Online Health Chat with Dr. Michael J. Manos

December 7, 2011


In the past 10 years, the number of diagnosed cases of attention deficit hyperactivity disorder (ADHD) in children has increased nearly 4 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 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.

Michael Manos, PhD, is Head of the Center for Pediatric Behavioral Health in the Children’s Hospital at 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 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: Welcome to our Online Health Chat with Dr. Michael J. Manos. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.

Symptoms and Diagnosis

emeato: What are the signs of ADHD in children? Are there things that can be done to reduce the symptoms without using medication? Also, can a child with ADHD still be an A/B student? Or do most children with ADHD struggle with academics?

Dr__Manos: The core symptoms of ADHD are: inattention, hyperactivity and impulsivity.

Behavior modification can be effective; however, what is most effective is a combined approach of behavior therapy and medical treatment.

Many children with ADHD do very well in school. Academics become problematic when the child's academic demand and need for organization exceed ability. This is the heart of the matter. Children who are very bright may need to listen in class for only 10 minutes out of the hour in order to get everything, so they appear to do well. Sometime in their academic career, however, demand exceeds ability to keep up, and they begin to falter in their grades. This often begins in about 4th grade when children stop learning to read and start reading to learn.

alice: How is ADHD diagnosed in children?

Dr__Manos: A thorough assessment typically involves a structured diagnostic interview with the patient (and other informants if possible), completion of questionnaires that provide the patient’s 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.


Nickelgranny: How do you get a school to help your child after diagnosis? All they want to do is punish.

Dr__Manos: One of the best strategies is not to punish the teacher or the other school personnel back. It is always best to establish a cooperative relationship with the school from the start. If this cannot be achieved, then it is certainly appropriate to seek an advocate. To locate an advocate in Cuyahoga County, for example, parents may contact the educational service center at

Nickelgranny: What do you think of class meetings where students do nothing but complain about an ADHD student’s behavior?

Dr__Manos: Complaining is never productive; it only propagates a problem. A more effective strategy is to turn the complaint into a request and take it the person who can do something about it.

nhks: Busy teachers frequently push parents to medicate children. Is this desirable or would a parent be better off home schooling with help from school systems?

Dr__Manos: Conversations about medicines are always engaged with a physician. It is true that many children work very well one-to-one when they are home-schooled. This does not, however, work with many children, and it is best to be with their peers in a classroom. This is a decision only a parent can make. Home-schooling is most effective when an adult provides a high level of one-to-one engagement with academic work.


1rubylain: My experience with Ritalin (methylphenidate) in generic form hasn't been great with regard to severe headaches. I've read on the Internet by users that the brand Ritalin does not have as many side effects. Do you have any experience with this?

Dr__Manos: Assuming that you are referring to brand versus generic, if headaches are so severe that they do not outweigh the benefits, then most physicians would tell you to change the method of delivery of the medicine that you are taking or to actually change medicines, such as using a generic delivery system for dexamphetamine. It is best under such circumstances to talk to your physician.

sandy77d: Is there a benefit to taking breaks from ADHD medication when not in school?

Dr__Manos: Using medicine as it is prescribed by the physician is always advised. Structured treatment interruptions, otherwise known as drug holidays, are often recommended by physicians when demand is low (such as during summertime or long breaks from school). However, if a child's behavior impairs his or her functioning and intrudes on the functioning of others, medication without holidays is likely going to be the recommendation of the physician.

The one exception is when teenagers with ADHD learn to drive. In these cases, effective medicine is likely to be prescribed by the physician seven days per week.


jhagen: What is considered 'normal' behavior in a child? And who defines that?

Dr__Manos: Normal is only a setting on your clothes dryer in the laundry room. When we look at mental health conditions, we look for clustering of symptoms that represent a global condition. The American Psychiatric Association has taken these clusters and given each a name that defines the condition. There are nine symptoms for inattention that tend to cluster together and nine symptoms for hyperactivity/impulsivity that cluster together. We call this ADHD.

carrie_ann: What does the term self-efficacy mean?

Dr__Manos: Self-efficacy relates to teaching a person to act effectively in the world around him or her.

We often consider self-esteem to be a very important condition for people. Actually, self-esteem does not have much to do with people's success in life. What actually is important is how effective people are in taking action in their lives to moving closer to how they would like their lives to be.

For example, one might feel they are good enough to be married, but if they never ask anyone, they are not likely to be married. The latter is what we call self-efficacy.

emeato: What other methods can be used with children to minimize the effects of ADD/ADHD without the use of medication? Can you tell me more about behavior modification? What does that entail?

Dr__Manos: Behavioral treatment, often called behavior modification, is not about changing a child's behavior and it is about changing the behavior of parents and teachers, who are the primary change agents in a child's life. Many times, and without realizing it, parents and teachers behavior is shaped by the child. Parents learn to yell loudly, for example, because it often will stop the child's behavior immediately. However, in the long run, the behavior persists and sometimes even gets worse.

Parents can learn to use effective consequences -- such as time out, verbal acknowledgement, incentives and response cost (i.e., removing privileges) -- to effectively increase behaviors they want to start (keeping room clean) and behaviors they want to stop (noncompliance). Refer to the book 1-2-3 Magic by Thomas Phelan.

Related Disorders

1rubylain: Do patients with ADD or ADHD typically have other mental/emotional challenges i.e., depression, mania, etc.? If so, can you recommend a good source for reviewing drug interactions? I realize you cannot advise treatment.

Dr__Manos: Yes, there are often co-morbidities, especially with adults. The question you ask about drug interactions is a very important one. There is current research, for example, that indicates stimulants are safe to use with some antidepressants. However, this is not medical advice, and any polypharmacy should be under the direct supervision of a licensed medical doctor. A good Web site that discusses this issue is the website.

nhks: ADHD to bipolar in adulthood? Is this a theory? Would appreciate a bib with official transcript?

Dr__Manos: There is no research that indicates that ADHD later results in bipolar disorder; however, there is a strong relationship between the co-morbidity of ADHD and bipolar disorder. For example, more people with ADHD end up showing symptoms of bipolar disorder than occurs in the typical population. The website may be helpful in this area for articles.

Adults with ADHD

happyfeet: Can adult ADHD symptoms begin in adulthood or was it just unrecognized as a child?

Dr__Manos: By current definition, ADHD does not have adult onset. Clinical dysfunction due to ADHD symptoms may emerge in adulthood, but you must consider these symptoms to have been developed and possibly been unrecognized since childhood. In other words, there is no such thing as adult-onset ADHD.

doreen90: What treatment do you suggest for someone diagnosed at age 20?

Dr__Manos: The treatments for young adults are the same as those for younger and older people. The combination of behavioral therapy and pharmacotherapy (medicine) typically shows the best results. This is especially true for young adults who may be in college or starting work. Knowing that "pills do not teach skills" is helpful to keep learning skills of organizing, relating to others, and managing responsibilities, such as bills and the like. These don’t happen just by taking medicine, they happen by exercising the skills that get the job done. Many therapists are very capable of teaching these skills, as are behavioral coaches.

emorrison40: For adults with ADHD, I would think this condition jeopardizes a lot of relationships. Any advice for someone in a relationship with an adult with ADHD to help understand the issues that go along with this condition?

Dr__Manos: Relate to the adult with ADHD not only from the aspect of what they do but also from who they are as a committed partner in the relationship. Many adults with ADHD do not do the things they do intentionally. Rather than focusing on the individual and trying to 'fix them,' focus on what will work in order to handle the responsibilities and intimacies of the relationship. There are many good books written about this topic. You can go to the ADD Warehouse online to find a number of them.

julie543: Does ADHD/ADD tend to run in families? I swear my husband and his family are all affected except for his father.

Dr__Manos: ADHD does tend to run in families. People who have been diagnosed with ADHD typically have a family member who also has ADHD. Many adults do not realize it until their child is diagnosed.

In one study, for example, 57 percent of the children that were reported to have ADHD had one of their parents diagnosed. In another study, if a child was diagnosed with ADHD, almost one third of the parents were diagnosed, and there was a 21 percent chance that a sibling was also diagnosable.


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 questions about ADHD.

Dr__Manos: I want to leave you with something to think about 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.

Dr__Manos: Thank you for joining me today.

More Information

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