ADHD and Kids with Dr. Michael Manos

Podcast Transcript

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Annie Zaleski: Hello, and thank you for joining us for this episode of the Health Essentials Podcast. I'm your host, Annie Zaleski. And today, we're talking about kids with ADHD with pediatric psychologist Michael Manos. Kids living with ADHD, or attention deficit hyperactivity disorder, often have difficulty paying attention to just one thing. They demonstrate symptoms of inattention, distractibility and hyperactive impulsive behavior. This can pose challenges in school and in social situations, although there are treatments and strategies available. Dr. Manos is here to discuss ADHD symptoms, how to get a diagnosis for your child and how best to approach treatment. Dr. Manos, thank you so much for being here.

Dr. Michael Manos:  You're welcome. Thank you for having me.

Annie Zaleski: So I'd like to start our conversation by having you tell us a little bit about your work at the Cleveland Clinic — what research and clinical work do you do?

Dr. Michael Manos: I am the clinical director of the ADHD Center for Evaluation and Treatment, we call it ACET. And we function to diagnose ADHD in both children and adults. And we have a number of different programs that we offer, like the summer treatment program, which is a seven-week all-day sports program for kids with ADHD, where we train particular behaviors and emphasize the use of particular behaviors, as well as work with parents. Also, we conduct a series of groups, for example, an organizational skills training group, a social skills training group, an executive functioning skills training group, and the like, and as well as a parent training group, that's ongoing throughout the year from the summer treatment program. Our research focuses on the behaviors, the strategies that influence the behavior of kids with ADHD. And also, for 25 years, we have been studying and collecting data in a very systematic way on children's titration of medicine.

That is when physicians prescribe medicine, stimulant treatment for kids with ADHD, what works and what doesn't work. And we've been collecting this information for 25 years. We now have a database of about 5,000 kids with a thousand variables on each child. We've just contracted with a researcher from Stanford who is evaluating these data and studying them to determine which medicine works best for which kid or, what we call, Phenotyping — what characteristics of the child will predict which medicine to use — because right now, physicians are required to more or less guess at what medicine to use, should medicine be prescribed. So our research is rather wide ranging, related to behavioral intervention with kids with ADHD and pharmacological intervention with kids with ADHD.

Annie Zaleski: I'm glad you mentioned all of that because I think both of those are topics that I want to get into later in our conversation. And we are talking about ADHD specifically in kids today. So give us an overview of a definition of what that is and how prevalent ADHD is today in kids.

Dr. Michael Manos: So the question is a very pertinent one, the Centers for Disease Control reports, and this is a few years ago now, about five to six years, seven years, that the prevalence of ADHD in the U.S. is about 11.2%. Other prevalence estimates range from about 4% to 11%. So a lot of people have ADHD. Worldwide prevalence is generated to be between 4 and 7.2%. So there is a very high incidence of ADHD in the world population, as well as in the U.S. population. For example, there are about 202, 203 million children with ADHD in the world. And in the U.S., we have about 6 million kids with ADHD.

Annie Zaleski: How does that compare to other disorders? And that seems very high.

Dr. Michael Manos: Yes, it is very high. And how does that compare? Well, it compares, typically, it's higher than some of the other conditions. It is the most diagnosed mental health condition in children in the world actually.

Annie Zaleski: So what are the causes then? What are some of the common ones? What are doctors finding?

Dr. Michael Manos: ADHD is generally considered to be genetic, a genetic occurrence. And that the tendency for ADHD to be diagnosed is probably higher than most other diagnoses in childhood. And it actually is higher than most diagnoses in childhood. It is considered to be a genetic occurrence. Though there may be other sources, other causes of ADHD in some children, like lead poisoning, very disruptive childhood experiences. ADHD is considered to be a genetic condition associated with the availability of dopamine and norepinephrine in particular circuits in the brain.

Annie Zaleski: So walk us through, I guess, what an ADHD brain looks like then — are they producing too much dopamine, is it too little dopamine? What does that look like?

Dr. Michael Manos: And it's not a question of quantity of dopamine or quantity of norepinephrine, it's actually the availability. So you may have heard of the “notion of reuptake.” So when, for example, a certain circuit uses a neurotransmitter to increase a connectivity, the neurotransmitter is taken back up into the pre-synaptic membrane and, sometimes, it's taken back up before it can actually activate a receptor on the opposing neurotransmitter. So we call that reuptake, like serotonin reuptake inhibitors are useful medicines for the treatment of depression. So in ADHD, the pharmacol therapy, or the stimulants used to treat ADHD, allows the neurotransmitters to do their job before they're taken back up. And so that's the impact of ADHD. In people with ADHD, the neurotransmitters tend to be taken back up or their re-uptake happens sooner than they can activate the receptors on the opposing neurons to activate a particular circuit.

Annie Zaleski: That's so interesting. And that makes a lot of sense considering how ADHD manifests in terms of the major symptoms that you tend to see.

Dr. Michael Manos: Yes. So what's very interesting is that most of us don't pay attention to our attention that much. We look at our awareness and something floats into our awareness or we become aware of something. And sometimes, we activate our own awareness towards something. So, for example, the two kinds of attention that we use as human beings are called automatic attention and directed attention or effortful attention. Automatic attention is what the brain is activated by just by something occurring in the environment around us. So, for example, my office is right here next to the autism school. And one of the students from the autism school just walked by. So my attention automatically noticed that this young man walked by, that's automatic attention. Automatic attention is also activated when we're doing something that is of interest to us.

So we were talking before about journalism and writing and people who make a living by being writers are writing stories or articles typically that are of interest to them. And all of us have particular interests. For example, having dinner with a close friend or going to play basketball with a group of friends or seeing a good movie, those all activate automatic attention — you do not have to work hard to use automatic attention. It's automatic, it just occurs. And many of us, if we're lucky end up being in careers that activate automatic attention by and large.

Directed attention, on the other hand, is the attention a person uses to do a task that is of low interest. So, for example, a child sitting in the classroom, looking out the window at, say, a squirrel in the tree, is activating automatic attention.

That event is activating automatic attention. And then the teacher says, "Children pull out your math books and do page 45." So the child hears that, but would rather watch the automatic attention. So typically the teacher will have to give two or maybe even three more comments or directives for the child to pull out his book. And finally, the kid will pull out his book. The book doesn't move, it doesn't change, it doesn't climb, it doesn't run, but he has to bring his attention to the book and make sense of the book, that's directed attention or effortful attention.

Annie Zaleski: Well, and it seems like then, if kids have ADHD, that's more effort and that can be tiring if you have to put in more effort, I would think, to have to pay attention to things that maybe aren't as interesting to you.

Dr. Michael Manos: That's actually very insightful of you, Annie, to make that comment that it tires you out. It actually does tire you out. So consider when you were in school and you had a day, a whole day that you had testing all day long, when you got home, the last thing you wanted to do was to do more academic work or to read something that was of low interest — because you wear out directed attention. It tends to lose its salience at the end of the day. So it's more difficult to use. So, for example, a child comes home from school, throws his shoes and throws his jacket down and runs off to play video games. And the mom or the dad say, "Son, come back here and put your shoes away and hang your jacket up." And the kid has a tantrum because even a simple task like that, using directed attention is unavailable to him because of directed attention depletion.

Annie Zaleski: And that makes sense. That makes total sense. They're tired. They don't want to deal with it. So what are some other, I guess, ADHD symptoms then, and how else does this manifest in kids? Obviously, a kid who's maybe quiet and distracted and daydreaming is easier to overlook than a kid who's running and jumping or having a tantrum.

Dr. Michael Manos: Very well said. So the issue of running and jumping is more typical in boys, and over-activity and impulsive behavior is easier to see in younger children, which is why some children get diagnosed much earlier than others. And the point you're making is an excellent one in that, inattention can often be overlooked because many people who are very, very bright can get through school very easily. They can write their papers at the last minute, for example, or do a big assignment at the last minute and do well in it, get a very good grades in school, but they nevertheless are highly inattentive. They do not have to pay attention as much because they can hear one thing and be able to make sense of it. Whereas other people must have it repeated over and over. So very bright kids, for example, may have ADHD and be overlooked oftentimes until they even get into college, in that the demands of school do not pose them a problem because they master it just fine.

And then when they get to college, they realize, "Whoa, this requires a lot more work than I thought." And a lot more planning and organization than they're capable of. So organizational skills are very important for children and adults with ADHD because it's not as effective for them. It doesn't come naturally to them. Other characteristics are forgetting things, losing things. Sometimes, people who are in conversation with another person will look at the other person who wonder whether they're even listening. So sustaining a directed attention of behavior, even in a conversation may be difficult.

There are, so, just to sum, there are nine behaviors consistent with inattention and nine behaviors consistent with hyperactivity impulsivity. In a child, we are looking for six in one or both of those categories. In an adult, we are looking for five. Now it's not enough that somebody just shows these characteristics because everybody is inattentive from time to time, everybody drifts off in a conversation. It's when these behaviors become dysfunctional, when they become a problem in living everyday life, that's when we have to look for ADHD and see if there's something we can do about it.

Annie Zaleski: I think that's a good point because in discussing this conversation with a colleague, their question was, “maybe someone's just an energetic toddler” — when is it the line crossed between, “My child might have ADHD” and “oh, they're just a three-year-old acting like a three year old”?

Dr. Michael Manos: Yes. That's actually also very well said. Because these are behaviors. The behaviors that we're looking for, for ADHD, are behaviors that everybody shows at one time or another, but it's when they are problematic. We have parents come in all the time and say, "Well, he's just acting like a boy." Well, what does that actually mean? And how intrusive is this “acting like a boy” getting to be in this child's life or in other people's lives?

Annie Zaleski: Well, I think that's a good point because then, at a certain point, then maybe the line is that a kid isn't paying attention in school, so their work isn't getting done or their tests, when they take a test — maybe their mind wanders so they don't finish it in time or at home, maybe their room is so messy, you can't even walk in it or they don't pick up and they don't listen with asking small tasks. So I think is it fair to say that it's something that maybe builds up over time as well, that you're like, "Huh?" You tend to notice that this isn't just a one-time thing, maybe a kid just being cranky and on a bad behavior, but over time things stack up.

Dr. Michael Manos: So, again, well said. So having a one-time incident is not ever going to diagnose ADHD. These are behaviors that are exhibited over time and they are problematic over time. So now, what's very interesting is that the genetic variance of ADHD has diminished over the years. So, but these variants that described ADHD have been around for thousands of years, there was a fascinating study conducted by a person at UC Irvine named Jim Swanson. They followed behavior patterns of indigenous peoples in migration patterns from South America to North America and looked at the genes in each of these. And this went back 20,000 years, and there was a significant representation of the ADHD genes that they were looking at in these hunter gather tribes more or less. Then, after the ice age, what was very interesting is that these genes tended to diminish over time.

And evolutionary biologists indicate that when something exists, at least 1% of the population, then it's likely due to the genetic variance associated with natural selection in evolution. So you have to wonder now, why in the world would ADHD be selected for in evolution when the world was a very dangerous place? Well, likely, the ADHD brain helped survival because the ADHD brain could notice subtle changes and be activated by what occurred in the world around them. So that people knew if there was danger that way, they need to go this way. After the ice age, when people settle on farms, a brain that could wait a long time for plants to grow or seasons to change. So the requirements of survival changed and so natural selection then also started weeding out the ADHD brain.

But because there were so many people with ADHD or so many hunter brains, you might call them, that to replace them with farmer brains that could wait a long time for plants to grow or seasons to change was likely this certainly was going to take a long time. So the tendency for school tasks to be associated with farmer brains, there's a high correlation between the two. So, I mean, when you think about studying, what is studying? It's paying attention to one thing for long period of time, like waiting for something to happen or looking for something. The ADHD brain tends to exploit and engage with the natural world, the farmer brain, the non-ADHD, the neurotypical brain performs well with tasks that are self-selected or directed, as we call directed attention.

Annie Zaleski: I like that because I think especially now that there's a lot of conversation where people are saying, "Hey, an ADHD brain has a lot of strength, if a kid is really interested in something, they're going to learn about it, they're going to focus on it and they're going to become experts in it." And as they grow up, that can serve them very well. There's kids, I know kids who are very interested in roller coasters, and so they have a scientific brain and they learn about it. And so, I like that's flipping the script a little bit.

Dr. Michael Manos: It's still, I think it's still necessary to be cautious about glamorizing the ADHD brain because people with ADHD, nevertheless, still have significant difficulty in managing their behavior in a world that requires sustained directed attention. I mean, look at what we have to do every year. Everybody has to do their taxes. Now, I'm not quite sure that people enjoy doing their taxes, but they make themselves do it. Some people who do not have as greater control over their own directed attention don't make themselves do it. And so you see the problems that it can cause, and especially in our modern world.

Annie Zaleski: So one of the things that comes up sometimes are there also common comorbid or coexisting conditions with ADHD.

Dr. Michael Manos: Oh yes. One of the common questions that I ask, every person who walks in my office, seeking a diagnostic assessment is, are you self-critical? And the older a child is, or an adult, the more and longer time they've spent being self-critical. Typically, the tendency to be self-critical is associated with “not good enough” or “something must be wrong with me.” Because it starts very, very early in school. So just consider a very inattentive little boy who's sitting in class and the teacher says, "Kids pull out your pencils. You're going to take a spelling test now." Child doesn't hear it. So the teacher has to give constant reminders to the little boy.

The little boy is not oblivious to the fact that the teacher has to spend more time giving directions to, sometimes even criticism toward him as opposed to other students. So what does a child do with that? A child resolves that there must be something wrong with me. How come I can't do it like other kids? So being self-critical is very consistent. And the constant tendency to be disorganized also gives the feeling of being overwhelmed or irritability, being irritable or being agitated. And those emotions often over time can result in a diagnosis of ADHD or also of anxiety. So comorbid conditions, what we call comorbid conditions, like depression or anxiety disorders, are very common in ADHD.

Annie Zaleski: So when do these symptoms, I guess, start to, typically, start in kids then, and are there symptoms that emerge sooner than others?

Dr. Michael Manos: Well, children who are very active and hyperactive and impulsive, that shows up very early — and you really can't diagnose ADHD before the age of three years — some people say four years. So being able to diagnose ADHD requires being able to clearly know what is expected at that developmental level. And then, is the child exhibiting behavior that is outside of the norms for that developmental level? So you can diagnose starting at about age three or four. And the oldest person that I've seen was 74 years old. So you can diagnose all the way through the lifespan.

Annie Zaleski: How do parents, I guess, for kids, seek out a diagnosis then? Would you talk to your pediatrician first and get a referral? How does that work?

Dr. Michael Manos: The most common way of parents identifying ADHD in their children is to talk to the pediatrician. Now, the problem is that because of the demands that pediatricians have, the number of people that they must see, the time that a pediatrician can spend with a family is going to be maybe 15 to 30 minutes. When we do a diagnosis here in our offices, we spend a minimum of 90 minutes because the diagnostic process has three things associated with it. First are the symptoms there, are the behaviors that represent ADHD there? The six of nine for children, the five of nine for adults. Secondly, are those behaviors a problem or do they just seem to be present from time to time? So the second question, however, is, are those behaviors due to a particular circumstance, are they due to something else or are they due to ADHD?

Because depression can often look like ADHD. Depression can often look like inattentiveness. Anxiety can often look like even impulsive or hyperactive behavior. Because a person is constantly trying to make up for things and do something. So ruling out alternative causes for the behaviors, a child whose parents are constantly at odds of each other and actively fighting, for example, can cause a world of disruption in a child whose behavior may be very aberrant in school. And the child may not be a rule follower. The constant use of punishment in the home, that can result in ADHD behaviors. So you have to rule out alternative causes for why the behaviors are there. And many people, many adults, for example, come in and they think they have ADHD. But the number of people who demonstrate anxiety is often very high because their constant concern about getting something done or the constant concern or anxiety about their own safety can often be problematic and look like ADHD when actually it's not ADHD.

Annie Zaleski: All of those points, they make so much sense, and especially that if you're not paying attention and then you get upset with yourself and that snowballs too over time, and then anxiety and everything builds up. And when you're little, you're trying to figure out what all these things mean, too, when you're trying to figure out how to process it. So anxiety might manifest in a different way. So I think that all makes a lot of sense.

Dr. Michael Manos: Now that's actually a very good point in that children are very good observers, but they're very poor interpreters. So to see that all the other kids finish their tests sooner than one child does, the child will interpret that to mean, "Well, I must be dumb or there must be something wrong here." And when actually the case is that the child is simply taking longer to complete tasks and may not be ADHD. It could be obsessive compulsive disorder, for example, with the constant repetition of behavior or the constant over focusing on something.

Annie Zaleski: Well, I think we've reached a point in the conversation where, OK, someone has gotten a diagnosis, then, what are the next steps? What are the medications and treatments? And you mentioned very early on that that's something that's been studied for many years then. And so what do doctors typically do then?

Dr. Michael Manos: So first of all, getting a diagnosis is the first step. So people can actually re-attribute the concerns that they have, not to themselves as being a bad person, but to themselves as having a particular way that their brain functions, the brain of an ADHD person works differently. Automatic attention is exceptionally strong and it's much stronger than it is in the neurotypical person. Directed attention, however, on the other hand, is much weaker and subsequently, as adults, we're supposed to find our way and choose what we're supposed to do and then continue to do what we say we're going to do. The biggest problem with adults is leaving things incomplete, that is starting something and then not finishing it. Now everybody does that, but when a person does that and it infiltrates their work, their occupational work or it infiltrates problems in managing a household, that's when person may wish to investigate whether ADHD is present. But the brain actually works differently, it functions differently.

I know I have a number of colleagues who differ with me on this, but many times, ADHD, many times, I think that ADHD does not need to be considered a mental health disorder as much as it is a functioning of the brain that can be managed effectively. And the decision to use pharmacotherapy of course, is up to the individual. And if it's a child and it's up to the parents. Pharmacotherapy can certainly make a huge difference in the child's ability to be able to use directed attention, that's all it does. So when the teacher says, "Pull out your math books and do page 45." The child can turn away from the squirrel in the tree and pay attention to the book that doesn't move or jump because they can actually use their directed attention as opposed to having it not available to them.

Annie Zaleski: Does that mean that other kids might benefit from maybe not having medicine or having some behavioral therapy, or could both have medicine and a combination of medicine and behavioral therapy might work better? So it sounds like it's very also tailored to the individual.

Dr. Michael Manos: Again, your comments are very insightful, Annie. Because research has demonstrated that the most profound effects, the biggest effect on a child's behavior, even an adult's behavior, has to do with using a combined approach of behavioral intervention and medicine. And there have been several studies that have indicated that when you use very good behavioral intervention, you can reduce the dosage of medicine given to a child or an adult, for example. So in the adult world, people tend to use coaches, ADHD coaches, to help identify what should be placed in the physical world in order to assist a person to get things done.

So, for example, I always ask a person, “What is your organizational strategy? What do you use to organize yourself?” And people who tell me, "Oh, I just remember it." Then I tell them that the world has gotten far too complex to try and remember things. An organizational system should be something that exists in the external world, that exists in the physical world that you can refer to at any time, not in the brain. The brain is highly unreliable, it's not a good place to put things these days. So developing an effective organizational system is ideal. And I mean, the best thing to do is to have someone who follows you around all day long and says, "OK, this time, you have this, at that time, you have that." But probably the only person that has that is the president of the United States. Most people of course do not.

So our organizational system has to work, and in childhood, parents keep track of that for kids. And then as kids advance in grade level, they have to become more and more in charge of it themselves. So they devise their own systems and they study at certain times. A very interesting notion along these lines is what's called “social scaffolding.” We are writing a paper for the Cleveland Clinic Journal of Medicine on adult ADHD. And that's one of the interventions that we recommend adults take advantage of. People have friends and they have family. And this strategy can be burdensome if it's not managed effectively, but many ADHD adults tend to marry somebody who's going to be highly organized or who has a propensity to be able to keep track of things that are going on. That can be a, certainly, a benefit. Many people use ADHD coaches to put together a system, like reminders on their phone when they have an appointment or similar sorts of strategies that allow a person to pay attention to their responsibilities in the physical world.

Annie Zaleski: So as we're looking to wrap up here then, are there any big myths about kids in ADHD that you commonly see or you commonly have to clear up?

Dr. Michael Manos: Well that, oh, there is one of them, yes. What you mentioned before, children with ADHD often tend to have emotional dysregulation. So they're more prone to tantrums and the like, but not every child does. Back in the 70s and 80s, the definition of ADHD included a condition of emotional dysregulation. Then, shortly after that, it was taken out of the definition. We thought they were going to put it back in 2014 when the new Diagnostics and Statistics Manual that has the definitions of mental health disorders in it. But they did not. So some children with ADHD do have emotional dysregulation because, how do we manage our emotions? We manage our emotions using directed attention. For example, if somebody says something that is offensive to you, rather than yelling at them or knocking them, bumping them or something, we don't, we restrain ourselves and you restrain yourself by using directed attention.

And then, you can bring it up at another time when it's safer to have a discussion about something. So emotional dysregulation is not necessarily a characteristic that defines ADHD. Another characteristic is that people generally think people with ADHD have more creativity. And in some sense, that is true because children tend to be very observant of their world and being observant in their world, they tend to make associations that many other people may not make, but it is not a general characteristic that every child with ADHD is creative. So there are some senses of ADHD that are generally not true, but attributed to children with ADHD.

Annie Zaleski: That's so interesting. I mean, I think we're about ready to wrap up here then. Is there anything else you want to add?

Dr. Michael Manos: There is one thing that I just forgot, I wanted to say when I was talking about creativity. ADHD tends to have an exploring manner about it. Whereas, people who have very strong directed attention have an exploiting manner about how their brain works. So the brain explores the environment, and that's typical for ADHD, and the brain exploits the environment. And I don't say the word “exploits” in a negative sense. I say the word “exploits” in that you identify what's present and you put it in its proper place, or you use it in its proper way. So people with very strong executive functions tend to exploit the environment or exploit the world around. Whereas the ADHD brain is far more prone toward exploring the environment.

Annie Zaleski: That's so interesting. And that's so subtle, too, I think.

Dr. Michael Manos: Yeah, it actually is. Thanks for noticing.

Annie Zaleski: Thank you so much for being here, Dr. Manos. This has been a really great conversation.

Dr. Michael Manos: My pleasure, Annie, thank you very much for participating in this whole thing.

Annie Zaleski: For more information, or to make an appointment with our ADHD Center for Evaluation and Treatment, call 216.448.6310 or visit clevelandclinicchildrens.org/ADHD.

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