Podcast Transcript
ADHD Diagnosis and Treatment in Children and Adolescents
Summary:
ADHD is the most common neurobehavioral disorder of childhood, affecting attention, impulse control, and activity level in approximately 7-8% of the child and adolescent population. Early diagnosis and treatment are beneficial, as they can help improve social functioning, prevent secondary issues like anxiety and depression, and provide support for families and caregivers. In preschool years, ADHD presents more with hyperactivity and impulsivity, while in elementary and middle school, inattention and executive functioning difficulties become more pronounced. In adolescence, a comprehensive evaluation is critical, as symptoms may be driven by other factors like anxiety, depression, or substance use in addition to ADHD. Treatment approaches include medication management, behavioral therapies, educational interventions, and lifestyle changes like exercise and sleep hygiene. A personalized, comprehensive, and long-term approach integrating multiple strategies—multimodal treatment—is important for successful ADHD management.
Kevin Antshel, PhD
Kevin Antshel, PhD, is a licensed psychologist and professor of psychology at Syracuse University. He is the director of the clinical psychology doctoral program and directs the ADHD Lifespan Treatment, Education and Research (ALTER) program at the university. He is the author or coauthor of more than one hundred and fifty peer-reviewed publications and book chapters, most of which focus on ADHD and better understanding the heterogeneity associated with ADHD. He is a member of the editorial boards of the Journal of Attention Disorders, Research on Child and Adolescent Psychopathology (formerly the Journal of Abnormal Child Psychology), and the Journal of Child and Family Studies. A practicing psychologist, he is board certified in clinical child and adolescent psychology and has received several awards for his teaching activities.
Max Wiznitzer, MD
Max Wiznitzer, MD, is a pediatric neurologist at Rainbow Babies & Children’s Hospital in Cleveland, Ohio. He is a professor of pediatrics and neurology at Case Western Reserve University. He has a longstanding interest in neurodevelopmental disabilities, especially ADHD and autism, and has been involved in local, state, and national committees and initiatives, including autism treatment research, Ohio autism service guidelines, autism screening, and early identification of developmental disabilities. He is on the editorial board of Lancet Neurology and the Journal of Child Neurology and lectures nationally and internationally about various neurodevelopmental disabilities.
Learning Objectives
- Identify ADHD symptoms for children and for adolescents.
- Explain the benefits of early diagnosis and treatment of ADHD.
- Understand the importance of a comprehensive ADHD diagnosis.
- Learn about the effectiveness of various ADHD treatments.
The following transcript has been edited for clarity.
Announcer (00:00): You are listening to Pocket MD training on ADHD in children and adults.
Dr. Max Wiznitzer (00:07): Welcome to another episode of Pocket MD, the ADHD information series. From CHADD’s National Resource Center. I'm Max Wiznitzer, co-chair of the professional advisory board, member of the board of directors of CHADD, and with me today is Dr. Kevin Antshel, who will be acting as our moderator. Dr. Antshel, would you please introduce yourself to our audience?
Dr. Kevin Antshel (00:30): Sure. So, thank you very much for the opportunity to be here. My name is Kevin Antshel and I'm a professor of psychology here at Syracuse University. I'm really enthusiastic about the conversation that we're going to have, Max.
Dr. Max Wiznitzer (00:44): As am I. So, before we go any further, let's just get ourselves started so we can address the key questions that the audience would expect the answers to.
Dr. Kevin Antshel (00:54): Sure. All right, and so as the moderator, I'm happy to pose a question to get us kicked off. Max, can you give an overview of ADHD and why early diagnosis and treatment are beneficial?
Dr. Max Wiznitzer (01:06): ADHD is the most common neurobehavioral disorder of childhood. What that means is that from a behavior standpoint, it's what we hear about most frequently from families and from caregivers in general. It is a disorder that affects attention spans leading to a short attention span, affects impulse control, which basically means do you act before you think, or you think before you act. And people have an increased impulsivity, and it affects the activity level of the person, which goes anywhere from being fidgety, whether it's internal or external, or to really literally bouncing off the walls. It occurs in about, as a conservative number, about seven to eight percent of the population, and it's a source of significant dysfunction in the school and outside the school setting. It can impact how children learn, it impacts how children interact with other people, and it also has impacts on them themselves, because it puts them at risk for dangerous situations, such as running into the street without looking for cars. During the teenage years, which Dr. Antshel can address in much more detail, [ADHD] puts you at risk for things such as using illegal substances, or even if they're legal things like smoking and drinking, things that we do not want children to be encouraged to do.
Dr. Kevin Antshel (02:26): Great. Yes, and so absolutely, I’ll highlight a few of the other benefits of early diagnosis and treatment. You definitely provided a very comprehensive overview, and you hit on a couple of these [benefits of] early diagnosis. One of the ones that I will highlight that I don't believe have been mentioned yet is social functioning. Untreated ADHD can lead to difficulties in peer interactions and friendships, and early supports and early treatment can help children to develop social awareness and better emotion regulation. And there's also a reduced risk for other co-occurring conditions that ADHD very often co-occurs with, [as well as] other conditions in childhood such as anxiety, depression, also learning disabilities. Addressing it earlier can hopefully prevent some of these secondary issues from worsening. And then also, support for families and caregivers that an early diagnosis allows parents, allows educators and others to implement some strategies that may be able to accommodate the child's needs, which might have some impact on family dynamics and reduce stress in the caregivers. And so again, those are some other potential benefits of early diagnosis and treatment.
Dr. Max Wiznitzer (03:38): And if we don't have that early diagnosis, we have concerns and worries and people can start developing negative attitudes towards things that they're doing as well as negative attitudes towards themselves. There's an increased risk of depression, and anxiety related to situations in which they feel they're not performing well. As I stated before, it can lead to taking up dangerous behaviors such as smoking and drinking. In those circumstances, we recognize that if we know what we're doing and we intervene at an earlier time, the hope is that these kinds of behaviors will be lessened and/or won't occur. And therefore, I guess it leads to the segue about how do we recognize when ADHD is there?
I'm going to start with, or maybe we'll do it back and forth, but I'm going to start with the preschool years. And if we're looking at, because we're looking at the core features in attention, motor overactivity, and impulsivity or difficulties with impulse control, if we're looking at a presentation in the preschool years, we have to take it in the context of what children normally do in that environment. In the preschool years, they don't have the best communication skills because they're still working on their language. They are working on self-control and self-regulation anyway, which is why we know about things such as the terrible twos and the worse threes. They're basically exploring the world around them and trying to get comfortable with how they interact and deal with other people.
Now, if you start showing ADHD features, the things that we tend to see is not necessarily as much of the inattention, but more of the overactivity. They don't sit still, they'll run into a street without looking for cars. They'll dart in parking lots, they disappear in stores. I've had kids who go hanging out the window, climbing up on rooftops of their homes. [They] can easily be overactive in that regard. Now that behavior also in a preschool setting will clearly lead to potential chaos. The child runs out the door every time the child has that feeling to do so. Or, if the child is interacting with other children but not sustaining that interaction, not sitting still at circle time.
The second thing is the impulsivity. And the impulsivity can be in terms of actions that they take, such as hitting people easily, screaming and yelling, having major temper tensions and meltdowns. And if you think about it, in the preschool years, ADHD is one of the core reasons why children may have what we call oppositional defiant behaviors. And I think we have to be very careful not to take oppositional defiant behaviors as an entity in and of itself, but always to ask the reason that's driving it. ADHD is clearly one of them. So, these are the kids who present in the preschool years, but Dr. Antshel, as they get older, the picture does change, doesn't it?
Dr. Kevin Antshel (06:20): Yes, it does change. So, you definitely highlighted the hyperactivity and the impulsivity that tends to drive concerns in referrals in preschool. Once we transition into elementary and especially middle school, it's much more the inattention that tends to drive referrals. Then parents and teachers grow concerned about inattention in the classroom, because that obviously impacts school functioning and can also impact social functioning. In the elementary school years, and then definitely in the middle school years, it's much more the inattention, and also the associated executive functioning difficulties—for example, difficulties in organization, difficulties in planning, difficulties in time management that we know that can accompany an ADHD diagnosis in childhood—become much more primary. When you're doing any type of assessment for an elementary-school child, you definitely want as much information as you can get as the child is in two different environments.
So, for example, I think a combination of both parent and teacher reports is crucial in helping to arrive at an ADHD diagnosis. Also, an interview in which you gather information about how the child is both at home and at school, and asking about times outside of homework. In my experience, parents very quickly will tell you about how difficulties with inattention impact homework. But I often like to ask about chores, ask about the weekends, ask about the summer, trying to get a sense of how this child is in different environments. That definitely creates some complexities in doing an ADHD assessment, because you really should be getting input from people in different environments.
Dr. Max Wiznitzer (08:05): We have to remember also, as that you pointed out before, there's the social aspect in the elementary and middle school years in which the children basically, if their ADHD behavior is intrusive enough, if they don't respect personal space, can actually antagonize their peers and [cause them to] be rejected by them, which can lead to self-esteem issues and also lead to belligerent and unwanted behaviors as a response to the feedback they get from their peers. And whether it's in the preschool years, whether it's in the school-age years, as we'll talk about a little bit in the adolescent years was pointed out, we want to make sure that we get feedback from multiple places. ADHD is not diagnosed by having the behaviors just present in one setting only. They have to be impacting your functioning in multiple settings.
Now, if there are environments that are very structured, where there's a set routine-—as I always tell folks—with structure, routine, and consistency, you may not be as symptomatic as when there's not as much supervision, when they are more left to their own devices and things of this nature. You want to make sure you sample not only, for instance, how the behavior is in the classroom, but also are there behaviors in the lunchroom, are the behavior at recess or in the gym, where the limitations or the expectations for, we'll call it appropriate behavior, may not be as rigorous, and therefore the children take advantage of it. We know these children can also be very perseverative, which basically means that they will do the same thing over and over again. If they want something and you say no, they keep coming back and asking again. They lose or misplace things, as was pointed out, they're not as well organized. They try to avoid tasks that they think are more challenging to them in that regard. So, when we look at these children, we recognize that to evaluate the children, we really have to have a clinical diagnosis.
The clinical picture you’ve got to see is, Are the ADHD behaviors there, and does ADHD best explain the diagnosis? Most of the time it's done by using certain checklists, rating scales, and checklists depending on what the physicians want to use for comprehensive diagnosis. We also have to make sure that there's not some of the coexisting conditions that are present, such as learning disabilities, anxiety disorders, mood disturbances. And one that people tend to overlook a lot, but that occurs quite often in the ADHD population, is problems with fine or gross motor coordination. In other words, the children are a bit awkward, they have difficulties with tying, with buttoning, with zipping, handwriting looks messy. And that can also have a negative impact on how you function, even if you do manage the ADHD behaviors themselves. Now, what about adolescence?
Dr. Kevin Antshel (10:40): I think everything that we've been talking about up to now probably applies to adolescence, but I think probably what is somewhat different in adolescence is [that] we tend to rely a lot more on the child's report, or in this case the teenager's report of their own functioning. For example, ADHD assessment in preschool very often does not involve a clinical interview with the four or five-year-old. And in elementary school, we tend to place a lot of emphasis on what the parent and teacher is saying. In adolescents, we definitely place as much or more emphasis on what the teen themselves is reporting. So, in my experience, making a diagnosis of ADHD in an adolescent who doesn't have an existing ADHD diagnosis, is tough. This is something that is hard to do without a comprehensive evaluation, just because there are so many things that can make a high school student inattentive or hyperactive that it isn't at all ADHD—for example, anxiety, depression; something we haven't talked about yet is autism, also difficulties with sleep—these kind of things need to be ruled out as primarily driving the ADHD symptoms.
What makes this so challenging is that all of these things commonly co-occur with ADHD. And so, the clinician is often left trying to decide, “Is this explaining the symptoms or is it running concurrent with the ADHD symptoms?” And that's tough. That's tough. And you're also introducing things like substances and things that you mentioned as potential risks. These are also things that we tend to be more attuned to in adolescents just because of the increased prevalence of this in adolescents. And so, the comprehensive evaluation for an adolescent who doesn't have a childhood ADHD evaluation, that's so critical towards making an accurate assessment because your assessment's going to drive your treatment.
Dr. Max Wiznitzer (12:31): And I think when we suspect some of these co-occurring disorders, we also have to make sure that we get other specialists involved. For instance, we know that a large percentage of ADHD children will have problems falling or staying asleep. If need be, we get the sleep medicine colleagues involved in their care. As I stated before, [for] the ones who have problems with their motor coordination, occupational therapy can be very helpful in that regard. And as you go through all the others, you basically have to identify—is there something going on that is not typical for ADHD—what would benefit from the input. If the child has a history of coexisting language problems, they may have some problematic social skills because we know ADHD children can be socially immature and therefore their social interactions may not be age appropriate, and they might benefit from some coaching and support in that area by individuals who do it. Many times, it might be a local speech therapist who does that kind of support. Now, it's interesting when we have all this information and we have all these details, what do you think about evaluating these children virtually? The first is that doing assessments totally by a virtual visit versus an in-person visit?
Dr. Kevin Antshel (13:37): That's a great question. I'm really glad you asked it, because I think the toothpaste is out of the tube. I think before COVID, we didn't really do a lot of this work virtually, and then COVID forced us to do everything via telehealth and telemedicine. And so, I think the future of ADHD assessments and probably treatment is going to be virtual. And so, I think currently in 2025, a comprehensive ADHD assessment can be conducted virtually, but there are some limitations and considerations that people need to meet. And certainly we have advances in telemedicine or allowing clinicians to assess ADHD symptoms remotely through interviews, questionnaires. There are also some performance-based tests, et cetera, but the challenges exist in observing certain behaviors and ruling out co-occurring conditions. I don't know if you've ever tried to do an interview with an eight-year-old via telehealth; I think most of them, if not all of them, are inattentive on telehealth, and so, it can be very difficult to do. However, in my opinion, there is some potential to virtual ADHD assessment, but there definitely are some limitations, particularly that direct behavioral observation.
Dr. Max Wiznitzer (14:50): And I state that when these younger children are sitting in a doctor's office, whether it's a psychologist or a physician, they're on their best behavior because they're in a new place where they don't know people. When you do it virtually, they're at home, they feel comfortable. I've had children doing cartwheels behind their parents while we're taking histories, which is a bit of a giveaway as to what possibly might be going on in terms of their symptoms. It gives us an extra peek and a look at them, at the children and their typical world, and not just in the artificial world that we offer within the office.
Dr. Kevin Antshel (15:24): And I think the last thing I'll mention, at least from my perspective on this, is just because it's virtual doesn't mean it has to be quicker. And so, the idea of an ADHD diagnosis being made after a ten-minute interview really concerns me greatly. I think that really runs the risk for misdiagnosis both in an under-diagnosis and over-diagnosis way. And so just because [we are] doing things now more via some type of virtual or remote, that doesn't mean that it requires less time to be able to do this well.
Dr. Max Wiznitzer (15:56): After we've made the diagnosis, as soon as we've made the diagnosis, we have to give families information about what the intervention is. Obviously, one of my views is that it's done as a partnership, and that the families have to be informed consumers, which means they have to understand ADHD. They have to understand where ADHD starts and also when it stops. But if you don't mind, what we'll do is we'll split this into two parts. I'm going to address medication management and I'll have you address basically the more of the, we'll call them the psychosocial or behavioral management strategies that can be very helpful and successful.
The way I look at it is, medication for ADHD treats the core symptoms, improves the attention, reduces the impulsivity, and also reduces the overactivity that's present. However, I do not yet know of a medicine that teaches children how to behave or that teaches children how to learn. In that regard, probably the medicines that work the best, as far as we know in terms of having the biggest bang for their buck, are the stimulant medications, the Adderall or amphetamine-type medications or the Ritalin and methylphenidate preparations, and they come in a variety of preparations. There's immediate release and then there's extended release lasting for eight hours. There's extended release lasting for twelve hours. There's even sixteen-hour preparations that are now available in case people really want to use those. It comes as a liquid, comes as a pill, comes as a melt tab, comes as a patch. There's a variety of ways. And even within the pill, they come as regular tablets. They also come as capsules. You can sprinkle out the contents or dissolve the contents in water, depending on what's in there. So, there's a variety of choices that are there.
But for children who do not tolerate the stimulant medications or don't get enough of an effect from that, there are the nonstimulant medications such as clonidine and guanfacine, the short-acting and long-acting formulations, as well as the medications such as atomoxetine and viloxazine—brand names would be Strattera and Qelbree—that are on the market.
There's some interesting data coming for the latter medications, the medicines and that grouping, that they may not only help the core ADHD features, but also may have an impact on executive functioning, which means the skills of time management and organization, which clearly can have a negative impact on what's going on. But again, I've got someone better focused. They're not bouncing off their chairs anymore. Now, Dr. Antshel, what do we do so they can learn those good skills so they don't get into trouble and they can really fulfill their potential?
Dr. Kevin Antshel (18:27): With regard to the evidence base for non-medication, I'm going to group them really into three categories. The first category is behavioral therapies or behavioral treatments, and here it really depends upon the age of the child. So, for younger children—the preschool child or the elementary school child—it often involves working with the parents and the teachers and helping to train them in behavioral management; helping the parents to reinforce positive behaviors, to set clear expectations. This tends to be much more effective the younger the child. So, that is an evidence-based ADHD treatment, training the parents and also the teachers.
With regard to middle school students and high school students, that involves a lot more direct work with the student themselves. And so, the umbrella term cognitive behavioral therapy, this is a behavioral therapy that has an evidence base for adolescents and adults. It does not have a strong evidence base for children with ADHD, but [for] teens and adults, with regard to teens here, it really helps the teen to develop the coping strategies for emotion regulation, time management; again, it's very behaviorally oriented, talks about how to develop routines, how to develop schedules, what are things that they can do in their own environment to improve focus and task completion. So, those behavioral therapies are one category.
The next category is really the educational interventions. These include things like an IEP (an individualized education plan) [or] a 504 plan in the United States. This can include things like extra time on tests, access to quiet spaces, and include some type of behavioral support, often with the school psychologist for organization and executive functioning challenges that the student may have.
The third category I'll refer to as lifestyle approaches, and this includes things like exercise, physical activity, and mindfulness. These are things that are used. Exercise, so regular physical activity, this is good for all of us. It boosts dopamine. There's a pretty sizable literature base that's associated with approved executive functioning, and so, regular physical activity, that's often a component of the treatment plan. And then for teens, there is some evidence that mindfulness can help, particularly with emotion regulation, and so that's something that often is included. And then the last one, under lifestyle, is sleep, that we know poor sleep makes your ADHD symptoms worse. And so, trying to create consistent bedtime routines, doing things with regard to technology at night that are going to allow you to be able to hopefully go to bed earlier, this hopefully can improve your focus and your emotional stability through the next day. So, those three main categories, the lifestyle approaches, the school approaches, and then the behavioral therapies are the evidence-based [interventions] currently.
Dr. Max Wiznitzer (21:25): And also, as people always ask us, are there other things that we can do in terms of impacting [symptoms], people will talk about complementary treatments. There are some individuals that there are certain components of the diet; some individuals report that certain food coloring may lead to an aggravation of behavior. There are medications that can clearly aggravate and worsen behavior that you have to watch for. From my standpoint, since I'm a neurologist, medications such as Levetiracetam or Keppra or Valproate or Depakote are known to do this. Other medicines that are commonly used, something like Montelukast or Singulair, which can lead to these kinds of things, just to watch. In other words, if you introduce a new medicine, behavior gets worse, consider what the medicine's doing and fade the medicine to see what happens in that regard.
People always ask things like, what about fish oil? And there's small evidence that you can see some improvement, modest improvement, if you use omega fatty acids in certain combinations, that might prove useful, but the impact is not really significant. It's not monstrous; it's more mild in that regard. And the same way people talk about vitamins and certain supplements that if taken at certain doses can do that, but that requires a trial of at least two to three months to see what it would do. And at the best, it has a modest effect that's there. Other strategies that people have pursued in the past have not really been shown over time to be as effective as we would desire for ADHD. And while people can pursue them, I would not recommend that they do that as the sole intervention and ignore the things that the medications and the behavioral strategies that have been shown to clearly be helpful for this population.
One last thing we always have to remember also is that ADHD symptoms can fluctuate. You can be more symptomatic or less symptomatic depending on your age and also your environment. If you're in a structured environment with supportive parents and teachers, the ADHD symptoms may not be as obvious, as evident, as if a child is in an environment that does not have structured routine and consistency—maybe they're not getting a good night's sleep and things of this nature. So, we have to remember that just because they're doing better at one time does not necessarily mean that the features are going away. Look at the factors that are in the environment at that time that might be having a positive [effect] on helping that individual self-control and self-regulate.
Now, if we're going to look at successful treatments, if we're looking at successful treatments for these families, what would you inform families are some of the important points, Dr. Antshel?
Dr. Kevin Antshel (23:59): In my opinion, managing ADHD effectively really requires a comprehensive and personalized approach that integrates multiple strategies; for example, a consistent support system, a combination of all the treatments that we just talked about. But I think a successful ADHD treatment really starts with an accurate diagnosis. You want to make sure you're not confusing ADHD with some of the other conditions that we've talked about. And then, assuming you have an accurate diagnosis, the next most important thing is the entire family, the parents and the family, because ADHD affects the entire family and getting the support of the parents, plural, it's important. It's effective getting the school on board as well, because ADHD impacts executive functioning, which definitely can impact their performance at school. And then trying to make sure that you have adherence to the treatment, and also long-term monitoring, long-term adjustment, as you mentioned, ADHD symptoms change over time and your treatments really have to evolve accordingly. The transition from elementary to middle school definitely brings new challenges, academic pressures, pressure for independence; you have to have better emotion regulation. And so, these transitions, in my experience, are probably when the treatments and the success of the previous treatment may no longer work, and so, you really need to think about how can we personalize it to this new environment or this new phase of life.
Dr. Max Wiznitzer (25:39): One of the things that we have to always remember is that we'll say a failure to adequately intervene for ADHD can have negative consequences for decades after that time. When we look at the adult outcome of individuals with ADHD, especially those where treatment has not been maximized or treatment has not been done, we have situations such as a shortened life expectancy, more years of unhealthy living, increased risk of medical conditions such as diabetes, heart disease, obesity, increased risk of mental health issues such as depression, anxiety, suicide attempts. There are lots of potential negative ramifications for the population that have been identified, which basically means that intervention early on, which is our hope. And by the way, we've talked several times about substance use and the use of illegal substances, drug use, alcohol use, cigarette smoking, that can accrue, especially if you do not intervene. And we know that early treatment, especially with medication, does not aggravate that problem; in fact, if anything, it lessens the risk that problem is going to be there. But at the bottom line, we want to make sure that we maximize their potential, which means we need to give them all the opportunities we can in terms of being able to control their ADHD and learn good habits to be successful as adults.
Dr. Kevin Antshel (27:03): Super. Yes, I absolutely agree with you, and I think the best outcomes for ADHD treatment occur when the treatment is holistic, consistent, and adapted over time. And so, I think that's a good way to think about it. We are almost out of time today, Max. Is there anything else you think is important for our audience to know about ADHD in children and adolescents?
Dr. Max Wiznitzer (27:24): I think we've covered some of the core issues, but of course, if they want more information, they're always welcome to go to CHADD at www.chadd.org so they can become clearly informed consumers about the disorder.
Dr. Kevin Antshel (27:39): Great. So, thank you very much for your time and your expertise. It was an enjoyable conversation. Thanks again,
Dr. Max Wiznitzer (27:46): And thank you for input and for your expertise.
Dr. Kevin Antshel (27:49): Of course.
Announcer (27:49): Pocket MD is brought to you by CHADD with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.