SRQ: Is there a formal definition of ADHD? Kristine L. Vallrugo, Comprehensive MedPsych Systems: There’s no such thing as ADD, we can all agree on that. It’s all Attention Deficit Hyperactivity Disorder–even if a child isn’t hyperactive, it’s still considered ADHD. There are different subtypes of ADHD. For example, there’s the inattentive type, in which the child doesn’t necessarily have hyperactivity but is inattentive, and then there’s children that have both. It depends on the patient but it’s all considered ADHD.

About ten years ago, ADD was all over the news as the thing for parents to look out for. What changed? Jeffrey Kanter, Comprehensive MedPsych Systems: What they found was that all the kids had some level of hyperactivity anyway, and that was not a differentiating aspect. So it changed from ADD with multiple subtypes such as a hyperactive subtype versus non-hyperactive subtype, to ADHD. The hyperactivity piece was pretty much present in most kids so at one level or another the impulsivity and the hyperactivity are part of the syndrome. Ann Taylor Roman, Center for Integrated Therapies: It just might be expressed differently.

Do we know what’s happening inside the brain when someone has ADHD? Patricia Jo Ryan, Mind, Body Wellness Center: Generally speaking, ADHD children have a lot of slow wave activity in their head, in terms of slow brain waves, and that often interferes with their focus and their concentration—generally, they don’t like things changed—and so consequently there is some neurological base to ADHD as well. Kanter: Dr. James Hale has done most of the research on brain-based ideology for ADHD and what he found is that there are actually two different circuits in the brain that result in different types of behaviors, which then respond to different levels and types of medications. So the impulsivity type of behavior is much more frontal lobe-based and the kids who have the inattentive piece actually have a different circuit. Depending on how you evaluate this, how you look at executive functions and how you assess for impulsivity and attentiveness, an evaluation can lead you to figuring out which types of medication can be used and what effect it’s going to have. You want to have medication that affects both the attention side as well as the impulsivity/hyperactivity side.There are some brain-based behavioral correlates there.

What signs do you look out for during diagnosis and what do you have to be careful of?Kanter: So many different disorders will look like attentional problems. On the outside we’re obviously looking at attention, distractability, poor focus, restlessness, fidgetiness, difficulty transitioning from one task to the next, higher level problem solving, independence—all those types of things. A good evaluation is going to look at is this truly a biological and neurological issue or is this actually anxiety, depression, sensory integration issues, trauma, family problems, learning disabilities or just low IQ. There are so many different things, so one of the things that we do is the neuropsychological evaluation, which is typically a six-hour evaluation that looks at every different piece to figure out exactly what is going on. A neuropsychological evaluation in and of itself doesn’t diagnose ADHD. What it does is check out all the other things that it could be and either rule them out or say that they are important in the child’s presentation. Ryan: One is that things easily distract them, like noises or just a variety of outside stimuli. As psychologists we have to distinguish between differential parenting and ADHD because that can be a very important factor. If you have parents that have a different idea of childrearing, then sometimes the child’s confused by what is going on and the type of parenting that the child is getting. And so consequently, we have to differentiate between those kinds of things. Roman: Working along with medication to support the family system is one of the really important things we can do as therapists. So if the family system is really disorganized or if it’s impulsive itself and doesn’t follow a regular schedule—those kinds of things can help soothe the child and help them to work effectively within their family system. There was originally a big debate about ADHD and about blaming parents—do you have an overactive child because of the diet you’re feeding them or the behavior that you’ve taught them—and there actually is a real cause to this and we have to tease out the nurture aspect of it.

What environment are we providing our child to help sooth them and help them to work effectively with what they have and what we can provide to them? Viktoria Bakai-Toth, Jewish Family and Children’s Service of the Suncoast, Inc.: It’s important to mention that it’s not just the diet and the parenting that we have to look into, but also sensory integration disorders. We have to look into trauma. All those can present as easily distracted or unfocused or oversensitive. Just because someone is easily distracted, does not mean we can say that this child has ADHD and needs medication. Kanter: If the child does poorly on the attention tests and they have the behaviors and they don’t have anxiety or depression and the family structure seems to be intact and there’s no other sensory or trauma issues, absolutely this could be an ADHD diagnosis.

Once you have a diagnosis, what are the first avenues of treatment or management that you explore? How early does medication enter the equation? Vallrugo: I find that children sometimes not only have ADHD but they also do have another disorder. It’s very common to find kids that have anxiety or depression and ADHD. That’s where the testing can be very helpful, to differentiate because concentration is a notorious symptom of depression in adults and children. Sometimes I see a patient with all three, so the medication issue is challenging because you need more than one type of medicine. I usually try to deal with the problem that’s most interfering with the child’s life first, whether that’s ADHD or depression, and try to go from there. If you try to start two medicines at once, you don’t know what’s working and what isn’t. Kanter: The comorbidity of other disorders in addition to ADHD is remarkably high. Fifty to 60 percent of kids have ADHD and another disorder such as anxiety or depression. Is there a causal link between the disorders, one root cause or are they unrelated? Ryan: There’s rarely one root cause to any psychological problem. Generally speaking, it’s multiple causes that combine to create those kinds of behaviors.

What medications are available now for children with ADHD and how effective are they? Vallrugo: Stimulants are by far the best drugs for ADHD in terms of effectiveness. There are many types of stimulants and they all work generally in the same manner, but they’re all different as well. Sometimes a child will respond to one but not another. Side effects tend to be a big problem with stimulants. Appetite seems to be the biggest problem—all those drugs notoriously decrease appetite. So although they may be beneficial, you’ve got a child then who’s not eating, especially during lunchtime. You have to deal with weight loss sometimes. It can be a really challenging situation to try and figure out, balancing how effective the medicine is versus the side effects. Sleep is sometimes impaired, too, by these drugs. Roman: When it’s the right medication, it’s extraordinarily effective. I’ve sat in a playroom with a child unmedicated and the next time medicated, and it’s dramatically different. It’s an enormous disadvantage to not treat. Imagine being in a classroom and unequipped to focus and take in the information around you. So I always help to coach parents to balance acceptance and change in what the child really needs to be effective. Vallrugo: One nice thing about the stimulants is that they’re very flexible. You take them, they work and then they’re out of your system. It’s very different from an antidepressant that needs to be taken every day. There is one medication that’s FDA-approved for ADHD and you have to take it every day, although it’s not a stimulant. That would be another option, but in my experience it’s not as effective. But the stimulants are good because there’s so much flexibility. Kanter: You have to be very careful about medication noncompliance, selling medications, giving it away to other kids, having college kids use it just to do papers late at night. That’s where the contact with the psychologist or the counselor is really important, so that you don’t lose control over the whole scenario.

What is neurofeedback and how is it used to treat ADHD? Ryan: Neurofeeback is a computer-based method basically measuring brainwave patterns, and you’re feeding back the brain its own state. And the brain is a wonderful organ in that it can change itself, and this is based on what is called neuroplasticity. Back in 1965 it was discovered that our brains could develop new neural pathways and that it wasn’t just static. In fact, it can do its own work and take care of itself if you give it the right information, and I call neurofeedback “brain food.” You give that brain the right feedback and it will change itself. It’s very much like learning how to ride a bicycle—you don’t cognitively learn how to ride, your brain directs you how to gain stability. Neurofeedback has become a wonderful tool to enhance that process. They sit in a comfortable chair, sensors are placed on the head very similar to how a physician might use a stethoscope to measure heart rate and we measure brainwaves. We break those brainwaves down into slow wave activity, alpha wave activity, beta wave activity—which is the normal awake and alert state—and high-beta. We look at all those patterns and we give the brain back the information it needs to self-correct. Kanter: You’re teaching people how to change their brainwave patterns. Ryan: The brain is learning. The brain is actually learning how to change itself based on the information that it gets. That’s why it’s called biofeedback, because you’re feeding back a biological system to itself. Kanter: You show the child the actual brainwave patterns in different ways with games or graphic designs. Basically you use that to have the child learn how to change his own brainwaves, which can actually change their ability to pay attention, focus, deal with anxiety and other things as well. It’s a pretty powerful technique. Ryan: It’s very rewarding, but unfortunately it’s a slower process because the brain takes its time to change.

How long does the process usually take? Ryan: Generally speaking, I’ve found it’s somewhere between 40 and 60 sessions, and actually the brain will need less medication as it stabilizes. They’re generally half hour sessions. Bakai-Toth: About neuroplasticity and food for the brain, working in the school system and seeing that the children are in that setting for eight active hours of their day, which is a long time for them, with artificial lights, artificial temperature, lots of time in front of a monitor—this is far from the right food for the brain. They are deprived from nature—I work with children who have never been to the beach although that is hard to imagine around here. There are very basic things they don’t do anymore. What education is putting on them is just not congruent with biology at all. It’s good to talk about medication, it’s good to talk about all those things that we can do, but I also think that parents have to make an effort to go back to the basics and take their children to the park and let them hang upside down. Get them out of the room and away from the computer.

What’s the connection between those physical activities and brain health? Bakai-Toth: This all goes back to the sensory piece. Experiencing different textures—digging through the sand, going into the water—and in general physical activity give the input that the body needs and the brain craves for those healthy patterns. It’s helping the brain develop those healthy patterns instead of getting everything through visual monitor stimulus.

How do you define successful treatment or management? Can a patient ever be rid of ADHD? Ryan: Well you don’t get rid of things; you manage various kinds of behaviors. The brain is what it is, but you can give it information so it can change itself. There’s a really good book that parents may want to read called The Brain That Changes Itself, by Norman Doidge, a psychiatrist who has written quite extensively about neurofeedback. Kanter: The issue of whether it gets better or you grow out of it is a good one and it’s a little complicated. There are certain kids who don’t need medication after a while or by the time they hit 14, 15 or 16 if they’ve been treated correctly, then they don’t need as much medication. On the other hand, you have a different set of life circumstances as you go from grammar school to elementary school to high school to the job market as a young adult, and so you’ll also see adults with ADHD. But you typically do not suddenly develop ADHD when you’re 30 years old without any history of learning problems.

How effective are treatment methods besides medication and neurofeedback, such as talk therapy or other sorts of physical therapy? Kanter: The research on it is pretty clear that aside from neurofeedback, which is a separate intervention and has a very good efficacy rate, a combination of medication and counseling produces the best effect in terms of ADHD. Ryan: Even if you’re doing neurofeedback, you want to work with the physician who’s seeing the patient so you’re working congruently. Kanter: You’re dealing with kids who don’t have fully-formed brains to begin with—so you’re asking their brains to do something that they may not be capable of. But it’s talking with them about what happens when they feel they want to do something and how to stop it. The other side is emotional because these kids are teased; they don’t do well in school and they feel like failures. Ryan: Or they’re called retards, very often by their own classmates. Kanter: The emotional and self-esteem issues you’ve got to deal with as well, to really help these kids realize that they have very unique capabilities and they can channel some of this activity and impulsivity into something positive instead of always being seen as a negative. Roman: Never underestimate the power of behavioral reports. When we set up a system and one goal for the week—that every time the teacher gives you an instruction you respond in this way—and if you get a star each time you respond in that way, by the end of the week you’re going to be responding. What’s most important to you? Set that as your goal. Children are highly motivated to please. We can’t have 20 goals at once for a six-year-old, we set three for the whole week, and when we work specifically towards that goal, we will reach it.

How do you help children develop those strategies? Ryan: It takes time. Lots of time. Kanter: It’s really important. Therapy is focused on developing coping strategies—how do they deal with their impulsivity, with when they want to act without thinking, when they’re going to get themselves in trouble—and getting them to slow down and focus on their own behavior so that they can catch themselves and stop and think.

How important are external support systems to your work with the patient? How involved can you get? Ryan: I also work with the parents; I don’t just train the child. This child is in a system, and frankly, if the parents aren’t willing to work with me, I won’t work with the child. Kanter: With difficult and disruptive kids that have a hard time paying attention, you get stressed-out parents. So which one causes the other is always a question, but they come as a package and you have to deal with both. You don’t just treat the child for ADHD and not work with the parents. How the parents work together as a team is a critical piece of the intervention. Ryan: There are times when the child can change even though there may be more chaos in the family, but it’s rare. We are a social organization and the family is a social organization, and the family is where the child basically gets their early education about how to be social. Kanter: Parent involvement is critical. You can do all the intervention in the world and if they go back to that house with conflict with the parents or siblings that doesn’t get resolved, then it can be very disruptive to the child and make symptoms much worse. Bakai-Toth: And hopefully the school as well. In general, schools are very accommodating if you keep that conversation going and you’re willing to communicate. They have their own process—the 504 plan, a very common accommodation—and parents can talk to their Education Advisory Committee liaison in the school and they’ll be willing to help you out. Kanter: The 504 plan, which allows the child to have extra time and other types of accommodations that help the child deal with what is, in effect, a disability. There are other private schools out there like the Pinnacle Academy that specializes in children with learning disorders and ADHD. Roman: Dreams Are Free is another program at St. Martha’s that offers special programs with small classrooms. Most teachers are really well-educated on it now, so they are willing to say “What can we do for help?”