Dr. Theresa Cerulli Discusses the Complexity of ADHD

In this video, neuropsychiatrist Theresa Cerulli, MD, addresses the myth that most cases of attention-deficit/hyperactivity disorder (ADHD) are simple to treat. ADHD is in fact a complex and heterogenous disorder that is difficult to both diagnose and treat, she says.

Dr. Cerulli, who has specialized in ADHD for approximately 20 years, is on staff at Beth Israel Deaconess Medical Center in Boston, Massachusetts, and works in private practice in North Andover, Massachusetts. She is a clinical instructor at Harvard Medical School in Boston and a clinical supervisor for the Harvard Longwood Residency Training Program. 

This is Part 2 of a 4-part video series marking ADHD Awareness Month, which is held in October.

Part 1: The Importance of Using Multiple Approaches When Treating Pediatric ADHD

Read the transcript:

Hi. I'm Dr. Theresa Cerulli. October is ADHD Awareness Month. This seems the perfect time to address a longstanding clinical myth that "most cases of ADHD are simple to treat."

This is not true. Fact is that ADHD is a very complex, heterogeneous condition, making it both difficult to properly diagnose and difficult to treat. As a neuropsychiatrist specializing in ADHD for 20 years or so, I've been on the front lines with families struggling with this disorder. In addition to my professional experience with ADHD, I also happen to be the mom of a 15-year-old daughter with ADHD. I've personally seen how complicated this condition is in our own household.

I remember when I first started as an ADHD specialist, friends and colleagues would say, "Theresa, don't you get bored seeing the same patients with the same condition all day?" I'd laugh, "Au contraire. ADHD is never the same."

ADHD is challenging. That's why we as clinicians tend to both overdiagnose and underdiagnose this condition. For example, there's a tendency in kids with behavioral problems to just rush to an ADHD diagnosis. In the quiet inattentive ADHD kids, especially the girls, we tend to miss the diagnosis altogether.

The three core symptoms of ADHD, which are inattention, hyperactivity, and impulsivity, unfortunately, don't leave us with much help in nailing down this diagnosis. Now layer in the additional challenges that upwards of two-thirds of our ADHD kids also have coexisting psychiatric conditions, and an astonishing 60 percent of those have 2 or more psychiatric comorbidities with their ADHD.

No, I'm not just treating ADHD kids in my ADHD practice. I'm seeing depression, anxiety, bipolar disorder, insomnia, tic disorders, the list goes on, in terms of what I'm treating along with ADHD.

I was pleased to see in the last year that—ready? breaking news—our diagnostic and treatment guidelines for ADHD have been updated.

The American Academy of Pediatrics and the Society of Developmental and Behavioral Pediatrics, their guidelines have appropriately evolved to recognizing the fact that ADHD is complex. The timeline for this was that last fall, it was the AAP who updated their guidelines to include comorbidities as part of the evaluation for ADHD kids.

Approximately February of this year, the SDBP followed suit in calling this condition "complex ADHD," with the emphasis now being placed on having to evaluate and treat the comorbidities along with the core features. So remember, complex ADHD is more the rule of thumb than the exception.

I'm really glad to see that there is emphasis placed on the comorbidities that we need to be paying attention to and treating these kids for, in other words, addressing the whole picture. Here we have a complicated, highly genetic, highly heterogeneous disorder with heterogeneous comorbidities, which is why ADHD is not simple to treat.

What do you do? Clinicians should be prepared to collaborate with their ADHD families around both pharmacologic and nonpharmacologic treatment options.

For medications, we have several FDA-approved options including stimulant medications, which is either the amphetamines or the methylphenidates, and we have nonstimulant medications such as the long-acting guanfacine and clonidine, or alternatively atomoxetine.

Depending on the patient, I may prescribe a stimulant, a nonstimulant, or a combination of both. Stimulants, of course, are controlled substances due to their abuse potential and can exacerbate comorbidity sometimes, such as anxiety or insomnia, so our patients obviously need to be closely monitored.

Also, some patients are just not good candidates for stimulants due to underlying medical conditions such as seizures, or tic disorders, migraine headaches, or cardiovascular risk factors.

In addition to the black box warning regarding abuse and dependence with stimulant medications, side effects may include insomnia, decreased appetite, agitation, elevations in blood pressure and heart rate, and wear off effects at the end of the day. In kids, we often call this the witching hour for the kids at the end of the day.

Besides the stimulants we've talked about, I briefly mentioned, there are alternatively three nonstimulant medications that are FDA-approved for treating ADHD. To date, the nonstimulants have not matched stimulants in terms of efficacy in treating these core symptoms—the inattention, the hyperactivity, the impulsivity.

There's really for future direction in the ADHD field, I would say there's a lot of room for advancement here in our pharmacologic treatment options. We’re really due.

How about the nonpharmacologic treatment options that I said we want to use in combination with the pharmacologic options?

Nonpharmacologic treatment options. I like to tell families that I envision a treatment table with four sturdy legs, structural legs, of support. One, the first leg, is psychoeducation. In other words, really teaching families, parents what ADHD is and what ADHD is not, just helping them understand what the heck this means.

The second leg of the table, counseling. That may be individual counseling, family counseling, both, whatever type of counseling is needed for support for that particular individual family. Third leg, some parent coaching or executive skills training. This depends really on the age of the child and the capacity.

If it's a younger kid, it's really the parents that you're coaching to help coach the kid at home. If it's an older kid going into the teenage years, executive skills training, where they're really learning how to use the coaching skills to implement good strategies in their day-to-day practice—how they approach their homework, remembering what's needed for assignments, keeping a calendar log, etc.

Finally, the fourth leg of the table, diet, and exercise. Paying attention to diet, exercise, and let me add sleep. Those other everyday measures that can be of huge help or a huge hurdle, depending how they're utilized.

This is, of course, these structural legs of this table, in combination with what we're doing to optimize treatment with pharmacologic options. The way I look at this, the medication is really working from the inside out, and the supportive strategies are working from the outside in for our ADHD kids.

In our household, we've had to get creative to make the supportive strategies more user-friendly during COVID, which I know has been difficult for many families, not just ours. My daughter plays hockey, and she finds her outlet in sports and exercise for her hyperactivity. Without school sports, now we had to come up with other ideas.

We set up a shooting alley in our garage for her to roll around in her rollerblades, using those as her ice skates, and shooting at nets at each end of the garage. Now, I admit this was not without its own side effects. We had 30 plus holes in my garage walls.

The good news is that she was then responsible for also patching the holes, which was another great hands-on skill to learn as an ADHD kid, rather than sitting with a textbook when she needed a break.

My parting message to you is that ADHD is not simple to diagnose or treat, but it is highly treatable. These kids are a lot of fun to work with. While you're optimizing their medications, find what they're passionate about. Find what they're excited about. It's such a rewarding field to practice in. The great news is these kids can excel not in spite of, but because of their ADHD, when the right supports are put in place.

Thanks for joining me today and thanks for caring about your ADHD patients.