Dr. Nathan Fox speaks to Dr. Mala Baum, a child psychologist regarding ADHD in kids. They discuss what it is, common signs in children, and treatment options.
“ADHD: Everything you need to know” – with Dr. Marla Baum PsyD
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
All right, Dr. Marla Baum. Marla, welcome back to the podcast. I’m sorry I’m not sitting with you in person. I know you’re very busy. You see a lot of people and they wanna see you, and it’s hard for you to get over from your office to my office, but we’ve known each other a very, very long time so I’m gonna pretend that you’re with me.
Dr. Baum: I’m with you in spirit, Natey. Thank you for having me back.
Dr. Fox: You’re with me in spirit, but it’s all good. And, you know, before this, we were just chatting about our kids and what they’re up to, and this and that. And as always, it’s crazy how they’re getting old, which means we’re getting old.
Dr. Baum: Exactly, Natey. I’m more concerned about that than I am about anything.
Dr. Fox: It’s a thing. But you are a child psychologist. You work with children, you diagnose, you test, you treat, and you’re awesome. And you have been on the podcast before, and you were awesome then. And obviously, I wanted to have you back on. And I thought we would talk about ADHD because this is like a really big topic and you are the person, and that’s what Michal said, my wife. She said, “Talk to Marla. She’ll tell you everything you need to know.” She said, “Marla could talk about this in her sleep.” So, you’re not asleep now, you’re awake. So, thank you for doing it. I appreciate the time and I’m sure our listeners will, too.
Dr. Baum: Sure. My pleasure.
Dr. Fox: So, I just wanna start from the beginning. Can you just clear up what is ADHD? What is ADD? Well, like what’s the terminology? What are we saying nowadays? And are there differences or are we just all outdated with what we’re saying?
Dr. Baum: Excellent question.
Dr. Fox: Thank you.
Dr. Baum: We’re not outdated. It’s just the merging between the actual diagnostic labels and how people think about ADHD. So, the actual diagnostic label is attention deficit hyperactivity disorder. It then has three subtypes. One is the inattentive type. The second one is the hyperactive impulsive type. And the third is the combined type, which is where you have the inattention and the hyperactivity.
So, sometimes people will say, “Well, do I have ADD or do I have ADHD?” And when people are talking amongst each other, they’ll often drop the H from the ADHD if they really just have a difficulty paying attention. Diagnostically on insurance still, and neuropsychological reports, you’ll see that it will say ADHD, and then you qualify it with which type of ADHD that the person has. I tend to come across mostly the combined type where there’s an inattention and a hyperactivity component. A lot of times there are kids that just have the inattentive type. I have rarely met a child that only has the hyperactivity part and not the inattention. [crosstalk 00:03:08.878].
Dr. Fox: I probably would’ve been told I had that as a kid. I was kind of… Yeah.
Dr. Baum: A lot of us had this when we were younger, and our teachers would deal with it by, you know, sending us out of the room, putting us in the corner. Some teachers were very good and made sure to put these kids in the front, which is actually what works best for most of them. But really, it wasn’t really dealt with nearly as comprehensively when we were growing up. And, you know, I’m approaching 50 and 80 is not that far behind me, and we’ve gotten much more astute at how we handle ADHD in the classroom.
Dr. Fox: Yeah, I wanted to ask you. The prevalence of it seems to be going up. Do you think it’s actually going up or we’re just sort of a little bit better at diagnosing it or finding out kids who should be assessed and diagnosed for it? So, that’s the first question. The second question I’m gonna ask you is, if it’s the latter, is that a good thing or a bad thing?
Dr. Baum: Right. So, if you asked me this question about autism and why the rates are going up, I would tell you that it’s because of better diagnostic criteria, widening the catchment of what constitutes autism or being on the spectrum. My professional opinion, and I’m sure if you ask some of my colleagues, they will agree, and if you ask others, they will disagree, I think part of the reason why the diagnosis of ADHD has gone up so high is because a lot of people present with things that look like an attention problem, but it’s not. Those difficulties in paying attention are actually masking something else. It could be a learning disability, it could be an anxiety disorder, it could be a host of other things. And a lot of people feel that if you’re displaying symptoms of inattention and hyperactivity, just go straight to the psychiatrist or your pediatrician and get a prescription.
Now, that’s a perfectly valid way to go, except that in my clinical opinion, there’s a lot of things that look like ADHD that aren’t, and you run the risk with kids of missing something if you don’t get them fully evaluated by a neuropsychologist. So, I personally think that the numbers have gone up because people are not necessarily putting the resources into getting their child evaluated in order to make sure it’s just an attentional issue and not anything else.
Dr. Fox: Oh, so basically like, it could be true that the prevalence is going up in terms of the number of kids given this diagnosis in their medical record and their school record and whatever, you know, but you’re saying that it’s possible that a percentage of them, a significant percentage of them may have symptoms that are like it, but actually their diagnosis should be something else?
Dr. Baum: There’s a very good chance that there’s something else going on, especially for kids developmentally. And so, I always think it’s best to be a little bit more thorough before we just deal with symptoms, per se.
Dr. Fox: It’s interesting. And yeah, I just wanna ask you, there’s also this idea that it’s situational. Meaning, let’s say I’m in a school that’s very rigorous. You’re sitting in a classroom, you know, eight hours a day, and they’re pouring homework at me, and this or this. I’m gonna be like a little bonkers because of it. And like, so I can’t deal with this. I’m like, you know, getting up and running around this. Whereas if I was in a school that maybe was more interactive or hands-on, like I was farming, right, and doing that all day, that I would have no symptoms and I’d be perfectly fine. A, do you think that’s a correct assumption? And B, what does that mean? Like, is it really a diagnosis or just like this kid’s in the wrong place?
Dr. Baum: Well, right, so that’s another reason why it’s really important to meet with a psychologist, in my opinion, to prop this all out, because you’re absolutely right. There are certain schools that demand a lot more of the child than where they’re at physiologically and developmentally in their brain. So, you have to take into account where they go to school. Well, we’re talking about kids here. So, where the kid goes to school and what type of teacher they have. Does the teacher have a lot of leeway for the typical, you know, shenanigans in the classroom? Or do they want their kids sitting front-center in their desk not moving, right? So, you have to take all these factors into account. The other thing to take into account is that it’s not officially a diagnosis unless it comes up in more than one setting. So, for children, the two main settings are school and home.
I’m thinking of a child I just finished testing, and he is perfectly well-behaved at school, and it’s at home that he starts to get a little wonky, so to speak. He can’t get his homework done, he can’t regulate himself, whatever. So, that is not necessarily an attention deficit disorder if he’s responding really well to the structure. Or it could be that it is, and he requires that structure, which is why it’s really important to tease all of this out with a clinician, because it could be very different in different settings depending on what the expectations are.
Dr. Fox: And we’ll get to treatments later, but the treatments would differ based on precisely what you find on the testing?
Dr. Baum: Correct.
Dr. Fox: Got it. That’s…
Dr. Baum: The treatment depends on many things. It depends on what we find. It depends on the familial resources, what the school can do. There’s a lot of factors that go into play when you’re designing an intervention plan for a child.
Dr. Fox: That’s really interesting that you said more than one setting. What other settings would there be for a child besides school and home? Where are these kids going otherwise? Like school, home, and the arcade? I mean, what’s the third place?
Dr. Baum: Well, it’s interesting. It could be play dates at other kids’ houses.
Dr. Fox: Oh, like social. Okay.
Dr. Baum: It could be, yeah, any social situation, or like doctor’s office, or going to the movies, or synagogue, or church.
Dr. Fox: Oh, okay.
Dr. Baum: You know, there’s a lot of different ways that if you have this issue, it can manifest in a lot of different ways, so it’s always good to look across. Yeah.
Dr. Fox: Are there also like gradations or severity, like you say, this is a mild case of ADHD, inattentive type versus a severe case? Does it work like that?
Dr. Baum: I say that to parents just to help them sort of understand, especially if the child is only inattentive. Then that sometimes is hard to convey because they’re not doing anything that’s, like, calling attention to them, right? So, I find it more important to qualify those things when you’re talking with the parents of a purely inattentive child. When the child is hyperactive, I also put it into categories, but it’s not as challenging to do that because of, you know, the nature of the problem.
Dr. Fox: It’s pretty obvious.
Dr. Baum: Yeah, exactly. Exactly.
Dr. Fox: Let’s say even without treatment, does it always continue into adulthood? Or is this something that you can “grow out of?”
Dr. Baum: So, it’s an excellent question.
Dr. Fox: Marla, you know, I’m throwing heat at you now.
Dr. Baum: I know. You can throw it around me.
Dr. Fox: I’m bringing it over at 100 miles an hour.
Dr. Baum: Yeah. I got it.
Dr. Fox: You know, I know you. I’m not taking it easy on you, Marla. This is like an interrogation, so you get ready.
Dr. Baum: Please don’t. This makes me feel like I know my stuff. It’s good. Wait. Oh my God, Natey, repeat the question. I forgot what you asked.
Dr. Fox: Oh, no, so I’m gonna say I want the truth, and you say, “You can’t handle the truth,” like “A Few Good Men.” No. Okay. So, I was asking if this is something that kids can like “grow out of,” or does it always continue? This is our old age coming through. Our memory, short term memory is quite less.
Dr. Baum: Exactly. I forgot the question. I got distracted, lo and behold. Okay. So, what ends up happening is that children usually present with this at, like, three different points. Either number one, they show up in preschool and it is clear as day, or it’s when they are in the lower elementary grade and there’s a lot of focus on basic skill building across academic domains and that comes up then. Another way it can come up is in middle school when the kids start to have more classes that they need to pay attention in, and different teachers, and different demands, and everything. And then the final set is more like when kids are older, like into high school, that’s when the later type of ADHD will emerge. Those are just different developmental points where you tend to see these things.
Now, in terms of growing out of it, there’s a lot of research that shows that a lot of the hyperactivities that you see will go down in adolescence with all the hormonal changes and bodily changes. And it’s usually the inattention that persists. Now, in terms of growing out of it, this is an interesting notion and it’s gonna tie in a little bit to the treatment option, but, you know, we can figure out how to piece it back together when we talk about treatment later.
But the research shows that kids with ADHD, for a long time we’ve known that they can do this thing where they sort of learn the state of being focused through the interventions they get when they’re younger. So, if a child is medicated for ADHD, which I will often recommend, not always, but often, they take the medication and there’s a lot of research that shows that after two or three years of being on the medication, the brain is starting to fire as if it’s on the medication even when you stop the medication, which means that the brain is being sort of trained how to focus better, which goes along with something that we’ve seen in the field for a very long time, where kids after receiving treatment for ADHD, they can sort of put themselves in the zone of being able to focus. And so, we always called that learning the state of being focused. And then now the brain imaging research is backing that up, that there are some real positive changes in the way the neurons are firing. The brain gets a little bit trained, so to speak.
So, it doesn’t necessarily go away, per se. Unfortunately, each kid is different. Some kids will learn the strategies that they need or take the medication that they need, and they will be okay. Other people might need the medication every now and then in their careers. For example, I have people that I worked with who are now adults, and they have to go to those eight-hour conferences in those dimly lit ballrooms, and they have to sit there all day, and that can be challenging for them. So, maybe they’ll take one of their prescriptions just for that day so they can be on their A game for work, you know, throughout a relatively mundane, less active day like that.
Dr. Fox: Yeah, I’d probably recommend taking the opposite and just get a really good nap during one of those events. That sounds gruesome.
Dr. Baum: Yes. Yeah. Right. Right. It can still feel tedious for people when they’re adults, even though they’ve really outgrown a lot of it. So, it doesn’t really go away. I think that you just learn how to deal with it in the most adaptive way possible, which is really everyone’s challenge in life, is whatever your weakness is, to figure out how to work around it. So, we have to help these kids, too.
Dr. Fox: Is ADHD something that we know to be genetic or have a genetic predisposition? Like if you have it, are your kids more likely to have it, or siblings, things like that?
Dr. Baum: Yes. There’s a very strong genetic component. Almost every time I’m doing an intake with a parent for most of these disorders that I treat and I assess for, 9 times out of 10 there’s a family member that had something similar, which really speaks to the genetic loading.
Dr. Fox: Right. So, when you’re testing the kid and the father’s walking circles around the room and can’t sit?
Dr. Baum: Exactly. Exactly.
Dr. Fox: Oh, interesting. All right.
Dr. Baum: Or when a parent can’t keep track of, you know, the session times and, you know, they miss appointments. It’s like, okay, you know.
Dr. Fox: Here’s my card.
Dr. Baum: But really, I mean, you know, it’s just a matter of whatever your weaknesses are, and, you know, figuring out how to work with them.
Dr. Fox: Right. And also, is ADHD only an issue in terms of like function, you know, like the reason it’s a problem is because my kid can’t get through their school day, or I can’t get through my workday? Or is there some other aspect of it that like affects you in your life? Like does it affect like relationships or does it increase your risk of like a mood disorder if it’s untreated? You know what I’m trying to get at? Like, is the treatment just like task specific, like let’s get you through school, or is there something about it that it helps to be treated otherwise?
Dr. Baum: Well, that’s interesting. It really depends on what’s going on for the child, but I will tell you that a lot of times the kids are… Let me think about how to formulate the answer. It feels like a really good question, but a complex question. Oh, Natey, now you stumped me.
Dr. Fox: Wow.
Dr. Baum: Now you stumped me. So, sometimes the attentional issues really just impact the kid’s learning. Sometimes the issues can affect the kid’s ability to make friends and maintain their friendships. As adults, a lot of times couples will get into arguments because, you know, one of the people in the couple cannot keep their things organized, and they’re like full of clutter because they can’t organize themselves, you know, and then it’s messy in the house and it becomes stressful for the other person in the couple. Or it could be a matter of if there’s a lot of places that you have to drive your kids around, you know, as an adult, that could be very overwhelming to figure out how to get them to activity A, to activity B, to activity C, and to be able to sort of negotiate all that. The ability to do that is what we call executive functions, which we’ll talk about next.
So, there’s a myriad of ways that these can affect the kids, from their learning to their friendships, and then as you get older, it can really affect relationships also. I have colleagues who specialize in working with couples where one of the people is ADHD, because it can be very challenging.
Dr. Fox: And is there a lot of overlap with other conditions? I mean, again, we’re talking not misdiagnosing, but, you know, you test them in this. Do you frequently see you have ADHD plus, you know, a learning disability, or plus anxiety, or plus depression, or plus whatever?
Dr. Baum: Yes. A lot of times there’s overlap. ADHD is one of those disorders that has one of the higher rates of what we call comorbidity, because the issues themselves can lead to different learning disabilities. And, you know, the ability to regulate yourself emotionally as a child, it falls under executive function, which is related to ADHD. So, if the kid’s ability to regulate their emotion is on the more difficult side, then it’s important to keep in mind, is this gonna turn into an issue with anxiety, an issue with depression, an issue with behavior and conduct? So, there’s definitely a lot of comorbidity.
Dr. Fox: Interesting. All right. So, let’s do this. Let’s go a little bit nuts and bolts here. And we’re definitely gonna do a separate podcast on executive function, like what that is and what you do about it, but I wanna just write, how do you diagnose ADHD? Meaning what is typical for like a parent or a teacher or a child themselves, like what they see or what they report? And then they come to you, what do you do to help make that diagnosis or a different diagnosis?
Dr. Baum: So, what I do, and obviously this is my bias because I’m a neuropsychologist…
Dr. Fox: That’s fine.
Dr. Baum: I do a full evaluation where the child does many tasks that are structured and many tasks that are much less structured. The ability to sort of organize yourself in order to complete something new is a very important thing to assess for a child, because that’s the foundation of executive functioning for a child. So, I assess it through the structured tasks that I do. I’m constantly taking notes about their behaviors, you know, and how well they’re able to maintain their focus. You know, what types of behaviors am I observing that makes a child feel more focused, whether it’s holding a fidget toy the whole time, or one time I had a boy literally sitting upside down in his chair, so his legs were on my wall and that his head was like hanging over the seat of the chair. So, he was performing in the 99th percentile, but that’s what he needed to do in order to do that. So, you know, that’s why I feel like clinical observation and impression is really important.
And whenever you’re working with a child, you have to talk to the other people in the child’s life. So, I’m constantly talking either to the teachers or the school psychologist or the guidance counselor. Sometimes the heads of school wanna get involved. I think it’s very important to hear everybody because you really have to tease apart, you know, the circumstances of every situation the kid is finding themselves in to help make the diagnosis.
Dr. Fox: But you’re doing essentially formal neuropsych testing, which is what we spoke about, you know, a while ago on the other podcast.
Dr. Baum: A while ago. Yeah.
Dr. Fox: It’s a full evaluation. Now, what do they… If someone comes in and either they say, “I think my kid has ADHD, or my kid’s doing A, B and C and I don’t know what it is,” and you find out it’s ADHD, what are the symptoms that people are typically gonna report? And let’s start with a young child, you know, what is it?
Dr. Baum: Sure.
Dr. Fox: They’re just running around a lot?
Dr. Baum: So, for the young child, it’s how well they can respond to structure. So, yes, kids are very fidgety, right? By nature, they like to run around a lot, but when they get into a situation where they have to sit down for circle time or they have to transition between activities to go from circle time, to go getting your jacket, to lining up, you know, to go out for recess and all of those skills in the preschool classroom, those are important behaviors that might signal an issue. If it’s hard to sit during circle time, if it’s hard to transition between activities, that’s what you look for on the preschool level. A lot of these parents will also report that when they took their child to soccer class, “The other kids were able to just sit there and listen to the teacher, my child had to run around.” You know, so those sorts of things that you see.
Dr. Fox: Is it typically something the school brings up for the first time or something the parents bring up for the first time? I mean, is it typically the school says, “Hey, your kid’s like a little bit…you know, not handling school so well,” or is it something the parents always knew?
Dr. Baum: Right. So, a lot of times the parents always knew. It really depends. It depends on how astute the parents are and what their own experience is with it. So, a lot of times I’ve had it both ways. Sometimes the school will call and say, “We must figure this out.” And the parents are like, “Okay. He’s fine at home, but I’ll bring him in.” And then there’s other times where the parents felt very strongly that something was wrong, but the school feels like they’re on top of it and you don’t necessarily need to evaluate.
Dr. Fox: Right. And as you said, it could be that there’s actually only an issue in one setting and not the other. That’s a possibility. And it’s also possible, like some parents would be like, “No, this is normal behavior. This is what I was like as a child. This is what all kids do.”
Dr. Baum: Exactly. Exactly. So, that’s why it’s really good to have someone outside of the family say, you know, there’s something. So, 9 times out of 10 it’s the school, or sometimes it’s the pediatrician. Those are the two main places where you’re gonna get a referral for a child because they see in the classroom… I went over what happens in the preschool classroom in the, you know, early elementary grades, it’s how well can they sit and listen to the lesson. And then when there’s a task to do to reinforce what was taught in the lesson, can the child get started and, you know, take care, you know, do what they have to do in order to get it done? You know, are they constantly being prompted by the teacher to, like, move on to the next thing? Those are the things that you’ll start to see in the early elementary school grades.
And then there’s always a subset of kids, I had said before, like, they’re fine in the early elementary grades because there’s one teacher, so there’s not as much to keep track of, versus in middle school there’s always a subset of kids that all of a sudden, they can’t handle having eight folders, and eight different teachers, and keeping track of their assignments and whatnot.
Dr. Fox: When you do the neuropsych testing, is the diagnosis of ADHD, is it typically certain, like you’re like, yes versus no? Or is it, do you ever get like, well maybe, you know, not sure, possibly, something like that?
Dr. Baum: You know, I’ve had both experiences. I’m officially old enough to say that I’ve been doing this a long time. I mean, 99% of the time I can tell from sitting with the child, from watching them work. I also have the benefit of having done a lot of executive functioning coaching with kids. So, I see how it looks in their daily life, the way it looks when they’re in my office for the evaluation. So, I like having all that information, so it informs how I assess, and it also helps in terms of how I help the kids with executive functioning and attention issues.
Dr. Fox: Right. But predominantly you know? Predominantly you’ll be like yes, or no?
Dr. Baum: Yeah.
Dr. Fox: Okay. No, that’s fair.
Dr. Baum: Yeah. It’s rare that I’m surprised that the kid is coming up with an attention issue. Most of the time it’s the other way around that they look inattentive, but really like there’s a severe language processing disorder, and so the kid is goofing off in class all day because that’s his defense mechanism because he’s not understanding anything. Right. I have a case like that on my desk right now, so it’s very prominent in my mind. Right. Like, ADHD is the least of that child’s issues.
Dr. Fox: Right. I was told that I was goofing off because I was bored. That was the conclusion that everyone reached with me, why I was so like running around as a kid. I’m just bored. Okay. That’s fine. You know, I’m less bored now.
Dr. Baum: Right. But we both know what school you and I went to. I mean, you know.
Dr. Fox: Yeah. I tell people that through 12th grade basically it was just sort of like daycare with occasional heat during the winter. Yeah. All right. That’s…
Dr. Baum: I don’t think you and I would survive the high school that you and I attended the way it is now.
Dr. Fox: No, I wouldn’t have gotten in. Do you walk around town and say like, “Oh my God, this guy’s definitely got ADHD and was never diagnosed. She does.” And I mean adults, like, you know, all of us, our generation people. I mean, we never got tested as kids. They just, whatever. They just got us in trouble and sent us home. Do you see like, “Oh man, if I only had these people 40 years ago, I would’ve really done some good work with them?”
Dr. Baum: You know, I gotta tell you, most people I know, we’ve all been very fortunate that we’ve figured out how to overcome it. Like, I have a good friend, I know the husband is dyslexic, I can just tell, but he’s so successful. So, we obviously figured out a way to, you know, get a job that’s more about like working with people, you know, it’s like his people skills are what he ended up capitalizing on in his career.
So, really the ultimate goal has always been the same even from when we were growing up. It’s how do we learn how to live with this? What’s nice is that what’s different from when you and I were growing up is that now there’re so many more interventions to intervene earlier. So, when it comes to ADHD in particular, you know, a lot of these parents will be like, “Well, I live this way. Why do I have to medicate my kid? I wasn’t medicated.” And I’ll say, “But how did you feel about yourself as a student?” And they’ll say, “I was the clown.” And 9 times out of 10 they don’t have good feelings when they think back about their school experience because of exactly what you said, Natey. Like, you know, you and I, you know, were very active people. You know, like I always had to like go up… You know, I had to go for a walk. You know, I had to go do this, I had to go do this. You know, you just learn how to deal with it.
Dr. Fox: Yeah. I had to ditch school with David Amouyal and rent movies. I just had to. That was it. And get caught. Yeah, I was actually gonna ask you if you get a lot of pushback from parents? Obviously, with treatment you might, but just on the diagnosis, you know, the school sentiment, and you say, “You know, I think your kid has A, B, C, and D.” Do you get a lot of parents saying like, “No, you’re wrong. You’re over-diagnosing. You doctors are nuts. Like, what’s wrong with you people?” Does that happen?
Dr. Baum: I rarely have that experience.
Dr. Fox: Oh, good.
Dr. Baum: I can count on one hand the number of people that, you know, were like, “You know what, you’re all nuts. The school is crazy, you’re not correct. I’m out of here.” And they get up and they walk away.
Dr. Fox: Wow.
Dr. Baum: But 99% of the time they understand and they wanna do right by their child. I find the parents that are the most effective with handling this are the ones that even if they have their own feelings about the diagnosis and what it means for their child, they’ll still do what they have to do. They might have reservations about medication, but they have, you know, a number of experts saying this is the way to go, then they’re gonna do it.
Dr. Fox: It’s encouraging.
Dr. Baum: What I get nervous about are the parents that don’t know how to separate out their own feelings about it versus what the child actually needs.
Dr. Fox: Fair. Let’s shift to treatments. So, you’ve made the diagnosis. How do you approach it sort of either stepwise or globally…
Dr. Baum: Yeah, sure.
Dr. Fox: …through these families?
Dr. Baum: I basically go through the four main modalities of treatment that are available and the research shows that they’re effective. Number one, we’ve talked about the medication piece. Number two, there’s behavior therapy that can be done with a behaviorist in the classroom depending on the level of severity. The behaviorist can also come to the house once or twice a week and do sessions with the child in the house. The third treatment modality is to do both of those, the medication and the behavior work. There’s a whole other wide range of holistic interventions that people try. This could be anything from some of what we call brain-based training programs to sort of train the brain to be more focused, sort of the same way the medication does. So, there’s all these brain-based programs.
One of the most famous ones is called the interactive metronome. There’s a lot of diet interventions that people try, whether it’s gluten-free, dairy-free, or no dyes in the food, or, you know, reduce the child’s simple carbohydrate intake. I’m actually very excited, I’m going to a conference about nutrition and all of these diagnoses, so I’m very excited to hear the latest research. I’m happy to, you know, talk to you about that another time because I think that I’m very excited for that. But as of now, all of those strategies and interventions, there’s limited research about their efficacy overall. The two main treatments that still hold fast and best are medication and behavior management.
Dr. Fox: So, let’s talk about the medications.
Dr. Baum: Sure. So, the medications, the most common ones are in this class of drugs called stimulants. Now, parents will say, “Dr. Baum, why a stimulant? My kid is stimulated enough, they need to calm down.” It’s a bit of a misnomer. What the medication does is stimulate the dopamine production in a particular part of the brain that is central to attention and executive function. So, what happens is that we all have a dopamine loop in our brain, and when we feel motivated by something and you get that physiological, you know, rush of happiness and adrenaline and over being productive and doing what you wanna be doing, that’s your dopamine system working for you to keep you focused.
Kids with ADHD have a developmental lag in their ability to turn on that dopamine loop. They have to be interested in order to focus, whereas people without ADHD do not need to be inherently interested. They can turn on the dopamine loop in their brain and get that sense of satisfaction no matter if they’re interested or not. So, what the medication does is it helps stimulate the production of dopamine so that the child gets interested and will focus, which goes along with what a lot of people say, “Well, why won’t my kid focus when they want to?”
Dr. Fox: Right. I was gonna ask you like…
Dr. Baum: Because when they want to, it’s never a problem.
Dr. Fox: Yeah, like sometimes like my kid can play whatever, this board game for three hours…
Dr. Baum: Exactly.
Dr. Fox: …and not have an issue.
Dr. Baum: Exactly.
Dr. Fox: But if you want them to like, you know, read a book, forget it, or vice versa.
Dr. Baum: Correct. Because that’s the dopamine. The dopamine is the neurotransmitter in the brain that gives us a sense of satisfaction and productivity. On the adaptive side, it’s, you know, when you get all your work done, you clear your desk to go on vacation, all your emails are done, all your papers are done. On the more debilitating end of it, it’s, you know, people that gamble, that rush of dopamine when they’re winning, winning, winning, and it keeps them inherently, you know, interested.
So, this is why the medications are such an effective way of treating ADHD because they’re going directly to the neurotransmitters and adjusting them as need be so the child can focus. There are certain subsets of kids that don’t react well to stimulant medication. And so, they’ve developed a lot of non-stimulant options. But the problem is that because those medications are trying to work around the problem, they have less efficacy than the medications that directly treat the problem. So, most psychiatrists will start with the regular stimulant medication and if there are any bad side effects, then they’ll maybe switch to something else.
Dr. Fox: What is the downside? Why would people be hesitant? Is it just sort of like conceptually they don’t want their kid on meds, or is there an actual risk to being on these medications?
Dr. Baum: So, the ADHD meds are the ones that have been studied the longest.
Dr. Fox: Right. So, we’re talking about like Ritalin, Adderall, those guys?
Dr. Baum: Ritalin. Exactly. Exactly. The only real downsides are for kids who are experiencing difficulties with their growth and their appetite, because the two main side effects are that they don’t eat when the medication is active and therefore there’s a little bit of an impact on their overall growth in terms of their height. So, you know, some pediatricians are okay with that. Some families are okay with that, and some aren’t. If you’re dealing with a family that really cares about their child’s height for whatever reason, then that’s an issue because they might not be on board for medication if that’s gonna potentially impact them, you know. So, it’s important to address whatever people’s concerns might be.
The only other side effect with these medications is sometimes it’s hard for the kids to fall asleep. So, that’s when you hear that a lot of people give melatonin…
Dr. Fox: At night. Right.
Dr. Baum: …to their child to help them fall asleep. But that doesn’t always happen right away. In my experience, that happens after the child’s been on it for a little while and they have to get to a bigger dose when they get older.
Dr. Fox: Are they addictive?
Dr. Baum: I don’t think so. People will tell you that they are because every now and then there’s a “New York Times” article about someone who was addicted to their pills and selling them on college campus, and you hear these stories. But by and large they’re not addictive, and this is where I think the messaging from the family is very important in terms of what the pills are for, making sure that the kids don’t have access to the pills. In my experience, I’ve never had a patient that’s gotten addicted to them. If anything, they wanna come off them.
Dr. Fox: Interesting.
Dr. Baum: And they’re able to when they see that they have learned strategies so they can function.
Dr. Fox: Now, in terms of using the medications, is this something that automatically is taken every day or is this something that can be done intermittently, like just take it on school days and not on weekends…
Dr. Baum: Excellent question. Excellent question.
Dr. Fox: …or during the school year and not in the summer, something like that?
Dr. Baum: Correct. It’s a great question. You know, again, unfortunately, I always start with it depends.
Dr. Fox: That’s fair. It’s not unfortunate.
Dr. Baum: If a child is really just having trouble being attentive in class, then they will probably just need it for the days they’re in school. If a child is very hyperactive and it gets in their way socially, then you might wanna consider giving it to them on the weekends because, you know, they’ll be able to have really nice play dates with their friends that way, or they’ve got a soccer game and they need to be able to focus, you know, so that they do well on their soccer game. What’s nice about these medications is that they’re in and out of your system very quickly. They have, like… I can’t remember the medical term.
Dr. Fox: Clearance.
Dr. Baum: They have a short… No, it’s not even about a half-life because these meds don’t…
Dr. Fox: Short half-life. No, that’s correct.
Dr. Baum: Right. They have a short half-life. Thank you. So, they’re in and out of your system very quickly. These are not like the anti-anxieties and the anti-depressants where you have to build a steady state in your bloodstream and get your liver function checked with different points and whatnot. These are fast-acting, they’re in and out of your system quickly, and you can make a decision as to when to take it. So, like some kids just need it for school and they’re fine on the weekends, and they don’t take it. Other kids will start taking it on the weekends if they start to have a lot of homework and they can’t sit for four hours on a Sunday and do their work without it. So, that’s nice is that you don’t necessarily have to give it every day. And if they’re not hyperactive and it’s not getting in the way socially, then maybe they don’t even need it for camp.
Dr. Fox: Interesting.
Dr. Baum: You know, these are all decisions that are made on a case-by-case basis. Also, the break from the medications is what we call in the business a drug holiday, which can help in terms of mitigating the impact of the potential side effects of lack of appetite and growth. Because then if they’re on a drug holiday, then conceptually, theoretically, they’ll eat and they’ll eat a lot, and so then they will catch up in a sense.
Dr. Fox: Interesting. Now, you mentioned behavior therapy. Is that specifically related to executive functioning?
Dr. Baum: No. Behavior therapy is really about shaping a behavior that you wanna see in the classroom. So, it’s very Pavlovian. The process is you pick target behaviors that the teacher and the parents want to see an improvement on, and you literally implement a token economy or some more of their sort of behavioral plan where the child gets reinforced for the behaviors that the teachers wanna see. So, the idea would be that, you know, for every five minutes that they’re sitting focused in class, the teacher will come over and put a check on a piece of paper. And if the child gets a certain number of checks by the end of the day, the note home says that, and then the parents at home will reinforce the child. The behavior work does a lot to unite the parents and the teachers in terms of helping the child. And the research really shows that if you’re gonna do behavior interventions, it has to be done in both settings. It can’t just be done in one place versus the other.
Dr. Fox: That makes sense.
Dr. Baum: So, that sort of leads us into the issue with doing behavior therapy is that it’s very time consuming. A lot of teachers don’t have the ability to do it, not because they can’t, but because there’re so many other demands on them in the classroom. So, it can be an option if the situation presents itself that there’s extra teachers in the room that could help facilitate it. It’s also very expensive because you’re basically paying for a behaviorist to be there in school if the teacher won’t or is not capable of doing it the right way. So, it’s very costly.
You know, but some parents won’t mind if they don’t wanna put their child on medication. They’ll do it. That’s why it’s important to understand what the parents want and what the family resources are. I can’t recommend a behaviorist for a family if they can’t afford to pay for it. Then what’s the point of the intervention plan that I designed if I design a plan that they can’t afford or that I know the school can’t do? So, that’s why when I’m designing these interventions, it’s very important to take all these factors into account, so that the child will actually be successful.
Dr. Fox: No, that makes a lot of sense. And in your experience doing behavior therapy, or medication, or the combination of both, what is the likelihood that it’s gonna be effective? Like 100%, or like are there some kids who are just nothing works?
Dr. Baum: Oh, gosh. You know, I don’t know the latest numbers, but it’s definitely the best level of efficacy is with both.
Dr. Fox: Right. But my point is, is it very high? Meaning should parents expect that if, you know, they see you, they get their kid evaluated, they get the right treatment, you know, it may not work exactly immediately, but once you sort of settle into it, these things work?
Dr. Baum: Yes, for sure.
Dr. Fox: Great.
Dr. Baum: For sure. Without a doubt.
Dr. Fox: That’s amazing.
Dr. Baum: Without a doubt. Really, it’s one of the disorders that we’ve known how to treat the longest. And, you know, we’re really just talking about the attention. Executive function is a whole other ballgame.
Dr. Fox: Yeah. Good segue. We’re gonna have a separate podcast on executive functioning. Where can our listeners learn more about ADHD? Are there any, like, books you recommend, or websites, or articles, or something, if they just wanted to learn more about it?
Dr. Baum: Yeah. So, one of the top psychologists that’s done a lot of research and has written a lot of really good books about ADHD is a doctor by the name of Russell Barkley. He’s one of the original gurus, so to speak, in terms of dealing with attention and executive function issues. So, anything like I’m looking at my book, I always recommend this to parents is his book called “Taking Charge of ADHD: The Complete Authoritative Guide for Parents.”
Dr. Fox: Ooh.
Dr. Baum: That’s really one of the best that I recommend for dealing with the attentional piece. Also, there is an excellent parent network across the country called CHADD. It’s for Children with ADD. So, C-H-A-D-D. They have an excellent website with a lot of resources and materials for parents to review and to learn more about their child. And the other thing I was going to recommend is a magazine called “ADDitude,” but instead of A-T-T, it’s A-D-D.
Dr. Fox: Ooh.
Dr. Baum: So, it’s “ADDitude,” A-D-D-I-T-U-T-E. It’s published by a group of people who are experts in the field. And there is a wealth of information in those magazines from the latest on treatments and how to talk to your kids at different developmental stages. And they also have a lot of resources in their advertising section for camps for kids and different colleges that are better equipped at helping these kids in terms of support on the college level. So, that magazine is also just a wealth of information for people.
Dr. Fox: Amazing. Marla, God bless you. Thanks for coming on to talk about this, and…
Dr. Baum: You’re welcome, Natey. Anytime.
Dr. Fox: Yeah. Well, I’m gonna have you back on in about four seconds in real time to talk about executive functioning, but it’ll probably drop the following week. All right. Marla Baum, the best. Dr. Baum.
Dr. Baum: Thank you. Thank you.
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