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Attention Deficit Hyperactivity Disorder (ADHD) in Children&Adults

Online Health Chat with Dr. Michael Manos

April 11, 2012

Introduction

Cleveland_Clinic_Host: Nearly 5 million children in the United States have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). It’s estimated that up to 70% of children with ADHD will continue to have significant ADHD-related symptoms persisting into adulthood, which could impact education, employment and interpersonal relationships. ADHD is characterized by multiple symptoms, including inattentiveness, distractibility, impulsiveness and hyperactivity. Due to the fact that ADHD is caused by both environmental and genetic factors, an individual’s symptoms can change over time but never be fully outgrown. Michael Manos, PhD, Head of the Center for Pediatric Behavioral Health at Cleveland Clinic Children’s Hospital, answers questions about ADHD in children and adults, from identifying the disorder to developing an individualized plan to manage it.

In the past ten years, the number of diagnosed cases of ADHD in children has increased nearly four percent every year. With more children being diagnosed, the need to understand and manage the disorder is becoming increasingly important. Children with ADHD can be classified one of three ways, depending on their specific symptoms: children with more inattention symptoms, children with more impulsive and hyperactive behavior symptoms, and those children with both sets of symptoms. Although there is no cure for ADHD, medication and counseling or therapy services can help reduce symptoms and allow your child to lead a normal, healthy life into adolescence and adulthood.

Michael Manos, PhD, is the Head of the Center for Pediatric Behavioral Health in the Children’s Hospital at the Cleveland Clinic. He is the founding Clinical and Program Director of the pediatric and adult ADHD Center for Evaluation and Treatment. Dr. Manos also is Adjunct Faculty in Case Western Reserve University’s College of Medicine, Department of Psychiatry. His special interests include attention deficit hyperactivity disorder (ADHD), adults with ADHD, behavioral pediatrics, clinical behavioral pediatrics, family management, and pharmacotherapy research.

Dr. Manos completed his graduate degree at John Carroll University. His post-graduate training includes an internship at the University of California Los Angeles in the Neuropsychiatric Institute, a doctorate in Special Education and Clinical Psychology from the University of Arizona, and a fellowship in Psychology from University Hospitals of Cleveland.

Cleveland Clinic Children’s Hospital offers a comprehensive approach, including medication and skills training, to help manage your child’s ADHD. Our team of psychologists, psychiatrists, pediatric and child psychiatry residents, as well as social workers, licensed counselors and nurses will develop an individualized treatment plan for your child. Cleveland Clinic Children’s Hospital’s commitment to family-centered care and use of state-of-the-art technology helps your child best manage his or her ADHD while maintaining a normal, active lifestyle.

Cleveland_Clinic_Host: If you would like more information on the Cleveland Clinic Children's Hospital ADHD Center for Evaluation and Treatment (ACET) or general information on ADHD visit us online. For general pediatric information, visit Cleveland Clinic Children’s Hospital or to make an appointment with any of our pediatricians or pediatric specialists, please call 216.444.KIDS (5437) or call toll-free 800.223.2273, ext. 5437.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Michael Manos. We are thrilled to have you here today for this chat. Let’s begin with some questions.


Finding a Specialist

Sal: Where can I find a specialist to work with adult ADD?

Dr__Manos: Regarding finding a doctor to treat ADHD as an adult, you can find more information about ADHD, resources that may be helpful, and professionals in your area who specialize in ADHD at the website of Children & Adults with ADHD (CHADD), www.chadd.org/

nystrom: Are ADHD coaches an effective tool for families or even adults with ADHD? What about support groups?

Dr__Manos: ADHD coaches are an effective source of support, especially for adults with ADHD. The CHADD web site is one resource. You may also want to go to http://www.addclasses.com/; they offer regular (and sometimes free) teleconferences with coaches and experts who discuss strategies that can make a big difference.

Cognitive-behavioral therapy (CBT) is showing promise as a treatment alternative for adults with ADHD, especially those that target organizational management and prioritizing skills.


ADHD Medications and Complementary Medications

MelanieH: I have an eight-year-old girl with combined type ADHD. She has been on Concerta® for the last two years. We have had to give her a higher dose every school year. How much is too much and what other alternatives are there to medication to have "normal" behavior and focus?

Dr__Manos: I do not practice medicine, and I cannot give medical advice, so please let me refer you to your physician. Let me say, however, that in many of the research reports, it is not uncommon to increase the dose of medicine as the child grows older. There are many behavioral strategies that are effective in managing ADHD. The ideal combination of pharmacotherapy and behavioral intervention produces the best result. Here at the Cleveland Clinic, we offer intensive behavioral intervention within a summer treatment program, essentially a sports camp for children that runs for seven weeks for eight hours a day. Included in this program is parent training on behavior management of children with ADHD. One of the common strategies to use is a daily report card where specific target behaviors in school are reinforced in an all-positive system by parents at home. This program works quite well, and significant behavior changes are typically evident. One key notion to keep in mind is that the goal of such programs is not to change child behavior; it is actually to change caregiver behavior. Parents and teachers are the primary change agents of children with ADHD. Children will subsequently adapt their behavior to the parent and teacher. What is key in this approach, then, is teaching parents and teachers to use new behavior, new ways of interacting with their child. That is the focus of behavior therapy. At all costs we train parents to avoid engaging the definition of insanity--"doing the same thing over and over while expecting a different result." One of the simplest examples of this is asking the common question, "Why did you do that?" Though parents do this frequently, it never produces a lasting result (and still it happens).

MSM: My son has a very unusual cardiac history and, as a result, we are reluctant to try medication for his ADHD (inattentive type). He is 10 and doesn't appreciate his own challenges. How can we help him improve his working memory, especially outside the classroom?

Dr__Manos: This is a very interesting question. Always consult with your physician with regards to cardiac conditions, of course. With regard to working memory, there is evidence that a system called Cogmed Working Memory Training improves working memory. Its long term durability however, is not known.

Lynnf: I am a 30-year-old adult with ADHD, and I wanted to know if there are any dietary/supplement/natural recommendations to aid in the treatment of ADHD in adults and/or children. These would be used as alternatives to medications, or in conjunction with medications.

Dr__Manos: At present there are no dietary supplements or recommendations from complementary medications that sufficiently manage the characteristics associated with ADHD, for example, helping a person sustain attention or strengthening a person’s ability to not respond to distractions. I know that many people will say they have tried this remedy or that remedy and that it worked. I am not invalidating anyone's personal experience with different remedies; what I referred to is that no controlled scientific study has confirmed that anything works better than combined pharmacotherapy and behavioral interventions for the treatment of ADHD. With that said, there is scientific evidence for positive effects from Omega 3 fatty acids and L-carnitine. The effects from these two supplements, however, are nowhere near those of behavioral intervention and medicine. Be wary of the claims of marketed items. Use Carl Sagan's rule: “Remarkable claims require remarkable evidence.” Other strategies are common sense, such as maintaining a consistent schedule from day to day and getting proper exercise and rest.

t2run4: Can the effects of medicine such as Ritalin® be used as a proof positive or confirmation of diagnosis? If Ritalin "works" as expected, is that confirmation that the neurological disorder truly exists?

Dr__Manos: The answer to this question is, in fact, no. Response to stimulants does not confirm diagnosis. In a classic study conducted in the 1970s, a study that could not be conducted now, both children who were typical and children who were hyperactive responded well to medicine. Response to medicine is not diagnostic of ADHD.

emenst: My developmental pediatrician tends to look to me as the parent to determine when medication should be started for my 5-year-old with ADHD as opposed to the pediatrician instructing me to medicate. This puts a lot of pressure on a parent to decide when the time is right without having all of the medical background to understand when it is necessary. What are some tools that should be tried before medicating, and what signs may be a definite indication that medication is necessary to help the child?

Dr__Manos: Parents may wish to give a child assistance through medicine when children begin making negative self-statements about their ability to do school work, call themselves stupid, or say "I'm just not smart enough.” We all need to remember that the ADHD brain is just not designed to do school work in the way that academic material is presented in most schools.


Behavioral Management of ADHD

blsfield: I am new to the ADHD diagnosis and am interested in getting information on how to develop the best individualized plan for managing a 7 1/2 year old with combination (attention deficit, hyperactivity, and impulsivity) ADHD both at school and at home. Specifically, I would like to know what I should be doing from the behavioral perspective. I think we've finally got the medication part finalized, but now I need to concentrate on what I should be doing behaviorally and the best way to find/evaluate resources in my area (San Diego, CA).

Dr__Manos: There are many behavioral strategies that have been demonstrated to be effective with ADHD. One of the best books in managing home life is "1-2-3 Magic.” Another excellent website for further insight into the use of behavioral strategies in the home is CHADD.org, which can help you to find resources in your area.

MelanieH: Are there books or resources about ADHD for children to read?

Dr__Manos: There are a number of very good books about ADHD for children. You may wish to go to ADDWarehouse.com for this information.

csom12: Can you recommend any strategies to try with children who struggle with inattention? I am looking for options outside of medication to help my son.

Dr__Manos: Children with ADHD, inattentive type, will respond when two conditions are present:

  1. They get immediate feedback on their performance.
  2. Are shown what to do next.

There are several situations that provide this; the most common one is the use of a tutor. A tutor can show a child whether they got the right answer and can then direct the child to the next problem. Many people may have noticed that children with inattentive type ADHD tend to perform quite well with one-to-one teaching and one-to-one behavior management.

Another condition that performs these two functions is the use of a computer. Many educational programs clearly let a child know when they got the right answer and then automatically present the next problem.

There are many ways of replicating tutoring, for example;

  • by having same age or older age study buddies
  • study groups such as those used in college classes
  • study methods that use the survey-question-read-recite-review method (SQ3R).

jack_coop: My wife and I are reluctant to put our child on medications if she does not need them. How well can our 6-year-old daughter be helped with her ADHD without medications?

Dr__Manos: It is generally a good rule of thumb to use behavioral intervention first. Medication may be needed when even intensive behavioral intervention stops yielding a result. But remember, the most effective way of dealing with ADHD symptoms is to use a combined approach. What to watch for that may point to the need for medicine is the child is trying very hard to master school tasks and not succeeding. Often what occurs here is that children make negative self statements, blatantly avoid school work, and consistently doubt their ability to be successful in school.

hard_pressed: Do you feel that special schools for ADHD give that much of an advantage to children with ADHD and learning how to function through their lives? I have considered such a school for my son, but it would put a strain on the family budget. However, if that is what can give him the best chance for his future, I would do what I have to do.

Dr__Manos: Special schools can contribute significantly to children with ADHD by being accepting of the condition rather than punishing the child's performance when they cannot do what typical children can do in school. Many children base their identity and sense of being effective in the world by how well they do in school. They compare themselves to other students and see their own performance lacking. Then they conclude, "There’s something wrong with me." Attending a good special school keeps this from happening and actually teaches the child new skills, not because they're disordered but because their brains work differently, and as such, must learn different ways of doing things.


Diagnosing ADHD

happy_feet: How exactly does a doctor come to a correct diagnosis of ADD or ADHD? How subjective is it? My son has seen a couple of different physicians who have each given a different diagnosis and treatment plan. How do you know who to trust?

Dr__Manos: The diagnostic process should include several elements. First, broad-band rating scales are very useful. These rating scales give indication of the presence of ADHD symptoms and other conditions that may accompany the symptoms. Then, a good narrow-band rating scale should be used. A narrow-band rating scale just rates ADHD symptoms. The most common one, appropriately named, is the ADHD rating scale. Next, a very thorough semi-structured interview should be conducted. This interview covers areas such as the child's social network, family management plans, behavior management in the home, the daily routine, trauma and transition in the child's history or current routine, and personal characteristics of the child, such as how well they express their own feelings and how well they understand the feelings of others.

Essentially, the diagnostic process answers three questions:

  1. What are the symptoms exactly?
  2. 2. Is there any explanation, other than ADHD, that might account for those symptoms being present?
  3. Are there any co-morbid conditions, or things that might be considered secondary concerns?

nystrom: Is there a difference between adult and childhood ADD/ADHD in regards to diagnosis and symptoms presented?

Dr__Manos: The prevalence in school-aged children is 9.5%. The prevalence of ADHD in adults is 4.4%, based on most recent Centers for Disease Control estimates. Interestingly, symptoms that are evident in childhood change or migrate over time through adolescence and into adulthood, but they are still the same symptoms. For example, hyperactivity in childhood as evidenced by children's heightened and chronic movement and motor activity in adulthood translates into a chronic sense of restlessness, a feeling that one always has to be doing something. In summary, the symptoms are the same, they just have different expression.

jkm: I am the type who has to always be busy, whether cleaning, vacuuming, dishes, laundry or typing. When I am not doing something, I pick and scratch at my face without even realizing it until someone points it out to me. I can't even go to the movies because I will destroy my face sitting for two hours just watching with nothing else to do with my hands. I have scars as a result. Could this be a symptom of adult ADHD?

Dr__Manos: Picking and scratching is not a symptom of adult ADHD. It may represent an underlying condition, so I suggest you see your physician.

t2run4: Can the effects of medicine such as Ritalin® be used as a proof positive or confirmation of diagnosis? If Ritalin "works" as expected, is that confirmation that the neurological disorder truly exists?

Dr__Manos: The answer to this question is, in fact, no. Response to stimulants does not confirm diagnosis. In a classic study conducted in the 1970s, a study that could not be conducted now, both children who were typical and children who were hyperactive responded well to medicine. Response to medicine is not diagnostic of ADHD.

bsapfield_1: I've read that the younger children are diagnosed with ADHD, the more susceptible they could be to depression later on. Is this so? If so, what can a parent do to try to minimize this risk?

Dr__Manos: There is no clear evidence that establishes early diagnosis of ADHD makes a person more susceptible to depression. In fact, there is evidence that the opposite is true; that is, that the earlier a child is diagnosed, and the earlier that intervention, whether behavioral or medical, is provided, the better children do academically and socially. It is untreated ADHD that makes people more susceptible to co-morbid conditions.

jlo3: Do you feel that ADHD is over-diagnosed or that too often kids are medicated who really don't need to be? My son has ADHD and has a friend that is on ADHD medications and often does not take them. He doesn't seem that different to me if he does or doesn't.

Dr__Manos: I know that many people feel that ADHD is being overdiagnosed these days. But from my perspective, it looks like it's being underdiagnosed. If we have almost 10% of the childhood population diagnosable with ADHD, we're only identifying and helping about one-third of that number. Given the number of children whose parents are seeking help, it is probable that at times pharmacotherapy is applied when it does not need to be. But this is probably quite rare as most physicians are competent to recognize the symptoms and diagnose the condition.

go_forward: My son is a very active little boy. His kindergarten teacher has asked whether he had been tested for ADD or ADHD before. His pediatrician has never suggested such a thing. How do you know when your child should be tested?

Dr__Manos: The time to seek out assistance is when a child's behavior significantly interferes with his or her functioning.


General Questions

astridava01: Dr. Manos, I have two young sons. One was diagnosed at age 4 with ADHD. The other was diagnosed at age 5 with ADD. Both take daily time-released medication for their disorders. As they get older and mature, we notice they are improving, and needing a smaller dosage of medication to assist, especially in a classroom setting. I want your professional opinion on three questions. Will they eventually be able to grow out of their symptoms? Does this occur more in males? And is this hereditary? (To our knowledge, we have no one in the family that has ever been diagnosed with ADHD or ADD.) Thanks much!

Dr__Manos: In response to your questions, as children move into adolescence and adulthood, symptoms of hyperactivity and impulsivity tend to tone themselves down, starting at age 11 years, and increasingly so during adolescence. Symptoms of inattention, however, remain in adulthood. Such symptoms of inattention then tend to be managed through various coping mechanisms and strategies in adulthood.

In childhood, the ratio of boys to girls diagnosed with ADHD is about to 3 to 1. In adulthood, however, the ratio is 1 to 1.

All evidence points to a strong biogenetic origin. At present, about 21 genes have been identified as associated with ADHD, and these are largely connected to the development of specific neuronal pathways and specific areas of the brain. The genes are associated with various executive functions of the brain. Seventy percent of ADHD is accounted for by genetics.

WN: Do persons with ADHD often have other behavioral or psychiatric diagnoses, such as OCD, depression, etc.?

Dr__Manos: The simple answer to that question is yes. To explain further, adults tend to have more "comorbid" or secondary disorders such as depression, anxiety disorders, and the like. Many children also experience concomitant conditions such as oppositional defiant disorder.

WN: Is there a higher rate of divorce in those with ADHD?

Dr__Manos: The spouses of individuals with ADHD tend to have challenges in marriage. The ADHD brain tends to be engaged with interesting tasks over important or effortful tasks. Thus it is often difficult for a person with ADHD to maintain the agreements and schedules that are required for family life. Many individuals are unable to resolve the challenge of maintaining their agreements within the family structure. However, with love all things are possible.

WN: Is there a correlation between in utero activity and young children diagnosed with ADHD?

Dr__Manos: There is no established relationship between in utero activity level and ADHD. There are temperament characteristics that are recognizable in infants that do have a correlation to ADHD, but certainly are not diagnostic of ADHD. ADHD is only truly diagnosable after the age of three years.

jump_up: Can you give some good coping mechanisms for when you just can't sit still and feel like you have to move? I need help sitting through a class or a movie without embarrassing myself.

Dr__Manos: I don't think there is anything embarrassing about getting up and moving. It's okay to let the people who are with you know that it is often difficult for you to stay seated and that you may, from time to time, get up and stand. You point out a major difficulty that many adults with ADHD have--just accepting your own unique characteristics and needs.

nystrom: You mentioned “executive functions” of the brain. Can you elaborate?

Dr__Manos: Executive functions come from the "command" center of the brain -- prefrontal cortex. An example of an executive function is working memory. Working memory is like the scratch pad of the brain; it is the part of the brain we use long enough to carry them out. Another executive function is to "encode," in other words, to give meaning to an instruction.

apikeefmn: My 6-year-old son has ADHD and recently is undergoing testing for Tourette Syndrome. Is there much correlation between the two? Are there specific things I should be asking and looking for during the testing that is more ADHD and not Tourette symptoms?

Dr__Manos: ADHD and Tourette often are diagnosable together. However, they are two distinct conditions. ADHD is recognizable by the core symptoms of inattention, hyperactivity and impulsivity. Tourette disorder is a condition that is recognizable by multiple motor or vocal tics -- a tic is a sudden rapid, recurrent, stereotyped motor movement or vocal sound (like a repeated cough or glottal sound). Tics are usually seen many times a day and may interfere with social relations.

emor40_1: Are there organizations to assist adults with ADHD to better manage a child with ADHD? It is difficult when both are suffering from the same condition. This is a divorce situation as well; the father has custody 50% of the time and is having difficulty helping his son.

Dr__Manos: The scenario you describe, where the parents are no longer together and parents might not see eye to eye on how to manage their child with ADHD, is one of the most heartbreaking situations. The best results are derived when parents agree that something has to be done, and they agree on what that “something” is that has to be done. It's ideal when the same kind of behavior management happens in each household, so the child does not have to figure things out because one parent does something differently than the other. Where a parent has difficulty implementing a management program, but the parent’s intentions are solely focused on benefiting the child, professional coaching can make a big difference. A helpful website may be www.adhdcoaches.org.

hard_pressed: Is home schooling a good idea for a child with ADHD? How about missing the social interactions and such of a regular school?

Dr__Manos: Many parents of children with ADHD are moving to home schooling for their children. This is because home schooling can provide (not necessarily does provide) the two elements that work well for an ADHD brain—immediate feedback on performance and moving to the next problem. You bring up the key element in home schooling, which is ensuring that children maintain social interactions. People create friendships and social relations by rubbing shoulders with people of their same age in joint activity. If you can provide that, then you've solved a major problem of home schooling. A way of doing so is making sure that your child participates in sports, attends after-school extracurricular activities, has the opportunity for play dates and even participates in in-school nonacademic projects.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Michael J. Manos is now over. Thank you again Dr. Manos, for taking the time to answer our questions today.

Speaker_-_Dr__Michael_Manos: Excellent chat. Thank you for having me. I do want to leave you with something I said during our 2008 web chat that is still significant today.

One final note, as part of learning to “love the climb,” parents with children with ADHD or adults with ADHD can learn to accept themselves and their behavior (for good and bad). Accepting does not mean a person stops doing things to manage the responsibilities of life; it is simply that people acknowledge ADHD symptoms for what they are.

Sometimes the more people refuse to accept “what’s so,” the more difficult it is to manage “what’s so.” In dialectical behavior therapy (DBT), for example, one of the concepts is called radical acceptance. It illustrates the human phenomenon that it works better to simply accept behavior traits, such as getting over focused or side-tracked, rather than making them wrong.

With making traits wrong, a person continues to feel bad about being late, or distractible, etc., accepting traits, a person can begin to notice more easily what behavioral strategies work for and which ones do not. Basically, you can stop fighting it (and feeling bad about it) and then truly place your energy on adjusting the environment around you in such a way that you are able to be productive, punctual, and feeling better.

Another way to think of this is a saying that we use here at Cleveland Clinic Behavioral Medicine: “Having a child or adult with ADHD is like climbing a mountain with no summit. You must fall in love with climbing.”


More Information

More information on ADHD Center for Evaluation and Treatment at Cleveland Clinic or for general information on ADHD.

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