#160 The Current State of ADHD | Signs, Steps & Treatment for Your Family with NYU Professor Dr. Yamalis Diaz

Oct 3, 2022 | BRAIN HEALTH, The Gabby Reece Show

Dr. Yamalis Diaz Landscape

My guest today is a clinical assistant professor of child and adolescent psychiatry at the NYU School of Medicine and a licensed clinical psychologist: Dr. Yamalis Diaz. Dr. Diaz specializes in ADHD and focuses on ways to put systems in place to support people with the diagnosis. What is happening that is different in the ADHD brain in structure and function? Dr. Diaz gives us a deeper understanding of what that child or adult is navigating and how we can help them. What have they discovered in the research in the last 10 years? How has our environment and technology have exacerbated the situation? She shares the meaningful impact of certain lifestyle habits and changes that can be made to make getting out of the house or the learning environment much easier. Like all situations that have unique challenges she gives us the wonderful reminder that when directed correctly this is a super power. Also if you are interested in more information on ADHD I would recommend the movie ‘The Disruptors’ directed by Stephanie Soechtig. Enjoy.

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The Current State of ADHD | Signs, Steps & Treatment for Your Family with NYU Professor Dr. Yamalis Diaz

“The ADHD brain is always looking for dopamine, creative food, and input that’s going to feed it. There are some settings that are less structured that provide that. It comes down to understanding, individually, what brain does this child have? How does ADHD manifest itself in real life? Not just because we’re saying they have ADHD but in real life, how do they have ADHD? What setting would make the most sense for them?”

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“Simply saying that somebody has ADHD doesn’t tell us that much. On an average Monday, how does ADHD show up? How does it convert to behavior, habits, skill deficits, or challenges in the way that they have to function in their world? Are they so distractible they’re not getting their work done? Are they so distracted that they’re not learning in the classroom? Are they hyperactive that they can’t be seated? Their parents have suspended activities and vacations because the hyperactivity is too much to manage. You tell me in that little equalizer way exactly which symptoms at what level in what settings for this child and then we have a good understanding of this particular person’s version or rhythm of ADHD.”

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“It is important for children and anybody with ADHD to hear and begin to understand how their brain can also be extraordinary. We don’t want to oversell the superpowers to the point where they don’t pay attention to the challenges. I have seen kids, their brains make me feel in awe of what they’re capable of doing.”

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Welcome to the show. My guest is Dr. Yamalis Diaz. She works in the field of child and adolescent psychology. Her specialty is ADHD, Attention Deficit Hyperactivity Disorder. We’re talking about somebody who works a lot with children and adolescents but that’s us too. In some ways, ADHD is an extension of normal human behavior that’s maybe turned up a little bit, and getting an understanding of that.

A lot of us hear diagnoses that get thrown around and people are throwing medicine or treatments at it. Is it right for your child or yourself? What is going on? What’s going on with the structure of your brain? What’s going on with the function of your brain? Because it’s different, it doesn’t make it good or bad. It makes it different. We live in a world with a certain system. We’re all supposed to adhere to this way like sitting down at a desk and this is how we’re learning. Not everyone’s like that.

She breaks down the clusters of behavior that show up that you go, “Maybe my child or myself has this going on?” What’s going on inside the brain? What can you do to support them naturally through lifestyle, through different systems in place, types of communication, and finding that homeostasis but then creating these outlets for intense creativity? That’s the other thing.

It’s important to not stigmatize this. It’s to look at this as, “This person works and learns differently.” Also, within this, there’s a lot of magic if we can help them get to the place where they can be creative, hyper-focused, and all of these things. A lot of time, it works out when we’re adults but it’s a challenge when you’re sending a kid who’s got to be on a schedule and they’ve got to get to school. She breaks it down. There’s so much information and understanding ADHD and the research and things that are out there and available to support the person and the people around the person. I hope you enjoy.

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Dr. Diaz, thank you for joining me. I appreciate learning from you. I watched the film The Disruptors by Stephanie Soechtig. The topic of ADHD or ADD and maybe we can get into the subtleties is something that only is thrown around a lot but a lot more people are dealing with it than maybe we’re aware of. You work with child and adolescent psychology but I’d love to know how your journey has brought you here.

Thank you for having me. I posted on social media and did my little celebration of what I’m referring to as my twenty-year ADHD-aversary. I happen to stumble upon an old notebook where I wrote the first set of notes with my graduate school advisor, it was our first call. I hadn’t initially been meant to work with somebody who specialized in social anxiety.

When I wasn’t able to work with them, they paired me with Dr. Andrea Chronis at the University of Maryland. We had a call.  I took notes. In these notes, I’m writing, “Attention Deficit Hyperactivity Disorder,” and the treatments for it. I can recall sitting in my parent’s living room freaking out that I was going to start graduate school and that I was going to be specializing in ADHD because that’s who would take me, essentially.

It wasn’t my choice to specialize in ADHD. The reason I posted about it is that, and it gets me a little choked up, you don’t know when you’re going to find your purpose and your passion. It finds you. This is what I was meant to do. Children with ADHD, their families, the parenting challenges, the school-based challenges, and all the amazing strengths that we can squeeze out of this beautiful brain, this is what I was meant to do.

My journey started by accident. In hindsight, these kiddos are my kiddos. These are the kids I was meant to focus on. It doesn’t mean I don’t work with kids that have a whole range of other concerns but ADHD is my true passion. It’s been over twenty years of studying ADHD and treating ADHD. I feel like I’ve gotten to know a lot about this wonderful brain.

What have you seen even in the last several years of research that is significantly different than maybe prior to the first several years that you were working in this field?

We’ve made good headway in particular on understanding the brain function of ADHD and some great fMRI and MRI research brain scans. Research pivoted to focusing not on intervention development but on getting some good information about the way that the brain might be different in somebody with ADHD compared to somebody without ADHD.

We’ve learned a lot more over the last several years about not only structural differences in the brains of people with ADHD but also functional differences. The structure is like, how is it built? What are the parts? What’s going on with those? The structure and the function are like, why does that matter? How do certain networks talk to one another? Is that a good thing? Is it not a good thing? What’s the deficit? What’s the difficulty there?

[bctt tweet=”Dietary shifts in terms of energy and being able to consume the right calories and avoid some of the crashes, all of that is important.”]

We’ve learned a lot more about the differences in both structure and function of the ADHD brain. That’s a huge leap forward not only for our understanding but to, first of all, destigmatize the fact that this is not just, “By the way, this is bad behavior, environmental, etc.” There are real differences there. That has been a lot of the work that has been done.

On an actual practical level, because brain-based research only takes you so far, you want to know, “What can we do about it?” One of the other things we’ve done well in the field is honing in on how to better assess it, diagnose it more accurately, and treat it in a way that can improve some of the challenges that come with ADHD.

I’m not afraid of a little bit of science. If you’re not afraid and you’d be willing to share with me at a reasonable level. I would love to break down when you talk about the difference in the structure of the frontal cortex. If we could also maybe go there a little bit. It is fascinating when people talk about having certain diseases that somebody can’t see. It’s almost like we relate to it differently if we can understand the mechanism a little bit. If you wouldn’t mind dividing and explaining the structural differences. You don’t have to get crazy but I’d love to know that and then some of the functional differences.

The good news, Gabby, is that I am not a neuroscientist myself so I won’t go too into detail for fear of making a complete fool of myself as well. At a basic level, we have some science and some research to suggest that there are certain parts of the brain that are smaller in volume or smaller in size among people with ADHD. I do not want people to misinterpret that as a smaller brain equals less intelligence, that is not the case.

We’re talking about the fact that noticing that there are real differences in the size and the way that certain parts of the brain function tell us that there’s something going on neurologically. There are certain parts of the brain that are a little smaller. Let’s call those structural differences, the way that it’s put together.

There are functional differences in terms of how the networks of different parts of the brain talk to one another. Think about it like a relay race where you have the first person that takes off on a relay has to carry the baton and then pass it successfully to the next person who passes it to the next person. If the baton drops, you’re probably not going to get around as fast and you might lose the race.

One of the things we know is that there are certain networks that, unfortunately, almost short-circuit in the ADHD brain. They don’t carry messages back and forth as efficiently as they should, meaning as quickly as they should or as effectively as they should, meaning they might not ever carry the message at all, they might drop the baton. That might mean that the child or the person with ADHD is picking up information from their environment.

Somewhere in the brain, the baton gets dropped, which means that they can’t execute. They can’t do anything with the information they picked up. That slows them down. It makes things harder. It makes things take longer. It makes things feel more challenging, etc. Lastly, there are some neurotransmitters, which are chemicals in the brain, they are chemical messengers. In this metaphor, it’s the actual baton. I hope no neuroscientists come after me for that one but let’s go with that. It’s the actual baton that’s supposed to be passed.

There are chemicals in the brain that are used to communicate between part 1, part 2, and part 15. Unfortunately, we know that there are certain neurochemicals that are lower or underactive in the brain and some that are overactive. One of the primary ones we know affects children and adults with ADHD is dopamine. The last thing I’ll say about this is that dopamine is the feel-good hormone. It makes you feel awake, alert, tuned in, motivated, and excited about things.

Unfortunately, the ADHD brain is dopamine deprived if you will. It’s always hungry for more stimulation that’s going to make it feel activated. I often tell parents and anybody who will read that if the ADHD brain is always hungry, it makes sense that they’re always looking for food. Food, in this case, is pretty much any stimulation that is going to get the brain excited. Those are the main three things, structure, function, and then these neurotransmitter differences.

There is some science suggesting that you can inherit this. Isn’t it more common that girls inherit it from their parents? For boys, it could be either one.

It’s one of the most heritable psychological disorders or neurological disorders known. We know that upwards of 50% are heritable from parent to child. If you have one child who has ADHD, you’re likely to see siblings who have ADHD. It does run in families and it does genetically get passed along. There is some research that suggests that girls have a higher heritable rate of ADHD than boys but not so much that we would say boys aren’t inheriting the ADHD components. It also tends to run in families.

Keep in mind that anything that we inherit, any of this also interacts with the environment. There is a gene-by-environment interaction. In some cases, you might inherit all the genes that say, “You should have ADHD.” The environment is supportive, structured, well organized, or whatever it may be that you may never see the manifestation of the challenges that might be related to ADHD. A child might look like they don’t have ADHD when, in fact, neurologically, they might.

Dr. Diaz, can you break that down for me? When you say an environment that’s structured and supported, can you tell me what that looks like? That’s an interesting idea. I always joke, it’s such a moving target how to connect with your child, how to speak their language, how to get them to self-manage, and things like that. In this instance, you can make up a scenario. You could take one person and put them in one environment and it might express itself versus a different type of environment and it maybe doesn’t show up quite as much.

Let’s think about either home or school. First, we’ll go with home. You might have one child who has ADHD and does well in a home environment where parents are like, “You’re going to figure this out. We’re going to let you self-manage and self-direct. Eventually, you’re going to figure it out.” The problem is that for the ADHD brain, it might take much longer to “figure it out.” There might be too many bumps, bruises, and crash landings along the way that will therefore start to affect the child’s self-esteem.

The interaction between the child and the parent might eventually work out but it might be with a lot of bruises and a lot of “damage” along the way. What we know is that the ADHD brain does better in a more structured environment where expectations are clear and consistent and there’s a pattern and a rhythm to the way that you expect the brain to organize itself. Whereas a child without ADHD, if you put them in an unstructured environment, they might catch on a little quicker. They might not have as many bumps, bruises, and figuring it out.

Dr. Yamalis Diaz Caption 1

Dr. Yamalis Diaz – People do misunderstand ADHD as only being a deficit. It is important for children and anybody with ADHD to hear and begin to understand how their brains can also be extraordinary.

Similarly, in a school setting, we know that kids with ADHD thrive in classrooms that have some good organization and structure and consistent expectations. A teacher that manages not only the expectations but also gives them a little bit of wiggle room for some of their hyperactivity, impulsivity, their need for breaks, and their need for creativity. To throw one additional loop in there, there are some children who have ADHD and if you place them in a setting that’s much more expressive, creative, and open, let them figure it out.

With a little bit of guidance, they thrive in that environment too because the ADHD brain is always looking for dopamine, creative food, and input that’s going to feed it. There are some settings that are less structured that provide that. It comes down to understanding, individually, what brain does this child have? How does ADHD manifest itself in real life? It’s not just because we’re saying they have ADHD but in real life, how do they have ADHD? What setting would make the most sense for them?

This is for maybe people who don’t know much about ADHD or even maybe have children and they’re saying, “My child isn’t learning the same way. They’re not responding the same way.” In the ways that they have ADHD, we all think, “Maybe they’re distracted and there’s a little more impulsive or direct and things like that.” What you’re saying is it shows up also differently. Can you tell me what that looks like?

We know that ADHD has eighteen symptoms. You can imagine those music mixer boards if you were doing a little like music and equalizing. You have eighteen buttons that go from 0 to 100 and all eighteen of those, you are fiddling with to figure out, “Exactly what version of ADHD does this person have? What is their unique rhythm of ADHD if you will?”

Simply saying that somebody has ADHD doesn’t tell us that much. On an average Monday, on an average Saturday morning, how does ADHD show up? How does it convert to behavior, habits, skill deficits, or challenges in the way that they have to function in their world? Are they distracted that they’re not getting their work done? Are they distracted that they’re not learning in the classroom? Are they hyperactive that they can’t be seated?

Their parents have suspended activities and vacations because the hyperactivity is too much to manage. You tell me in that little equalizer way exactly which symptoms at what level in what settings for this child and then we have a good understanding of this particular person’s version or rhythm of ADHD. I use a lot of metaphors. I hope that works.

It’s great. For example, I have a friend who was diagnosed at 10 with ADD. Can you explain some of the differences? I have three daughters and I don’t have a son but I have an active partner. My husband, for sure, when he was a kid, is the definition of hell on wheels and encouragable. It’s constantly and yet directed in the correct way. The disruptors talk about this.

I want to remind people that there are a lot of superpowers if there can be an understanding and systems put in place and people understanding and the person who’s dealing with this finding these outlets. It’s their capacity to hyper-focus or creativity and things like that. I’m not interested in putting a stigma on it. As an outside person, it feels like a natural way that humans would behave and it would have its incredible strengths.

Maybe before when we were more naturally active, outside, or living in this way that this type of behavior probably worked better than, “Sit down at your desk and be quiet. Ride the train and here’s your cell phone.” Going back to my 10-year-old friend, could it not also be a natural moment in development for a young person? I would think especially males because of testosterone and other natural behaviors.

One of the things that you’re highlighting is probably one of the toughest parts of not only assessing ADHD and diagnosing ADHD but also deciding what treatment, if any, is necessary. We know that ADHD, all eighteen symptoms occur in all humans at different levels. If you look at all the eighteen symptoms, it’s like, “Who’s not a little inattentive, distractible, forgetful, or disorganized sometimes?”

One of the biggest details that’s super important for people to understand about diagnoseable ADHD versus average behavior or an average point in development is that the behavior clusters with at least six different problems. It isn’t 1 or 2, it’s at least six all clustered together happening at a much higher rate than is typical for that developmental level and perhaps, most importantly, causing functional impairment, meaning it’s getting in the way. Something is getting in the way of what you’re supposed to be doing in your setting.

It is true that a lot of people look back in time and they say, “We didn’t use to have so much ADHD. What’s going on?” Some of it is that we assess it better. We were more accurate in our diagnosis. Some of it has to do with the fact that the expectations of society, school, and competition, you name it, expectations of society have continued to go up. It means that if you are inattentive, unfocused, distractible, disorganized, hyperactive, impulsive, and you are not producing in a more competitive or more structured environment, you are going to be named.

Somebody’s going to point and say, “Something’s going on here.” That’s where the functional impairment comes in. You’re not producing whatever it is you need to produce in the setting that you’re trying to function in. That is where it separates from average developmental little hiccups to this sounds like it could be something different. If we don’t intervene, this child, teenager, young adult, and, God forbid, an adult is going to tumble through instead of riding through.

My biggest goal in doing all the work that I do with ADHD is not to get people to feel like, “ADHD is a thing.” I care mostly about the experience of a child, a teenager, or a young adult with ADHD and the fact that it doesn’t have to be bumpy. If we don’t give them the intervention and the direction that they need, it’s probably going to be bumpy and that’s what I’m trying to prevent. It can be smoother. We can put them on the right track to use all of those beautiful strengths and some of the ways that their brains are uniquely qualified to do some great things.

If we don’t intervene, it often either takes longer to figure it out. Your friend or your husband might tell you, “Yes, I eventually figured it out. Yes, I’m successful now. Yes, I got all of these strengths. I get it now. 8th grade was not great. The sophomore year wasn’t great. I felt like I was always getting called out. I feel like I was always behind everybody. I always wondered what was wrong. My parents were always frustrated with me.” It was so much bumpier and it didn’t need to be as bumpy. That’s the reason to assess, diagnose, and treat.

All of us can agree. I would imagine you taking your path and doing your job, you have run into probably large challenges and those are the same things that also have made you probably the badass that you are right now.

Thank you.

It’s true. It’s like, “You can’t do that or you can,” or, “You’re a female,” or, “You come from whatever family.” Who knows? When I hear this idea about 8th grade and 10th grade, there is a part where a lot of parents or someone is going to be like, “This too is a part of life. This too is what makes us better and great.” Where does that break? You said it shows up in clusters. The clusters are things where it’s now jeopardy for the person and possibly their family because there’s frustration and other types of ways of acting out.

Maybe we could start with a younger person. You 3-year-old or a 4-year-old and they have a lot of energy. Maybe it’s showing up differently. They’re not playing well with other their kids. They go to the little kindergarten and they can’t follow along. If I’m a parent, what’s the first step in diagnosing or recognizing?

[bctt tweet=”Teachers can be a great first place to get a sense of where your child is on any spectrum if you will. Pediatricians at your visits, you can also be raising it to them.”]

If you’re a parent and you are concerned that the pattern of behavior is pretty consistent, that’s a real telltale sign. It’s consistent. We’re not just talking about a few tough moments or you had a little fight with one friend but you have all of these other friends. We’re talking about a pretty consistent pattern of challenges and difficulties that are starting to affect the child and/or the family negatively.

This is where you can wrap your mind around it. Bumps and bruises are part of life. We do want kids to develop some resilience and some grit. Things aren’t always going to come easy. That’s not what we’re trying to do. If it’s as frequent as is common for children and teens with ADHD, that’s a lot of bumps and bruises. It’s like death by 1,000 paper cuts. Everybody else without ADHD only had fifteen paper cuts. They have 1,000. Eventually, it starts to hurt.

The issue is it isn’t that we’re trying to wipe away the challengers. We know that the challenge is to give them some grit and tenacity and we love that but it also usually hurts. For parents, what you’re looking for is like, “What is the consistent pattern? Am I starting to see that my child compared to other kids of their developmental level is struggling socially, struggling in the classroom, and struggling at home? I’m constantly calling their name. I’m constantly redirecting. I feel frustrated with them.” They themselves are “ruining” family moments.”

This is one of the things that breaks my heart. Kids will eventually say, “It was me again.” They start to know it’s them. They’re the ones who ruined Christmas, Hanukkah, the trip to Disney, the family outing, or dinner time. They get it. It starts to accumulate. I want to point carefully to the frequency. The sheer frequency of difficulties is too high.

Before we go on to the first steps of trying to navigate, getting help, and getting resources, first of all, can we decipher between ADD and ADHD?

ADD is technically a retired term if you will in the psychology world or the psychiatry world. It stands for Attention Deficit Disorder. The reason it was retired is that eventually, what was decided is that it would all be called Attention Deficit Hyperactivity Disorder and it has three subtypes. Predominantly inattentive subtype is what was formerly referred to as ADD. Predominantly inattentive, meaning most of your difficulties are with regard to attention and you don’t have too much of the hyperactive-impulsive component.

There is the predominantly hyperactive-impulsive subtype, which means not so much a focus issue, mostly hyperactivity and impulsivity. This is the least common. We’re more likely to see that in young kids mainly because we can’t see problems with focus and attention just yet. There’s the combined subtype, which is the most common subtype, especially among boys. Predominantly inattentive is more common among girls, the formally ADD terminology. What we find is that in the combined subtype, you have at least six symptoms of inattention and at least six symptoms of hyperactive-impulsive behavior. A total of twelve symptoms out of the eighteen.

Let’s say I have been diagnosed myself. I’m a parent. I’m getting ready to have a baby. I’ve been diagnosed with ADHD and I know there’s this possibility. It’s like anything. Is there anything showing up in the lifestyle not just with the child that comes out, and I want to get into that, but for the adults. Let’s say I’m managing it through lifestyle habits and choices and I have systems in place to help me keep that soft structure or keep things rolling. I’m curious if they’ve seen anything that a person or a parent can do to maybe help minimize or change the outcome or the potential for my child.

Sure, there’s plenty. Where the environment begins is in the way that the parent is parenting and what is the home structure? Probably the first thing we would be thinking of is if you are managing your symptoms of ADHD or ADD by your habits, your systems, or your organizational structure, that’s probably all you need to do as a starting point. Make sure that the environment is as quiet and rhythmic as possible, routinized, and structured.

As I say that, anybody reading is like, “That doesn’t sound like what happens when a baby is born.” This is the problem. The problem is that when a baby is born and it throws the family and the whole system into a little bit of chaos, that is likely to then exacerbate the parents’ symptoms of ADHD. They’re going to be sleep deprived. They’re not going to be eating. They’re probably not exercising and taking care of themselves. They are tired. There’s a crying baby. They have to manage many different things. All of a sudden, the system is starting to get a little chaotic and a little disorganized.

The best thing that a parent with ADHD can do, especially at the beginning of their newborn toddler stages, is to pay careful attention to even the small things that they can do to get a rhythm, organization, and structure back in place. The ADHD brain does so much better. It gets quieter. It gets happier. It gets more homeostatic if you will in a rhythm that is predictable and consistent until it goes looking for stimulation and creativity in which case, we open it and invite some of that delicious creative energy in. We then close it again and put them back on a consistent rhythm.

What we’re trying to do for kids is let them have those outlets, let them go in search of dopamine, and let them go find some creative things to futz around with, but then we need to reestablish some consistency because that’s where they’re going to thrive. For parents who have ADHD themselves, one of the best things they can be doing is self-identifying, “In what way does my ADHD affect the way that I run my life and my world? How does it frustrate me? When do I get overwhelmed, disorganized, or feel like I’m in chaos?” Figure out what little tweaks you can make to your lifestyle to try to reestablish some of that rhythm because it will help your children who might themselves have ADHD.

For example, if something’s wrong with a “child”, it was pointed out a long time ago about how parents would drop their kids off to you and be like, “Fix my kid and I’ll pick them up when they’re fixed,” versus, it is the collective. It’s everybody in the house also getting on board. A hard thing for us parents to look at too is that we will have to make changes in support of the environment and the child to elevate the whole thing.

If someone’s reading this, if the child is going through something, don’t be afraid to get involved and also see how the changes that you can make. It makes that change happen a lot quicker and a lot smoother than, like, “They’re broken. Fix them, medicate them, or do whatever. Let’s get them back home and get on with it.” That suggestion is great. If someone has a young child and they’re seeing these clusters of behaviors, where do they go? What’s the first step to getting real help? One of the things that can be hard in dealing with any type of new situation is getting that oriented towards results help.

Pediatricians and teachers are always going to be in the first line. They see thousands of children. They have a good normative comparison sample. They know what feels like it’s off the course and what feels like it’s still totally normal for this developmental stage. The teacher who’s been teaching first grade for ten years has a lot of children to compare your child to. If you go to the teacher and say, “Can you tell me if you think my child is struggling in these ways?”

Teachers are usually quite good at being able to say, “This still feels normal to me. It’s causing some real trouble.” Teachers can be a great first place to get a sense of where your child is on any spectrum if you will. Pediatricians at your visits, you can also be raising to them, “My child is having trouble focusing. This is what I’m hearing from teachers. This is what I’m hearing from their little friends. I’m noticing.” Pediatricians can be great at not only giving you some feedback about how far off the beaten path your child might be but also at assessing ADHD. That is one avenue you can certainly pursue.

Dr. Yamalis Diaz Caption 2

Dr. Yamalis Diaz – One of the things that we want to do early is to address any sleep difficulties because sleep deficits plus ADHD is going to show up in the classroom or anywhere else this child needs to be.

Psychologists, psychiatrists, and other mental health professionals that are pediatric that specialize in children would be the second next step. A lot of times, parents will come to us after they’ve checked with their pediatrician and their pediatrician identifies, “There might be a little bit of trouble here.” There are some beautiful strengths.

This is usually what brings people in, it’s like, “This is causing a problem of some sort and we need to figure out what’s going on for my child.” As you work with your mental health professional, there are other professionals that can be brought in to help with any number of challenges your child might have. Occupational therapists at school. If your child is having some social challenges, the child can be working with a therapist as well.

One of the unfortunate other parts is that ADHD has a lot of what I refer to as first cousins in the brain, meaning where you see ADHD, you’re likely to see a couple of other diagnoses that are closely nearby. That includes things like anxiety, some tantrums, oppositional behavior, depressed mood, or self-esteem challenges. Where we see ADHD, we’re likely to see some related diagnoses and concerns. Those are also something that needs to be addressed in good treatment.

Let’s say they go, “We’re recognizing there’s something and we’re going to go down this path of improving the situation.” A lot of times, as parents, you get concerned that the first thing that will happen is they go, “We’re going to throw a medication at the situation.” There are quite a lot of things. You talked about putting a system in place and some gentle reminders. Can you share the things that get experimented with first to help the child and smooth out the environment prior to medication?

One of the things I want parents to understand is going in to see a mental health professional to see if there’s ADHD and/or anything else going on with your child does not automatically mean your child is going to be “put on medication.” You will have the ultimate decision-making power as far as that’s concerned.

Will a psychiatrist or provider suggest that as a first-line approach? Perhaps, but that shouldn’t stop you from going in to find out if there might be a problem. If you feel strongly about wanting to start medication, you can decline the invitation to participate in that treatment, if you will. I don’t ever want that to be the reason parents don’t come in in the first place. You can decide, once you have better information, what course of action you want to pursue.

That being said, one of the things we know is that with or without medication, behavioral interventions for children with ADHD are critical. If you’re going to put your child on medication, you should still be getting some behavioral interventions and supports in place. If you’re not going to pursue medication, you should especially be thinking about what behavioral strategies you can be using.

We know that ADHD ends up manifesting as behavior. There are specific things that your child either does well or does not do as well. What we want to do in behavioral therapy is figure out which behaviors are we trying to reinforce, meaning we want more of that, and which behaviors are we trying to reduce. We can think creatively and strategically, using behavioral interventions that have been studied and supported in research, they demonstrate good effects, especially over the course of development, what it is your child needs to thrive in the environment that they’re in.

I call these recipes. We can think of behavioral strategies as ingredients. Let’s say putting up a routine using a reward, taking things away, and giving them neutral feedback, those are all ingredients. The goal of behavioral interventions is to help you mix and match those ingredients to develop a good recipe. Children with ADHD require and will do my best in a situation where some of these strategic parenting efforts are in place. For children without ADHD, this is just good parenting but like not essential.

For children with ADHD, here are my favorite recipes. My first favorite recipe is always going to be a structured routine, meaning what is their morning routine? What is their homework routine? What is their bedtime routine? Those three routines are probably the most critical. With those routines, because you need them to complete them, you need them to be on task, and you need them to reduce disruptive behavior while they’re doing these routines. You’re trying to build a habit and the best way to do that is to add a reward. Routines plus rewards is my favorite starting recipe.

You can see some nice reduction of disruptive behaviors and improvement of some of the positive behaviors like leaving the house on time, completing the morning routine, finishing their homework, turning their homework in, getting to bed on time, and turning off electronics. I could go on. These are all things that happen in the context of daily routines. If we can get them to understand exactly what the expectations are at different times of the day and then build those habits with rewards, you can do quite a bit of managing the ADHD symptoms with that starter recipe. There are some other things that parents can be doing but that’s one of the top ones.

It’s an interesting mix of, why couldn’t they do that anyway? Is it the habit, consistency, and then that positive response? The reward would give you some dopamine. Is it grooving that pattern that helps facilitate the child’s ability to task completion and continue through?

Yes. I love the term that you used, grooving the pattern. Now they can follow along. Because it’s such a little groove, you can ride smoothly. It’s like a paved road. Do you want to be on a gravel road? You can probably still get down the street but the paved road makes it much easier. It’s like paving a road. There are specific ADHD-related challenges that make that difficult for children with ADHD to do. One is that they are they tend to be what we call time blind. They have a hard time noticing the time, paying attention to time, knowing when time is passing, and estimating time. If they’re supposed to be “ready” in 45 minutes, they don’t know what 45 minutes feel like. They’re losing track. That’s part one.

Part two is the ADHD brain has a hard time organizing itself in strategic steps. If you give them ten things that need to get done as part of a collected routine, those ten things are happening in a bippity-bop fashion. They’re moving over here and then they’re moving over there. They do this and they do that. Maybe it does get done but it’s disorganized. A routine gives them not only when does it start, when does it end, but what is the flow? What are the things? What’s the collection of tasks that we’re calling this morning routine? When they do that in this routine way over and over again with some reinforcement, it does become a groove. It’s like their brain doesn’t need to think about it as much.

The last thing I want to mention is when routines are tedious and what routines aren’t tedious. There’s a lot of tediousness and routines. When they’re tedious, their brains are also much more prone to be more distractible, having a really hard time staying motivated to get things done, playing with the dog or the cat instead of getting their shoes on. Now their brain is being pulled in more directions not just the direction of the routine.

Whereas a child without ADHD might be able to make it through their routine with minimal distractibility from point A to point Z pretty easily. Whereas a child with ADHD will be all over the place. Perhaps the worst part of this is that means that almost every day, they’re going to be hearing their name, their gentle correctives, frustrated correctives, a lot of redirection, and that’s just Monday. It happens again on Tuesday. It creates this negative pattern.

[bctt tweet=”The ADHD brain is more sensitive to a dopamine hit or more sensitive to criticism, more sensitive to failure, and more sensitive to challenges.”]

If we can equip them with something like a routine, sometimes I joke that it’s like plugging in the directions in your navigation system in your car. If you’re not good at getting where you need to go and you’re using your navigation all the time, guess what happens when you don’t have directions, you get lost. You don’t know which end is up. That’s me, by the way. I’m terrible with directions. Routines are like telling the child’s brain, “You are going from point A to point Z. Let me help you see exactly what turns you need to make all the way there.” That way you don’t give the brain as much room to get distracted and be off course.

For example, let’s say someone has an 11-year-old or 12-year-old and they’ve been fighting this since the kid was 3 or 4. To have them think, “Maybe we should go get help.” These systems in place at least help smooth out the road a little bit for people.

That’s exactly what happens. By the time anybody has come to see me, patterns have been developed. They have found their pain points where they find themselves getting frustrated or their child is frustrated or they’re having more arguments. The first thing that we want to do is smooth out the edges so that we can reduce the negative interactions. That is often where we start.

I often think about even the transition of going through adolescence. If this hasn’t been dealt with or someone isn’t understanding what this young person is going through, I can imagine that it would add a layer especially because of the social ramifications where the kids are getting into hassles at school and always getting nagged at by the teachers. This could be a pretty frustrating scenario for both, the parents and the child. Can we visit a 30,000-foot view of how typically ADHD would show up in a young child and then how it starts to maybe change or show up through adolescence and even young adults?

In young children, we all have this quintessential picture of the bouncing child who’s hyperactive and impulsive. I want to be clear in highlighting that may be the case for children who have the combined type or the predominantly hyperactive-impulsive type. In children who have the predominantly inattentive subtype, what we tend to see is that they’re quiet, they don’t disrupt anything, and they fly under the radar.

Eventually, they seem to be spacing out, they missed what I said, they don’t seem to be listening when I’m talking to them, they’re missing some instruction, and they’re not getting stuff done. We might see a lot more disruption in the academic setting for the predominantly inattentive kiddos. The hyperactive-impulsive ones are more obvious because they tend to have a lot of difficulties staying seated. They’re constantly fidgeting. They’re always moving from thing to thing. It might be difficult for them to function in settings where they’re expected to contain all of that energy.

As development continues, let’s say all of the above have problems with inattention. Those tend to stay pretty consistent and pretty stable. Whereas hyperactive-impulsive symptoms do, thankfully, start to come down a little bit. We have the development on our side here so the brain is starting to wire itself. We’re starting to get a little help. We tend to see the hyperactivity-impulsivity start to come down with one important caveat. It’s not always, by the way. Sometimes we still see that restlessness.

The impulsivity might not look the same as when they were younger. It might look different in teenage and young adult years where it transfers from blurting out things in the classroom interrupting a lot to things like making impulsive decisions. Unfortunately, things like speeding in a car and being more likely to kind of get in little accidents or big accidents because of impulsive decision-making. More risk-taking behavior like drugs and alcohol and more indiscriminate decision-making around sexual activity, for example.

If impulsivity is still pretty prominent in the teenage years, that would be where we would be thinking about paying careful attention, it’s risk-taking behavior. Are they making impulsive decisions that are going to get them in trouble eventually? Thankfully, hyperactivity and impulsivity tend to die down a little bit as development goes. Thank God for that frontal lobe functioning. The frontal lobe is developing, The brain develops from back to front. The frontal lobe is coming online as they’re getting older. We’re waiting for it to kick on. Thankfully, that starts to improve.

What we do see is that the inattention starts to or continues to create some difficulty. What we might then start to see is even more pronounced challenges with something like executive functioning, having trouble managing multiple classes or multiple demands, having trouble managing schoolwork and a sport they play, or some other extracurriculars and social life. They can’t juggle all of those balls so they tend to be much more disorganized and a little more chaotic.

That’s important because if you think about these kids going on to either college or early career as young adults, we might then expect to see a lot of difficulty with being able to be on time and complete tasks as needed whether that’s an assignment in college or tasks as part of your job. Not all young adults will go to college.

If they’re going to go into the workforce, we tend to see a lot more disciplinary action, getting written up for showing up late, potentially getting fired more often, and switching jobs more regularly. We still see that inattention, executive functioning, and some impulsive decision-making start to impact their functioning. Mainly because the more responsibility they have to take for managing everything, the more those challenges are going to get in the way.

Whereas when they’re younger, parents are still driving the car more regularly and creating that structure in that scaffolding. As they get a little bit older, parents are expecting, “They should be able to do this without my support.” They take their hands off the wheel. Unfortunately, teenagers and young adults with ADHD probably still need a little bit more of that support.

Is the frontal cortex going until we’re about 25?

Until about 25 is what the science tells us. This is a fun fact, it’s one of the reasons that you can’t rent a car without having an adult co-signer under the age of 25 in most states. There’s a reason for that and it’s because of frontal lobe functioning. Car insurance premiums start to decline after 25. There’s a reason for that and it’s because we know that the brain finally rounds out with its frontal lobe.

The frontal lobe is like your executive assistant, it tells you where you’re supposed to be. It manages your time. It helps you organize. It helps you make decisions. It helps you control your emotions. It helps you process information in a way that allows you to weigh consequences more effectively. You can almost see it happen. I have the fortune of teaching a class that I developed at NYU called Twenty-something. It’s been fascinating to almost watch as the brain is coming online while they’re in my class. You can see when those mechanisms are starting to kick in.

For young adults, we’re not as in control of their day-to-day. I’m always going to be pushing for a healthy lifestyle. Sugar is probably not anyone’s real friend. I am curious when you have a younger person and a teenager, how much getting outside, being somewhat active, and not eating a bunch of processed garbage? Does that help the brain find more quiet spaces?

Lifestyle changes can make a big difference, for sure. What we’ve done in the field is we’ve shied away a little bit from talking too much about that. There’s a reason and the reason is that, for a while, people were focused on dietary changes for managing ADHD that it steered them away from other treatments. We know that dietary changes can help but won’t likely shift the impairment that you see with ADHD. You still need treatment. The field as a whole seems to move away from talking about that.

Dr. Yamalis Diaz Caption 3

Dr. Yamalis Diaz – Let the kids have outlets, let them go in search of dopamine, and let them go find some creative things to futz around with, but then we need to reestablish some consistency.

Let’s think about this as just a brain. With or without ADHD, if you haven’t slept well, you’re probably not going to attend to things and be super organized and super productive that day. If you haven’t eaten, you’re probably going to be hangry and unfocused. If all of those things are true and, on top of that, you haven’t been managing your stress, you haven’t been exercising, and you haven’t been interacting with friends in a pleasant way, it’s going to affect your mood and your well being. You swish all of that around and it could look like ADHD when maybe it isn’t even ADHD. It’s all bad habits.

With ADHD on board, we do want to focus. One of the things I tend to focus on as a starting point is we know that kids with ADHD have poor sleep overall. They have difficulty with sleep onset, meaning falling asleep. I had a child who once said, “I’m trying to fall asleep but my brain won’t let me.” He was 5 when he said it. He knew that his brain was wiggling him and he could not fall asleep even though he desperately wanted to be asleep.

Not only sleep onset but we know the quality of sleep. The time spent in REM sleep tends to be disrupted. They get much more restless sleep. They don’t wake feeling amazing. They wake feeling often pretty tired even though they might have slept the requisite number of hours. Sometimes we have kids who have all of those difficulties and the audacity of this brain wakes them up early. I hear from parents all the time, “No matter what time they go to sleep, my child is up at 5:00 raring to go.”

One of the things that we want to do early is to address any sleep difficulties because sleep deficits plus ADHD is going to show up in the classroom or anywhere else this child needs to be. Also, dietary shifts in terms of energy and being able to consume the right calories and avoid some of the crashes, all of that is important.

Last but not least, I often do tell parents, one of the things we can set our watch to or our calendar to is that right around November to February in the Northeast, we know that the behavior is going to become more disruptive. They’re going to be more dysregulated. They’re going to seem more anxious. They’re going to be more oppositional or whatever it happens to be.

We know that there is at least some seasonal peace to this. One is they’re not going outside as often. They’re not getting as much sunlight, which carries vitamin D. They’re not getting as much exercise. They’re more sedentary. It’s darker and quicker. The next thing you know, their whole mood and all of the ADHD symptoms are exacerbated. It seems to lift a little bit as the weather brightens and we get more sunlight. What does that mean? It means that, especially if you can, you want to get your child to have all systems on go so that the brain has its fair shot at doing what it needs to do.

In a way, anyone who’s contending with this, it feels like they’re a more sensitive version of how all of us are. Do we give young people Omega 3s or any supplements? Are you guys comfortable with that?

We sometimes refer to it as medication hesitant. Parents and children, if they want to stay off medication and want to try other more natural things like Omega 3s and other dietary and habit changes in their lifestyles. What I tell parents is, “Do all of that. If that’s where you’d like to start, let’s do that. Let’s put some consistent structure and behavioral interventions in place. Let’s see what we have left over.” At each turn, we will reassess if there’s anything else I would recommend or whether or not your child is making the improvement we need to see for you to feel good about where they are. If that’s not the case, that might be where we start having a conversation about medication.

I’m curious, maybe they’re contending with a larger amount of ADHD. Maybe their brain is working at a different speed. Are there any brain mapping programs? We have done this for sports where one part of the brain is more sleepy or what have you and you go in these programs and you try to fly things with your brain and do all these games. Are they incorporating anything else? I would imagine if you could get a young person to do some type of yoga or breathing exercises, that’s good for their brains. I was wondering if there are any of these other fun programs or things that are showing up that are starting to get incorporated.

They certainly exist. We know that kids love them. It’s easier to get them engaged and involved. There are probably two things to think about if this is something that parents decide to pursue. One is that those programs are not covered by insurance, even less so than any medication or behavioral therapy would get covered. It’s like an add-on. If you have the resources and you want to give it a shot, by all means, go for it. It’s not going to do any harm. Your child might enjoy it. You might feel it’s showing a little bit of improvement. The science is still rolling out on some of these programs and the longevity of the results.

The second thing I would want parents to keep in mind is that the speed at which you see some improvement is going to be so slow that you might feel like you’re putting in some real effort, your child is listening to the music every morning, or whatever it happens to be or going to this center and flying the airplane with their brain or slowing down their breathing when they noticed the biofeedback. The reduction of impairment related to ADHD, disruptive behavior, and all of the challenges might be too slow for you to feel good about this being the only treatment that you’re doing.

I often say to parents, “As impairment is accumulating, I want you to imagine that if there’s a hole being dug and maybe you’re throwing a little bit of the dirt back in the hole but the hole is still pretty deep, we cannot afford that for them. They will eventually have to dig themselves out of that hole.” They might fail grades, they might lose friends, and they might feel bad about themselves. You might be fighting with them all the time and all the things that we know can go wrong. We can’t afford for it to be a wait-and-see or a slow crawl to the finish line. We need things to be working sooner rather than later.

You’ve been doing this for over twenty years. How much has the internet and social media and all these things exacerbated this dynamic? Are you seeing an uptick in some of that?

We’re waiting for science to give us more. I know and we know that one of the things we’re starting to suspect is that social media and other versions of the technology are probably playing a role in a number of important things. One, it probably is training a reduced attention span. Over time, this is going to keep playing out. We all have heard the little funny anecdotes of even those three-minute TikTok videos that are too long.

People keep scrolling because what they need is multiple inputs on a consistent basis. This is what kids and teenagers are growing up with. They are essentially training their attention span to consume information in small little bits and bytes before they lose focus and lose attention. We suspect that this is probably going to affect how attention is organized and whether we see some long-term effects of that is entirely possible.

The other way that social media and the internet and technology are also exacerbating ADHD and related issues is in dopamine production. I call these dopamine sources. They go seeking dopamine sources. Their brain is dopamine hungry. They will find the best sources of dopamine that makes their brain feel the most enticed, activated, motivated, and happy. They end up almost conditioning their brain to only feel happy, motivated, and excited in these environments where lots of information are coming at them. It does exacerbate the ADHD brain in that way as well.

On a practical level, it also exacerbates the daily struggles of parents trying to get their kids off of technology. One of the top daily arguments that I hear from parents of kids of all ages is that once their child is on devices or technology of some sort, because their brain is intoxicated by how happy and comfortable it feels at a nice level of dopamine, it’s even harder to get them to stop. It’s harder to get them off.

[bctt tweet=”This is one of the things that breaks my heart. Kids will eventually say, “It was me again.” They start to know it’s them.”]

Unfortunately, what we often hear from parents is then it creates almost like a little drop in dopamine, like a crash. They’re irritable after using it. This turns into quite the struggle for children and teenagers with ADHD and parents who are trying to manage device use. Those are some of the ways that I’ve seen it play out.

To your point, ADHD or other, you take a phone away from a kid and it’s like taking drugs away. It is no joke. That’s my husband’s job.

I like the way you framed it, Gabby. The ADHD brain is perhaps more sensitive to some of these things. You’re right, all of these things are true for kids without ADHD. These are daily hassles and struggles and challenges that parents are dealing with all the way across the board. It just so happens that the ADHD brain is more sensitive to a dopamine hit or more sensitive to criticism, more sensitive to failure, and more sensitive to challenges. It accumulates more of that. Eventually, it does a little more damage. It is true, all kids, teens, and young adults are struggling with some of this.

One thing that showed up for me in The Disruptors film was the one mother of a daughter. It was like, “This wasn’t the plan.” The disappointment of her. Almost not believing that her daughter was going through this. Her daughter was faking it. It’s interesting, as a parent, you don’t want to admit that you feel disappointed sometimes because you thought you have a plan. We don’t know better and this is how it’s supposed to go. Your child is going to have their experiences and go through things.

What I want to remind people is, a lot of the time, what you see is this can work out quite beautifully if the kid can get assistance. We learn different languages and we learn to figure it out together as a family and a community. It’s okay for parents to feel disappointed but then to be like, “Now what are we going to do?” That showed up for me when I saw that because it’s like, “They’re different.” It’s great too if you can help them navigate.

Unfortunately, the school in our system, we have one. These people, a lot of them, might be extraordinary and do something way different. They have to navigate this weird one system. It doesn’t mean that’s fair or right. That showed up for me. Dr. Diaz, I appreciate your time and your insight on this. If I was missing anything that felt important to you, I’d like to make sure that I don’t forget something that feels significant.

Gabby, the point that you highlighted is probably the only point that is worth repeating. It gets me every time. People do misunderstand ADHD as only being a deficit. It is important for children and anybody with ADHD to hear and begin to understand how their brains can also be extraordinary. We don’t want to oversell the superpowers to the point where they don’t pay attention to the challenges. I have seen kids, their brains make me feel in awe of what they’re capable of doing. They require some good guardrails. They require a paved road and guardrails.

Parents are allowed to be disappointed because all parents have ideas in their minds about what they hope to accomplish and what they want their children to be. Anything that challenges those ideals is going to feel disappointing. That is quite the job of a parent, to have ideals, and to encourage them. When kids are bumping up against those, you’ll feel disappointed and then you figure out, “What do we do next?

I don’t want parents to ever feel like they’re not allowed to feel that because now they know that the child has some challenges. You’re allowed to feel that this is hard and disappointing. More than anything, I do hope that parents, children, educators, and anyone who cares about the kids, the teens, and the young adults with ADHD. If you can identify the challenges and put some support in place and then identify those strengths and the ways that their brains do extraordinary things and put wind behind that and some air behind that in whatever way you can, that’s where you’re going to see those superpowers just thrive. That’s the goal. That’s the goal for all kids.

It’s especially important for children with ADHD because the number of paper cuts, bumps, bruises, and negative feedback loops that they will experience in comparison to kids without ADHD is much higher. The frequency is too high. We need it for them to start to understand what they’re good at and what they’re capable of. The more we do that, the more you will see what an amazing brain this ADHD brain can be. Thank you for highlighting that. That’s important.

Thank you, Dr. Diaz. If people want to learn more about you or if there’s even a book or things that you like, maybe you could direct them there.

First and foremost, I’m @Dr.Yamalis across platforms. Maybe eventually I’ll post more stuff. I’m also at the NYU Child Study Center where we provide services for kids and families and a wide range of disorders, diagnoses, and challenges. The two places where I would direct parents as a starting point is the CHADD website, which is the national organization for children and adults with ADHD. It’s ripe with information of all sorts for anyone who needs it. I would highly recommend that.

One of my favorite YouTube series related to ADHD is How to ADHD. She does such an incredible job of animating and explaining using science but using layman’s terms how ADHD works and all the different areas that it might affect. That might be another resource that parents and other people might find helpful.

Thank you so much.

Thank you so much for having me. It’s been a pleasure.

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Thank you so much for reading this week’s episode. Stay tuned for a bonus episode where I go deeper on one of the topics that resonated with me. If you have any questions for my guests or even myself, please send them to @GabbyReece on Instagram. If you feel inspired, please hit the follow button and leave a rating and a comment. It not only helps me, but it helps the show grow and reach new followers.

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About Dr. Yamalis Diaz

Dr. Yamalis Diaz Headshot

Dr. Diaz is a Clinical Assistant Professor of child and adolescent psychiatry at the NYU School of Medicine and a licensed clinical psychologist at the NYU Child Study Center at Hassenfeld’s Children’s Hospital, where she specializes in behavioral therapy for children with ADHD and disruptive behavior disorders. Dr. Diaz also serves as the Department’s Diversity Ambassador, working closely with the Office of Diversity Affairs to develop and disseminate training and recruitment guidelines and practices that will help increase diversity in the Department of Child and Adolescent Psychiatry and across the medical center.