(upbeat low-key orchestra music) (upbeat low-key orchestra music continues) - A recent report from the Centers for Disease Control shows about one in nine children in the US between the ages of three and 17 have been diagnosed with attention deficit hyperactivity disorder, or ADHD.

About 6% of adults have ADHD.

So, today I am joined by Dr.

Kyle Boerke, and he is the Director of Behavioral Health Ambulatory Services with OSF Healthcare; and Michelle Little, she is a family nurse practitioner with OSF Healthcare.

Thank you very much for joining us.

- Yeah, thanks for having us.

- Well, a lot of misconceptions about ADHD, so let's set the record straight.

First of all, Dr.

Boerke, what is ADHD?

- Yeah, I think the best way to start is talk about those letters.

Everybody knows the letters, but some people don't know what that means.

So, ADHD, attention deficit hyperactivity disorder.

It is the most common diagnosed behavioral health condition that we have in the world, and it is a childhood onset disorder.

So, it starts in childhood, but that doesn't mean that it doesn't impact adults too.

Sometimes it will persist all the way through into adulthood.

- But if an adult is diagnosed with ADHD, does that mean they've had it for a long time?

- There's some conversation out there, but yes, more likely than not, it went undiagnosed.

I think the thing to remember about ADHD is it is classified as a neurodevelopmental behavior, so it's rooted in brain structure.

- Okay.

Michelle, I know, with these things, nothing simple.

There's three types of ADHD.

Can you tell us a little bit about those?

- Yeah, so ADHD stands for attention deficit hyperactivity disorder.

So, there's the predominantly inattentive type to where people just have a hard time focusing, processing information.

There is the hyperactivity type, where it's impulsivity; more hyperactive, can't stay in your seat, fidgeting.

And then, there's the combined type, where really you just kinda have a combination of both.

So, you can be attention predominant, hyperactive predominant, or both, kinda difficulties processing both.

- Sure.

So, some of those are obvious symptoms.

What are some other symptoms of ADHD that people can look out for?

- Yeah, so if we kinda take those three types, right?

So, they're fairly aptly named, right?

So, the ADHD, the predominantly inattentive type named because there's some difficulties with attention.

But I will say I think it's probably the world's worst name because it's actually quite the opposite.

It's not the inability to pay attention, it's actually the inability to stop paying attention.

While you and I are having this conversation, if I'm somebody who struggles with ADHD, I'm trying to pay attention to you, but I'm also paying attention to the lights, I'm paying attention to the car door that just slammed outside, the bird that's chirping out the window.

And because I'm paying attention to all of these different things, it makes it very challenging for me to pay attention to the primary stimulus, which is you.

Whereas somebody without that inattentive-type ADHD, they're able to really hone in on the primary stimulus.

When we go to the combined type, or let's go to the hyperactive impulsive type first, that is more the fidgeting, restlessness, feeling like you just have to move at all times.

You might blurt out.

If she was struggling with ADHD, she has something to say, she'd just talk right over the top of me.

- I would interrupt.

- I would interrupt him and not let him finish, 'cause otherwise my thought is gone if I don't get it out of my head immediately.

- Yeah, and then the combined type, right, it has both the struggles with the inattention because of that over-attention thing and with the hyperactivity and impulsivity all at the same time.

- Is that why it can be difficult to diagnose?

Because you just mentioned nine tenths of kids on this planet, you know.

I mean, everybody at some point has some of those symptoms, so.

- [Michelle] Yeah.

- Well, before we talk about how it's diagnosed, let's talk about the causes.

Is this something that people are born with?

- There's definitely a genetic predisposition to it.

I don't wanna say we're necessarily born with it, but the genetic predisposition really biologically based.

And I think, a lot of times, the environment kind of pulls the trigger on that predisposition.

So, huge genetic component.

- Yeah, and I might go a little bit more direct with that, 'cause it is a very complex question, right?

It gets into the nature versus nurture debate; it really does.

If I had to answer in one word, I would actually probably answer "Yes."

We're born with ADHD, right?

As I mentioned earlier, it's a neurodevelopmental disorder.

So, it is rooted in, you know, the brain, in the brain structure.

We actually know enough about ADHD and our brain now that we know where in the brain ADHD is causing the difficulty.

It comes from right up here from the brain called the prefrontal cortex.

That's where we get all of our what we call executive functioning; so our planning, our decision making, our activity levels, all of that is really stemming from the prefrontal cortex.

To get more scientific, sorry, we actually know the impulse control, self-control, self-regulation is coming from an even more specific part of the prefrontal cortex called the dorsal lateral prefrontal cortex.

That's where a lot of that is based in the brain.

- You mentioned nature versus nurture, and I'm curious.

If a child is raised in a household that's loud and noisy and talkative and things like that, how much of an effect would that have on a child, and could that contribute?

Any thoughts on that?

- Well, I'd say, I don't know if there's a difference between a child being raised in a quiet, calm atmosphere versus a loud kind of more chaotic atmosphere and whether or not that would cause them to have ADHD or not, because like Kyle said, yes, it's a neurodevelopmental, it's genetic you're kind of born with it type thing.

But with that said, if you have ADHD and you are in a house that's very chaotic, it's gonna be much harder on you, because having consistency and structure is beneficial to a child with ADHD, as opposed to kind of that chaos and having no structure and so many moving pieces, because like Kyle said, you're focusing on everything.

Like, there's so much going on, you can't just stop and hone in on what's going on 'cause there's too much going on - Totally agree.

Yeah.

your predisposition is there, right?

It's gonna give you this range.

You're gonna fall somewhere in here based upon your genetics and your brain structure.

Now, whether that's over here on the really severe ADHD, or that's over here on the, you know, very well functioning, that's gonna be where that environmental, you know, structure comes in.

- Okay.

Now let's talk about the diagnosis, and let's start with children.

At what point if a parent thinks, "Oh, maybe their behavior isn't 'normal.'"

When should a parent go to a medical professional?

What kind of a medical professional should they go to.

- As soon as possible.

That's the easy answer.

Early intervention is always the best.

If you look at the actual DSM criteria, symptoms have to have been onset before age 12.

So, if I have somebody never struggled with symptoms of ADHD ever, and they come to me at 15, I'm not gonna diagnose with ADHD.

Symptoms did not exist before age 12.

So, we have to have that.

Besides that, then there are all these different criteria, and I think this is one of the most fascinating things about ADHD and diagnosis of ADHD, especially when we talk about adults.

There's a lot of adults saying, "You know what?

I think I have ADHD."

But then, they look at somebody, you know, a neighbor or a friend that has been diagnosed with ADHD, and they're like, "Well, maybe not, because I don't struggle with the same things that they struggle with."

But I think that's the fascinating part about this.

ADHD, right, there's three different types of ADHD, so it can look very different from one to the next to begin with.

But even if it's, you know, the ADHD, the predominantly hyperactive impulsive type, one person and another person can look very different.

We use what's called a polythetic criterion set, which means we have this list of criteria that need to be met, but only a certain number of those need to be met.

So, if I, as an adult, struggle with criteria 1, 2, 3, 4, and 5, I can be diagnosed, right, 'cause we need five for an adult to be diagnosed with ADHD.

Children, by the way, it's six symptoms that have to be utilized.

However, if person B struggles with 5, 6, 7, 8, and 9, they can also be diagnosed.

And you might notice, there's only one overlapping symptom there.

So, they're both diagnosed with ADHD, but their presentation is gonna be very, very different.

- Oh, I was gonna say, you know, Kyle had a point that onset has before the age of 12.

And early intervention, absolutely important.

I love the early-intervention programs that we have in Illinois, which is like birth to three, and then after that it turns into preschool, helping kiddos.

What we tend to see, though, is we really see the symptoms kinda take off once they hit kind of that school age, because there's so much more demand on them to pay attention, to sit in your seat, to be quiet, to not do these things.

So, at home, prior to school age, the parents are like, "Oh, they're being a kid.

They're having fun.

It's not bothering me."

But when you get into that structure, that's kind of that school structure where it's like, "You need to sit.

You need to be quiet.

We have to study for four hours, then you can have a break."

Really, then we start seeing symptoms kinda take off, and having those demands put on a child to pay attention, do this, do this.

That's when people tend to realize, "Oh, there might be something else kinda going on here besides a kid being just a kid."

- Yeah, and just to expand on that even a little bit further, when it comes to ADHD, the younger ages, it's a lot of rote memorization, right?

And a kiddo might be able to get through some of that rote memorization very, very quickly because it's just memorizing, right, two plus two is four.

Where we really see in school age that kind of jump happen is kind of that third grade, because that's when it's not just rote memorization, it's not two plus two is four, it's now the dreaded story problem.

I have to now keep in mind Billy has two balloons, and he gives, you know, three, or two, one to somebody else, and then he gets three from somebody, and I now have all these different pieces that I have to keep in mind at the same time.

And when you're talking about somebody with a difficulty, right, with focusing for an extended period of time, those details become much more pronounced at that kind of third, fourth grade age.

So, if your kiddo does not struggle in first or second grade, and now is struggling third or fourth grade, that's maybe a good indication that some of their ability, their innate intellectual ability has been able to overcome, but now that it's the story problem, it's more challenging.

- It's that executive function that's a lot more difficult for 'em.

- So, as far as the effect it has on kids, I mean, school is up there for sure.

- And social interactions.

- Yeah, tell us about that.

- Yeah, so social interactions, one of the, you know, pieces of being able to hone in and attend to important stimulus is the social cues.

So, as I'm talking to you, I'm paying attention to the social cues I'm getting from your face, from your body language.

It's very challenging for kids with ADHD to pay attention to the social cues.

And so, they might think somebody that smiles is making fun of them.

And so, now they get frustrated because they misinterpreted that social cue.

- And how is it different in adults, or is it similar?

- Both.

It can be both.

I've noticed, as a practitioner, similarities; how we spoke about interrupting and not being able to, you wanna get that thought out real quick.

I see that a lot with adults, kind of being on the louder end.

I see a lot of the hyperactivity.

With adults, it might not necessarily be that they can't stay in their seat.

They might be overly loud, they're interrupting.

I see a lot of issues at work.

Is it affecting their work?

So, they might come across as very disorganized.

They might not meet deadlines the way they're supposed to.

They might lose things that are important for them to complete the task at hand.

So, I see that a lot more with adults than kiddos.

And then, it can really affect home life, too, you know, and their marriage and not getting projects done at home, their honey do list if it's not that it's always men, you know, but the honey-do lists tend to go to the guys, that they're not getting those things done or not starting a project, not finishing it at home.

- Yeah, I think that's one of the important factors, right, is we might have this great impulse; "I'm gonna go fix whatever," right?

And the ADHD, "Okay, go.

Go do it."

But we don't finish the task.

And I think one of the other fascinating things, and one of the most hopeful things to me as a practitioner, is we actually naturally see the hyperactive impulsive type of ADHD, the prevalence goes drastically down as we get into adulthood.

You're gonna see far more adults, if they're going in to be diagnosed now, they're diagnosed with the inattentive type.

It's less common for them to be diagnosed with the hyperactive impulsive type, or the combined type, because we naturally learn how to regulate our own behavior.

If I walk into a business meeting today, I'm not gonna see somebody jump on the table and start screaming about a movie they just watched.

I very well may see that at the elementary school, okay?

Now, will I see somebody staring off into the distance or doodling on their paper?

Yeah, but those are more those inattentive-type symptoms.

- Okay.

Something I was researching online is ADHD and what you call it, a condition, whatever.

I'm curious, is ADHD considered a disability?

- It can.

Under the Americans with Disability Act of 1990, it can absolutely be considered a disability.

The important thing to keep in mind is how much it's impacting their daily functioning.

So, does it have to be a disability?

No, because people can, like Kyle was saying, you know, as you you age, you tend to learn how to manage some of those symptoms.

So, it doesn't have to be a disability, but in some people, it absolutely can be, just depending on how much it's affecting their daily functioning.

- Yeah, I think I wholly agree, right?

It could be a disability according to federal law.

I think a more appropriate way to think about this is it's a neurodevelopmental disorder that impacts how the brain regulates attention, concentration, impulse control, and those kind of things.

- Doctor, tell me about ADHD triggers.

- So, this is one of those things that I feel like is a little misleading as well.

So, ADHD triggers would make it seem like I'm going along with no problems with ADHD, and then a trigger happens, and all of a sudden I have ADHD stuff going on.

That's not how it works.

Symptoms are present.

They're always going to be present.

I manage them with the tools that I've been giving from seeing a professional.

The ADHD trigger is, I am in a very chaotic environment, or I am in a situation in which there's just a lot going on that's hard for me, or I'm sleep deprived, right?

And now, my ability to manage those symptoms as I have done very well in the past is all of a sudden limited.

So, it's not that the trigger creates it, it's that the trigger, whatever that environment is, makes it more difficult for me to manage those symptoms appropriately.

- Michelle, what's ADHD rage?

Sounds a little scary.

- It does sound a little scary.

So, you know, as Kyle's was saying, you have your symptoms that are always kind of there, and you're managing them.

But sometimes, life can get a little too overwhelming.

And it's an intense frustration, intense anger that can come on when you finally just kind of hit your limit, you're overwhelmed, you're overstimulated, and you're like, "That's it.

I can't take it anymore."

And then, you see an outburst.

You tend to see it more often in children, hopefully, at school, and they frustrated, they're angry, they might throw a fit, whatnot.

And you're kinda looking at them, going, "Where did that come from?

That was something real simple that shouldn't have aggravated you that much."

And to us, it seems like, "Well, that wasn't a big deal," but to the person who's been trigger, trigger, trigger, overwhelmed, overwhelmed, overwhelmed, you've hit your limit, and you have this outburst, and it can kinda scare people or throw people off.

- We've explained to people what ADHD is, and we've talked about symptoms.

Let's talk about treatments, you know, whether it be pharmaceutical or otherwise.

What options are out there, doctor?

- Yeah, so there's really two approaches to take.

You have the therapeutic approach, which is, you know, talk therapy; It's called CBT, cognitive behavioral therapy.

And then, you have the medication piece.

I'll let her talk the medication piece here in a second.

But from the therapeutic talk-therapy approach, it's gonna look very different when we're talking about children versus adults.

So, I'm a pediatric specialist, so I'll talk about the, the peds more in depth.

But when it comes to ADHD, our kiddos struggle with what's called the internal locus of control, right, so that ability to really manage their own behaviors, 'cause the impulsivity is there, 'cause they're not attending.

And so, from a treatment perspective, we rely on what we call the external locus of control, which would be the parent or the teacher.

And so, treatment for ADHD looks a lot like we're actually training those people in the child's life in order to help them create a structured environment in which that child's gonna thrive.

So, a great example is, if I have a parent come to me, their child is really struggling in school, they're not, you know, getting their homework done, so they're failing all their classes.

That does not mean that they're not intelligent.

What it means is we are having something that's creating a barrier.

So, we will track all the way back, and we will find out, "Oh, they're not writing their assignments down," or, "Oh, they have their assignments written down, but they're not bringing their materials home.

They didn't bring their math book home, so they can't do their math homework, so now they can't turn it in, and they get, you know, poor grades."

And so, intervention would look like we're gonna work with a teacher to help that child get them to write their assignments down.

And we're gonna work with the last teacher of the day to make sure that that child is getting all the materials out of their desk into their backpack so it's coming home, so a parent can now look at here's what the homework is, it's written down.

Here's what the materials are, and we can get that done.

And over time, with enough repetitions, that child doesn't need the teacher to tell them to write their homework down.

They're just starting to write their homework down, and they don't need the teacher to prompt them to pull their materials out.

They're starting to learn that.

So, it's that habit that's formed that can help that child manage some of those symptoms.

- Yeah, from a medication standpoint, there are stimulants and non stimulants.

Gold standard for ADHD is a stimulant.

And especially with children, stimulants work the best.

Many various different types of stimulants, but stimulants, so Ritalin, Adderall, Vyvanse, Concerta; those are common names that people would recognize for stimulants.

Non stimulants, we have straterra, which is a little newer on the market; I'd say a few years, you know, not brand new like this year, but that one's a non stimulant.

And then, especially with adults, we try to utilize some other non-stimulants.

So, we have Wellbutrin, which affects the norepinephrine and dopamine receptors in your brain, and that can really help with the attention.

And same with sometimes some SNRIs can help because of the norepinephrine can kinda help people focus a little better, give them a little pep in their step to focus a little better.

- Are doctors more inclined to give an adult medication as opposed to a child?

Or would they try other things with the child first, and if those didn't work, do the medication?

- So, I would say, right, and I work with all the pediatricians in the area very closely, and I would say, please send them to me first.

Let me get some of my therapeutic work done first, and then we can bring in a stimulant if necessary.

And here's why.

The stimulants really do work very, very well, right, when you find the right one, and we call them medication trials for a good reason.

You do have to try out a few before you maybe find the right one or the right dosing, you know, of that.

But they do work very, very well.

So, I have a family that's really been struggling with their children's ADHD, and they get put on a medication.

And now the referral got put into me a couple months later in to see me, and I say, "All right, what's going on?"

They're like, "Oh, no, we're good."

Well, no they're not, because the reality is, once that medication's outta the system, which happens at about three, four o'clock, you know, in the afternoon.

- If that.

(laughs) - All of the symptoms are right back to where they started.

Or if there's a health issue and that child can no longer be taking that medication, nothing was done, right?

So, I really prefer, let's come in, let's get some of the treatment end outta the way.

Let's get those things in place, those routines, those organizational skills.

And now, if we're still struggling, now we can use that medication to bring that barrier down a little bit.

- You know, with anything, when we treat any type of disease process, the first thing we like is lifestyle modification, no matter what it is.

If it's diabetes, hypertension, ADHD, lifestyle modification is one of the first things that we want to do.

So, that's comes the therapy, learning routines, and how to manage some of your symptoms before we try medicating.

So, I 100% agree with Kyle; if we can do it without medication, awesome, or can we learn some skill sets first before we add on those medications?

And that's the same for a child versus adult, hands down.

- Yeah, and I do wanna touch on, 'cause I touched on the pediatric level of this, but I didn't talk about the, you know, CBT for adults.

It's a little simpler for adults, right, 'cause we don't have to necessarily involve teachers, or we're not gonna involve your boss, right, to help you get your stuff done at work.

But, so it's a little easier, 'cause they have developed the ability, they've developed some skills, and so we use CBT to help improve those problem-solving skills, their organizational skills, task initiation, time on task, things like that.

At the same time, though, it can also be a little bit more challenging.

If we're talking about a 50-year-old, they've been dealing with some of these symptoms of ADHD for, you know, 40, 45 years.

And so, some of that does take a little bit more to break through.

- Real quick before we go, what's the best lifestyle for someone with ADHD if they can control their environment.

Let's start with the kids.

- Yeah, so having a routine and a structure.

It's the easiest way that we can mitigate some of these difficulties from the outset, - Michelle?

- Exactly the same.

Having a routine and structure, that's gonna be the best thing for an adult, as well, to manage their symptoms.

- Okay.

Well, it's a very interesting topic.

It's one of those conditions that I think people that don't have it don't necessarily understand it and don't take it seriously, but if you have it, it's not fun.

- [Michelle] No, it can really impact your daily functioning.

- Yeah.

Well, it's good that there are treatments out there, and we appreciate both of you coming on to explain all of this, because it's, like I said, very fascinating but complicated.

Dr.

Kyle Boerke, the Director of Behavioral Health Ambulatory Services with OSF Healthcare; and Michelle Little, family nurse practitioner with OSF Healthcare.

Thanks for coming in.

- Thank you.

- Thanks for having us.

- Appreciate it.

And thank you for joining us.

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