THE HEART OF THE MATTER
a special program of the National Emergency Medicine Association (NEMA) 

Transcripts: 530-1 to 530-5

Week: 530.1 Guest: Dr. Peter Kahn, Sr. Child Psychiatrist, Dir. Forbush School, Shepherd Pratt Health System Topic: Attention Deficit and Hyperactivity Disorders/ Part One-What are they? Host: Steve Girard

NEMA: Attention Deficit and Hyperactivity Disorder...what is it? Today we talk with Dr. Peter Kahn, Senior Child Psychiatrist at Shepherd Pratt Health System...

KAHN: There's two types: there's that which is primarily problems with attention, that's the inattentive type and then there's that which is primarily hyperactivity and others who have combined. The basic problem in the inattentive type has to do with the organizational management of time, of motor activity, verbal activity, the capacity to concentrate, stay on task , sustain activity on a task...also the ability to inhibit other behaviors that would take you off-task. So these children will be forgetful, disorganized, they will be very easily distracted, they will appear to not listen, they'll have difficulty following more than one step directions, they'll start on an activity, and the next thing you know they're responding to some other stimulus in the room...they've gotten off-task, not necessarily intentional.

NEMA: The classroom is usually where ADHD is seen...and starts the process of diagnosis...what are children who have the disorder like in that setting?

KAHN: They'd be seen as...interpreted as being oppositional...just not listening. This may or may not be the case. The difficulty is to focus on what is being said, and not get off track. The difficulty in managing time and space also is reflected in their social relationships...so, these children cannot get the gist of a situation...they can't read interactions very well, they won't know how to integrate themselves into an activity that has already begun or into a peer group. This is further complicated by those symptoms of more hyperactive, impulsive type. Here, there's problems with both controlling verbal and motor impulsivity...from the verbal point, they blurt things out, they interrupt...from the motor standpoint, they're restless, fidgety, they can't wait their turn, they can't wait on line...they intrude into group activities, push their way into things, they just can't figure out how to navigate into social situations. These kids are often described as always on the go...driven by a motor. And there are different degrees of intensities for these , so the child can have either the symptoms of difficulties attending, organizing, managing what they're doing...and they may or may not have the impulsive behaviors.

NEMA: The process of diagnosing a child with Attention Deficit and Hyperactivity Disorder is thorough....we'll discuss it next with Dr. Kahn in our special series. I'm Steve Girard.

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Week: 530.2 Guest: Dr. Peter Kahn Topic: Attention Deficit Disorders/ Part Two- Diagnosis Host: Steve Girard

NEMA: We're with Dr. Peter Kahn again, continuing our discussion on attention deficit and hyperactivity disorder. We've talked about the kid who may have ADHD...having trouble with organization, management of time, staying on task...and perhaps motor and verbal impulsivity. What are so called normal kids doing in these situations....

KAHN: Well, that's a really important point...because one could say, "My child is active, has difficulty paying attention, doesn't like to brush his teeth"...what we have to look at is what are the norms for this age group. And a lot of these symptoms are shown at school...so what we ask the teachers, and perhaps we can have the school psychologist also making observations... is are we looking at a child whose behaviors are considerably out of the norm for their grouping. And are these symptoms shown in more than one type of situation. If you have a child who is just having difficulties at school, it doesn't mean they have ADHD... they can have undiagnosed learning disabilities, they can have undiagnosed language difficulties in where they may not be able to truly understand what is said to them, or have difficulty formulating their answers and become frustrated. They may be children who are very anxious, worrisome, and afraid and as a result of that show a lot of motor activity, and daydream a lot.

NEMA: What steps do parents take to make sure their child is helped...and since they would logically go to their pediatrician first, how does that link between that pediatrician and the psychiatrist work?

KAHN: What we're talking about here with ADHD is a persistent pattern with an onset before age seven, frequently seen by kindergarten, clearly having to exist for more than six months...not precipitated by a environmental stress. Now in the process of trying to make the diagnosis, frequently the referral or the request comes from the school teacher. Then one goes to the pediatrician, and the way one should be making a diagnosis here is you need to sit down and interview the parents, you need to have information from the school teachers, we need to know if a child is placed correctly in a class, do they have some kind of learning disability, undiagnosed, that's making their placement very frustrating for them....we can't make a diagnosis based on the child's behavior when we do an examination...kids with ADHD do very well in novel experiences and in one to one. The symptoms really have to be occurring in more than one place. It may be that its more a problem at school than at home, and in some situations more at home than at school, and this may have to do with the management techniques employed by parents or by the schoolteacher. If you are in a family, or a classroom that is disorganized, poorly structured, inconsistent rules, inconsistent rewards, inconsistent consequences, these children will have more problems.

NEMA: In the next segment of our series on Attention Deficit and Hyperactivity Disorders, we'll talk about the controversy over drug treatment for ADHD. I'm Steve Girard.

Week: 530.3 Guest: Dr. Peter Kahn Topic: Attention Deficit Disorders/ Part Three- Treatment: Drug and Otherwise Host: Steve Girard

NEMA: We're here again with Dr. Peter Kahn, Senior Child Psychiatrist at Shepherd Pratt Health System in Baltimore...talking about Attention Deficit Disorder. People think, Ritalin' when they hear ADD...but aren't there other ways of handling the condition, even before going to the medications?

KAHN: The younger the child, the better I think it is to hold off on the prescription of the medication, and look at the environmental factors. If this is a child who is in a pre-school and is having difficulty, perhaps they will need a more structured, sophisticated, pre-school. We try these things first, before we get out the prescription pad and hand over a prescription of Ritalin. particularly for a young child. We have to make sure we're not having a pressed or anxious child. Handing over Ritalin for someone who's anxious is not gonna take care of that part of the problem. So, its not just...my child is this way, give me the medication...we've got to do more of a broad approach. If we get to the area of medication, there are a number of choices there, the usual would be Ritalin, followed by Dexedrine. These are stimulants, what parents worry about are some of the side effects. "Is this going to make my child a drug addict"? There is no research that shows that to be true at this point. Now these do suppress appetite. These kids will often weigh less, and its not just the medicine, if you run around all day, you don't gain a lot of weight. But we watch this, we chart this, we want to know their rate of growth in terms of the weight and height...what happens is that in the first year of the medication, there may be some suppression in terms of height. Usually its made up for in the next couple of years.

NEMA: You've confirmed for me that some kids get zombie-like on Ritilan...that its one of the possible side effects...

KAHN: Whenever I hear about these things, I wonder why is it that the parent is continuing to give a medication where they see that their child is having a strange reaction. Parents need to be active with this and talk to their doctor.

NEMA: What about the other types of non-chemical treatment for ADD?

KAHN: We also need to provide what we call psycho-educational information. We teach them about their disorder, what things are going to be more difficult for them, what things are going to be easier for them. We also can provide social skills training. These children have difficulty reading social situations often, they don't know how to fit in. They can be taught this sort of thing. Another type of treatment could be a type of cognitive therapy with an individual therapist where children are taught to realize when they're off task...they're taught to say and think certain things to cue themselves to learn to self monitor their own behavior.

NEMA: Our thanks to Dr. Peter Kahn, Senior Child Psychiatrist at Shepherd Pratt Health System. Next in our series on Attention Deficit Disorder, many adults, some of whom have not been diagnosed until recently, have to deal with ADHD and its family repercussions. I'm Steve Girard.

Week: 530.4 Guest: Dr. Richard Perlmutter, Sr. Psychiatrist, Shepherd Pratt Health Systems and Author: A Family Approach to Psychiatric Disorders Topic: Attention Deficit Disorder/ Part Four- Adults Host: Steve Girard

NEMA: We've been talking recently about Attention Deficit & Hyperactivity Disorders...or ADHD...and today we look into what its like to be an adult with this problem...we're with Dr. Richard Perlmutter, a senior psychiatrist with Shepherd Pratt Health Systems, and author of A Family Approach to Psychiatric Disorders.

Dr. P: The kind of things that adults get into are very much the same kind of things that kids get into: the issue of boredom and restlessness, not being able to finish tasks, not being able to listen, sort of having tantrums, lowered self esteem because they're a little different than other people...these are the same issues for children and adults.

NEMA: How many adults have the disorder, and how many remain undiagnosed in adulthood?

Dr. P: The idea that ADHD can be even an issue with adults is so new, that there is no solid research on the prevalence. If I had to guess clinically, I'd say at least a third to a half of children with ADHD have symptoms in adulthood.

NEMA: Do some of the symptoms fade...or do they somehow learn how to deal with it?

Dr. P: I think in maybe the next decade, they'll be a bunch of good studies that will show how many people actually outgrow it, in quotes...because right now it looks like some do...many don't, and the exact reason and how much we don't understand yet. But its been a fairly dramatic discovery to find that adults are struggling with the same thing...in adults, its harder to tell what it is, you don't have the classroom setting to judge by. In adults, it looks like other things....it looks like some kind of personality problem... many adults with this don't recognize that that's what it is.

NEMA: What social problems do those adults with ADHD have, relationship issues...vocational problems...is there a pattern?

Dr. P: Most people get married, so let's say you have an ADHD person who is married, the person has trouble listening, so what's that gonna do? As you might imagine, it tends to interfere a little bit with intimate relationships. For him or her to realize the other's not able to pay attention, not able to listen to the sentence...the spouse is usually gonna feel kinda hurt, because the person hasn't heard a word that's been said. The other large category symptoms are the impulsivity stuff...I mean adults have toys that children don't have...like credit cards...they tend to spend more, do impulsive things, make decisions that aren't the greatest, so that you can see what that can do to the person's economic life, and what it would do to the person's marital relationships... You have to realize that ADHD is not the whole person, so you have some people with extreme intelligence and talent, who can do extremely well in the vocational arena...they take jobs where somebody else does the detail work, they know how to come up with the ideas, in fact, they can generate ideas sometimes even faster than somebody who's actually paying attention because they don't get locked on one channel, they're on 18 different projects.

NEMA: Psychological therapies...in adults, well...ADHD can cause bigger problems in the area of relationships....

Dr. P: With adults, what are you trying to repair? Well, if its a marital situation, you're trying to help the spouse understand that all the attributions about why the person's been acting this way may have been incorrect, that they may be acting this way out of a ...something they couldn't control. Out of some sort of biological tendency to be inattentive, to be impulsive, to be sensation seeking, for instance, and this changes things quite a bit. If the marriage is not totally destroyed, you can often bring it back, you can repair it as long as the spouse begins to see these things. So, you're repairing different things.

NEMA: Dr. Richard Perlmutter and I will talk again soon on the ripple effect ADHD causes in families....I'm Steve Girard.

Week: 530.5 Guest: Dr. Richard Perlmutter, Sr. Psychiatrist, Shepherd Pratt Health System Topic: Attention Deficit Disorder/ Part 5- Affects on Families Host: Steve Girard

NEMA: We've talked about Attention Deficit and Hyperactivity Disorder in the last several programs.. Dr. Richard Perlmutter, senior Psychiatrist at Shepherd Pratt Health Systems and author of A Family Approach to Psychiatric Disorders, talks about the ripple effects ADHD can send through a family....Doctor, a lot of pressure rests on persons diagnosed with the disorder...and all of the people close to them also have a lot to learn and adjust to....

Dr. P: A family who has just heard the diagnosis can react different ways...some are thrilled to at least have a label for it, to understand it, to make sense of the chaos of what its been like to raise this child, and many other families react the opposite...they're angry at the diagnosis, they say, "Oh, you're just one of those shrinks making this faddish diagnosis....you think everybody's got this ADHD thing", or they may be in denial about it, "That's not my kid, he's just a little bit restless, he's just got a lot of energy, a fast motor". And they don't want to face it. Now, sometimes they're right, and the diagnosis is overdone but sometimes reports from the schools and the pattern of peer interaction is just to classic to deny it...and it is worth paying attention to it. So, parents have all kinds of reactions. Sometimes parents also react, like they do with everything, to guilt...with guilt. Because if the child has this thing, then they must have given it to the child, so they feel bad about that. Some parents become kinda confused. "You tell us not to have such high expectations of the child, but what are we supposed to do? We don't want the child to think he doesn't have responsibility for his actions ", and they get confused about the instructions they get from experts. The issue of how to set limits with children of ADHD is confusing to parents because you have to set limits for children, or its not fair to them, they develop no sense of how to behave with other people....but if you set them too excessively with an ADHD kid, then the child becomes a mess because he can't do it...and then finding they can't meet the expectations and continuing to get the attributions of being uninterested, lazy...it doesn't take very many of those sequences for the child to give up or to become angry, because its just too aggravating to have these attributions put on them when they can't seem to do anything to get out of them.

NEMA: What about the other children in the family?

Dr. P: The sibs...if they don't have it...tend to get annoyed by the habits of the ADHD child often...they tend to feel they are getting short changed because this other sib is so high maintenance, and they begin to ...it has to have an affect for everybody in the family, they have to think..."well, how am I gonna get attention, or what do I have to do to be noticed like that?" or "how come all this money has to be spent on his tutoring and his medicines", and so on. So, those are just some of the other imbalances in families that has to be addressed as part of the overall treatment.

NEMA: Our thanks to Doctors Richard Perlmutter and Peter Kahn, both senior psychiatrists in the Shepherd Pratt Health System in Baltimore for their help on our special series on Attention Deficit and Hyperactivity Disorders. They emphasize that ADHD, while exhausting to diagnose for families, pediatricians and psychiatrists, can be treated very successfully, and provides rewarding results for all involved. If you have reason to believe you or your child may be affected, get your pediatrician's advice and referral to a psychiatrist before any medications are prescribed. I'm Steve Girard.