Ask the Doctor with Dr. Ken Duckworth, NAMI Medical Director

1. How can families and individuals living with ADHD secure an accurate diagnosis and what should they ask their mental health providers?
   
   
   Most people—especially children—are, at times, distractible, restless or impulsive. Individuals who live with ADHD demonstrate clear and sustained difficulties in the areas of attention, impulsivity and/or restlessness/hyperactivity that cause significant limitations in important areas like school or relationships.

   I encourage individuals and families to start getting oriented to the concept of being affected by ADHD by getting good information on the condition. There are many resources to get current information on ADHD. Familiarize yourselves through these resources: NIMH, Mayo Clinic, The Hallowell Centers, CHADD, The National Resource Center on ADHD and AACAP are very good places to learn. If you think you or your child may be living with ADHD based on your reading, have a conversation with your physician, pediatrician or a mental health professional about your concerns. Getting a comprehensive assessment that looks at you and your life or at the whole child, his/her school and family life, medical concerns, family history, stressors and the child’s strengths and resilience is essential.

   With children, teachers and parents are each in unique positions to make observations to inform the evaluation. If your child’s teacher has suggested an evaluation of your child based on observations, then those observations can be one key piece of the diagnostic puzzle. There are standardized parent and teacher rating scales to place these observations in a more structured way. Examples of these tools are the Child Behavior Checklist or the Connors Rating Scale. Your child’s pediatrician or a mental health professional should be able to make recommendations on the best tool for you.

   This diagnostic evaluation conducted by an experienced clinician is the current standard for making an accurate diagnosis. For children who also receive neuropsychological testing to evaluate their learning style (sometimes an issue in kids living with ADHD) there are certain subtests that assess attention—these can corroborate the clinical diagnosis, but should not be used the make the diagnosis per se. There is no one single test for a diagnosis of ADHD. Learn more about ADHD symptoms, causes and diagnosis.

   To assist the diagnostic process, it is also important to share any family history of ADHD or symptoms. ADHD has a strong genetic element and runs in families. Many parents I have met identify with the same symptoms as their child’s, but were never evaluated or assessed. Some parents note the same traits in themselves as they describe in their child, and that can create an opportunity for more formal assessment if desired.

   
   
2. Do parenting styles or family dynamics affect the development of ADHD in children?
   
   
   I think the challenges for families encompass how they frame the condition and how they take care of themselves while also developing strategies to improve their capacity to support their child. Family relationships and dynamics are important to put the condition into a healthy framework. One positive framework is that ADHD is a condition that impacts millions of Americans and one that may have upsides. For example, having a “race car brain,” as Dr. Ned Hallowell describes it, helpfully implies both power and the need for more control (or better brakes). Finding and nurturing the child’s strengths and maintaining his or her relationships in and out of the family are essential. Parents also often have a challenging job raising kids who live with ADHD, so it is important to go easy on yourself and recognize that this can be daunting and, at times, exhausting. Find other parents in the same boat to increase support and help take care of you. Local chapters of CHADD and NAMI offer monthly support groups in many communities throughout the country.

   Familiarizing yourself with parenting strategies that support your child, such as tips for organization, structure, limits, aerobic exercise and behavioral strategies, will also serve you well. In addition, you can also work to develop an understanding of how the educational system can help your child once the diagnosis is made; this could be as simple as sitting in front of the class and having extra time for a test, but could require more accommodation depending on your child’s specific learning needs and style. Learn more about options for the education accommodations you can seek. Also, review the ADHD and parenting section for tips and suggestions.

   
   
3. Can my child out grow ADHD as his/her neurological development matures, or is it a lifetime illness?
   
   
   That is a very good question. We can’t predict who will grow out of ADHD, but we do know that a substantial subset of youth will continue to live with ADHD into adulthood. Most teens living with ADHD grow out of the hyperactivity element of ADHD but have elevated risks for other issues such as substance abuse and driving accidents. Adult ADHD can be successfully treated, but it first has to be considered and evaluated. In the book Positively ADHD (by Catherine A. Corman and Edward M. Hallowell, M.D. , Walker Books, 2006), the authors chronicle a series of successful and creative adults who are thriving with ADHD. ADHD does not begin in adulthood—the symptoms manifest early in the lifespan but may have been overlooked. In my experience, over time, people learn about what works for them and can also become more accepting of their way of experiencing and engaging the world.
   
   
4. What is the prevalence of youth living with ADHD and co-occurring disorders?
   
   
   Youth living with ADHD frequently have other co-occurring conditions, which is why it is so important to tailor the interventions to support the child’s specific strengths and address his or her individual vulnerabilities. The Centers for Disease Control and Prevention (CDC) states that 9 percent of children aged 3-17 live ADHD, and that boys are twice as likely to be diagnosed. A worldwide meta-study found that the overall prevalence of ADHD was 5.2 percent (Polanczyk, American Journal of Psychiatry 2007) and noted that difference in methods of defining ADHD explained most of the variation across countries. NIMH’s study, Multimodal Treatment Study of Children with ADHD (MTA), found that Oppositional Defiant Disorder (ODD) was present in 40 percent of children, minor depression in 21.6 percent and generalized anxiety disorder in 15.2 percent. Children living with ADHD also have higher rates of substance abuse; this concern is even more likely if substance abuse is in the family history. Other important co-morbidities for youth with ADHD include an increase in learning disabilities and an increased risk of co-occurring bipolar disorder. The latter diagnosis is a source of controversy and continued research to better understand its prevalence and defining characteristics in the child and adolescent population is needed.
   
   
5. If my child or adolescent is showing signs of oppositional behavior along with ADHD, what additional approaches can I use?
   
   
   Oppositional behavior is part of many normal stages of development and often complicates the clinical picture of ADHD. Since ODD occurs in about 40 percent of children with ADHD, it is not uncommon that it co-occurs with ADHD. Working with a therapist is often helpful. A mental health professional or therapist can review what is motivating the defiant behavior and to problem solve on how best to adapt your parenting to reduce this behavior. Examples can include identifying the reinforcers (rewards) the child perceives, offering alternative pathways for him or her and reducing your emotional response to the behavior. The most well-studied intervention to help parents manage oppositional behavior is called Parent Management Training (also known as PMT). PMT improves many outcomes in the child’s oppositional behavior and can improve the relationships within the family as well. Ask the mental health professional or therapist how they understand the roots of the behavior for your child and how their efforts and yours can support your child’s development.
   
   
6. Are ADHD treatment options different for adults versus children (And will my child require medication as an adult, too?)
   
   
   When parents describe their children’s ADHD symptoms, I have had several note that they themselves have many of these same traits. This isn’t surprising as ADHD runs strongly in families and has a genetic component. Adult ADHD diagnoses often come as a relief, as they place many challenges into a context and a diagnosis offers hope for strategies that often work. Many of the strategies that help in youth, such as structure, organizational tips and coaching, to name a few, are helpful for adults living with ADHD. For many adults, medications are critical as well, and developing an individualized approach for adults is just as crucial as it is for children. Learn more about ways of managing adult ADHD.
   
   
7. What are some effective medication treatments and what are the potential side effects of these medications?
   
   
   The U.S. Food and Drug Administration (FDA) has approved several medications for the treatment of ADHD. Other usage of medication is “off label” and should prompt a conversation with the prescriber about why they are making that specific recommendation as opposed to a compound approved by the FDA.

   
   

   Side effects:

   All medications have two important areas to be concerned about—the common side effects and the serious ones. In stimulants, the most common side effects are reduced appetite (which over time can limit growth) and difficulty sleeping. The development of tics (involuntary movements) is less common, but important.

   The FDA voted to label stimulants with a “black box” warning, which I explain to my patients is the most serious “stop sign” the FDA has for prescribers and patients to consider before starting any medication. The FDA warning is as follows.
   

   Drug Dependence

   [TRADEMARK]*should be given cautiously to patients with a history of drug dependence or alcoholism. Chronic abuse can lead to marked tolerance and physiological dependence with varying degrees of abnormal behavior. Frank psychotic episodes can occur, especially with parenteral abuse. Careful supervision is required during withdrawal from abusive use since severe depression may occur. Withdrawal following chronic therapeutic use may unmask symptoms of the underlying disorder that may require follow-up.

   *Name of drug goes here

   
   

   Recently there have been concerns over a possible connecion between stimulants and heart concerns including sudden cardiac death. At this time there is no black box warning for this concern for stimulants. Ask your preseciber their take on this issue and be sure to tell your doctor if you have a family history of cardiac concerns before taking any medication. See also the FDA black box warning regarding Strattera and suicidality.

   FDA-approved medicines have been shown to meet their standards for clinical usefulness and safety. Selecting the right medication is a process between the prescriber, the individual and the family and is benefited by the use of rating scales to make clear what is and is not working to help inform the medication trial. Often the individual will report his or her experience—good or bad—on the compound.

   In regard to children, finding the right medication and dose has always been a challenge, but with the publishing of the follow up of NIMH’s Multimodal Treatment of Children with ADHD study (MTA) (Jensen cite, Molina, et al., Journal of Developmental and Behavioral Pediatrics: Feb. 2001, Volume 22, Issue 1, pp 60-73), practitioners and researchers are also now working to better understand the best developmental window and amount of time for a child’s medication usage. Learn more by visiting the NIMH Q and A on MTA. This study helps us to stay humble about how much we do not yet know and also to see the profound challenge that is ADHD and that we as an advocacy community have to support the effort to find treatments that can make a difference for a child’s outcomes in the long term as well as the shorter term. The many challenges in finding the best long-term interventions for kids living with ADHD makes me reflect on the importance of how children are viewed in the family, how their strengths are maximized and how they are loved while living with ADHD.

   
   
8. What psychosocial interventions have been found to be effective for children living with ADHD?
   
   
   
   One of the most successful interventions is using positive reinforcements. When a child or adolescent follows instructions or exhibits good behavior, he or she should be rewarded in some way that encourages that behavior in the future. It is important that parents acknowledge even incremental success and that they do it consistently. Research shows that using positive reinforcement is a strong motivator for children and adolescents. You will want to work with your child’s teachers to make sure that behavioral interventions are also in place in the classroom. There are also measures that you can put in place to help your child keep track of homework and other important information. You will want to consult with your treatment provider who can identify behavioral strategies that will address your child’s needs. Ideally, this would be done after an evaluation and diagnosis and modified as issues arise.
9. Besides medications and psychosocial interventions, what are some complementary or alternative methods used for intervention with ADHD?
   
   
   I prefer the term complementary to alternative, as these treatments can be added to the best treatment plan without sacrificing any potential upsides. NAMI supports the concept that research should support recommendations we make regarding all the various interventions and treatments for adults and youth with ADHD. The National Center for Complementary and Alternative Medicine at the NIH is a good resource to evaluate the state of the evidence for all of these kinds of services and treatments.

   These types of interventions typically do not have clear scientific studies to draw definitive conclusions regarding their use, but also typically have few risks. Examples of complementary approaches are dietary changes, (both restrictions and supplements like Omega-3 fatty acids), cerebellar (motor skills) training and biofeedback. My reading of the evidence for a contribution from additive and food colors is mixed; I think the best strategy based on this is to reduce these when possible and to select a healthy diet. Omega-3 fatty acids are clearly good for your heart and brain, so I like them in the diet. For more on health and wellness for people living with mental illness, visit the NAMI Hearts & Minds online program.

   I also often recommend interventions like martial arts and aerobic exercise, as the former is about self control and mastery of one’s body and the latter has shown effectiveness for anxiety and depression, which we know sometimes co-occurs with ADHD. There are a variety of stress management strategies in this complementary field—meditation, yoga and acupuncture to name a few. Learning more from research and trying what works best for you, provided it has minimal downsides, is a good approach in general.

   Learn more about treatment, services and support.

   
   
10. Can you discuss some challenges and tips for young adults living with ADHD entering post-secondary education and the workplace?
    
    
    I think there are clear times in life when people living with ADHD face noteworthy developmental challenges that just come with the territory of that stage of life. Third grade is often one developmental hurdle, as the amount of homework and task completion increases from the prior two years. Middle school is a well-described challenge I have seen for youth living with ADHD—different classes, more work, more responsibility for time management and increased social demands is a risky time frame for a child which requires thoughtful planning. After high school, youth living with ADHD can have an opportunity to better match their brain style with what they want to do next. There is no one-size-fits-all approach here, and the lack of structure in life after high school can be daunting. I encourage youth to capitalize on their strengths and attend to their vulnerabilities, remembering that life is a continuous learning lesson for us all. For example, one path for a young adult with a co-occurring learning disability is to attend a small college designed specifically for that need, and smaller schools tend to work best for many in my experience. Large state universities can have “schools within a school” that can help to reduce the at times overwhelming nature of the larger environment but still give access to the stimulation that many people with ADHD are drawn to. And for some young adults, the freedom to work in the world without school is a chance to simply experience something different and find what works for them. Read more about ADHD and college.

    In the workplace, Living with ADHD in the workplace can present challenges, and playing to one’s strengths is a balancing act. Many people living with ADHD are entrepreneurs and find they like working for themselves, although structure can be an issue at times for people who do not have regularity in their lives. Others are drawn to high stimulation tasks like teaching, coaching or theatre. Many can succeed in traditional office jobs, but will likely benefit from strategies that can help, such as a quiet space to reduce additional stimuli or staying with one task at a time. Adults with ADHD should implement as many strategies as they can on their own. But there are also laws in place that provide for accommodations under certain conditions. Learn more about ADHD at work.

    
    
11. What are some good questions for mental health providers?
    
    
    
    It is important for them to offer practical suggestions that you can use right away, such as guidance on organization, homework and structure. Ask about familiarity with behavioral strategies and Parent Management Training when indicated. I also believe having measurements of what is and isn’t working is helpful—what measurement systems do they use? Ask them how many people living with ADHD they have worked with in the past. Do they have the capacity to add or recommend a neuropsychological tester and/or tutors/coaches and social skills groups to further support the treatment goals? If they recommend a medicine, ask them how you will work together to understand how the benefits weigh against the risks of treatment. Do they work with schools? Go into schools? Finally, I would ask them how they talk to youth about ADHD, listening for a positive framework that is easy for a child to hear. Lastly, you should reflect to see if your child will like them. An alliance makes a difference in all aspects of the mental health field.
12. What advice do you have about personalized treatment plans?
    
    
    Every constellation of individual, family and school and work environment is unique. I would be sure to see how your or your child’s strengths and capabilities are being advanced in the treatment plan. The examples noted above for different interventions—to use martial arts or social skills or behavioral strategies or parent training or medications—should be tailored to your or the child’s needs. For children, working with the school to have a seamless integration of the home and school life is also optimal. Use any additional information about your family history you might have along with information gleaned from your past experiences to inform what could be tried going forward.
    
    
13. Can ADHD cause someone problems in his or her marriage?
    
    
    Yes, the symptoms of ADHD can cause problems in any relationship, from friendships to marriages. ADHD impacts one’s ability to pay attention, focus on tasks, and control impulsivity. These are all characteristics that can have a negative impact on any relationship. Both people in any marriage have to commit to certain responsibilities around the house and in other areas of life. But what happens when a person doesn’t live up to his or her side of the deal? It causes tension. What about when the person with ADHD impulsively makes an expensive purchase on a joint account or doesn’t pay bills on time? It goes without saying that these issues can cause a great deal of problems between two people in a relationship. And when you factor in the fact that often people with ADHD have a hard time paying attention to what their spouses are saying, you can have serious problems. But these issues are not insurmountable. More information and tips are available in the NAMI fact sheet on ADHD and relationships.