NIMH Expert Dr. Mary Rooney Discusses Managing ADHD
MARY ROONEY: Hello, everyone. Thank you for joining me today. I'm Dr. Mary Rooney, a Clinical Psychologist and chief of the Child and Adolescent Psychosocial Interventions Research Program at the National Institute of Mental Health, or NIMH, which is part of NIH, the National Institutes of Health. October is ADHD Awareness Month. And as many of you here will know, ADHD can have a significant impact on social and family relationships, as well as schoolwork. And children and adolescents with ADHD may face extra challenges dealing with the changes during the COVID-19 pandemic. For the next half hour, I'll discuss signs, symptoms, and treatments for ADHD, as well as tips for helping children and adolescents manage ADHD, while attending school during the pandemic. Then at the end of this session, we'll have some time for questions from the audience. It's important to note that I can't provide specific medical advice or referrals. So please consult with a qualified healthcare provider for diagnosis, treatment, and answers to your personal questions. If you need help finding a provider, please visit www.nimh.nih.gov/findhelp. And if you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK. You can also ask for help in the comments section of this feed, and someone from NIMH will assist. All of the websites and phone numbers I just mentioned will be posted in the comments section of this feed as well so that you can access them easily. So I'll start off by describing what ADHD is and some of the signs and symptoms for those of you who are newer to the concept of ADHD, or who may suspect that you or your child have ADHD. So if you, your child, um, or a teen finds it hard to pay attention, or if you feel the need to move constantly during times when you shouldn't, or you find yourself constantly interrupting others, and these issues are ongoing and seem to be negatively impacting daily life, then it could be a sign of ADHD.
MARY ROONEY: So people with ADHD show an ongoing pattern of three different types of symptoms. The first type, um, are generally related to difficulty paying attention, and we call these the inattention symptoms. The second, uh, related to being overactive in a variety of ways. And we refer to this as a hyperactivity cluster of symptoms. And the last falls in the category of acting without thinking, and that's what we refer to as impulsivity. These symptoms get in the way of functioning on a daily basis and interfere with the important development of skills over time. And when someone has ADHD, these three different types of symptoms can show up in a variety of different ways. They may overlook or miss details and make what appear to be careless in schoolwork or at work, or even during other activities. They can have problems sustaining attention in tasks, or even while they're playing, and different-difficulty paying attention can occur during one-on-one conversations, during lectures at school, while reading, while playing a game, et cetera. They might seem as though they're not listening when someone's speaking to them directly or, um, might see a child not turn their head when you call their name over and over again. Uh, they may fail to follow through on instructions or finish schoolwork or tasks that they've started. And you'll see that some people with ADHD just jump into a task pretty quickly, but then lose focus or motivation and struggled to finish what they started. Other struggled to just get started on task, um, but once they get going, they're able to finish at least some of the time. They have problems organizing tasks and activities, um, such as doing tests in the correct order, keeping materials, belongings, and homework, or work papers organized and managing time and meeting deadlines. People with ADHD typically avoid or dislike tasks that require sustained mental effort. And what we mean by this are things like schoolwork or homework, and generally in areas that are not particularly interesting to someone.
MARY ROONEY: Um, and for teens or in older adults, you'll see this come up when it comes to preparing reports, completing forms, or reviewing lengthy papers. Losing things is also a common challenge, especially things that are, um, necessary for tasks or activities like school supplies, pencils, books, wallets, keys, paperwork, eyeglasses, cell phones, things that, you know, all of us lose sometimes. It's just that this happens a lot more often for people who have ADHD. And they'll become easily distracted by sometimes just unrelated thoughts in your head, um, or by eye and sights and sounds in the room or in the setting wherever you happened to be. And forgetfulness is also something that happens a lot. So forgetting to do chores, run an errand, return calls, or forgetting they have an appointment was even scheduled. And when it comes to hyperactivity and impulsivity, um, these signs can include fidgeting and squirming, um, getting up and moving around in situations when seated-- when staying seated is expected, right? So like in the classroom or in the office. For younger kids, it can show up as running or climbing in situations where it's not appropriate. And while teens and adults might not climb or run excessively, they'll often feel physically restless to the point of being uncomfortable if they can't get up and move around. You'll also see in kids, um, they're unable to play or engage in hobbies quietly. They're always making noise, even if it's a quiet-- well, typically be considered a quiet activity, and are constantly on the motion. Um, just on the go, almost acting as if they're driven by a motor and just can't stop. Nonstop talking is also very common. So parents of kids with ADHD often say to me, "Oh my goodness, I just wished I could have one quiet moment or just a moment of peace because, um, my child just talks nonstop." Um, individuals with ADHD have trouble waiting their turn. Um, this could be waiting in line. It can be, um, during conversations or, um, for kids, um, you know, waiting their turn in playing games.
MARY ROONEY: And similarly, interrupting or intruding on others is common. Um, so interrupting games, activities, or conversations. So showing these signs and symptoms does not necessarily mean that a person has ADHD. Other problems like anxiety, depression, certain types of learning disorders can all have similar symptoms. And today, you know, many adults and kids are working and learning virtually. And this lack of in-person interaction can lead to feelings of boredom, isolation, and loneliness. And this lack of structure can just make it harder for everyone to accomplish tasks, not just people with ADHD. So if you're concerned, um, that you or your child might have ADHD, the first step is to talk with a healthcare professional to find out if the symptoms that you're seeing or feeling really fit with an ADHD diagnosis. And a diagnosis can be made by a mental health professional, like a psychiatrist or a clinical psychologist, or by a primary care provider in some cases, um, or a pediatrician. So let's talk a little bit about when ADHD is diagnosed and who's specifically as at risk. So for an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before the age of 12. Um, so ADHD symptoms can occur as early as the preschool years, and continue through adolescence and adulthood. In some cases, you don't really start to notice the symptoms, um, in some kids until they're kind of getting into later elementary school or early middle school, um, when the demands increase and symptoms of inattention, for example, an organization really start to be common pairing. Um, across childhood and adolescents in particular, a symptoms of ADHD can be mistaken for emotional or behavior problems and hyperactive or impulsive kids and teens. And kids and teens and adults who've displayed primarily in attention symptoms, so difficulty with focus or organization with little or no difficulties with hyperactivity or impulsivity, their symptoms might be overlooked entirely and dismissed as simply someone not trying hard enough or not applying themselves or lacking motivation.
MARY ROONEY: Both of these scenarios can lead to delays in diagnosis and missed opportunities for important, uh, early treatment. And adults with undiagnosed with ADHD have a history of symptoms, a longstanding history of symptoms, as well as a long standing history of academic or social difficulties during their school years. And in many cases, ongoing difficulty and work and, uh, difficulty in their close relationships as adults. ADHD symptoms change over time. So in young children with ADHD, when they have symptoms of hyper activity, you actually see their hyper activity levels, uh, decrease as they get older. So they may remain fidgety and restless, but, um, luckily, they're no longer climbing on things excessively, um, or running around as if they're just driven by a motor. Difficulties with impulsivity, might shift from being primarily physically impulsive to being impulsive and relationships or decision-making, um, in personal finance management, um, and even sometimes risky behaviors. And then symptoms of inattention, uh, typically become more pronounced over time. So, uh, during elementary school, often around second or third grade is when you start to see, um, the symptoms become more impairing. For some kids, they, again, like I mentioned before, it's not really until middle school that they really become very impairing. Um, but they typically continue to cause difficulties as well into the teen years and into adulthood. So researchers aren't 100% certain about what causes ADHD. We do know that genes play a very important role though in most cases. Um, other causes can include in utero exposure or alcohol or drugs or environmental toxins, lead exposure during childhood, um, low birth weight and traumatic brain injuries. An ADHD historically was considered something that was primarily seen in males. But we now know that it's almost equally as common in females.
MARY ROONEY: And the presentations may be different, um, with many not all-- but not all boys, uh, display more hyperactive and impulsive features, um, as well as symptoms of inattention. But then in girls, we often see more symptoms of inattention and disorganization and less, um, in terms of hyperactivity and impulsive. So let’s talk about treatments for a few minutes. So there's no cure for ADHD. Um, but there are currently available treatments that can help reduce symptoms and really improve functioning. And these treatments include medication, behavioral interventions, skills training programs, and a combination of these treatments. For many people, ADHD, medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. And medication actually can also improve physical coordination for individuals who struggle in that area. Sometimes several different medications or doses have to be tried before finding one that works well. Um, and that process can be frustrating for kids, parents, and adults. Um, but it's often well worth the effort because if a medication does work well, you see a huge improvement in symptoms, um, in the child or in an adult. And symptoms of stimulants are the most commonly prescribed medication. Um, and for the most part, they're the most effective medication for ADHD when they're, um, well tolerated. Stimulant medications began working very rapidly, um, within, uh, you know-- within a half hour, typically at most. Um, and they wear off very quickly within, uh, 4 to 14 hours, depending on the formulation. Under medical supervision, stimulant medications are considered very safe. However, there are risks and side effects, especially if they're misused or taken in excess of the prescribed dose. So anyone taking medications for ADHD must be monitored closely and carefully by their prescribing doctor.
MARY ROONEY: There are also non-stimulant medications available, and these take longer to start working, and leave a person's system more slowly than stimulants, but in many cases, they can also improve focus, attention, and impulsivity. Doctors might prescribe a non-stimulant when someone has side effects from stimulants that can't be tolerated, when a stimulant simply isn't effective, or in combination with a stimulant to really boost effectiveness. And although not approved by the US Food and Drug Administration or the FDA specifically for the treatment of ADHD, some antidepressants are used alone or in combination with stimulants to treat ADHD, and they can simultaneously treat the symptoms of co-occurring conditions like depression or anxiety. But again, doctors can work with you or your child to find the best medication or dose or combination medications that will be most effective. There's also several specific psychosocial or behavioral interventions that have been shown to help patients and their families manage symptoms and improve functioning. And the most effective interventions for children and teens with ADHD that are those that also include parents and/or teachers and the treatment. Parenting skills training sometimes called behavioral apparent management training, teaches parents the skills they need to encourage and reward positive behaviors in their children. Um, behavioral parent training helps parents learn how to use a system of rewards and consequences to change a child's behavior. And parents are taught to give immediate and positive feedback for behaviors they want to encourage and ignore or redirect behaviors that they want to discourage. And parents can also learn how to structure situations in ways that really support the behavior that they want to see from their child. Specific behavioral classroom management interventions have been shown to be effective for managing youth symptoms and improving functioning at school and with peers. And these use research informed strategies, um, like t-teacher-implemented rewards programs, and point systems, um, and communication with parents via daily report cards, um, which is, uh, a rating system that gets filled out during the day by the teacher and then get sent home with the child so the parent can review it and ideally, um, provide a reward at home.
MARY ROONEY: Skills training programs focus on social skills or organizational skills that can also be effective for kids and teens with ADHD. These skills-based interventions include components that are focused on teaching the child or teen skills and providing accurate opportunities for practice during the therapy session. But they also include components for teaching parents and teachers strategies for coaching the child or teen outside of the therapy sessions so that they can use the skills effectively in their daily life. Many schools offer special education services to children with ADHD who qualify. Educational specialists can help the child, parent, and teachers make changes to the classroom and homework assignments to help the child succeed. And public schools are required to offer these services for qualified children, which may be free for families living within the school district. These services are covered under the IDEA Act, and to learn more about this and about special education services for children with ADHD, I recommend that you fill out-- uh, that you visit the US Department of Education's, um IDEA website . For teens and adults, cognitive behavioral therapy, or CBT can be helpful for changing problematic thoughts and behavior and for learning strategies for self-monitoring, time management and reducing risky, uh, unproductive, or unfulfilling activities, as well as techniques for stress management. And many adults with ADHD and their spouses actually benefit from couples therapy, where the focus on both practical tools and strategies for managing the challenges that come with ADD-ADHD as well as ways to overcome the frustration and the resentment that may have built up in the relationship as a result of ADHD-related difficulties.
MARY ROONEY: Not surprisingly, ADHD is a disorder that affects the whole family and all family members can benefit from support, whether or not they have ADHD themselves. Stress management techniques can benefit parents of children with ADHD by increasing their ability to deal with frustration so they can respond calmly to their child's behavior. You can learn more about stress management, um, by visiting 5 Things You Should Know About Stress. Support groups can help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, do exchange information about recommended specialists and strategies and talk to experts. And to learn more about support groups and other resources that are available these days virtually as well as locally, I recommend that you check out the National Resource Center on ADHD . It's a program of CHADD® or Children and Adults with ADHD, and it's supported by the CDC . Um, so there's a lot of very useful resources on there. You can reach the center online at www.chadd.org or by phone at 1-866-200-8098. All right, let's switch gears a little bit and talk about things that are affecting kids and teens and of course their parents and teachers as well during COVID-19. Um, the pandemic and the return to school this fall is really disproportionately affecting kids and teens with ADHD in negative ways. Um, and there are things parents can do to help. Um, for kids and teens, uh, many of the ADHD symptoms are most impairing when they're in school. And the added stress of attending school during a pandemic is leading to some changes in mood and behavior for kids with ADHD, and in some ways that shows up as an exacerbation in symptoms. Um, and sometimes it shows up in other ways.
MARY ROONEY: So here's some things that parents can be on the lookout for. In terms of behavior, you might see an uptick in oppositional behavior from your child or teen. This might stem from frustration over dealing with demands that are greater than what their ADHD brains can handle. It may also be a natural reaction to seeing-- receiving so many corrections or negative feedback throughout the school day, if they are repeatedly and often accidentally not following the new COVID-19 public health rules, if they're attending in-person school or struggling to stay on task and on target, um, through virtual learning. Oppositional behavior can also be assigned that your child is anxious or overly stressed, but lacks the ability to express their feelings. When it comes to mood and anxiety, um, many kids with ADHD also struggle with depression and anxiety at some point during their child or teen years, and stressful situations increase the likelihood that they'll develop clinical levels of anxiety or depression. Across the board, we're seeing higher rates of anxiety and mood-related challenges among kids with ADHD since the start of COVID-19. Some key signs of depression in kids and teens include low mood, or increased irritability, a lack of interest in things that they usually enjoy, social withdrawal, and/or changes in sleeping and eating habits. And signs of anxiety can include physical complaints like stomach aches or headaches, school avoidance, or refusal, a worsening of preexisting attention problems, a fear of being away from family members, so kind of what looks like typical separation anxiety, difficulty sleeping. Um, and for some kids, their main symptom will actually be an increase in disruptive or oppositional behavior. When it comes to learning, focusing and learning throughout the school day requires far greater mental effort for kids with ADHD under typical non-COVID-19 circumstances. And when you add the additional strain of remote learning or following and coping with COVID-19 school rules, it's easier to see how the extrovert and will negatively impact academic learning more severely for students with ADHD than for students without ADHD.
MARY ROONEY: So it's expected that your child or teen will have a more difficult time meeting academic demands this school year, even when they're trying very hard and potentially doing the very best that they can. So as a parent, it can be really hard to know how to support your child or teen with ADHD when they're struggling, and it can be even harder to provide support when you're feeling overwhelmed yourself as so many of us are right now. So let's spend some time talking about the things you can do that are most likely to have the biggest impact on your child or teen this school year. I think the first thing and potentially the most important thing is to set realistic expectations. So kids and teens with ADHD are going have a more difficult time right now, uh, both academically and in terms of remembering to follow all of the COVID-19 public health requirements and added school rules. And this includes things like remembering all of the social distancing requirements in terms of physical distancing, um, remembering to wear their mask and even simply figuring out how to keep track of their mask, uh, remembering to wash their hands every time they're supposed to. So don't expect perfection. Um, and also, though, don't expect to-- or so don't hesitate to commonly provide reminders and provide any kind of support that you can, like packing extra masks, uh, packing plenty of small bottles of hand sanitizer in their backpacks. And also very importantly is remembering to praise them when they do follow through. So this is a case where catching your child or teen doing something right can really go a long way. Also very important is to advocate for your child into this current situation. So you can partner with your child's school to ensure that your child or teen is receiving the behavioral and academic support that they need. If your child already has an individualized education plan IEP, or a 504 plan in place, then consider having the plan expanded to account for COVID-19 related changes in the classroom environment, or changes in the school schedule, changes in the quantity of the academic material, or changes in the method of instruction.
MARY ROONEY: And if your child does not currently have a special education plan, then, uh, consider initiating the process for getting one started now. Routines are also extremely important right now. They're always important for kids and teens with ADHD, but now they may be more important than ever. Um, so routines create a sense of security to your child and minimize organizational difficulties at home by following, uh, allowing you to follow a consistent routines, um, and consistent patterns at key points in the day. So this includes a morning routine where the same thing happens at the same time every morning, and after school or homework routine and an evening routine. And this is something where even if things change in your child's school setting, if they, for example, switch to a virtual school environment from an in-person environment or vice versa, these routines can still stay the same, and that really provides some important consistency for kids right now. Prioritizing physical health is also important. So your child or teen will be able to manage their ADHD symptoms and cope with stress much more effectively if they're getting enough sleep and physical activity, as well as eating well. So put your child's physical health needs first, and then you'll see that their mental health and academic skills will follow. Couple of more points are to provide some additional learning support, um, in order for your teen or child to keep up with academic demands and avoid falling behind their peers, they're likely going to need some additional learning support, and this can be obtained in many cases privately through cheer-- tutors or learning centers, or through your child's school, especially if they have a 504 plan or an IEP.
MARY ROONEY: And then lastly, adjust your child's ADHD treatment plan as needed. As children and teens grow and demands on their attention increase, they're going need to make adjustments to their ADHD medication, behavior management plans. So work closely with your child's teen or doctor therapist to optimize their ADHD treatment throughout the school year, and promptly address any symptoms of anxiety or depression that might emerge. Um, so although the focus of our discussion today has primarily been on children and adolescents, we know that many parents and other adults are also managing their own ADHD, and this can be hard, um, for parents who are struggling to just keep up with everything. And also for adults who don't have children and are still struggling to keep up with everything within the context of the pandemic. So I recommend working with a counselor or therapist to learn strategies for managing symptoms, staying organized, coping with feelings of anxiety or being overwhelmed, and dealing with other challenges that come with ADHD. And medication can also be very effective for adults, and your primary care doctor can be a great starting point for discussing medication options. And if needed, they'll give you a referral to an appropriate specialist for prescribing purposes. So I'm on to make sure we can leave a few minutes for some questions from the audience. Um, I'll stop there and take a look at some questions that have come in, and feel free to submit some questions now. Um, we have just a few minutes. Hopefully, we can cover a couple of things. Um, okay. So one question that came in is from someone asking about what happens if you have adverse reactions to medications, um, like mood stabilizers, or antidepressants, or are just generally very sensitive to medication? So this is the case for, um, many kids and adults as well, that, um, they may experience side effects from a medication, um, or sometimes even not respond.
MARY ROONEY: But, um, when it comes to side effects, the main thing really is to work closely with your prescribing doctor. Um, in the easiest of cases, medication for ADHD means that your doctor prescribes a stimulant, and you respond well with minimal side effects. There's plenty of cases where it's a little bit more complicated, and you do need to, um, try different medications. And sometimes a combination of medications is important. And medications don't work. There's then that's the time to really work closely with a therapist on, um, behavioral interventions and psychosocial treatments, uh, that can be very effective on their own, um, for reducing, uh, impairments and improving functioning that comes with ADHD. And unfortunately, we're actually already getting really close to the end of our time here. So, um, I'm going to have to end our discussion here, uh, with only one question, but thank you very much for joining me today. And to learn more about ADHD, you can visit www.nimh.nih.gov/adhd. And thank you again for joining today, and please everyone stay well. Thank you.