Online Health Chat with Michael Manos, PhD
September 26, 2013
Nearly five million children in the United States have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). In the past ten years, the number of diagnosed cases of Attention Deficit Hyperactivity Disorder (ADHD) in children has increased nearly four percent every year. 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 seldom be fully outgrown.
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. With more children being diagnosed, the need to understand and manage the disorder is becoming increasingly important. 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.
About the Speaker
Michael Manos, PhD, is the Head of the Center for Pediatric Behavioral Health at Cleveland Clinic Children’s. 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 fellowship in psychology at University Hospitals of Cleveland after completing his doctorate in special education and clinical psychology at the University of Arizona, in Tucson. His post-graduate training includes an internship at the University of California Los Angeles in the Neuropsychiatric Institute and earning his graduate degree from John Carroll University, in Cleveland.
Let’s Chat About Focusing in on ADHD
Moderator: Welcome to our chat ‘Focusing in on ADHD’ with Michael Manos, PhD, Head of the Center for Pediatric Behavioral Health at Cleveland Clinic Children’s. We are very excited to have Dr. Manos available to chat today!
mck25: What is the ideal age to have your child evaluated? How does one distinguish between a hyperactive six-year-old boy and a child with ADHD (attention deficit hyperactivity disorder)? How does one distinguish between a bad temper and ADHD impulsiveness? Is medication the best solution?
Michael_J._Manos,_PhD: Thank you for your thought provoking questions. One can begin diagnosing ADHD starting at the age of three years old, although typically an ADHD diagnosis is more common made around the ages of five to six years old, i.e. when a child begins school. ADHD is distinguished from typical developmental behavior by the clustering of symptoms. To diagnose, six of nine symptoms of inattention must be present and/or six of nine symptoms of hyperactivity/impulsivity should be present. To distinguish between a ‘bad temper’ and ADHD impulsiveness, the diagnostician should discriminate between emotional dysregulation (which may be evidence of childhood depression or other mood disorder) and repeated frustration intolerance (which is more typical in children with ADHD). Nevertheless, a ‘bad temper’ is often typical of an inability of a child with ADHD to manage their own emotions effectively and in socially acceptable ways. Finally, pharmacotherapy (or medicine) is one of the best ways of treating ADHD although it should always be used in combination with behavior therapy. Understanding pharmacotherapy should require close collaboration with the child's primary care physician. Behavioral intervention requires close collaboration with the other change agents in the child's life, such as teachers, relatives and, of course, both parents.
erush2575: What steps are taken to reach a definitive diagnosis? Is treating underlying cause the best solution?
Michael_J._Manos,_PhD: When diagnosing ADHD (attention deficit hyperactivity disorder), three steps are typically followed. The first step is to determine what symptoms are present. The second step is to determine what cannot be ruled out as the source or cause of those symptoms. And the third step is to determine if any other condition accompanies the primary symptoms. ADHD is determined to be present if a cluster of six of nine symptoms of inattention are present and/or a cluster of six of nine symptoms for inattention and impulsivity is present. The clustering of symptoms is critical to an appropriate diagnosis. This is determined by using a combination of direct clinical interview, narrow-band rating scales (such as the ADHD Rating Scale), broad-band rating scales (such as the Child Behavior Checklist), and the observations of more than one person (typically this is a parent and a primary change agent, such as a teacher or family member). The exact underlying cause of ADHD is, at present, not known. ADHD is a neurophysiological condition which is largely biogenetic. It is addressed with both behavioral and pharmacological interventions.
ADHD vs. ADD
Kathleen: What is the difference between ADHD (attention deficit hyperactivity disorder) inattention component and ADD (attention deficit disorder)? Isn't the term ADD used anymore?
Michael_J._Manos,_PhD: ADHD is the term in the diagnostic category. It is all called ADHD. There are three types of ADHD: predominantly inattentive presentation, predominantly hyperactive/impulsive presentation, and combined presentation.
Dual Exceptionality – ADHD with Giftedness
LinDan: Can you please discuss the diagnosis of dual exceptional—gifted with ADHD (attention deficit hyperactivity disorder) inattention component?
Michael_J._Manos,_PhD: Not every individual with a diagnosis of ADHD is considered gifted, although some research indicates that individuals with ADHD tend to be more creative. The individual who is ADHD as well as gifted is often not diagnosed until later in life, such as in middle school, high school, and into adulthood, because raw ability gets them through. With such individuals it is typically best to allow them to pursue their interests and to be accommodating in how they learn.
msnyde03: I work in a doctors' office and it seems that more adults are being diagnosed with ADHD (attention deficit hyperactivity disorder). Do you find that in your practice, and is there any reason why?
Michael_J._Manos,_PhD: We have seen an increase in the number of adults who come to our clinic seeking assistance for symptoms of ADHD. Because of the increase in awareness of ADHD, more people would like an explanation for personal characteristics that they have struggled with throughout their life. To me, this is evidence of people who are willing to take charge of their life and to contribute to their jobs, families, and work in a way that they have never been empowered to do before. We have a thriving adult practice, and it serves to give adults the perspectives and skills needed to make them more effective in the world. Because of ADHD symptoms, many adults have failed to realize their own personal potential. It is our privilege to teach adults that they can be effective and how to do it.
ADHD Symptoms Through Life
jemmelkamp: What percent of children that are diagnosed with ADHD (attention deficit hyperactivity disorder) do not have the same symptoms by adulthood?
Michael_J._Manos,_PhD: Prevalence rates for children, as determined by the Centers for Disease Control, is presently nine and one half percent. Prevalence rates for adults is about four percent. Most individuals with ADHD whether diagnosed in childhood, adolescence, or adulthood, show a change in symptoms. Symptoms ‘migrate’ over time. Carelessness in childhood often occurs as disorganization in adulthood. In essence, the same symptoms in childhood are present in adulthood, they just may have different forms.
Idiosyncrasy of ADHD
Paula1028: My husband was diagnosed with ADD/ADHD (attention deficit disorder/attention deficit hyperactivity disorder) and is takes Concerta®. He is doing o.k. on it, but still is having problems speaking in full sentences. He can think of what he wants to say, but can't speak it. What treatment, therapies or other medications would possibly help him? This is getting very frustrating for him, as well as me, since I am his caregiver.
Michael_J._Manos,_PhD: You may not like the content of this reply. Sometimes individuals with ADHD have idiosyncratic characteristics. Your husband's inability to speak when he wants to say something may be one of these. This would require patience on the part of other people as well as patience on your husband's part. It may take him longer to say what he really means. Another possibility is perhaps there is another medium of expression. For example, it may be easier for him to write or type what he really wants to say. Such a situation requires compassionate understanding.
Handedness and ADHD
going2needhelp: I recently read an article stating that people who are left-handed are at higher risk for ADHD. Is there any truth in that statement?
Michael_J._Manos,_PhD: There is no evidence that left-handers are at greater risk than right-handers for ADHD. This is one of those urban myths, unfortunately.
Prevalence of ADHD
erush2575: Why is there an increase in children with diagnosis? On a personal note I take medication for this problem and I am in my 60s. My physician is one of top 100 psychiatrists in the country.
Michael_J._Manos,_PhD: Although it appears that there is a substantial increase in the number of individuals with ADHD (attention deficit hyperactivity disorder) in the U.S., this is most likely because we are aware of more people diagnosed with ADHD. Prevalence rates of ADHD are now established by the Centers for Disease Control at 9.5 percent. ADHD has long been established as a worldwide phenomenon. As such, it is not that there is an increase in individuals with ADHD, but an increase in the diagnosis of individuals with ADHD.
Behavioral Therapy for ADHD: Positive Reinforcement
Cabaco: How can I achieve getting my son to do everyday tasks, i.e. picking up after himself, doing homework, practicing good hygiene and being a lot more aware of his surroundings?? He is on Concerta® 36 mg and this has helped with classroom focus, but it is still a continual struggle at home.
Michael_J._Manos,_PhD: The interesting phenomenon associated with ADHD is that we can use aversive or negative consequences to train children to do something. What may be effective in your case is to use positive consequences. What is typically not well understood is that when we use aversive or negative consequences (such as taking things away, spanking or yelling) as punishment, it never teaches anything new. It only teaches what not to do. When we want children to learn something that they do not do, i.e. a ‘start’ behavior, this is best accomplished by using positive reinforcement. Work with a behavioral psychologist who can assist you to develop strategies that incorporate positive consequences.
ADHD Medications: Goals of Treatment
bobcat10: In your opinion, what are parents’ perceptions about giving their child medications to control ADHD (attention deficit hyperactivity disorder)?
Michael_J._Manos,_PhD: Parents who come to our clinic have one primary concern: To provide the best possible circumstances for the success of their children. As such, using pharmacotherapy to assist children to effectively direct their own attention so much so that children succeed in school, is the primary concern of parents who provide medication to their children. I know that many parents suffer because other people think they are ‘drugging’ their child or that they are being irresponsible by not ‘disciplining’ their child. This argument is seldom true in my experience. Medicine's effect is to strengthen what is called ‘directed attention’. This is the ability of a child or an adult to direct their own attention toward self-defined goals and objectives. Directed attention in school is needed consistently, but to children with ADHD—it is not as available as it is to neurotypical children. A parent who works with their child both pharmacologically and behaviorally is doing the right thing.
ADHD Symptom Control
enjoylife: What do you recommend if medication and therapy are not working? My 11-year-old son is taking Focalin XR® (dexmethylphenidate,or d-threo-methylphenidate [D-TMP]) 5 mg in the morning and sees a therapist once or twice a month. He has just transitioned into middle school, and is having a difficult time with teachers, peers and school work. He has difficulties with his impulsive behavior, like lying and stealing. He has a negative outlook on school. My husband and I want to turn this around, but, do not know where to go from here.
Michael_J._Manos,_PhD: This is not a question that is easily answered. I may recommend two courses of action. First, talk to your child's primary care physician about pharmacotherapy. Many times dosage levels can be changed or the use of a different psychostimulant can make a difference. Your physician can help you with that. Second, work with a behavioral therapist to determine a strategy for dealing with his behavior.
Puberty and Symptom Management
Dufresne: My 14-year-old son has ADHD (attention deficit hyperactivity disorder). It seems that his medication, Vyvanse® (lisdexamfetamine dimesylate or L-lysine-D-amphetamine), does not last as long lately. (He is more wound up and ‘wild’ earlier in the day.) Could this have anything to do with a change in his hormones with the onset of puberty? Or perhaps, does his dosage just need to be adjusted since his body mass is greater?
Michael_J._Manos,_PhD: As you know, I am not a physician, I do not prescribe medicine, and do not give medical advice. It is best, of course, that questions regarding medicine related to treatment of ADHD should be asked of your primary care physician. However, based on research and on the typical pediatric practice, psychostimulant treatment of ADHD often changes throughout life.
Medication Side Effects
kitruth1: My seven-year-old granddaughter has ADHD (attention deficit hyperactivity disorder) and it is starting to affect her grades. My daughter is having a difficult time finding the right medication that works. She has tried three and they all had side effects that my granddaughter experienced. One medication seemed to help and she and liked the way it made her feel, but experienced side effects of arm tingling and headache. Therefore, her mom stopped the drug. Now we hear that side effects may go away with time. Is it safe to do this? Is there any way to know which medication will work better? We don't want to keep giving her different drugs trying to find one that works.
Michael_J._Manos,_PhD: Only a medical doctor is trained to prescribe medicine for ADHD. Clinical trials indicate that the gold standard for treating ADHD is the use of stimulants. Yes, these sometimes have side effects. Your child’s primary care physician can help you tell whether these side effects are due to treatment. Yes, some side effects can decrease or even stop over time if they are not severe in the beginning. Again, consult with your physician. At present, the only way to know that a medicine works is to try it and discern its effects. There is not a good way to determine whether one works better than another, other than to work with your doctor. It is considered safe to stop the stimulants abruptly as determined by the American Academy of Pediatrics.
Long-term Effects of ADHD Medications
bobcat10: Are there any long-term effects associated with taking ADHD (attention deficit hyperactivity disorder) medications? If so, what are they and what medications are implicated?
Michael_J._Manos,_PhD: Many parents are concerned about the long-term effects of taking medicines. One of the best sources of information for this question is the Multimodal Treatment Study of ADHD (MTA). This study was a very large study of the treatments typically associated with ADHD, pharmacotherapy, behavioral intervention and their combination. Evidence regarding the side effects of using stimulant treatment for ADHD shows that long-term use of medicine may decrease stature. However, in children who have continued use of medicine with generally higher doses of methylphenidate, stature differences remain relatively small. The use of stimulants to treat ADHD both in the short-term and long-term is considered safe by most of the major medical organizations, including the American Medical Association and the American Psychiatric Association.
Nutrition and Symptom Management
litvolt: Are there specific kinds of food to give or to avoid giving to my seven-year-old with ADHD (attention deficit hyperactivity disorder) to help him sit still and concentrate? He cannot have red dye. It is very hard for him to have his routines changed. Any ideas to help with this on a vacation?
Michael_J._Manos,_PhD: The effect of specific kinds of food on symptoms of ADHD has been studied for a number of decades now. Unfortunately, research has not confirmed that diet change has a clear and substantial affect on symptoms of ADHD. There is good evidence that some children react to substances such as food dyes (typically red and yellow), but symptom reaction is generally episodic and not pervasive—like ADHD symptoms are pervasive. Diets that advocate the elimination of milk, sugar or gluten may certainly be healthy, but that main ingredient in affecting ADHD is that a parent and child using such a diet must undertake significant cooperation and interaction. It is usually this interaction, i.e. the cooperation of parent and child, which makes a difference in the symptoms. The influence of parental attention and cooperation in the family is significant in treating ADHD.
Treatment Alternatives to Medication
lightning#: What do you suggest to people with moderate ADD (attention deficit disorder) to do in place of medications?
Michael_J._Manos,_PhD: Individuals with ADHD (attention deficit hyperactivity disorder) who do not use pharmacotherapy should learn best to manage the world around them rather than to try and fix themselves. We now have a myriad of electronic ways of reminding ourselves to take action. It is still useful to perform partnerships with people who are willing to assist in accomplishing the tasks that confront people with ADHD daily. For example, if a person wants to exercise and knows that he or she will not do it all on their own, forming a partnership with someone who exercises regularly and agrees to meet them would help. Such arrangements are typically effective in getting work done.
Changing Routine Activities
litvolt: What ideas can you share with me about making it easier for my seven year old to enjoy a family vacation even though he has trouble adapting to changes in his routine?
Michael_J._Manos,_PhD: You pose a difficult question. Children who enjoy routines and thrive with routine have difficulty when that routine is disrupted. Nevertheless, there are some strategies you can use. Inform your child what is likely to happen when you go on a family vacation. Showing pictures of where he will stay, give him an idea of what the family will do, and let him know that you will be there. On the evening before each day and then again during the morning, review with him what he will do that today and what will be available to him. Do so in a matter-of-fact reassuring way. Gain insight of any suggestions of what he would like to do, but be aware that he may not want to do anything—so gently encourage him to participate with the family. In essence, bring as much certainty to the family vacation as you can. Although there will be times when the spontaneous occurs—after all, isn't that what vacations are about?—you are best to minimize these events and let your child know that he is safe.
Building Understanding in Agent of Change Partnerships
enjoylife: What can be done to bridge the gap between teachers, school staff, parents and doctors as it pertains to ADHD (attention deficit hyperactivity disorder)? It seems that these kids are not really understood and labeled as bullies and troublemakers early on in school, which I believe compounds the ADHD issues. The concern is always raised that these kids should still be expected to control their behavior.
Michael_J._Manos,_PhD: Your question is excellent. Forming a cooperative relationship with teachers, school staff and other parents is essential. Forming such partnerships makes a difference in assisting children to succeed in school. Treating ADHD not as a disorder, but as a difference, can go a long way in assisting with the situation you describe.
Relationship Building with ADHD
LynneP: Can you offer some generalities about common relationship issues for two young adults with ADHD (attention deficit hyperactivity disorder)? How do relationships tend to do if both parties have ADHD?
Michael_J._Manos,_PhD: Couples with ADHD have unique challenges and they have unique opportunities. Usually an adult with ADHD finds a partner or business associate who is highly organized and subsequently offsets the tendency to be disorganized. Two individuals with ADHD who have formed a partnership provide something that is, at times, left out of relationships. They can understand and completely accept the other person's behavioral idiosyncrasies. Acceptance of ADHD characteristics is essential and best provided by someone who shares those characteristics, such as a partner with ADHD. Of course, difficulty arises when the logistics of living life are somehow compromised. For example a partner who is left to pay the bills and does not, poses problems for the relationship. A partner who says he will show up at a certain location by a given time and does not, also poses problems for the relationship. Although the essence of love in a relationship is acceptance, people also must discover the strategies that have been effective in the world to handle the logistics of work, family and of pursuing aspirations.
Moderator: The hour has gone fast. I'm sorry to say that our time is now over. Thank you, Dr. Manos, for taking your time to discuss ADHD with us. Your answers were very detailed and personal.
Michael_J._Manos,_PhD: Thank you very much for the opportunity to participate with you.
To make an appointment with Michael Manos, MD, or any of the other specialists in Cleveland Clinic Children’s Center for Pediatric Behavioral Health, please call 216.445.7574 or toll-free at 800.223.2273, ext. 45437. You can also visit us online.
For More Information
On ADHD (Attention Deficit Hyperactivity Disorder)
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Cleveland Clinic Children’s offers a comprehensive approach, including medication and skills training, to help manage children’s and adult’s ADHD. Our team of psychologists, psychiatrists, pediatric and child psychiatry residents, as well as social workers, licensed counselors and nurses develop individualized treatment plans to meet the needs of each child.
Cleveland Clinic Children’s commitment to family-centered care and use of state-of-the-art technology helps the child best manage their ADHD while maintaining a normal, active lifestyle.
Cleveland Clinic Children’s is ranked nationally among the best children’s hospitals in the United States by U.S. News & World Report.
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