ADHD in the Age of COVID – PediaCast 473
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- Drs Ben Fields and Kelly Wesolowski visit the studio as we consider ADHD in the age of COVID. What challenges are in store for families as they encounter the new classroom, remote learning and hybrid models of instruction? What does ADHD look like at home and school? How is it diagnosed… and managed… in 2020? Join us for answers!
- Attention Deficit Hyperactivity Disorder (ADHD)
- Coronavirus Pandemic (COVID-19)
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. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in the Columbus, Ohio.
It's Episode 473 for September 23rd, 2020. We're calling this one "ADHD in the Age of COVID". I want to welcome all of you to the program.
Our last couple episodes explored many topics related to the children returning to school in the year 2020, which we hope has been helpful information for families as they embark on a schoolyear like none other in recent history.
We've talked about social distancing, physical distancing, really the better term, hand washing, staying home when sick, reasons for COVID testing, and what to do if your child or another child at school or a teacher tests positive. We've covered in-person instruction, home schooling, remote learning, and hybrid models of teaching.
And a couple weeks ago, we explored student athletes returning to sports following a COVID infection including mild cases and even those who seemed to have had no symptoms at all but they test positive for COVID-19. Turns out inflammation of the heart is still possible in those folks who have very mild cases, and certainly if you have symptomatic COVID-19, we also worry about inflammation of the heart.
This is known as myocarditis and it can cause electrical problems in the heart, which in turn can interfere with the normal heartbeat and even result in the sudden death of an athlete who has myocarditis and is actively exercising or playing sports, which is why there's been so much controversy with fall sports including college football.
And although we do not know for certain how common myocarditis is following COVID infection or how often significant problems including sudden cardiac death might be expected in athletes with myocarditis, we don't know for certain because we're still learning about this associations and risks. The science is emerging and each day, we learn a little more which is why you see evolving recommendations. Recommendation change as science reveals more answers.
However, we do not need all of the answers or the complete picture to take actions that protect our children, right? And it's out of this abundance of caution for the safety and well-being of our children that we say all student athletes, at least right now on September 23rd, 2020, student athletes who have had an infection with COVID-19, all of them, even those with mild or no symptoms, you need a period of rest.
And you need clearance from a doctor who can address the possibility of heart involvement and gradually medically supervised return to play, much like we do for student athletes with a concussion.
We had lots more to say on this topic including the role of cardiac or heart MRI in detecting the presence of myocarditis and student athletes. We covered all these inconsiderable detail during our most recent episode, "Returning to Sports After COVID" and that was PediaCast Episode 472. So, that's an episode I will highly recommend for families with student athletes at home.
Our recent episode involving COVID in school, that was "Back To School with COVID", Episode 471, lots of great information there as well. And I will put links to both episodes in the show notes over at pediacast.org for this episode so you can find them easily.
Today, we cover a third topic related to school and COVID as we think about ADHD in light of the new school year and the coronavirus pandemic. How does ADHD impact students and families in 2020? How might this common condition create challenges in the new classroom and with remote learning, homeschooling, and hybrid models of instruction?
What are the telltale signs of ADHD at home and in the classroom? How is it diagnosed? What can parents do when ADHD impacts members of the family?
To help us explore the topic and answer all of these questions and more, we have a couple of terrific guests visiting us this week, Dr. Benjamin Fields and Dr. Kelly Wesolowski. Both are clinical psychologists with the Big Lots Behavioral Health Services at Nationwide Children's Hospital.
Before we get to them, I would like to remind you, you can find PediaCast wherever podcasts are found. We are in the Apple and Google podcast apps, iHeart Radio, Spotify, SoundCloud, and most other podcast apps for iOS and Android. If you like what you hear, please remember to subscribe to our show so you don't miss an episode.
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We're also in social media and love connecting with you there. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.
We also have a Contact link over at pediacast.org if you like to ask a question or suggest a topic for a future program.
Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.
Let's take a quick break. We'll get our experts connected to the studio. And then, we will be back to talk about ADHD in the age of COVID. It's coming up right after this.
Dr. Mike Patrick: Dr. Benjamin Fields and Dr. Kelly Wesolowski are both pediatric psychologists with Big Lots Behavioral Health Services at Nationwide Children's Hospital and assistant professors of Psychiatry at the Ohio State University College of Medicine. They're here to talk about attention deficit hyperactivity disorder, also known as ADHD.
And there are lots of points to consider as we think about this condition in 2020, as children return to school in the context of the worldwide pandemic and a host of educational models including in-person classes which look quite a bit different from last year. Remote learning, hybrid plans, and home schooling, ADHD impacts all of these choices and gives us much to consider.
But first, let's extend a warm PediaCast welcome to Dr. Ben Fields and Dr. Kelly Wesolowski. Thank you both so much for stopping by today.
Dr. Kelly Wesolowski: Thanks. Thanks for having us.
Dr. Benjamin Fields: Sure, sure.
Dr. Mike Patrick: So, let's talk first just in general, ADHD, Ben, give us a brief definition. What exactly do we mean by that term?
Dr. Benjamin Fields: ADHD is a nerve developmental disorder which means, basically, it's a disorder that starts to reveal itself and cause problems as the brain develops during childhood. And really, in general, to try to sum it up for people, it really impacts the way the brain regulates a lot of functions, how a kid controls his attention, his behavior, his motivation, and even emotions which is often kind of overlooked.
What underlies these symptoms of ADHD is what we're calling executive functioning deficits. Executive functions are set of cognitive abilities that help us to regulate and organize our behavior. And these abilities continue to develop even into our late 20s, even in people without ADHD.
And typically, kids and adolescents with ADHD are delayed in terms of the development of those executive functions and, in a lot of cases, won't completely normalize in adulthood even, although some of them appear to.
Dr. Mike Patrick: And as we think about that executive function and attention and how we regulate ourselves and activity, it's so different depending on a child's age. That at one age, you would say, "Well, maybe a kid does suffer from this." But that could be totally normal behavior at another age.
So, how do you tease out what's normal behavior for a child at this specific age and then what you would consider to be a problem?
Dr. Benjamin Fields: Now, I think that's the whole question. That's the whole trouble with this, right? The trick in diagnosing this is that all the symptoms of ADHD basically at some level, as you mentioned, are developmentally appropriate at some age. And it is more difficult when kids are younger to tell if it is developmentally appropriate or not.
And it usually reveals itself again over time. A lot of times, these kids are in school and the demands increase and it becomes more obvious to the adults sitting around them, that their behaviors are not lining up with what the other kids do.
Dr. Mike Patrick: Yeah, and so ultimately to some degree, we have to look at the function of a child within their environment to determine whether this is a quote problem or not a problem. You could have some environments where a kid would be just fine with their level of attention and activity, and in other situations, it's not so fine.
And so, some point we have to decide is this interfering with the quality of the child's life, their education, the family's life? And so that can be pretty tricky at not a one size fits all, correct?
Dr. Benjamin Fields: For sure. And we do like to see some overlap, right? We'd like to see that these symptoms are appearing in more than one setting and causing some difficulties across settings, but as you mentioned, it's definitely not the same across there.
And there may be certain environments where a kid's interest are high or the demands or such that you might not see these, these might not be noticeable symptoms at all. You put them in a different situation and they're very evident, so.
Dr. Mike Patrick: And then, who is affected by this condition? How common is ADHD at least here in the United States?
Dr. Benjamin Fields: Our best estimates are that it occurs in probably 5% to 7% of kids and maybe 3% to 5% of adults. Some adults what's happening is some adults in that criteria as kids don't meet full criteria as adults. They don't demonstrate enough symptoms or impairment as adults to still meet full criteria. But a lot of those adults who don't meet full criteria for ADHD still experience some symptoms and impairments even as adults.
Again, it may interact with their environment in a different way. So, for example, when you see adults who are working in a job that they're very interested in and good at, some of these things are not going to cause as many issues necessarily.
It does look at boys are more likely than girls to be diagnosed with ADHD. And that seem to dissipate over time though into adulthood and seems to equalize more. This is present across social classes, ethnic groups.
We see it at different countries. Some of the differences and prevalence across different countries are probably due to some cultural factors, what's considered abnormal, and how much impairment those symptoms cause. And that can depend on, again, the environments, what's the demands are in a kid in certain situation.
We really seen cases of ADHD described for centuries really pretty detailed description for over 100 years. The name is varied over the years, but this has been around for a long time. So, most people think of this as a very modern problem and it doesn't look like this.
Dr. Mike Patrick: When you say that you see across all socioeconomic backgrounds, all cultures, is there disparities in the diagnosis and treatment of this condition? I mean, this is something that affect some people more than others because maybe it's not being diagnosed and treated?
Dr. Benjamin Fields: There certainly are concerns, right, that certain groups of people might be not identified as much or inappropriately underidentified or overidentified. And I think the research is still developing in terms of what we know about that.
But certainly, we just think about too like disruptive boys or just identified easier, for example, than the kind of quiet, disorganized inattentive girls that's kind of a classic demographic difference that we see a lot.
Dr. Mike Patrick: And as I ask that question, I was thinking more of people who would be underdiagnosed, but you're right. I mean, there may be overdiagnosis depending on the tolerance of specific behaviors within a group setting. And that can be just as much of an issue as overdiagnosing or underdiagnosing it.
Dr. Benjamin Fields: Absolutely.
Dr. Mike Patrick: Do you see this running in families? Is there a genetic component do you think to this condition?
Dr. Kelly Wesolowski: For sure. ADHD is inherited to the same degree as height. So, if you have a parent with ADHD, the child is over 50% chance of having it. It definitely runs in the family. It's in fact that's our most common answer, I guess, when parents start to ask us why is this happening or where did it come from?
Oftentimes, we can look back in the family tree and whether it's the parent themselves that had been diagnosed or at least the parent who might say, "Yeah, I was like that when I was kid and I wasn't really diagnosed," or, "People just thought I've misbehaved or I was put in a class for slow learners," or something like that.
And sometimes, you'll have parents say, "I didn't have that problem, but my brother did or my sister did when they were younger." So, it definitely runs in families for sure.
Dr. Mike Patrick: As we think about the cause, the genetic component, are there any environmental factors that would cause ADHD?
Dr. Kelly Wesolowski: I would say not an environmental factor that would necessarily cause it, but certainly environmental factors can exacerbate symptoms, right? So, stress in the family, parents who are struggling with their own ADHD or other mental health concerns that sort of thing could definitely intensify potentially symptoms. And then, certainly, challenges in a school environment as well could intensify symptoms or make them look more challenging.
Dr. Mike Patrick: And especially as we consider this school year and things not being normal and kids not really working on school in the ways and the environments that they are used to in the past, that may bring out more of these symptoms in kids who may have only have mild symptoms before, right?
Dr. Kelly Wesolowski: For sure.
Dr. Mike Patrick: Before we talk more about diagnosis and management of ADHD, let's drill down just a little bit further for parents who may be interested in the science of this. What's happening in the brains of these kids? What causes ADHD at the cellular or tissue level of the brain?
Dr. Kelly Wesolowski: Well, what we know is that from a brain perspective, the processes that are impaired in people with ADHD are definitely located in the frontal lobe. And the frontal lobe is the part of the brain that's responsible for functions like problem solving, memory, motivation, impulse control, decision making, attention, time perception, amongst a lot of other things.
And so, these are definitely functions that then all are impaired in children and adolescents and adults with ADHD. So, we know that there are differences in the brain structure, in the network, some of the neurotransmitters like dopamine, and norepinephrine and kids with ADHD, especially within that frontal lobe. So, those are some of the factors in the brain and that's kind of where the disorders are located, if you will.
Dr. Mike Patrick: If you just Google ADHD and causes, you're going to see all sorts of things. But some of them are actually ideas that are ingrained in lots of families. So, you think things like, "Oh, they had too much sugar, so they're going to be more active." Or artificial colors, dyes in foods and these kinds of things. Is there any validity to those assertions?
Dr. Kelly Wesolowski: Well, I think we've certainly met families where they've cut out things like sugars or dyes and maybe they've seen some changes in hyperactivity, for example. But I would say largely there still other issues, right? So even cutting out on dye may make a child not quite as hyperactive but they're still struggling with attention in the classroom setting or something like that.
So I think, by and large, we would say that kind of globally speaking, I'm not sure that those would be the primary cause of the disorder. But for some kids, it may play a role in the presentation of the symptoms.
Dr. Mike Patrick: And if taking something away is not harmful for the child and it makes a difference, then it's hard to argue with not doing it as long as it's, again, not harmful in some way?
Dr. Kelly Wesolowski: Definitely.
Dr. Mike Patrick: So, then kids who then have ADHD, what sort of signs and symptoms are associated with this? What does this look like on a more granular level so we can say, "Oh yeah, problems with attention or you have hyperactivity." What does that look like?
Dr. Kelly Wesolowski: I mean, if we think about problems with attention, we will see kids that tend to make a lot of careless mistakes in their schoolwork, right? So, they're missing problems or pages or they're adding when they should be subtracting or something like that.
We see issues with staying focused, kids that are just really distracted, anything that is going on around them seems more interesting than what they're supposed to be doing at the time. We see a lot of them late on some tasks, particular tasks that are going to require more focus or tasks that have a lot of steps to them.
We see issues with following through and not following directions, forgetting things. Parents often will talk about forgetting things but simple stuff that kids do every day, like forgetting to put toothpaste on the toothbrush, that sort of thing.
And so, those are some of the inattentive pieces. And I think with the hyperactive impulsive pieces, they were seeing things like being fidgety, not being able to stay seated. Families will say they can't go out to eat at restaurants because kids can't sit in the table, they can't sit in the booth.
They're up and moving around, Lots of talking, lots of noises, lots of difficulty kind of waiting their turn or sort of being physically intrusive, not being able to keep personal space, and just impulsive behaviors, right? Just doing things without thinking about the consequence of the behavior.
Dr. Mike Patrick: I like that you add that in there. I mean, there's a tension, there's hyperactivity but there's this impulsiveness too that didn't earn a place in the name of the condition. But it's really an important part of it.
It's just that lack of filter, right? It goes to your mind and so you think it, you say it, you do it and that can get a lot of kids into trouble. And there's still things that we as adults may think and think about doing, but you have that filter that stops you. And so these kids may just lack that filter with regard to impulse.
And I think from a parent and a teacher standpoint, it really takes a lot of patience and understanding that this kid's not a bad kid because he's saying and doing the things that a lot of folks would think about saying and think about doing. He just went ahead and did it, right?
Dr. Kelly Wesolowski: Yeah, definitely. And I think on one hand, we've got this behavioral impulsivity. He is right to sort of acting, the same talking without that filter. I think one of the other components of ADHD that oftentimes families aren't as much aware of is that there's an emotional impulsivity piece, too.
This is a feature of ADHD that has been studied more recently. And most of the kids that I see with ADHD, they struggle with emotional impulsivity. And it's the idea that kids feel these emotions intensely, sort both positive emotions like excitement, for example, and negative emotions like anger or frustration. And then, they have this kind of struggle to regulate them.
So whereas other kids may be able to mask different feelings, kids with ADHD kind of wear them on their sleeves.
And so parents will describe kids as having these really huge reactions to things that are somewhat trivial. And parents often assume or maybe they're questioning that there's something else going on with the child. But, really, when we look at it, we determine that there are often triggers to the emotions.
The emotions may be really big compared to really what the triggers are, but there's a trigger nonetheless. And so we get lots of crying or anger. Or sometimes, it's excitement, so much so that parents are not telling kids things until the very last moment because they know that kids are going to get so overly excited about it, that they'll be difficult to stand.
I think the emotion impulsivity to us is a big piece and something that we often have conversations with families about.
Dr. Mike Patrick: That's really an important point for parents to understand, especially as they're spending more time with their kids during 2020.
And so, when kids have that extreme reaction and emotions, I think it would be easy for parents to react to that with their own strong emotions. And then, you can really get into some pretty heavy conflicts because of that.
Ben, what advice do you have for parents in terms of reacting when their kids have such extreme emotions?
Dr. Benjamin Fields: So, I think that a big part to consider with that is that, as you mentioned, it's very difficult not to react to that, a big part of it is understanding what it is that they're seeing. And that's why one of the recommendations, it's the first recommendations I always make for families when I diagnose a kid with ADHD, is that the parent get education about what this is, how this works or what they're seeing.
And that's a huge piece of it. If you can get a parent understanding what they're seeing and that this isn't just necessarily a kid who is trying to be difficult or is just overreacting to something, but actually seeing this as an executive deficit in terms of how self-regulation that's related to this real thing, ADHD, I think sometimes that helps parents to be more understanding, patient.
Same thing could be true of teachers, which is why we want to get kids accurately identified.
The other piece is everybody wants to know what do you do when a kid is escalated. What do you then? And really, I think the bigger key is how do we keep them from getting to a place in the first place? Because truly, once a kid is up to a certain level, there's not much to do other than just suck the air in the situation, let them re-regulate, wind down or move stimulation or move engagement, and let them pull it back together, essentially.
But really, much more of our intervention is trying to help people to figure out ways to keep kids from getting to that point, in the first place. Because we're going to have an issue if we get to that point.
Dr. Mike Patrick: Absolutely. We've talked about what this looks like during normal times. How is the pandemic and hybrid learning, remote learning, homeschooling that more and more folks are doing, how does ADHD play into complicating those kind of educational setups?
Dr. Benjamin Fields: It's interesting because I don't think anybody would say that they experienced something just like this. This is kind of new to all of us which is tricky and we're still figuring out as clinicians. We're still trying to figure out with families what exactly are kids and families being asked to go through remote learning. It varies from school to school and grade and district, and all that sort of stuff, too. So, that's tricky.
On the other hand, we can anticipate some of the things that are going to be difficult and are probably likely to come up in the context of hybrid or remote learning. Because, as we mentioned before, what ADHD looks like is largely determined by the context, by the environment, the demands that are place in that environment.
And so if you're in a situation that is maybe less structured in which a kid is being asked to do things that they might not find naturally engaging, interesting or fun, which frankly is going to be a lot of school assignments, then we're likely to see a lot of these symptoms and behaviors cause problems.
So, many parents are struggling with this, for sure. That said, it really depends on the kid as well. Some kids, their home environment is probably more conducive to getting work done if parents are able to remove distractions, have a pretty controlled setting, maybe have some oversights.
There are situations where parents are limited by where they live and the setting, and how many kids are around, things like that. There may be a lot more distractions that are present in school.
So, given that, I've seen parents will say remote learning in spring actually went better than normal because we're able to control any way we can at school. Then by the same token, there's people who said it was a disaster because all that structure that's provided by that regular schoolday kind of telling you where to go and you move through that process each day is gone. And now, parents are left with trying to implement some of that structure themselves which is a big, big challenge.
Dr. Mike Patrick: At the end of the day, it really comes down to are you having difficulty at home.
Dr. Benjamin Fields: Oh, sure.
Dr. Mike Patrick: And so, I'd really encourage folks who are listening, you're frustrated, you're involved in remote learning or hybrid learning, or you're trying to homeschool and things aren't going as you would expect, please reach out and get help. And that first point of reaching out may be your child's primary care doctor, that knows what resources are available in your community and can get you plugged in and at least get the right diagnosis and the right treatment plan.
I mentioned right diagnosis because there are other problems that can cause signs and symptoms that are similar to ADHD but may have a very different treatment. And so, it's important to keep those on our radar. What are some of those other problems, Kelly?
Dr. Kelly Wesolowski: One of the first challenges I think with this diagnosis which we've talked a little bit about already is that many of those core ADHD symptoms are relatively typical behaviors in particularly younger children. And so, sometimes, the issue is just distinguishing between normal restlessness or normal attention difficulties versus kind of ADHD.
I think there are other areas that we also want to assess, so certainly sleep. If a child is not sleeping, their focus is not going to be there. Or they may be more irritable or moody or something like that.
Learning issues, right, sometimes, that feels kind of like a chicken or the egg game, right? So is the child not paying attention and as a result, they're having trouble learning? Or is that child really having issues learning, and as a result, they sort of head zoned out or given up or something like that?
So, I think learning challenges, we definitely want to look at as well. Anxiety and depression would also be considerations, so kids who are anxious, kids who are depressed, can be restless, they can be fidgety.
Anxiety is a big one for us. I think often families may think that kids are displaying anxiety and sometimes it's really ADHD. So, for example, you've got a kid that's asking questions repeatedly and an interpretation of that is, oh, they must be anxious or worried about whatever this thing is.
And when we boil it down, what we find out is they're asking questions repeatedly, not because they're afraid something is going to happen. It's because they're impatient and they're excited or they want something to happen.
So, I think there are also just some kids that may have general disruptive or defiant behaviors. And so teasing apart what is ADHD versus what might just be general oppositional behavior or just then disruptive behavior is something we take a look at as well.
Dr. Mike Patrick: Yeah, absolutely. And we think about other medical conditions that could also cause something like this. It's not even in the realm of behavior or mental health but things like hearing and vision problems, For example, problem with the thyroid gland, your child might be on medications that have some side effects.
And so, this is another reason really to get your child's doctor involved who can think outside of the box a little bit from what you would initially as a parent think might be going on. But at the end of the day, ADHD is so common. It's almost more likely to be that and some of these other things. But you don't want to discount those things in case they are going on.
So then, Kelly, how do you go about diagnosing ADHD? How do you get to the point of from, "I think this is what's going on" to the diagnosis?
Dr. Kelly Wesolowski: Well, in spite of it being brain-based disorder, there's not a specific medical test or a brain scan or some blood work or something like that that we do. Really, it's kind of putting pieces of a puzzle together.
So we typically want to see a very good developmental interview. So, we want to look up what are the symptoms or problems that the child has and what context and for how long, other aspects of their development and functioning, other stressors in the environment that could be contributing to the presentation, as well as what parents have already tried to do to address the concerns.
So, this is an interview that's typically done with parents or caregivers. It's good to see kids obviously with ADHD to help make that determination. But quite honestly, they're not the most reliable reporters of their symptoms especially the younger kids.
So, they often lack self-awareness in general. So reporting about whether they're focused or impulsive or something like that is probably not our most reliable piece of data. We're definitely talking to parents and caregivers.
We also like to use norm reference behavior checklist, both measures that assess broader based behavioral and emotional concerns. So that we can try to rule out things like anxiety or depression that can be contributing, as well as narrow band measures that directly get to the ADHD symptoms.
So we do, in order to make the diagnosis, need evidence of symptoms and impairments in multiple settings. So most commonly, that's home and school.
And so, this has been and continues to be somewhat of a challenging thing with COVID at this point, as many kids haven't physically been in the school setting, in front of a teacher, in person since March. And can continue to be problematic even in the hybrid learning model, where maybe they're only seeing a teacher two days a week or every other week or something like that.
But we're still gathering information and looking at historical data to try to help support and make sure that we're not missing cases just simply based on that reason.
I think one of the additional things that sometimes we'll do in terms of an assessment and diagnosis would be something like a measure to assess cognitive functioning or IQ or academic skills to help us rule out any kind of learning conditions. But those aren't necessary, if you will, for making the diagnosis. Really, it's about that good interview and then cooperating with that with some questionnaires.
Dr. Mike Patrick: Is there a minimum age where you would just universally say that this is not ADHD? How young can it really be diagnosed? And I know that there may be varying opinions on that but what do you think?
Dr. Kelly Wesolowski: I would say, when making a diagnosis, I like for a child to be in a structured school settings, so like kindergarten maybe. I've diagnosed preschoolers like four-year olds if they're in, if I can get overly good secondary structured settings. So maybe they're in a special needs preschool program or they're there five days a weeks or a structured daycare environment or something like that, definitely less on that four-year old range.
I usually tell parents we can be reasonably certain by the time a child hits the age of about six. That if we're seeing a lot of these challenges and they hit the criteria, then that would be the diagnosis. But I've seen certainly four-year-olds where it's kind of a problem for sure.
Dr. Mike Patrick: And it's impacting the child's life and the family's life and, really, that's the root of it, that things aren't going well at home and or school. And we need to do something about this to help the family and to help that child and everyone else who's in that situation.
And so, that really brings me to treatment once we've determined that there is a problem and we think that it is ADHD. And I think a lot of parents would be, their first thought is, "I don't want my child on medicine." And there are some non-medicine strategies that are useful for helping these kids and these families, right, Ben?
Dr. Benjamin Fields: Yeah, definitely. And I'll come back first to that idea of just education for parents as being an initial part of intervention that actually I often spend a significant period of time on. Like multiple sessions and actually sending people back to look at resources and stuff like that outside of sessions because I do think there's so much benefit from that. And it helps parents, families to take advantage of treatment more effectively better if they have that information.
So I'll make a plug really quick. There is a video on YouTube. It's called Essential Ideas for Parents and it's by a psychologist name Russell Barkley, who is a psychology researcher. If you type that in to YouTube, you'll find it.
It's very long. It's almost three hours long. You should not watch it all at once. It's kind of overwhelming. But it is the single best resource I've ever found for A to Z, really gives you an understanding of what this is, how it works. And then from there, what we do about it and why certain things need to work and why other things don't.
It's Essential Ideas for Parents by Russell Barkley. So, you type that into the search window on YouTube, you'll find it, both in long form, it kind of broken up into topics as well. But I have never found a single family or clinician or teacher who has watched that video and come without saying, "Oh yeah, I already had that." Everyone benefits a lot from it. So, that's my first plug.
The second piece, really, and where I think both Kelly and I really encourage families to put most of their efforts in terms of a non-medical intervention for ADHD is really in a behavioral managements and environmental structuring interventions. This is essentially the broadest down, we are adjusting things outside of the kid or the adolescent rather than really changing something internal.
So, what this is going to look like is really mostly the therapist works with the parents or caregivers. They consult with school on how do we arrange the environment, how do we put into things this kid is more successful so these symptoms don't cause as many problems.
That kind of treatment really isn't focused as much on decreasing actual symptoms. It's helping the kid to function better despite those symptoms. Frankly, it's definitely I think where you should put your time. That's what the research would say, but it is frankly a pretty hard sell for people.
It's not what people are picturing. It's not what parents are picturing when they come in for treatments. They're not expecting that. They're expecting that someone would work directly with their kid, which I totally understand. But we just don't have a lot of evidence that makes meaningful differences in how these kids function.
You can go over lots of good strategies with these kids about what to do in different situation, things to try and they can understand those things.
The problem is with ADHD, they have a hard time doing them when it comes down to it. That's where it's going to come down mostly to caregivers again to arrange the environment, reinforce, reward appropriate behaviors, things that we want and try to extinguish some of those behaviors that are causing problems or diminish those.
So, that's definitely I think where we would plug for this. I think this is really misunderstood but people do much, much better. These kids do better and families do better when they get that kind of intervention.
Dr. Mike Patrick: What does that look like then in the home level, especially kids who are doing remote learning and hybrid learning now, who might be having trouble paying attention and sticking with doing things?
I would imagine, the actual environment of where they're doing school is going to be important and then, incorporating routines during the day and frequent breaks, short breaks here and there. Am I off-based on those?
Dr. Benjamin Fields: Nope, absolutely. A lot of structure, a lot of predictability, breaking things into chunks, giving kids step-by-step instructions.
My favorite way to describe this to parents is I give them the example of like Lego directions. You see parents that, I can't count how many times I've seen this. You run into a parent of a child with ADHD who basically would describe to you that this kid cannot get through on multi-steps sequence on school assignment, for example, to save their life. They've got to have a constant oversight to get them through that.
And then at the same time, they'll say this doesn't make any sense because this kid can put together a Lego set that literally got thousands of pieces and hundreds of steps and do it with no supervision and stick to the task maybe for hours. How is that possible?
And I kind of come back to two pieces. One, it's the nature of the activity. Legos are fun for most people. That's a challenge we run into a schoolwork because a lot of schoolwork is not that fun. And I used to be a teacher, so I don't feel bad saying that but it's the truth. Compared to some other things, schoolwork is not fun for kids, not appealing.
But besides that, when you think about Lego direction, there is no spinning your wheels that goes on there. You think about those directions that says, go, you need this many pieces of these sorts. And then, you're going to put them here and then you're going to put this here and it will get you to the next step.
And you work through that and you're just moving this kid through these tasks step by step. If we can think about turning kind of other tasks that we have for kids into that sort of a thing, that step-by-step instruction, it really increases efficiency. Again, decreases what I call spinning the wheel, they're sitting there, they look like they're doing something but nothing is getting produced. If we can do that...
Dr. Mike Patrick: They need some kind of reward.
Dr. Benjamin Fields: Absolutely.
Dr. Mike Patrick: Like when you put a Lego thing together, you got that thing.
Dr. Benjamin Fields: Absolutely. It's very satisfactory.
Dr. Mike Patrick: That's probably the case.
Dr. Benjamin Fields: And that's the other piece, right, that I would mention, is besides this external structuring that we want to do of the environment and of schedules and of tasks, breaking things down, this is maybe the most key concept I think in managing kids with ADHD. It's we got to have provide some external motivation when the internal motivation is not there.
When something is difficult or tedious or boring for that particular kid and that can vary from kid to kid, we are going to have to find external sources of motivation to move the wheels. That's tough for people to swallow, that of grates on people which I understand. But the quicker we can embrace that reality, the quicker, again, we're moving the wheels with these kids and getting them going.
And again, different tasks will post different challenges for different kids. If you have the kid who happens to really like reading, you may not have to provide that sort of thing to get them to sit down and read. They may read on their own for hours.
At the same time, if you have a kid with ADHD who for one reason or another does not like reading, either because it's difficult or they're just are not a big reader, you're going to have to provide that external motivation to get through that. And if we pair that with the structure, we're going to see those wheels moving.
Dr. Mike Patrick: During the school day when kids were in school traditionally and the school day was broken up because now, you're doing classwork but now you're going to have Music class or Art or Physical Education. And so to some degree, those breaks and change in what you're doing was built into the schedule and maybe even getting through the rigorous classroom work, part of the motivation is knowing that gym class is right around the corner or whatever it is that motivates your child.
And so, now that folks are doing school at home and with remote learning, there's less of that built-in change in variety. And so, parents sort of have to take it upon themselves to build that into their kid's schedule, right?
Dr. Benjamin Fields: Absolutely, and that is not easy. I think it's easy to underestimate. Really good effective teaching even with older kids and adolescents does incorporate those changes even within a single class period. Really, teachers are looking to vary the activities and mix it up. And I think we miss that as parents sometimes, the amount of variety that's built in there.
And so, yeah, we're going to have to deliberately incorporate that into a kid's day and be taking those assignments that the school is giving us and breaking that up for kids. It's a very big challenge both because parents aren't familiar with that, and also parents may not be there or have the ability to attend to that as close as they might need to.
Dr. Mike Patrick: And Kelly had mentioned sleep earlier. That's also going to be important for kids who are learning at home to get a good night sleep because you're going to definitely do better during the day if you have that, with the better attitude, better ability to concentrate, all of those things.
Now, before we talk about medicine for ADHD, I think that there are some non-medicine strategies that are put out there especially on the Internet as kind of a magic bullet to help with ADHD. And I'm thinking about things like vision tracking and eye training and video games, that there may be some video games that can help kids with ADHD. Kelly, can you address some of those things?
Dr. Kelly Wesolowski: I think if you Google ADHD treatment, you can get a lot of those things. I think what we think about is what is the purpose of the intervention? So, if the purpose of the intervention or the treatment is to change the core ADHD symptoms, to change something in the kid and it's not medication, then we might want to think about that a little bit.
I think for us, we are looking at strategies and treatments and interventions that are changing the environment for the child, to help them to be successful.
And I would encourage parents to be good consumers of information. So, what's the research? Who's done the research? Has it been replicated and done by somebody outside of the people who are trying to make you participate and whatever they've got going on?
And so, who stands to benefit from the success of the treatment? And I think if we help families to understand who's behind the research and what evidence there is. And I think that age-old kind of it sounds too good to be true, it might too good to be true is probably fair in assessing some of the things that are out there as well.
And we talked already about other things like dietary changes and that sort of stuff. And again, I think if it's not harmful or stressful to the family to make some of those changes and they see some benefits from it, that's great and I'm not going to discourage a family from that. But typically, there's some other stuff left over that there's a reason they're still in my office talking to me about the challenges that they're having in spite of doing that.
I think being skeptical, appropriately skeptical and knowing how to look at what's out there critically is an important thing. And I think to that extent, having people that you trust on your child's team, so consulting with their pediatrician or their family physician about what you're interested in or a school counselors, somebody at the school that you trust or a mental health provider, person that made the diagnosis for your child's something like that, I think is important. Just to make sure that you're not going down a path and spending lots of time and resources, finding extra resources on something that ultimately may not be most effective for your child.
Dr. Mike Patrick: Yeah, absolutely. So, when do you decide that you're going to use medication as part of the treatment plans? At what point does it enter into the conversation, Kelly?
Dr. Kelly Wesolowski: I think it's probably always should be part of the conversation when you're discussing treatment of ADHD. We know in younger children, preschool-aged children with the diagnosis, typically, the recommendation is to do some pretty intensive behavioral therapy, behavioral interventions before turning towards medication. But for our school-aged kids and our adolescents, I think typically we recommend that kind of medication and combination with behavioral intervention like we've been talking about.
And I think sometimes this is confusing to parents because sometimes medication and behavioral intervention are presented as if they're like equal treatment options, and they're really not. Maybe they address different things.
So your medication address is your core ADHD symptoms and it works when it's in the system, whereas behavioral support, change and alter the environment and impact the day-to-day troubles that those ADHD symptoms cause.
So, medication is a lot like the glasses that I wear. So, my vision is impaired, so I put my glasses on and I see better. But when I take my glasses off, my vision is still impaired.
And I think it's important for parents to have appropriate expectations for the type of treatment that they're selecting. So, they use medication, it works. When it's in the system and addresses those core symptoms, then it addresses them pretty well. But when medication wears off, we're back to having trouble with focus and being impulsive in our action.
So, that's why that pairing of medication and then the behavioral supports becomes pretty important. And in fact, the research says if you do that, you actually have to use lower doses of each, if you will, lower doses of medication and lower doses of behavioral support.
But ultimately, it's a parent's right to choose which direction they go and we always encourage them to have conversations, again, with those trusted team members, the pediatrician or the family doctor about what the options are.
Dr. Mike Patrick: Great points all around. We could do an entire hour-plus long podcast on ADHD medication. And so, Ben, I just have to ask you to give us a brief overview of the types of medications that are options and very briefly how they work, but again, knowing that we could spend lots and lots of time on this.
Dr. Benjamin Fields: In general, I think the things to know are that stimulant medication has been around for the longest time and really seemed to be the most effective for the most kids. The majority of kids respond to one of those classes of stimulants and that's why they're typically prescribed first.
They can be, again, have some side effects, but those side effects, in general, they tend to be more annoying than they are dangerous. Obviously, your child's physician would assist whether there's any medical reason not to use those medications, but they are used the most frequently.
People don't love the idea of using stimulants. I think they think of it as like giving your kid speed or something like that, so it throws a lot of people off. But, again, the reason they are prescribed the most is that they do seem to work for the most kids most effectively.
There are also non-stimulant options. Strattera, for example, a non-stimulant option, a lot of times is used to really address more of the inattention portion of ADHD, and sometimes kids have some comorbid kind of co-occurring anxiety too, they'll use Strattera. And then, there's also some other non-stimulants in a hypertensive blood pressure medication, actually, like Intuniv that are also used. A lot of times, they address things like impulsivity and sometimes you see combinations of these things that are used, too.
Those are the biggest classes. There's also, sometimes, if you work way down the line and you're not finding one that works, you might have a physician that would prescribe by the certain antidepressant or something like that, but that's used much less overall.
And the piece there is, unfortunately, we don't really know much about what's going to work best for a particular kid, until there is kind of a certain trial and error process. Unless you have like a very close relative, like a parent or a sibling who's done particularly well or poorly on a certain kind of medication, there is some trial and error that goes with that.
That's something I think parents are naturally not comfortable with, which I understand. But that's why you have to take this with the physician that you trust. And, really, the key there is closely monitoring the symptom response, which is typically through rating scales that are filled out by parents and teachers. And that's how the best way that physicians are then able to tailor that to the kid.
Dr. Mike Patrick: I would say from the general pediatrician point of view, the importance of titrating the medicine for an individual child is so important because there seems to be a sweet spot for a lot of these medications. We're like, "Too low of a dose isn't going to do it. Too high of a dose is also going to cause problems."
And finding that right dose and it's different for each kid and a lot of times, some of the younger kids compared to their weight, it's seems to be a much higher dose because their bodies are just metabolizing it, it's just chewing it up. And so, you have to use some higher doses compared to body weight.
And so, there is some art and we get a little uncomfortable, I think, in science. We don't have the data. But there's an art part of this too in trying to figure out the right medicine and the right dose for each individual child.
Dr. Benjamin Fields: For sure. And I just come back again too, to me there's just no substitute for those rating scales being done, right? I see it really frequently people relying in anecdotal information. It's kind of like, "Whoa, what are you..." The parents say, "I don't really see a difference." Well, depending on the medication like a stimulant that's in and out of the kid's system within four, six hours, you might give the kid the medication in the morning, the parent may not see any difference during that time of day they're seeing this kid.
If you survey the teachers, however you may see a different story with older kids. You may see differences from different classrooms, different teachers.
So, the importance is just gathering that information, I think it's just so critical. And it's so really easy to do. Those rating scales, you can get for free online like Vanderbilt rating scales are available online. It's just a great tool to be used in that.
Dr. Mike Patrick: One more point on medication and that is that we do sometimes see comorbidities. So, other mental health conditions that will go along with ADHD, kind of go along for the ride, things like anxiety and depression. And so those may need to be treated with additional medication as well, correct?
Dr. Benjamin Fields: Absolutely. And that's why you work, again, with the professional that you trust. I think sometimes when you get into those comorbid conditions where you have co-occurring like ADHD or anxiety, depression especially, those are significant. That sometimes when I think primary care providers would want to refer to a psychiatrist that specializes in some of these stuff, but that depends on the individual physician, obviously.
But a part of that whole working with the team is also to sort out things like are both of these conditions here or is it maybe one of the conditions contributing to the other? One thing that I think we see a lot is kids with poorly managed ADHD have some anxiety and have some low mood.
And the conclusion in some cases is, I think if these kids with ADHD were better managed and was more successful socially, academically, behaviorally with his family things like that, these other symptoms might resolve. And so that's, again, why it's just so important to work with professionals. They were able to view that whole landscape and try to figure out what's driving the car there.
Dr. Mike Patrick: Yeah, absolutely. I mean, each child and each family is really unique and you need someone to step along with you, to figure these things out sometimes. And it's not just the child who's really impacted by this, right? The whole family unit when there's a child with ADHD in the house, even the kids who are siblings that don't have ADHD, they're also affected by this, right?
Dr. Benjamin Fields: Absolutely. We see a lot of parents who come in who are just sort of exhausted. Their putting a lot of effort is usually not the problem. We see people, they're coming and seeking out these services. They're generally working really, really hard doing the best they can to manage us and try to help their kid. But they're really getting limited return on that investment. They're spinning their wheels again, not getting much return.
There's lot of conflict. It often kind of just seems like a grind to get this kid through the day every task kind of needs oversight. There's arguments, and there's pushback, and there's repeated commands. And then, the tension builds up and people have conflict and we have these blowups, either from the kids or the from the parents.
So, it does absolutely take a toll on all members of the family. That's hard for siblings too, if that's what's going on there. And we come back to, again, can we get effective treatments so that everybody really benefits from that?
Dr. Mike Patrick: And I imagine that this is amplified in the age of COVID. For some of these siblings going to school and being outside of the family is kind of a relief for awhile and when you're all stuck inside together, it can cause more tension.
And I would just encourage parents, there is no failure in getting help for yourself as well, right? And talking to a counselor and seeing someone and learning better ways of dealing with things you may not have control of.
Dr. Benjamin Fields: For sure and I'll just note in particular, what we see, as Kelly mentioned earlier, there is a really high incidents of parents of kids with ADHD, the parents also have ADHD. They may or may not be aware of the fact that they have ADHD.
We know that one of the primary predictors of the behavioral treatment for ADHD not working as well is if we have a parent with unmedicated ADHD, right? Because, again, that intervention relies so much on a parent's ability to organize and manage these things and keep emotion under control.
If they're having similar problems as their child is, it can be sort of a powder keg. So, definitely that's another thing that will try to steer parents towards if that looks like that's contributing. But no, no shame in that and, certainly, we're going to get the best outcome.
Dr. Mike Patrick: Yeah, absolutely. Kelly, what is the long-term outlook then for kids with ADHD? We talked about there are adults with it. Is this something that they are then destined to have their entire life or do kids largely outgrow their ADHD?
Dr. Kelly Wesolowski: I think the good news is that brain development continues to happen throughout childhood and even into adulthood. And so, I think many kids will continue to take that diagnosis into adulthood, but it looks different. The symptoms persist but it looks a little bit different.
I think the other thing that happen is adults or later adolescents, if you will, can also play a larger role in their treatment. And they have some flexibilities in there and what they're doing. So, maybe by the time you're in later high school, for example, you're not in a traditional school setting but you're doing something that's more hands-on type test.
I think the short answer is kids with ADHD can certainly become productive members of society, holding jobs, going to colleges and universities. I think we would expect that they may still need some supports even in higher education and those are available, through universities and colleges.
We definitely, as we mentioned, see parents who have ADHD and they're very successful people. And their environments typically suit them well. They're doing something that they're very passionate about. They've put the right structure and organizational strategies in place for themselves to be successful.
I think the outcome can be great. I think we do need to remember though having ADHD does place kids and adolescents at risk for more challenging issues primarily related to their impulsivity. So things like substance abuse and proneness to traffic accidents and money management issues and that sort of thing.
And that's why recognizing or making the diagnosis and providing those treatment and that treatment early on and educating parents and the world around that the child or adolescent is important, to try help ward off some of those things.
So we see kids with ADHD who grow into adolescence with ADHD, who grow into adults with ADHD but that doesn't limit their ability to be successful in the world.
Dr. Mike Patrick: I love that you say we really put supporting structures around. And that's where, to some degree, we pick our careers based on our ability to concentrate and pay attention and how active we need to be. I've always said that if I have to be an accountant and sit at the desk looking at numbers all day, I would go bonkers. And so, I think that being a physician and seeing families and different things, walking from room to room for me, it's sort of my personality style and there probably is some degree of ADHD there.
But again, it's important as an adult, if you are having difficulty to get that help. And as you said, we do see more substance abuse, there's more divorce, there's more incarceration, especially when ADHD goes undiagnosed and untreated into adulthood. So definitely, get that help if things aren't going well in your life.
Dr. Benjamin Fields: And, Mike, I'll just add too with that is that there's a part of it that's negative but it's a positive, is that we know that the vast majority of kids now with ADHD do not get the treatment that is considered to be the most effective.
Many of them are prescribed medication but it may not be really taken consistently or monitored to figure out the best dosage or the course of that. Many of them stop taking that after a short period of time. And then, in terms of this behavioral intervention that we're talking about, it's really staggering what low percentage of parents ever even find out about that being a key part of this.
And so, when I look at some of these statistics about problems associated with ADHD, the good part for me is if we can get people linked up with the treatment that makes a lot of sense and get people understanding what they're dealing and how to manage this. I do think we can improve outcomes a lot, but a lot of people aren't getting that.
Dr. Mike Patrick: I think you make a really important point in this. And in medicine, and I don't want to offend any of my listeners but there a lot of primary care providers who do the same thing because that's what you're trying to do, but you were trying to do that 20, 30, 40 years ago.
And so as a parent, if your primary care provider is saying, "Here, just take this medicine" and there's no mention of any behavioral plan, be an advocate for your child and just say, "Hey, can we also talk to a psychologist? Can we get a counselor involved? I'm fine with the medicine but let's also get some behavioral changes around our child in our family."
And so, please do be an advocate for your child. And that leads me into Behavioral Health Services here at Nationwide Children's Hospital, Big Lots Behavioral Health Services. Tell us about your program, Ben.
Dr. Benjamin Fields: So Big Lots Behavioral Health Service line is one of the largest divisions in the hospital, provides hundreds of thousands of visits per year to families from Ohio and surrounding states. The most recent numbers I saw from 2018, there was over 30,000 different patients just that year served by Behavioral Health.
The hospital has made really unprecedented commitment to behavioral health, really just as not seen. And that's because there really seems to be an understanding that the health of our kids in the community is really dependent on good mental health services. And that's being done here in a way that I think is really unusual and super encouraging and exciting.
We have a new behavioral health pavilion that opened. It's got a lot of in-patient, kind of acute crisis services located there but a whole range of services that honestly I can't even keep track of how many different behavioral health services that are offered here and that are being developed all the time.
So, definitely reach out to get to our intake department to get a referral if you have concerns. There are a lot of good evidence-based services being provided here.
I also encourage families, so if you look at the Nationwide Children's webpage, if you look under Family Resources and Education, there is a list of courses for parents and kids. And there are a lot of options for different things, but there's a whole range of ADHD related courses.
They're called ADHD Academy, most of them are parent-focused, a couple of them are for older kids or siblings. But it covers a whole range of topics from ADHD medications to alternative treatments, behavioral interventions, school issues, legal rights within the school for kids with ADHD.
And you can access those and find the schedule on that website. And those are constantly being ran at different sites for Nationwide Children's. So look into that, please. It's a good place to find information.
Dr. Mike Patrick: How has your service responded to the pandemic? So are you guys really geared up in terms of telehealth visits? And are these kind of programs for parents, has there been a move to run this virtually?
Dr. Benjamin Fields: Yep. We transitioned really unusually fast, I think, with a lot of people working very hard to get telehealth up and running, and are still providing I think tons of services via Zoom visits and working very well.
Some of our programs are going back more into a face-to-face mode now. I know an outpatient where Kelly and I work were still largely doing it virtually. But yeah, all these education courses are still being provided via Zoom. We have parent behavioral management groups that are being ran via Zoom. And individual therapy sessions also being ran by Zoom. So, we're continuing to provide this I think at a high level, even with the limitations.
Dr. Kelly Wesolowski: We're doing ADHD assessments via Zoom, too.
Dr. Benjamin Fields: We are.
Dr. Mike Patrick: That's really fantastic. I will put a link to the Big Lots Behavioral Health Services at Nationwide Children's Hospital in the show notes for this episode, 473, over at pediacast.org.
Some other links, we'll put in there for you, the organization, Children and Adults with ADHD also known as CHAD, really a comprehensive site. It's a national organization with lots of educational materials, local support groups, that sort of thing. And then of course, I'll put a link to Essential Ideas for Parents, Russell Barkley on YouTube.
Dr. Benjamin Fields: So worth your time. I cannot recommend it highly enough.
Dr. Mike Patrick: We'll put a link to that in the show notes as well over at pediacast.org.
So, Dr. Benjamin Fields, and Dr. Kelly Wesolowski with Behavioral Health Services here at Nationwide Children's Hospital. Thanks once again to both of you for stopping by today.
Dr. Benjamin Fields: For sure. Thank you.
Dr. Kelly Wesolowski: Thank you.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week Dr. Benjamin Fields and Dr. Kelly Wesolowski, both clinical psychologist with Big Lots Behavioral Health Services at Nationwide Children's Hospital.
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