Show Notes
At least 5 percent of American children have Attention Deficit Hyperactivity Disorder, or ADHD. Today, we’re speaking with pediatrician Dr. Rachael Fournet who takes us through some key points about ADHD in less than 30 minutes. If you’ve got a child who’s ADHD or think they might be, you may be just feel a little better after listening to what Dr. Fournet has to say.
Transcript:
Roland Wilkerson
0:06 At least 5% of American children have ADHD. According to the US government, it can wreak havoc in the classroom cause big problems at home and seriously damage a child's self-image, which can unleash a whole other set of problems. I'm Roland Wilkerson with Novant Health, Healthy Headlines. And today we're speaking with pediatrician, Dr. Rachel Fournet, who takes us through the key issues around this in less than a half hour. If you've got a child who's ADHD or you think they might be, you might just feel a little better have you here with Dr. Renee has to say here.
One footnote, for many years, there was a distinction between ADHD and ADD. But today, the formal name is ADHD. But it still gets called ADD and everyday conversation. And that's what we do in this discussion.
So the way I describe it to parents is that everyone is born with a certain set of cards that makes up their temperament. So everyone is either an introvert or an extrovert, they are a high energy person or a low energy person, they are high intensity or low intensity. So when they feel happy, they're very, very happy, or when they feel sad, they're very, very sad. And then there's also children that are high at fast adapters, which means that they can kind of go from activity to activity very quickly, versus a slow adapter, which those kids don't do well going from activity to activity. And they need, they need more guidance and more mornings, "in five minutes, we're going to go get ready for bath," "in two minutes, we're going to get ready for bath." So these these different cards that make up your personality and your temperament can sometimes look very much like add. So a child might be fast adapting high energy, high intensity. So they are bouncing all over the place, they're going from activity to activity quickly. And they might be really loud and really excited. And that can look like a child who might have a hard time in a classroom setting. But it doesn't become ADD until their function is impaired. So that's the line that has to cross they need to actually fail to function in a classroom setting. So a lot of it might be that we've had warning signs, we've been wondering how they would do in kindergarten. But we're not going to know until they're there until we get those reports back from teachers when we start seeing that they're not keeping up with their peers, because their temperament is now impairing their functioning in a classroom setting. Okay, a lot of kids, it might be that the classroom is really hard, and they have a hard time functioning, but they're fine in the mornings at home, getting out the door on time, eating their dinner, going to bed, where their ADD maybe doesn't affect all aspects of their life. But then there's some kids where from sunup to sundown, their inability to rein it in and follow a task and stay on focus does start to affect how they function within their family unit as well.
And so typically, it sounds like you're saying it really presents itself or it really becomes evident to parents and teachers when the child starts school.
Correct and usually sick 5,6,7 years old tends to be when these conversation starts happening. So what I do first with parents is really break down what part is the child's you know, inherent personality, what other things in their environment and in their lifestyle could be contributing. So I always go through a very thorough diet history asking about what are what are they eating for breakfast, lunch and dinner? How much sugar are they getting in their diet, there's been some more, I guess, subjective findings where parents have found that artificial dyes have kind of affected their child's add and made it made it worse, I think the main thing that they should look at is just clean eating. So where you tend to find dyes, you also tend to find sugars. And so is it the diet or is it the sugar either way, they probably shouldn't be eating that fruit snack, or the Starburst candy or, you know, cookies or a muffin for breakfast. So looking at their diet, looking to see if they have a good energy outlet. So every child wakes up with a certain amount of energy every day that they need to flush out of their system. When children are on iPads, and they're playing video games after school and they sit all day in a classroom, when they sit when they get home. They never flush out that energy from their system. And that can look a lot like ADHD, they're you know that they're pent up, they're bouncing all over the place. They're not listening, they're, you know, impulsive and hitting their brother. And sometimes you just need to like harness that energy, get them involved in sports, karate is fantastic ride their bike, even if they don't need to join a sport, have them like run laps around the house before dinner and time them with their siblings to have a race and see who's fastest. You know anything to say that you know that they're kind of burning it off. And then I also want to have a good sleep history. So poor sleep can look like add the next day. It is very hard to focus if your brain did not get to recharge the night before. And so finding out you know, does a child go to bed at a reasonable hour meaning usually before
9:30, 10:00pm? Are they getting good quality sleep? Are they snoring? Are they restless? Do they wake up after 10 hours but still seem really tired and groggy? Are they school age but still taking naps? Those are all signs that maybe there's something disrupting their sleep causing them to look like they have ADD in the classroom. And then the last piece of the puzzle is rolling out that there's an any other comorbidity happening like anxiety or depression. And in little kids, sometimes anxiety doesn't look like it does in adults. It doesn't always, you know, kids can't verbalize "Oh, well, I can't fall asleep tonight, because I'm worried about what's going to happen tomorrow in school." No, instead, they you know, they avoid going to school, they get stomach aches before school, they get headaches before bed. They physically feel their worries. And so if a kid has a lot of anxiety, especially about school, well, when they're in school, they can't focus because their brain is going a million miles a minute thinking about all the things they're worried about. So they can't do the task at hand. So by asking all of these questions, usually we're able to kind of paint a picture of, you know, do we need to work on some things first, and get out sugar from the diet, maximize exercise, maximize good quality sleep, make sure there aren't other anxieties and comorbidities, then we try to get feedback from the teachers. So the tool that we use is usually the Vanderbilt form. And that there's a parent and a teacher one. And what that is helpful with is knowing are these issues happening in both places. Because sometimes you'll have teachers raising the child very high on the Vanderbilt saying that they have a DD, but the parent who maybe is not ready to move forward with medication management, they rate that the child has zero symptoms. So that will then lead to conversations of readiness like are what are you worried about? Are you worried about a stigma? Are you worried about medicine and side effects? That's maybe slanting the way that you are grading your child? Or we have the opposite the parent rates that they have severe ADHD at home, but the teachers all say that, that they're an angel that they focus that they have no behavioral outbursts?
Does that happen?
Oh, yeah, absolutely. And when that happens, I often wonder one, how well does a teacher know the child? And I'll say, how many hours a week do they spend with this teacher? Do you feel like you have a good relationship with the teacher? How well do you think the teacher knows your child? And then I asked what else is going on in the house? So is it that the parent is having a hard time with the child being stubborn, being obstinate, having you know, sleep issues, throwing tantrums at the dinner table? And it's all behavioral? It's not ADD? Was there a recent divorce? Were there any other traumas that have happened in the child's life that have kind of disrupted their foundation to make the child act out and make the parents see it as possibly being? Well, he never he can't follow an instruction. He doesn't listen, he hits his sister all the time, he can't sit still. Is it really something else going on in the household? So these are just investigative tools that we use to kind of paint a big picture of what's going on with that child. And whether or not ADD might be affecting them. And then whether or not it is affecting their function. So I have diagnosed children with ADD and said, Yep, they have it, but how are they doing? How is their function? And if they're making good grades, if their teachers aren't complaining, if they're not getting in trouble from their impulsivity in class, we don't do anything about it. But educate, help them more with, you know, usually using visual cues to help the child stay on task in the morning, when getting ready little like laminated pictures of all the steps of getting ready in the morning, making a checklist of what do we need to check in your book bag to make sure you didn't forget your homework at the kitchen table, those type of behavior modifications, cleaning up the diet, getting your sleep, but we don't use medicine, we really don't turn the medicine until we hit that wall that we've known this was coming, we've been talking to the teachers for years, we have the diagnosis. And now our, his or her function is being impaired, they're falling behind grade level, they're starting to lose self-esteem from it, they start, the child will start calling themselves dumb, they'll say I can't do it, I'm just stupid, I I'm going to fail, they start feeling bad about themselves, they start to hate school and hate learning. And that's where I really caution parents that like this is when we need to intervene. Because if you let that keep going and going, one, you end up with a child who might be you know, way behind grade level. And that takes a lot longer to catch up while your peers are, you know, still on an upward trajectory of learning your child, the longer you wait, the bigger the gap gets. But also, a self-esteem is a hard thing to turn around. So if your child is starting to show signs of, you know, feeling bad about themselves calling themselves stupid, that can take years for them to erase that self self worth. And so that's usually when I recommend, you know, why don't we try medicine. And I say try, because parents sometimes feel like it's this giant fork in the road where if they pick a one way, they have to stay there forever. And that is 100% not the case. So medicines that we use for add, they are work when you take them when they were off, they're gone. And there is no residual side effect. So think of it like a Tylenol, you have a headache, you take Tylenol, it helps the headache go away four hours later, it wears off maybe your headaches back. So when you decide you're going to do medicine and say you give this stimulant medicine for add one day, one week, one month, one year, 10 years, there's always a point where you can decide to stop. And there are no long term repercussions. There is no weaning, there is no rebound, there is no withdraw, you just use it when you need it. And you can stop it anytime.
And what what does the medication actually do in the brain or in the body that that that affects ADD? And are there any potential downsides to it?
Sure. So what at what ADD is the way I explain it, it's like you had to tech two phones sending text messages to each other. So it's, you know, in a normal functioning brain, you would type the text message you would hit send, it would get released into you know, the atmosphere go through cell towers, etc. And then it would land and the other person would receive the text message and be able to read it. Okay, that's the normal setup. With ADD one cell phone types the text message, but it doesn't hit send into the message never gets across to the other cell phone. So there's no problem with the child making all of the neurochemicals that they need, they don't release it, to send the message to the next neuron to get the message to carry it along. And so you have this disruption in the way that the that the brain is communicating within itself. And so the way that the stimulant medicines work is that they press send. So the brain naturally makes the text message but the medicine hit send, the message is sent to the next cell phone, and then the message is able to be you know, sent on its way. And so it's helping the brain function the way it's supposed to, almost that I explained it to the kids, it's like your brain is working against you, taking the medicine makes your brain work for you. So that if you sit down and you try your hardest, your brain actually does what you want it to. And that way you don't get fussed at as much you don't get, you know, yelled at at home. Because you try to stay focused, you try to go take the trash out and move your shoes and you actually can do those two steps, and your parents are happy, and then you're happy. And then everybody's getting along better. Because your brain is working the way it's supposed to. So the positives for the ADHD meds are, if you if they work for that child, if it's a good fit, the goal is that your child is still your child. They're almost like just a heightened, will say better version of themselves, where they're listening ears are on, their ability to do the task at hand is there. But there's still themselves they still get excited, they still feel all the normal emotions. If your child turns into a quote unquote, zombie that is never okay. We never want to blunt their personality, we never want them to become like Eore, and mopey, and they're not talking to their friends. And they're not excitable, that is never acceptable. Usually, that means it's not the right medicine or it's too high of a dose. So that is the goal is to be on the lowest dose possible with the maximum benefit and the least amount of side effects. The possible side effects that are we just kind of accept that they're going to be there and we've had to work through them are the decreased appetite at lunchtime. So what I educate parents on is you have to make up for it on the other end of the day. So breakfast needs to be hardy it needs to have protein healthy fat, a complex carbohydrate. Think savory, not sweet. So go with your, you know, egg sandwich, go with a peanut butter bagel. Go with Greek yogurt, oatmeal don't, go for pancakes and syrup and Lucky Charms cereal. So you need to make breakfast matter and have a lot of calories in it. And then when the kid gets home from school when the medicine wears off, usually they're; ravenous feed the beast. So let them eat to their heart's content. But make sure again that it's high quality food. It's not just Fritos and Cheetos, and empty calories, but almost like they're eating their lunch at 4pm. And then they're still eat dinner at 6pm. And sometimes they might want to post dinner snack before bed, that's fine.
Let them eat at the ends of the day. Because we understand that if the medicine is working, usually they're not going to eat a good lunch. And that's okay. We pediatricians, when they're on medicine, we see them every six months to monitor their growth, we want to know and make sure that they're still getting enough calories to grow adequately. Because that would be a game changer. It's I'm not gonna let a child not grow because I'm treating them with a medicine. So we always monitor that on our end. The other side effects that I call more speed bump side effects, these are ones that are going to happen over the first two weeks or so of starting a stimulant medicine or changing doses. And this is going to be headache and stomach ache. And we're you know you're altering brain chemistry. And so they're going to be adjustment periods. So understanding asking those questions when your child gets off the bus, where was your head hurting today? Does your stomach hurt at all, a lot of times the the reason that they're having headache and stomach ache is because they're not eating and they're not drinking. And if anyone went eight hours without eating or drinking, they might have a headache and a stomach ache. So that's where you educate the child. Even though you're not hungry at lunch, you gotta eat something, you have to eat a couple bites of something. And even though you're not hungry, you still have to drink. And so kind of giving them water goals, you need to have had one water bottle by this time in the morning, you need to have had another one by lunchtime, you know, and that way they keep up with their fluids. And most kids kind of get over that speed bump and they adjust. And then those side effects go away.
When ADD first started getting a lot of attention, like 20 or more years ago, there was kind of a pushback that we were basically drugging a boys in particular would come up, you know that we're medicating boys for perfectly normal for perfectly normal behavior. What is that is still still a debate in the medical world or...
So I will say that they're going back to the beginning that temperament. Right? So yes, some boys are high energy, high intensity? Are they supposed to be able to sit still for eight hours? I think the answer is no. And I think that's where the school system is almost creating part of this problem by setting the standards, which I think are unacceptable and unreasonable for children. So
talk about that. What do you mean?
Second graders should not be able to sit still for seven hours a day and learned yet that is what our school system is doing to them. And that is what the expectation is coming, is pushing academics as opposed to giving them that kind of free range learning opportunity, letting them go outside and play burn off that energy, play with their hands, explore their they're taking away physical education, music, art, the arts, all together. So everything's moving more towards sit still and learn science, math, English, you know, at such a young age where they're cognitively sometimes not even ready. But emotionally, physically, I think it's pushing kids into a box that they're not suited for, and then being disappointed with the outcome that they get. Wow. So, so do I think some kids get the diagnosis of ADHD because they're not functioning in the standard that we have created, even though I think that it might just be that that's their temperament. And that child needs more of a physical outlet. Yeah. But this is kind of how we're playing the game, the child is to succeed in the marriage conversion of academics, then these are the rules we play by. And if their way that their brain is and the way their temperament is and how much energy they have in a day, and their ability doesn't fit exactly in that box, then they fall behind, they fail, they don't get to college, they can't get a job they might want. And so this is how we play the game, if they need it to function, then often we will use medication to help them function. And that's why you sometimes you see adults that still need add medicine long, you know, through adulthood, and a lot of times you don't, they needed it to survive the the box of education, you know, the K through 12 education system. And then once they were able to get into a field that they that was suited for them, then suddenly they're able to function, they're able to work around their temperament and their maybe ADD, because they work with their hands, they're able to take breaks, they're able to, you know, sit on a yoga ball at their desk, they're able to work from home, some, you know, so they go into a field that usually fits what their temperament and personality is, and what their what their strengths and weaknesses are.
That's fascinating.
Yeah. So if a person that has has natural add, and they may be hated their, you know, the typical school system couldn't wait to get out, they're not likely going to become an accountant, right? Are they going to sit in a cubicle, still for eight hours and crunch numbers on the spreadsheet, they're probably not going to enjoy it, and they're probably not going to be great at it. Instead, they'll probably go towards more of a career that's going to be adaptive and communicative and working as a team working with their hands being able to jump from task to task, because that works with their brain. But the way the school system is, it's all or nothing. It's one size fits all. It's black and white. And you either sit and listen and sit still and pay attention and do well and learn the material and spit it out on an EOG. And that is the that is the equation for success. Or you fail.
Wow, I can hear some teachers or have you ever gotten any pushback on that theory from teachers or from educate?
No,I would say if anything, teachers agree,
Right? Too much testing too much...
Yeah, too much testing too much, forcing kids in a box and holding up to a standard, too much being forced on kids at too young of an age. You know, they're saying that what was expected of us, me I'm in my 30s back in third grade is now what we're expecting kindergarteners to do academically and they're not ready for it. They're not ready. You know, what really needs to be focused on in kindergarten is the social emotional education side. So can you share with others? Can you you know, not throw a chair across the room because you didn't get your way? That is the setup for success later is really focusing on on the social emotional stuff, and not on you know, can have you memorized all 50 states have you, you know, do you know presidents, you know, parents are showing flashcards to their kindergarteners trying to drill in all this information like it's the essay tease, you know, when really they need to be talking to them about you know, are you feeling worried? Are you feeling jealous? What do you do with those feelings? How do you work through that social interaction when you felt left out on the playground? So then what we see our children that are hitting, you know, 9, 10 years old, and are having severe debilitating anxiety, depression, are cutting our school avoidant because they're they've been pushed too fast, too far too hard, too early. And nobody focused on their their emotional health all along the way.
What's the biggest misconception you find with parents when it comes to their child who may have ADD?
I think parents fear that a few things. I think parents fear, a stigma and a label. And they don't want their child at school to be a thought of as being like not special education, but almost that like, Oh, he's different. He's special, he needs extra, you know, help. They don't want them to be labeled as like the bad kid, the troubled kid. And so I find instead that having the formal diagnosis, helps the school system give the child accommodations that will help that child specifically learn. So the school is not allowed to diagnose add, I am. And so a lot of times the school say we think this might be going on to your pediatrician, I do the diagnosis, they go back to the school and say Yes, you are right, they have ADD, then the child's able to get maybe an IEP, an Individualized Education Plan, where they do more kind of psycho Educational Testing, they roll out other learning disabilities, they do IQ testing, they see what they're reading fluency is. So a whole new level of kind of investigation into that child's learning is done. Once they have that diagnosis of ADHD, then there's something called a 504 plan, which is for accommodations, saying that maybe this child needs to be all kind of big state testing needs to be done in a smaller classroom size. So there's less distractions aren't 28 Kids coughing and scooting around in their chairs during a big or an EOG test, maybe that child needs one of those kind of cardboard boxes like that the tri fold that that way, they don't physically see everything going on in the classroom, they're in their own little cave, doing their test. So those accommodations can happen because of having a formal diagnosis and having a child quote unquote labeled. So I usually try to reverse that stigma for the parents. And then I think parents are afraid that their child will become addicted to the medicine. And by no means is this medicine addictive at all, there's no withdrawal, and that's the diagnosis of the medicine being addictive is that there's a withdrawal when you stop, and there is no withdrawal. They think their child will be on it forever. And again, once a child is medicated, they often can learn coping skills around their ADD so that when in the future, if they come off their medicine, they still have those coping skills, you can't teach a child coping skills when they can't focus on what you're telling them. So helping them focus helps them learn how to cope, and then potentially later helps them get off the medicine. Also, in the teen years, a lot of kid’s brain chemistry shifts, and sometimes it shifts for the better. And they're suddenly able to send this text messages across their brain. And a lot of kids will come off of their ADD meds or lower their doses when they hit puberty. As opposed to I might have a six year old on a higher dose of medicine than I do a 16 year old. It's not weight based. It's just what that child needs. And so I have some teenagers who come down are off meds and they're teenagers. So that's another kind of myth buster. And then I think there are horror stories. I think parents hear that "Oh, my child, they put them on a medicine and they became a zombie; they were aggressive and acting out." And that's terrifying to parents. And I don't I don't think they realize that. It even if that happened one time, if you don't give the next dose, it won't happen again. So if your child acted like a zombie on a new medicine don't give tomorrow's dose and they'll go back to their normal self. If a child was aggressive in the afternoons when the or moody when the meds were off and they're crying and you know, fighting with their brother more tell your pediatrician, it might be in the wrong medicine or the wrong dose. But again, if you don't give tomorrow's dose, all of that goes away. So nothing's permanent.
So bottom line, as a physician, you're here to help them figure it out.
Exactly, right. And it is it is definitely a bit of a of a pathway of trial and error. With parents, some kids it's like the first big pick is the perfect medicine the perfect dose. And that does not always happen. When it does it's great. But sometimes its try this medicine try that medicine. Let's go up a dose oop, no too much. Let's go back down to this. So we do see them often, usually once a month while we're tweaking their medicines. And then once we find a good fit, we see them every six months.
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