November 30, 2021
Cindy Lopez:
Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen. Welcoming back Dr. Glen Elliott to discuss the ADHD diagnosis and next steps. So your child may have just been diagnosed with ADHD and you’re wondering what’s next. You’re probably going back and forth from wanting to learn everything you can to denying it even exists. ADHD is a lifelong journey full of wonderful surprises and yes overwhelming and difficult experiences, but the bottom line is that you want the best for your child. So, what can you do? Listen in to this podcast episode with CHC’s ADHD expert, Dr. Glen Elliott, as he shares his wealth of experience and knowledge with you. You’ll walk away with valuable insights and practical ideas as you support your child.
So Dr. Elliott, thanks so much for joining us today. And I’m just wondering if you have anything that you’d like to share with our listeners as we get started.
Dr. Glen Elliott:
I have actually had a chance to work with families and children in adolescents with ADHD since 1984. And in addition to my professional experience, I have a younger son who has had ADHD his whole life. So, the things we’ll be talking about are based both on my professional knowledge, as well as my personal knowledge. And as we’ll discuss the changes in the way we think about ADHD have been pretty dramatic over the 30 plus years that I’ve been involved in this. And usually in positive ways, we have a lot more information about sort of what to do and how to be most helpful with these kids than we used to.
Cindy Lopez:
We know it’s a lifelong journey and there are lots of really successful people with ADHD, but what does it really mean?
Dr. Glen Elliott:
Well, it partly depends on the age of the child and the type of problems that the family and the child are specifically experiencing. So there’s no general answer. It also partly depends on who made the diagnosis and how thoroughly the child was assessed. With very young kids usually within preschool we’re really talking about behavioral problems. They’re not following the rules, they’re getting kicked out of daycare because of aggressive behaviors, that’s very different than a child who’s having a lot of trouble in school in first, second and third grade, and different yet again from adolescents who may be having trouble keeping up because of problems with organizing what they’re supposed to be doing.
So two immediate questions that come to mind when the family approaches me is what do we know about that child and that’s going to depend partly on age and partly on who did the diagnosis. Many children are diagnosed with minimal assessment by a pediatrician, sometimes that works just fine and those are not typically the ones who come to see a psychiatrist, but pediatricians are not equipped to look for other kinds of problems. And especially in latency aged kids and by latency age, I mean 6 to 10, basically pre-pubertal. So that elementary school age, we know that about two thirds of those children have some other problem that may need to be addressed in addition to the ADHD. So the first thing that I would talk to families about is what’s your child been assessed for? Are there areas besides behaviors related to the ADHD that have concerned for you and do we need to do additional testing?
The second thing I do pretty routinely is sort of just walk through their day and find out what ADHD is doing to interfere with family function and child function. So there are some kids for example where it’s the morning that’s just impossible, they don’t want to get up. They can’t get organized enough to make it possible for them to get ready to go to school. If you’ve got two working parents, I can certainly attest to the difficulties that can cause. There are other kids where the families feel that the child at home is doing well, but the school is having a lot of difficulties and that leads to different set of concerns and different potential treatment approaches.
And then there are some kids that are blessed with problems in all areas, but the last type is sort of late afternoon and in the end of the evening, and the children were disruptive during that period of time, they don’t want to do their homework or can’t do their homework because of attentional problems. They don’t want to go to bed, they become irritable and difficult to deal with. So ADHD as a diagnosis is the ballpark and then what we’re interested in is what are the specific issues within that ballpark for this particular child?
Cindy Lopez:
Yeah that’s interesting ‘cause I think lots of parents have had their child diagnosed because they’re seeing some behavior, right, and so the behavior is just kind of a symptom of what’s going on and it’s important to understand what’s going on throughout the day at school and at home. What do you think is the most important aspect for parents to understand about ADHD and can the child ever outgrow their ADHD?
Dr. Glen Elliott:
Yeah, that’s a great question. Essentially all children with ADHD get better with time. Unfortunately, it’s a long view. We’re really talking mid to late adolescence usually, but the main symptoms evolve with time.
There are three different types of ADHD. There’s the so-called combined type ADHD, which is problems with hyperactivity, impulsivity and inattention. With the younger kids before age five, often they’re just diagnosed with hyperactivity and impulsivity. That’s probably because expectations around inattention are very limited for 3 and 4 years old.
Once they get into school, first, second and third grade any of those kids go on to have the so-called combined type. And then there’s the inattentive type, which often doesn’t really get picked up until age 9, 10, 11, even as late as 12 and doesn’t involve hyperactivity, doesn’t involve impulsivity or at least not to any great extent, but these are the kids who sit in the back of the room, they drift off, the teachers are disappointed in them. We’re increasingly aware that those kids have real issues as well. This idea that they’re just lazy or they’re just not motivated is just plain wrong. There are very remarkably few kids where motivation is the issue. They may stop trying because they fail all the time, but if parents can sort of approach the issue as my child is trying as hard as he or she can, what can we do to make it better? That really is some of the approach that we need to take, and we need the same interaction with teachers as well.
Cindy Lopez:
So I have some education background, 30 years in education with a lot of that in the classroom and it’s kind of hard to manage some kids with ADHD in the classroom because what you see is distraction or not paying attention and you’re thinking, why aren’t they paying attention, why can’t they pay attention or you’re seeing some disruptive behavior. And so it’s easy to think about the child or the student as a problem and what we want to do is think about what is causing what you’re seeing, and if you can help the parents figure that out, then you have some ways to hopefully make the child more successful in the classroom.
ADHD doesn’t usually come by itself, right, so what does that mean?
Dr. Glen Elliott:
Right. Yeah. So what we call comorbid that means an additional diagnosis with ADHD is something called oppositional defiant disorder that often shows up quite early as young as three or four or five and is particularly difficult combination with ADHD. What that means is that the child’s interactions usually one to one, child to parent often starts in the family, but sometimes spreads into school as well is an immediate reaction of, no, I won’t do that. Now all kids have that to some extent, but this becomes a way of life for some of these children and unfortunately although medicine can help some with that or other treatments, we don’t really have a specific fix for that. It can be, in some ways, much more difficult to find the right system to help with that, but that’s by far the most common. It’s not subtle, parents usually experience it pretty early and, it’s almost always associated with the so-called combined type ADHD. So you’ve got an impulsive child who sorta keeps pushing for what he or she wants until parents finally say okay, yes, you can have this. Which unfortunately is the absolutely wrong thing to do. As I’ve said, all of us, including myself have certainly fallen prey to that. Other common problems are learning disabilities, speech and language difficulties, anxiety, depression, those are probably the five biggies and that’s where the pediatric diagnosis really doesn’t capture those kinds of other potential issues.
On the other hand, you don’t want to just evaluate every child for everything just because you can. So it really is time for sort of a thoughtful, where are the difficulties happening? Often schools can be really helpful and sort of thinking about is this child reading and writing and doing other academic tasks more or less at grade level, despite the fact that he or she is being really disruptive or are there areas where it really doesn’t feel like things are progressing very well and that’s where I definitely recommend if they haven’t already had it, psychological testing. They’re not really very helpful until children are at least six preferably seven or eight just because the kinds of things we’re looking for don’t really develop in the brain until about that age, but those are really important to pick up. Hearing is another one, it’s much rarer, but even being deaf in one ear can significantly inhibit the child’s ability to function. So doing just sort of a, a thorough screening of hearing and eyesight and all of those things to make sure that there aren’t physical, correctable problems that are actually adding to the difficulty, is really important.
There’s a famous psychiatrist in England, Sir Michael Rutter who developed the modestly named Rutter Scale. An it just counts up the number of diagnoses and what he showed was that it’s not a linear problem, it’s an exponential problem. So, as the more diagnoses you have, the more likely things are going to turn out badly. So the inverse of that is the more problems we can identify, and either fix or diminish the better outcome we’re going to have.
Mike:
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Cindy Lopez:
You made this comment to me, Dr. Elliott, recently, you said sometimes parents can feel like they’re doing this for themselves versus the child. Can you comment on that a little bit more?
Dr. Glen Elliott:
I actually confronted that just this week with a family, where the father is opposed to medication because he feels somehow that that’s for everybody else and not for the child. I can assure you the child is very aware that he or she is not fitting into his environment. This becomes particularly obvious at age seven, eight and nine when the child develops the ability to sort of compare the child’s behavior versus what’s going on around him or her. And one of the most common referral questions when parents come to me at that age, these are not newly diagnosed kids usually, is I just want my child to have friends and I want my child to be happy, and unfortunately we don’t have medications for either of those things. So sort of figuring out what’s going on with the child that’s causing difficulties in that area, can make a huge difference. And again it requires kind of an analysis of what it is that is interfering with the child’s ability to be developmentally progressing.
And this is such a crucial area. If you think about anybody who’s been through this, if you think about the changes that occur between, say a 5 year old and a 10 year old, it’s truly astonishing the blossoming of different skillsets and you find abilities and interests that just weren’t there earlier on. And having something prohibit a child from doing those things that’s correctable it is not just about the parent making things easier for the parent or the teacher, it’s really about facilitating the child’s ability to function.
Cindy Lopez:
Yeah i, I remember a student that I had who was diagnosed with ADHD and was having a really hard time in the classroom behaviorally and was disruptive, and then he had a hard time coping. He didn’t know what to do with his frustration. As we think about the strengths as well as the struggles of ADHD, for him a strength was music and so he was able to really use that strength to help him cope, to help him be more calm and in some ways to help expresses his learning, but it was, definitely an outlet for him. So the idea that yes, students with ADHD can have a really hard time in the classroom at the same time they can also have some amazing strengths that it may take some time for them to figure out and into adulthood those strengths may become the things that really help make them feel successful.
Dr. Glen Elliott:
I have a colleague who loves to say that if you wanted to create an environment that really brings out the very worst possible aspects of ADHD it’d be hard pressed to come up with a more appropriate environment than school. There are long moments when you’re bored, when you can’t move when you need to, where you’re expected to be attentive most of the time, if not all the time. Those do not play to a child’s strengths. So, you know, finding ways to facilitate within the classroom approaches that are more reasonable for that particular child is a very important component of this. It’s not just a school-based disorder by any means, but school really can bring it out and that leads to a downward spiral. The child starts feeling like a he or she’s failing, the teacher becomes increasingly frustrated. Parents being reasonable advocates, not denying that there’s a problem, but saying, yes there’s a problem what can we in collaboration with the schools do about that problem, really is important. And sometimes particularly with kids who are reasonably bright, it’s just a matter of recognizing that, doing a problem set for a hundred questions may not in fact be all that educational for that child. If the child masters whatever the knowledge base is in 10 questions decreasing sort of those kinds of expectations sometimes can be, relieving for everybody.
Cindy Lopez:
So Dr. Elliot, I’m wondering too thinking about the child what could or should the parent share with their child about their ADHD?
Dr. Glen Elliott:
That’s a great question. Depends a bit on the age, but my general recommendation, especially with kids in elementary school is not to tell them you have ADHD, particularly with combined type ADHD kids, one of their characteristics is they’re impulsive. So if they’re given a label, I can promise you they’re going to share it with everybody and not that it’s a shameful thing, but it further separates them from their peers and causes difficulties.
So what I usually recommend is to focus on symptoms rather than on a global diagnosis. So you have trouble sitting still in the classroom, you have trouble listening to the teacher all the time. And if you can ask the child, the child certainly by nine or ten is going to know what’s difficult and what’s not so difficult. So saying, you know, what we’re going to do is help you pay better attention, what we’re going to do is make it easier to stay in your seat, those kinds of very symptom directed comments I think are much more helpful and much more likely to both recruit the child to help with the problem, but also diminish the social consequences of a label.
Cindy Lopez:
Yeah, I like the idea of bringing the child into the conversation and asking them like, what’s going on and what kind of bothers you the most about whatever situation they’re in, whether it’s school or play with friends or whatever. I’m wondering what final thoughts you might have for our listeners today, from both your professional and personal perspective?
Dr. Glen Elliott:
Although it doesn’t feel like it’s going to happen, these kids do get better with time almost uniformly. I mean, there are some rare exceptions, but the big studies that have been done and there are really a number of longitudinal studies available now suggest that ADHD really changes in terms of what needs to be looked at and overall success, in a positive way over time, but we’re really talking all the way through late adolescence and into adulthood. There are kids, we’re not really sure that their ADHD goes away, but it becomes so under their control that they’re actually able to make use of it rather than having an interfere with their life and that typically happens like with my son that really happened in junior college. I wish it had happened during high school, but it didn’t. So, you know, sort of holding that hope out. Back in the seventies, when I was a med student, the belief was that it magically went away with puberty, that we now know is not the case, but it does change with puberty. What tends to happen is the hyperactivity diminishes. The impulsivity probably diminishes somewhat, although the opportunities and the consequences of being impulsive get more problematic, but what really becomes problematic at that point is sort of the school load often and other sports loads and those kinds of things. You have to be much better organized as an adolescent to just make it through the day and that’s not a natural function. So you end up having to help support them, often externally. And fortunately, there are a lot of technology developments that have occurred over the last 10 years that really helped to support this. So my son, for example, uses timing devices for almost everything because one of his problems is he forgets when he’s supposed to do something. And you know those organizational kind of things, there’s a whole field that spread, that’s grown up around this, which is really very helpful called executive functioning coaches, that’s what their job is to help figure out what’s causing a child to have difficulties and find the tools that are likely to diminish that.
I think the really key thing, and my son’s a great example. I genuinely, despite the fact that I knew how bright he was genuinely was just astonished that he made it to high school, and for him to then go from there to college pretty much on his own and go from a B/C student to an all A student and end up as a triple boarded physician was nothing I would have predicted at age 13. It’s hard to imagine that in five to six years they’re going to turn into adults. That phenomenon is amazing in it of itself. Even with the child has no problems. With ADHD it’s a more complicated process, but it does happen much more frequently than anybody would tend to guess when they’re dealing with their 13 year old child.
Cindy Lopez:
I’ve been part of conversations with you and your son and I know that one of the things that made a big difference for him is that he felt loved unconditionally and that acceptance, from you, from his parents was a big piece of being able, like to give himself a little grace, right. To know that not everything is going to be perfect. And so I think that’s a good word to parents. Just always reaffirm that relationship with your child and that you love them no matter what…
Dr. Glen Elliott:
I think that is crucial. I think at the same time, you also need to be able to say firmly, this isn’t acceptable. I love you, but…
Cindy Lopez: I Agree. Agree.
Dr. Glen Elliott:
Or I love you and I guess is the better way to phrase that. And I guess the other thing that one really needs to think about particularly if the impulsivity lasts into adolescents is being pretty explicit as a parent about what the risks are driving, sexual relationships, alcohol and substance abuse. We know these kids are all more at risk for those kinds of things. And being as upfront as possible, saying know part of my job as a parent is to help protect you during this period. I sometimes tell parents for adolescents you’re really main job is to help them survive that time period in a quite literal sense, without any major consequences, because if you can get them through that things almost always then begin to get better and late adolescence and into adulthood.
Cindy Lopez:
At CHC, we currently offer parent support groups online, and we also provide evaluations and teletherapy services, and you can learn more about all of this at chconline.org. And we have a podcast episode we did in our last season with a young adult with ADHD and his journey.
Dr. Glen Elliott:
There’s actually a parent network called CHADD Children and Adults With Hyperactivity, Attention Deficit Disorder, it’s parent run. They also have a lot of resources that parents may want to think about accessing in addition to the CHC site.
Cindy Lopez:
Thank you for that reminder, Dr. Elliott, and we will include some of these resources in our podcast webpages. Thank you for joining us today, Dr. Elliot and to our listeners thank you for joining us, and we hope that you’ll listen in again for the next episode.
Dr. Glen Elliott:
My pleasure.
Cindy Lopez:
Visit us online at podcast.chconline.org. Make sure to subscribe to Voices of Compassion so you never miss an episode and we’d love it if you’d leave us a rating and review. Have a question? Send us an email or a voice memo at podcasts@chconline.org. We’re here for you when you need us.
