S1 Episode 54: Focus on ADHD

Diagnosing and treating attention deficit disorder can be tricky – not every hyperactive kid has ADHD, and some very calm children are extremely inattentive. Pediatric clinical neuropsychologist David Salsberg, PhD, explains what part of the brain is “asleep” in those with true ADHD, and how to identify kids who need intervention. Plus… when is medication really necessary?

Dr. Phil Stieg: Hi, this is Dr. Phil Stieg. And with me today is Dr. David Salsberg. David is a neuropsychologist and adjunct assistant professor in the Department of Neurological Surgery at Weill Cornell medicine. You may be surprised to know that up to 10% of people in the United States have a learning disability and estimated 6.4 million American children between the ages of four and 17 have been diagnosed with ADHD. We have Dr. Salsberg here today to discuss this in more detail with us. David, welcome. So let’s start off with the ultimate question. What is ADHD? And is there a spectrum of ADHD?

Dr. David Salsberg: So there’s absolutely a spectrum. So ADHD, attention deficit hyperactivity disorder, is the name of the diagnosis, and it really should be a deficit in attention that it is very hard for you to pay attention, very hard for you to think before acting and control impulses, and not be distracted. Those are some hallmarks. Sometimes it’s with the hyperactivity, sometimes it’s not. And there’s three different classifications ADHD with hyperactivity predominant, or predominantly inattentive, or combined. So that’s the core deficit. That’s the neurological underpinnings, is that the part of your brain in charge of how you shine a flashlight and where you shine a flashlight in terms of attention is not operating the way it should be.

Dr. Stieg: We all remember the kid in the corner of the room during kindergarten because he just, he or she just couldn’t sit still. Is this something that you pick up on very early or are there later onset disorders of ADHD or ADD—both?

Dr. Salsberg: And this is part of the problem is that it often is more picked up in the child. Who’s running around the class and externalizing their difficulties, as opposed to someone who might be more passive, who might just be in their head or, or not necessarily show it behaviorally or externally, they might have just as horrible control of their attention and need as much services as the child who’s much more squeaky.

Dr. Stieg: What I’m hearing from you is that the inattentive form of ADHD is probably a little bit more difficult for you to treat than the hyperactive form.

Dr. Salsberg: I think it’s more difficult to identify and know that it needs treatment. The treatments will not necessarily be different it’s just those kids might fall through the cracks for a longer period of time and then develop other difficulties.

Dr. Stieg: First of all, what are the signs I, as a parent, or as a coworker, what would I see in somebody?

Dr. Salsberg: Sometimes you again, see it as they’re just not looking at you or focusing. So I could be twirling around in my chair right now, but if I was actually still speaking into the microphone and continuing my paragraph or understanding your questions, that’s not so much the attention deficit, that’s more behavioral and physical movements without as much of the attention difficulties. So you might see that tuning out, uh, needing to repeat things over and over again, needing to break instructions down to one or two steps as opposed to three steps. So those kinds of things are things that you see in childhood, as well as in adulthood.

Dr. Stieg: There’s some suggestion that this is more common in boys than it is in girls. Is that real or is it just not picked up as well in girls?

Dr. Salsberg: Probably a little bit of both. It probably is a little bit real, but certainly it is underdiagnosed in girls. It’s underdiagnosed in children who just manifest behaviors differently. We’ve seen children with severe ADHD that have not been identified because they’re really sweet and they’re smart enough to get by. They’re not causing problems, and the squeakier wheel next to them is. And that is more the manifestation without sounding biased, girls are not as annoying as boys, typically.

Dr. Stieg: I know some incredibly successful people that have the worst cases of ADHD, but because they can multitask and just flip from one thing to the next they’re incredibly successful.

Dr. Salsberg: Someone who is able to really focus on their areas of passion, and a child who has ADHD might focus for hours on something—chess or Harry Potter or something that that is their passion. And the parents are always saying, well, I don’t understand, “He or she focuses for five hours. How could they possibly have it?” But if you take the skillset that forms pathology and concern in childhood, passionate about something and can pay attention to that ad nauseum and get doesn’t get stuck in the minutiae or the little steps along the way, just wants to focus on the big picture and move on. Those are qualities that are really hard to deal with in elementary school and throughout school, but are what we applaud in many areas of successful adults.

Dr. Stieg: Every time I see a hyperactive person in the workforce, somebody says, “Oh, they’ve got ADHD.” What are the mythologies around this disorder?

Dr. Salsberg: There’s certainly a lot of talk about diet and sugar and gluten and all of these different things that are thought to be either causes or interventions that are proven. Again, there isn’t a lot of research to say that any of these things cause that. I would say that a child with deficits in attention is a little bit more sensitive to some of these difficulties. If all I ate was white bread and processed pasta all day, every single day, I will be more cranky, a little bit more tired, and not as attentive. If I already have a deficit in attention, yes, that might manifest even greater in me, but it doesn’t mean it’s the cause.

Dr. Stieg: Are the brains in a person with ADHD, any different when we image them?

Dr. Salsberg: So yes, there’s definitely differences in imaging and differences. Sometimes in the EEG, the electrical activity that we see in even a very hyperactive child, the part of their brain in charge of attention actually might look like they’re sleeping. They have these, increased, what are called theta waves. The predominant waves, when you’re sleeping, seem to be the predominant wave in that area of a brain. And that should not be, that’s an inattentive brain. And we want to see more of the active brain electrical activity. So we’d sometimes actually can confirm that with different imaging or EEG tests.

Dr. Stieg: Let’s focus on two things, a diagnosis and what you do about it. So I’m a parent. I’m worried that my child has ADHD. What do I do?

Dr. Salsberg: So well, first and foremost, get an evaluation.

Dr. Stieg: By?

Dr. Salsberg: By a psychologist, neuropsychologist, educational psychologist. Sometimes that’s available through school. Sometimes you have to go outside to get more information. And psychiatrists, neurologists pediatricians also give the diagnosis. The diagnostic criteria for ADHD is pretty simple. Some people literally just diagnose it with a checklist from a parent and a checklist from a teacher—poof, you have the diagnosis. Of evaluations such as what we do and other professionals are, there’s a lot more due diligence involved. So yes, there’s the deficits in attention by observation, but let’s look at all the different strengths and weaknesses. Let’s see, make sure there aren’t other learning disabilities or other emotional things that are happening. You can be inattentive for a lot of different reasons. You can be a very anxious person who does isn’t paying attention. So the diagnostic clarification is crucial and understanding and necessary in my opinion, in terms of treatment. And then we get to treatment recommendations and intervention recommendations.

Dr. Stieg: I’m not a big proponent of going to drugs as the first form of therapy. What do you, as an expert in this area suggest as the hierarchy, where do you start and where do you?

Dr. Salsberg: So I chose my profession as a neuropsychologist, as opposed to a neuropsychiatrist because I also don’t believe in medicine. When I identify ADHD, I sort of go through three steps with parents before I even talk about medicine. First, do I feel that this ADHD is not within their control, that this is clearly biological or neurological as if we were diagnosing God-forbid, diabetes or something that was clearly not within their control. We could say, you’re going to go to the 50 yard line and the Super Bowl if you could pay attention for the next hour and the kid can’t do it. That’s first. Second is that attention because we know your brain will get better and mature over time. Is it affecting their education, their learning, because we can’t wait and see for their child to get more mature. And then, then be behind educationally. The crucial thing that tips my scales for telling parents, we have to explore and talk about medicine is self-esteem.

Dr. Stieg: So you start with what types of therapy? And then when do you get into medication?

Dr. Salsberg: First and foremost, understanding. Having a child and the adults around them understand this is not in their control. No one gets mad at a child for not controlling their blood sugar, if they have diabetes. So first that level of debriefing and understanding then accommodations in the class—where they sit, how they sit. Maybe they do need to get up some schools and see that even some work sites have have standing desks for a reason. It helps them pay attention. Maybe every 10 minutes, we remind them to get a drink of water. If they’re not attending, tap them on the shoulder while you walk by, instead of calling their name across the room, there’s nothing good will come from that. Behavioral interventions, therapist, psychologist at the school, outside of the school to help set up checklists and behavioral structure.

Dr. Stieg: When do you say it’s time for medications?

Dr. Salsberg: When it’s impacting them educationally, and certainly if it was looking like it’s starting to impact them socially and emotionally, that that time is crucial, but also speaks to why you need to do it early. And you need to understand the whole child, because if the child is, let’s say already suffering self-esteem and anxiety, and here we are introducing a medicine, which typically is a stimulant, which makes you more focused. Doesn’t tell your brain what to focus on. You might now be more focused on, “Oh my God, I’m in trouble all the time,” or, “Oh my God, I’m two grades behind.” Whereas before you weren’t ruminating on that, because you were inattentive and moving on to something else. So it really requires a lot. It’s not an easy fix.

Dr. Stieg: And finally, what’s your success rate? I’m sure there’s a spectrum of success, but define that.

Dr. Salsberg: When we attack it in a multifaceted way with interventions in school, out of school and understanding and awareness, the success rate is very strong and it is often with medicine. Parents often say, well, what are the long-term effects of medicine? And my answer to them typically is, well, I could tell you what the long-term effects of feeling terribly about yourself as a student are. And those are not pretty. So let’s, before we think about long-term effects of medicine, let’s talk about doing it and seeing how a child does. These medicines can be done for shorter periods of time, but at least then you’re learning what you need to so you’re not behind educationally. We’re hopefully making you feel better and more empowered as a student and derailing any of the negative consequences.

Dr. Stieg: David, thank you for enlightening us on attention deficit disorder and attention deficit hyperactive disorder. I don’t think any of us has not had experience with knowing somebody that has this issue. And it’s extremely nice to know that there is hope for these people. Thanks so much for being with me.

Dr. Salsberg: Thank you.