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Attention Deficit Hyperactivity Disorder (ADHD): Understanding the Diagnosis

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This is the weekly dose of wellness brought to you by MemorialCare health system. Here's Deborah Howell.

Deborah Howell
Welcome to our show. This is your weekly dose of wellness. I'm Deborah Howell and today's guest is Dr. Gary Feldman, Medical Director, Stransky Children's Developmental Center at Miller Children's and Women's Hospital, Long Beach. Dr. Feldman completed his residency in pediatrics at Red Cross Children's Hospital and University of Cape Town in South Africa, and worked in primary care pediatrics for five years prior to moving to the United States in 1999. Welcome, Dr. Feldman.

Gary Feldman, M.D.
Hi, thank you.

Deborah Howell
Pleasure to have you. Attention Deficit Hyperactivity Disorder, or ADHD, is one of the most common childhood brain disorders in the U.S., according to the CDC, about 11% of children four to 17 years of age. That's 6.4 million kids have been diagnosed with ADHD as of 2011. That is that is an astounding figure.

Gary Feldman, M.D.
Indeed, it is. You know. In the in the field that I work in, that's kind of what my bread and butter and what are the and one of the some of the myths that need to be built about the conditions. The terminology that people will say, you know, you use the term ADHD, then ADD. But essentially just to clarify, ADHD is sort of the unifying universal term attention deficit hyperactivity disorder. Just like if we had to say and talk about ice cream, you might ice cream. But you know what flavor, ADHD comes in different flavors that are or chocolate Neapolitan. Another would be say, the problem the ADHD with the subtype, inattentive type and the other variety would be ADHD, hyperactive, impulsive type, and then you can combine them into ADHD combined. So the term is an older term, which is no longer used. But it's helpful us to develop because sometimes people think, Hey, I'm talking about ADD not ADHD. Category hyperactive, underlying qualifier..

Deborah Howell
So what are some of the signs and symptoms then of ADHD?

Gary Feldman, M.D.
Well, the first thing is to understand that the neurological disorder, it's not like there's a blood test for it. So essentially what you're doing is you're looking at the child's behavior when it's their child, it can affect adults as well as both the age spectrum. So. It's essentially observations, if you're talking about inattentive Typekit kids primarily will have difficulties with focusing, for instance, they can they're not going to have difficulties with attention to detail. They have difficulty sustaining attention. They're easily distracted. If you ask the child, you know, go pick up your toys and then go and brush your teeth, they might start picking of the toys in the plane. Then they go in the doing something else. They just can't follow through and instructions because they get distracted, And this really has an impact on this school because with all the goings-on in the classroom, distractions are so high. These kids, you know, they're they're like little Pac-Man. They get there and everywhere. They just can't construct what they have to do, and they can be incredibly, incredibly forgetful and losing. That's where they're at school losing items. If you speak to parents, the kids with kind of ADHD, they'll say, Oh my gosh, don't talk to me about the kids isn't there. And then you can get the other, the other, the hyperactive, impulsive type, which is generally like they have the engine part of them, which never turns the going on the go on the go to the hyperactive, they're running around and building bridges. They can be impulsive, they can blow their top in the classroom. They talk excessively, have difficulty waiting their turn. Those are the sort of a cardinal feature. And it basically it's something that has to be persistent. In other words, the symptoms have to be there for six months and all the continual basis and have to be in existence under the age of twelve years of abuse. And the other thing is that you've got to look at it and say, Well, the four-year-old kid is naturally going to be hyperactive, that geez, is every four-year-old kid have ADHD. So it's got to be in the context of where they are developmentally. So the symptoms have to be the next exit. It's very difficult to diagnose ADHD in a four year old, maybe extremely hyperactive, but as they grow older, the symptoms may consolidate and become more obvious, which usually happen kind of. When these kids start elementary school or kindergarten grade one, you might be the of the emergency become more significant. Essentially, it's going to affect the symptoms have to be present in multiple situations, like at home and at school, and it has to have to affect the quality of life that could be affecting your academic performance could be affecting your social life in how you interacted with family and friends, or if you're all that may affect the basically the job the program.

Deborah Howell
It must make parents crazy when they have a four year old like that and all of a doctor can do is say, Well, we don't know yet.

Gary Feldman, M.D.
Yeah, you're absolutely right. But, you know, the implication of the diagnosis are pretty, they're not dire. I mean, it's just a lot of work to do that, a lot of interventions that you really want to be sure and you want to you want let it play out because you don't. The other thing is you don't want to diagnose ADHD, which is in common people, you know, in pulmonary medicine. They say everything that wheez is not asthma. Well, in this field with everything, not everything that ADHD is ADHD. Because you can have kids eat M&M's or have some kind of food die be extremely hyperactive and nothing to do with ADHD or a child. It's not sleeping well or a child that has a medical condition like they may have exzema or something that's really bothering them. And it might look like they have ADHD child that stressed or anxious because of some kind of environmental stressor, parents getting divorced and fighting or arguing. So you can have the appearance of a hyperactive child or a child that easily distracted, but that may not actually be ADHD. So it really has. The diagnosis has to be made very carefully and with not only a lot as much observation as you can because you may have a child in your panic that may have real ADHD, but in the clinic they are the ones with situation. There is a strange environment. They actually may be very still. So you need questionnaires. You need to get the input from the teachers, the family members and use the range to help standardize the information that we give.

Deborah Howell
OK, now in your opinion, what are the reasons why this disorder continues to grow so steadily and so quickly?

Gary Feldman, M.D.
Great question, and when we say great question, which probably means we don't have good enough answers. There is a genetic component for sure. And generally you'll see that if the child with the diagnosis invariably is going to be inherited as the diagnosis, but they are the trigger factors. For instance, if you're born premature or you're born with the low birth weight is a high incidence. If you were exposed to nicotine in utero and the other condition like exposed to alcohol and drugs in utero, that rate of ADHD, if you had some problems with brain hormones for those who had a brain injury when you were younger, or difficult delivery, it's possible. I you say that in every case, you know, this has happened to my child in delivery or before that they're going to have ADHD, but it increases the risk. But they are and they know a certain genetic conditions that are associated with other genetic disorder that are associated with ADHD, for example, of what we call 22q11 deletion syndrome or DiGeorge syndrome. And it is a number of different genetic conditions that have ADHD associated with other conditions, Tourette syndrome often associated with AHHD. And the list goes on.

Deborah Howell
So how has ADHD diagnosed if it's neurological, but there's no such thing as a brain scan that will show definitively that you have it. How do you diagnosis as a physician?

Gary Feldman, M.D.
Presently, the only means of diagnosing it is by a history and observation history. It's, you know, direct questioning, but also reading skills that they use. There are some experimental tools out there, but they haven't been validated sufficiently to be used in clinical practice when it's experimental to talking about specific types of brain. But that's not really considered. The gold standard way of diagnosing the way of diagnosing is really getting as much information about the child's behavior from as many sources as possible.

Deborah Howell
So what are some of the treatment options that are available for ADHD?

Gary Feldman, M.D.
You know, the keyword here is multimodal, high modal that's essentially using as many facets of input as you can. That's really a combination of behavioral therapies. And like environmental therapies let me explain and then, if necessary, medication. So if behavioral therapies would be really helping or teaching the child to become aware of the behavior and learn to self-monitor, so you then check in the morning, this is what you have to do when you get up, do this, do that. If you have checked this visual check that the child in, do each thing and check this thing so they don't get on track if they're in the classroom situation that we might talk about by five or more accommodation. So these kids may have preferential seating, they may be sitting right next to the teacher. The teacher may have signs the child where the child is all targeted, they might have symbol that the child sees and then bring them back on track. They may have extra time to write to me when I write this, and they didn't have why they needed multiple interventions that will be done in the classroom environment, Parents helping parents to help these kids with their behaviors. And then, you know, medications are a tool. And I mean, I think that's one of the strengths of the tool. It doesn't cure. I use the analogy of driving in the snow and you can have a call that has four by four adult whistle. But they've been hey, a little changed because you will, in a sense, meditations lack change that we'll just be the next interaction that will solve the problem. It just helps get momentum, as do the other interventions as well. Just to get the job done.

Gary Feldman, M.D.
So tools and techniques and behavior monitoring and encouragement?

Gary Feldman, M.D.
Yeah, Absolutely. You know, just there's another concept about ADHD that just could be that I think it's fairly new, which I think it's important to know about. And that is executive functioning deficit, essentially as part of your kind of neighborhood where they think that ADHD, you know, whether ADHD is the problem in the brain, where ADHD exists. Executive functions, essentially it's like in the olden days what you had, switchboard the telephone exchange and the person taking the wires and plugging them into the little socket. Well, that's what your executive functions are really doing and deal with how to organize and prioritize it with things, then attention, how to monitor what you're doing, what they call active working memory. Many of those functions of the difficulties that actually have ADHD. So there's a very close crossover when talking between executive functioning deficits and ADHD, that when we're talking about treating ADHD, about being able to fix it, you're also trying to teach the kids how to improve it. And the executives feel the whole field of things that emerging regarding the interventions that you can help kids in content, executive function and also improving ADHD.

Deborah Howell
So new treatments, new interventions and possibly new drugs on the horizon. So there is a lot of hope. And I want to thank you so much, Dr. Feldman, for coming on the show today. It just seems like we just had touched the topic, so I hope you can come back and we can speak more about this.

Gary Feldman, M.D.
Thank you. Thanks very much

Deborah Howell
For our soon-to-be moms listening or mothers who have a child with ADHD. Can you just tell us where they can go to learn more?

Gary Feldman, M.D.
You know, there's a plethora of resources out there, I think a good website to start with is the chadd.org. And children and adults with attention deficit hyperactivity disorder. It's a good it's a really good resource and another good resource for this executive bill, Dr. Thomas Brown and then there's the National Center for Mental Disabilities. And also very good, I think, very good start, and that so many books out there, yes, there's good books, then there's not the good books, but neither of these are. I think these are valid websites with good, valid information,

Deborah Howell
A great starting place. Again, thank you so much for your time Dr. Feldman and your expertize. We really appreciate you coming on the show today

Gary Feldman, M.D.
Sure, you are you welcome. Thank you.

Deborah Howell
To learn more or to listen to a podcast of the show, please visit MemorialCare.org. I'm Deborah Howell Join us again next time as we explore another weekly dose of wellness. Have yourself a fantastic day!

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood brain disorders in the United States. According to the Centers for Disease Control and Prevention, approximately 11 percent of children 4 to 17 years of age, 6.4 million kids, have been diagnosed with ADHD as of 2011.