AUAA… Episode 30 – ADHD – Penn State Health Milton S. Hershey Medical Center

If we’re too busy we’re sleep-deprived,
we haven’t had our caffeine will feel more inattentive or restless.
That’s certainly intrusive. The key, you have to remember that ADHD is a disorder
and a disorder means that we struggle with something more than the average
person in that setting our age. So when you’re dealing with three-year-olds lots
of luck they’re all generally going to be pretty hyperactive and you’re gonna
have to repeat yourself. But once you get into a school setting where you can put
a child next to 20 other kids their age and have them do tasks that
are typically normal for the age, like sitting in a desk for 15 minutes, pay
attention to a teacher while she’s talking, complete 10 minutes of math in
the given time frame, then you can start to see where these things might cause
problems. So if you’re so off task you don’t get your work done, you can’t hear
the instruction, you’re so restless that you can’t stay in the seat or you’re
disrupting other people around you or you’re so impulsive
that you have any much harder time managing your anger than another child
your age, then we have a problem. And then that’s typically when the term ADHD
might get used and that’s really and only when we should consider treatment
for the disorder. I hear ADD, I hear ADHD, are the two terms interchangeable?
Largely, we used to have to separate by suppose diseases. Recognizing that maybe
kids who are purely and intentive are a little bit different than kids are
permanently hyperactive. It turns out they’re much more similar than they are
different so we tend to use the catch-all term of ADHD but recognize
that some kids can be more prominently or visibly inattentive where some kids
can be more visibly hyperactive. Dr. James Waxmonsky is our guest for Ask Us
Anything About… ADHD from Penn State Health. We welcome your questions and
your comments, just add them to the comment field below this Facebook post
and won’t be sure to pose those questions here to the doctor. You talked
a little bit about how ADHD is detected like for example in the classroom
setting. So there obviously is not a blood test or a clinical type test. It’s
really behavioral i guess? Mostly, we’re dealing with observations interacting
with the children and most importantly getting feedback from parents and
teachers. The latter which can be a little bit challenging sometimes but to
call something a disorder we want to here that there’s impairment in the setting.
So that’s why it’s really particularly critical to get not only feedback
directly from parents about how their child is behaving but particularly from
teachers. Teachers are fantastic. They may not necessary
be experts on ADHD but they know what a seven-year-old supposed to be able to do
in a 45-minute class and if the child’s not doing it, again, that’s that marker of
impairment. So the standard of care, obviously interact with the child, you
have parents fill out rating forms or complete an interview and then you have
the teacher fill out rating forms about both symptoms like hyperactivity and
impulsivity but most importantly how actually is the child doing in the
classroom and if you have the symptoms and you have the impairment especially
at home in school, we’re pretty comfortable making the diagnosis. You can
get more high-tech and we can run kids through EEGs and you can actually MRI
brains and there is a kind of prototype of an of an ADHD brain but the problem
is it’s, A, too expensive B, there’s too much variability so you can’t
definitively use it to say one child has ADHD and one child doesn’t but you could
take a hundred kids with ADHD and a hundred kids without ADHD and you could
see an average difference in their brain functioning. That’s certainly true. Not
necessary for diagnosis? Oh no, we don’t even recommend it. Really, rating scales,
sitting down with kids, your average pediatrician can largely establish
the diagnosis. What do we know and even not know about causes and risk factors
for ADHD. Yeah, it’s a very good question. The brain is probably the most complex
part of our body so it’s very challenging to understand exactly what
causes ADHD there are some clear risk factors. It is a hereditary disorder so
if you have a parent who had traits of it as a child or still has traits of it
as an adult, you have maybe a one in five one in four chance of having a child who
has the disorder a few things like, nicotine exposure in utero. So, smoking
during pregnancy has been clearly established as a risk factor. There’s a
whole bunch of theorized things from pesticides of the most probably
intensely debated one is modern media. So if you put infants and toddlers in front
of too many screens are we actually physiologically shortening their
attention span and that’s debatable. There’s certainly value with monitoring
screen time but we’re not really clear yet if it’s causing ADHD in any way. What
do we know about the prevalence? I’ve read online anywhere between, depending
on the article you read, it could be three percent could be twelve percent of
the population? Right. So most studies now will center around six to seven percent
including those from across countries. We use slightly
different diagnostic criteria than some of the European countries. They tend to
be a little bit more strict requiring hyperactivity. We don’t actually require
it as long as you’re prominently inattentive. So that’s one of the reasons. The thing the studies do is they go out in the
community and ask families, has your child ever been treated for ADHD? Have you
ever been told your child has ADHD? Then that’s a bit different than a diagnosis.
Those rates will push up to about 11 ish percent and then most importantly the
rates of treatment are about 5% so you go into a classroom and five percent of
American school kids have been on medication for ADHD. Meaning that more
than one in every classroom are probably going to have been treated at some point.
We’ll definitely talk more about treatments in a little bit here on Ask
Us Anything About… ADHD from Penn State Health I’m Scott Gilbert. This is, Dr. James Waxmonsky. He is a chief of child psychiatry here at the Milton Hershey
Medical Center and he welcomes your questions about this topic. Whether
you’re watching this video live or even if you’re watching it on playback. And
regardless of how your or when you’re watching it, please do click on the share
button and share this content with other people in your feed to help get the word
out about some of this important information. You know, I would like to ask
about, back. I guess, some people feel that ADHD is a relatively new diagnosis so
you know it’s common for adults to say well back when I was a kid there was no
ADHD. Was there and perhaps we just didn’t call it that? Sure. Well certainly,
there was. Whether or not this has become slightly more prevalent over the
last several decades? It’s probably we’re getting better at diagnosing it. Again, we
may debate things like modern media exposure but certainly the prevalence
was there when we go back. If you go back, there’s German nursery rhymes for
the turn of the 19th century that clearly show hyperactive kids falling
off walls and having all these awful things happen to them like many old
school Nursery Rhymes do. So the construct was there. The original term
was this fun thing called minimal brain dysfunction which dates back to the 20s
or 30s. The first treatment for it was back in the 1920s when they realized
that stimulant medicines like Adderall, they were being given to treat pain post
spinal taps for headaches and lo and behold the kids behave better.
So the actual treatments themselves date back 75 years. In the 50s, a small percent
of kids were treated and then over the course of the 80s and 90s we really had
a boom both in diagnosis and treatment. Mostly because we got better treatments
and because we got more aware that it isn’t just a young kid disorder, it kind
of hangs out and cause more problems later in life so we wanted to do more to
identify and treat it. We have talked a little bit about treatments. Let’s delve
into those a bit more. What medications are out there that can help people with
ADHD? So let me step back a second, because we always tend to think of
medications when we think of ADHD because everybody’s heard of Ritalin and
Adderall for good or for bad, at the end of the day behavioral treatments are
just as helpful AND in many ways possibly more useful than certain medications
their preference for kids who are very young who may have a hard time handling
medications and when you’re young the behavioral treatments pull the parents
in as much as the child because it’s very hard to teach a four-year-old a new
skill. It’s much easier to work with their parent and help them kind of
redirect the child in the minute and to consistently reward good behavior and
consequence bad behavior. I was wondering, how much of it is training the parents
to work with a child to help them through? RIght, and young kids that’s
mostly it and you can get as large effect for benefit for ADHD with the
behavioral therapies as you can with the meds and you have less side effects. The
trade-off is it’s sometimes hard to find people who do those things and then also
it takes time. The meds are wonderful and that they work right away, you get a
visible reduction in hyperactivity kids can sit longer, they can stay focused longer in an activity and that’s instantly, whereas,
the therapies obviously take time and effort. But when we look down the road
when they’re older and whether they’re better off for
treatment. The behavioral treatments really start to have clear benefit. I
imagine that some parents too may have some concerns, some very well founded
concerns about not wanting to rush to put their children on medication for
something like this? Yes and we A, try to be very careful with the
diagnosis we want to make sure that the symptoms are persistent and causing
impairment ideally at home and at school before we identify diagnosis. Secondly, we
want to offer treatment that goes after the impairment. So you can be
a hyperactive but if it bother anybody, I don’t necessarily need
you to be calmer. If you’re so hyperactive that you’re disrupting your
learning or other people’s learning, then we want to treat you. So linking the
treatment to the actual problems that kids have are probably works better. It’s
easy to do with behavioral therapy because we can shape the treatment to go
after whatever the problem is. The meds though are effective and there’s
certainly a very reasonable part of treatment. They’re the most commonly used
treatment, they significantly reduce hyperactivity, they significantly improve
attention span and they significantly improve impulsive behaviors whether
they’re blurting out in class or whether they’re getting overly frustrated in the
minute. You’re watching, Ask Us Anything About… ADHD from Penn State Health. Dr.
James Waxmonsky is chief of child psychiatry here at the Milton S. Hershey
Medical Center. We welcome your questions. Stacey has entered a question here,
she’s asking, ADHD and OCD – Do the children grow out of these or are they on medication
the rest of their lives? That’s a good question becasue we’re talking
about children here but [cough] excuse me. um What about the long-term? Right! So
that’s a fantastic question and starting with ADHD if you had asked this question
20 years ago the answer would have largely been “yes.” It kind of stops being
a problem around middle school. But now we know when we start to track people
actually longer that what goes away is there physical hyperactivity. You can’t
see me run around the room when I’m thirty but you can still see me struggle
with inattention or being impulsive such as making quick and problematic
decisions. So the visible symptoms go away a bit but the more internal
symptoms, it actually caused most of the impairment hang out about two-thirds of
the time. Now that doesn’t necessarily mean you need medication lifelong. In
fact, with kids, we’re always looking for opportunities to see, “hey, have they made
enough development?” “Have they made enough gain?” That in fact, they don’t need meds
but if you do need meds they’re largely safe developmentally and there are
people who use them all the way through their life and they are just as helpful
for adults as they are for young kids or teenagers. Can having ADHD makes someone
more prone to other conditions? Yes, and that’s where, maybe not so much
OCD per se but certainly depression and anxiety, substance use actually the rates
of cigarette use are much higher because sadly nicotine is slightly improves your
engine span. But you can imagine if you struggle in school, if you struggle to
maintain friendships because other kids find you Restless, impulsive or
inattentive, you’re going to get rejected more and if you’re frustrating at home
you’re going to get punished more or even yelled at more and that affects
rates of depression, rates of anxiety and can lead to things like school dropout
and substance abuse later into adolescence. Now that’s not necessarily
the course for everybody but we know that both those disorders and the things
that we don’t want our kids to do like quit school or get arrested or use drugs
are a little more likely with ADHD not gigantic risks but those are the things
we do have to watch for. If parents suspect that their child may have ADHD,
what’s a good next step? Should they speak with their primary care provider
or reach directly out to a specialist? In most cases, it makes sense to reach
out to your primary care provider. ADHD is like the ear infections of child
mental health. Almost every primary care provider season on a regular basis .They
are aware of the treatments, many of them are comfortable with the medication
treatments and some of them know where to find the behavioral treatments here
at Penn State Hershey in Pediatrics our pediatricians are
excellent at this. With good awareness about both the meds and the behavioral
treatments and also we have specialists embedded right within primary care so
you can work with a mental health professional in the same place you go to
get your vaccinations for your child. Not every place has that but yes starting
with a primary care doc is a very good bet if for some reason that’s not your
preference, you can reach out to a specialist and
this is where our field gets confusing. I’m a psychiatrist which means I’m a
medical doctor which means I happen to do behavioral treatment because I think
it’s important but most psychiatrists will focus on assessment and medications.
Whereas counselors, social workers therapists will be behavioral based and
it really depends on what treatment you want to start with where you go. And
there is no best answer. It’s partly more what you’re comfortable with and what
your child’s comfortable with. Sounds good! And of course, we will put a link
below this Facebook post to the division of child psychiatry here at the Milton
S. Hershey Medical Center. So if you have some questions you can reach out to Dr.
Waxmonsky’s division. Thanks a lot for your time today. Good
talking with you. Anything else you would like to add as we bring things to a close? I would
mention that certainly some kids don’t respond to initial treatments and for
those particularly interest in using behavioral treatments, it really is one
of the focuses of our division here at Penn State Hershey. So we have a broad
number of counseling programs, behavioral interventions and even medication
treatments that are available through families and the our information is on
the website if you look under the Children’s Hospital or Penn State
Psychiatry. We have a wider range of treatments that would fit I think every
family. So please, look us up. Good! Dr. James Waxmonsky is chief of child
psychiatry here at the Milton S. Hershey Medical Center. He’s been our guest today.
Thank you so much for watching and feel free to add your questions. Again, whether
you’re watching this live or on video playback, we’ll get answers to your
questions about ADHD from Dr. Waxmonsky. Thanks for watching, Ask Us Anything
About… ADHD from Penn State Health.

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