Brought to you by the Depression Is Real Coalition, The Down & Up Show is dedicated to the reality of depression. Our hosts will talk with some of the world's top experts on depression, as well as people who have been impacted by this illness. The reality of depression is that it is a debilitating and potentially deadly medical condition that affects more than 15 million Americans every year. The other reality of depression is that there is hope.

Down & Up Show #33: Depression and ADHD

DR. RAHN BAILEY INTRO:
Today we are lucky to have Dr. Carolyn Robinowitz on the show. Dr. Robinowitz is currently president of the American Psychiatric Association; she's a former Dean of the Georgetown University School of Medicine where she also served as Associate Dean for Students and Professor of Psychiatry.

She's a recipient of the National Institute of Mental Health Career Development Award, has made contributions to medical education, psychiatry and health policies and women in the profession. She is in the clinical practice of general, child and adolescent psychiatry.

It's good to speak with you today Dr. Robinowitz.

DR. CAROLYN ROBINOWITZ:
It's good to be here.

DR. RAHN BAILEY:
I appreciate it. Maybe we could talk a little bit about depression and ADHD or attention deficit hyperactivity disorder, topics that are very commonly discussed and near and dear to all of our hearts I'm sure. Can you begin by maybe defining ADHD for our general listeners?

DR. CAROLYN ROBINOWITZ:
Yes, attention deficit hyperactivity disorder, ADHD, is a neuro behavioral condition characterized by excessive restlessness, inattention, distraction and impulsivity. It's usually first identified when children are school age, although it can be diagnosed in people of all age groups.

And it's widely recognized in the scientific, medical and educational communities as a serious ailment that affects millions of children in the United States and also adults. It's the most commonly diagnosed behavior disorder in childhood and affects some three to seven percent of school age children.

DR. RAHN BAILEY:
You described sort of symptoms and I imagine that you know the big ones that most people tend to really hone in on are the activity and the over-activity I might even add. I think increasingly in this day and age we spend a little bit of time discussing that there are some persons, and some may argue even girls more then boys sometimes, that may not be hyperactive or over-active, but they still meet criteria of the diagnosis and still have (unint.).

DR. CAROLYN ROBINOWITZ:
Well that's right because the children who are diagnosed with ADHD and interestingly enough we used to call it just simply attention deficit disorder, because hyperactivity isn't always present and as you noted particularly in girls. But these have symptoms that impair their ability to function as well as other children of the same age.

And you know high activity levels, short attention spans are a normal part of childhood for many if not most children. But for children with ADHD, the hyperactivity and inattentiveness are excessive and they really interfere with their daily functioning. Some children with ADHD only have problems with attention and others only have issues with impulsivity and hyperactivity.

And many children have problems with both. And overtime, the children with ADHD tend to shed some of the impulsivity and the hyperactivity while continuing to have some significant problems with and attention and organizations and what we call executive functions.

And the main thing is that ADHD can interfere with a child's abilities to learn, to perform in school and their capacity to develop and maintain good social peer relationships with other kids, it can increase a child's risk of dropping out of school, it can increase a child's risk of having disciplinary problems and also there are other problems that have increased risk such as cigarette smoking, other substance use or abuse, driving accidents, hazardous driving.

DR. RAHN BAILEY:
I want to have you give a a brief review of the treatment considerations relevant to ADHD.

DR. CAROLYN ROBINOWITZ:
Well let me start, before you have treatments, you really need to have a careful assessment and diagnosis. So every child ought to have a careful medical history and a physical examination and the ADHD symptoms should be carefully assessed by a healthcare professional.

And I think that you know whoever is treating the youngster needs to have experience with ADHD normal child development and behavior because there really are many treatments, there's medications, behavioral therapy and of course a combination too. Let me talk there's a multi-modal treatment study of children with ADHD called the MTA.

And the data from this study I think really focused on the effectiveness of medication in treating symptoms of ADHD either alone or in combination with behavioral therapy. And I think it's very important to understand the treatment that includes medications has been more effective for the symptoms of ADHD, such as hyperactivity, then behavioral therapy alone.

And this is especially true of course when the therapy is closely monitored for the dosage of personalized and carefully monitored for each child. And the research shows that the medication really dramatic reduces hyperactivity, improves attention and thus eventually improves schoolwork and increases the ability for the youngster to get along with others.

Now, as noted, it's not the only treatment for ADHD because the MTA study found that when you combine behavioral treatments with medication, this is very useful in helping the children learn ways to manage their own behaviors that cause problems at home or school, but also helps families and teachers, help the kids, help the youngsters.

And in addition for some children, having behavioral treatments, as combined treatments, meant that they could manage with lower doses of medication for the same effect.

DR. RAHN BAILEY:
This will be very important, the reality is I think that so much of what we do of having a behavioral focus diagnostically and concerns, goes so much further to us getting the answer right, giving an appropriate or effective diagnostic providing treatments that are going to be a lot more likely to be over the long haul.

DR. CAROLYN ROBINOWITZ:
Right and I think there as you point out, there really are two issues here. One is we don't want to give youngsters any more medication then necessary and if psychological behavioral treatments, talking therapies, cognitive therapies are helpful in reducing medication, that's terrific.

But it's just as bad, maybe worse, to give an insufficient dose of medication, it really needs to be tailored to the youngster's behavior and the impact of the medicine. One size doesn't fit all and I sometimes think because it's easy to have bad press about too much medication, that's sometimes youngsters will be only partially treated.

So they'll have a slight effect that it's not the right dose and the really important thing is to get it right for the child.

DR. RAHN BAILEY:
Absolutely. And that really makes you think about this combination or this co-morbidity to your clinical depression and it is the talk about some of your work addressing that connection and what are some of the key caveats that this thinking about if they have a relative or a colleague or a contact or a child that they think may actually for clinical depression and ADHD?

DR. CAROLYN ROBINOWITZ:
Right, well you know about two-thirds of children who have been diagnosed with ADHD have at least one other mental health or learning disorder co-occurring and commonly of course is depression and depression in children doesn't necessarily appear as it does in adults.

Some children may appear sad but others maybe more irritable, negative, sulky, show anger, get into trouble at school. So it's very important I think in assessing a child's behavior this is one time where a psychiatrist is very helpful in out these behaviors which may not seem typical of depression and may seem more of oppositional disorder, conduct disorder, you know kind of bad behavior on the part of the child.

But really reflects a mood disorder, that can be responsive to intervention. Now I think the figure is about a third of children with ADHD have a problem with mood disorders and/or anxiety and again these are treatable with medication and various forms of again talking behavioral therapy.

DR. RAHN BAILEY:
Do these patients children, adolescents or otherwise, have other you know co-morbidities, medical illnesses in addition that parents are or listeners today should be watching out for, in addition to ADHD?

DR. CAROLYN ROBINOWITZ:
Well I think it's very important for any youngster with ADHD to be monitored you know by the pediatrician or family physician as well we're always concerned about the impact of stimulants on children's growth increased appetite in some youngsters, change their growth curve.

We're also concerned about possible cardiovascular effects and stimulants product more rapid heartbeat. So it is important to keep track a kid's general health and also in this day and age, as much as we hate to think about it, to avoid diversion of medication, you know the improper use of prescription medications to other youngsters, or you know, on the streets.

DR. RAHN BAILEY:
And it really sneaks up on you almost insidiously with think patients are getting better treatment, more adults for example, have been focused on having ADHD or disorders and those treatments actually, may actually help individuals function at work, at home, and otherwise.

DR. RAHN BAILEY:
I do think we're on the same point, that was exactly the question I was asking. I note your comment about kids with ADHD and depression looking more oppositional, more so then melancholic and sad and you know dysphonic and you know isolated.

I think the MTA that you mentioned earlier showed I think about 40 percent of kids with ADHD also being co-morbid with ODD disorder, so it can be a very different clinical presentation. And my impression, I see that in my own practice, and I don't specialize solely on kids with ADHD, but the reality is it is certainly a pattern that I think we see.

And it's important, because these are the very human beings who are highly likely to be misjudged, in my opinion, and maybe mishandled if not mistreated, again in the school setting or even in the home setting

DR. CAROLYN ROBINOWITZ:
Or even in a court setting

DR. RAHN BAILEY:
Absolutely, absolutely right. Cause they're viewed as being as angry and irritable and bad, bad apples in a system

DR. CAROLYN ROBINOWITZ:
Yeah.

DR. RAHN BAILEY:
We should be the ones to come in and say, this is a part of the clinical process.

DR. CAROLYN ROBINOWITZ:
Absolutely and and I think the other thing we have to watch out for and I've seen this summer with parents but with some pediatricians or teachers to say, oh, you know so and so will grow out of it. And while it is true that adults with ADHD are a smaller proportion then kids with ADHD, what you see is these youngsters tend not to grow out of it.

Or they grow out it with scars scars that include not learning up to their potential or social relationships lower self-esteem difficulties with the law, substances things you figure it's things that aren't good for them where intervention without blaming or or even putting the quotes around ñthis is a sick childî.

But that this child has you know a neuro developmental disorder that we can provide good treatment for.

DR. RAHN BAILEY:
Well I agree, I think almost certainly the key challenges we or some of them that parents and friends, teachers and other colleagues you know must willing to be understand, I guess this is why education information with advocacy groups and and professional organizations like ours, must be on the ball about getting the information out so that the child with a fighting chance, that those around understand what is likely to occur once the diagnosis is made and how best to handle it.

DR. CAROLYN ROBINOWITZ:
Right and I think two things with it, you know, one is you know there's a strong genetic inheritability to ADHD, so in many families someone will say, oh I was like that as a kid and that can be good or bad, it can give some understanding but it can also have as the next sentence and I grew out of it fine so why are we bothering about junior?

But I think parents often do understand because they have experienced that in their family, but I think the other thing is we need to have the advocacy, we need to have the resources, you know, the American Psychiatric Association, the American Academy of Child and Adolescence Psychiatry recent published the Parents' Medication Guide, which is what is it ñParents' Medication Parents' Med Guide.orgî on the web, Parents' Med Guide.org which provides a host of information about ADHD, also about depression.

But now ADHD diagnosis, treatments a lot of links to resources and is a very good public information site done entirely through professional resources which I think is very helpful for parents and for teachers who want to know about these youngsters. There's a Spanish version also and it's and the download is free.

So this is something that can provide a lot of information for family members and for teachers and I think be very helpful.

DR. RAHN BAILEY:
It all too often, more often then you would imagine, regardless of what the initial, formal topic was to be that day, questions come up sometime when there's a good free-flowing discussion with lay people about psychiatry, questions come out regarding ADHD. It is just this huge issue that seems to dominant the discourse very often.

And I think we have to do the best job we can ensuring that the correct and accurate information is is disseminated because inaccurate information can really be be harmful and hurt and limit access of care, I think.

DR. CAROLYN ROBINOWITZ:
Absolutely and I'm very concerned that there are some groups whose belief is just that this is does not exist, that it's made up, that there is no treatment. A lot of negative stereotypes that just don't hold and I think it is important for parents and others to have a trusted site and a trusted place they can go to get information so they can help their kids grow and have a healthy life.

DR. RAHN BAILEY:
Absolutely. Any comments regarding what additional points or any for parents and friends, teachers and others should be considering as far as supporting a child, adolescent with ADHD and depression?

DR. CAROLYN ROBINOWITZ:
Well I think the main thing for parents and teachers and other (unint) again, but for parents especially is they're not alone oftentimes parents can feel very self-blaming or that no one can really understand or they're ashamed of their child's behavior and they don't want to talk about it.

But this is a common condition, it's nobody's fault, it's a no-fault brain disorder and the more parents can seek help, support groups community support, I think the better it is for them and for their children because they they feel less alone. There also arel some therapeutic programs that help parents deal with how best to manage some of the difficulties in raising a child who is hyperactive, has attention deficit disorder or learning disability.

Also to help parents understand more about depression there are a number of support groups as well as web-based resources pediatricians are often and there often are community places, but I think for parents if we can help them understand that there doesn't need to be shame, blame or stigma attached to these disorders, that's a first step in helping them help their children and also help themselves.

DR. RAHN BAILEY:
It has to be, I think, the most important take home message, I I clearly believe in my practice and others, that patients and family and the friends that are there that love them, can help them help themselves as as interconnected groups of families can do a lot to help that child or adolescent function optimally in the of life, home and school and other areas as well.

So I think that much of the information on them, Parents Med Guide.org, those bring that level of hope and optimism out, I'm pretty (unint.).

DR. CAROLYN ROBINOWITZ:
Yes I I hear your take home message which is is you know and I real disorders, it can be diagnosed by trained professionals. There are good treatments available treatments don't have to break the bank, the treatments work and that people can have very productive lives, the youngsters can grow up and I've seen this in my own family of offspring who have ADHD and have done very well growing up, in school and school, past high school, college, professional schools and done very well.

And that's that's the good news take home, very real message, treatment works.

DR. RAHN BAILEY:
Any final insights or final comments which is regarding ADHD and depression as co-morbid diagnosis, in terms of regarding the APA or its future initiatives or any other new hot items that I think we need to be aware of so we can see it marching forward?

DR. CAROLYN ROBINOWITZ:
Well I'm very excited at the possibility that parity, non-discriminatory access to care will become the law of the land for far too long all our patients who suffer from mental disorders, ADHD, depression, other mental disorders have been shunted away from care by a variety of discriminatory barriers, higher co-pays greater some greater financial barriers that affect the patient.

Not necessarily the physician providing care, but the family member and all too long stigma has affected people's comfort in accessing care. I think seeing parity as for psychiatric disorders as with other medical illnesses turns that around. It both helps people access care, it reinforces our message that we do have treatments that work.

And I think even more it makes people understand that these disorders are real and they are treatable as any other medical disorders. So I'm delighted that parity is on its way and this is not a political announcement, but I think we certainly should keep working for it because I think it is going to pass.

And if not in this calendar year, certainly hopefully early in the next.

DR. RAHN BAILEY:
Absolutely excited is the term and as am I.

DR. CAROLYN ROBINOWITZ:
Great.

DR. RAHN BAILEY:
I just can't thank you enough for spending this time with us, Dr. Robinowitz, I'm very confident our listeners have benefited from this information every bit as much as I have. And I just want to thank you again, your comments have timely and and outstanding and hope that the entire audience has really benefited as well. Thank you so much.

DR. CAROLYN ROBINOWITZ:
Well thanks for the opportunity and thanks again for all the good work you do.

DR. RAHN BAILEY:
Well I appreciate it my friend. For Depression is Real Coalition, I'm Dr. Rahn Kennedy Bailey, please join us next time for another segment of the Down and Up Show on www.depressionisreal.org.