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Helen Dandurand (Host): Welcome back to the Well Within Reach podcast, brought to you by Riverside Healthcare. I'm your host, Helen Dandurand. And joining me today is Dr. Federico Herrera, pediatrician at Riverside Healthcare, who's here to talk about treating ADHD in children. Thank you so much for being here today.

Dr. Federico Herrera: Oh, it's absolutely my pleasure.

Host: Good. Good. So, could you start by telling us a little about yourself in case someone hasn't heard of you or listened to one of your podcasts? You've already done a few with us.

Dr. Federico Herrera: Yes, I did. My name is Federico Herrera. I'm originally from Argentina. My background, I'm a pediatrician. I have not a particular interest, but mental health is, by far, one of the things I've seen the most, and I have personal interest since it hits close to home. I have three boys, two of my boys have autism, and the middle one has autism with ADHD, and the oldest one has ADD. So, I'm very familiar with the both sides, the professional and the personal aspect of ADHD.

Host: Well, that makes you the perfect person to kind of give us the information that we need and that parents need. So, can you start by telling us what is ADHD, and how do you know when a child's behavior may be more than just a typical, like, childhood energy kind of thing?

Dr. Federico Herrera: Well, ADHD, kind of the condition defines the way the patient presents. ADHD stands for attention deficit hyperactivity disorder, which means there's two components, the hyperactive component and the attention deficit component, which they can coexist. That's when we come to diagnose. We have the naming or diagnosing of predominantly hyperactive, predominantly attention deficit, or combined type. And that's a very interesting question, and the best answer I can give you, of course, usually the most common presentation is sort of coming from parents' concerns when they notice that their kid is nonstop. It's like the Energizer bunny on steroids. That's kind of like the fun part where they usually express it or the how I see it. But then, it's a hard part to diagnose ADHD on a younger kid. And as you were saying before, when it comes to, like, normal behavior of a toddler.

So initially, when they're preschool, that's a kind of like a gray area, which we need to ask particular questions, kind of dig in a little bit more, how the dynamics in the household maybe work when it comes to discipline, tasks, et cetera. It's a little bit easier, and I'm doing, like, quotes with my fingers here, when they're in school already, because technically speaking, ADHD is a condition that it will not only manifest in one single setting. It will manifest in more than one setting. So, it's usually problems at home and problems in school.

Host: Great. Could you tell us, this wasn't even one of the questions I had thought of before, but now that you're talking about it, it came to my mind, kind of girls versus boys. is there a difference in how females typically present with ADHD as children, or is it all the same?

Dr. Federico Herrera: So to start with, statistically speaking, there's a predominance towards males more than females. And usually, females present more, which now people individualize within the ADHD component to ADD, which is purely attention deficit with no hyperactivity. But that does not mean that they will not present or have patients with ADHD combined and hyperactive that are female as well.

Host: So once a child is diagnosed with ADHD, what are kind of the different treatment options that you have available?

Dr. Federico Herrera: So, there's medicine versus no medicine. The non-medicine, which is always addressed and it's extremely important to address, and as long as parents and even patient, depending on what age we're talking about, can be engaged, is more on the behavioral therapy and counseling. Both actually coexist. It can be either or or both. And then, on the medicine side, of course, medications, we have different types of medications that I guess we'll approach them briefly in the next few questions.

Host: So many parents, they're kind of hesitant on the ADHD medications. Are there some big myths or misconceptions that you hear and that you want families to know, like, you know, this isn't true?

Dr. Federico Herrera: The biggest myth and the biggest two fears. One is a myth, and the other one is not a myth. It depends on the prior experiences of parents per se or, like, friends or family members.

The biggest myth by far is that ADHD medications are addictive, and no, they're not. There's different actually plans that we can outline to the patient and to the parents to, like, tailor the treatment to each patient. Of course, there's a core guideline that we have to follow and the ones we usually do, but that's part of the medicine the way I see it. Yes, medicine is science-based, but it's still an art. So, every patient is an individual, completely different from the next one, although they may sound similar, may look similar, when we end up treating them, addressing the questions and everything, what is the most concerns.

So, treatment-wise, as I was saying before, it can be tailored. And then, when we come to the fear that parents may have is that when they come and tell me the big word that I actually address it and when I say, you see the parents nodding is zombie. Parents are afraid, scared that their kid is going to turn to a zombie.

And usually, what I address is that an appropriate treatment is to address the problem without changing the core personality of who the kid is. And also, just to address as well, usually the main concern when we treat patients, at the end of the day 90% or more, but there's a little 10% that doesn't qualify into that group, which is school. So as long as the patient does well in school, then the medication, usually the amount of time it lasts is through the school hours. So usually, by the time the kid goes back home, medication wears off and kid is going back to their selves, which is also important to address why when I started treating my patients, I would always address to the parents, although we may tailor the plan to do, for example, Monday through Fridays when they go to school, off on vacation, holidays, et cetera, I tell them like the first month, maybe two months, I do want them to do it every single day because I want parents to be knowledgeable or seeing how their kid is actually with medications.

Host: Yeah. That's all really good info breaking down in there. I really liked what you said a little while back about medicine being a science and also an art to trying to figure out exactly what is right and being there, like with patients.

So, we're going to take a quick break really quick to talk about primary care at Riverside, and then we'll be back.

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And we are back. Okay. So, you touched on this slightly, but besides medication, what therapies or just strategies have you seen make a big difference for children with ADHD?

Dr. Federico Herrera: So therapies, so just recapping for what I said before, counseling and behavior therapy, they both work really good. Not just for the patient itself, because part of the therapy is not just sending the patient to the therapy, but also interacting of the therapist with the parents to also, like, giving some tips on what to do at home to help them.

And that's where the home strategies may be applied and help towards improving the patient's behavior inside the household as well. Try having a structure at home. Not to be, like super rigid. There can be some sort of flexibility, but having a structure, inside the household with a calendar, an itinerary. A lot of parents use those big charts with stars, like, to put some sort of goal for patients to achieve. And then, of course, the reward system, it works in a short term. So, it's just, like, to show them and making them see that good behaviors have a positive impact on things that may happen to them.

But again, more so to slowly get them used to achieve a goal by following steps. That is the best way to put it. And then also now we're surrounded with technology with AI as well, which is embedded in all the personal assistants we have right now. So, sometimes using technology in that way may help, like sending reminders, and I use them a lot, and saying, "Hey, remind me of this." And then, having that possibility of having something reminding you at times that, "Hey, you need to do this." Sending timers to achieve a goal, for example, when you're doing your homework. Sometimes it's not just, okay, you do your homework, especially a patient with ADHD, ADHD has nothing to do with the cognition, how smart a kid is. So, a kid may be able to achieve a goal of performing or completing the homework, but the problem sometimes is how long it may take him to achieve it. So, putting timers may actually reminding them that, okay, this is the five-minute mark, 10-minute mark. So, it's a constant reminder to be able to get to that goal and not get lost in track.

Host: Yeah. So, it sounds like there's the medication, there are therapies, could be both, and then you get strategies from those therapies, and that's how parents can play a role, in helping a child, is to figure out what might work best for them with those strategies and using them at home to make those things happen. Do schools also play a role in helping children with ADHD succeed? And is there a way, like, parents and schools can kind of work together?

Dr. Federico Herrera: Yeah, absolutely. So when it comes to schools, there's the administrative help that they may get, and then there's the teacher side, which thankfully what I hear from my patients around the area, that they always get a good support and help for the vast majority of the time, which is teachers, when they are aware of the situation, they may be adjusting despite of what I'm going to talk later on the admin side, to make that patient more successful in school.

For example, instead of putting him all the way in the back, putting closer to the teacher, and be able to, like, not get easily distracted, maybe away from the window, the same thing. So, teachers have a major role in understanding that the patient has this condition to be able to assist in the care and, again, make the patient successful in school.

Now, the administrative side, there's what is called an IEP, the individualized educational plan, where it's a deficit in some subjects, academically speaking. They may have further assistance in those subjects where they may need, again, help. But then there's the Plan 504. Plan 504 is a federal educational plan. It's for school to be ready and capable of interacting and helping that patient with that chronic condition. It doesn't just apply for ADHD. It applies for any medical condition, not just mental health, but also, for example, patients with asthma, sickle cell, et cetera. And having that in place may actually allow the patient to, for example, in like in my oldest kid, Fede. And by approaching the ADD problem, it may be adjusted that if he needs to, for example, sit for a test, he may be, allotted a little more time to be able to complete that test.

It's not having preference, with the patient with, again, ADHD, although medication may help, it doesn't, like, wipe away the problem. It may still have some lingering. And again, I'm kind of like overstep on myself saying things. But then when approaching the treatment, sometimes we need to get to that treatment that is just enough for the patient not to be completely distracted, but not enough maybe to completely, as I was just saying, removing the problem because I don't want to go to that higher dose where the patient may cross that zombie line that the parents may be afraid of.

So, having that Plan 504 and IEP in place may help the patient be successful without having to increase, for example, a medication, which again, I think the minimum dose that is effective and is making that patient successful is what we need to achieve.

Host: Yeah. So, it sounds like that your pediatrician and your parents and the school, everybody needs to work together in order to kind of get the best plan and to be communicating so that you can reach those optimal kind of levels there, right?

Dr. Federico Herrera: It takes a village, yeah.

Host: Yeah. Absolutely. So, can children outgrow ADHD or ADD, or is that something they continue to manage all through adulthood?

Dr. Federico Herrera: So statistically speaking, 50% of patients with ADHD will carry on to continue to need medications through adult life. Does that mean the patient outgrows or like cures of ADHD? Absolutely not. I actually have a lot of patients, teenagers that showed being very responsible, like knowledge and very aware of their condition in which that allows them to already recognize what triggers, what things may distract them or keep them off track. And then, I have a lot of successful stories that patients actually decided, choose, give it a try without medication, and they continue with being successful through high school without medication.

And the same thing applies towards adulthood. When you become an adult, then it's a little more, and this is the way I see it and the way I explain it to my patients as well. It also depends a lot on what you're going to do with your adult life, let's say. If you want to study something that requires a lot of concentration, a lot of long hours of focusing, focusing, or in your job life require to have a lot of people to supervise, a lot of things to pay attention to, keep it up with calendars, keep it up with emails, then that person may be actually in a little more of need of continued medication than a person, which not undermining any type of job here, that may have their own schedule.

For example, a person that owns a landscape company and he's part of the workforce, then that may not require so much of having a rock solid structure that it will be harder to follow. So, things that are more in the artistic. For example, when it comes to sports, when it comes to art, when it comes to musicians, maybe that actually requires more freedom and actually part of that freedom and ADHD in that situation actually helps a lot of people I've heard. It may not require medication, long story short.

So, I don't think ADHD disappears. And actually I've talked to many parents, they tell me like, "Oh, I, I have ADHD. I haven't taken medication," and they're successful the one they do. I think it depends, again, it's individual case. And that's always something that I tell my patients and my parents. There's no way of me knowing who will or who will not be able to be off medications by the time they turn into adults.

Host: Yeah. I feel like that's all really, really wonderful information. Is there anything that we didn't touch on today that you wanted to add on?

Dr. Federico Herrera: Just expanding on what I said before about medicine overall, I really think me- medicine is a big mix of science, art, but also humane. Science is of course based in all decision-makings that we do is proven behind science, statistics, numbers, studies, et cetera, which defines and help us by building guidelines, so we need to follow. Then, there's the art. We need to, like, tailor and use those guidelines to how to best apply those treatments to these patients, especially when it comes to mental health.

But then, also, the humane side. You may have two patients that may look alike a lot, but there's a lot behind them that may be also going on. It may usually is not just ADHD. ADHD is very often associated with anxiety because once especially the patient is aware having that condition, it causes a lot of anxiety on the patient and the family as well. So, the humane side of understanding that there's more to just a patient with ADHD, it has a lot to do with it.

But also from our perspective as well as, doctors, we are human as well. We have our own things going on. So, I like to treat my patients in the best way I can, but also like patients sometimes we need to explain that we are humans as well. To err is human and so understanding that especially when it comes to mental health, there's not a magic pill that can say this works for everyone. Sometimes we are lucky. And thankfully, it's more than 50% of the times that we start a patient on a medication and it works like a charm, but sometimes it takes trials. You do a short trial of a medication, it may not work, may have side effects. So, we need to switch completely to a different medication. Sometimes that is not the correct dose, so we need to have patience to the medication to developing the system and start like showing its benefits. And if it doesn't work, and then we continue trying.

Thankfully, there's a lot of treatment options nowadays, which gives us like a big book of options to start trying, but at the same time may be scary. Because when parents are doing the Googling with the AI, ChatGPT, or whatever they use nowadays, they give so much information that sometimes an overload of information, and that may be helpful or it may be very scary and actually causing more damage than actually helping.

Host: Yeah. I think that's where, you know, it comes in handy to have a provider that you trust, that you can work with, that has your best interest at heart, which sounds like you really are able to connect with patients and work with them to do what's best for their kids.

Dr. Federico Herrera: Actually, that's a very good point. Establishing not just a doctor-patient relationship, but again, developing the trust, going beyond just I'm going to see my doctor, but knowing that that doctor is listening, understanding, and knows who you are, not just what conditions you have.

Host: Yeah, absolutely. Well, thank you so much for being here today, Dr. Herrera.

Dr. Federico Herrera: Absolutely. My pleasure. I love coming here, and as much as I can help the community, I'm all for it.

Host: Great. And thank you listeners for tuning in to the Well Within Reach podcast, brought to you by Riverside Healthcare. Be sure to like and subscribe to Well Within Reach on Apple, Spotify, or wherever you get your podcasts. To learn more about the services at Riverside Healthcare, go to riversidehealthcare.org.