Today Karen and Sunny ask clinical psychologist Dr. Staci Bolton your questions all about raising a child with ADHD. Dr. Bolton brings years of wisdom and expertise to this conversation, including her take on the difference between ADHD and a typically developing active child in the early years, the misdiagnosis of ADHD,  and practical strategies for families dealing with the difficult dynamics ADHD can introduce into sibling and parent relationships. This conversation was so rich, we've split it into 2 episodes so you have time to digest all of the information Dr. Bolton shares. 

Links from today’s show:

Dr. Staci Bolton’s practice

Social Skills Group in Atlanta for ADHD children aged 7-10

ADDitude Magazine

Parenting the Strong-Willed Child by Rex Forehand

Understood.org - website full of resources and articles for families with an ADHD child

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Question 1: How do you specifically discern ADHD over a child who has a higher level of energy or is just more spirited?

Dr. Staci’s Answer: While some children with ADHD are noticeably more energetic or spirited, having high energy alone does not suggest a diagnosis of an attention disorder. In fact, some children with ADHD can be hypoactive or not have increased energy at all. Some children struggle more with inattention and may or may not have noticeable differences in energy levels. ADHD is more related to the ideas of self-regulation, impulse control, and managing one’s energy level effectively. So, to better answer the question, in order to be diagnosed, children who have a high level of energy would need to show impairment in multiple aspects of their daily life. So, when evaluating a child, we talk to parents, teachers, and sometimes other observers to assess the impact of the child’s high energy on his or her performance in the classroom, relationships with peers and family, the ability to participate appropriately in extracurricular activities, etc. It’s important to recognize that the child’s difficulty with regulating his or her activity level would need to be pervasive and ongoing and not simply developmental in nature. So, the age-appropriateness of environmental expectations, like in a Kindergarten classroom, is also another important factor to keep in mind.

Question 2: Is ADHD over diagnosed? Is it really on the rise? If so, do you have an opinion as to why?

Dr Staci’s Answer: The question of over-diagnosis requires a somewhat complex answer, but I know we want to be mindful of using our time here wisely. The bottom line is that misdiagnosis is more common than over diagnosis. In other words, it is thought that some children are mislabeled as having an attention disorder when in fact they exhibit difficulties with attention due to another root or core problem - such as anxiety, depression, or sensory processing problems. In other words, it is much less common for a typically developing, psychologically healthy child to be diagnosed with an attention disorder (which is what over diagnosis actually means) and more common that a child who has a mix of symptoms is not carefully assessed and isn’t given the most accurate or helpful diagnosis.  

The question of whether ADHD diagnosis is on the rise does not have a simple answer either. Currently, research shows that ADHD occurs in approximately 3-7 percent of the childhood population and approximately 2-5 percent of the adult population. Interestingly, these prevalence rates are fairly consistent around the world and not unique to the United States (though the actual name of the disorder can vary in different countries - such as using the term Hyperkinetic Disorder of Childhood in the UK). There is definitely ongoing debate about whether there is an actual increase and what research methods are being used to obtain the prevalence rates and measure any potential rise in the numbers. The specifics of that debate could fill an entire podcast, but the short answer is many experts conclude it is not actually on the rise. My understanding is that the only clearly documented rise occurred in the 1970s, which was attributed to the increased survival of premature and high risk babies due to improvements in NICU accessibility at that time. The CDC has shown some mild increases in numbers (such as nearing 10% rather than the more commonly accepted 5-7%) but those data have been criticized by researchers due to limitations of their research methods, such as using one-question surveys to identify patients. 

Question 3a:  ADHD has wreaked havoc in our home. I have 4 children (ages 12,10,8,5) and my youngest son has ADHD. He is very impulsive with his mouth and behavior despite all forms of discipline and praise. He says things out loud or to others in public that are socially unacceptable. He can be very defiant and disrespectful at times and it’s hard to be in public with him and my other children together.  

I’ve sought help through a counselor and ABA therapist and spent the last year and half studying this. As a nurse I want to understand what’s going on with him. I’ve tried educating my other children to give him positive attention before he seeks negative attention from them. But our family needs help. Any tips on how to manage this as a family and how I can help my other children?

Question 3b: In our family, both my husband and I share some of the symptoms of ADHD... what kind of practical tips can you offer for a whole household that would in turn support a child, too?

Dr. Staci’s Answer: Attention disorders can certainly have a significant impact on relationships - with parents, siblings, peers, and between spouses. I think the mother in the first question is very wise to seek professional support to explore parenting strategies and learn more tools to help not only her child with ADHD but the siblings who are also affected by the increased stress in the home and when going places together in the community. I think it is very important for parents to have those difficult conversations with siblings, to show them their parents understand when they feel embarrassed in public and empathize with their disappointment when they miss out on an opportunity due to their younger brother’s behavior. Trying to carve out 1:1 time for special outings and regular conversations without the child with ADHD being present can be very helpful. While we always want to encourage family outings and shared activities, it is also important to guard some time with the other siblings, either as a subset of the family or 1:1 with a parent. The other children need to have opportunities and become comfortable with sharing their thoughts and feelings, especially the negative ones, with their parents so they can explore ways to cope with the challenges that come from having a sibling who acts impulsively. Sometimes the other siblings need family counseling or a few sessions on their own to help them find more ways to deal with their frustrations and disappointments. Unfortunately, there is rarely a simple strategy to target the behavior problems, and it takes consistent changes in multiple areas to see noticeable results. That is why having support from a therapist, like the mom has already consulted, can be so helpful to parents, who often feel overwhelmed or defeated. If this mom hasn’t already tried it, a social skills group or social skills summer camp with outings in the community could be very effective for giving this child an opportunity to practice interacting with others while receiving feedback from therapists and peers. The mom also may find the book Parenting the Strong Willed Child by Forehand and Long to be helpful. It is a research-based book for 2-6 year olds and addresses ADHD specifically.  

As far as the parents who share symptoms of ADHD, my first tip would be to try to create as much structure and routine at home as possible. Having clear systems in place will help their children know what to expect and increase their sense of security. Often parents need support for time management skills and sometimes for organization strategies. There is a great website called Additudemag.com (like ADD-i-tude rather than at-i-tude) that offers helpful articles, practical tips, and recommendations for apps that can be very helpful to adults or teens who are working through symptoms of ADHD. It is also a print magazine, and they have a Facebook page that posts some great articles.  Understood.org is another great resource for parents to help learn more ways to effectively manage daily tasks and routines at home. The website also has some helpful resources, like dealing with sibling conflict, that could help the mother in the first part of the question as well. 

Show Credits: hosted by Karen Stubbs with Sunny Williams, written & produced by Katie Leipprandt, edited by Kyle Cummings

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