October 10, 2008
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Michael J. Manos, PhD, Head of the Center for Pediatric Behavioral Health, Pediatric Institute, Cleveland Clinic. He is also is the founding Clinical and Program Director of the pediatric and adult ADHD Center for Evaluation and Treatment of Cleveland Clinic in Cleveland, Ohio. He is Adjunct Faculty in Case Western Reserve University School of Medicine, Department of Psychiatry.
Dr. Manos has worked for more than 25 years in pediatric psychology, special education, and child and adolescent psychiatry. He has authored or contributed to scientific articles and informative book chapters on the diagnosis and treatment of attention deficit/hyperactivity disorder. He also has presented numerous papers and symposia on child and adolescent behavior disorders.
Dr. Manos is a member of several professional organizations, including the American Psychological Association, the American Psychological Society, and the Association for Behavioral and Cognitive Therapies.
During the next hour, Dr. Manos will answer your questions about Attention Deficit Hyperactivity Disorder (ADHD) in adults and children. Before we begin taking questions, Dr. Manos will address some of the most common concerns about ADHD.
What is ADHD?
Cleveland_Clinic_Host: What is ADHD?
Speaker_-_Dr__Michael_Manos: ADHD stands for attention-deficit/hyperactivity disorder and is a psychiatric diagnosis that involves a persistent pattern of inattention and/or hyperactivity-impulsivity that is more severe and more frequently observed than is typical in individuals at a comparable developmental level.
Cleveland_Clinic_Host: Dr. Manos - can you spell out the sign and symptoms for ADHD that appear in adults or children?
Speaker_-_Dr__Michael_Manos: Yes - Signs and symptoms of ADHD are clustered into three primary groups: inattention, hyperactivity, and impulsivity. Inattentive symptoms include failing to pay attention to details or making careless mistakes in work, difficulty sustaining attention in activities, often not seeming to listen when being spoken to directly, often not following through on instructions or failing to finish work, difficulty organizing, avoiding tasks that require sustained mental effort, losing things necessary for tasks or activities, being easily distracted, and often forgetful in daily activities.
Hyperactive/Impulsive symptoms include being fidgety or squirmy when seated, often leaving seat when expected to remain seated, often running about or climbing excessively, difficulty playing quietly, often "on the go" or acting as if "driven by a motor," talking excessively, often blurting out answers before questions are completed, difficulty waiting turns, and often interrupting or intruding on others.
Cleveland_Clinic_Host: How is ADHD diagnosed?
Speaker_-_Dr__Michael_Manos: A thorough assessment typically involves a structured diagnostic interview with the patient (and other informants if possible), completion of questionnaires that provide your medical, social, family, and educational/occupational histories, and completion of emotional-behavioral rating scales that provide information about the presence and severity of symptoms.
The diagnostic criteria used to diagnose mental health problems are outlined in the Diagnostic & Statistical Manual of Mental Disorders (4th edition, revised), published by the American Psychiatric Association. There is no brain imaging or blood testing that assists in diagnosing ADHD though these are likely to be available in the foreseeable future..
CLawyer: My 6 year old daughter reacted badly to several stimulants (zero appetite, oppositional behaviors, tics), and is on Straterra. How does it work, and is there something that can be added to address the hyperactivity the Straterra does not fully address?
Speaker_-_Dr__Michael_Manos: Straterra is not a stimulant medication; rather, it is best identified as a noradrenergic reuptake inhibitor, meaning that it strengthens signals in some neuronal pathways that manage the executive function of attention.
Regarding medical intervention for hyperactivity, please consult your physician as polypharmacy may be an option. Polypharmacy is the practice of using multiple medicines to treat a condition or combination of conditions.
Also please consider behavioral intervention both at home and in the classroom that emphasizes the use of incentives or positive consequences.
CLawyer: Can you discuss what benefits may be gotten from having my daughter see a psychiatrist along with her developmental pediatrician regarding her ADHD?
Speaker_-_Dr__Michael_Manos: The advantage of seeing a psychiatrist is that psychiatrists are skillful in recognizing and managing symptoms and complications of ADHD (such as negative responses to medications) and concomitant disorders such as depression and/or anxiety disorder.
Pediatricians in general and developmental pediatricians in particular are skilled in managing symptoms of ADHD in children.
pitterpatter: Once diagnosed with ADHD – can you outgrow it? For children – is medication required for the rest of life? What about if it was not discovered until adulthood? Do I have to take medication forever?
Speaker_-_Dr__Michael_Manos: You do NOT outgrow ADHD. Sixty percent of children diagnosed with ADHD will show symptoms in adulthood.
Although many adolescents' need for medication does decrease over time, others take it well into adulthood. It is really an individual determination.
For most people, ADHD is treated best with a multimodal approach that includes medication and behavioral management.
wileycoyote: Do ADD/ADHD children typically have higher IQ’s? Why is giftedness so common with these individuals?
Speaker_-_Dr__Michael_Manos: The distribution of IQ in the population of individuals with ADHD is the same as in the normal population. Though some individuals with ADHD are gifted, giftedness is not just associated with ADHD.
fazio: How do I handle the frustration I feel as a parent dealing with my child that has ADHD?
Speaker_-_Dr__Michael_Manos: I often tell my patients that raising a child with ADHD is like climbing a mountain that has no summit...the only thing to do is to learn to love to climb! That is, a parent may learn to continue to intervene and make a difference with their child as the child grows and develops—to “fall in love” with continuing to intervene.
gaoa: Are there specific strategies you could recommend as study techniques for college students?
Speaker_-_Dr__Michael_Manos: It is helpful to establish a regular routine for yourself in which you block time out for homework (along with other activities that are important such as exercise, breaks, etc.) Reward yourself for accomplishing small parts of your homework, or even enroll someone else in helping you reward yourself after getting parts of (or all) a project done.
If you are a "techy" person, then the use of a PDA (person digital assistant), such as a palm pilot can be helpful. There are several software programs available that are designed to assist you in organizing and prioritizing tasks and goals. One in particular with a large ADHD following is the program called Life Balance, which is available for your PC and your handheld (www.llamagraphics.com/).
stevieh: Does alcohol affect people with ADHD differently? I am a college student, on meds – but I am in college and drink.
Speaker_-_Dr__Michael_Manos: Talk with your doctor, BUT be aware that taking a stimulant along with alcohol, a depressant, is not generally recommended.
gonebatty: Is there are link with ADHD and alcohol or substance abuse?
Speaker_-_Dr__Michael_Manos: There is a link between untreated ADHD and alcohol or substance abuse.
Actually, research has illustrated those treated with stimulant medications in childhood are less likely to abuse drugs in adolescence and adulthood than those who were not treated..
missmollie: Do you see ADD not ADHD in adults?
Speaker_-_Dr__Michael_Manos: Inattention is the symptom that drives ADHD in adults. For most individuals ADHD symptoms continue to be impairing throughout life. Symptoms are likely to change over time especially from childhood to adolescence and early adulthood. Symptoms of hyperactivity and impulsivity, for example, tend to translate into a subjective state of restlessness from childhood into adolescence and adulthood.
However, this is not to say that the symptoms no longer create impairment, as the symptoms of ADHD can certainly create problems throughout the lifespan. Additionally, if left untreated, ADHD can lead to other problems later in life, including higher risk for being diagnosed with another mental health disorder (e.g., substance abuse, anxiety, and depression), having job dissatisfaction and difficulty maintaining employment, experiencing marital problems, and having higher rates of unwanted pregnancies, sexually transmitted diseases, and traffic violations.
pitterpatter: Where can I find a doctor to treat my ADD/ADHD as an adult?
Speaker_-_Dr__Michael_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/
concap: I am hearing information about ‘executive function’ floating around. Can you explain this and address if it is related to ADD?
Speaker_-_Dr__Michael_Manos: The frontal cortex is like the secretary of the brain: it tells you what to do and when to do it. These executive functions occur in the frontal cortex. Individuals with ADHD have more difficulty with executive functions than people without ADHD.
Cleveland_Clinic_Host: How is ADHD treated?
Speaker_-_Dr__Michael_Manos: Research supports the use of a combined approach of medication and behavioral management to treat ADHD.
Regarding medication, the stimulants (e.g., Adderall XR®, Concerta®, Metadate CD®, Focalin XR®, Daytrana®, Vyvanse®, Ritalin LA®) are still the "gold-standard" in the treatment of ADHD symptoms.The non-stimulants (e.g., Straterra®, Wellbutrin®) are effective though they generally have lower effect sizes (a statistical measure of effectiveness).
pitterpatter: When medication is used, should it be taken at all times or is it okay to discontinue it during summer vacations, weekends, etc.?
Speaker_-_Dr__Michael_Manos: Although I cannot provide you with medical advice, and I encourage you to discuss these issues with the physician who is currently managing ADHD symptoms, I can tell you that the American Academy of Pediatrics and other professional medical organizations recommend 7 day per week administration of medicine as optimal treatment.
Remember that medication is used for dysfunction and where there is dysfunction it is appropriate to treat. Some physicians will recommend longer breaks such as summer vacation when symptoms are not significantly impairing performance because summer vacations typically have lower demand, especially academic demand thus children may show less dysfunction. Nevertheless, it is always important to consult with your physician prior to making any changes.
The American Academy of Child & Adolescent Psychiatry and the American Psychiatric Association just released a Medication Guide for Treating ADHD for parents which discuss these exact issues. You can download this for free at http://www.parentsmedguide.org/.
newtonm: As an adult I feel taking Adderall does help me with focus issues. But I experience a lot of irritability & mood changes at the end of the day. This is leading to difficulties in other areas of my life. Should I be taking additional medications for the emotional side effects along with the Adderall?
Speaker_-_Dr__Michael_Manos: Again - I would refer you to your physician for medical management of this side effect. This is often referred to as a "rebound" effect, because when the medication is wearing off a person may become more irritable and emotionally labile.
costalot: Are ADHD coaches an effective tool for families or even adults with ADHD? What about support groups?
Speaker_-_Dr__Michael_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.
The Genetics of ADHD
elliev: Does ADHD appear have a genetic link? My son has it, my husband’s showed up mid-life and I swear my mother-in-law has it also. As my son improves, my husband is getting worse. Nobody is taking meds. At least my mother-in-law lives out of town. I am going nuts!
Speaker_-_Dr__Michael_Manos: Generally, ADHD is considered to be a bio-genetic condition—it runs in families. Currently seven gene markers are considered to be associated with ADHD. ADHD does not suddenly show up in adulthood. Symptoms are likely to have been there all along. Conditions such as increased demand in a person’s daily life exacerbate the symptoms.
madden08: If the attention deficit is related to the learning disability, should it be treated with drugs? Is there any link between ADHD and Alzheimer’s? My mother is a nursing home resident, with advanced Alzheimer’s. As I think back, she had many ADHD symptoms. She walks around the nursing home all day.
Speaker_-_Dr__Michael_Manos: There is a higher incidence of learning disabilities in children with ADHD than in the typical population. Learning disabilities are not successfully treated with medications at present.
I am not aware of any link between Alzheimer’s and ADHD.
ADHD and School
CLawyer: Can you suggest accommodations I should specifically ask my 6 year old daughter's school to include on her IEP to improve the learning environment? For example, removing some of the distracting materials posted on the classroom walls, her placement in the classroom, etc.
Speaker_-_Dr__Michael_Manos: First - removing the distracting materials from the environment such as the walls in the classroom has not been proven to be effective in managing symptoms of ADHD, as children and people in general tend to habituate (to get used to) to their surroundings.
I would recommend that you and the school begin to use a positive system that gives her feedback when she is managing her behavior successfully.. You can even set up a positive behavior chart...she can earn small rewards, for example, when you (and even her teachers) give her a positive report. There is information about setting up a daily report card (DRC) at www.wings.buffalo.edu/psychology/adhd
Other common recommendations for the classroom are - having an older age study buddy or tutor (5th or 6th grader); giving tests in a quieter room; providing one to one or small group instruction; and repeating instructions when necessary.
Confused: I need to begin to gather some information about IEP's, MFE's and 504 plans. Where do I begin?
Speaker_-_Dr__Michael_Manos: A multifactored evaluation (MFE) determines eligibility for special education services and is conducted by the school. These are referred to as an Individual Education Plan (IEP) or 504 Plan. Schools may also use what is termed an ITA (Individual Team Approach). ADHD is identified as ”other health impairment" by the school under the Individuals with Disabilities Education Act (IDEA), and your child has certain educational rights within an educational system. For more information on IEPs, MFEs, and other educational law issues, please check out www.wrightslaw.com/. The Learning Disabilities Association of America (LDA) may also be a useful resource (telephone: 412-341-1515; website: http://www.ldanatl.org/ ). Again, the other excellent resource is CHADD.
jenjen: Should a teacher know when meds are started or find out after the fact?
Speaker_-_Dr__Michael_Manos: It is best for the teacher to provide information back to the physician in the initiation of medical treatment for a child with ADHD. Our Medication Monitoring Clinic always includes the teacher in the titration of medicine because the teachers are with the child during the day when medicine is in effect. Additionally, teachers are excellent observers of behavior.
Cleveland_Clinic_Host: Dr. Manos - Children with ADHD often show difficulties getting along with their friends and siblings. Where should a family begin to address this concern?
Speaker_-_Dr__Michael_Manos: It is common for kids with ADHD to have trouble handling others' differences as well as trouble interpreting people's verbal and non-verbal behaviors. It is often difficult for them to pick up subtle cues in social interactions, thus social skills training can be an important part of a child’s successful adjustment to developing friendships and getting along with adults.
For example, our ADHD Center sponsors Social Skills Training groups and a Summer Treatment Program.
In social skills we teach children the actual behavior of getting along with others. We also teach the parents and teachers how to strengthen those same skills in real life.
In the Summer Treatment Program, a seven week all-day sports program, we teach specific social skills in the morning and use them all day long.
Nutrition and ADHD
CLawyer: Is there anything more than anecdotal evidence that dietary changes help, like no wheat, no dyes, organic, etc.?
Speaker_-_Dr__Michael_Manos: This has been investigated since the 1970's. To date, there is no definitive evidence that confirms the effect of diet to improve ADHD symptoms. Elimination diets, such as removing sugar, wheat or other supposed allergens have shown no noteworthy effect in treating ADHD. Bottom line - children should have a well balanced diet.
Cleveland Clinic ADHD Center
mitch: Is the ADHD center for adults as well as children?
Speaker_-_Dr__Michael_Manos: The ADHD Center for Evaluation & Treatment (ACET) at the Cleveland Clinic is for individuals across the lifespan. We have worked with children, teenagers and adults - ages one and a half to seventy-nine years old.
salkel: What web sites are credible for information about ADHD in adults or children?
Speaker_-_Dr__Michael_Manos: First, as stated earlier, there are great books that have been published on this topic. You may find them at the ADD Warehouse http://www.addwarehouse.com/ . You may also wish to browse the material on this topic at the following websites: Children and Adults with ADHD (CHADD) http://www.chadd.org/ and Attention Deficit Disorder Association (ADDA) http://www.add.org/.
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.
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.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.