Advances in the Management of Complex ADHD in Pediatric Patients - Episode 3
Theresa Cerulli, MD: How does ADHD [attention-deficit/hyperactivity disorder] affect the quality of the patient’s life?
Frank Lopez, MD: That is a very complex question to answer because there are many things that happen here. I think the most important aspect of this is that the core symptoms will interfere with how well they interact, not only with other kids, but with their parents. And if you happen to have a child who has a problem with attention, hyperactive and impulsive behavior, you have to be ready to be flexible in your approach to them.
I used to teach years ago, and I would tell my interns and residents that if you ever wanted to experience ADHD, to go sit in front of the emergency room [ER] door. Because these kids will come in, these adolescents will come in with multiple injuries, things that you would never expect. It is the land of mistakes—that’s why we call it “ER.” Pronounce it phonetically, it’s “ERR,” to make a mistake, you’ve made a mistake, you’ve walked in.
That’s the way I used to make them think about it. Look at the actual physical consequences of not paying attention, of being impulsive, not thinking about the consequences. All of those things add stress to the family, to the siblings, to the society that they live in, work in, breathe in.
Again, these issues continue on, especially if they’re untreated, as young adults or adults. ADHD doesn’t go away when you’re an adolescent, it continues. About 70% of kids will continue to have symptoms into adolescence and adult life. I’m sure that with your background you’ll be able to outdo me in terms of the information that you could provide in regard to what you see in your families that you treat, and more immediate, the actual patient. If you think about an adolescent who’s learning to drive, I always pray that we have shown them the way to be a little more calm, a little less impulsive, because they’re behind the wheel of a vehicle, which is actually a weapon to some extent if they’re being impulsive.
Theresa Cerulli, MD: Frank, I’m starting to break out into a cold sweat here because I have had the privilege and pleasure over many years of working with patients with ADHD, but also of having a daughter with ADHD who just started driver’s education last week. I feel the pain of the ADHD parents. So clinicians who are listening to this, please know I speak both from personal experience as a parent, as well as a professional treating individuals with ADHD.
There are many, many challenges, and it goes well beyond the core symptoms, and it shifts over the years. What you might see in elementary school can look quite different to adolescence. But we do know that driving data with ADHD, it’s really important, unmedicated ADHD behind the wheel of a car can look like having a couple of glasses of alcohol behind the wheel of a car.
It becomes so important to think about consequences not just about what happens, risk factors, adverse effects for treating ADHD, but what are the risks of not treating ADHD? As a parent of an adolescent about to enter this part of her life with driving, I think about it quite a bit, and we certainly talk about the importance of medication; the importance of medication that covers 24/7, it’s not just about school. It’s not just about work for adults with ADHD, it’s the whole picture; this is a 24/7 condition.
Frank Lopez, MD: It’s interesting. As I’m sitting here listening to you, I’m traveling backward in time. I’m having one of these out-of-body experiences, if you will, and I’m remembering Russell Barkley, PhD. Back in 1989, which is just around the corner so to speak, I was at a CME [continuing medical education program] that he was presenting. And he used a phrase that I have used repeatedly over the years, especially for the adolescents who are starting to drive, or starting a job. He said ADHD medication is like the American Express card—you never leave home without it.
And honestly, not a truer statement has been made. You have the child on medication, they leave, it helps. It’s not going to prevent everything, but it’s certainly going to make things a lot easier.
Theresa Cerulli, MD: To circle back to when we were talking about what to watch for in terms of signs and symptoms with ADHD, because when we’re talking about deciding on medication, it’s important to also make sure you’ve got the diagnosis correct. I think, as clinicians, we’re used to looking for the more obvious visual cues for ADHD; we talked about some of the things that we see in our offices with kids ping-ponging around the room, and as teachers see behavior problems in the classroom, but that’s the hyperactive aspect of ADHD. Then perhaps the reason that we miss the diagnosis in girls is they have more inattentive symptoms and less hyperactivity, an overgeneralization on my part, but it may be why we saw that ratio years ago of 9:1, boys to girls. We just weren’t seeing the visible sign sometimes in the girls, the things that you can observe.
Frank Lopez, MD: I completely agree with you. I think part of the problem, too, the inattentive subtype, it’s a nebulous area to some extent because there you see some of the other concerns that arise academically—the learning issues, and in particular, language processing issues.
If you have an individual who is sluggish in their cognitive temple, and the teacher is moving on at a rate of about 60-miles-an-hour so to speak, and their vehicle can only go about 40-miles-an-hour, they’re going to lag behind, and they’re having difficulty keeping up. Part of that may be due to their ability to understand, decode, and re-encode the language message so that they can get through it. So it’s really critical that when we see a child who is not bouncing off the walls, that we understand what their processing abilities are.
I’ve seen lots of young people who have word retrieval deficits, who have difficulty filtering out background noises. Meaning the other kids in the classroom, or whatever else is going on around them. And now in the COVID-19 [coronavirus disease 2019]-era even more. But it is critical because that leads to frustration intolerance, that leads to difficulties in socialization. If I can’t keep up with your conversation, if I can’t get that to-and-fro going, it’s going to be very difficult for them.
Theresa Cerulli, MD: I’d like to paint a picture wearing my parent hat to share with the professionals in some of the analogies I use that ring true, or some illustrations. You may remember Winnie the Pooh and Tigger. I think the character Tigger, who’s bouncy, energetic, and enthusiastic, but changing topic, that’s what I think we’ve had as a picture of ADHD.
I’d like to add to that visual picture. I don’t know if you remember the cartoonist on “Family Circus?”
Frank Lopez, MD: Absolutely.
Theresa Cerulli, MD: One of the characters—I’m not diagnosing Billy with ADHD by any means—but 1 of the clips that I would often see was, he’d have stepped in mud and then you’d see the footprints all through the household, over the couch, under the kitchen table, and handprints. So it was the trail. And truly, looking at my household, my daughter has not had the hyperactive component and has done well in school and has no behavioral issues. She’s the kid who never would have been picked up clinically because there were no visible signs.
But if you follow the signs around the house, every cabinet, getting up in the morning, the bed is never made. Getting dressed in the morning—every single drawer is left open; it’s never open and then close the drawer. Follow down to the kitchen—every single cabinet she’s been in to get the cereal bowl and the spoon in the morning, again, left open. It’s that, “my mind’s moved on to the next topic, and I didn’t follow through on closing off the last one,” literally.
So a big part of what folks struggle with who have ADHD, in the more silent type, or less visible type, is the cognitive process. Their mind changes channels like a radio dial, moving channels without necessarily voluntary control.
Transcript Edited for Clarity