Attention Deficit Hyperactivity Disorder Experts Answer Your ADHD Questions

Dr. Dodzik: Thank you. Thank you for having us. My name is Dr. Peter Dodzik and I’m a pediatric neuropsychologist here in Chicago. I specialize in young children to school-aged children, maybe 3 to 12, with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder , autism, Asperger’s, learning disabilities and then also a variety of mixed medical conditions.

Dr. Stasi: I’m Dr. Greg Stasi. I’m a pediatric neuropsychologist here in Chicago as well. I specialize in more elementary-aged as well as adolescence, and also see neurodevelopmental conditions, Attention Deficit Hyperactivity Disorder, learning disabilities and autism spectrum as well.

Erin: What is Attention Deficit Hyperactivity Disorder and just how common is it?

Dr. Dodzik: ADHD, or Attention Deficit Hyperactivity Disorder, is a neurobehavioral disorder that has onset in young children, perhaps as young as 3 or 4. Essentially, it is a disorder of self-regulation. The children have a difficult time maintaining their attention or focus, particularly in those activities that they’re either not good at or don’t find a lot of enjoyment in. It also impacts their ability to delay gratification, to wait their turn, to know where their body is in space, and to control their impulses.

Dr. Stasi: It’s also one of the most common neurodevelopmental conditions. Current studies indicate that anywhere between 4 to10% of elementary-aged children have Attention Deficit Hyperactivity Disorder.

Erin: You hear ADD and ADHD used frequently. Is there a difference between the two?

Dr. Dodzik: I think that as the definition of that condition has evolved over the years they ultimately decided that children who have ADD, or Attention Deficit Disorder, were originally thought to have primarily inattentiveness or distractibility, but they share so many common features with children who are diagnosed with Attention Deficit Hyperactivity Disorder, primarily hyperactive and impulsive types, that they ultimately decided that there was enough commonalities between the two conditions that they rolled both of them into one.

In the current diagnostic definitions, Attention Deficit Hyperactivity Disorder is the only disorder and it’s broken into subtypes. There’s primarily inattentive type, there’s hyperactive-impulsive type, or combined, with the latter being the most common, perhaps 80% of the cases.

Erin: Because 3 or 4 year-olds have so little impulse control anyway, is there a difference in expression between boys and girls when you’re looking at those younger children?

Dr. Stasi: Sure. I think what we see a lot of times with boys is more the impulsivity and the hyperactivity. With girls we see a lot more of the inattention component come out in play.

Erin: What is going on in a child’s brain when they do have Attention Deficit Hyperactivity Disorder?

Dr. Dodzik: In many cases, what we know is that the frontal lobe is involved with planning, judgment, and also things like working memory and controlling impulses. What we think is that in children with Attention Deficit Hyperactivity Disorder there’s a developmental lag in the frontal lobe’s ability to regulate these underlying impulses that children have or to sustain them in moments when they aren’t doing things that they inherently enjoy or that are immediately rewarding. In some cases, the frontal lobe continues to develop in such a way that they catch up, and in other ways they chronically lag behind. In those cases, it’s generally what we
see as the behavioral manifestation of Attention Deficit Hyperactivity Disorder.

Erin: I’ve heard the term “executive functioning” a lot. What is exactly is that?

Dr. Stasi: Executive functioning consists of a variety of skills, including a child’s organization, problem-solving, planning, initiation on tasks, and self-monitoring. They’re basically a child’s skill set of how they complete their work on a day-to-day basis “Can I sit up and do homework assignments appropriately?” “Can I do projects?” Planning morning routines. Those are all executive functioning type skills.

Erin: How do you determine what is normal executive functioning and when a child might be lagging in that area?

Dr. Dodzik: Like a number of developmental skills in children, such a language or memory, or even reading and math, executive function has certain expectations at each age. Even from preschool age into kindergarten and elementary school-aged children, there is a certain amount of planning and organization that we expect from them.

Teachers are often a key point of information when a child is falling behind in tasks related to executive function, such as being able to write down assignments, get the materials needed to complete them, take them home, complete them, bring them back, turn them in, get started on writing assignments, or even keeping their desk or locker in some neat and organized fashion.

In many cases, the parents at home are seeing the child as being unable to follow through on two and three-step directions, and the teacher is finding it difficult for them to manage a lot of their work that’s supposed to be independent on their own.

Erin: How do you know a child really has Attention Deficit Hyperactivity Disorder versus just being lazy or unmotivated?

Dr. Stasi: I think we get that a lot in our practice. The parents will often come in and just say, “My child is just lazy. He can do all of this.” I think we always want to talk to the parent about the expectations that are set for the child, find out what the peers are expected to be doing in a certain situation, and really identify whether it’s more of an affective anxiety-based or mood component or if it’s really an attentional-based component.

Dr. Dodzik: I don’t think they’re always mutually exclusive, either. I think when children have expectations they can’t meet or are unsuccessful at something they begin to lose motivation. By the time we see them for an evaluation, oftentimes motivation is a problem and effort is a bit lacking.

What we try to do is an evaluation with a set of neuro-cognitive instruments that will highlight specific deficits in working memory, executive function, impulse control, and then subjective rating scales from parents and teachers or other people familiar with the child. When we see deficits across domains and across instruments, oftentimes we know that there is in fact an issue. Whether motivation becomes a component of their treatment is often fairly common for that condition as well.

Erin: What else might it be if it’s not Attention Deficit Hyperactivity Disorder ?

Dr. Stasi: One of the largest studies indicated that upwards of 70% of children who have Attention Deficit Hyperactivity Disorder have some coexisting condition, be it a learning disability, an emotional disorder, anxiety, depression, or even social concerns. I can say that in our practice the majority of the time that we see a child it’s not just because the child has Attention Deficit Hyperactivity Disorder as the diagnostic question. There’s always something else going on. Learning issues in the school environment, the child is struggling socially, or there might be anxiety popping up. It’s kind of unraveling it to figure out what is the biggest factor for the child and for the parents and what needs to be addressed today.

Dr. Dodzik: There are also a number of other conditions that can mimic the symptoms of Attention Deficit Hyperactivity Disorder. Common examples that often are not thought of by parents or physicians are things like sleep disorders.
Children who have sleep disorder breathing, chronic snoring, or apneic events such as restless leg syndrome, or other events that can affect the total amount of sleep they get or the quality of the sleep that they get, often in the daytime world present as symptoms similar to Attention Deficit Hyperactivity Disorder.

It’s less commonly thought of because in adults the most common outcome of poor sleep is daytime fatigue, whereas in children that’s much less common. Hyperactivity, impulse control and irritability are the more common presentations. There are number of other conditions, like Central Auditory Processing Disorder, that can mimic some of the distractibility or lack of attention that often is seen in Attention Deficit Hyperactivity Disorder.

Erin: Why would it be important for a child to have a formal evaluation?

Dr. Dodzik: There are many conditions that manifest themselves as Attention Deficit Hyperactivity Disorder or that co-occur with ADHD, such as anxiety, depression, or even learning disabilities. In addition, if many children come in with more than one condition, and we know that is common in ADHD, many of those other issues such as anxiety or depression merit different treatment and have a very different course of treatment. I think, also, in cases where there are learning disabilities, evidence-based interventions to address those underlying conditions are going to be important.

In some cases, children come in and are spending six hours a day at school being told that they are not listening, they are not focusing, or they are not being successful somehow in their academic world, and then having similar complaints from parents at home. That can then begin to manifest itself with mood or behavioral problems.

Also, if a child has a learning disability they’re often not understanding what’s being asked of them or what’s being taught to them in the school, so they look like they’re often distractible or not on task. Finding out what is the major emphasis of a problem can help with deciding whether we have one issue, Attention Deficit Hyperactivity Disorder with some secondary problems, or if there are multiple things going on that merit treatment. A formal evaluation can help answer those questions.

Erin: So that formal testing is going to give us a lot more than just talking to your child’s teacher and/or pediatrician?

Dr. Stasi: Exactly. A formal evaluation is going to look at cognitive ability, academic achievement, attention, organization and executive functioning skills, memory, and also social and emotional function, and compile all of the data together to figure out what interventions the child is going to need within the school setting, home, and also in the clinic environment.

Erin: Medicating; when would that be appropriate?

Dr. Dodzik: When you’ve had a formal evaluation and we have ruled out any other potential causes for the child’s condition, that is probably a time where medication should be considered. In looking at long-term studies on the impact of pharmaceutical agents with Attention Deficit Hyperactivity Disorder, medications are generally the most robust in terms of their ability to treat the patient’s underlying difficulties.

I think as long as we have a plan to deal with any of the other issues, if they exist, medication is probably one of the best interventions in terms of its efficacy. I’ve also found that in the long-term studies that have considered outcomes for ADHD, children who have been medicated during their school-aged years for as long as is necessary tend to be less likely to be retained in grades, more likely to complete schooling and go on to higher education, to complete advanced degrees and hold jobs and earn similar income.

Erin: If your pediatrician is writing a prescription for Attention Deficit Hyperactivity Disorder medication, do you follow that directive or follow up and explore with a formal evaluation?

Dr. Dodzik: In some cases the pediatricians will have done a thorough history and examined whether siblings, parents or other family members who have the condition, will have asked about other mental health issues, and may have even sent rating scales to the parents and to the teachers. I think in those cases where there’s been some attention to whether or not there’s anything else going on, it might merit a drug trial.

In many cases, however, life is sticky and there are mood issues or learning problems or other things that really haven’t been fully explored. In those cases we do recommend that a certain amount of formal testing be completed so that we can address all issues at once or decide if one behavior is masking or manifesting as another.

Erin: Assuming that medication is appropriate, as a parent what kind of side effects might I expect with my child?

Dr. Stasi: You might expect to see stomach problems, headaches, appetite suppression is common, and also onset insomnia so the child might have difficulty falling asleep. What is recommended is that as long as the side effects are tolerable you try the medication for about two weeks. We usually will see a decrease in any side effects if there are any.

Erin: Does medication itself alter something in your child’s brain? How does the medicine work?

Dr. Dodzik: Well, you’re not giving them anything that they don’t already have. The common medications that are used for Attention Deficit Hyperactivity Disorder are psychostimulants. They work on the basic premise that the frontal lobe, which is essentially in charge of the brain’s activities in many ways, is unable to produce or has inadequate amounts of dopamine, which is a neurotransmitter that the frontal lobe uses, among others, to regulate lower level regions.

You have these lower level regions of the brain that are involved with feeling primary urges such as hunger or thirst, but also, “I want what I want when I want it.” If the frontal lobe is unable to control those urges and impulses, that’s the manifestation of Attention Deficit Hyperactivity Disorder, and the stimulants give more available dopamine to allow the frontal lobe to better regulate other systems.

There are non-stimulants and alternative medications for Attention Deficit Hyperactivity Disorder that act on a variety of different principles, but they all have that same underlying premise, which is to give the frontal lobe more control over the rest of the brain.

Erin: What kinds of therapies are available for children with Attention Deficit Hyperactivity Disorder ?

Dr. Dodzik: All the therapies are generally targeting some particular aspect of the disorder or of the child’s difficulties. There’s been a wealth of research that has emerged comparing different treatments and following long-term outcome. Some of the more common ones, in addition to medication, are accommodations within the school to help create a structure and organizational system that will help scaffold, model, and teach the child how to become more self-sufficient and more organized.

There are also behavioral interventions that can help parents learn to navigate and deal with a child who requires a little more monitoring and redirection. Many of them are targeted specifically to the child’s underlying needs.

Erin: How is behavior therapy beneficial to a child?

Dr. Stasi: Behavior therapy is really targeting improving positive, on- task behaviors while extinguishing negative, off-task behaviors. It’s really working with the parents and working the teacher to talk about implementing strategies to help the child become regulated, sort of become the frontal lobe of the child and organize on a day-to-day basis.

Erin: So essentially the parents need to be educated as much as the child on that front.

Dr. Dodzik: Yeah. In many cases, because the children lack their own ability to self-regulate, someone needs to do it for them or needs to help them learn how to do it. The accommodations that are done in the school will help give the child a structure by which to follow and a set of rewards that will help keep them motivated to comply. That’s very similar at home, where there are reward-based systems that help them to stay on-task and give them a little more awareness over what’s expected of them and what will happen if they do comply.

Erin: What about the parent’s role? What kind of things can parents do once their child is diagnosed with Attention Deficit Hyperactivity Disorder?

Dr. Stasi: The parent has a really important role as the main advocate for that child. The parent is going to be the one who talks to the pediatrician when deemed appropriate, talk to outside professionals who are going to be providing the therapy, be the advocate in the school settings to set up accommodations and interventions as warranted in the school world, and making sure that any outside therapy is going to be implemented effectively.

Dr. Dodzik: And patience. If there’s one thing that we can help the parents understand, it’s that you need to be patient. These children are often difficult to deal with in terms of their impulsivity, staying on-task, and getting through the day-to-day elements at home. They have a little bit more of a challenge at school of staying on-task and staying with it.

We really want families to be able to enjoy their kids. I want them to be able to take the time to come up with alternative strategies. In many cases, I think parents get too quickly into dropping the hammer. “This is what we need to do and this is when we need to do it.” With children with Attention Deficit Hyperactivity Disorder you need a larger bag of tricks, where sometimes you can make activities into a game to keep them motivated and get them through all of the day-to-day life demands.

Erin: So different techniques for parents that they can employ at home that’s going to make everything smoother.

Dr. Dodzik: There are a number of them, and certainly we try to fit the types of interventions that we give to the philosophy and style of the family. Some parents do better if you lay it all out for them and say, “Look, when he does this, you do this. Don’t do it that way. Do it this way,” and with other parents there are more types of collaboration or trying to figure out how to navigate what are, these days, many nontraditional families and family structures.

Erin: We touched on the cognitive element. What about social functioning for a child that’s been diagnosed with Attention Deficit Hyperactivity Disorder ?

Dr. Dodzik: ADHD can have an impact on a child’s ability to make and keep friends or sustain relationships. I don’t think that in many of the cases it’s a skill deficit as much as in younger children the impulsivity can get them into situations where they’re pushing other kids out of the way to get to the slide or taking toys or objects from other children. It’s not a malicious act as much as, “I want this and I want it now.”

At older ages we see them oftentimes wanting to engage in social tasks when they should be focusing in the classroom. They’re chatting with other children while they should be paying attention to the lecture. At times that could mean being moved in their seating arrangement, being brought to the front of the class. In adolescence, at times it can lead to more dramatic responses in social relationships.

Erin: How do you address that, specifically? Is that also through medication or are there separate therapies that are going to address that social element?

Dr. Dodzik: Anecdotally, I definitely think that medication can have an impact on impulse control. In many ways it does help with knowing where your body is in space, standing still in line, and not taking things from other children. In many cases, though, there can still be some lingering social deficits because the child really is egocentric in many ways. They’re focused so much on their own needs that they don’t always pay attention to the needs of others. In those cases, social skills groups can be really effective.

Erin: Besides medication, what other services are available for a child with Attention Deficit Hyperactivity Disorder within a school setting?

Dr. Stasi: A lot of children with Attention Deficit Hyperactivity Disorder qualify for accommodations or interventions within the school environment. The most important piece, though, is to identify if the child who has Attention Deficit Hyperactivity Disorder is really being impacted on a day-to-day basis in the school setting. We have to make sure that the inattention, the impulsivity and the hyperactivity are really impacting the child who is struggling academically and socially. If so, then we can qualify for the child for either accommodations or interventions.

There are two types of services that are available. There’s a 504 Plan, and that’s Section 504 from the American Disability Act. Then there’s an Individual Education Plan, an IEP. The main difference between the two is that the IEP provides intervention, working with a learning resource teacher to develop any academic or organization skills. The 504 Plan are accommodations, be it extended time, preferential seating, a second set of textbooks, and so forth.

Erin: If the parent doesn’t want to medicate their child, what other interventions are available?

Dr. Dodzik: That comes up a lot. I think there are a number of families, even when the evaluations have been done and they know that their child has Attention Deficit Hyperactivity Disorder, that are really not comfortable with the idea of starting a medication, sometimes at all or sometimes without trying a number of other alternative strategies. There are also a number of other children who, because of side effects or other medical conditions, can’t take a stimulant medication.

We’re often asked to come up with a number of other interventions that might help the child and their needs. In those cases, I think that school interventions, such as accommodations for organization, some behavioral plans that help motivate them and keep them on task, and strategies to get work home and back to school again, are often very effective during school time. Behavioral interventions at home that help the child stay on task, that help them deal with transitioning between things that they want to do at home and things they don’t, those kinds of behavioral strategies can also make a meaningful difference for a child.

Erin: I’ve heard of neurofeedback. Is that a viable therapy for a child with Attention Deficit Hyperactivity Disorder ?

Dr. Dodzik: It’s unclear. There have been a few published studies that have looked at neurofeedback. The idea behind it is that a child is connected to EEG leads much the same way if you were taking a reading to see if they have seizures. Instead of looking for epileptic activity, though, the leads are picking up activation of the frontal lobe.

The idea is that we can give you some visual cues that your frontal lobe has come on through what essentially looks like a video game, much like if you went to the gym and you got on a stationary bike and it showed an image of you riding as you were pedaling. In that same way, we can show the child, “Your frontal lobe has been activated by whatever you’ve done, so keep doing more of it,” and the child can thereby learn more control over their frontal lobe.

The problem or limitation of neurofeedback, at least at this point, is that it’s not entirely clear whether that generalizes to their everyday life. These children don’t actually have as much difficulty with activating their frontal lobe. They can control their behavior just find if they’re playing video games. It’s when they’re doing things that they’re not interested in that they need more activation.

We’re not entirely clear at this point that the literature has demonstrated neurofeedback generalized enough to make it a viable first-tier recommendation.

Erin: Diet. Is there anything you can do to alter a child’s diet that might improve their symptoms of Attention Deficit Hyperactivity Disorder ?

Dr. Dodzik: That’s another question that we get a lot. I think there have been a number of agents that people have looked at, from vitamin supplements to eliminations of wheat, dairy, food additives, or sugar. Again, the literature has not been very robust on that. They’ve done meta-analyses, which are essentially taking all of the studies that have looked at elimination of a compound or a food additive and combined the results or pooled the results. When that’s been done, we haven’t seen major changes.

The ideal format for a study would be, let’s say the question was about red dye or a food additive of some sort, you would let the child eat whatever they normally eat for 60 days, then eliminate that from their diet completely for another 60 days, and reassess their behavior as evidenced by rating scales or computerized or neuropsych testing. The final arm, which is the one that doesn’t get done as often, is you would flood them with the compound, giving them four to ten times as much as they ate at baseline, with the idea that they would have a baseline behavior get better and then suddenly get worse. In general, when you look at those studies it’s just a flat line.

At this point, in the number of small studies that have shown any positive findings they’re not enough to really think of as being generalizable to the everyday world, and also probably as useful as some of the other evidence-based interventions that we go to first.

Erin: Dr. Dodzik, Dr. Stasi, thanks so much for joining us today. We encourage you to check out the other links on the website.