the parenting as well, because one of the things that we know with this condition is if it's not understood the relationship between the parent and the child, that there can be a, let's call it a cycle of frustration, where perhaps the child isn't performing well academically, and the parents get frustrated and put pressure on the child, but that pressure won't solve the neurologic issue, the neurologic difference, and then the child may at times become frustrated themselves and less motivated and so forth. So, understanding this for parents and being able to step outside of that cycle of frustration and get help both for the parents and for the child is so important to be able to understand how to do some of the things you are talking about, like providing structured support. So, tell us, are there any other specific strategies or tools that can help children with ADHD manage their symptoms more effectively?

Dr. Agenia Delouche: Right. So, there are some large scale things and then some more specific things. So, I'll touch on both. Positive support is really important overall. So, being really understanding and patient with your child is going to be key. It's really important for parents to also educate themselves about ADHD, kind of, you know, this conversation is a great opportunity to do that and to learn more. It's very complex, right? A lot of times, we see it and we think it's very simple, but it's actually very complex. So, educating themselves more about ADHD and how it affects their child is really important. Things like establishing a structured routine can help. And we know again that they thrive on consistency, these kids and teens. Also, breaking tasks into more smaller, manageable steps and asking children to repeat back instructions when they're told, right? So, you're providing those clear and concise instructions, and you're asking, "Okay, I just told you what to do. Can you repeat that back to me?" Just so that you can check and make sure that they heard you and that it provides them another opportunity to remember what it is that was said.

I always tell parents, never, never, never underestimate the power of positive praise, right? Positive reinforcement is so, so crucial, and praising efforts and celebrating small achievements to build confidence is really, really key, right? So, those are kind of those larger things that you want to do in terms of your affect and how you support your child, but there's also more specific strategies, using tools like visual schedules, timers, and organizational aids can be also very helpful. I was actually just thinking about this and providing this advice to a parent. Using timers is awesome. I use it all the time in my therapy sessions. I'll say, "All right. We're going to finish our activity in two more minutes." And I'll set the timer and I show them and I notice that they do so much better transitioning to the next aspect of our session when I do that. So really, providing these organizational tools can be key. And we know that these symptoms can also manifest in terms of difficulty with peers and managing social relationships. So, any sort of behavioral therapy or social skills training can also be very beneficial.

Host: That's great. And thank you. And one of the things we love to do on this podcast is give real-life suggestions and solutions where we can. I'd love to hear your thoughts on this. A parent once brought up the issue of the timer and they were using their phone as a timer. And of course, every time the phone went off and dinged, that alone was distracting, then the child would reach for the phone to turn off the alarm and be tempted to play on the phone and so forth. So, we tend to lean right towards apps, right? Is there an app for this or is there a timer on the phone? But the parent suggested the good old fashioned-- you can buy them on Amazon for a few bucks-- the little sand timers, right? Ten, 20, 30 minutes, they're quiet. There's no distraction with the phone. And I think that that was a brilliant suggestion by one of our parents. And I'd love to hear your thoughts on that.

Dr. Agenia Delouche: Yeah. And that is a great suggestion. Oftentimes, if I'm using a timer, whether it's a sand timer, a lot of times those come in games, which is great or even on my phone or on my watch, trying to keep it out of their reach. Because again, we don't want to encourage distractibility, but also saying things like, "One minute left," "Thirty seconds left." So again, you're constantly providing those prompts. The sand timer is also really great because it provides a visual aid, but also doesn't provides so much distractibility for them. So, I actually think that's a great suggestion.

Host: Yeah, terrific. I want to take a step back, because I love how we jumped right into providing resources for families and talking to parents about how to interact their children. But let's go back and talk for a minute about what should parents consider when deciding to pursue a diagnosis and treatment. So, maybe there's someone listening and some of the symptoms resonate with them. They may see some of these things in their child. So, how do they know if their child actually has ADHD? And how should they know, who should they go to to pursue a diagnosis and start a treatment protocol?

Dr. Agenia Delouche: Absolutely. And that's a great question, right? Because I can be distracted. I have difficulty sustaining my attention too, right? So, sometimes there's this question of how do I know that it's a full blown disorder of ADHD, or it's just day to day symptoms that, you know, everyone might experience a little bit. So, if you notice that your child's inattention or their hyperactivity and impulsivity is significantly impacting their daily living activities, so they're having a really hard time just getting ready for the school day. You notice that it takes a lot longer than usual. And, again, debunking that myth, it's not that they're just being lazy, but they're really having a hard time. You notice their academic performance maybe isn't so great. They're having poor grades. The teacher is mentioning that they're having a really hard time staying focused in class or your child is coming back and saying, "I don't even remember what I learned today in school," right? So, you want to look at those impairments. You want to look also at the social interactions. Are they having a hard time maintaining friendships and maybe being impulsive in friendships as well? These are all factors.

We always want to look at functional impairments. That means in the areas that are most important to a child's life, are these symptoms really impacting them to the point where they can't get the things done that are really going to help them be successful? So if you notice these things, it's really worth consulting a healthcare professional of some sort, whether that's your primary care physician, so your pediatrician or a psychologist. You really want to make sure that you're asking these questions early and really assessing early because early diagnosis and intervention is really key. It really can make a huge difference in providing the support and tools needed. You also want to make sure that treatment plans are really tailored to the individual child's needs, right? So, this is not just a one-size-fits-all model in terms of what can be done to help, but you really want to consider potentially a combination of behavioral strategies, educational support, and possibly medication. So, what we call multimodal treatment.

Host: I think you're right on in the advice about starting with your pediatrician, as the best starting point. I think in today's environment, all of the pediatricians understand ADHD well and are an excellent resource as the first line approach, if you will. And then, once beyond that, with the kaleidoscope of Medicine today with developmental pediatricians and neurologists, psychiatrists for prescribing medicine. Is there one specialty today that does more ADHD when it goes above the pediatrician or is this something that really is done together as a team with the pediatrician and the appropriate specialists from perhaps different types of backgrounds?

Dr. Agenia Delouche: Yeah. I would say it's more the latter. I mean, even right now, I have patients with whom I'm consulting with their pediatrician, their neurologist, and their psychiatrist, right? So, oftentimes, we're working in a team and there's collaboration, because you have multiple professionals who are trained to be able to treat the symptoms of ADHD and also provide medication. So whether it's a psychiatrist, a neurologist, or your pediatrician, they're all great members of a team to help with managing these symptoms.

Host: Amazing. And of course, the amazing work that our psychologists do is such a key component of this. And I know we have an incredible program. And the support you provide so many children and so many families is just wonderful for our community. Before we wrap up, is there a key message that you'd like to leave our, our parents and caregivers of children with ADHD?

Dr. Agenia Delouche: Sure. So, my key message would definitely be to remember that children with ADHD have incredible and immense potential. I get so many parents and caregivers who come concerned and they say, you know, "I see all these symptoms and I'm nervous. What is their future going to be like? Are they going to be successful? How will they be in school?" And I always let them know that they have so much potential. With the right support and understanding, these individuals can really thrive, right? You know, you focus on their strengths, you provide consistent and compassionate support. Again, not underestimating that power of the positive praise that can be provided to your child is really key. And then, seeking that professional guidance when needed. All of those things together, I think, I think that would be my key message and my takeaway. So, your advocacy and your belief in your child can really make a difference in their success.

Host: I love it. And there is no advocate for a child like a parent. And I think you said that so eloquently. Thank you so much, doctor, for sharing your expertise with us today. It's been a pleasure having you on and the information you've passed on to our families, I think, is going to be so critical for so many families.

Dr. Agenia Delouche: Awesome. Thank you so much for having me.

Host: Of course. That concludes this episode of the For Peds Sake podcast. We hope you've learned some helpful tips from Dr. Delouche. Make sure to stay tuned for our next episode. And in the meantime, be sure to follow us on all social media channels. You can find Nicklaus Children's Hospital on Instagram, Facebook, TikTok, and YouTube. See you next time!