Andrew Harper, MD, child and adolescent psychiatrist and clinical professor at the Texas A&M College of Medicine, explains attention deficit hyperactivity disorder (ADHD), common symptoms, medications and why it's no longer referred to as ADD.
Mary Leigh Meyer: Howdy, everybody. My name is Mary Leigh Meyer.
Sam Craft: And I’m her co-host, Sam Craft.
Mary Leigh Meyer: And we are here today with Andrew Harper. He’s with us from the Texas A&M College of Medicine. Tell us a little bit about who you are and what you do.
Andrew Harper: Howdy. I’m Dr. Andrew Harper and I’m a clinical professor here in the department of psychiatry, and I’m involved in the clinical work of the department and I’m a child and adolescent psychiatrist.
Mary Leigh Meyer: Okay, perfect. So, we picked you and you’re the perfect person to come talk to us today about our topic.
Andrew Harper: Oh, well thank you!
Mary Leigh Meyer: We are talking about ADD and ADHD.
Sam Craft: What’s that? I’ve already lost track. What are we talking about?
Andrew Harper: Exactly.
Sam Craft: See?
Mary Leigh Meyer: Yeah.
Sam Craft: You just lost it too, didn’t you?
Mary Leigh Meyer: Oh, okay.
Sam Craft: What just happened to you?
Mary Leigh Meyer: I don’t know.
Sam Craft: You’re like a deer in the headlights. I can’t even make a joke with you anymore.
Mary Leigh Meyer: Oh.
Andrew Harper: That’s a distractability. That’s a characteristic. It is.
Sam Craft: We’re already talking about it. We’re already here.
Mary Leigh Meyer: Gosh, you’re so distractable, Sam.
Sam Craft: I was just playing into the topic today because the way I understand ADHD and all of the other ones, to me it’s like you’re doing one thing but you can’t pay attention to doing other things and either you’re really focused or you’re trying to do too many things and your brain is going other places.
Andrew Harper: That’s exactly right. Distractability is a big characteristic. And technically, the diagnosis is attention-deficit hyperactivity disorder, ADHD. Although a lot of people will talk about ADD, that’s sort of not the correct or official terminology, if you will, but there are three subtypes.
Mary Leigh Meyer: Oh, I always thought they were two separate diagnoses.
Sam Craft: Yeah, that’s me, too. So those are actually the same thing, but people confuse them as different things or did I mix that up?
Andrew Harper: Well, the attention-deficit disorder is old terminology, if you will. It was updated by the field and now everything is attention-deficit hyperactivity disorder, but there are three subtypes. One of the subtypes is inattentive type and that would cover what was previously called just ADD. There’s also a hyperactive and impulsive type, and then the third type is combined where they have symptoms in all three areas, the inattention, the impulsivity and the hyperactivity.
Sam Craft: I didn’t realize there were so many subcategories of things. I mean, when people get diagnosed, they’re put into one of these three areas?
Andrew Harper: Typically. One of the reasons it was split out like this is there are some gender differences. For example, girls tend to be the inattentive subtype, and it’s thought that they are underdiagnosed because they’re not causing a behavioral problem typically.
Sam Craft: Is that just genetics that causes that, I mean, in the different male/female, or I mean, do we even know?
Andrew Harper: It’s genetics, but it’s also physiology and the way the brain develops. We know that boys’ brains develop at a slower rate than girls, but we do catch up.
Mary Leigh Meyer: Are boys typically diagnosed later in life or…
Andrew Harper: Earlier.
Mary Leigh Meyer: Earlier? Ooh, interesting.
Andrew Harper: Right, because what typically causes a kid to be diagnosed is their behavior. For example, if a little girl is sitting in a classroom but not causing a problem, not attending to her work, she may get sort of judged to be, “Well, maybe she’s just a little bit slower or not as bright,” when she could be intelligent, just the distractability and an attentiveness interferes with her work completion.
Sam Craft: So kinda like when people say…I know sometimes young kids are saying they get bored in class, so either they’re just way past that in life, at least as far as knowledge or whatever, or it could be something like this where there really is something wrong.
Andrew Harper: That’s a good point because a really bright kid may get bored because they’re not academically challenged. That’s why it’s important to get assessed when you suspect that there’s a problem.
Mary Leigh Meyer: And how do you know? Say you’re the teacher in the classroom and little Susie’s not paying attention, kind of not following along. How do you know if … That seems like a very wide range of possibilities on how to approach helping little Susie.
Andrew Harper: Well, that’s correct. And that’s why I would say it would be hard for the teacher to know. He or she could suspect, but it’s important to get an evaluation because kids can be inattentive for lots of reasons. For example, if they’re having trouble at home or if their caretaking environment is disrupted or perhaps, unfortunately, in an abusive caretaking environment, that can also lead to behavior problems in the classroom.
Sam Craft: So, over the years, I was born in 1980, and so growing up in the ’90s, I think all of this was still really fresh and it seemed like kids just not behaving got blamed or categorized as this a lot. It felt like they just fed us drugs just to calm us down. For what we know now, with the research that’s been done over the years, looking back on that kind of situation, were they right in doing so and just kind of guessing on if this is the right diagnosis? I know nowadays, it’s probably, again, a lot more easier for us to diagnose because we’ve seen all this stuff before.
Mary Leigh Meyer: Well, then to that vein, I also feel like there is a lot of not diagnosed children, but then a lot of children who are incorrectly diagnosed.
Sam Craft: Yeah, along the same lines. Yeah.
Mary Leigh Meyer: Medication plays a weird, tricky part on both sides of that.
Andrew Harper: You both are right in that there are kids that are missed or not diagnosed correctly, but also kids that are misdiagnosed, because it’s assumed that the problem is the ADHD versus other issues going on with the child. For example, even depressed kids can sometimes have trouble paying attention and may have some irritability that looks like hyperactivity or impulsivity.
Sam Craft: Like I was saying, most of the time it’s just like, “Oh, well, he’s got ADHD,” and that’s just what it is. And it’s like, “Well, maybe that’s not what it is. Maybe we need to get deeper into this and see what it is.” Again, me growing up, a lot of my friends, they just gave them whatever it was I took for it and we just moved on. But I don’t think that was always the case. I think sometimes it was just misdiagnosed.
Andrew Harper: Yeah, I think you’re probably right. And I think there are probably kids on medication that don’t really need it.
Sam Craft: Speaking of medication, if that were to occur, I mean, it does happen, obviously, does it hurt the child in any way? I mean, what do those drugs really do?
Andrew Harper: Well, there’s several classes of drugs that are used to treat ADHD. The most common class are the stimulant medications. And we have a lot of experience with those medications. They’ve been around for many years. Tons of kids have been exposed to them and they’re viewed as one of the safer medications that we use for psychiatric problems in children and adolescents.
Mary Leigh Meyer: I feel like a lot of these medications, some students take when they don’t have these diagnoses to help themselves in school, help them study, help them focus here and there. Is that…
Sam Craft: I had plenty of friends that did it over overnighters and finals and that kind of stuff. I mean, I can honestly say it wasn’t me. I grew up with the pharmacist’s son, so I knew better, but I had plenty of friends that were like, “Yeah, this is it.”
Andrew Harper: No, I think you’re right. Unfortunately, these drugs can be diverted and used for other purposes. I think a couple of things to think about in that regard. Well, first off, I would say that the effects on attention are nonspecific, so it’s not a diagnostic test. If you have an inattentive kid, you give them a stimulant and their attention span improves, doesn’t prove that they have ADHD. We could all take stimulants and our attention span would be longer. The question would be is do we really need it? Even though the safety profile is good, it’s not without side effects. You’re medicating a kid whose brain is still growing and developing. I think you have to think really carefully before you commit a kid to a medication trial.
Mary Leigh Meyer: And so, what you said, “medicating a kid who is still growing and developing”, is that a bad thing to give medication to these kids or is it more of something where the kid is not learning behaviors and they’re reacting with their medicine? Do you get what I’m asking? I feel like I didn’t ask that very well.
Andrew Harper: I don’t think it’s just about learning behaviors, although there are some behaviors that are helpful for the child and adolescent and even an adult because this is a disorder that can persist into adulthood. What we think in part is happening is that the regulatory parts of the brain in folks who are dealing with ADHD are maturing at a slower rate or may not be as effective for those individuals as they are for other folks.
Mary Leigh Meyer: Oh, that’s interesting.
Sam Craft: So, it’s a good point you bring up about the adults you mentioned. I’ve never heard of ADHD being an adult situation. I mean, not one that … I guess my question is, as an adult, if you’ve never had it before, can you be diagnosed with it as an adult?
Mary Leigh Meyer: And then do kids grow out of it?
Sam Craft: Yeah. And that that’s kind of along the same lines. As a kid, can you grow out of it?
Andrew Harper: Well, some kids will grow out of it. Typically, the hyperactivity diminishes, but the inattentiveness is the symptom that’s most likely to persist into adulthood. Your question about can it be diagnosed in adults, it can be, but there needs to be a history of symptoms in childhood to correctly make the diagnosis. I think what happens in some adults is folks who have maybe a milder case and who might be brighter kids develop some compensatory strategies and are able to kind of manage themselves and they may not get diagnosed until they’re in college or pursuing graduate education where the academic load becomes more challenging.
Sam Craft: So more than likely, it’s always been there. They just might not notice it until something triggers it or it just becomes more aware?
Andrew Harper: Correct. And remember, there’s a normal range of attention spans, probably and activity levels. Probably everybody has someone that they consider hyper or know that they’re distractable. But what we look for when we’re making a diagnosis is we’re looking for impairment. Is it really causing a problem, and is it causing a problem in more than one setting? For example, if the child only acts up at school, but at home there are no problems, none of these behaviors or symptoms are seen, maybe there’s something at the school environment that’s disruptive for the child or maybe this child has an undiagnosed learning disability and is frustrated at school and it’s easier to be the kid who’s the class clown than the kid who can’t do their work.
Sam Craft: Yeah. Maybe they’re just four years old and angry. I have one of those.
Mary Leigh Meyer: Or they’re just a teenager or they’re just a college kid or they’re just an adult who’s bored at his job, Sam.
Andrew Harper: And I’m glad you said the four-year-old because…
Sam Craft: Oh, that’s not very nice.
Andrew Harper: I’m glad you said the four-year-old, right, because I think it needs to be diagnosed very carefully in very young children, right, because sometimes the initial line of intervention should be maybe working with the caretaking environment and helping with some parent management strategies.
Sam Craft: So, speaking of four-year-olds, as we are, because I have one and now I’m curious, I just attribute him not listening or doing just sporadic things to being four years old. What kind of symptoms should you be looking for at a child that young knowing that they really haven’t developed their…I say, societal norms?
Mary Leigh Meyer: Classroom etiquette.
Sam Craft: Yeah, or even home etiquette or that kind of thing.
Andrew Harper: I think at that age, obviously you’re right. There’s going to be some developmental considerations that have to be put into place because four-year-olds are going to be more impulsive. They’re going to be more distractable. They’re going to be oppositional at times, and that’s all completely normal.
Sam Craft: It’s like dealing with a terrorist.
Andrew Harper: Right. And they can have temper outbursts and that’s not a surprise.
Sam Craft: Yes, yes, they can.
Andrew Harper: So, what you’re looking for are kids who might be outliers from their peer group, with the caveat that kids have different dispositions. Within a family, so those of you that have more than one kid, you probably recognized early on that their little personalities are quite different. And it’s typically evident at a very young age. You can tell that some kids are just calmer and risk adverse and other kids are more adventure seeking and they never saw something that they couldn’t touch or climb on, that kind of thing, and that can be normal.
Sam Craft: That’s mine. Yes.
Andrew Harper: Yeah. Exactly.
Mary Leigh Meyer: I definitely see that personality difference in my cats.
Andrew Harper: I can’t speak to ADHD in cats.
Sam Craft: She just recently adopted a little one, what, a few days ago?
Mary Leigh Meyer: He’s so precious. Less than a week ago.
Sam Craft: Well, hopefully they don’t exhibit any of those crazy signs.
Mary Leigh Meyer: Well, they’re kittens. They act like there’s a ghost in the room at all times and fly against walls and if there’s a water glass on the table, there’s no longer a water glass on the table.
Sam Craft: Just lay out the cat nip for everybody’s sake.
Mary Leigh Meyer: Okay.
Andrew Harper: Well, at least you’ll have interesting videos to post.
Mary Leigh Meyer: Oh yeah.
Sam Craft: Valid point.
Mary Leigh Meyer: Oh yeah. My phone is full of them. When you think your kid has these symptoms, who do you bring them into, your primary, to a psychiatrist like you, and then what are these medical professionals looking for?
Andrew Harper: Well, I think a primary care physician could certainly diagnose attention-deficit hyperactivity disorder, and that would be a really good place to start. If that physician is uncomfortable making the diagnosis or is thinking that it might be more complicated than a simple ADHD, then a referral to a mental health professional might be in order. And that could be a child psychiatrist, it might be a nurse practitioner who’s adept with psychiatry.
In the assessment, we’re looking for symptoms in three major areas. There’s inattentiveness, hyperactivity and impulsivity. The things that we would look for are kids who have trouble following sequential instructions. Maybe they do the first thing and then can’t remember any of the other instructions, kids who have trouble collecting items together for a task. Obviously, the hyperactivity, kids whose baseline activity is higher than their peers, or they can’t contain themselves so that in a school environment they’re jumping up and down out of their seat, they’re running around the classroom, and kids who are externally distractable. They have a lot of difficulty attending to really anything except things that they are very interested in, so that’s not a sort of killer of the diagnosis if they can play video games for hours. And in fact video games, if you think about what’s going on there is there’s constant shifting of attention, right? Because things are flying in or blowing up or coming up behind you or coming out of the sky or up from the ground, so there’s always stuff going on. They could still have ADHD and be attentive to certain activities.
Mary Leigh Meyer: And are there any other therapies or ways to manage these symptoms other than medication?
Andrew Harper: There actually are some strategies, some organizational strategies that can be helpful for these kids in the classroom. If they can sit up front to minimize external distractions, that can be helpful, as well. Physical activity can help. So if you can intersperse physical activity with their academic work, for a lot of kids, that is helpful. The other question I would always ask about diagnoses is I always want the symptoms to be present in more than one setting, right? If they’re only having these symptoms at home, but at school they behave well, they’re doing well academically, the teacher when you talk to them says, “I don’t know what you’re talking about this kid,” then you would think about, is there some stress in the home environment? And vice versa. If they’re only having difficulties at school and not at home, then I would wonder if there’s some educational issue, learning disability perhaps. We do know that learning disabilities are frequently associated with ADHD, so usually we encourage educational testing for those kids.
Mary Leigh Meyer: And is that done through a psychiatrist like yourself or is that through a different professional?
Andrew Harper: So, psychologists do the testing and that can be done through the school. Parents can request that from their school if the child is showing symptoms of academic difficulties.
Sam Craft: I think that sometimes parents, including me for that matter, because I am a parent, I don’t want to say we feel bad about getting these diagnoses. Maybe nervous, maybe scared, I guess. What’s your advice to parents that think there might be a problem, but don’t want to pursue it because of what might be actually happening?
Mary Leigh Meyer: They don’t want to put a label.
Sam Craft: Yeah, I mean, I think because kids are mean, and if one kid hears this about another kid, even though it’s something that is very common that I know of. What’s your advice to parents in that aspect of things?
Andrew Harper: Well, I think recognizing that there is potentially a stigma, I would encourage parents to think of it as any other medical issue that their child might have. For example, if their child had trouble with asthma, they would seek correct evaluation and pursue treatment. And as you mentioned, it’s not uncommon. We think 3 to 5 percent of school-aged kids have some degree of attention-deficit hyperactivity disorder. Some kids may be able to develop compensatory strategies and others may need medication and other assistance to manage.
Mary Leigh Meyer: Tell us more about the medications. We kind of talked about it a little bit earlier, but are they different? Is there a difference in them?
Andrew Harper: Well, there are different classes of medications that can help. The gold standard are the stimulant medications, and there tend to be two groups of those. One groups are the methylphenidates and related compounds, and the other group are the amphetamines and amphetamine salts and related compounds. And they come in different formulations and they’re marketed under different names, but really they go back to those two molecules. And many times, the difference is the extended release formulations and how they are put together and kind of the mechanics if you will of the delivery system for that extended release feature.
Mary Leigh Meyer: Growing up, I had a friend who took … I don’t know what type of medication, but some sort of medication for her ADHD. And she almost had … You could tell when the medication wore off because she almost had a crash or her behavior was drastically different. Is there some sort of, I’m going to air quote the word crash, after these medications wear off?
Andrew Harper: For some kids, there can be. These are very short duration medications, so unless they’re an extended release formulation, the medications only last three to four hours, so that obviously won’t cover the school day. What that means is the child may have to go to the nurse’s office to get a dose of medication, and I think the issue was stigma was brought up a little bit earlier and certainly in that case, if the child has to go take a medicine in the middle of the day, that can become very obvious to their peers. So most folks recommend using the extended release formulations.
That kind of gets at two things. It gets them through the school day and the immediate afterschool period, but it also can eliminate this sort of up and down kind of feature that you may see with the short-acting meds. Even with the extended release, though, some kids will have a little bit of rebound at the end of the day when the medications wear off.
Mary Leigh Meyer: Is there a benefit to the short-acting medications?
Andrew Harper: Depending on the situation. For example, an adult with ADHD may only need a short-acting for a portion of the day and not need the extended release formulation or someone who maybe sleeps in and doesn’t want to take an extended release that’s then going to interfere with their sleep onset when they go to bed.
Mary Leigh Meyer: Ooh, that’s interesting. Do they interfere with sleep and diet and what about other lifestyle things like those?
Andrew Harper: Right. If you take it too late in the day, it will interfere with sleep, and the appetite suppression is very common, so we usually recommend to families is that they get a good breakfast in the child before he or she heads off to school and then they may have appetite suppression at lunchtime and not eat well at lunch, but when they come home from school, then maybe a little bit heavier snack or really focus on a nice substantial supper in the evening.
Mary Leigh Meyer: Then what about the impact of caffeine?
Andrew Harper: Well, caffeine is a stimulant, right? But it’s not the same kind of stimulant and caffeine has been tried in kids with ADHD and it’s really not effective in their symptoms.
Mary Leigh Meyer: Interesting. And then for adults, what about the impact of alcohol on someone taking these medications?
Andrew Harper: For adults that are on stimulant medication, alcohol is not contra-indicated. Obviously, everyone should watch their drinking and drink in moderation and all of the other sort of caveats that we have when we’re talking about adult drinking, but it’s not forbidden, if you will, in someone who’s taking stimulants.
Mary Leigh Meyer: Do people need to ever adjust their dosage of these medications?
Andrew Harper: Some people do need … Especially if they are started on medication as a very young child, as they grow and develop, typically, the medication may need to be increased or titrated.
Mary Leigh Meyer: What about families who are hesitant to put their child on a stimulant?
Andrew Harper: Well, that’s certainly understandable. There is some, I guess, concern in some folks about using stimulants. The first thing I would say is that we know the stimulants hit all three symptom areas, the hyperactivity, impulsivity and inattentiveness. But there are other medications that can be helpful. Oddly, one group of medications are traditionally used for hypertension. That’s guanfacine and clonidine. They act in a way that tends to help with the impulsivity and hyperactivity and can help a little bit with kids who have some irritability. And for kids who have really on the extreme side behavioral difficulties, sometimes the medications that are used for more serious mental illnesses may be tried in low doses in these kids.
There is another alternative, a non-stimulant medication called atomoxetine, which people may have heard of. It’s thought to be a little bit less effective than the traditional stimulants but can be a choice for milder cases or early in the course of treatment to see if it’s effective, as well.
Mary Leigh Meyer: But the connotation of the word stimulant, it isn’t a bad thing necessarily … Are people that have that worried…
Sam Craft: When you say stimulant to me as a parent, it freaks me out.
Mary Leigh Meyer: Yeah. Is that worry founded?
Andrew Harper: Well, it sounds like a street drug, right? So I think families worry about that, and it can be diverted. Some kids will sell it. It does have a street value. Unfortunately, it can be a drug of abuse.
Sam Craft: It’s like anything else in the medicine cabinet nowadays. I mean, I don’t want to call this one thing out because I mean, all prescription drugs can be that way nowadays it feels like.
Andrew Harper: Right, or some parents may even worry, “If I start my child on a stimulant, am I predisposing him or her to”…
Sam Craft: It’s a gateway drug.
Andrew Harper: Exactly. Are they going to have problems with drug abuse later?
Sam Craft: Sure.
Andrew Harper: So, there’s actually research on that. We know, unfortunately, individuals with ADHD have a higher incidence of substance use disorders later in life. That’s just an unfortunate co-occurring feature of this diagnosis. But it appears, and there’s some mixed evidence on that, it appears that ADHD kids who are treated have a lower incidence of substance use than ADHD kids that are not treated. And interestingly, it appears that treatment that starts earlier, in school age, elementary school age, has a more preventive effect if you will, on later substance use. It doesn’t prevent completely, but it may reduce the ultimate risk that the child engages in risky substance use behavior later in life.
Mary Leigh Meyer: So you definitely don’t want to ignore these symptoms out of fear for a diagnosis.
Andrew Harper: Right. And the other thing to remember is that a young child with ADHD can be very annoying to his or her peers because they have trouble playing in team sports, taking turns, waiting in lines, that kind of thing. And a lot of important social development is going on early in elementary school, and you don’t want the child to fall behind in that area. And the other thing about school obviously is the academic work. You want them to be able to stay on track with their academic development so as the coursework becomes more challenging in middle school and high school, they have the fundamentals and the basics in place to do that work.
Mary Leigh Meyer: Yeah. Well, I think that’s a good thing to wrap up on. It’s a good thought. Anything else that we need to say to our listeners about ADHD? Not ADD, ADHD?
Andrew Harper: I think it’s important to get a complete evaluation. That would be, I think, the primary concern I would have. Sometimes schools can be very insistent when a particular school official decides that the child has the diagnosis. Really, really encourage you to get the child professionally assessed. Again, that could be in a primary care office or if you have access to a child psychiatrist, that’s another option as well.
Mary Leigh Meyer: Well, okay. Dr. Harper, I think this has been a good show. Hopefully our listeners learned quite a bit and hopefully that stigma we talked about a little bit can start to disappear. Thank you for coming on the show.
Andrew Harper: Thanks for having me!
Mary Leigh Meyer: All right. Thank you all for listening. This has been another episode of Sounds Like Health.