Doctor Gives ADHD His Full Attention

Posted: February 28, 2017

Attention Deficit Hyperactivity Disorder (ADHD) is characterized by a difficulty in focusing or paying attention for a continued period of time. That wasn’t a problem for fans of the NorthBay Healthcare Facebook page on Feb. 22, as pediatrician Michael Ginsberg, M.D. captivated his audience with the latest data, advice and information on ADHD during #OurDocTalk, a live Facebook chat on the subject.

Dr. Ginsberg’s chat garnered the largest response yet to one of the every-other-week Facebook chats, with more than 200 reactions (likes, loves etc.) and 38 posted comments and questions.

The scheduled half-hour chat stretched to a full 45 minutes as Dr. Ginsberg answered dozens of questions that largely focused on diagnosis and treatment options along with plenty of parental concerns on how to help children with the disorder.

Asked how early a child can be tested for ADHD, Dr. Ginsberg said some clinicians will diagnose children as young as 4 but he prefers to wait until closer to age 5.

“This is because the diagnostic strategies that we have may have trouble differentiating the difference between ADHD and other diagnoses, or teasing out other diagnoses that the children may have in addition,” he noted.

Dr. Ginsberg also shared his own experience with ADHD, even injecting some humor, when asked by parents concerned about what adult life will be like for those diagnosed with ADHD in childhood.

“I think that all parents worry about their children and how adult life will be for them! Children with ADHD are no different in that respect, I suppose,” he wrote. “I also have ADHD and my parents agonized about how my adult life would be. Turns out that I have done quite well, if I do say so myself!”

His simple advice was for parents to “never give up” because “sometimes teenagers will surprise the adults in their lives when their brain maturation kicks in. They should do everything they can to maximize the teenager’s educational achievements and opportunities, but in the end, he will have to choose his own path as he approaches adulthood. As long as that path is reasonable, they should support him.”

The future for children with ADHD was also the focus when one Facebook follower asked if a child can “grow out of” the disorder.

“The simple answer is: ‘yes.’ In some cases, children who have the diagnosis of ADHD may no longer meet diagnostic criteria for ADHD in adulthood,” he noted. “That said, what does ‘growing out of ADHD’ look like? Rarely do these individuals turn into long-range airline pilots who are very good at staring at gauges for hours on end or secretaries who love sorting documents! However, adults with ADHD who may have had ADHD as children often display a skill set that is compatible with fast-paced careers in which they must respond to rapidly changing conditions. Many firefighters, EMTs, and emergency room physicians might have had ADHD as kids. Obviously, I encourage my pediatric patients with ADHD to follow their dreams, but part of that is choosing a career that maximizes their strengths, whether they do or do not grow out of it.”

Dr. Ginsberg didn’t shy away from technical answers during the chat, either. At one point he explained a brain study that showed the biological basis for ADHD, attaching a colorful image of a PET scan from the study and explaining why stimulant medications are helpful in treatment.

Not all of the posts during the chat were questions for the doctor. In fact, dozens logged on just to sing Dr. Ginsberg’s praises.

“We love Dr. Michael,” noted one fan.

“Dr. Ginsberg is fantastic. I can’t say enough good things about him,” added another.

The chat can still be found on the NorthBay Facebook page (Facebook.com/NorthBayHealthcare) and here is an edited transcript:

Comment:  My kids pediatrician.....Best ever!!

Comment:  Mine too

Q.: Any data on foods that help?

Dr. Ginsberg: Unfortunately, there isn't much evidence of a benefit to most dietary modifications. There are a few studies that have shown that supplementation with omega-3 fatty acids (mostly EPA and DHA, which are found in fish oils but not in flax oils) may be of some benefit in the management of ADHD. However, these are not miracle foods and the improvements are usually quite subtle.

There is no evidence that diets such as the Feingold Diet are of any use in ADHD.

Comment:  He's the best! Been with him ever since my child was new born... did anyone else get the "parent’s guide"? Hand book? LOL

Comment: We love Dr. Michael

Comment:  I was SOOOO sad when my daughters insurance had to switch to Kaiser. Dr. Ginsberg is fantastic. I can't say enough good things about him. Thank you for all of your help, work, advice during our time with you!

Comment: My kid's Doc, going on 7 years now! He's great!!! Kids think so, too!

Q.: How early can you test a child where results are reliable and if they are ADHD, what interventions can we give that are not medicinal? Can they qualify for ABA therapy?

Dr. Ginsberg: This is an area of active research and there is a fair amount of controversy. A major limitation to most of these studies is that there is no one "gold standard" diagnostic test for ADHD.

Some clinicians will diagnose children as young as four years of age, although I like to wait a bit longer until closer to the fifth birthday. This is because the diagnostic strategies that we have may have trouble differentiating the difference between ADHD and other diagnoses, or teasing out other diagnoses that the children may have in addition.

Generally, for non-medical intervention, I would recommend a good behavioral modification therapy program. I have found that ABA programs are usually more effective in children on the autistic spectrum than behavior modification.

Just a warning, though: for the child with poor attention span, poor impulse control, and who can't sit still for even a few seconds, behavior modification may be very ineffective and we usually find that a combination between appropriately dosed and supervised medication AND behavior modification therapy works better than either option alone.

Comment: He is terrific!

Q.:  Can a child grow out of ADHD

Dr. Ginsberg: This is an interesting and nuanced discussion. The simple answer is: "yes." In some cases, children who have the diagnosis of ADHD may no longer meet diagnostic criteria for ADHD in adulthood. Different studies have yielded wildly varying answers about how often this happens, though. Some studies have shown that only about 5% of children grow out of ADHD while other studies have shown that as many as ~60% of children will grow out of ADHD. 

My guess is that the true answer is probably less than 30% but that's only my educated guess.
That said, what does "growing out of ADHD" look like? Rarely do these individuals turn into long-range airline pilots who are very good at staring at gauges for hours on end or secretaries who love sorting documents! However, adults with ADHD who may have had ADHD as children often display a skill set that is compatible with fast-paced careers in which they must respond to rapidly changing conditions. Many firefighters, EMTs, and emergency room physicians might have ADHD as children. Obviously, I encourage my pediatric patients with ADHD to follow their dreams, but part of that is choosing a career that maximizes their strengths, whether they do or do not grow out of it.

NorthBay: NorthBay Healthcare Dr. Ginsberg knows what he's talking about. Check out our story on him and ADHD from WellSpring magazine: http://wellspring.northbay.org/articles/the-faces-of-adha

Response: Thank you very much

Q.: Interested to hear about older teenage girls with ADHD

Dr. Ginsberg: Of course, each and every person with ADHD is an individual. Thus, I can't make any absolute blanket statements about older teenaged girls with ADHD.
Boys with ADHD are more likely to have hyperactivity and impulsivity as major features, while girls are more likely to present with a primarily inattentive type. That said, there are plenty of exceptions to that rule!

So I think that the best way to approach girls and young women with ADHD is to approach them as individuals and focus on their needs, rather than approaching them based on their gender.

Q.: Is medication the only way to treat ADHD? What if a teen/child refuses to take medication? Is it hereditary? And is ADHD a chemical imbalance ? What are some early signs of it?

Dr. Ginsberg: In 1990 a study by R. Zametkin et al was one of the first studies to show that there is a biological basis to ADHD. In this study, patients underwent a kind of brain scan called a PET (Positron Emission Tomography) scan. In this imaging modality, patients are given an IV drip of glucose that has been tagged with a radioactive atom. The scanner, which is a ring surrounding the patient's head, can pick up the radioactivity from this small amount of glucose and this shows where the brain is most active.

Dr. Zametkin's team averaged the images from a set of patients who have no psychiatric diagnosis and compared them to a set of images from patients with a clinical diagnosis of ADHD. The differences are striking.Brain image from Ginsberg Facebook chat

You can see that in the patients with no ADHD there is a fair amount of activity scattered around the entire brain structure. But when we look at the image of patients with ADHD we see much less orange and red, indicating much less brain activity overall. The biggest difference is at the front of the brain where there is essentially no orange or read in the ADHD patient set.
This may surprise a lot of people who would expect that the brains of hyperactive and impulsive children would have more activity, rather than less. But it turns out that most of the outputs from the brain are what we call "inhibitory" outputs, meaning that much of what the brain does is that it prevents things from happening.

The area at the very front of the brain, the "frontal cortex," is involved in filtering out extraneous stimuli and also filtering out the strange and seemingly random impulses that we all feel throughout the day. So in the patient with ADHD they are more likely to respond to these stimuli and impulses than their non-ADHD counterparts.

I think that this shows very nicely one of the ways in which there is a biological basis for ADHD and it also helps to show why stimulant medications are so helpful, even though we'd expect the opposite to be true.

Comment: Our doctor as well love him!!

Comment: Best Doctor, He explain everything properly, he is the best!!

Comment: My girls doctor they love him

Q.: I know someone who has been on all of the meds, the last being Concerta. Medical provider took them off of that medication and they now suffer without it. They say this person had outgrown it but they still struggle with GAD. They take a low dose of an anxiety medication. Is this the best remedy?

Dr. Ginsberg: I'll emphasize that I don't know this patient and that I only treat children, so I can only make some general statements.

First of all, many patients with ADHD do have "comorbid" (meaning "along with") anxiety and/or depression, so treating anxiety and depression may help patients with ADHD in that respect. That said, the medications used for anxiety and depression are usually not very effective in managing ADHD itself.

I'm not sure why this patient was taken off all ADHD medication, but s/he might want to seek a second opinion if s/he is still struggling with ADHD and isn't having good results with this physician.

Q.: I know someone with a 14-year-old with ADHD, learning disabilities, and more. They are concerned about how adult life will be for him. What can they do to better prepare him?

Dr. Ginsberg: I think that all parents worry about their children and how adult life will be for them! Children with ADHD are no different in that respect, I suppose. I also have ADHD and my parents agonized about how my adult life would be. Turns out that I have done quite well, if I do say so myself!

My advice to that parent would be to never give up. Sometimes teenagers will surprise the adults in their lives when their brain maturation kicks in. They should do everything they can to maximize the teenager's educational achievements and opportunities, but in the end, he will have to choose his own path as he approaches adulthood. As long as that path is reasonable, they should support him.

Q.: How does one go about get tested/diagnosed for other problems associated with ADHD like, slow processing, executive functioning etc.? It seems like once a child has been diagnosed with ADHD thats what they stick to for everything else....

Dr. Ginsberg: Generally when I suspect that a child has a diagnosis that is comorbid ("also comes with") ADHD and I am unsure of that diagnosis, I will refer them to a psychologist for additional diagnostic clarification.

As a physician I am, of course, trained to focus on treatment. There may not be good treatment for executive function difficulties and the like, but there may well be good accommodations in school and at work that allow the child or adult to perform well with reasonable assistance. That's why the management of ADHD is more than just "take this pill." It's a multidisciplinary process that involves many people in the patient's life working together for success.

Response: Thank you.

Q.: Regarding a 5-year-old recently diagnosed with ADHD, and showing signs on sensory processing issues. Do these typically go hand in hand? Child is also having a hard time staying asleep (bedtime around 7:30-8) and he's up at 4...See More

Dr. Ginsberg: In this child, it's difficult to say what is related to the ADHD and what may be something else. So let me break this question down:

1) Sensory processing difficulties are common in children with ADHD. They are also common in children who may be on the autistic spectrum. Children may have ADHD and be on the spectrum at the same time. It is very common for children with ADHD to have more than one diagnosis.

2) Sleep difficulties in children are so common that Russel Barklay, one of the "gurus" of ADHD, argued that a sleep disorder should be included in the diagnostic criteria for ADHD. Many children with ADHD have difficulty settling down at night and/or difficulty getting going in the morning. A few well-done randomized controlled trials have shown that melatonin given an hour before bedtime improves sleep onset and sleep maintenance in children with ADHD. 

Melatonin is quite safe and is available at most pharmacies. I usually start with 1mg given an hour before bedtime (it takes a long time to work) and then parents may adjust the dose up and down from there as needed. Generally, doses over 10mg usually don't work any better than 10mg, although there are always exceptions.

3) Picky eating is very normal in young children. At times --and especially with children with sensory processing disorders-- it can become very problematic. I generally recommend (as difficult as this sounds), not giving into the crying fits. Serve him his dinner and if he wants to eat it, he may. If he does not want to eat it, he doesn't have to. When he gets hungry enough, he'll eat. He doesn't *have* to eat dinner every night. I have seldom seen the child so picky that s/he'll starve him or herself to the point of malnutrition.

Q.: If a 9 year-old boy was on great meds that have been working well and no major issues issues in school but had some big changes at home then started having social problems at school, would you recommend dosage changes or counseling?

Dr. Ginsberg: In a case like this, I think it's important to listen to the child and his family. If you feel that the meds are working well and the problems are caused by the changes in the child's environment, then I would argue that changing the dose is not the appropriate response. If you feel that it's primarily due to the changes at home, then I'd start with the assistance of a psychologist and then monitor the focus and attention as to when a dose adjustment is required.

Comment: Best doctor ever!!!!

Comment: Dr. Ginsberg treated my son. He actually listened to his concerns and reacted to them. He's a very good man, and excellent doctor

Q.: I know someone with two sons that have ADHD who are taking their medicine but says it does not work. What else can they do to help these boys?

Dr. Ginsberg: My first bit of advice would be to return to that physician and explain that the medications are not working. Certainly, we do not want to keep a child on medication that isn't providing any benefit. Perhaps they need a higher dose? Perhaps they need a different medication? There is no one perfect treatment for all patients; these treatment plans must be carefully tailored for the individual patient through trial and error and adherence to a consistent clinical algorithm. All in a day's work for me, and it should be all in a day's work for any physician who treats ADHD.

Q.: Is it typical for a child going through puberty to no longer have the same response to medication they once did? I know a boy who just turned 13 and it seems the medication that once worked, no longer does, even after an increase in dosage. Currently he takes 54mg Concerta. Would you recommend a child at this age seek a different drug altogether?

Dr. Ginsberg: Adolescence is a challenging time even for children with no psychiatric or psychological diagnoses. Teenage boys in particular go through a period of shockingly fast physical growth and changes in metabolism during which the response to medication may decrease. Sometimes the solution is to continue to increase the dose as the child grows until an effective dose is found. Sometimes we find that it is necessary to try a different medication. 

There is no one solution to this problem and I have had to use different solutions in different patients.

Comment: Doctor has been very supportive as we chose to medicate our kids and also very supportive when we chose to remove my kids off of medication

Q.: I know a girl with ADHD diagnosis along with anxiety and OCD since May. Her parents have tried four different medications ... could this be something else?

Dr. Ginsberg: Certainly at times when patients fail multiple medications appropriately chosen for a given diagnosis, it may be time to rethink the diagnosis. So when one of my patients has, for example, failed the amphetamine class, methylphenidate, atomoxetine, guanfacine, and combinations thereof, my practice is to refer to a psychiatrist or psychologist to revisit the diagnosis. Sometimes the diagnosis is wrong and the treatment is inappropriate for the correct diagnosis. This is why medicine is both an art and a science!

Response: Thank you.

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