Understanding ADHD with Dr. Zachary Blumkin

Welcome to Health Matters – your weekly dose of the latest in health and wellness from NewYork-Presbyterian. I’m Faith Salie.

Whether it’s on social media or in celebrity news, attention-deficit hyperactivity disorder — or ADHD — feels like it’s being discussed everywhere. But it’s also a condition that a lot of people misunderstand.

This week, I spoke to Dr. Zachary Blumkin, a psychologist at NewYork-Presbyterian and Columbia to help explain ADHD. He dispels myths, explains treatments, including medication, and talks about why it’s so important to recognize and address ADHD.

Faith: Dr. Blumkin, thank you so much for joining us today.

Dr. Blumkin: Thanks for having me.

Faith: Can you start by giving us a broad overview of what ADHD is? And I think we need to start by explaining what the acronym stands for because everybody’s heard of ADHD, but what are those words?

Dr. Blumkin: So ADHD stands for attention-deficit/hyperactivity disorder and what we know now is there’s three presentations within ADHD. So there’s ADHD hyperactive, impulsive, and that’s kind of what we think about when we think about pop culture or the movies or sort of what you hear on the news.

But there’s also ADHD inattentive presentation. And that presentation is for the folks who are kind of a little bit lost in the clouds, difficulty focusing or paying attention, kind of easily distracted, maybe losing things a lot, or a little bit disorganized. That’s another presentation of ADHD.

And then the third presentation of ADHD is hyperactive, impulsive, and inattentive.

Faith: I’m thinking in the olden days back when kids would just throw labels at each other, so it sounds like, oh, that kid’s hyper or that kid’s spacey.

Dr. Blumkin: Well, I really love that you’re bringing this up because I think in many ways what we’re talking about is the stigmatization of mental health issues. Everyone loses things sometimes, right? Everybody’s a little spacey sometimes. But when you see somebody with ADHD, this is a really, really disruptive disorder.

This impacts children, teens, even young adults and adults in multiple settings within their life. So it’s a very serious thing. And it would have to be to a degree where it impacts social functioning, academic functioning, relationships, maybe ability to engage in different activities inside of school, outside of school, and that’s something that we’re sort of looking for.

Faith: Can you shed more light on that? So how does ADHD impact thoughts and behaviors?

Dr. Blumkin: Yeah, so if you have a child with ADHD, if they’re in school and somebody asks them a question, they may not have been paying attention in that moment. Or maybe they rushed to answer the question without actually thinking what their response is or what the question was asked.

With social situations, sometimes they interrupt people a lot. Sometimes they have difficulty paying attention or focusing on the conversation at hand. They can seem spacey or out of it, which kind of are all social characteristics that folks don’t necessarily enjoy in relationships. We know that if you have ADHD and you meet the criteria for ADHD, you’re likely going to struggle in some of these areas.

Faith: I can only imagine that the consequences of experiencing this are really tough from an emotional and mental health point of view. Because when people don’t understand it, people can assume a kid is rude or not paying attention on purpose or is a behavioral problem in school. And that must be so painful for these kids.

Dr. Blumkin: That’s absolutely accurate, which is why it’s so imperative for our frontline folks. So our teachers aides, our coaches, our dance teachers, our, our parents, our pediatricians and healthcare providers to be aware of what ADHD is. This also allows us to talk about two separate groups that I think are marginalized.

So we’ll often see that Black children specifically are targeted and identified as problematic when in fact they may be struggling with other mental health issues like ADHD. So the diagnosis is missed, and then they’re then seen as a behavioral problem and we’re not targeting the right intervention.

Another group that I think we can talk about are girls. So girls are more likely to present with ADHD inattentive presentation rather than ADHD hyperactive, impulsive presentation. Because of that, the diagnosis is often missed in girls because if you think about a young girl in a class who’s not necessarily paying attention but isn’t presenting with behavioral issues, they may go through school not meeting their academic potential and not necessarily meeting the potential socially, but it’s just generally missed because they’re seen as a spacey kid, right? And so these are two groups that we really want to make sure that we’re paying more attention to so we can make sure that we’re providing enough support for them.

Faith: I was looking at some statistics that say, almost 10 million children in the U.S. have been diagnosed. Now who knows how many kids haven’t been diagnosed? And something like almost 5 million adults probably have ADHD, 20% of whom might know they have ADHD, right? So all of us must know someone who has this challenge.

Dr. Blumkin: Yeah, ADHD is one of the most common neurodevelopmental disorders in childhood. And I think that if you work with children or you have children or you’re friends with, folks who have children as well, this is something that’s probably going come up in your life.

Faith: You touched on some of our stereotypical understandings of someone with ADHD – maybe not being able to focus. Can you list some kind of specific criteria that you use to diagnose ADHD?

Dr. Blumkin: Yeah, so. For me, I’ll use a, a rating scale for parents and teachers and or coaches to fill out that helps identify these issues. But for our listeners out there, you want to think again in those three different categories, right? So you want to think about inattentive presentation, hyperactive impulsive presentation. For inattentive presentation you’re thinking about failing to give close attention to detail. So that’s like making careless mistakes in schoolwork, or trouble focusing or holding attention, not seeming to listen when people speak directly to them, difficulty following through on multiple steps when giving them instructions, trouble organizing tasks, or avoiding or disliking tasks that require significant mental effort, losing things a lot. They seem distracted or they’re often forgetful. Those are really the key features of inattention.

Faith: Do researchers have a sense of what causes it?

Dr. Blumkin: As far as I know, researchers don’t have a great sense of what causes it, but we do know that it is biological, meaning that, if you look at different aspects of the brain and even different parts of the brain from size, structure, or function, we can see that there’s differences in individuals who are suffering from ADHD versus those who don’t meet the criteria for ADHD.

So we know it’s biological and we know it’s in the brain, but we’re not yet at the step of being able to sort of do a nice and easy brain scan to kind of identify, OK, this child does ADHD versus this child does not have ADHD, therefore, let’s try this treatment.

Faith: Are there ever cases where children with ADHD grow out of it?

Dr. Blumkin: So what we think right now is about 30% of people with ADHD will likely not present with ADHD or symptoms of ADHD in adulthood. We don’t really know why. It’s possible that they kind of grow out of it, or there’s some major biological change, or maybe they’ve learned different skills and strategies over time. So now they are still struggling with it, but it’s not impacting them in any major way. Another 30% will go on to struggle with it on and off and to a significant degree where it’s impacting them, but not so it’s having some major impact in their life.

And then about 30% of folks, and these are folks who are untreated, will go on to have major issues in their life. Car crashes, emergency room visits, even suicide, premature death, criminality, depression, substance use, these are all things that we see. And so that’s likely some form of coping with the issues of untreated ADHD.

And the treatments are really straightforward, that it’s not usually that way for psychiatric issues, but for ADHD it is. So it’s really upsetting to see this go on into adulthood and for folks who really struggle.

Faith: It’s really hopeful and comforting to hear that the treatment for ADHD is straightforward. What does the treatment look like?

Dr. Blumkin: So I’ll put a disclaimer on this. The treatment is straightforward, and it’s very effective, but it sometimes, I should say, almost always requires parents to make the difficult decision of putting their children on medication. And the first line treatment for ADHD is stimulant medication.

And so I understand that parents don’t want to put their children on medication. I have three children and to think about putting them on a medication that they have to take every day, a medication that does have some side effects is a really difficult decision. And I say this to all of the families I work with. If I had a child that was diagnosed with ADHD, I would put them on medication because I think the benefits outweigh the risks in a major way.

Faith: As you mentioned, medication is not an easy decision to make. So how do you help parents decide if medication is the right choice for their child?

Dr. Blumkin: I think in the cases where we see a child who’s presenting with some of the symptoms but isn’t meeting full criteria, that’s a great time to meet with a healthcare professional and get some solid advice. In that case, you may not want to put a child on medication, but also in that case, they might not be meaningful criteria for ADHD, so it’s something that we’re going to want to continue to monitor over time. If these issues of maybe being a little bit spacey or forgetful, or disorganized, or even interrupting folks is not causing impairment in their life, then I don’t necessarily know that a major intervention like medication is needed.

It’s possible then maybe some parenting work or even some work with the child on social skills could be helpful. Or maybe the issue isn’t actually ADHD, it’s related to another issue that needs to be identified and treated. So I think you’re absolutely right. But for those children that are very clearly suffering with it, the best and most first line treatment is medication.

Faith: Why is medication so unquestionably the gold standard here?

Dr. Blumkin: So the way that you want to come back to thinking about it is that this is biological. This isn’t something that our children have necessarily control of. If you have a child with ADHD and you tell them a hundred times over and over again to sit down and don’t get up during dinner, they may not be able to do it, and that’s not because they don’t want to not listen to you. Of course they want to listen. Of course they want to be good. Of course they want to follow directions and receive praise, but biologically they’re moving too quickly and they’re having trouble controlling those hyperactive, impulsive movements and behaviors. And therefore we know that medication — and very safe medication, medication that’s been around for many years — is the first line intervention.

I’ll also say you often have to try multiple medications before you find the right one, and so your doctor, usually a psychiatrist and sometimes a primary care physician, if you don’t have access to a child psychiatrist, will walk you through some of those risks of trying a medication and figuring out that it’s not working, so we need to try a different type of medication. But there are lots of medications that can be very helpful and be a game changer for not only children, but for the stress that the families incur as well.

Faith: Besides medication, what other treatments are available?

Dr. Blumkin: Yeah. Yeah. Another aspect of treatment that can be helpful in addition to medication is thinking about other behavioral interventions that can augment medication. Now we know that these behavioral interventions on their own often don’t make a major impact.

And certainly combined with medication can be really helpful. But sometimes doing behavioral parent training, so giving parents some parenting skills, as well as doing some classroom management training or behavioral classroom management can be helpful. There’s also what’s called organizational skills training that’s got some research to support it as well.

So these are other treatments that can be utilized in combination with medication. And often families will say, well, I want to start with the behavioral treatments first. I think that’s an OK thing to do and if you notice that, it’s really not making that…a major impact. That’s when to really consider medication for your children.

And again that decision is not taken lightly. I understand that this is a big deal for families, as it should be, and I’m hoping that you’re meeting with providers that are offering a lot of validation and support for a decision like this.

Faith: I have to think that there are some adults listening to this wishing, I wish someone had seen this in me when I was a kid. I wish I could have gotten help. Is it common for adults to seek out a diagnosis later in life?

Dr. Blumkin: It’s becoming more and more common and there’s more and more evidence on adult ADHD and what that means. And I think again, that reduces the stigma of ADHD and the stigma of mental health in general, so we are seeing it much more over the last decade or so.

Faith: And how does treating adults look? Is it different than treating children?

Dr. Blumkin: So it’s pretty similar to treating children. It involves medication often, but it also involves cognitive behavior therapy for ADHD. CBT, or cognitive behavior therapy, has been around for a while, usually utilized for anxiety and depression, trauma and other issues, but it’s certainly now being focused on in the research on how we can utilize these skills and strategies with ADHD.

Faith: It strikes me that the environment that we put our children in from preschool all the way through high school, and then likely college for some kids, is this kind of artificial environment where all the things that are challenging for them are expected of them. Whereas once you reach adulthood, you are not expected to sit still for eight hours a day or be quiet while you’re doing your work.

Dr. Blumkin: Faith, you’re absolutely correct. And so we earlier discussed the idea that 30% of individuals no longer struggle with ADHD in young adulthood and adulthood. And one hypothesis is that some folks with ADHD are drawn to certain professions or jobs that would really be helped by thinking quickly and moving quickly and having a ton of energy and being on top of that idea of not staying stagnant in some way. And so I think that can be really helpful for individuals, as they move forward and certainly a plus. This is a very hopeful diagnosis based off the treatments that we have in getting the supports for the children, and for our adolescents is the most important thing.

Faith: Dr. Blumkin, thank you so much for talking with me today.

Dr. Blumkin: Thanks for having me.

Our many thanks to Dr. Blumkin

I’m Faith Salie.

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