Adhd_healthcast4_13

TuftsMedicalCenter.tv
Healthcast: ADHD
Wednesday, April 13, 2011

Julie Jette
Good morning everyone, and welcome to Healthcasts, a monthly podcast series on
TuftsMedicalCenter.tv. I’m your host Julie Jette and today’s topic is Attention Deficit/Hyperactivity
Disorder, or ADHD. If you’re listening live, please join the conversation by submitting a question at
TuftsMedicalCenter.tv. You can also tweet a comment with #tuftsmctv or cal us at 1-855-DOC-CHAT,
that’s 1-855-362-2428. Just a reminder that this Healthcast is not intended to provide medical advice,
diagnosis or treatment and is not a replacement for an in-person consultation with a physician.
So I’m joined today by Dr. Karen Mil er, who is a Developmental-Behavioral Pediatrician, and Clinical
Neuropsychologist Dr. Hope Schreiber. Great to see both of you here today, thank you for joining us.
Dr. Hope Schreiber
Thank you.
Julie Jette
Before we start, let’s do some introductions. Dr. Mil er, welcome, and can you tel us a little bit about
yourself and your experience treating patients with ADHD?
Dr. Karen J. Miller
Yes. I’m a Developmental and Behavioral Pediatrician at the Center for Children with Special Needs at
the Floating Hospital for Children at Tufts Medical Center. A Developmental and Behavioral Pediatrician
has been trained as a pediatrician and then had extra training to work with children who have
developmental and behavioral disorders, and that’s what we do. The center helps evaluate and treat
children who are struggling with school problems, behavior problems and a variety of developmental
disorders. We do a lot of consultations for families and refer to people like Dr. Schreiber for help in
understanding them better.
Julie Jette
So, Dr. Schreiber, can you tel us a little about yourself and your experience working with this patient
population?
Dr. Hope Schreiber
Sure. I am a Clinical Neuropsychologist based in the Psychiatry Department at Tufts Medical Center, I
co-direct the ADHD clinic there, where we see children and adults, people real y throughout the lifespan,
who come in not only with simple attentional problems but also with other associated issues that may
have come up in their life. I also direct the Col ege Learning Disorders ADHD program and see a number
of young adults who have ADHD.
Julie Jette
And it’s great that you bring that up because one of the things I think we’l be talking about today is the
fact that this is not a disorder that only affects children, this is something that affects people across their
lifespan.
Dr. Hope Schreiber
Julie Jette
So, to get started, could you each talk a little bit about exactly what ADHD is; if you can define it. It’s
something that I think everybody has heard of, but may not real y understand. And I know there are
different sub-types of the disorder and they present differently, so if you could each talk a little bit about
that, that would be terrific.
Dr. Karen J. Miller
So in understanding ADHD it’s important to realize that the symptoms of ADHD, what people see, are
things that are not abnormal behaviors, so everybody is a little distracted or a little disorganized
sometimes, but we’re looking for a pattern of behaviors that are above and beyond what we’d expect for
a child’s developmental level.
So we look at symptoms of inattention such as having difficulty concentrating or staying focused on a
task, being excessively forgetful, having difficulty picking out the right thing to pay attention to. Or they
may have trouble control ing their behavior, so they may be overly fidgety, they may have problems
control ing whether they talk or don’t talk at the right times, but that it’s excessive for their developmental
level and that it causes them to have difficulty functioning in different settings. And it needs to be in more
than one setting. So not just at home or not just at school, but also perhaps with peers or doing things in
other activities.
So it’s a variety of symptoms that we look for that reflect an underlying problem with the way the brain
regulates the choices that you make on a moment-to-moment basis. So this is a brain-based disorder – a
neurologic problem – that is also developmental in that it changes over time. And that’s what we look for
on the surface.
Julie Jette
So how it looks in a five-year-old is not necessarily how it’s going to look in a 10-year-old or a 14-year-
old…
Dr. Karen J. Miller
Exactly.
Julie Jette
So, Dr. Schreiber, if you talk a little about the neuroscience…
Dr. Hope Schreiber
Sure. We understand ADHD to be real y a neuro-developmental disorder, it has a very strong brain basis
and this brain basis is highly genetic. We believe across a number of studies that on the average there is
76% of the time it has genetic origin. When you look at identical twins it’s 92% of the time, so it’s hard to
imagine a disorder that has more genetic basis right now.
Now that being said, we understand that how a family manages such unusual – very, very active –
behaviors or how it handles disorganization can affect outcome. But there’s real y a core genetic basis. A
lot of very exciting new neuro-imaging research has come out even just this year where a number of
areas in the brain have been identified as associated with ADHD. So we’re learning new things al the
time.
Julie Jette
Now, I think one aspect of this that probably a lot of people are confused about is, I seem to remember
that this used to be cal ed ADD and that was kind of the term that was out there. Is that the same thing
as ADHD? Or is that a subtype of ADHD? Or what is ADD?
Dr. Karen J. Miller
So, the understanding of what we’re cal ing Attention Deficit/Hyperactivity Disorder has changed over
time. The first scientific article describing these kids was actual y published in 1902.
So, as it wasn’t cal ed ADHD back then and people focused at first on the hyperactivity side of it, so it
used to be cal ed the hyperkinetic reaction of childhood. Then they recognized that attention problems –
how you focused and how you picked what to pay attention to – was real y important, so we cal ed it
Attention Deficit Disorder. And as it’s changed, we've changed the name of it, even though the
symptoms have been the same.
So currently the official term is Attention Deficit/Hyperactivity Disorder and it has subtypes. So if you just
have the inattention side, you have the inattentive subtype. If you’re primarily hyperactive, it’s the
hyperactive-impulsive subtype. Most of the kids have combined problems that they have both inattention
and hyperactivity problems. So the subtypes are important because it helps you know what to look for
and also sometimes what other things you need to look for in terms of other kinds of problems that often
co-occur with ADHD that are important for management, such as learning disorders or other behavioral
or emotional disorders.
Julie Jette
So it’s probably important to note also that it doesn’t just look different among people of different ages
but also individual to individual. It’s not a blanket diagnosis where it looks the same in each person.
Dr. Karen J. Miller
Right. So if your neighbor’s child has been diagnosed with ADHD, it may not look the same in your child
and there can be differences in how some girls present versus some boys present. And we’re learning
more and more about how ADHD presents in girls and women and that we need sometimes a different
approach.
Dr. Hope Schreiber
I think one of the nice things about the current terminology is that it al ows us to look at some of the silent
problems with ADHD like executive functioning. And these are problems that affect daily living in very
profound ways and they’re quite – we al know what we’re talking about when we talk about the child who
is total y disorganized, who can’t get their homework from home to school, who somehow even when
they do the homework can’t manage to turn it in to the teacher. Those people who never clean up their
rooms. There’s a level of disorganization that’s visible and also internal y. The child who can’t write a
paper because when they start by the time they get to the end they’re working on a different topic; very
important skil s to have.
Another executive function that’s enormously important is cal ed working memory. That’s the ability to
hold on to information long enough to do something with it. So an example of that would be doing an
arithmetic problem in your head or even learning a new language, remembering the basic mechanics of
a new language, learning new math rules; very important to be able to do that in school. Forgetfulness,
time management, managing multiple demands and keeping track of al of them. Now this is something
probably al of us could use help with…
Julie Jette
I was going to say, you’re starting to remind me of myself, so…
Dr. Hope Schreiber
Right, but when it gets to a certain point that it interferes with daily functioning that’s when it’s worth
taking a look at.
Julie Jette
So that actual y bring us to a real y important question, which is: How do you diagnose this? And let’s talk
about sort of how you diagnose it in a relatively young child, kind of early on in school, and then maybe
we could talk about how you diagnose it in adulthood, since it’s a very different presentation at that point I would imagine. Dr. Karen J. Miller
So for the young child, the American Academy of Pediatrics guidelines on ADHD recommend that a
pediatrician or a physician consider ADHD as part of the problem when a child presents with any kind of
behavioral, emotional or school-based problem because it can manifest in any of those ways. So it can
show up as being a problem with getting along with other kids because you impulsively push people
rather than handle conflict in better ways. It can show up as a problem with academics because you
have difficulty getting work done or listening to the teacher consistently enough to learn. Or it can show
up as problems being cooperative at home and being able to do things you are told to do.
And the pediatrician needs to then look through what happened before. So is this a problem that just
started in the last month? Or has this been real y kind of a problem for a long time? So whether or not
these symptoms have been there chronical y or just happened, it wil help you decide whether or not it’s
a brain-based disorder or perhaps an environmental y caused disturbance. If your parents have just
separated, you may not pay attention very wel at school and it may not be ADHD. So you’re looking for
the chronicity of the concerns, so they change over time. Whether or not there are any medical
problems, so for example, if the child has had a brain injury because they fel off their bike, that’s going to
disrupt some of these symptoms and you may have a medical problem.
So you’re looking for any medical disorders that may look like ADHD, and then you’re also looking to see
whether or not there are any other kinds of problems that can look like ADHD, like a learning disorder.
And so, we may need to refer for further testing either with the school or getting a neuropsychological
evaluation. Then we go through the criteria and see whether or not they meet al the symptoms for
ADHD and then decide if anything else needs to be done to assess for other problems.
Julie Jette
And is there, Dr. Schreiber, is there a – we’ve had a couple of questions come in – for example, we have
a question here from Liz who said that: My son’s school told me I should have him tested for ADHD. Is
there a blood test for it? I mean is there any sort of neurological, sort of, brain scan test or anything that
you can do to get, sort of, an incontrovertible identification of this? Or is it real y something that has to be
worked out over perhaps several office visits and that sort of thing?

Dr. Hope Schreiber
We wish there were a blood test and of course there isn’t. I think the process of establishing a diagnosis
of ADD is complex and you want – a physician involved is helpful, too. When the school or other people
refer for testing for ADD, that’s one way to get more information about what’s going on. What you real y
get from neuropsychological testing is a good map of cognitive strengths and weaknesses. Classical y,
what you might see is general intel ectual functioning wel in a normal range, but there are dropout areas,
there are areas where working memory, for example, where a child cannot maintain their usual
functioning in certain discrete areas that are characteristic of some of the executive functions we just
talked about, or where they may respond so impulsively they real y interfere with their own best possible
performance. So in testing you can get that.
What it’s most helpful for then is making recommendations back to the school about how to manage
these problems and move the child forward in their own educational progress. They can also provide
information to families around how to think about what’s happening with their child. Their child may not
be intending to be oppositional, they may not be intending to disrupt family activities, but if there is some
understanding about how to help manage and contain behaviors, things may go a little better.

Julie Jette
I’m sure this behavior can be extremely frustrating for parents and teachers alike, especial y if it comes
off as a child just being difficult or being obstinate or what have you and I’m sure it’s chal enging.
Dr. Hope Schreiber
Just to carry it forward as the child becomes an adult. On the col ege level, testing is very handy in terms
of suggesting accommodations, for example, someone who is very distractible may be a slow reader.

And having extended time can real y make a difference in success or failure in the col ege level. It’s also
very important to detect coexisting learning disorders and in that respect you can also suggest
recommendations both for school, col ege and education in general.
Julie Jette
And, Dr. Mil er, I saw you – it sounded like there are a couple of points that you wanted to jump in with
there.
Dr. Karen J. Miller
I wanted to just highlight exactly what Dr. Schreiber was saying, is that a lot of times when we are asked
does this child have ADHD, the question is not just whether or not they have ADHD, but what else is
going on? Because what you’re trying to get is a comprehensive plan that addresses al the strengths as
wel as the more chal enging areas and how we can leverage or use what the child does wel to help
them perform in the more difficult areas. And to explain the child to the adults so they don’t get blamed
for their neurological y based disorder, but that everybody is on the same team. So my goal for an
assessment is always to help the child understand their strengths and weaknesses, as wel as the adults
in their life understanding what they do wel and how they can help them be more successful.
Dr. Hope Schreiber
This may be a good moment to mention also there are a number of other disorders that characteristical y
hang in with ADHD and to miss them would real y not do the student or patient credit.
Julie Jette
So what are some of those kind of coexisting disorders that you might be seeing?
Dr. Hope Schreiber
Wel , in young children that oppositional defiant quality is fairly common. Anxiety disorders, 25% of
children may have that with ADHD and it’s much higher for adults in fact. Depression is present in both
children and adults with ADHD in a higher rate than the general population.
Julie Jette
Now that’s interesting because you would think that the characteristics of depression would be different
from those of hyperactivity, or what have you. You think about depression as a slowing down. So why do
you think that is?
Dr. Hope Schreiber
Wel , there’s probably more than one reason. I think if you are chronical y feeling like you’re just working
so much harder than your peers to perform in the same way that could be fairly demoralizing.
But also there is some thought that there might be some genetic way in which some of these disorders
are inherited together. So it may be different for different people. Learning disorders actual y have a very
high frequency of coexistence with ADHD – 40% to 50% are the figures that are quoted in the literature –
but it may be higher than that from my clinical experience.
Julie Jette
And when you say learning disorders, you’re talking about things like dyslexia and other types.
Dr. Hope Schreiber
Yeah, there are many different kinds.
Julie Jette
So this is probably a good time when we’re talking about diagnosis to talk about how ADHD manifests
itself differently in a five-year-old versus a 15-year-old, perhaps versus an adult. So could you talk about
that a little bit?
Dr. Karen J. Miller
So, a five-year-old may present as being overly active and impulsive and this has often been an area of
misunderstanding because people sometimes wonder if – wel , is it just that he’s being a boy and we’re
over-diagnosing the ADHD. And again, it goes back to: Do they meet criteria? Is this chronic? Is it
inappropriate for his developmental level? And this is where the other recommendation of the Academy
of Pediatrics is important in that you need information from multiple settings. And you’re looking at: Does
this interfere with functioning in multiple settings? That’s very helpful.
So we’re looking for hyperactivity, which tends to manifest first, as wel as the poor impulse control and
as you go into more demanding settings, the attentional problems become increasingly important. In a
15-year-old, you may find that they’re stil having difficulty with inattention though the hyperactivity itself
may have gone underground and is more a sense of either restlessness or expressed as boredom
because things are not happening fast enough, it’s not exciting enough, and so they may have difficulty
tolerating things that are boring. As a young adult, you may have more difficulties with some of the life
things.
Dr. Hope Schreiber
Beginning in adolescence you start to see some behavioral problems. The “stop and think” kind of
problems where we talked about car crashes before we got started, temper outbursts, interrupting others
in class; things that are real y behavioral regulation kinds of issues.
In col ege you can imagine that transition can be very significant, from a point of being managed by
parents and school real y al of the time. Many col ege students when they arrive, who have ADHD, they
have no one tel ing them what to do, they have no one tel ing them to go to class, they have no one
tel ing them to do their homework, and some of those kids could real y crash and burn without any
structure at al . So preparing for that can be very helpful for them. What is characteristical y problematic
are those organizational problems. Time management problems…
Julie Jette
Huge chal enge for a col ege student, for any col ege student…
Dr. Hope Schreiber
For any col ege student, exactly. Learning how to communicate with other adults, like teachers, to
advocate for yourself to get extra time, can be very embarrassing, I think, for some people. So they’re
new chal enges altogether, and the whole aspect of being in control of yourself, at that point in time in
development, can be enormously chal enging.
Julie Jette
Wel , that actual y brings us to a question that we have from Al y, who says that: I’ve helped my son
battle ADHD for almost 10 years, but he’s going to col ege in Florida in the fal . I’m real y worried about
how he is going to handle it. Can you tel me a little bit about what ADHD wil look like in a col ege
student and what should I look out for? And probably what she also needs to know is what can she tel
him about managing his symptoms going forward?
Dr. Karen J. Miller
So one of the things that we are always looking for and including in our treatment discussions over time
is not just how parents can manage the child but including the child in learning to manage themselves
and understanding. So one of the first things that a parent needs to do is to educate themselves about
the facts of ADHD, not just the myths that they wil encounter from friends, family and the web. So that
they can then help their child understand how ADHD affects them and start helping them be better
problem solvers and this can start at the age of five. This doesn’t have to wait for adolescence.
So part of the treatment of ADHD is real y the education of the family and the education of the child, so
they become better self-managers by the time they’re ready to be launched, and that’s real y one of the
most important treatments of ADHD, is the educational side of it.
Dr. Hope Schreiber
I agree 100% with Dr. Mil er on this. One way to think about it is that the point of going to col ege is the
point at which the child becomes their own CEO. They have to run the show and helping them real y
think about it that way is one good way to get started. Pragmatical y, on every col ege campus, there is a
learning disability or disabilities office, Academic Support Service. And scoping that out before arrival can
be helpful so that there is a point person on campus who can be a resource before they even get there.
Dr. Karen J. Miller
I think that one of the things that that mother can do with her child is to actual y sit down and write down:
What are your three strengths? What do you do real y wel ? What are the three things that have been
hard for you especial y over the last two years? What are your three chal enges and what are the three
or four things that you have found real y helpful in managing these things? And having thought these
things through in advance so they can then go explain themselves better to their professors wil be
helpful, because if they haven’t had the support in figuring those things out it’s real y hard to explain them
to somebody else.
And it comes to the whole idea of treatment for ADHD. Part of the treatment is the education, part of it is
learning self-management and part of it is learning what role medication plays in your life. So that the
child who’s going off to col ege knows what medicines do and don’t do for them. And what part of their
self-management is the managing of their medication most effectively as many kids do benefit and
continue to benefit from medication even into col ege and adulthood.
Julie Jette
Wel I think that takes us to a very important topic around ADHD which is the medication surrounding it.
We have a question here from RaeAnne, who’s asking: What drugs are used for ADHD? Is it just Ritalin
or are there other options? So let’s talk about that a little bit and of course there’s sort of the whole
debate out there over whether too many of these kids are put on these medications or what have you. So
if you could talk a little bit about how important medication is in this disorder and how it should be used.
Dr. Karen J. Miller
I think it’s important for people to realize that the use of medication in ADHD is probably one of the best
studied, most wel -researched topics in child psychiatry, mental health and behavioral health; that the
first study was published in 1937…

Julie Jette
That’s amazing.
Dr. Karen J. Miller
…on using stimulant medications. And what they noticed was that it real y helped them in school that
they were able to focus and do better at school. So the class of medication that is the classic ones are
what’s cal ed the stimulant medication and that includes the Ritalin family, which is methylphenidate, and
the dextroamphetamine family, which is Dexedrine and Adderal and some other medicines that are
used. And what they do is that they actual y stimulate the parts of the brain that are under-active, that are
under-functioning, which are those parts of the brain that let you control what goes on. It gives you a little
bit of space to actual y make a choice; you can stop and think rather than just doing or forgetting.
And there are lots of new variants of both the classic medication as wel as some non-stimulant
medication such as Strattera, and there are medicines you’l see advertised which are in a new class
cal ed the alpha-agonist, which are things like clonidine, Tenex or Intuniv, which have effects on different
areas of the brain than the classic one. So we have a lot more choices but it requires a team approach to
managing the medications.
Dr. Hope Schreiber
But you know, some people think once you enter adulthood the medications are no longer effective, but
that has not been our experience. I recal one of the first people we saw in our ADHD clinic was a young
adult who wanted to go back to school to become a physical therapist and he had had just a terrible time
in school for most of his life.

He had a trial of Ritalin and came back and said, for the first time in his life he understood what people
meant when they said “study.” He was able to sit at his desk long enough to be in the right place at the
right time; but also when he read, he held on to the information better, he was able to think about the
information – not just read through it – and he was able to retain the information, and needless to say
this real y changed his life.
Julie Jette
So, medication plays a very key role in the treatment of this disorder. Is it always used, or are some
patients successful y managed through behavioral methods?
Dr. Karen J. Miller
For children, it’s one of the components of a treatment plan. You want to make sure that the parents
have gotten some help in learning how to manage the behavior by understanding. Because medication is
kind of like eyeglasses – it only helps you focus on what you’re choosing. It’s not going to tel you to do
anything.
So if the child is choosing to focus on the squirrel going up the tree out the window, they’l do a better job
of that. If they want to poke the kid sitting in front of them, they’l now have the impulse control to wait
until the teacher turns around before poking the kid. So it gives you that impulse control. But it’s part of a
total treatment plan. About half the kids wil be on medicine at some point, and we need to give them a
total treatment package, not just medication.
Julie Jette
Now, we only have about a minute left, but one question that’s come up and I think this is something that
we’ve heard about a lot in the popular media is the role of diet in ADHD. So, we don’t have much time to
talk about that, but is that something that parents should be looking into in terms of what’s in their child’s
diet?
Dr. Karen J. Miller
There’s several different studies, most of the studies have been negative. There may be a subpopulation
of kids who have some responses to different things in their diet, particularly in the chemical y based
diets that people have now. And I would recommend that people take a look at their child, keep track of
what’s going on, and consider the whole treatment, but it’s not been shown to be a highly effective
intervention for the vast majority of kids.
Julie Jette
Okay. Wel thank you very much. Thank you so much, Dr. Mil er and Dr. Schreiber. I’m sure that was
very enlightening to a lot of the folks listening in today. We want to remind everybody that today’s
discussion wil be saved as a podcast at TuftsMedicalCenter.tv and on iTunes. And we invite everyone to
join us for our next Healthcast on Friday, May 13th at 11:30 am, where we’l be discussing breast cancer
with Dr. John Erban, who is the Clinical Director of the Cancer Center at Tufts Medical Center. And you
can post questions for Dr. Erban at facebook.com/tuftsmedicalcenter or by tweeting a comment with
#tuftsmctv. Thank you so much and have a great day.

Source: https://www.tuftsmedicalcenter.tv/files/204_ADHD_Healthcast_4_13.pdf