ADHD--Bridging the Gap Between Academic Potential and Performance

We start our problem-focused podcasts with ADHD.

What is ADHD?

What causes the gap between ability / potential and performance?

What are the specific elements of ADHD?  Inattention, Hyperactivity, and Impulsivity

ADHD in boys vs. girls.

Nature and Nurture in ADHD

Are there mimics to ADHD?

Adult ADHD

How are children diagnosed?  What is the evaluation process?

Treatment options for ADHD? Non-medication options?

Medication options for ADHD?

Side effects of medication?

Reasons for medication hesitancy?

Follow-up expectations.

Book Reference: Smart But Scattered

CDC Link
https://www.cdc.gov/adhd

Chapters

• 0:42 Welcome to Podcast
• 1:53 Beginning of ADHD content

Transcript

ADHD

WELCOME TO THE NEXT PHASE OF OUR PODCAST AS WE MOVE INTO FOCUSING ON SPECIFIC CONCERNS PARENTS HAVE.

I have been eager to move into talking about some of these topics—specifically mental health concerns which have been so prevalent over the past 3 years

BEFORE WE START—WHAT IS YOUR FAVORITE RESTAURANT?

MANDARIN

TODAY WE WILL BEGIN TALKING ABOUT ADHD

• What is ADHD?
   
  • I summarize ADHD as a gap between potential and performance—child with this high potential and low performance.

WHAT DOES THAT GAP LOOK LIKE TO A PARENT?

• Shows up 2 ways
   
  • higher intelligence kids get missed for awhile where the amount of time and effort to get work done is excessive—parents find this more, often tearful 
  • other where kids not getting work done and falling behind—teachers help find these and bring them up at parent-teacher conferences
  • Self-esteem issues start to arise—the child is not performing where they know they could be—they see other kids getting more points with the classroom reward programs
• WHAT ARE THE SPECIFIC ELEMENTS OF ADHD?
   
  • Three elements of ADHD—Attention, Hyperactivity, and Impulsivity 
• WHAT DOES INATTENTION LOOK LIKE?
  • Not paying attention, not focusing 
• HOW ABOUT HYPERACTIVITY
  • I think this the classic presentation of ADHD, the child Constantly moving and crawling over everything, never stops moving, acts as if driven by a motor, disruptively energetic
• WHAT DO WE MEAN BY IMPULSIVITY?
  • Not thinking before acting, hitting kids without considering consequences, pulling hair
• IS THERE A DIFFERENCE IN PRESENTATION BETWEEN BOYS AND GIRLS?
  • Boys > girls with more hyperactivity and impulsivity and girls more inattention
  • Boys get diagnosed more earlier because they are more disruptive with the hyperactivity 
• WHICH IS STRONGER—NATURE OR NURTURE?
  • Strong biological component
  • No strong links with media usage, but some data showing that screen time before age two can alter child’s expectation for entertainment and being able to sit still
  • 7-8%  
• WHEN ARE THEY DIAGNOSED? 
  • Symptoms should at least be present by age 12 but most have symptoms by age 5-6
  • More severe—earlier diagnosis—we really shouldn’t be treating before age 6 as kids needs time to work through their normal attention, hyperactivity and impulsive behavior common to their age
•  WHAT CAN LOOK LIKE ADHD?
  • depression, anxiety—1/3 will have this as well, oppositional defiant, learning disability
• WILL THIS LAST INTO ADULTHOOD?
   
  • Can persist into adulthood
  • Up to 50% 
  • Most children grow out of the impulse control and the hyperactivity with time—naturally with brain maturation and better decision making.  Inattention may be present for longer.
• WHAT COMMENTS DO YOU HAVE ABOUT ADULT ADHD?
  • Fastest growing segment of ADHD is adult ADHD
  • Many adults recognize their own behavior in their children as their children get help
  • Met criteria earlier but never diagnosed and treated, 4-5 fold increase
  • Adult Rxs are now greater than Childhood ADHD
• HOW DO WE DIAGNOSE ADHD?
   
  • The definition of ADHD is that Symptoms present before age 12, present in more than one setting and there is INHIBITION in academic performance 
• WHAT IS THE EVALUATION PROCESS? 
  • Option 1:
    • Request in writing a School-based Behavioral Evaluation through your school psychologist.
    • We need this data from the school to make good diagnoses
    • Set a date for a follow-up appointment with me at about the time you have this meeting with him/her.Bring in a copy of the report from the school psychologist (or we can copy it for you) a few days before the appointment with me.  I will review the detail of report and be ready for our visit with suggestions and treatment options.
  • Option 2:
    • do my shorter forms that are not as complete and not as thorough to evaluate for ADHD.  Complete forms from parent and teacher and return them to me at follow-up appointment
  • Option 3:
    • For the most comprehensive evaluation I recommend evaluation by a neuropsychologist to make sure we are working on the right diagnosis--most thorough and comprehensive evaluation of mental health and brain function 
• WHY WOULD A PARENT TAKE ONE OR ANOTHER OPTION? 
  • Offer more detailed evaluation to provide MORE DATA TO GIVE reassurance that the diagnosis is done correctly and not rushed 
  • Overworked school staff may not have the bandwidth to be helpful
• HOW DO WE TREAT ADHD?  ARE THERE COUNSELING OPTIONS
   
  • With other mental health problems like depression or anxiety we can work on counseling—when you have intrusive sad or anxious thoughts you can counsel on pushing those thoughts out.  This isn’t true of ADHD.  When someone cannot focus you cannot expect them to focus.  Medication is the mainstay of treatment.  
• WHAT ARE THE MEDICATION OPTIONS?
   
  • Medication is grouped into two categories: stimulants and non-stimulants.  Stimulants function like a light switch—being turned on and off each day.  Examples would be methylphenidate and the amphetamines.  When these work they are more obvious.  Non-stimulants function more like a sunrise—gradually working over weeks and continue to work around the clock and not just for a few hours at school.  Examples are atomoxetine and guanfacine.  Their action is not as pronounced. 
  • 80-90% will respond to one of the two common stimulants that most people know as methylphenidate which is ritalin OR the amphetamine which is Adderall
  • Prefer to use long acting medication to avoid having the child have to take a second dose at lunch time every day
• WHAT ARE THE SIDE EFFECTS PARENTS SHOULD KNOW ABOUT? 
  • Highest on the list is that stimulants suppress appetite so we have to plan for that.
  • Taking them too late in the day can cause sleep problems
  • Some are more emotional on these medications
• WHAT ARE THE REASONS PARENTS ARE HESITANT TO TREAT?
  • Daily medication
  • Developing brain
  • Addiction concern—attorney patient.  Treating probably decreases substance abuse by providing appropriate treatment vs. finding illicit treatment
• ARE THERE CONSEQUENCES TO NOT TREATING?
  • self-esteem issues
  • academic performance issues
• ARE THERE NON-MEDICATION OPTIONS?
  • Lifestyle adjustments
  • Sleep—brains always have a lower bar for problems with lack of sleep whether it is headaches, seizures, ADHD or depression—super important
  • It always helps to  promote a healthy diet.
• WHAT ABOUT EXERCISE? 
  • Critical that children have excellent movement and exercise every day—doesn’t have to be structured—they just need to play hard as kids
• ANY OTHER TOOLS TO USE AT SCHOOL?
  • modify environment, 
  • allow for more movement, 
  • kinetic chairs
  • There are alternative offerings for ADHD, but mostly helping a child to be organized with tools like homework trackers.  
• ANY OTHER COMMENTS ON TREATMENT OPTIONS?
   
  • We all see that most humans are VERY impulsive at 2 but improve by 20.  My goal for treatment is to help a child to bridge this gap—sometimes over many years— by being successful at school, shoring up their self-esteem that they are smart and they are good at school.  I wish there were more options for this, but medications are the mainstay of therapy.  Very important to note that I encourage parents to explore all seeking answers and help from many sources. What I help with is medication—it is what I am trained for and others have other training and offerings. 
• WHAT CAN A PARENT EXPECT ONCE A DIAGNOSIS HAS BEEN MADE AND YOU HAVE DECIDED TOGETHER TO TRY A MEDICATION?
   
  • Trial of medication for the next month.
  • If medication works well then will continue and possibly increase dose. 
  • If medication does not work well or side effects are problematic then will change class of medication.
  • Option: Rx Match testing--pharmacogenetic testing to guide prescribing.  Genetic testing to know which medications will work best, which will cause side effects, and which medications will not be effective. 
  • Complete a medication follow-up form for parents and teacher on improvements and side effects and return in 1 month.  
  • GOAL—medication is helpful and doesn’t cause problems—if it doesn’t help or causes side effects then we change medications
  • Follow-up in 1 month
• Book Reference
• Smart But Scattered