Transcription:
ADHD

Melanie Cole (Host):  There’s no handbook for your child’s health. But we do have a podcast featuring worldclass clinical and research physicians covering everything from your child’s allergies to zinc levels. Welcome to Kids HealthCast by Weill Cornell Medicine. Our topic today, is ADHD and my guests are Dr. Shannon Bennett, she’s an Assistant Professor of Psychology and Clinical Psychiatry at Weill Cornell Medicine and Elizabeth Poole-Disalvo, she’s a Developmental and Behavioral Pediatrician and an Assistant Professor of Pediatrics at Weill Cornell Medicine. I’m so glad to have you both with us ladies. Dr. Poole-Disalvo, I’d like to start with you. Set the stage for us. What is ADHD and what’s the difference between ADHD and ADD?

Elizabeth Poole-DiSalvo, MD, MPH (Guest):  ADHD is a neurodevelopmental disorder that’s characterized by difficulties with attention and or hyperactivity and impulsivity. Many children have some of these symptoms some of the time. But for a child with ADHD, these symptoms are persistent and are more frequent and severe than expected for a child of the same age and developmental level. And ADHD can be categorized as predominantly inattentive, predominantly hyperactive and impulsive or combined type based on the symptoms that a child is experiencing.

Host:  So, Dr. Poole-Disalvo sticking with you for a minute, do we know what causes this? is there a genetic component? Do we know anything about that?

Dr. Poole-Disalvo:  So, while a single cause of ADHD has not been identified; we do know that there is a genetic basis for this disorder. Research has suggested that certain neurotransmitters like dopamine, serotonin and norepinephrine help to regulate attention in certain parts of the brain. And multiple genes involved in neurotransmission may play a role in ADHD. There are also differences in brain structure and function that have been observed.

Host:  Dr. Bennett, what are some symptoms that parents would notice that would cause them first of all, to take their child in for a visit to see what’s going on? What would they notice at school? What would they notice at home?

Shannon Bennett, PhD (Guest):  As we just heard, many children will have difficulty with attention or impulsivity or hyperactivity. When parents should think about bringing their children in for an evaluation is when these symptoms of inattention or inability to sit still or difficulty in academic or social settings is really getting in the way of them meeting their developmental goals and milestones. When their academics are suffering, or their social relationships are suffering or homelife is suffering and this is tied back to the child’s behaviors and their difficulty regulating their attention and their behavior; that’s when parents should speak to their pediatrician or find a referral to a child psychologist or a child psychiatrist for a comprehensive evaluation.

Host:  So right along those lines Dr. Bennett, you mentioned a few things; family and social consequences of not treating ADHD. What would parents need to know if there is somebody who says oh no, no, no, I don’t want to see somebody about that. There are consequences, yes?

Dr. Bennett:  There are. While we recognize that it can be a tough decision to move forward with treatment for ADHD; without treatment, a child with ADHD may fall behind in school, they may have trouble with friendships and life at home may also be more challenging. Untreated ADHD can cause strain and conflict between parents and their kids and between siblings. Teenagers with ADHD are at increased risk for driving accidents, and studies suggest that adults with untreated ADHD have higher rates of divorce and job loss when compared to the general population.

In general, we also find kids who have ADHD that is not treated and are struggling in these academic, social and homelife domains, may also start to feel bad about themselves and become demoralized or even depressed.

Host:  Wow, what an important point to make for parents Dr. Bennett. Thank you so much and Dr. Poole-Disalvo how is it diagnosed? Is there a screening? Is this something that pediatricians do at well visits? Tell us about that?

Dr. Poole-Disalvo:  ADHD is usually diagnosed after a comprehensive evaluation by either a pediatrician, a developmental pediatrician, child psychiatrist, a child neurologist, or a child psychologist. And the diagnosis is based on guidelines that are available in the American Psychiatric Association Diagnostic and Statistic Manual or DSM and the American Academy of Pediatrics also has clinical practice guidelines for the diagnosis. And this diagnosis is given when a child is demonstrating significant difficulties with attention and or hyperactivity that really interferes with the child’s functioning in various settings; usually home, school and other environments.

And the symptoms have to have started before the child is age 12 and they can’t be better explained by another medical or developmental condition. And screening can be done in the pediatrician’s office and there are various screening instruments available that can be completed by the child’s parents, or the teacher and these can provide very useful information on the difficulties that a child is having at home and in school. These screening instruments should always be used in conjunction with a comprehensive history and physical exam before the diagnosis of ADHD is given.

Dr. Bennett:  I would just like to add sometimes it’s important for parents to understand that this is an interview. So, these questions are often asked, the evaluation is done in an interview with your doctor or psychologist. There’s no “test” or computer test that can diagnose ADHD. There are supplemental tests, that can be done and may be recommended by your doctor such as a neuropsychological evaluation that can provide additional information about a child’s strength and weaknesses, inattention and learning and memory. But the actual diagnosis of ADHD is made as was just stated through a comprehensive interview and evaluation and discussion with your doctor to ensure that the symptoms and behaviors that you are seeing are attributed to ADHD and not to some other type of condition.

Host:  Thank you for clearing that up Dr. Bennett. So, Dr. Poole-Disalvo let’s start with you on treatments. Parents have hesitations, they have questions about ADHD meds and how these can help and sometimes they are hesitant. What do you tell them when this subject comes up about ADHD medications?

Dr. Poole-Disalvo:  So, when we think about treatments for ADHD, we always think about the child’s age first. So, for preschool aged children; parent training and behavioral interventions are very important. For school-aged children; classroom accommodations like sitting close to the teacher, having work broken down into smaller, more manageable parts, allowing the child to take breaks for movement, having prompts for refocusing and positive behavioral supports can all be very useful. And then some children also benefit from extra time to complete testing and testing in a quite location to minimize distractions.

Some children also benefit from working with a child psychologist to help learn strategies for maintaining attention, regulating activity level and managing impulsivity. For many school aged children; in addition to these accommodations and interventions; medication to help with symptoms of ADHD can also be very useful. And stimulant medications which include methylphenidate and amphetamine medications are considered to be first line treatment for ADHD. And they are thought to work by increasing the availability of the neurotransmitters dopamine and norepinephrine in the brain circuits that regulate attention.

These medications help the brain to focus better and they also can reduce hyperactivity and impulsivity. While stimulant medications have been around for a long time and are generally well tolerated and generally considered to be safe; understandably parents may have concerns about starting their child on medication for ADHD. And it is important to be aware of some of the side effects that we can see with this type of medication.

One of the side effects that we can see fairly commonly is decreased appetite. We particularly see this at lunchtime once the medication starts working. And ultimately, we want to make sure that a child takes in enough calories throughout the day to gain weight and grow so we recommend giving the medication in the morning with a good breakfast and then sending the child to school with a nutritious lunch and snacks that a child likes to eat. We monitor weight gain and growth at every visit.

We can also see that some children may have difficulty settling down for sleep on these medications and it’s really important to have a consistent and relaxing bedtime routine in place and also to limit screen time before bed. Some children might have headaches or stomachaches when they first start on the medication, but these usually get better in a few weeks once the body adjusts. If there are any severe issues; we would advise using a different medication.

We can also see increases in heart rate and blood pressure which are usually very slight, but we monitor heart rate and blood pressure and listen to the heart at every visit. And children with heart problems or a family history of heart problems would need to see a cardiologist before starting this type of medication. It’s important to keep in mind that with any medication, even over-the-counter medications, there is a potential for side effects and if parents have any concerns, they should always let their doctor know.

Overall though, the side effects with these medications are typically minor and the benefits of the medication in terms of improvement in focus and overall functioning often outweigh the potential risks.

Host:  That’s great information. So, medications, great advice about school and working with the schools. Now Dr. Bennett, where do things like behavioral therapy, cognitive therapy, psychotherapy fit into this treatment and while you’re answering that question, tell us a little bit about family members and how they get involved in these types of treatments.

Dr. Bennett:  Absolutely. Medication is our first line treatment, but the outcomes can be improved with the addition of other therapies. For example, behavior therapy can help a child learn to control their aggression or their impulsivity or other behaviors. Behavior therapy can help them improve their social behaviors and to be more academically productive or organized.

Cognitive therapy can help a child build their self-esteem, reduce their negative thoughts and improve their problem solving skills. And parent training, parents can learn through parent management training skills such as issuing instructions or directions one step at a time rather than multiple directions at once. And also learn how to use routines in the home and positive reinforcement to shape their child’s behavior in a positive direction.

The parents need support as well. This can be a challenging time and siblings may support as well. So, offering opportunities to improve family communication for everyone in parent child visits, or family visits can also be very helpful.

Host:  Well it’s certainly true as the family does need to be involved. So, Dr. Poole-Disalvo, first last word to you. How does the diagnosis and treatment change as a child is growing into their teen years and even possibly into their adult years?

Dr. Poole-Disalvo:  Many children who are diagnosed with ADHD will continue to have symptoms even into adolescence and adulthood. We think about ADHD as a chronic condition. What our hope is, is that with the right interventions, that child will really learn strategies for regulating their attention, regulating their activity level and managing their impulsivity and will be able to function as best as possible.

Host:  Dr. Bennett, off to you. What would you like the listeners to know and to take away from this segment, the main message that you’d like parents to hear about ADHD and if they have a child, the treatment options that are available. What would you like them to know?

Dr. Bennett:  The most important take away is if you notice the symptoms of inattention or hyperactive or impulsive behavior are getting in the way of your child’s day to day life at school, at home or with friends; there are very effective treatments available, to talk to your pediatrician or other healthcare professional, to get a comprehensive evaluation and to look into these treatment options.

Host:  It’s great advice. Ladies thank you so much for joining us today and sharing your expertise because parents need to hear this and it’s so helpful. Thank you again.

That wraps up this episode of Kids HealthCast with the experts at Weill Cornell Medicine Primary Care. You can head on over to our website at www.weillcornell.org for more information and to get connected with one of our providers. If you found this podcast as informative as I did; please share with friends and family, share on your social media. That way we all learn from the experts at Weill Cornell Medicine together. And don’t miss all the other fascinating podcasts in the Weil Cornell Medicine library. Until next time, I’m Melanie Cole.