All About ADHD – PediaCast 246
Dr Rebecca Baum joins Dr Mike in the PediaCast Studio to discuss the nuts and bolts of ADHD. This comprehensive podcast covers the cause, diagnosis and treatment of this common condition. We also cover comorbid disorders, adult ADHD and the hottest topics in ADHD research.
Attention Deficit Hyperactivity Disorder (ADHD)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Episode 246 for March 27th, 2013. We're calling this one "All About ADHD".
This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio.
I just want to welcome everyone to the program. We have another big one lined up for you today. It's a topic that affects lots of families — attention deficit hyperactivity disorder. And we're going to take another nuts and bolts approach. We'll cover the scope of the problem. We'll talk about what cause it, what makes it worse.
Are all hyperactive behaviors ADHD? For that matter, are all behavioral problems or school problems caused by ADHD? Of course not. I mean, ADHD isn't the only cause of behavioral and school problems. So what are the other possibilities and how do you distinguish them from each other? And what if more than one diagnosis is at play, how do you untangle that web? How do you diagnose ADHD? What are the treatment options? We'll also discuss the various medications that are used and talk about how they work. What problems are associated with each of those medications, including addiction, potential heart problems, suicidal thoughts?
See, I told you it would be a comprehensive program today. So we'll leave no stone unturned.
What if you elect not to treat ADHD, what other problems can take root if it's poorly treated? Also, how young is too young to diagnose ADHD? Do kids outgrow it? What is the long-term outcome? And what about adults with ADHD?
All these plus the hottest topics in the world of ADHD research. And to help me cover all of these items, I have a great studio guest joining me today. Dr. Rebecca Baum is a developmental and behavioral specialist here at Nationwide Children's and we'll get to her in a moment.
And I do want to sincerely and humbly apologize for this. I realize that you spent time thinking about and composing your questions, and you entrusted them to us, and we flushed them down the drain. So, please know I'm not happy about this situation in the least, but some decisions are out of my control. So, again, I humbly ask forgiveness on this one.
If you've never written in, this is a great time to do it, because I need new questions. It's easy to get in touch with me, just head over the pediacast.org and click on the Contact link. And it's pretty self-explanatory, just fill in the information, ask your question and send it along and we'll get to it here on the program.
I want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, we're going to take a quick break and we'll be back with our studio guest and talk all about ADHD. That's coming up right after this.
Dr. Mike Patrick: All right, we are back and we have a special guest in the PediaCast studio today. Dr. Rebecca Baum is a pediatrician and specialist in developmental and behavioral medicine at Nationwide Children's Hospital. She's also an assistant professor of Pediatrics at the Ohio State University College of Medicine. She joins me today to talk about the nuts and bolts of attention deficit hyperactivity disorder, better known as ADHD.
So welcome to the program, Dr. Baum.
Dr. Rebecca Baum: Thank you. Good morning.
Dr. Mike Patrick: Really appreciate you stopping by. So let's get right to it, what is ADHD? How would you define that term.
Dr. Rebecca Baum: So first of all, I think it's helpful to review what ADHD stands for. And Dr. Mike, as you just said, it stands for Attention Deficit Hyperactivity Disorder. So that really means that kids who have ADHD might have a hard time paying attention. They may also be kids who have a very high energy level and have a hard time sitting still. They may also be kids who are what we call kind of impulsive. So they sort of have a hard time thinking through some of their ideas before actually putting them into action.
Dr. Mike Patrick: Now, there's another term out there, ADD. How is that different from ADHD?
Dr. Rebecca Baum: That's a great question. So the term, ADHD, is actually an umbrella term. And what I mean by that is that, really, when we think about it, it describes sort of three different conditions.
So one is ADHD combined type. And those are kids who might have trouble with both paying attention, as well as having the overactivity and impulsive behavior that we talked about. Bu t there are also kids who might have what we call inattentive type ADHD. Those are kids who predominantly have troubles focusing and they aren't those sort of kids running around with a lot of energy. And so that's often what people will refer to as ADD — so, without the hyperactivity and impulsivity portion of that.
And then, there are some kids who actually are able to pay attention just fine. And they are more of the overactive impulsive kids and we call that hyperactive-impulsive type.
Dr. Mike Patrick: Great. Now, how do you determine what the normal attention span for given ages. So, you know, when you talk about hyperactive and impulsive, I think like a three-year-old, they're pretty hyperactive and impulsive just, you know, as their baseline. So, how do you determine what's normal and what's not normal.
Dr. Rebecca Baum: That's just a great question. So, by definition, I think two-year-olds sort of almost all have ADHD because they're exploring the world and they're enjoying their activity. And so, when we think of whether or not a diagnoses of ADHD makes sense, we absolutely have to take that developmental perspective into account. So, we're going to expect a five-year-old to have a much different attention span than, as you suggested, a three-year-old.
And I think parents and teachers, in general, have a nice kind of inherent understanding of this. Oftentimes, parents might be concerned when they start to compare their child to other kids and they feel like, "Gosh, you know, this other kids at the park can sort of stick with one activity and my child seems to be running from activity to activity without settling in to something." But it's a difficult thing to assess. And oftentimes, we in the medical profession can help families understand, "Gosh, does this feel like it's normal for the child's age or does it seem like it's a bit out of the range of what's typical?"
Dr. Mike Patrick: Sure. So, really, I mean, if parents have question about it and they can seek medical advice and should be prepared. You know, they may say, "Hey, this is normal," but at least the parents reassured that it's normal for the child's age.
Dr. Rebecca Baum: Absolutely.
Dr. Mike Patrick: Great. Now, how many kids are affected? How big of a problem are we talking about.
Dr. Rebecca Baum: You know, it's a little bit of difficult number to get our hands around. And there are some varied estimates out there. But in general, I think, saying about 6% to 7% of the population might be affected by ADHD in childhood, I think that's a pretty reasonable estimate.
Dr. Mike Patrick: So we're really talking millions of folks.
Dr. Rebecca Baum: Absolutely. That's right.
Dr. Mike Patrick: Is there a difference between boys and girls?
Dr. Rebecca Baum: There is. There's also a difference between certain cultures and ethnic groups. There's also a difference in our recognition rates. So, we know that mental health services can be tough to find in some communities. And so we might have some children who just aren't able to receive help or receive a diagnosis.
In general, we think that ADHD tends to affect more boys than girls. And we also see that boys who have ADHD and girls who have ADHD might look a little bit different. So the boys might have more of that high energy level and impulsive behavior and girls might more of that trouble focusing. And what's interesting about that is that it sometimes leads to delays in diagnosis for girls. So that they're not bothering anyone, they're at the back of the classroom and they seem to be doing okay, except that they're really struggling.
Dr. Mike Patrick: Now, when we talk about a lot of diseases, we talk about genetic component versus kind of environmental component to it. Is that true also with ADHD?
Dr. Rebecca Baum: Yeah, and I think for awhile, we used to have the great debate of what we called nature versus nurture. Which is, is it genetics or is it the environment? And what we're really learning is that the answer is yes and yes, so that it's really both. And what's even more fascinating is that we think that there's probably an interaction between genes, meaning the chance that you could inherit this from your parents and the environment. So that, there might be some things in the environment that increase the chance of those genes being what we call expressed or showing off.
And there might be other environmental factors, other things that are happening in a child's life that might reduce the chance of that child ending up having ADHD.
So that's really important as a parent comes to me and says, "Well, I have ADHD so I guess, I should just assume that my son or daughter will as well." And it turns out that it's not quite that clear-cut.
Dr. Mike Patrick: What are some of the environmental factors that could cause the genes to be expressed or not be expressed?
Dr. Rebecca Baum: Many of these environmental factors, I think we're still learning about. And as I mentioned, we used to think that we'd find the answer that it would be just one gene that caused ADHD. And now, we really understand that there are probably many genes, and then we have this complex interaction with the environment.
If we look at large population of children and things that they might have encountered in their environment, we see some varied things pop up. So one of those is maternal smoking during pregnancy. Another one is lead levels. So if we look at a population, children who have higher exposures to lead look like they're at greater risk for developing ADHD.
Dr. Mike Patrick: What about home instability? Do you see more ADHD if there's like a single mom or recent divorce or stresses? Do those play a part in expression or not really?
Dr. Rebecca Baum: Yeah, absolutely. And I think the one point to make here is that when we look at this research,the point is not to blame anyone.
Dr. Mike Patrick: Oh,sure. Yup.
Dr. Rebecca Baum: And I know you didn't mean to suggest that. But we do see higher rates of ADHD in families who are affected by poverty. There are certain parenting styles that tend to make ADHD behaviors more challenging and perhaps maybe even lead to a more likely diagnosis of ADHD.
Dr. Mike Patrick: Sure.
Dr. Rebecca Baum: So those factors are very important as well.
Dr. Mike Patrick: And I suspect, it's not just the home that's an issue, but also the school environment and sort of what kind of teaching style and what kind of classroom. And those kind of environmental factors at school make a difference, too.
Dr. Rebecca Baum: Very much so. You might imagine that in a small class size, the teacher might be much more able to pay attention to each child's behavior. But if we have a class size of say 30 or 35, it may be difficult for that teacher to really pay attention to each individual child.
Dr. Mike Patrick: Sure.
Dr. Rebecca Baum: There's also some interesting studies out there that show that kids who have an earlier birthday, so that they're the youngest kids in the class, tend to be more likely to be diagnosed with ADHD because they look somewhat perhaps more immature than their peers.
Dr. Mike Patrick: Sure. Now, let's really kind of focus in now. Instead of talking about environment, focus in on the brain, what is happening at the brain level that cause ADHD symptoms?
Dr. Rebecca Baum: We now think of ADHD as being what we call as neurodevelopmental disorder. And really, what that means is that this isn't just a child not being able to behave but there are actual brain changes or differences in children and adults who have ADHD. So when we look at the brain there, different parts of the brain have different jobs. So the one part of the brain that's very important in children who have ADHD is the part that we call the prefrontal cortex. That's the front part of the brain that's really sort of the command center for organizational skills and staying on task and staying focused.
And so, if we look at studies where we're trying to figure out what parts of the brain are light up or become active in different types of tasks, we see that part of the brain in children who have ADHD functions a little bit differently than people without that diagnosis.
We also know that there are certain chemicals in the brain which are called neurotransmitters. And we found that the neurotransmitters in children who have ADHD are lower in that prefrontal cortex. So, again, just increasing evidence to show that there really are some actual differences biologically in children who have ADHD.
Dr. Mike Patrick: Now, we do have some clinicians in the audience, pediatricians and scientist-type people and some interested parents as well. And since we're going to talk about the mechanism by which some of the medications that are used for ADHD work, what are some of the neurotransmitters that we're talking about?
Dr. Rebecca Baum: So, dopamine and norepinephrine are the two that we think really play a role in ADHD.
Dr. Mike Patrick: Now, we talked about genetics and environment. A couple of other issues I know some parents have a question in their mind, what about in the diet? People talk about kids getting sugar and getting hyped up on sugar, is there any reality to that?
Dr. Rebecca Baum: There is really…
Dr. Mike Patrick: [Laughter]
Dr. Rebecca Baum: So there's really not a lot of good evidence. When I say evidence, I mean a very rigorously designed scientific study to suggest that an excess amount of sugar leads to ADHD symptoms. In the early 1970's and 1980's, there was a specific diet called the Feingold diet and some folks thought that perhaps that could be a treatment for ADHD. And again, there's not a lot of evidence that dietary changes like that really contribute to ADHD or can really be successful in ADHD treatment.
Now, I will say that whenever a parent comes to me and says, "Dr. Baum, I really feel like every time I give Johnny sugar, his behavior goes off the charts." That's certainly nothing I would necessarily argue with, unless sugar is probably good for all of us.
Dr. Mike Patrick: What about dyes and artificial colors? Are they same as the sugar there?
Dr. Rebecca Baum: Yeah, and that was really the purpose behind the Feingold diet, thinking that there might be certain dyes that contributed to ADHD-like behaviors and really, not a lot of good evidence to suggest that that's the case.
Dr. Mike Patrick: Now, in terms of signs and symptoms then that this problem the brain causes — so sort of what the parent sees then — what sort of behaviors, signs and symptoms of ADHD do we see?
Dr. Rebecca Baum: So, in general, we think of things in terms of these two categories that I've mentioned. So categories of inattention or having a hard time staying focused. And then, the category of hyperactivity — high energy level — and impulsivity, sort of having a hard time waiting. And so we look at, actually, the number of symptoms, the intensity of those symptoms, how often they're happening. And we're looking not only for the types of symptoms that we see, but in a child who we're actually going to make a diagnosis of ADHD, we're looking if in fact those symptoms cause significant difficulties for the child.
I think we all know people who are really busy and have a lot of energy, they don't necessarily have ADHD unless those types of symptoms are causing them significant difficulty. And for kids, we're talking about difficulty with peers, difficulties at school, significant difficulties in the functioning of their families.
Dr. Mike Patrick: So if you have a kid who's easily bored or they frequently daydream, I mean that could be an attention issue but it's only really an issue if it's affecting their life.
Dr. Rebecca Baum: That's right. And just to give you a sense on how we diagnose ADHD, I think all of us are waiting for that test we can run to know if in fact ADHD is there. But it's really what we call a clinical diagnosis. So we gather information from families. And we gather information from teachers because we know that kids obviously spend a good part of their day at school with really rigorous oftentimes requirements for them to stay focused and stay in their seat.
And so, we look at these types of symptoms and the type of impairment they're causing. And then, also, we have some additional tools that we like to use to make sure that the information we're getting is really on target. And we could talk about those if you'd like later on.
Dr. Mike Patrick: Yeah. Yeah, go ahead. Let's go ahead and talk about that. So we're talking sort of behavioral skills kind of things?
Dr. Rebecca Baum: That's right. That's right. So in order to get information in what we call more of an objective way, we also like to gather, Dr. Mike, as you said, what we call behavioral rating skills or screening tools. And so, if a parent is asking to have their child evaluated for ADHD, they might want to be prepared for some additional questionnaires that ask specifically about the symptoms of ADHD. And then, usually, teachers are asked to fill out those kinds of questionnaires as well.
The questionnaires help us understand if it looks like ADHD is present but also help us think about if any other symptoms could relate to other disorders. For example, sometimes, kids who are really anxious have a hard time paying attention, because they're so busy worrying about things. And so, the questionnaires help us both look at whether ADHD is present, but also look up if something else could be present as well.
Dr. Mike Patrick: Now, of course, something else being present could be a mental health issue. But then, there are also some medical conditions that could cause some of these types of symptoms, too. So what sort of medical screening is done on kids when you're first attempting to see if they have ADHD or not?
Dr. Rebecca Baum: So, one of the things we always like to make sure is that vision and hearing are what we call intact. So a child who has trouble seeing is going to, perhaps, look like they're having a hard time paying attention and same thing with hearing difficulties.
Some other more rare conditions that we might think about, maybe something like a seizure disorder. So, for example, there is a certain type of seizure which we call staring spells or absence seizures. And those kids might look kind of zoned out, like kind of spaced out or stare for a minute or two. The key point here is that, this is really different than daydreaming. The key point here is that if you try to get their attention or call their name or even touch them on their shoulder, they still just really can't focus on you, and can't pay attention. And just as quickly as it happened, they snap to and all of a sudden, they're able to interact with you again.
The other thing I'll just mention too is the issue of sleep problems. So many kids and especially teenagers are having trouble getting the recommended amount of sleep. And so a child who's sleepy during the schooled day might again have trouble paying attention. And even things like what we call obstructive sleep apnea so the child who not only snores very loudly but has trouble catching their breath and has obstructed sound and breathing. That's been linked to symptoms of inattention during the day as well.
Dr. Mike Patrick: Now, let's say that you go through this, you do a complete history and physical and any medical screening and the behavioral skills and you do come up with the diagnosis of ADHD. How do you go about treating that?
Dr. Rebecca Baum: I think, first, it's really important to talk about how the diagnosis is made. So I always like to go through that with families and make sure that they understand the process that we went through. And then, really start doing some education about that ADHD is. And so, a lot of the content that we've already covered, I talk about with families as well.
We, then, decide on some goals.So I like to talk with families about what goals are important to them. And I have in my mind what might be important to me. But to really be working together as a team, I think will be the most successful. And those goals could range from success at school. They could range from getting homework done. Some families tell me that they just would love to be able to go out to a restaurant together and enjoy a meal as a family.
And once we established those goals, we then have to talk about different types of treatment and how we may be able to achieve those goals. And for ADHD, those types of treatment usually fall in to sort of I would say two to three realms. One is medication, another is what we call behavioral interventions.
And then, the third is thinking how we're going to work with the school, because sometimes children with ADHD might benefit from support in the school setting.
Dr. Mike Patrick: And I think this is important because a lot of people, in their mind, when they think ADHD, they immediately jump to "Oh, my kid's going to have to be on medication." But there are some kids that, just by manipulating their environment both at home and at school, perhaps you might not have to do medication.
Dr. Rebecca Baum: I would say, again, if we look at large populations of kids in trying to understand what's the most helpful treatment, we probably get the most benefit from medication. But medication for some children either isn't an option or some parents are very wary of medication. And so, there is certainly some other techniques that we can use and sometimes they can be quite effective.
Now, let's go down that medication pathway then. What sort of classes of ADHD medication and how they work and some examples?
Dr. Rebecca Baum: So, what we call the first line treatment for ADHD in terms of medications is the group of medicines that we call stimulant medications. And parents always say, "Well, my child is so hyperactive, why do you want to put him on a stimulant?"
Dr. Mike Patrick: [Chuckle] Yes.
Dr. Rebecca Baum: And the way I think about it is that they stimulate those parts of the brain that aren't working as we would like them to, that prefrontal cortex, for example.
There are two main types of stimulant medications. And here I'm going to get a little bit technical. But I think it's worthwhile pointing what some of these names are. So one group is called the methylphenidate group and the other group is called the amphetamine group. And there are lots of medicines in each of those classes nowadays which is good news for us because we can really tailor the treatment to the individual child. But really, either of those two types of stimulant medications are pretty much equally effective and you can start with either class.
Dr. Mike Patrick: Now, we certainly don't advocate any name brands here or recommend one over another. But just so parents have an idea of what… So the methylphenidate group, we're talking things like Ritalin, Concerta, the Daytrana patch, that's sort of to that group.
Dr. Rebecca Baum: That's exactly right. And I think it is worthwhile to know some of the different brand names out there because we can say methylphenidate and that can refer to six to seven different types of medications.
So, in general , we have tablets and we have capsules. We also have a patch which is called Daytrana, as you mentioned. And the capsules and the tablets work a little bit differently. In general, the tablets are short-acting medications, so that a child would take one dose in the morning, a dose at lunch, a dose after school. And that Ritalin is a common form of the short-acting tablets.
Some of the longer-acting medications which could last anywhere from 8 to 12 hours are medications like Ritalin LA, standing for long acting, Metadate CD, standing for continuous delivery, Concerta, Focallin XR. Those are some of the long-acting medications and those often work well for school-aged kids who don't really like to shuffle off to the nurses' office in the middle of the day.
Dr. Mike Patrick: And then, what are some examples in the amphetamine group?
Dr. Rebecca Baum: So an older medication is Dexedrine and Dexedrine Spansules is a longer-acting version. We don't tend to use that quite as much anymore. You'll often see a medicine called Adderall, the shorter-acting version, or Adderall XR for extended release. And then, a newer medication called Vyvanse, which is very similar. In fact, it's the active ingredient in Adderall, but it's metabolized a little bit differently in the body. And so, sometimes it might work a little bit better for an individual child.
Dr. Mike Patrick: Now, how do these stimulant medicines work? What are they doing in the brain?
Dr. Rebecca Baum: The stimulant medications work by affecting those neurotransmitters that we talked about. So they work by increasing the levels of dopamine and norepinephrine in the parts of the brain that we think are important in ADHD — so in that prefrontal cortex, for example.
Dr. Mike Patrick: What about caffeine? Some people say, "I drink my coffee and that's how–" especially in adults. "That's how I keep my ADHD under control." Is there any benefit of caffeine in kids?
Dr. Rebecca Baum: Yeah. So, really, I would stir people towards the medications themselves because they would obviously be able to regulate them better. I do have families who come to me and say, "Gosh, I gave him some Mountain Dew and it really seem to help." But really, we think if ADHD is actually a disorder that's at play that using a medication that we could regulate at will. So there you go.
Dr. Mike Patrick: I told you I would ask you the tough questions today.
Dr. Rebecca Baum: [Laughter]
Dr. Mike Patrick: So let's talk the non-stimulant medications then. What kind of classes and drugs are available for that?
Dr. Rebecca Baum: So there are a few different types of non-stimulant medications. One group or one medication that I'll mention is called atomoxetine and the brand name here is Strattera. And this medicine was initially developed almost to look like an anti-depressant. But it turned out that it wasn't a very effective anti-depressant but had some benefits in people who were found to have ADHD.
One of the differences with atomoxetine as compared to the stimulants that we talked about is that it takes probably about four or six weeks for atomoxetine to work. So with the stimulant medications, they're nice in that you can give them and within about an hour or so, they start working. And then, they wear off and they're out of your system by the end of the day. With Strattera, the medicine really needs to build up in your system and you really need to take that medicine every single day, as opposed to the stimulant medicines which you could theoretically just give during the week and take a break on weekends.
Dr. Mike Patrick: There are some other classes of medicine, anti-depressant medicines, things like clonidine, what's the role of those in ADHD?
Dr. Rebecca Baum: So I would say after atomoxetine, we move down to a group of medicines that we call the alpha-agonists. And that describes a bit how their mechanism of action in the body. But there are two main groups of medications here.
One group is clonidine. And clonidine, we tend to give at night times, sometimes, if we have significant problem sleeping. But it recently received an FDA indication for treatment of ADHD. So it now comes in a long-acting form that we can give up to twice a day in order to help with daytime ADHD symptoms.
The other medicine that has an FDA indication for ADHD now is similar to clonidine. It's called Intuniv. That's the brand name and the generic name is guanfacin. Guanfacin is very similar to clonidine, except that it doesn't tend to cause as much drowsiness. So we will sometimes use the short-acting form up to three times a day, but now, we're lucky that we have this Intuniv which is a long-acting form and we could use it just once a day to treat ADHD.
Dr. Mike Patrick: In terms of medicine dose, I just want to point out for some parents that this is something that you really have to titrate on an individual level because sometimes you think littler kids need littler doses. But that's not always the case, is it?
Dr. Rebecca Baum: Yeah. I always talk to families about this, because I think it can feel a bit like we are experimenting and don't quite know what we're doing. In fact, the strategy we use for these medications is to start at a very low dose. In fact sometimes a dose that's so low, we might not even see any effects. And then, we gradually increase the dose until we're starting to see some of the clinical benefits but we minimize side effects along the way.
With some of our medicines, we dose them completely based on how much you weigh. And with these types of medicines, I'll say the stimulant medicines in particular, as you've mentioned, I have some really big kids on really low doses of medicines and some really little kids on very big doses. So we really need to individualize it to that specific patient.
Dr. Mike Patrick: And some of that is just how quickly their body gets rid of the medicine. So if you have a little kid who metabolizes or gets rid of the medicine, there's none left leftover to get up to the brain, is that correct?
Dr. Rebecca Baum: That's right. That's right. And probably in, I don't know, five or ten years, we'll be able to do some blood testing to see who metabolizes or who's able to get this medicine into their system quickly and who of us need higher dose because that metabolism is more slow. But right now, we're really left with the trial and error method. But I like to let parents know that a head of time.
Dr. Mike Patrick: Yeah. If their expecting it, you know then it's not issue. It's essentially about the education part of it.
Dr. Rebecca Baum: Right.
Dr. Mike Patrick: Now, there's a lot of bad press out there on some of these medications. Talk a little bit about addiction.
Dr. Rebecca Baum: We know nationally that there are certainly problems with these medications being taken for reasons that they weren't intended. So we call that diversion. That I write a prescription and it doesn't end up in the child. It ends up in the hands of someone who's using it for an inappropriate use.
For some families, they have concerns about whether or not an ADHD medicine might cause their child to develop an addiction later on in life. And so far, we really don't have evidence that supports that. In fact, what we think is that when ADHD isn't treated adequately, kids are more likely to have social problems, school problems and more likely to end up using substances than if their ADHD was treated appropriately.
So I think we need to be mindful of the fact that these medicines can be abused and certainly can be diverted to people who are using them for unapproved uses. But I would much rather treat a child appropriately and get them the help that they need and take safeguards for the other issues.
Dr. Mike Patrick: Absolutely. What about heart-related issues?
Dr. Rebecca Baum: So, the stimulant medications, almost all of them have a potential side effect of increasing heart rate and blood pressure. Now, usually, those increases aren't clinically significant. So that if my heart rate is 80 or 85, those two numbers really don't mean anything significant. Rarely, we'll see a child who really does get what we call tachycardia or increased heart rate or increased blood pressure hypertension from these medications. And so, we like to monitor children when they first start these medicines and then, during treatment to make sure that those problems aren't developing.
The other thing that we do is we like to take a careful history to make sure that child hasn't had any history of heart problems or that there's a history in the family of an unusual heart rhythm or early what we call cardiac death. And as long as those two things seem like they're not of concern, usually we can pretty safely use these medications in most children.
Dr. Mike Patrick: Is there a rule for getting an EKG before starting these medicines?
Dr. Rebecca Baum: No. Gosh, about five to maybe eight years ago now, there was a call for an EKG for a brief period of time before we started stimulant medications. And since then, we've really done a lot of research and there's been a lot of effort to understand if in fact that's necessary. And the current recommendations from multiple organizations are now that, in fact, you don't need to do an EKG before you start a medication. But you need to take that careful history as I was mentioning before.
Dr. Mike Patrick: Sure.
Dr. Rebecca Baum: And I will say if there were parents out there whose child does have a heart disease or has had heart surgery, we do know that some of those kids will struggle with ADHD symptoms for a variety of reasons. And often, when we work together with a cardiologist, we're able to use those medicines in a careful and controlled fashion.
Dr. Mike Patrick: You know, with some of these medicines, we see some appetite suppression and possibly some weight loss, speak to that.
Dr. Rebecca Baum: Yeah, that's another potential side effect, particularly of the stimulant medications. And usually, we can do some creative prescribing or creative meal planning to get away from those potential side effects. So, sometimes, we might switch to another medication going from, say, the methylphenidate group to an amphetamine type medication. And sometimes, by just switching classes like that, we'll see a reduction in that sort of side effect.
Oftentimes, kids who are on long acting ADHD medicines will get hungry after dinner and before bedtime. And so just building in a bedtime snack and trying to encourage those healthy but high calories food, that can often be helpful too.
Dr. Mike Patrick: And there's also been some press out there on the suicidal thoughts that's associated with some of these medications. Is there any concern there?
Dr. Rebecca Baum: So the medicine atomoxetine which I mentioned, otherwise known as Straterra, initially sort of marketed or developed to be an anti-depressant, it is somewhat similar to another group of medicines that we call this selective serotonin re-uptake inhibitor which we use for anxiety and depression. Sort of distantly related, but similar enough that the FDA thought they needed to put what we call a black box warning on the medication.
So there was a very small increase in suicidal thoughts in children who were taking this other group of medication. I want to point out that there were no completed suicides but a very small increase on the order of 1 to 2 % in the group treated with those medications. And the FDA sort of thought long and hard about what to do with that information and thought that it was best to put a black box warning on those what we call SSRIs as well as atomoxetine.
And so I usually again do talk with parents about this. I think their risk again is very low but it's a usual conversation to have.
Dr. Mike Patrick: So, once you started an ADHD medicine, then how do you go about kind of following them along and deciding whether you need to increase it? How do you follow and manage and adjust the doses.
Dr. Rebecca Baum: As I mentioned, we like to s tart low and then, gradually increase the dose. And this is where having those goals that I mentioned earlier really comes into play. So, we talk about, "I really want to make sure that Sam gets more than 85% of his homework assignments turned in." So that's a great goal to have. And we can determine how we're doing based on that goal as we increase or have Sam on his medication.
Little thing that we can do is use those same what we call behavioral rating scales or questionnaires that we use to assess a child for ADHD. We can use those to monitor treatment as well. So we would expect that, ideally, the child's score on those questionnaires would come out of the range of what we call clinically significant. So we'd see those symptoms really reduced. And that's what we'd like to see with an adequate dose of medication.
Dr. Mike Patrick: Now you talked a little bit about risks and complications associated with poorly treated ADHD, that there may be more adult addiction problems. Are there other issues? I mean, why is it important to treat ADHD? What can happen with the child if we're not treating it?
Dr. Rebecca Baum: I think there are really a couple of questions wrapped up into one there. So, one is the question of what happens to kids who have ADHD that's poorly treated. But then, also, the question of what happens to adults and some of that data's just really starting to evolve for us. In general , we tend to think of mental health condition in kids as sort of an extension of what we see in adults. And ADHD is really different. This is a condition that was identified in children and now, we're starting to have to think about what it means to have ADHD as an adult.
So, one of the challenges with pediatric ADHD is that oftentimes, kids will have ADHD and they might have another disorder as well or likelihood to develop another condition. And those conditions could be things like a learning disability, it could be anxiety or depression. And so, if a child has ADHD and they really continue to struggle at home with peers, academically, that child is probably at higher risk to develop some of these other symptoms like being problems with poor self-esteem, problems with anxiety, problems with depression.
So we really like to make sure that we're treating the ADHD so that child can be successful and we can see that self-esteem really grow and flourish during childhood and adolescence.
Dr. Mike Patrick: And I would suspect getting that good history and then, looking at the behavior rating skills focused on specific questions that look at disorder that look at other disorders and anxiety, oppositional defiant conduct issues, I mean, just that sort of helps give you an idea if there are those other things going on. And then, you would treat those in an appropriate manner as well as the ADHD.
Dr. Rebecca Baum: That's right. And in general, what we do is we treat the symptoms that are most significant at any given time. So if a child has ADHD and we think they're starting to get a bit depressed because of how they're doing in school, we would treat the ADHD and then sort of follow those depressive symptoms along over time.
The other thing that you mentioned which is a really important condition to talk about is something called oppositional defiant disorder. And a good percentage, probably more than 30% of kids who have ADHD also have enough symptoms that we might also want to think about a diagnosis "oppositional defiance disorder". And these are kids who tend to be oppositional. They tend to be kind of tough to parents and they tend to be a bit challenging sometimes.
And what I always remind families is that the medicine is really helpful to treat the ADHD symptoms but the ODD symptoms really don't respond to medicine and we need to have some other strategies to address that.
Dr. Mike Patrick: You know, you talk about some of the other complications if you don't have well-treated ADHD — so that poor self-esteem, poor school performance. I just, as an emergency medicine physician, would want to also say that you see increased accidents and injuries in kids who are impulsive and hyperactive. Kind of bad combination and another reason to treat them.
Dr. Rebecca Baum: That's really true. And you started off, I think, the PediaCast mentioning something about preschoolers. The idea of diagnosing preschoolers with ADHD is really an evolving one. But oftentimes the preschoolers who we see with ADHD as a concern are exactly the kids that you mentioned, the kids who have multiple accidents, serious injuries. And oftentimes, that's why they're coming to our attention.
Dr. Mike Patrick: Now, as we transition from pediatric ADHD to talking about adult ADHD, what is the likelihood that pediatric ADHD turns into an adult problem. Is this something that kids outgrow, don't outgrow and sort of what percentage will do which?
Dr. Mike Patrick: It's a loaded question.
Dr. Rebecca Baum: Yeah. So one of the tricky things. Remember, I talked about the prefrontal cortex, right? So that part of your brain turns out to be one of the last parts of your brain to mature. Kind of make sense as we think about teens and some of the behaviors that they are involved in. So, to some extent, we always wonder is ADHD sort of a developmental disorder? Meaning that prefrontal cortex is going to mature in some of those ADHD symptoms go away. And we certainly do know that there are children who had a diagnosis of ADHD when they were younger and really do seem to grow out of those symptoms as adults.
We also know that there are some kids who had a diagnosis of ADHD who find jobs and careers and relationships that really match their personality. And so, they still continue to have those ADHD-type symptoms but they don't have that impairment that I talked about earlier.
And then, there's a question of what percentage of kids who have ADHD really persist with those symptoms into adulthood. And to some extent we have to be careful about these studies. If you were to look in my clinic where I see patients, you would see a very, very high rate of ADHD because those are the families and patients who I see. So, it would really helps if we look at what we call community samples where we're looking across the community and track kids who have a diagnosis of ADHD over time.
There was a really nice study that was just recently published in April's edition of the journal called Pediatrics and that's exactly what they did. They follow the group of individuals who were born in the late 70's and early 80's and they've now followed them up into — I think they're about 27 to 30 now — and 30% of those children who had a diagnosis of ADHD in childhood went on, through very strict research criteria, to still have a diagnosis of ADHD in adulthood.
Dr. Mike Patrick: So this is a significant issue. But as you mentioned, to some degree, we can pick our careers and our relationships. So, you know, if you got a good match you can have those symptoms and it may not really interfere with your life as much as if you were in a different situation.
Dr. Rebecca Baum: That's exactly right.
Dr. Mike Patrick: So if you're an emergency medicine physician with ADHD, you'll probably do better than an accountant who's working on tax forms all day, right?
Dr. Rebecca Baum: Right.
Dr. Mike Patrick: Okay.
Dr. Mike Patrick: Not that I have ADHD. Oh, maybe I do, I don't know.
In terms of adults who have this, I also want to mention, just because people who have ADHD issues that are poorly treated, just as in kids, adults who are poorly treated who maybe do have that mismatch and things aren't going well in their life, is it true we do see more substance abuse, divorce, crime, incarceration for people who have poorly controlled ADHD?
Dr. Rebecca Baum: That's true. That is very true. And the study that I just mentioned have a bit of sobering statistic in it. Was that when they compared the two groups, they had a group of what we call control individuals who did not have childhood ADHD. And then, they looked at these individuals who's ADHD persisted into adulthood. They saw a significantly increased risk for suicide in the persistent ADHD cases.
Again, I think there are lots of factors that can be protective but I do think we need to realize that ADHD isn't just a disorder of childhood that can be sort of bothersome and frustrating sometimes. It really can have some long lasting effects.
Dr. Mike Patrick: And so the adult world needs to get on board, the adult medical world, with recognizing this and diagnosing it and treating it appropriately.
Dr. Rebecca Baum: That's right.
Dr. Mike Patrick: What are some hot topics in ADHD research?
Dr. Rebecca Baum: I think one of the hot topics is genetics. And I think, naively, we were hoping that there will be just one gene that cause ADHD. And we're really learning now, with ADHD and in fact many conditions that we see — mental health conditions and autism, for example — that there are probably many different genes. I think what's really interesting is that many of the genes that have been identified so far, and there are quite a few, actually are genes that play a role in those neurotransmitters that we mentioned and in metabolism, with the processing of things like dopamine and norepinephrine.
So I think that's encouraging because it means we're on the right track. But there's certainly is plenty more work to do, and I'll think what we'll see is more and more of information to help us answer that question of genes, environment and how those two things interact. And that field is called epigenetics.
Dr. Mike Patrick: Great. Well, we really appreciate you stopping by the studio today to talk about ADHD.
We do have some links for parents. We offer a program here at Nationwide Children's Hospital called the ADHD Academy and it's an educational program for parents. And in the Show Notes, I'm going to put a link to our education enrollment page for that. So if you're interested in more information or enrolling in that, particularly for those of you who are in Central Ohio, we'll put a link to that in the Show Notes. Also the ADHD services at Nationwide Children's, including educational resources, appointment requests, I'll put a link to all of those things as well.
And there's also a comprehensive site called CHADD or Child and Adults with ADHD. It's a national organization that offers education, support, local groups. Just lots of great of information there, and we'll put a link in the Show Notes. Again, this is Episode 246. So if you head over to pediacast.org and click on Episode 246, look for the Show Notes and we'll have links to all those things for you.
So Dr. Baum again, I really appreciate you stopping by today.
Dr. Rebecca Baum: Thanks for having me.
Dr. Mike Patrick: All right, we are going to take a quick break and I'll be back to wrap up the show right after this.
We choose one question each week and provide a video answer direct from the PediaCast studio, plus you'll find an archive of all of our past video responses to your questions. So be sure to check that out at the Nationwide Children's Hospital Facebook page. And again, you can find the link to that in the Show Notes for Episode 246 at pediacast.org. Or you can just hop over to Facebook and search for Nationwide Children's Hospital. It's an easy thing to do.
And that's my final word.
I'd like to thank everyone for tuning it today and to Dr. Rebecca Baum for stopping by and sharing her expertise on ADHD. I want to remind you, iTunes Reviews are helpful as links mentioned, shares, re-tweets, re-pins, all those things on Facebook, Twitter, Google Plus, Pinterest, et cetera. We're in all of those place.
Also be sure to tell your family, friends, neighbors and co-workers about the program. And most importantly, tell your child's doctor next time you're in for a well checkup or sick office visit. Just let them know about PediaCast so they can spread the news to their other patients and we do have posters available under the Resources tab at pediacast.org.
All right, that wraps things up for today. Until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids.
So long, everybody!
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.