Earlier this week the American Academy of Pediatrics released new guidelines for treating and diagnosing ADHD. The disorder, often characterized by hyperactivity and an inability to focus, is thought to affect about 8 percent of all kids. The new guidelines aim to help pediatricians identify ADHD in children as young as four. Previous recommendations applied to children six and up. Many pediatricians agree that attention deficit problems can be apparent in preschool age children, but there is debate over what treatments, if any, are appropriate. Join us to talk about diagnosing and treating ADHD in young children

Guests

  • Dr. Claudia Gold pediatrician and author of "Keeping Your Child in Mind"
  • Rick Ostrander associate professor and director of Pediatric Medical Psychology, Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.
  • Dr. Mark Batshaw executive vice president and chief academic officer, Children’s National Medical Center; professor and chairman, Pediatrics, George Washington University School of Medicine and Health Sciences.
  • Dr. Mark Wolraich professor of pediatrics, University of Oklahoma Health Sciences Center lead author, ADHD clinical practice guidelines

Transcript

  • 10:06:56

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. ADHD is the most common neurological disorder diagnosed among children. The American Academy of Pediatrics has issued new guidelines to help pediatricians recognize and treat ADHD in children as young as four. Joining me here in the studio to talk about the new ADHD guidelines: Dr. Mark Batshaw of the Children's National Medical Center, Dr. Rick Ostrander of the Johns Hopkins Children's Center.

  • 10:07:42

    MS. DIANE REHMJoining us by phone from Great Barrington, Mass., Dr. Claudia Gold. She's a pediatrician and author of "Keeping Your Child in Mind." I know that many of you are interested in this new research, this new report and in ADHD generally. I hope you'll join us, 800-433-8850. Send us your email to drshow@wamu.org. Feel free to join us on Facebook or Twitter. Good morning, Dr. Gold. Thanks for joining us.

  • 10:08:33

    DR. CLAUDIA GOLDThank you for having me.

  • 10:08:34

    REHMAnd to you, Dr. Batshaw, what's new in these guidelines, from your perspective?

  • 10:08:43

    DR. MARK BATSHAWWhat they're really doing is codifying changes that we've started to recognize over the last five to 10 years. One of those is that ADHD can be recognized earlier than was thought previously. While it was thought that you really have to wait till six years of age, now it's thought that, really, you can diagnose it as early as four years of age. And, similarly, while it used to be thought that this was a childhood disease, we now recognize that, in a sense, it's a chronic illness that can go into adulthood.

  • 10:09:22

    DR. MARK BATSHAWAnd then, lastly, it really focuses on the treatment approach, the importance of the combination of behavioral management and medication management and recognizing that ADHD may be associated with other conditions and that if you don't recognize these other conditions and treat them as well, you'll not get optimum outcome.

  • 10:09:44

    REHMWhat kinds of other conditions are you talking about?

  • 10:09:49

    BATSHAWWell, about one-third of the kids who have ADHD will also have learning abilities, and about 10 percent of them or more will have behavioral issues, such as oppositional defiant disorder or...

  • 10:10:04

    REHMWhat does that mean, oppositional defiant disorder?

  • 10:10:08

    BATSHAWWell, Rick can speak to this even more than I, but it basically is the child who has difficulty following directions and is oppositional to those directions. Rick?

  • 10:10:22

    DR. RICK OSTRANDERYes. Well, children with ADHD display a lot of behavior -- a lot of behavioral excesses. They don't pay attention. And so it's not surprising that they sometimes don't do as you tell them to do. They appear to be, in some cases, volitionally disobeying directors or parents, teachers and the like. And these oppositional tendencies tend to be more prominent largely because they have such a high level of behavioral excess. They're always on the go.

  • 10:10:58

    DR. RICK OSTRANDERMany of us have children that are -- we're lucky that don't have those types of behavioral excess, and so trying to -- getting them to be redirected is not all that big of a chore by comparison. Whereas these children, they are so active that constantly giving them feedback about how to behave more appropriately is a very difficult proposition for teachers and parents. And that's the result. They have more oppositional tendencies.

  • 10:11:26

    REHMAll right. And we're joined now by Dr. Mark Wolraich. He is professor of pediatrics at the University of Oklahoma Health Sciences Center. Good morning to you, sir.

  • 10:11:41

    DR. MARK WOLRAICHGood morning.

  • 10:11:42

    REHMI gather you were the lead author in this ADHD -- developing these clinical practice guidelines. Other than broadening the scope in terms of age -- rather than six to 16, it's now looking at young children as young as four -- how helpful do you believe these new guidelines will be to physicians and others treating, working with children who have ADHD?

  • 10:12:23

    WOLRAICHWell, I think they will be quite helpful, and we gave a good deal of thought to it. We, from our first guidelines, have combined both the diagnosis and treatment together. We've also included in the appendix, what we call, a process-of-care algorithm, and that takes the condition step by step to the process of what they can do to meet the guidelines. And then, in addition to that, we have revised to the toolkit based on our process-of-care algorithm so that they can also have the tools that are useful for the recommendations that we are encouraging them to use.

  • 10:13:07

    REHMTell me, Dr. Wolraich, how do you make a distinction between the normal rambunctiousness of young kids to what is now deemed to be ADHD? I find myself worrying about the expansion of this age parameter simply because it takes into account kids at age four are -- who are normally in that mode of behavior.

  • 10:13:45

    WOLRAICHWell, I think, two things. One, we really haven't expanded the ages. So that age was -- there was no lower age requirement that was put on the criteria for ADHD. And what we're doing is trying to provide better guidelines for how the clinician can distinguish that. And I think one -- what's key to the diagnostic criteria are not just the behaviors, but that those behaviors are causing significant dysfunction.

  • 10:14:17

    WOLRAICHSo we're talking about 4- to 6-year-old. We're really talking about the children who are not functioning well if they're in daycare or preschool program. Many of us have had patients who've gotten kicked out of two or three programs before here -- beforehand, are frequently in turmoil with their parents who are managing -- trying to manage their behavior. They tend to have more risky behaviors that you'll see because they're impulsive. So it's not just that you're looking at the behavior spectrum, but that those behaviors are causing significant problems for the children.

  • 10:14:59

    REHMAnd help me to understand how long one might observe a child before understanding really rationally that this is more than just ordinary rambunctious behavior.

  • 10:15:18

    WOLRAICHThe requirements for the -- that classification system, the DSM system has had -- is that it needs to be present at least for six months. And they -- since it's really something that is usually occurring from birth, even if we're not seeing it, they have concluded that it needs to be presenting before the age of seven. And then to be conservative with preschoolers, we've used the criteria that was used in a large multi-site study to examine method -- standard they used, which to be nine months rather than six months.

  • 10:16:01

    WOLRAICHSo we're really recommending to pediatricians to be more conservative in their consideration for -- particularly treatment with medication for children under six years of age.

  • 10:16:14

    REHMAnd who would be doing the observation as to the recommendation for medication?

  • 10:16:25

    WOLRAICHOur recommendations in the guidelines, which is carryover from our original recommendation, is to, if at all possible, have multiple sources and particularly parents and teachers have it for both because teachers are seeing children frequently for up to six hours a day. And they're also seeing them with same-age peers, so they have a really good sense of what children can do most of the time.

  • 10:16:57

    WOLRAICHSo -- and we're encouraging that, and that's also one of the reasons we included -- if we're talking about preschoolers that where possible they are enrolled in programs or at least there's a parent training program where there are some other observers of the child's behavior and the parent and child's interaction that's taken into consideration when deciding how serious the child's behaviors are.

  • 10:17:27

    REHMDr. Wolraich, what do you see as the risks of giving young children these medications? For example, Ritalin is the one that's most talked about. Are there any risks to those young children?

  • 10:17:48

    WOLRAICHThere are going to be risks with any intervention that's used, and even if we want to think in terms of behavioral intervention, there are risks to it. There certainly are risks to medication. And, again, we tried to be conservative in -- as using that as the last choice in terms of the intervention, which is a little different from we -- what we recommended for older children because there's a lot more evidence about the long-term effects or lack of long-term effects in older children.

  • 10:18:24

    WOLRAICHThere are certainly significant side effects, like reduction in appetite and possible difficulty with sleep, that we looked at. There are some children who have unusual reactions by creating bizarre behavior in that. There has been another thing...

  • 10:18:43

    REHMDr. Wolraich, I'm afraid we're out of time here.

  • 10:18:46

    WOLRAICHOkay.

  • 10:18:47

    REHMI want to thank you so much for joining us from the University of Oklahoma Health Sciences Center.

  • 10:20:03

    REHMAnd welcome back. You've just heard about a new set of guidelines issued by the American Academy of Pediatrics to help pediatricians recognize and treat ADHD in children as young as four. I hope you'll join us, 800-433-8850. Here in the studio, Dr. Mark Batshaw of the Children's National Medical Center and Dr. Rick Ostrander. He is assistant professor in the division of child/adolescent psychiatry at the Johns Hopkins University Children Center.

  • 10:20:54

    REHMAnd on the line with us, Dr. Claudia Gold. She is a pediatrician and author of "Keeping Your Child in Mind." Dr. Gold, I want to turn to you. Having heard from Dr. Wolraich about these new guidelines, what's your reaction?

  • 10:21:16

    GOLDWell, I think this is a very important discussion because it focuses attention on the social-emotional needs of the under-six age population, and I actually feel privileged to be part of the discussion. Also at the AAP meetings, there was presentation of the explosion of research and knowledge about early childhood development, and I'm absolutely in agreement that children under six can struggle significantly. In fact, kids who have behavior problems that present at four, often the roots are seen in infancy.

  • 10:21:48

    GOLDIn addition, there's a lot of research about gene, environment interaction, how early relationships shape the brain and how supporting early relationships promotes healthy development. And, conversely, that chronic stress in early childhood leads not only to emotional problems, but also problems of chronic illness. So I absolutely am in agreement that early intervention is essential. However, I differ markedly in terms of my idea about what form that intervention should take.

  • 10:22:23

    GOLDAnd I have concerns that, by describing these range of emotional difficulties that these children can have as ADHD, you're looking only at symptoms rather than underlying cause. If I may go on, in addition to focus on -- the treatment guidelines recommend things such as parent training, management of behavior. Families and clinicians often experience frustration when they focus exclusively on behavior rather than underlying cause.

  • 10:22:51

    GOLDAnd, in fact, there is extensive research by such people (unintelligible) and Peter Fonagy that show that children develop the capacity for self-regulation, which includes attention, behavior and emotion, when their caregivers respond to the meaning of their behavior rather than simply the behavior itself. And so my -- yes.

  • 10:23:23

    REHMDr. Gold, give me, if you can -- give me an example of exactly what you mean.

  • 10:23:29

    GOLDOkay. Sure, I have -- you know, so a child presents in school unable to sit in circle of time. You know, you do the Vanderbilt. They have the classic symptoms of ADHD. They're impulsive. They're inattentive. They're hyperactive. So that, you know, if they -- and -- but then you go and you take a detailed history, and you learn such things as, from birth, the child was very dysregulated, had trouble sleeping, was hard to feed, entered toddlerhood having above and beyond the normal number of tantrums.

  • 10:24:07

    GOLDIn turn, this may create a situation where there's marital conflict because the family is stressed by having a difficult child, and, you know, there's a whole -- either may have been lost. People -- I had one family where an uncle died when the mom was pregnant with the child. So -- and there's unprocessed grief that gets in the way of being with the child, so all sorts of things can be going on that are underlying causes of these symptoms. And...

  • 10:24:35

    REHMInteresting. All right. I do want to inject here an email from Cristina, which relates specifically to, perhaps, the new guidelines. She says, "My son finally got diagnosed ADHD this past summer. He won't be six until January. I've known since he was at least four that something was not right, but no one would listen to me because they said nothing could be diagnosed until he was six. He was kicked out of preschool at four, put into an autism program because his behaviors were so out of control."

  • 10:25:25

    REHM"He is now mainstreamed in kindergarten, but still gets special ed assistance because he was under six. We had to jump through a million hoops costing lots of money between pediatrician, psychologist and psychiatrist before we finally got him medication. I'm thrilled they had now lowered the age to four. We could have helped him two years ago instead of struggling with it. Now, it's hard on his relationships with other kids, teachers, although now, the medicine is helping a lot. I'm very happy about this decision." Dr. Batshaw.

  • 10:26:14

    BATSHAWWell, I think this really points out that the medications really can be very helpful. And it's interesting that stimulant medications probably have the worst reputation of any medication in our armamentarium in medicine. And yet, in many ways, they are best medication other than aspirin in terms of a benefit-versus-risk ratio. When you have a correctly diagnosed child, as it sounds like Christine's son is, medication works in 80 to 90 percent of these kids to improve the core symptoms of ADHD.

  • 10:26:58

    BATSHAWAnd while there are side effects, which include stomachache, headache, sometimes sleep problems and being not very hungry for food at lunchtime, these tend to be rather mild and, in many cases, they'll go away within a couple of weeks. So the medication, when properly used, can be extremely helpful.

  • 10:27:26

    REHMDr. Ostrander, when you hear an email like the one from Christine and you think about that parent's statement, I knew something was wrong with my child, and yet, apparently, she knew as early as two, what is the risk of offering these medications to a child between, say, two and four?

  • 10:27:59

    OSTRANDERWell, we really don't know that's a problem with a child that age. And I think, you know, with, as you mentioned earlier, children that are two are -- parents pray for when they turn three because they're so rambunctious, who are exuberant, perhaps, is another way to put it. So I think that's one of the reasons why I think the guidelines are pretty measured in terms of, you know, being very cautious about trying medications in particular. And, actually, what they recommend first is parent training or behavior modification.

  • 10:28:32

    OSTRANDERSo I think that, you know, with these very young children, you always want to err on the side of doing something that is less invasive, less medically oriented and more behaviorally oriented. But there are -- you know, there are some risks. In the study that was looked at, treating these children with medications, they did find some other side effects, including some irritability on some rare occasions immediately after taking the medication. There is some growth retardation that is -- it's held back based upon the dosage.

  • 10:29:09

    REHMYou mean height?

  • 10:29:10

    OSTRANDERHeight, exactly.

  • 10:29:11

    REHMI see.

  • 10:29:12

    OSTRANDERAnd -- but it's on every kid, and it's all related to the dosage. But on the other hand, I want to reinforce the fact that children with severe ADHD are at risk for a whole range of problems longitudinally. And about 30 percent of these children have something -- some other disorder that we believe may be the early stages of those other disorders are -- you can find them in these early years when they're interacting with adults and other children.

  • 10:29:43

    REHMAll right. I want to open the phones now. The lines are absolutely filled. As I suspected, there are a great many people who'd like to be part of the conversation. First, let's go to Helsinki, Finland. Good morning, David. You're on the air.

  • 10:30:03

    DAVIDGood morning. I'd like to know if this is becoming a witch hunt. Basically, what I'm worried about is the teachers with larger pupil classes and not having the time or the ability to take control of a class of 35 students at the very maximum.

  • 10:30:23

    REHMDr. Gold, what's your thinking there?

  • 10:30:28

    GOLDWell, I definitely think that the school environment is very important to look at. And, certainly, when children have impulsive behavior and it's a large classroom, it is a very difficult problem. And it's quite common in my practice for kids to come with the question, rule out ADHD as referred by their preschool teacher. And, again, as I was saying earlier, I often uncover, you know, a very complex story.

  • 10:30:59

    GOLDAnd I think that it's important to look at this beyond, does he or does he not have ADHD? But, really, what is going on for this child, and what is going on for this family? And if I may just speak to the mom before, with the email, that I think it's so important to validate a parent's experience from very early on, from when that child was two, and not say because there's no diagnosis, there's nothing wrong because there is something wrong, and they're struggling.

  • 10:31:31

    GOLDBut there are a whole host of other ways to intervene, a number of very well-studied programs that support parents when they're struggling in early years. So my hope would be to develop those kinds of programs rather than focus on just this question, does he or does he not have ADHD?

  • 10:31:53

    REHMDr. Claudia Gold, she's a pediatrician and author of "Keeping Your Child in Mind." And you're listening to "The Diane Rehm Show." And we'll take another call, 800-433-8850. First now to Mount Dora, Fla. Good morning, Ross. You're on the air.

  • 10:32:22

    ROSSGood morning. As a psychiatric physician assistant who has treated these children for 13 years, I'm concerned, on the one hand, that there's so much emphasis on hyperactivity. And inattentiveness is such an issue, particularly in girls, which is often girls aren't diagnosed, and the fact that sleep quality is such an important issue.

  • 10:32:53

    ROSSI found that -- when I found lowest effective dose, which helped improve these children's sleep quality, that they improved in a lot of other areas, I used the metaphor with -- explaining to patients and parents, especially, who are concerned that their children are being labeled, that it's like going through life with the wrong glasses prescription.

  • 10:33:18

    REHMMmm. Dr. Batshaw, what about girls? Are they less frequently diagnosed because boys tend to be more rambunctious?

  • 10:33:33

    BATSHAWWell, as is true of almost every developmental disability in childhood, boys are more affected than girls are. So I think, clearly, the epidemiologic evidence suggests that four to six times as many boys are affected as girls are. But girls...

  • 10:33:50

    REHMIs it that boys are four to six times more frequently diagnosed rather than affected?

  • 10:34:01

    BATSHAWWell, we think that ADHD has a very major genetic component, and girls have two X chromosomes, and boys only have one. And it appears that that second X chromosome is protective against a large number of disorders. So we think it's a real thing that boys are more frequently affected by ADHD. But, as you said, because they tend to be hyperactive and obnoxious more than girls are, they're also going to be identified earlier. But the important point that was being made was that it's important to identify girls.

  • 10:34:37

    REHMAnd, Dr. Gold, what about the idea of beginning at lowest dose possible?

  • 10:34:48

    GOLDWell, again, under age six, I think that there's a risk of going to medication at all because what happens is the medication may work -- and I agree with what's been said that these medications are very effective at calming symptoms -- but it invariably only lasts for a while. If you're -- or, you know, in an ideal situation, it lasts six months, but often they come back. The medication is not effective anymore. The dose is increased. A different medication is added.

  • 10:35:23

    GOLDAnd what happens is the whole focus of the treatment is about the dose of the medication. And so many other things that are going on in the child's life tend to kind of fall to the wayside. And I don't think that's the intention of the new guidelines, but, unfortunately, because there is such a shortage of other mental health services for young children, it may be an unintended consequence of the new guideline.

  • 10:35:49

    REHMDo you agree with that, Dr. Ostrander?

  • 10:35:52

    OSTRANDERWell, actually, I think that's one of the problems with the guidelines, actually, is that, in an ideal world, we would provide some type of behavioral intervention as a first line of...

  • 10:36:04

    REHMEarly on.

  • 10:36:04

    OSTRANDERVery, very early on. Unfortunately, it's hard for the lay public to know where to get that. It's not generally available. And it's not -- you know, you could go to your very well-intended and even very well-respected psychologist, who may be an expert in play therapy. That's not what you're -- you're not going to get behavioral therapy necessarily under those circumstances. And so what you're really doing with behavioral therapy is teaching the parent to be a behavioral therapist at home.

  • 10:36:34

    OSTRANDERAnd it's teaching these basic fundamental skills in order to teach them how to more effectively deal with their children because, after all, they're dealing with a child that has some risk that other parents typically don't have to address. And so they need to be more skilled at being -- at parenting, and that's what these behavioral interventions are intended to do. Unfortunately, there's no way for the lay public to really identify those practitioners in their community that can provide this type of service.

  • 10:37:04

    REHMYou mean there is no list of psychologists, psychiatrists who address these kinds of issues nationally.

  • 10:37:15

    OSTRANDERThere's no comprehensive way of people finding out whether their practitioner has the skill set or the orientation necessary to be able to provide these.

  • 10:37:25

    REHMDr. Rick Ostrander, he is chief of neuropsychology at the Johns Hopkins University Children's Center. We'll take just a short break here. More of your calls when we come back.

  • 10:40:03

    REHMAs we talk about the new pediatric guidelines for children with ADHD, we must not forget that, indeed, we have a number of teenagers, young adults who have been diagnosed with ADHD. Here's an email from Ruth, who says, "Where can I go for help in parenting my ADHD teenager with oppositional defiant disorder?" How do you address something like that, Dr. Ostrander?

  • 10:40:44

    OSTRANDERWell, the same basic behavioral principles are applicable for older children, adolescents, as they are with younger children. But the methods by which we implement those principles are somewhat different. And with -- as a general rule, what you're trying to do is focus the child on some rather specific, the most salient aspects of their lives to make sure that they get those tasks addressed, whether it's work, school, social relationships because you're not going to be able to treat all this -- the manifestations of ADHD, but if you focus on the things that are the most critical to that child...

  • 10:41:22

    REHMLike?

  • 10:41:24

    OSTRANDERThe most important ones are school-related, vocational-related issues and also social interactions.

  • 10:41:31

    REHMAnd, unfortunately, schools don't have the resources to deal with this kind of problem. And, as you've said, parents don't know where to turn. Dr. Gold, what would you say to the mother of a teenager with so-called oppositional defiant disorder?

  • 10:41:57

    GOLDWell, I think there are -- I look at three main areas, and one of them is certainly in an older child. There is a role for medication when school performance is affected, self-esteem is affected. There's a large body of literature about actual physical activities that can help children with help regulation, things like drumming, tae kwon do, swimming. So I think that looking at those is an important component of treatment.

  • 10:42:28

    GOLDAnd then the third thing is to look at the family situation, their, you know, family conflict is certainly associated with increased risk of ADHD. Often the problem itself causes family conflict because the family is struggling with the child who's -- who himself is struggling. But you can really...

  • 10:42:48

    REHMAll right. Let me, if I may, just go on and read the second part of Ruth's email because it does bring in something very important. She asks, "What medications are the safest?" She says, "We had a scary experience with Adderall when our son developed suicidal thoughts." Dr. Batshaw.

  • 10:43:17

    BATSHAWWell, stimulant medications, which include Adderall, is an amphetamine. And then Ritalin is methylphenidate. Those are the two types of stimulant medications. One has to be careful about potential side effects and looking for those things. They tend to be very rare. In fact, the suicidal ideation tends to be more common with drugs like Strattera than with the stimulant medication.

  • 10:43:47

    BATSHAWAnd you try and use -- you start at a low dose and see what is the lowest dose you can use in order to get efficacy, and you see do you need to use it every day or can you use it just five days a week, not use it on weekends, not use it during the summer or at holidays.

  • 10:44:06

    REHMGosh, you've got to be so careful. Let's go to Midland, Mich. Good morning, Matthew. You're on the air.

  • 10:44:15

    MATTHEWGood morning. I have a question. I was diagnosed with ADHD when I was about 21, and this was after a number of, I guess, behavioral issues and substance abuse. And, I guess, my question would be, how would you address the behavioral issues? I guess, for me, medication works the best so far, and that's what I take daily (unintelligible).

  • 10:44:45

    REHMWhat kind of medication do you take, Matthew?

  • 10:44:50

    MATTHEWI take Vyvanse.

  • 10:44:52

    BATSHAWVyvanse is one of the amphetamine medication and -- which is very good. The issue of adult ADHD, really, if you take the guidelines, the question is whether you had had symptoms as early as childhood and they just became worse over time or they suddenly developed.

  • 10:45:15

    REHMInteresting. All right. To Cleveland, Ohio. Good morning, Gina.

  • 10:45:21

    GINAGood morning, Diane.

  • 10:45:23

    REHMGo right ahead, please.

  • 10:45:26

    GINAI have an 8-year-old son who was diagnosed with ADHD when he was five. I knew by the time he was three or four that there was something wrong with him. And we struggled greatly with the medication issue, but we went forward with it because he couldn't function in school. He couldn't sit still. He couldn't basically do anything.

  • 10:45:51

    GINAWe tried behavior modification classes, but the issue was he wouldn't sit still. He wouldn't talk. He wouldn't focus. Now that he's on the medication, he's a straight A student, the best reader in his class. And without it, he wouldn't be in public school.

  • 10:46:08

    REHMThat's interesting. Dr. Gold, Do you want to comment?

  • 10:46:13

    GOLDWell, again, as I said before, the medication, certainly, are very effective. And as in -- when kids are in school and the academic pressures increase, I think there is a role for them.

  • 10:46:24

    GOLDI want to just address this issue of behavior therapy because, again, when you start with the much younger children when they're two or three, there are a number of very well-established interventions, such as the Minding the Baby program at Yale, Circle of Security, Promoting First Relationships, that work with parents and children together to promote the ability to self regulate, which is really what ADHD is a problem of, self regulation.

  • 10:46:52

    GOLDSo there are other forms of intervention besides behavior therapy. And, again, that kind of undermines the parents' natural authority if you give them training. But there aren't that many services. The problem is if the AAP kind of endorses medication in very young children, it will decrease the motivation to improve access to other interventions. And that's my biggest worry in very young children.

  • 10:47:15

    REHMWhat do you think, Dr. Ostrander?

  • 10:47:18

    OSTRANDERWell, I think that, you know, by far measure, the behavioral therapies tend to be the ones that has the greatest empirical support. Now, I'm not to say -- that's not to say that there are not other interventions that are not effective. But, you know, if -- what you -- it seems to me, the most prudent course is to take the medications that have the greatest demonstrated efficacy and try those first.

  • 10:47:43

    BATSHAWIf you don't achieve the -- you know, the level of improvement that you would desire, then it's -- I think it's a fair game to move on to some other interventions that are less validated in the literature. I think that -- you know, I want to mention one other thing Dr. Gold mentioned. I absolutely agree that sometimes, these kids' behaviors are so dysregulated that it does cause family difficulties.

  • 10:48:08

    BATSHAWAnd it's those family difficulties then, in turn, that causes other kinds of emotional behavioral problems. So it's a very dynamic process where the kid's behavior might inspire this certain parental reactions, peer reactions...

  • 10:48:23

    REHMIt becomes very circular.

  • 10:48:25

    OSTRANDERCircular, exactly.

  • 10:48:26

    REHMAll right. Let's go to Berlin, Germany. Good morning, Marchelle. (sp?)

  • 10:48:31

    MARCHELLEGood morning. Hi. Thank you for taking my call.

  • 10:48:33

    REHMSurely.

  • 10:48:34

    MARCHELLEI just want to include that my kids have had these issues, and I did notice it early on. And, yes, I know that there are drugs available. But there are also other ways. At least in our family, it's been very effective. We have changed their diets. We have given them omega-3s. We have put them on behavioral programs. We have meditated. We get them off sugar. We get them outside, doing sport on a daily basis, and it's been totally manageable.

  • 10:48:59

    MARCHELLEYes. There have been real boohoo moments, real moments of struggle and real challenges. But on the flip side of this coin, as this thing that is being called an illness or a disease or a dysfunction or whatever you want to -- whatever I'm hearing, the other side of that coin is these kids have amazing heads, and they see things in ways that I don't see them. And I'm forever impressed by their perspectives and their intelligence and their spatial reasoning and all of these other things. And I wouldn't change their minds with a chemical. No way.

  • 10:49:36

    REHMMarchelle, I appreciate your call. Dr. Gold, what about sugar? There are an awful lot of people who wonder about that, and, please, be brief.

  • 10:49:48

    GOLDOkay. Well, there is anecdotal evidence for diet having a role, and, certainly, in some individual cases, that is true. I want to speak, if I may -- I really appreciate that these kids have many strengths, and I think the model of calling this an illness is a big problem, and that looking at the whole picture, physical activity, diet, all of those things to help kids develop these as strengths in the future where they may be very challenging for families when the children are very young.

  • 10:50:20

    REHMAll right. Dr. Claudia Gold, she is a pediatrician and author of "Keeping Your Child in Mind." And you're listening to "The Diane Rehm Show." Let's go to Indianapolis. Good morning, Amy. Thanks for joining us. Go right ahead.

  • 10:50:42

    AMYGood morning. I have two boys, one is 20 and one is 15, and I also have a 12-year-old girl. But my oldest son was diagnosed with ADHD at about 4- or 5 years old. Excuse me. And the first medication we tried was Dexedrine, I believe it was called. It was very powerful medication, and then on to Ritalin. And now, I don't know if this is hereditary or what, but in my second son, who's now 15, I withdrew out of high school yesterday because of behavior problems.

  • 10:51:23

    REHMOh, I'm so sorry.

  • 10:51:25

    AMYI did take him to the pediatrician, and they recommended that he be put on Zoloft. In the school, I had -- I really kept this child busy in sports. He was very active and all of that stuff that the last caller mentioned. And we were able to control all of these. Now, since he's been out of sports, all these behavioral issues are coming up in school. And just like the doctor said before, if there's no diagnosis, there's no problem.

  • 10:52:02

    AMYSo being expelled, constantly being removed from the classroom, now falling behind and failing, I had no -- I mean, at this point, I felt I had no other choice but to try to, you know, try to -- try a medication to help him to be able to complete high school. And just like everybody else, I don't know where to go for help.

  • 10:52:27

    REHMWhere would you suggest, Dr. Batshaw?

  • 10:52:31

    BATSHAWWell, what you see is as children get into high school, the pressures become greater, the need for planning for long-term projects. And thing -- if a youngster has ADHD, frequently the symptoms can become more -- even more apparent at that point in time.

  • 10:52:52

    REHMDr. Gold, what would you say to Amy? First, on the question of hereditary factors that could be at work.

  • 10:53:04

    GOLDWell, there's definitely hereditary component and often does run in families. But, again, the research that I alluded to at the beginning had shown that there may be a kinetic vulnerability, but that doesn't necessarily mean you have the disorder so that, you know, by impacting on the environment and a variety of ways, you can change the developmental trajectory in any one individual child.

  • 10:53:30

    GOLDSo -- but I also want to speak to this issue of no diagnosis and no problem. I think that it's important to be able to validate a parent's experience without necessarily having to have a label of a major psychiatric diagnosis.

  • 10:53:44

    REHMSo are you saying that ADHD is somehow being overdiagnosed?

  • 10:53:54

    GOLDI think it's oversimplification often of more complex problems.

  • 10:54:00

    REHMHow would you speak to that, Dr. Batshaw?

  • 10:54:03

    BATSHAWIt's being both overdiagnosed and under-diagnosed. In one study, they show that one-third of children who are on stimulant medications, when it was looked at carefully, did not really have ADHD. And one-third of children who had ADHD and could benefit from medications were not on it.

  • 10:54:23

    REHMHas anybody done a significant test on the relationship between the intake of sugar and ADHD? Dr. Gold.

  • 10:54:37

    GOLDWell, again, I think there are a lot of studies about diet and not only sugar but food dyes and wheat. And I think that the evidence is primarily anecdotal. And, again, in any one individual child, they may do tremendously well on a specific diet. However, there are downsides. Some of the diets can be quite restrictive. In addition, if you have a side effect that you're getting into a huge amount conflict in a family around food, then the treatment may be worse than the problem. So it's a complicated issue.

  • 10:55:10

    REHMOf course. All right. One last quick call from Gary. He's in Harrington, Del. Good morning to you, sir.

  • 10:55:19

    GARYGood morning, Diane. How are you?

  • 10:55:21

    REHMFine, thanks. Quick call, please.

  • 10:55:23

    GARYMy daughter, at around 10 years old, was having problems with behavior. Bottom line is we took her to a psychiatrist who put her on Abilify, Celexa, number of other drugs, then she became suicidal, self-mutilating. The social worker and my daughter both decided they want to get her off of everything, clean her body out and then start from scratch. This is after about seven years of the meds. And the bottom line is she's been free from meds. She went off them. And I would say 95 percent of the problems went away.

  • 10:56:00

    REHMThat's interesting. What do you think of that, Dr. Gold?

  • 10:56:04

    GOLDYeah. I'm not surprised. I mean, certainly Abilify has huge side effects, a very powerful medication for a developing, growing brain. And that's not uncommon that you have the medication, you get sort of into this -- stuck in the cycle of adjusting the dose and adding something else. And the medication itself, eventually, may be causing the problem.

  • 10:56:27

    REHMDr. Claudia Gold, she is a pediatrician, author of the book titled "Keeping Your Child in Mind," Dr. Rick Ostrander, assistant professor in the division of child/adolescent psychiatry at the Johns Hopkins Children's Center, and Dr. Mark Batshaw, executive vice president, professor and chairman of pediatrics at George Washington University School of Medicine and Health Sciences. More questions than answers, but I thank you all so much for joining us. Thanks for listening, all. I'm Diane Rehm.

  • 10:57:10

    ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture, Monique Nazareth, Lisa Dunn and Nikki Jecks. The engineer is Erin Stamper. A.C. Valdez answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our email address is drshow@wamu.org. And we're on Facebook and Twitter. This program comes to you from American University in Washington. This is NPR.

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