ADD/ADHD - Diagnostic and Treatment Strategies that Work

this program is presented by university of california television like what you learn visit our website or follow us on Facebook and Twitter to keep up with the latest UC TV programs also make sure to check out and subscribe to our YouTube original channel you see TV prime available only on YouTube good evening everyone and welcome back to the mini med school in pediatrics I'm Glenn Rosen blue thumb one of the course co-chairs so we have a great speaker this evening dr. Neil Rojas who's faculty in the department of pediatrics dr. Rojas trained in pediatrics here at UCSF and then did a fellowship in developmental behavioral pediatrics in Boston and then we were fortunate to get him back on the west coast where he currently works at the Center for developing Minds down on the peninsula and also at San Francisco General Hospital and it does a great deal of teaching and is one of our most valuable educators and the department of pediatrics in the pediatric residency program so keeping with the theme that we've gone with some with some of our other lectures of new approaches to keeping kids healthy and trying to understand that balance between what's normal kid behavior and what becomes diseased and when does a pediatrician get involved we have a great talk this evening on ADHD and a DD diagnostic and treatment strategies that work we turn it over to dr. Rojas Thank You Glenn that was very kind um I want to make sure everybody understands sort of my perspective as a developmental behavioral pediatrician I'm a fairly rare breed there are a lot of developmental behavioral pediatricians around first and foremost I'm a pediatrician I care for kids and I'm a medical doctor as Glenn mentioned I did extra training three year fellowship and development behavioral pediatrics and I've been practicing if you include my training development Paiva pediatrics for about eight years now and pediatrics in general for about twelve years now and my perspectives are going to come from the vantage point of seeing a lot of children and working with a lot of families in multiple settings I've worked in public hospitals such as Santa Clara Valley Medical Center and San Francisco General I've worked in an academic setting such as Children's Hospital in Boston excuse me and I've worked in a private practice in los gatos and it never ceases to amaze me how many of the fundamental questions parents have about their kids are the same across cultures in socio-economic in geographic areas so um my just exclosure and acknowledgement I have nothing to disclose I have no financial relationships to products or treatment modalities mentioned in this presentation I'd also like to formally Thank You Jeanne a Chan one of my mentors and fellowship who gave me a couple of these slides as well as Damon Korb who's been one of my mentors after fellowship down at the Center for developing mind and he's been generous with some of these slides as well I always like to start off a presentation throwing questions out that seem to be important to try to answer or at least to get people thinking I stole one from from the write-up of the Maine med school for this topic our children today more inattentive or hyperactive than we were so if you can remember way back to when you were and think about how active you were or your peers were and can tell lots of stories about lots of kids and grew up in the mountains in Sonoma County so there was a lot of active boys and a few active girls but the question is how would we know whether or not hyperactivity or inattention changed over the ages without a time machine it would be extremely hard to understand that one thing that it may have changed since I was a use a long time ago was it or is educational standards and the the general pressure I think a lot of children feel this day and age and consequently their parents feel for them to achieve and I think if the biological bar has not gone down in terms of our capacity as a species in this short period of time 50 60 years that we've been talking about a DD ADHD perhaps the societal bar has gone up in terms of what we expect of children in terms of what they're supposed to do whether it's developmentally appropriate for them to be able to do that I often say well what is it that we think has happened with children in the last 50 years that makes them be you know able to do you know algebra by the time they're seven or eight because certainly in Silicon Valley when my primary practice is I have families who think that that's normal and it's not I remind folks in other countries such as Scandinavia where they have very very high literacy and education rates most professional educators don't even think about emphasizing reading until child seven years of age seven years of age except and and that's probably more congruent with the biology and the and the things that are necessary for children to be able to sit still and read and decode after the other questions that I wanted to throw out there is you know sort of what's normal variation of what's often called self-regulation and it's related to attention so that means where is it okay to say he's just active or she's just active versus hyperactive drawing that line is tricky there's a lot of diversity in how children behave in different sentence and drawing a very very clear mark in the Sam it's hard to do in that that begs the question where does normal end and pathology begin the more we look at what's developmentally sort of appropriate for attention I think the more gray the answers on what pathology versus okay normal functional the answer is something is generally really important I think for the public at large to understand about ADHD is what are the look-alikes meaning were the other things that can masquerade as an attention problem or can cause what looks like functionally an attention problem I'm going to touch on that heavily with a few slides and then I think really important which ties into the title of this talk what are the proper or accepted diagnostic approaches and treatment strategies to help children with attention challenges so lots of questions hopefully some answers and lots of time in the end for you to ask questions my background in development behavioral pediatrics the training is largely sort of driven by one of the founders of the field a guy named Mel Levine who tries to help people understand that attention is actually a complex function of the brain it is not something that's sort of yes or no it's it's it's not binary it's it's complex and a great quote from dr. Levine is is for attention to work well basically it functions as a good conductor of an orchestra of many parallel functions of the brain that serve the attention system and if we try to boil down as basically and somewhat simplistically as possible what those functions are dr. Levine boiled them down to mental energy control processing controls production controls and planning an organization and flushing this out a little bit more what what mental energy control is the ability to control your your focus like a laser beam okay and the analogy that's quite effective I think in helping people understand what's meant by this mental energy control is sort of if you know anything about how cars from the fuel injection system okay when when you step on the gas of your car whether it's a Prius or a Mazda or a Chevy and the idea is more mental inner more energy should be delivered to the engine to do the work of the car to go up the hill or whatever it's doing this thing the same thing exists in the brain people bear down they focus more they tried to marshal more of their energy on tasks that are harder and we see breakdowns of attention functioning mental energy control is often a very part of it so as a result there's procrastination there's avoidance of things that are harder because intuitively a person knows if something's really hard it's going to demand more and they tend to avoid it processing controls have to do with the input all of a different stimuli that comes in that one can choose or not choose to pay attention to and I liken this to a filter or a strainer some folks have really big holes in their strainer and stuff just fall through and other folks have two fine holes on their strainer and they everything is important that they're overwhelmed and having the right gradation of that strainer of your stimuli in each situation and being able to shift that the pores of that is an important function that is called processing control production controls are just the opposite whereas processing is input production is output so being able to modulate and modify ones up like I'm doing right now as I look across the room I'm seeing oh oh I'm going to lose a couple people I've better liven it up or some people look confused maybe I should slow it down a little bit maybe I need to speak higher maybe need to speak lower maybe I need to speak faster just like the conductor of an orchestra would be talking to different sections with his or her hands trying to get them to come on quicker or slower or faster or louder or more quiet the next big function in more advanced function of the tension system that's often overlaps with what are called executive functions is what allows us to plan and organize using the concepts of memory time and space so I like to use the example of how does how does a child or how does a learner think about doing something the second times I've done it the first time they did it maybe didn't go so well maybe they didn't understand it maybe they work too slowly maybe they worked too quickly how are they going to adjust now and plan how they're going to do it the second time what are the materials that they're going to need that they've learned that they needed from the first time what kind of space do they need to do the activity that skill obviously develops later in childhood so how this pans out for children in terms of attention functions are expectations that we have for them and what they'll need to do and I think school is eglise it is sort of the real stress or and tester of attention and kids by age four to five so sort of late preschool early kinder we expect you'll need to be able to participate in circle time you'll be able to sit still and focus their attention on whomever is presenting for several minutes okay ten fifteen minutes we expect that same child who can sit in circle time and not move around too much play by the rules of circle time to delay gratification if she sees that they're setting up snack across the room not just go put it in her mouth we can't be able to go I'm hungry but I'm going to wait till the teacher dismisses me from circle time we expect that same child if she's moving around too much to be able to modulate her behavior if a peer goes don't touch me or our teacher goes please keep your hands to yourself or my favorite line in preschool and kindergarten is crisscross applesauce when kids cross their legs and it actually helps them stay more physically quiet we expect that same child when she finally is allowed to get ready for a snack to attend the details of things basic tasks like washing her hands okay and for a four-year-old a detail of washing one's hands is something that the older children or adults might take for granted like using it so that's an important detail of washing once in just convinced to this day that scented soap was invented so that we can tell that kids actually used it when they washed our hands that's an important detail and we also expect form five-year-olds to be able to independently keep on a task at least long enough to get in to the task and the desired sort of lesson from the task so for example when I drop my pre scroll off every they've got all these puzzles set out on tables and I think we expect them all to sit down and look at the puzzle and spend several minutes solving it some three-year-olds do this most on a few more four-year-olds do this most fiver ones can do this within a year or two by the time we're in first grade the expectations are significantly higher sustaining concentration is now needed for 20-30 minutes during lessons and activities being able to filter more distractions of a louder classroom a busier classroom and children who are allowed to be more independently in a first-grade classroom who will interrupt each other and distract each other we also expect first graders to be able to plan things out to have their materials ready to have their backpack packed to turn in their homework and these are large expectations I think for that page and then stove areas considerably that being said it is extremely important that we think about what happens when this breaks down what happens when a teacher tells a parent this isn't working I'm having difficulty with a child what what is the pathology that is called ADHD from my perspective this is what I was taught as a fellow this comes directly out of the template we used when we wrote reports for families and we when we gave them our evaluations there's a lot in this but I think a lot of it speaks fairly true to this day after seeing hundreds of more patients since fellowship in my own experience and some of it is the little bit or gain a little bit mysterious and I think the general public especially needs to understand what what's meant by this so I'm just going to read this quote it HD is neurologically is a neurologically based condition that is outside the realm of maturity and motivation okay I highlight outside the realm of maturity and motivation because ADHD is considered a disease is considered something that is dysfunctional about how our child is working or an adult is working and it never surprised I mean it continues to surprise me how often parents say well if you would just try harder and the problem with the attention functions is the try harder part is the problem that's the one of the fundamental aspects of how the attention system works it's being able to step on that gas and marshal control over one's mental energy is an integral part of what's broken down so in other words children cannot simply outgrow these differences nor can they be expected to overcome them through sheer effort alone okay they will require intensified educational supports in order to be taught strategies for overcoming these weaknesses children and adults with ADHD exhibit a variety of behavioral and academic profiles so I highlight that phrase because the diversity of people children and adults who suffer from varying types of attention dysfunctions is as large and no two children that I diagnose or that I see have potential problems are the same and that's you know I think George Carlin said where would you be without a good stereotype you know when you think about what's the stereotype of the kid with a IDI or ADHD okay you know I'm going to get to some slides and some of the old pejorative terminology that was used but everybody in their mind sort of got this mindset of what's this kid like you know he's bouncing off the walls and won't he won't be quiet and he won't stop touching people or or she's very dreamy and she doesn't know what and and those are two stereotypes and children are a little more complex in that especially when they're interacting in multiple environments and the last part many of these children also have coexisting learning disabilities in addition to the academic challenges that their ADHD presents so here's the rub it's not simple it's not just attention there are other what I call neuro cognitive or neuro developmental skills that might not be working adequately such as the skills needed for reading or writing or doing that or controlling ones coordination in time and space these are very considerably in children with attention challenges and can compound their difficulties with attention I think a classic example that I see all the time is a child with a reading disability and attention challenges and it's hard to - excuse me separate those two things in an older child who's having difficulty reading because if you having a hard time focusing on reading is it because reading is hard or is it because yeah I mean hard time focusing on everything and what I have to do is a development we have a pediatrician is sort of sorted out well what other aspects of your life might you have challenges with attention or self-regulation and and is it just reading or is it also math is it the reading part of math or is it some of the more conceptual parts of math is it the attention part of math so Boyan it boiling it down to different sub skills that are required for specific performance is sort of the nature of what I do and it can be incredibly tricky for parents because well someone said it was this and it might it might just be attention but if it's also a reading problem treatment for attention things that could be effective for attention aren't necessarily going to solve the reading problem so it's important that we look at the whole child that's with anything getting to the phrase in that long-winded definition of ADHD it's a neurobiological disorder there are a lot of studies looking at the differences between how brain the brain functions in people with symptoms of ADHD and those without there's a growing understanding of the chemical messengers of the brain called neurotransmitters the two in particular that are most active with attention functions are dopamine and norepinephrine there's a large body of evidence showing that variable neurotransmitter receptors are distributed along different parts of the brain different pathways or connections in the brain differently among people okay that's along with its way of saying the way people receive these chemical messages and shunt these messages through their brain to get work done to get mental work done varies a lot and the belief at least is it it varies considerably in terms of how attention output functions vary so some folks may have stronger receptors in some areas and that might actually explain how American focus better um there's a strong body of evidence showing that one particular receptor is associated with risk-taking behaviors one type of that receptor for for dopamine and that's important to know because that there's a sub population of people with ADHD who are rolling in the sky diving and if they go to med school the real deal to become the emergency medical physicians because it's exciting there's also evidence for high variability and neurotransmitter receptors among individuals with or without ADHD I think I already said that so looking at what this bajji sort of translates to visually there's this overly simplified and seductive graphic that's used a lot in a lot of presentations on ADHD and and sadly I think because people are visual and they they like pictures and they especially like functional MRI studies that show how brains operate differently in different cognitive tasks it might make us think that we understand this better than we actually do but the purpose of this talk and for understanding what we do know when I was talking about receptors for these chemical messengers I'm talking about what right here is on the surface of a nerve cell and that allows it to process a signal and send it along a pathway and the pathways I'm talking about can start at the very base of the brain with some of our more primitive functions like staying awake during the presentation or being able to calm oneself down at night and finally fall asleep and stay asleep those those skills are highly variable and they're highly a state dependent and how much caffeine you had how much exercise you had and how much sleep you had the night before getting up to the prefrontal cortex where we plan and orchestrate our activities as humans this is the most advanced aspect of our brain and evolutionary biologists would say that the most recently developed and the latest to developed to develop in adolescence and 20-somethings so when a parent comes to me and they say how come he can't keep all of his notebook straight I'm saying well he's 12 and the part of his brain that helps him keep his notebook straight is really still half-baked and if there's some dysfunction it might even be a little less advanced than that so we've got to do some things to help catch up so I'm weaving back and forth between biology and sort of sociology because it's really important I think to understand where our knowledge comes from and that it actually has come a long ways relatively speaking ADHD back in the 40s and 50s was called minimal brain dysfunction how would you like to have been diagnosed with minimal brain dysfunction kind of pejorative slowly thereafter it was advanced to hyperkinetic disorder of childhood my father-in-law was a neurologist to use that diagnosis a lot in history in the early 70s there was a D D and a t /h d now it's equally confusing because ADHD is used both for people with inattentive subtype and combined subtype okay a lot of parents say in HD without the age because she's not hyperactive so it it does confuse folks but this is just sort of where the official coding as it were and and jargon came from and how we've understood clinically what this means it's always been mysterious but before some of the larger epidemiologic studies were started on ADHD in the 80s and before the technology existed to really compare how two different brains functioned in real-time it was always a mysterious and paradoxical sort of response to stimulants that kind of pushed the science of ADHD how is it that folks who are really active and restless get calmer on a chemical that makes other people really restless and I proactive that paradox has always been very hard for people to understand and one of the ways that I try to explain is one of the biggest functions of the brain that isn't working properly in somebody for example who is hyperactive are the brakes there are pathways that actually help one realize that they're moving around too much and help you put on the brakes and slow that down and when you enhance those pathways with increased access to norborne MO and dopamine the brakes can work a little bit better that's that is oversimplifying but but functional sort of understanding and now we've gotten to the point hopefully with the standard of care and the conventional wisdom that ADHD is a neurobiological disorder with great variation so most fairly sophisticated people who read understand that these the stereotypes aren't exactly in every child or adult with an attention problem that being said I think it's fun to go over what are some of the old myths of ADHD versus the current facts keeping in mind that the current facts might change in 10 or 20 years hopefully as science advances many still believe that ADHD is purely a social invention and the explanation of the increased rates is because we are holding children to a higher standard and that's the problem right there it's not that there's something wrong with them subsequent studies across the world have shown that in every population at least in industrial nations there are certain percentage of individuals who have very common characteristics of restlessness and difficulty focusing we needed a myth is that most children will grow out of it okay that could be said also for asthma for eczema for many things and that data varies with those conditions without studying it how could you say that and it has been studied in a third to probably two fifths of children grow out of many but rarely all of their symptoms the symptoms that tend to go down over time are the more hyperactive-impulsive symptoms those systems of the brain tend to mature out whereas the inattentive and disorganized symptoms tend to persist and sometimes the beacon they become exacerbated or worsened over time as the life's demands increase another myth is that motivation can erase symptoms now motivation can certainly help someone access treatments and do things that will help their attention system function better and get the support to think but the great irony as I alluded to earlier is that motivation is driven by the very system that is having a hard time pay attention system and executive functions so um I wanted to wait to talk about the prevalence of ADHD because I think at this point it should be abundantly clear that one person's definition of what attention problem is might be very different from another person's and clinicians aren't you know perfect that long shot you don't have to tell anybody who's been a patient including a clinician who's been a patient that clinicians aren't perfect and when you try to study a condition even if the criteria are really clear what this condition is versus where it's not and they're not as clear with ADHD results may vary in some studies we ask to me that the prevalence of ADHD is 3 to 6 percent well that varies by factor of 2 guess what some studies it may not be very good ones that quintuple is our hobby or even more that number okay and we know this number varies considerably based on the population that you study families who have more access to more clinicians get more diagnosis of the further kids that should come as no surprise to anyone in some populations in fact the level of attention problems may be underestimated part of this is because what we call in medicine comorbidities they mask the diagnosis so if a child has a learning problem like dyslexia or an anxiety problem how can you tease that apart from an attention problem it's really hard this is what I do for a living and it's really hard for me I often have to see a child two or three times and really see how they respond to different interventions and how different people who see that child in different settings report how that child does before I can say mm hmm this looks more like anxiety this isn't this is mostly not attention and sometimes after we treat me anxiety what's left might be the attention piece that's hard for that child intentive girls often under-recognized or treated if you look stepwise every two or three years in terms of percent of diagnosis by gender it's fascinating boys sort of stabilized by early adolescence the figure for girl's keeps going up all the way into adulthood and and some folks suggest that it even becomes pretty even but early on it's it's highly male predominant and the main reason we think at least for that is boys tend to have more of the external hyperactive-impulsive symptoms that aren't subtle and can create more problems so they get help faster in adolescence where there is a full-on storm of developmental changes in the brain in the body saying someone who's 14 as a new diagnosis of ADHD is also very difficult to do because where does normal adolescents in ADHD begin you know being sort of a forgetful teen and sort of redundancy or as Bill Cosby used to say their brain damaged okay that's Joe um adolescence really makes it hard diagnostically I will often have young teens come to me my practice for the first time and their parents like this can't be ADHD right because because we would have known sooner and a good percent of the time there is evidence to suggest that that that individual had problems with attention functioning much earlier other times there is it they were sailing along and for some reason now because of the fragile 'no sons during adolescence in particular with all of the different developmental changes of the brain during that time period they've met their water it's become harder for them um one thing that's part of me becoming more and more understood and I think this is an area of growing knowledge and research that I'm excited about because I think it's it's more compatible with a with a logical biological sort of plausibility for this disease this condition to exist is it goes into adulthood but it changes there's a natural history just like other chronic conditions what starts off as a in childhood may be a little bit different in adolescence it may be a little bit different in early adulthood and the high proportion of children who go on to adulthood with persistent symptoms show adult manifestations of their condition which are not trivial these have to do with social functioning keeping a job higher academic functioning driving problems with the law problems with relationships um when I talk about when I talked earlier about the comorbidities I think it's real important that people understand what goes what should go on in the mind of a clinician if they're seeing you or your child or your friend's child and attention has been raised as a problem okay lots of different things can cause inattentiveness or you could even some you could substitute hyperactivity this is a concept I learned as a pediatric resident here at UCSF from the lung doctors in their phrase was all that wheezes is not asthma okay and I superimpose that same sort of phrase on ADHD and try to list all the different things that could masquerade as an attention problem or a self-regulation problem in a child there are other medical conditions such as seizures anemia chronic pain sleep disorders there are actual major sensory problems with hearing or vision medication side effects can cause children to be inattentive or tired or hyperactive there are other neurobiological conditions which I've already alluded to like learning disabilities or intellectual disability autism is hiding right there there are emotional disorders such as depression anxiety bipolar there are sources of family distress divorce illness child abuse exposure to violence the challenges of foster care for children and their school factors there's mismatches you know kids who often do real well with the right teacher and quite poorly with a rock teacher and inappropriate school environments or expectations for some children not schools are not like Schuster's and one size fits all here or hats I should say so when a clinician in the community is looking at a child or adolescent or young adult and thinking about an attention problem it's important that the consumer the patient known that knows that ADHD is the behavioral diagnosis there is no specific diagnostic medical test so I'll have families who come and bring me reams and reams and reams of testing saying he knows them in HD or he definitely has an HD and one test to test three tests don't exist in isolation they don't tell you how that child does in swimming versus soccer versus reading versus math versus in the morning versus the evening and that's what a what we say in medicine a good old-fashioned H&P history talking and a physical examining tells a good clinician it's important also that people understand at least currently the criteria for ADHD the way they've been developed are very still very strongly biased towards school-aged kids you know keeps desk disorganized or messy is one of the criteria well first of all kids don't even have desks anymore if you've been into a classroom desks are an anachronism they're still out there but there are more and more classrooms where it's sort of a common workspace at table okay the kids are sharing spacing and three and four-year-olds really don't have desks on I talked about comorbidities it's important that if if symptoms of difficulty with attention or hyperactivity are coming from anxiousness for example you can't call that ADHD you call it anxiousness and you treat that first and it requires information from two settings this one's really tricky because what are those two settings most commonly in school and home okay clinicians I think have a bias towards what they see what we the feel smell can touch can hear clinicians I think are sometimes bias towards versus the story and the different perspectives of the different people around that child when I work with residents here at UCSF they sometimes have the opportunity during a rotation to do a school observation on a child that we're assessing you know permission of the parents in the school of course and I say that's going to be one of the most valuable things you see because this is catching a kiddo in their natural environment okay and I make the horrible comparison this is the difference between going to the zoo and looking at the tiger through the cage and going on a safari okay you see a lot more of the real behavior and the real expectations that are set for a child when you get the information from school or from other settings that tend to see the child a lot more than clinicians do most we see kids every few months for 15 minutes the official criteria comes from this book the diagnostic Statistical Manual for psychological and psychiatric illnesses most current version is version 4 it says that at least 6 inattentive or hyperactive / impulsive symptoms have to occur in order for it to be full-fledged okay pretty arbitrary it doesn't say that they have to be in all the settings all the time if it's five and one setting and six in another setting and I see that the child's having some real dysfunction then I'll make the diagnosis but if it's two or three that's not enough it has to cause some impairment before the age of seven this is tricky and I think this is going to change with the new criteria that might be coming out in a couple years with version 5 it's extremely hard an 18 year old who comes to my clinic to remember back what it was like when he was six it's very hard those of you who have kids who were teenagers and older now try remember what they're like number six I have a seven all I'm trying remember when he was like when he was six two more settings once again is important continuously for at least six months I think this is really important ADHD does it go on vacation when it kids on vacation it's still there might be different okay Maya Fest itself a little bit differently because there's less structure or less demand but there still will be manifestations of difficulties and the most important thing what else could this be so there's a phrase we use in medicine a lot condition is a diagnosis of exclusion meaning the clinician has gone down a list of all the things that this could be and essentially ruled them out based on the story and that's but it's not that it's not that all the all test for that maybe it's that I'll testify it's not that oh okay it's this okay and there's tension because if you if you're a parent of a child who's suffering of something that's relatively common like a TD or ADHD is and a clinician is going through and ruling everything under the Sun out with multiple tests and visits that could be a waste of time okay but it's important like anything that there's a balance that at least these other conditions are being thought of because miss diagnosing or misclassifying a child will lead to treatment that isn't as effective when I talk about different clinical perspectives people probably know but I'll just review the different people who make the diagnosis of a TD or ADHD in children adults are psychologists so pH DS or SIA DS psy DS people who are clinically trained to do testing in diagnosis of psychological and psychiatric disorders the bias of of psychologists and I work with several wonderful psychologists they'd like to test they'd like some hard evidence in perspective psychiatrists these are MDS who did a residency in psychiatry child psychiatry child adolescent psychiatry developing pediatricians like myself and child neurologists of the three MDS I think that the bias in perspectives on ADHD in terms of what perspective each person has based on their training does vary but what's interesting to me is when I talk to psychiatrists or child psychiatrist or child neurologist we're see the same kid and we use a lot of the same language and we almost always agree on what we're seeing but what's interesting is across the country who actually sees children with attention or learning problems varies a lot based on just the market forces of who's out there for example I had a patient in my private practice we've seen me and lift got those moved to Texas and they sent me a nice note saying how we found somebody and they were a neurologist because turns out this part of the country that's who sees kids with attention problems and so that varies an interesting study that I sort of alluded to earlier multiple studies actually say that only on minority about 20% of children who end up with a diagnosis of ADHD show hyperactive behavior in a physician's office or Ana clinicians office and I to me this really underscores the point that when we're looking at two settings the most important settings are where the kid actually spends most of the time and that's not in the clinicians office okay many many many children can do really well for fifteen or twenty minutes in an office and very very poorly in their classroom or on the soccer field and the contrary is also very true kids get the heebie-jeebies when they come to see the doctor who gives them a shot whether they have an attention issue or not doctors make people anxious and you see behavior when you make people anxious and then another point I needed to earlier and there's a lot of data suggesting that the distribution of ADHD diagnosis seems to fall along socio-economic lines so it's much higher in places that have higher access to these clinicians it would be extremely sort of one-sided an American of me to think that my perspective on ADHD was the only one and it's it to me I find it really fascinating when I talk to folks who've spent a lot of time in countries outside of the United States I'm going to read different papers and reports on how attention is viewed from different cultures one that I came across and I thought was nice to share was this one came from a recent Chinese - study done on a Beijing and Shanghai on the epidemiology or the patterns of attention and the perspectives of what ADHD my being with among parents and clinicians in China some parents and teachers regard attention deficit as an ordinary characteristic during a child's growing phases so not that different from the norm others are unwilling to admit that their children are suffering from a mental disease so perhaps an element of denial or not accepting that this is a disease which people do everywhere another interesting quote I came across French child psychiatrists in general view ADHD as a medical condition that has a psychosocial and situational causes notice not biological causes therefore instead of treating children's focusing and behavioral problems with drugs for instructors prefer to look for the underlying issue that is causing the child distress not in the child's brain but in the child's social environment it goes on okay my name is perspectives real important but it should come as no surprise the studies of ADHD in France have much smaller numbers than here because of this and this brings us to their opee if if one can swallow the pill and that this condition exists and there are some things to to help children and adolescents do better and functionally with attention on what are some of the things that help what do we know my background I have a master's in public health and clinical effectiveness I've done research I understand how to sort of interpret research but I'm a clinician at heart and I can read a lot of papers and say this is the evidence-based it's strong it's weak it's non-existent but when I have numerous patients who have tried things and it's helped them or not that's in my database to their different databases and I think the database that the general public uses the most based on one individual's background if you're a scientist maybe you read the papers too you know but sometimes folks trust what their type what happened to their neighbor's kid more than what their doctor says or what they read in the paper anecdotes are very powerful stories are extremely powerful and there are lots of stories that I've heard for many of these alternative therapies but fortunately there's also on the other side of the evidence spectrum some scientific backing or at least attempt to understand the validity of these different treatment modalities in particular psychological counseling which is a huge diverse category I'm kind of embarrassed just to lump it all together there's a mixed evidence of support for helping children and families with ADHD probably the strongest evidence is in older kids with one-on-one therapy okay and in group work with sort of medium age kids 8 9 10 where they work in groups to work on their skills in up self control and focusing and that's peer and social support there's strong evidence there exercise this is a strong body of evidence that cardiovascular exercise in particular but other types of exercise are very helpful for children and adults who have attention dysfunctions I'll touch on exercise later because it's one of my favorite things to prescribe environmental therapy so people have posited the theory that walking around in nature is soothing and helps an attention system mature and function that evidence is sparse but there's nothing wrong with walking around in nature hypnosis there are a few small studies of this the world a jury is not back on that but hypnosis has been used in other pediatric behavioral conditions very effectively meditation needs to be studied more biofeedback there's a mixed evidence biofeedback has to do with a person's ability in real-time to control how they're functioning based on getting feedback so a modality called neurofeedback has been tried where kids literally have sensors attached to their brain like for an EEG like for a brain scan and people with seizures have those brain scans but they have these electrodes put on their brain and they can play a video game that requires focus and the the object of the game like if it's a bird flying will dip down if they're less focused based on characteristic brainwave readings that are associated with more focus so that's real time biofeedback so but technically that sounds like a fantastic therapy in practice it's hard it's hard to do that and the people who do at a neurofeedback um they vary in quality and the variant protocols but it's a fascinating idea and for some kids it works and it could be quite expensive sensory integration therapy there's some evidence for this I work with several occupational therapists who have made a big difference in my patients but I think it's really under studied and under understood auditory integration therapy or listening therapy there's very little senators evidence to show that this works well but that I certainly have patients who have done it and said it helped them I've had a probably equal number of patients who have done it and said it was a waste or their time behavior optometry a small number of patients who have said this is work for them several others who have been disappointed with it but I do support many of these modalities but I hold them to the same standard that I would hold say medication I say hey let's look at the potential risks and benefits let's look at the time commitment the money commitment the hope commitment that you're going to put into this okay and think about how it might help your child exercise as I said is one of my favorite things to prescribe if I had a pill for and I'd be a billion many theories as to why exercise might help with ADHD if you were my fourth-grade teacher mr. stork you made us run because it just tired us out so much that we couldn't misbehave class and we may have been onto something certainly different forms of exercise promote coordination and social skills I mean that's hopefully abundantly obvious but exercise have been found in multiple studies to enhance learning pathways there's a thing called brain-derived neurotropic factor that actually helps you make new connections in your brain that increases with exercise so exercise can be very powerful that actually remapping and strengthening connections in your brain and this is carnal vascular exercise I was really good book out there that there's a nice companion of the evidence that scientific evidence for exercise with multiple conditions including anxiety depression menopause age and senility and ADHD by a guy named John ratty in it he talks about how men apparently have to exercise a little bit more than women do to get the same benefit that is interesting and I don't think anybody understands one you could always say it's because some women aren't then they're smarter already but no one's no one likes a useful exercise is a useful adjunct at the very least ok when patients do some exercise it'll enhance other aspects of their life as a primary therapy is the only thing like if you're Michael Phelps when he gold medals and you have ADHD exercise might be your primary therapy because you're swimming you know hours every day but for most folk practically you can't be your primary therapy because how much time in the day to do parents have to get the kids exercise some specific types of exercise have been studied gymnastics martial arts yoga I haven't seen any papers on swimming although I would love it if there if I saw some papers on swimming a recent paper came out on yoga that reduced stress and a lessons mmm not strong evidence yes yet about focus although it's highly suspected that yoga helps with focus when I work with families I like to talk about some of the basics that have been tried and tried again with many experts and clinicians around ATD ADHD the four R's can everybody heard about the 3 R's and academics where those the four arms of helping kids with that attention problems routines reminders rituals and rhythms ok routines have to do with how do you get up and get ready for the day how do you transition when you get home from school and how do you get ready for bed an example of a routine booster will be visual schedules for getting dressed in the morning I cannot tell you how many parents come to me with the pair pulling out of I can't get him ready for school ok and much of the time if we can break down a system that helps the child actually get themselves mostly ready and it's it devises them for doing that with a visual schedule it's helpful reminders for middle schoolers in high school or is not knowing what to put in their backpack where to put it and when to get it out is really hard and if you if you have them make a checklist and actually attach it to the backpack so they can see that checklist it can be very helpful but they have to be able to see it reminders a piece of paper in my pocket is the worst kind of reminder I find it after I've done the laundry it's this crumpled nassima what was I supposed to do it has to be it has to be in one's visual space to be useful certainly technology with everyone walking around with iPhones and bells and muscles can be helpful in that respect for reminders as well I have parents who don't remember to give their kids their meds and I say gosh get away from there when we set it up a reminder right now rituals so you know fighting over cleanup of toys or materials is a big thing okay kids with the attention challenges that they're really good at getting into it and then they're gone on to the next thing sort of great they're grazing across activities and the whole cleanup pieces like that don't want to do that I want to move on to the next one I'm along the next activity so creating a space creating trays creating easy access and easy put away rituals really helps cut down on conflict rhythms understanding that the access to mental energy and focus varies over the day and it varies individually some people are morning people some people are or afternoon people not trying to have a child do something that's really hard for them at the time of day where their energy is the lowest and is common sensical but there are many many situations in which the pressure of home work creates this horrible tension as soon as the kid gets home it becomes sort of the torture we must get this done whether we're at all ready to do it or not so a lot of families find out if they get a good snack in if they get a little exercise in Johnny's more ready for doing homework and some folks do really well with sprinting they get a timer and they do it for 20 minutes and then they take the break and they know they can work they can sustain their attention for that short period of time because they're going to get a break but when children are faced with this sort of Mount Everest of homework they don't think they're going to go to break it's it's a lot harder to marshal the energy and the motivation to do it that being said it wouldn't be a talk about attention challenges and I didn't talk about medication my philosophy about medication is it's one tool in the toolbox it's not V tool it's a powerful tool it's a tool that is often misunderstood and often overused and scary especially if you read the New York Times this weekend there's an article about the misuse of medicine to help boost test scores and potential addictive capacity of stimulant medications without lessons the criteria I use though in deciding whether or not to offer medication for attention dysfunction or ADHD first of all more safety I have some kids who bolt and if they bolt in front of a car they usually don't get a second chance to do that or they're really impulsive and other kids get hurt when they play with them and they feel really bad they don't want to hurt other kids it just happens problems with bonding or getting along okay when parents are tearing up because they're not liking their kids anymore or they're seeing other children not like their children whether they know that the teachers turned against their child that is often cause for thinking about what can we do to help this child do better obviously we have to work with the environment but if we can change the game and now this child is able to play and function we might be able to help their relationships problems of learning probably the biggest thing that brings in the most parents he's really behind in reading and that really matters to us and we want to do what we can to fix his reading and sometimes it's just the reading sometimes its attention sometimes it's reading an attention problems with self-esteem so younger kids they don't articulate oh I feel horrible about myself what's wrong with me in words much they get frustrated or easier they they don't try harder tasks older kids will say how come I come on the last one to finish this work how come how come I have to stay infirmary system finish this how come I can't get my homework done how come I'm stupid okay here I hear this all the time and it's pretty rare for me to march down this list with a family member and some of the stuff is you know happening and this isn't happening that being said what do we know about how medicines work in terms of effectiveness stimulants are first-line therapy at least currently form attention problems they've been the most studied in their the quickest and most effective of the medications lots of families come to me with an ad or TV commercial and say I want this and I say why and they say because it's not a stimulant and I say okay what if I told you the chances of a simulant working or three or four times higher than that oh really what if I told you that that has side effects too and these are the side effects are different from side effects of generics and families go oh okay that being said only 70% respond to a single stimulant meaning if you put all the names of all the products and a hat and used to can in there like little Chinese fortune pieces of paper you're pulling out and you say oh this one and you try it there's about 70% chance it's going to help if the diagnosis is correct that's pretty good in medicine there are a few things in fact in medicine that work that well but the onus is on the clinician to make sure that the diagnosis is accurate because if the diagnosis is inaccurate that number goes way down the number goes up even more if you are patient with your clinician and give them a second draw into the Hat okay that one didn't work so well we tried that at a couple doses didn't seem to do much let's try something different okay that being said there's still ten percent or so of kids who after several different medications they don't seem to get much of response the non-responders and the most important thing I think a parent or a teacher or clinician should ask themselves if a child's been an on responder is do we have the diagnosis correct what else is going on and if it seems like that's been adequately addressed then okay what are other things we need to be doing too sadly there are no indications which medications are try first there are trends based on the the bulk or the compendium of evidence out there the two different families of stimulants are a little bit different their side effects can be a little bit different they've been studied disproportionately one more so in young kids and one more so in older kids so I sort of use that as a guideline but I tell families if we've tried one in one family and we've gone up down the dose and we haven't gotten anything that we like and it makes sense to try something in the other family knowing that there's a diversity of neurotransmitter receptors across kids and how they're going to respond to different products differently I'm not wedded to any product I'm wedded to efficacy and what it being safe and effective in most clinicians on that's just how it works when deciding what medicine to use rather than pull the pulling the ad out of the parenting magazine or the commercial you saw on late-night TV clinicians should be asking can your child swallow pills because it's some medicines that's the only way to take them there's a patch for kids who can't swallow pills there are capsules that can be opened up and put on food which can be effective how long do you need the medicine to last there's short-acting medicines three to four hours there's medium aking medicines maybe six to eight hours and there's long-acting medicines ten to thirteen hours will it get paid for that's really important to patients I find I used to try to be puritanical and go well I'm going to prescribe what I think is going to work best for you or I don't care if your insurance covers it and that didn't last very long because I'm a patient too I don't want to have to pay fifty dollars for something that I can pay five dollars if it's going to work just as good okay I want something that I can actually try it takes a lot for a parent to get over a lot of the stigma and fear in deciding to try to use a medication for behavior and once they do that I want to do it they don't want to wait around for insurance to improve it or approve it or pay a lot for availability there is currently a national shortage of several stimulants and I'm just starting now to routinely ask my patients have you had a hard time finding that because I'm trying to keep track of what's going on because I don't want folks to be left high and dry if a medicine has been effective and helpful for them I want them to be starting up the school year without it family history um as the science improves understanding how the different genomes and different receptor profiles and individuals affects which medications work better is going to be really interesting to follow just clinically if I've got a parent who tells me I tried this and it worked really well I'm more likely to try that with their child because their child presumably they share a lot of biological characteristics this is my last line before questions in general I think and this is the case for probably all of the neurobiological disorders and really most conditions of childhood it is equally important to identify child's strengths as it is they uncover a child's dysfunctions I try to always start by listing a child's strengths when I'm writing out a plan for a parent because we want to keep those we want to develop those those can often be the islands that help the weaknesses the best prescription is apt to derive from the best in detailed description one of my favorite phrases for medical school is diseases don't read textbooks just because it doesn't sound exactly like the paragraph you have in the textbook doesn't mean it's not a problem there isn't something you can do about it a unitary form of management such as the use of medication is virtually never the whole answer to a child struggles there always should be a multi-faceted collaborative approach and that's where I see things taking off for kids with attention problems when sort of the triangle of home-school and the individual are all getting enhanced for that child's well-being function that's my last slide it's a great question the question was when there are several different problems going on simultaneously how do you prioritize or decide which one to address first and I think that really hinges on how the evaluation is done by the clinician okay there should be a lot of time in the evaluation devoted to how is the child functioning in their major environments how they function in school how they function at home how they function their basic functions like eating sleeping because when one lists problems out I mean we all use a common sort of triad learning disability anxiety and attention problem any one of those could be the lead player okay the story and how the child's functioning will often tell you which one so if a child has signs of anxiety throughout their day and it's limiting their sleep and it's a phone it's it's affecting how well they can focus and they also have a comorbid learning problem I'm probably going to focus on the anxiety as my number-one priority because if this child can have more coping skills or can biologically be less anxious they're going to sleep better and what's going to happen if they sleep better they're going to funk they're going to focus better what's gonna happen if they focus better then the learning disability won't be as exacerbated by the anxiousness and the attention problem so that is it's hard and it's and it's it's real important I think for clinicians to help families prioritize because it's overwhelming families come to me and I don't know what to do first I got all this testing and all these labels what's real here and what should i do first and if we just sort of get down and talk about what's a day in the life from Johnny like and whereas pitfalls and whereas high points where as low points it often comes out in the story which which of the challenges is the biggest one the analogy I like to use is for example it's a cloud over some other problems that are there that cloud lifts we can actually see what's going on a little bit better and then address what's left next question the question is is whether I as a development of a pediatrician work with schools in creating what are called 504 plans for adda ADHD and just as background a 504 plan is based on the educational law title 504 accommodations reasonable accommodations to help a child access the regular curriculum to be in a regular class if they have what's called resolve jargon is full of three-letter acronyms and Ohi and other health impairment it could be cerebral palsy could be diabetes could be ADHD anything that gets in the way of a child's ability to access the regular curriculum that's a health condition can trigger a 504 plan and what is a 504 plan it's accommodations in the classroom and and some general academic accommodations that allow the child to sort of physically and psychologically have access to the curriculum for childhood EDD some common examples of 504 plans are preferential seating so for anybody here with ADHD who really want to wanted to get every point in that be sort of lost in space for this lecture you should be sitting right here you should be sitting right here unless you're super anxious then a couple rows back okay preferential scene is actually really important for the educator - educator to monitor the child and for the child to monitor the educator and I always mentioned preferential seating first because thinking about how the space works for the child and the educator working with the child is extremely important okay because everything else that the educator is going to try to do that's an accommodation such as a secret signal instead of saying Johnny sit down Johnny sit down Johnny I told you to sit down going Johnny because they already agreed that means sit down that's more discreet it's a little funny it's more likely to get Johnny's attention and less likely to make Johnny feel embarrassed so there's a myriad of things there's testing accommodations for kids whose attention challenges only affect how they test there's lots of different things so a probably answered your question and whether or not I helped to develop these that I work with parents and say these are some things generically that will help your charnel using some things specifically it will help your child but like any sort of contract or piece of paper that ya put together and you work with the school or somebody with a child who has an attention challenge it's a dance it's a transactional experiments the parent needs to partner with the educator and the educator needs to partner with the parent to monitor how well it's going 5:04 is just a piece of paper I will often quiz my patients on what the accommodations actually are because if the kiddo has no idea that they're supposed to sit in the front row okay and they tell you that they're not clearly that's not happening right or they're not getting breaks or they're not I have a lot of older kids who have who have test-taking accommodations written in but they never take them because they're embarrassed they don't want to get out of the classroom and have to go to a quiet space and get more time to take the test and I try to encourage them try it use it or lose it if you don't try and see if it helps you or not it may help you may not help you you'll never have access to it later on when you might need so that's a that's an art there's a lot of good stuff written out there there's a website called rights law there are other websites schwab learning calm LD online might one of my favorites is attitude mag ABB I tud a really good website and just a blog they send you emails all the time I just got a new email today from attitude very helpful for parents abb i tud dot i think is calm lucky or good google it will think for you next question I'll tell you what I do personally based on my own training and I'll tell you what other people do in other disciplines like psychologists or psychiatrists or neurologists what they'll do it a little bit differently because I think the key here is it's like you know there's a recipe for success and accurate diagnosis and catching other things that could masquerade or go along with an attention problem and the key ingredients you need to have some semi objective assessment so I do a thing called the peaks in the pyramid they are assessments of what are called neuro developmental skills so it's these are games that were designed do you play with kids you look at how coordinated they are when they write you know look at how coordinated they are when they jump up and down you look at how the memory works for sequencing how their memory works for language how their memory works for visual spatial like pictures you look at how the reader reading comprehension works you look at what's called phonemic awareness which is critical for reading and people with dyslexia have poor phonemic awareness so breaks down many different skills required for learning when I do that targeted assessment with my patients it tells me oh this guy's got pretty good skills across the board but he's really inconsistent he like misses an easy one and then gets a hard one right he really has a hard time remembering two things at the same time it really is a hard time using new information that's sort of active working memory with new rules to solve problems those are all attention problems versus a kid who doesn't really get that pH makes fun and doesn't really get how to take one letter out of a word to make a different sound they just don't understand how letters make sounds make words that child probably has dyslexia and might look like they have an attention problem in a class that's a lot of reading so that's that's what I do huh I also do a parent and teacher behavior scale and their different behavior scales out there so the parent or teacher will fill in bunch of bubbles are lots of different symptoms that's sort of a global look at the child and I use that to make sure I'm not missing something like anxiety or depression or something else that might be going on emotionally with the child that could explain why their attention isn't working because nothing hurts the attention system more than saying depression in childhood kids who are really sad about what's going on in their lives have a hard time focusing and have a hard time motivating so I use a general screen for emotional stuff I use a specific targeted assessment to get at with their skills of learning on and then I add on the old-fashioned history and physical talking about problem when it began when it manifests itself what makes it better what makes it worse the kind of things that doctors should be doing with whatever you tell them psychiatrists have a somewhat similar approach they do less testing they do use a lot of brief assessments or score sheets Sanrio score sheets psychologists do a lot more testing they'll test the kids IQ they'll test their academic achievement they'll do all kinds of stuff to get as many perspectives quantum to quantify where their skills are as possible in addition to an overall assessment of how the kids functioning a neurologists do a lot with their physical exams is important and their observations are important so somewhat different perspectives based on on how a person's trained but I think a good history in physical something's in my objective where you really get a sense of the child's skills to make sure we're not missing a learning problem and a global look at how the child's functioning emotionally in Hallman at school those are all key ingredients and time I with experience I've learned that when the child comes back in a month or two the evaluation isn't over there's always more information that my nuance or change the profile of the diagnosis of the strengths and weaknesses of that child so you know ninety minutes is that 90 minutes is still just as that's that's how online new valuable new evaluations are it's still just a snapshot in a child's life some folks out there do three hour-long evaluations before they come up with a final sort of profile so the question is one of the tools in the toolbox I mentioned medicine is just one of the tools exercise is a tool okay those four are sort of using reminders rituals etc that's one of the tools a 504 plan with the school is one of the tools lots of things so it's it can be a very full toolbox which could make you know the parent a little overwhelmed at times on the art of really helping is giving the child and the family the right tools at the right time so I think good evaluations list several of the tools that will be helpful and even better prioritize which ones might give you the most bang for your buck in the beginning okay similar to the first question about sort of you've got different problems what which one do they attack first on medication so I think the question if I'm if I'm not mistaken is for people who start medicine and stay on it how how many stay on is sort of into adult early adulthood and the figure I showed earlier sort of 33 to 40 percent okay is ballpark what we think happens the problem is is when you become 18 even way before you're 18 medicine whether it's useful or not is an option it's not mandated so I've had several teenagers who have cheeked their pills meaning a stroke right now yeah mom I took it and when moms are looking in the garbage okay at a certain point kids decide whether or not to take the medicine whether it's effective or not so it's very hard to design a study that tells you exactly what percent of folks need the medicine still going on early into adulthood because at some point people decide they don't want to date now people don't want to take a medicine that might be a sample that's biased because they're having side effects or it's not helping most of the time if I have a kiddo who's pretty reluctant to take medicine if they decide to go along with it for a month or two and then they find that the medicines helpful they're not as reluctant because it's logical kids are very logical this is helping me fine I'll do it so the perception is it's not helping me or attorney me there side effects why would I do this so definitely it's you know I'd say at least the data I've seen argues for our strong third of folks going into adulthood still benefiting from medicine when we talk about adult or early adult ATD and ADHD I think a lot of the writing by John Rati and Ed Halliwell it's very useful they say in their book driven to distraction and delivered from distraction that probably two most important life decisions somebody makes who has an attention problem is who do you marry so who do you couple with who do you work with and what kind of work do you do okay if you want to be an air traffic controller you better exercise a lot and I have some tools that really help you be on point if you want to be an artist great fantastic okay if you want to do well in a work environment it better be a place that values you for your strengths and doesn't prey upon your weaknesses and in relationships hopefully somebody who kind of gets that person with ADHD is unique and has strengths and isn't just scatterbrained and not motivated that's a truly important because families who have one or more members with ADHD have a much higher rate of divorce and problems

Channel: University of California Television (UCTV)

Views: 175,037

Rating: 4.802052 out of 5

Keywords: ADD, ADHD, Attention Deficit Disorder, Dr. Neal Rojas, hyperactivity

Id: -mqpdomdnH4

Length: 87min 24sec (5244 seconds)

Published: Thu Oct 25 2012