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Miss Deena Kotlewski, Ma, Lcpc. On Adhd

Miss Deena Kotlewski, MA, LCPC. On ADHD

Interviewer: Welcome; you"re about to learn the inside details about attention deficit hyperactivity disorder. We"re here today with Miss Deena Kotlewski, MA, LCPC. Deena; thank you so much for joining us today.

Deena Kotlewski: You"re welcome.

Interviewer: So let's start with the basics; what is it exactly that you do? What's your day-to-day?

Deena Kotlewski: Well I work for Montgomery County Public Schools as a School Counselor. I also have a private practice in Chevy Chase, Maryland where I work with children, adolescents, and their families and I work with them to help them solve you know common developmental issues and day-to-day problems.

Interviewer: Great; and how long have you been working in this business?

Deena Kotlewski: I"ve been working as a therapist since I earned my Masters in 1995 and then I became licensed in 2001 and I opened a private practice in 2006.

Interviewer: Great; and--and why--why did you become involved in this area?

Deena Kotlewski: I realized that there was an unfulfilled need for children and adolescents--that they really needed someone to talk to and I enjoyed working with children and adolescents and their parents.

Interviewer: Great, great; are there any special career highlights that you"re especially proud of?

Deena Kotlewski: I suppose becoming licensed after many years was a career highlight and then becoming part of a leadership team for Montgomery County Elementary School Counselors would be considered a highlight.

Interviewer: Great, great; now describe the services that are provided you know with regard to ADHD and therapy.

Deena Kotlewski: Well my focus is working with children and adolescents to improve their skills navigating through life's challenges; I work with children who feel depressed and anxious and sad and their families try to help them develop better family communication and you know we do that with you know talking and developing new ways of dealing with issues.

Interviewer: And how can you be reached?

Adhd Lcpc Ma Kotlewski Deena Miss

Deena Kotlewski: I can be reached directly on my phone at (202) 423-6778 and I also have a webpage www.therapistdeena.com, t-h-e-r-a-p-I-s-t-d-e-e-n-a--dot com and that will provide a lot of information about my private practice as well as links to other mental health services.

Interviewer: Great; now let's--let's start with some of the basics behind this issue. What exactly is ADD, ADHD--what's--what's the correct term; you know what are the differences or the official definitions of this?

Deena Kotlewski: They"re actually three different types of ADHD; each with different symptoms. There's predominantly inattentive, predominantly hyperactive/impulsive, and the combined type. And to diagnose ADHD an individual must display at least six symptoms from very specific lists from the DSM-4 and the symptoms have to have started before the age of seven to diagnose a child. So they also have to have clear impairment in at least two settings, such as home and school or school and work and there must be clear evidence of significantly clinical impairment in social, academic, or occupational functioning. So there's very specific criteria that you need in order to diagnose a person with ADHD and if one is going to fall within the predominantly inattentive type they have to meet one--they have to meet six of these criteria--fail to pay close attention to details or make careless mistakes in school work or other activities, have difficulty sustaining attention to task or leisure activities; they may often seem not to listen when spoken to directly; they do not follow through on instructions and fail to finish school work, chores, duties; they have difficulty organizing tasks and activities; they avoid, dislike, or are reluctant to engage in tasks that require sustained mental effort; they lose things necessary for the task; they are easily distracted and are forgetful in daily activities. So if a child has six of these characteristics then they might be diagnosed with the inattentive type of ADHD.

If they are--if they fidget with their hands or their feet, they squirm in their seat, they leave their seat in situations in which they"re supposed to remain seated, they move excessively, they feel restless during situations in which behavior is inappropriate, they have difficulty engaging in leisure activities quietly, they often seem like they"re on the go or they"re driven by a motor, they talk excessively, they blurt out answers, they have difficulty awaiting their turn, they interrupt or intrude on others either in their space or verbally; if they have six of these characteristics then they can be diagnosed for the hyperactive ADHD.

But most commonly there's a combination of the ADHD--the hyperactive as well as the inattentive type.

Interviewer: Okay; now how common is ADHD?

Deena Kotlewski: It's actually quite common. It affects a--an estimated 2,000,000 American children, so at least one child in every US classroom can be diagnosed with ADHD. In general, boys outnumber girls with ADHD at a rate of about three to one and girls most often(ly) have the inattentive type.

Interviewer: Okay; is ADHD associated at all with any other disorders?

Deena Kotlewski: Yeah; in fact ADHD is often mistaken or found occurring with other neurological, biological, and behavioral disorders. Nearly half of all children with ADHD especially boys--tend to have also oppositional defiant disorder which is characterized by negative, hostile, and defiant behavior. They may also have conduct disorder which is marked by aggression towards people and animals and destruction of property, deceitfulness, theft, and serious rule-breaking. Those are often found to co-occur with an estimated--estimated 40-percent of children with ADHD. And approximately one-fourth of children with ADHD, mostly younger children and boys, also experience anxiety and depression and at least 25-percent of children with ADHD suffer some type of communication or a learning disability. And additionally they have found a correlation between Tourettes Syndrome, which is a neurologically based disorder characterized by motor and vocal tics and ADHD only, like if you were only an ADHD person is actually quite a small percentage; so they--there are quite a few other things that ADHD and other disorders are combined with.

Interviewer: Right; now what causes ADHD?

Deena Kotlewski: Well first of all it's important to realize that ADHD is not caused by dysfunctional parenting nor is it due to a lack of intelligence or discipline. Often people think that you know this child is stupid or you know they"re uncontrollable but in fact that's not the case. There is strong evidence to support the conclusion that ADHD is a biologically based disorder and recently the National Institute of Mental Health observed pet scans and showed significantly lower metabolic activity in regions of the brain controlling attention and social judgment and so therefore that also lends to the idea that it's biologically based.

Biological studies also suggest that children with ADHD have lower levels of the neurotransmitter Dopamine critical of regions of the brain, so that also lends to the idea that it's biologically based. There's other theories that suggest cigarette or alcohol and drug use during pregnancy or exposure to environmental toxins such as lead, may be linked to the development of ADHD. Research also suggests that there is a strong genetic basis to ADHD; the disorder tends to run in families. In addition, research has shown that certain forms of genes related to the Dopamine neurotransmitter system are linked to increase likelihood of the disorder, so there are biological bases, there are possible chemical bases, you know whether it be nicotine or alcohol; there are environmental toxins that may link to ADHD; so there's quite a few possibilities as to what may lead to a child developing ADHD.

Interviewer: Okay; and let's talk about treatment. What are some of the ways that ADHD can be treated?

Deena Kotlewski: Well the most proven treatments are medication in combination with behavioral therapy and stimulants are the most widely used drugs for treating attention deficit hyperactivity disorder. The four most commonly used stimulants are Ritalin, Dexedrine, Adderall, and Siler, and these drugs increase the activity in parts of the brain that are under-active, which often confuses people--why would we be prescribing a stimulant when the person is already hyperactive, but when you think about a drug stimulating areas of the brain that are under-active then it would make sense. Therefore it improves attention and it reduces impulsiveness, hyperactivity, and aggressive behavior. At times anti-depressants are prescribed for people who have ADHD and sometimes those help as well and most recently the FDA has approved a non-stimulant medication called Strattera and that also has been proven to be very helpful. But every person reacts differently to treatment, so it's important to work closely and communicate openly with your physician so that you know you have the best treatment as far as medically based treatment. It's also very important to remember the side effects of medications which include weight loss, decreased appetite, trouble sleeping, and in children sometimes a temporary slowness in growth, but however these reactions can be controlled by dosage adjustments. That's why it's always very important to talk with your physician frequently and especially as a child grows and their weight changes and their need for the medication may change, so it's very important to communicate openly with them.

And medication has been proven effective in the short-term treatment in more than 76-percent of individuals with ADHD. So medication is definitely one avenue to work and to--to look at treatment.

And then as far as behavioral therapies, behavioral therapy would--rewarding positive behavior change and communicating clear expectations to those people with ADHD--those things are very important. I mean the consistency where a behavioral therapy plan is delivered is very important. It's extremely important for family members and teachers and employers to remain patient and understanding and consistent but behavioral therapy in combination with medication or even without medication have been proven highly successful.

So children with ADHD can additionally benefit from caregivers paying close attention to their progress and adapting classroom environments to accommodate to their needs and using positive reinforcer(s) and where appropriate parents should talk with the school district to plan an individual educational program which is also known as IEP.

Interviewer: Great; are there any other treatments outside of behavioral and medication?

Miss Deena Kotlewski, Ma, Lcpc. On Adhd Health & Special Psychology

Deena Kotlewski: There are a variety of treatment options offered. So the--but some of these treatments are not scientifically proven to work; some of them include biofeedback, special diet, allergy treatment, vitamins, chiropractors, special colored glasses; I mean people have really tried everything. But the most proven treatments through research are the behavior therapies as well as medication.

Interviewer: Let's talk more about these other treatments. What are--what are some of these examples? Can you go into some detail on that?

Deena Kotlewski: Well even before accepting a diagnosis of ADD or ADHD parents should rule out other conditions that may be confused as ADHD. At times allergies or sensitivities to different kinds of food can affect behavior. Exposure to toxins has been shown to cause hyperactivity or attention deficit, so therefore you need to look at those kinds of things--children that might be exposed to pesticides or gasoline or herbicides or many things. Mild to high lead levels may cause the same symptoms as ADHD. Fluoride actually is a toxic chemical that has been linked to the increased lead absorption so therefore it--it may create the same--the same behaviors as a child with ADHD, high mercury levels has been shown to cause that same behavior, children that are exposed to carbon monoxide also show these same behaviors, hearing and vision and problems; that's actually a very important thing to rule out because if a child cannot see the chalkboard you know they may start to fidget, they may get frustrated, they may start to act out in class. If they can't hear the material that's being given in class, I mean that of course is very frustrating as well so that may also appear to be the same symptoms as ADHD. Also sometimes kids are just very excitable; that might just be their--their type of personality and just because they have a lot of energy does not mean that they are you know an ADHD child. So you still have to go through and make sure that they fit six of those criteria that I had listed earlier.

Sometimes gifted children display characteristics that are similar to ADHD when they"re bored in school and they may start to fidget, they may start to act--act out, so they may seem like they might need--need less sleep; I mean gifted children often show behaviors that are very similar to ADHD. And at times it--undisciplined children are sometimes labeled as ADHD because of their defiant and acting out behavior; children need a lot of structure and consistent rules to learn self-discipline and when they don't have that structure because of lack of parenting skills the child may appear to be ADHD.

Also one of the main reasons why a child acts out or throws temper tantrums when they have a problem is because of their lack of understanding of a problem and their lack of ability to communicate how they feel. So sometimes the child just needs some education as to how to communicate their problem or their frustration appropriately. Once they have that ability to communicate they are much less likely to act out and therefore somehow might seem less ADHD, so they might not really have ADHD.

Fetal alcohol syndrome also displays characteristics that are very similar to ADHD. Sometimes learning styles or learning disabilities cause inattention and acting out behavior; and children with a diagnosis of ADHD are typically different type of learners. They may be more tactile learners or audio learners, so you need to teach them in--in a style that they can learn and so there's a lot of things that you may want to rule out before actually diagnosing a child with ADHD--even Tourettes sometimes--it's a rare condition but it's disruptive and it involves children who have repetitive tics and facial movements and grimacing and they--that may present as ADHD but in fact it might be a completely different disorder. So it really takes a team to figure out whether or not a child has ADHD--being the physician, being the teacher, a school counselor, a private therapist, and you know all working together collecting data--you will be able to figure out whether or not a child has ADHD.

Interviewer: Right; now can you describe some of the concerns around medication with regard to dosage or side effects or things like that?

Deena Kotlewski: Well what's in a child's brain--a child who may have been diagnosed with ADHD, there has never been research that has proven a chemical imbalance within the brain, so the medication is given sort of as a hit and miss like trial kind of. And so sometimes it corrects this chemical imbalance but really there has been no chemical imbalance that really has been proven. And so parents should know that these psycho-stimulants that are prescribed for ADHD actually will help all people whether or not you are diagnosed with ADHD, but there--there are risks with prescribing medication.

Between the years of 1990 and 2000 over 569 children were hospitalized and 38-percent of them were life-threatening hospitalizations. Of course that is an extremely small percentage of the entire population of children that has been diagnosed with ADHD. I believe I said earlier, 2,00,000 children have been diagnosed with ADHD, so you imagine that this is a very small percentage of children actually having some kind of life-threatening issue based on the treatment from ADHD; but it's still something that's important to recognize and many parents don't--don't realize that their--if their child takes Ritalin or any other psycho-stimulant passed the age of 12 according to the 1999 Military Recruitment Manuel, the child may not join the Army, the Air Force, the Navy, the Marines, the Coast Guard, or the National Guard until a doctor has signed a paper stating that the child has been off medication for four years. So not only are there possible negative effects to your body for taking these psycho-stimulants but also there may be negative effects for your child's career.

Also if a child has used Ritalin or any other psycho-stimulant medication the State or Federal Government cannot hire him or her if the job involves State secrets or National Security because the child is classified as a Level 2 Drug User. So there are issues that a parent may want to consider before you know placing their child on medication.

Interviewer: Talk about the school setting with parents and teachers; if there's a child that might potentially have ADHD what's the process around how to deal with that?

Deena Kotlewski: Okay; the first thing that generally happens with a child who might have ADHD would be generally that a teacher would recognize it. A child would be acting out in the classroom; they would be--if--if they were ADHD with the hyperactive component they would be fidgeting, they would have difficulty sitting in their seat, they would be you know flinging around pens, they might be yelling out--not raising their hand; I mean often when you see a child like this--this--the child really does stand out in comparison with other students that don't have ADHD. And so the teacher would recognize that and the teacher might call the parent and suggest further action. The teacher might also start a process called the EMT which is Educational Management Team Review. So it would be a number of specialists within the school setting that would observe the child and start collecting data about the child and you know see whether or not we could help the child within the school setting. That would be the first step and have a meeting with the parent.

And then the next step might be for the parent to bring all the data and information that's collected by the teachers to a physician; that would be the next step. So sometimes we do these things called the Connor's Behavioral Scales and that would help pinpoint when the child is acting out, when the child has difficulty remaining on task or sitting still, and the parent would take these behavioral scales to the physician, explain what the teachers have recognized and then the physician and the parent would make a decision as to what to do next--whether they solely want it to be something that's dealt with in the school setting such as like a behavioral plan and then maybe some talk therapy with a licensed counselor or a licensed social worker, or possibly going on medication depending on what the parent preferred, but there is a lot that can be done within the school setting that does not involve medication. We often put a child on a behavioral contract and that encourages the child to take responsibility for their behavior. For example, a behavior contract might state don't--don't call out, and each time that a child you know calls out maybe they wouldn't get a sticker on their behavior contract, but if they did a good job and they you know maybe lasted the entire math class without calling that they would get a sticker. And then say five stickers in one day would earn them a successful day. And then if they had three successful days in a week then the child would be able to go to like the treasure box or have additional fun computer time, and that would be a way that you know behavior therapy would be played out in the school setting. And then that in addition to you know therapy outside of the school setting would be a way to handle you know a child without using medication. And then some children don't respond to the behavior contracts or behavior therapy and then medication is really warranted and--and it's often quite effective. If you get to a point after many months of trying different types of--different you know--types of ways of handling the behavior, the--you know medication may be something that you may want to try.

Interviewer: Great; now let's talk about--let's talk about some numbers. How many children or adults reportedly have ADHD?

Deena Kotlewski: Let's see; the number of preschool children being treated with medication for ADHD has tripled between 1990 and 1995. I think actually in general, all of the numbers have you know tripled, quadrupled as far as children either taking medication and being diagnosed for ADHD and that's because of the expanded criteria of symptoms for ADHD along with the increased awareness of these symptoms, and I think that is really why more children are being diagnosed with ADHD because there's--there's quite a bit of statistics that proves over the past 15 years there has been an increase of 311-percent of children ages 15 to 19 taking medication for ADHD, the use of medication to treat children between the changes of 5 and 14 has increased approximately 170-percent; generally though white suburban elementary children were given medication to treat ADHD at more than twice the rate of African American students. Ritalin is also being manufactured at two and a half times the rate a decade ago; so I think not only the awareness of how to diagnose but the expanded criteria and maybe even the--the attentiveness of teachers and parents to this disorder is what is making the increase in statistical data--and maybe also people really keeping track maybe you know two decades ago people were not keeping track of how often this disorder was diagnosed and being treated.

Interviewer: Are the children that are receiving the treatments--are they meeting all the criteria or are they just meeting some or how does that work?

Deena Kotlewski: Well really for a good diagnosis they have to meet six of the criteria for the hyperactive or the inattentive type and I would say maybe a very small percentage of children are being treated with you know medication or behavior therapy that are not diagnosed appropriately and that--that's really why it's very important to have a proper diagnosis with you know the help of the school officials as well as the physician as well as parents. I mean it's really a team effort to diagnose ADHD correctly.

Interviewer: Yeah; so just to clarify--this is not a mental illness. Is it biological or--?

Deena Kotlewski: It's considered a developmental disorder.

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Interviewer: Okay; now some people have confused ADHD with autism. Is it--it different from autism or other behavioral problems?

Deena Kotlewski: Well autism falls within the umbrella of developmental disorders but it is a pervasive development disorder and its prevalence is about 10 to 12 children per 10,000 children and it's characterized by severely compromised ability to engage in social interaction and it also has roots in both structural--structural brain abnormalities and genetics. There's a genetic link, so it is a much more pervasive and really when you see it being played out in a child you would say you know an autistic child who truly is autistic really does not resemble a child with ADHD. An ADHD child is usually you know much more--much better at verbally you know expressing themselves and an autistic child could be completely non-verbal. They often do repetitive--repetitive like rocking motions and--personally I"ve never seen an ADHD child rocking really. I mean I see them move around quite frequently but you know I don't see them repetitively doing any type of behavior as an autistic child would do.

Interviewer: Okay; now does ADHD have any correlation to intelligence level or is there no connection?

Deena Kotlewski: Well as far as the research that I have read there is no correlation between ADHD and intelligence. Often children with ADHD are quite bright and quite intelligent and if they can actually sit through an intelligence test which is often quite lengthy and difficult to--to sit still for you know their intelligence would be quite high on an IQ test. But sometimes it's real difficult to get them tested appropriately when they don't have the ability to remain concentrated on tasks.

Interviewer: Right; now a lot of people talk about how you know ADHD is here all of the sudden and they"re like okay; these kids weren't around when I was in school. So what is the history behind ADHD? Was it first discovered at a certain time or--or what is the background?

Deena Kotlewski: Well apparently it was first discovered in 1902 and it was written up in a paper on development back in England I believe. So--so this British physician described hyperactivity--hyperactive behavior but he described it as a deficit in moral control, so that was probably the very first time that it was really discovered. But you know I think with school systems becoming more standardized and with things like the No Child Left Behind Act, you know there is a lot--there is a lot of monitoring of children and whether or not they"re being successful and actually learning and behaving appropriately, so I think you know there's a lot of monitoring and now that there is so much monitoring you"re seeing children not you know fitting into the mold of you know the perfect child that sits quietly and learns. So I think it's just becoming more visible and also based on the criteria that you know it's--the criteria has been expanded and then there is also the DSM-4, so you have you know strict criteria to really you know label a child and make a judgment. Whereas you know back in the early 1900s it was just something that was noticed.

Interviewer: Right; let's talk a little bit more about the--you mentioned genetics and they"re--the possible connection between that. Is that--since it is developmental is there a connection between the whole pregnancy stage; does that affect development or--or what's the--the connection?

Deena Kotlewski: Well the etiology of ADHD still remains unclear; although multiple factures such as genetic susceptibility and biochemical dysfunction in the brain and environmental interactions have been proposed. So there are many different factors that may be causing ADHD. There is extensive evidence that supports the genetic factor for ADHD with greater risk of the disorder being found among family members. So there is a genetic link and in addition pregnancy and complications in infancy has been shown to influence ADHD--low birth weight in children has been found to be another contributing factor for ADHD as well as other learning disorders. There is a preponderance of evidence that supports this genetic neuro-neurobiological connection, so parents--[Laughs] it's very important that you know if a parent recognizes that they may have some symptoms of ADHD, quite possibly their child will also symptoms that are related to ADHD and also behavior management techniques have been found to be significantly relevant to the severity of the expression of ADHD. So therefore you know parents with better parenting skills are going to have a child that may not have as extreme ADHD behaviors, a parent who is more structured and more calm when the child is acting out and you know out of control is--they"re going to have a child that is less expressive of the ADHD behaviors. But a parent who also has very similar ADHD behaviors--isn't able to remain on task or is inconsistent with their parenting style--that child is going to be more--more ADHD, if that makes any sense. [Laughs]

Interviewer: Yeah; [Laughs] so talk a little bit about these contributors. Are there different types of contributors to ADHD? Can you go into detail on that?

Deena Kotlewski: Yeah; I mean most--most importantly I believe would be the genetic contributors and research evidence suggests that ADHD is a trait that is high hereditary in nature. Authors of studies found that 18-percent of biological parents of ADHD youths had ADHD compared to 6-percent of adoptive parents, so that means that there is a 12-percent biological connection; that's what they were finding. So you know biology is an extremely high contributor to a child having ADHD and there have been other studies where they"ve reviewed molecular genetics and they found that ADHD comprises several disorders having different genetic and non-genetic etiologies rather than a single unitary disorder, so if somebody has been diagnosed with ADHD genetically that they may not only have ADHD but they may have other things linked to that but that--this is getting like very specific in etiology but they have also found out that the co-morbidity of ADHD meaning that if you have ADHD you are likely to have you know a bipolar disorder a conduct disorder or you know oppositional defiant disorder. These are the disorders that I had mentioned earlier--that occur throughout the family. So maybe a person in your family might not have had ADHD but maybe your parent has bipolar; well then you have a higher--there's a higher incidence of your child maybe having bipolar in addition to ADHD. So that's why it's really important to look back at the genetics of a family to see if there are links for ADHD and you know not that it would--it wouldn't mean anything. Like if--if your parent had ADHD it would only provide you more information of making a better clearer diagnosis and once you have that better clearer diagnosis you will be able to treat the disorder better. So that--that's the only real reason to find out whether or not there is a genetic link. There's also biological contributors that are associated with ADHD and they"re related to the direct effect on brain development and functioning. There have been some studies on brains with MRIs and they"ve shown distinct physiological differences in brain regions between ADHD children and controlled children, so therefore you know if a child happened to have an MRI you may recognize that there is a difference in the brain of an ADHD child versus a child that doesn't have ADHD. So therefore there--there's a biological difference within the brain makeup and that's important to let parents know that because it's not something within a child's control. Your child is not you know fidgeting constantly in class or calling out constantly in class you know intentionally. And sometimes when parents believe that it's an intentional problem they"re very hard on their kids. But when they believe that it's something that is out of their control then it changes the way the parent views the child.

In addition, very low birth-weight children have been found increased prevalence of inattentive--inattentive ADHD and the hyperactive ADHD and so that's something else to recognize that if there is a child that has been born you know of two pounds or three pounds, you know they may have a much higher prevalence of developing ADHD. Also 22-percent of ADHD children had a maternal history of smoking during pregnancy as compared to 8-percent of the non-ADHD subjects, so of course we"ve heard this a million times--don't smoke when you"re pregnant or don't drink when you"re pregnant because you may have negative effects on your child.

So--and there's also family contributors to ADHD; boys with ADHD are more likely to have mothers with a major depressive episode or marked anxiety symptom and--within the past year and fathers with a childhood history of ADHD, so you know that just also contributes to the idea that you do need to look at the genetic history of a family in order to make a good diagnosis. And you know once again, they may have oppositional defiance disorder or conduct disorder or they may have fathers who have had that; all of these things are overlapping as far as a diagnosis. And also there have been found some possible neuro-developmental factors--cognitive and neuro--neurological contributors that may contribute to the development of ADHD; so--but at this point there's no single profile of ADHD. Like you couldn't say oh you know here's this--the cognitive functioning of a child and therefore they"re going to develop ADHD. I mean they haven't found it to be that causal but it's very important just to be looking at all of these different factors as far as diagnosing ADHD.

Traumatic brain injury also may then develop into ADHD or you know another type of diagnosis like conduct disorder but you know again that's--a traumatic brain injury, I mean that's a very, very small percentage of--of children. And there's psycho-social contributors that you need to look at as far as--as far as diagnosing ADHD-factors that are associated with ADHD include for example social conditions, family stability, marital discord, psychiatric disorder in parents, parenting style, the quality of family interactions--all of these things actually are extraordinarily important. I mean if you"re having parents that have--you know extreme marital discord, you know a child may be acting out in school consistently. They may be feeling nervous. They may be you know really crying out for attention because they"re struggling with the issues that are happening at home. Or, parents that are more lenient or parents that are very strict--I mean all of these things may have a child acting out in school and you know a teacher might think oh this kid has ADHD when in fact well you"ve got to look at you know what's going on at home. The child is not just you know living in a bubble in school; so these are all factors that are very important in making an appropriate diagnosis.

Interviewer: So with regard to the developmental aspect of it those contributors--is there a connection between you know the IQ or is it your socioeconomic status? What are--what are some of the factors associated with that?

Deena Kotlewski: Well in research literature, positive outcomes for ADHD children are associated with higher IQs, fewer health problems, an internal locus of control meaning that they feel like they"re in control of their life, physical health, high self-esteem, positive coping skills, achievement and social skills; so a child with a higher IQ and fewer health problems and parents that are--are good parenting parents and children that are from a higher economic status where they"re having all their needs met then therefore they"re feeling more calm and they"re better able to cope with the symptoms of ADHD. It's much easier to cope with things--any kind of issue when you are around a calm environment with calm parents and you know the child is going to be more successful in that kind of a situation. So when you feel more cohesion, more support, more warmth you"re not concerned about finances, there's a relaxed environment, there's two parents in the family--that's a predictor of a more positive outcome for a child with ADHD. When you don't have all of those factors which many children don't you"re going to have more issues related to ADHD.

Interviewer: Yeah; the whole right and wrong factor--do these children have trouble determining what's wrong and what's right?

Adhd Lcpc Ma Kotlewski Deena Miss

Deena Kotlewski: I think that the main issue here is when they"re sitting down and they"re calm and they"re able to decide what's right and wrong they are able to decide what's right and wrong. [Laughs] But when they"re in an impulsive mood or they"re not able to--it's not even an impulsive mood but if they"re just more impulsive or more agitated they"re--they"re not going to be able to make a better decision. But if you can catch them at a moment that they"re feeling calm and able to focus then they"re--they"re going to be able to make a very good decision. But I have to explain also that when you find a person who is not diagnosed with ADHD and they"re agitated or frustrated or irritated they"re not going to make as good a decision as they would if they were in a calm, relaxed environment.

Interviewer: Right.

Deena Kotlewski: So; you know I don't know about being right and wrong. [Laughs]

Interviewer: Well I mean you mentioned that--that there are the similarities and which moves into the whole transitioning as you grow. Can this be outgrown? Are there differences between how it manifests itself in children versus adults?

Deena Kotlewski: Well ADD and ADHD it's--it's not usually outgrown. It persists into adulthood and as someone with ADHD develops from a child into a teenager and then consequently into an adult the symptoms of ADHD may look different. Often the hyperactivity of childhood evolves into a more impulsive maybe even you know conduct disorder child, you know in that adolescents and executive functioning and--and self-regulation impairment takes a forefront as the individual copes with the complexity of life. So as things grow and--as the child grows in an adulthood the--you know the difficulties and challenges that they"re faced with become more and more, and so therefore ADHD is going to change as the person changed--changes. The hyperactivity may appear as uncontrolled arousal or feeling overwhelmed and talking excessively and impulsiveness may look like irritability, quick anger, inadequate censorship of rude and insulting thoughts, poor timing in interaction, so I mean if you think about the people that you know around you or people maybe that you have had interactions with you may even think about people that you know of that are like this that are quick to anger or that are you know--somehow you may say oh, these people are kind of tacky. But you know maybe they don't have the ability to regulate their impulsiveness; their inattentive may be shown as tuning out or the inability to focus, so that may sort of remain the same, the inattentiveness, but other things change and develop as the person changes and develops.

Interviewer: So do we know more about the disorder in adults than in children?

Deena Kotlewski: Um, I would think that we know more information about ADHD in children because that's when the majority of people are diagnosed. And a lot of the research takes place--so I would say more information is known about children in ADHD.

Interviewer: You mentioned earlier about the differences between males and females; can you go into more detail about that with how it manifests itself?

Miss Deena Kotlewski, Ma, Lcpc. On Adhd

Deena Kotlewski: Yeah; well girls--or females generally have ADHD without the hyperactivity. So they"re sort of more inattentive or more spacey and that occurs more often than in boys. And girls are not often diagnosed until the teenage years or later; instead they may be seen as like talkative or tom-boyish or particularly those that do not have hyperactivity--they might seem flighty because of their distract(ability) and they might seem kind of flaky or impulsive and some girls may have impulsive control issues like they"ll get into fights with others; they may be labeled as like difficult or emotional rather than having a condition rooted in the brain. And these girls that grow into women that have--that may have not been diagnosed with ADHD, they might find themselves facing the same challenges as men with ADHD, the social difficulties and the time management problems and the financial disorganization and the lack of feeling like they have control over their lives, but however because women are often expected to multi-task and handle a variety of work, family, and community roles, women may have several additional problems that men with ADHD might not have.

For example, they might have sort of like this super-woman perfectionism kind of syndrome. Many women feel that they need to do things extremely well and to the point where they"re completely stressed out and burned out and a woman with ADHD may find that they cannot meet even their most modest self-expectations and then they"re sense of self deteriorates, so they constantly are feeling like they need to produce something and then they"re not able to do it, so they constantly are feeling frustrated. And they may feel shame or embarrassment or guilt; you know in our culture there's expectations of women that you know they have to do all of these things and when they can't they may feel humiliated. They may have difficulty getting children to school on time or providing a consistent structure for homework and then somehow you know it's their fault. And then therefore they--they"ll feel shame or embarrassment; they may feel depressed.

While males might act out their symptoms of ADHD, females often internalize their stress, so therefore it might lead to symptoms of depression. Women may feel more anxious; they want to appear really good or even twice as good as men and in order to be treated as equals--so this can lead to a great deal of stress for women who are trying to keep it altogether and they"re not able to keep it altogether and so therefore they"ll feel more anxious. They also have you know these dual careers where women are responsible for the home and a job outside the home and families and childcare and housework. So women who have difficulty with organization and following through on all of these different issues, this may you know cause quite a bit of stress for a woman. Also single-parenting where marriages you know end in divorce, women are more likely to be the primary or sole parent and so not only do they have the financial responsibility, the disciplinary responsibility--you know all of the responsibilities of the home and managing all that and the organization, you know I imagine having ADHD on top of that I mean could be extremely frustrating. And not only that, you know women's hormones sometimes get in the way with you know creating moodiness or tension or a sense of feeling out of control or even when they go into menopause they might feel you know almost like a sense of craziness and you know all of these things are exaggerated with women who have ADHD you know. They have ADHD as the base and then you have all of these other things on top of it. So you know I would strongly suggest that any woman who is feeling any you know issues on top of already being diagnosed with ADHD I mean I would strongly suggest you know talk therapy with you know a licensed social worker or a licensed counselor you know just to help regulate and calm yourself.

Interviewer: Right; now there are some skeptics out there--we can't deny that--that question the existence of ADHD altogether. Some people may say it's just poor parenting. How do we--how do we respond to that?

Deena Kotlewski: Well first of all you know hopefully if people were listening there is you know quite a bit of etiology behind the diagnosis of ADHD so you know if you look at your family and the history of your family and all the many symptoms you know I would say that it would be hard to create all of these symptoms just based on bad parenting. Of course, bad parenting would be a contributor to--you know maybe exacerbating the effects of ADHD but I certainly couldn't say you know a bad parent could create a child like this. [Laughs] You know it's just--there's too many other factors.

Interviewer: Let's talk about some of the science. Is there research that's taking place on the disorder right now and--and who is doing it?

Deena Kotlewski: Yeah; there's--there's an enormous amount of research that's constantly going on. One good place that I like to look is the National Institute of Mental Health, NIMH; they often have numerous studies going on and they also have good research practices. So I think that's a really good place to look for reliable information. But many--many universities, you know UCLA, you know these big research universities--they often have lots of research that's going on in a lot of different areas of ADHD, so I would encourage people to read up on the subjects. There's lots that's going on.

Interviewer: So would you say that there are a lot of updates in research that like might reveal a breakthrough here and there or is there--?

Deena Kotlewski: Yeah.

Interviewer: You know anything going on in that area?

Deena Kotlewski: Yes; I mean there is so much going on constantly and even things that maybe that they thought were you know set in stone 10 years ago they may have found new information that refutes what they had found out 10 years ago. So--so it's always good to read all sorts of research and information.

Interviewer: Right; now with regard to diagnosis, are--what tests are normally used?

Deena Kotlewski: Well the behavior scales that I had talked about a little bit earlier, the Connor's Behavior Scales that are filled out by the teachers and the parents--collecting that kind of information and bringing that to a physician would be the best way as far as testing goes. I don't know of a specific test that they can use like an IQ test that could give you any kind of definitive information. But you"re--you"re basically making an educated guess with information from the parents, information from the teachers, information from the physician and combining all that information to have a proper diagnosis.

Also actually when somebody is accurately diagnosed and say their medicated, the medication usually is 100-percent effective or you know medication and the behavioral therapy; so when you have an accurate diagnosis, the treatment will be effective.

Interviewer: Great; now how early in a child's life can it be diagnosed?

Miss Deena Kotlewski Ma Lcpc. Adhd

Deena Kotlewski: I would say generally around seven; I mean a child is constantly being you know--developing, but the criteria that is used in the DSM-4 is the criteria needs to show up before age seven, so I kind of think that seven is a good marking place, so you can see if all the criteria has been met before age seven.

Interviewer: Great; now is it often misdiagnosed and if it does happen how is this resolved?

Deena Kotlewski: I don't know if it's often misdiagnosed, but you really do need to rule out the numerous other things that could be going on, you know the environmental toxins, you know maybe parenting skills, or dietary concerns, or allergies--you know I would go through the litany of things that it could be before diagnosing somebody with a diagnosis of ADHD.

Interviewer: Great; and is there a consensus amongst the peers, the psychiatrists about--about how it is diagnosed?

Deena Kotlewski: Well I think there is a consensus as far as you know collecting all the information together and you know making your best educated assumption as to what is going on here. You know ADHD is--you know when you really work with children on a daily basis [Laughs] as I do you can really see the difference between a child with ADHD versus a child that isn't. So you already have that sort of educated assumption and then you have not only your information but the teachers" information, parents" information, physician--you know physician information and if everyone is coming up with somewhat similar information that's a good way to diagnose and I would say we"d all be on a consensus at that point.

Interviewer: So let's talk myth versus fact; are there any common myths and misconceptions associated with ADHD that you really want to clear up and put out there?

Deena Kotlewski: I think probably the most common myth that I run across with many parents is that they believe that this is something within the child's control and I think that really does a big disservice to the whole process of raising your child, because if you"re viewing your child in control of these you know constant acting out behaviors you"re--you"re probably going to have a pretty negative view of your child. But I think really that's important to recognize that this is you know a neuro-biological issue and a developmental disorder, you know you--you don't want to blame your child for this. So that I would say would be the most common myth.

Interviewer: Right; now some people talk about how these stimulant drugs that are used to treat it are similar to cocaine. What's the validity if anything with regard to that?

Deena Kotlewski: Well you know these medications--all of them that I mentioned earlier for Strattera which is a non-stimulant medication are stimulants, so you know they"re stimulating areas of the brain that are a little more you know slow or inactive, so I--you know I don't know actually the chemical composition of cocaine or--or actually the chemical composition of you know these drugs, but I do know you know they"d all be considered stimulants. [Laughs]

Interviewer: Right.

Miss Deena Kotlewski Ma Lcpc. Adhd Psychology Special & Health

Deena Kotlewski: But I don't--I can't imagine that cocaine would act the same way on the same neuro-transmitters as prescribed medication but you know I--I couldn't say 100-percent. [Laughs]

Interviewer: Yeah; so have you come across any studies or heard anyone saying anything about a correlation between the disorder and then subsequent substance abuse or violence?

Deena Kotlewski: Well yeah; there is--I think there is a correlation between--people maybe who have not been diagnosed appropriately, so you have you know a child who has a lot--a lot of difficulty all the way through schooling, more than likely with their peers, more than likely with their family and they come across different--you know drugs that might help them; so you know it could be cocaine, it could be speed, it could be maybe even ecstasy which you know also has you know the amphetamine component you know that they find is waking up the areas of their brain that have been inactive and a lot of people use a lot of different recreational drugs to self-medicate, you know. When you know not only for people who have ADHD but you know people who you know have other issues; you know they turn to alcohol thinking that's going to solve their problem and maybe it does temporarily and you know in the same vein maybe cocaine or some other kind of illicit drive would satiate you know somebody who has never been diagnosed with ADHD.

You know--and--you know it is a problem; I think you know people who have not been diagnosed appropriately or you know not diagnosed at all they really turn to something that will help them.

Interviewer: Right; well let's talk about ways of--of coping with the disorder and--and enhancing one's quality of life. You know as--as a specialist in this area what have you found to be the most difficult areas with regard to coping as a child or--or an adult or--or treating it?

Deena Kotlewski: Well I really think a very appropriate diagnosis is the first place to begin. Once you have a very clear diagnosis, meaning you know if your child has ADHD you know do they have depression, do they have bipolar, do they have you know some other issue that's also hampering you know the ADHD? But once you have a very clear diagnosis whatever the treatment you know being medication or behavior therapy or you know changes in diet or whatever you know you have decided to use I would say that--that treatment should be done you know effectively and consistently for a while you know before deciding oh this treatment is not working. You know often a parent will start their child on you know for example Ritalin for you know one month or two months and say yeah, oh--oh that medication is not working. Well you know one or two month to change you know seven or eight prior years of behavior you know trying a treatment for one or two months is just--it's not you know consistent and you know long enough. So I think you"ve got to be patient; you have to be consistent; you have to really try. [Laughs]

Interviewer: Yeah; you--do you come across any bullying challenges with the ADHD children as opposed to those who aren't diagnosed or do you find that there's no difference?

Deena Kotlewski: Well you know I would say that bullying really roots itself in you know the feeling of low self-esteem, so whether a child is ADHD and maybe consequently has low self-esteem, yeah they might be bullies. But you know just as well a child who doesn't have ADHD and has low self-esteem may be a bully as well; so I kind of think it's a toss-up but either way you know you"d have to work on a child's self-esteem, self-worth to make them feel valued so that you avoid the whole bullying issue.

Interviewer: Right; so what kind of specialists--like who are the key players if you know a patient or a family wants to turn to someone? Is it counselors or is it social workers--who should they turn to?

Deena Kotlewski: Well first of all--[Sighs]--as far as a specialist, I mean you can run across a counselor or a social worker or a psychiatrist or a psychologist and they may have no clue about ADHD. But there are quite a few of us out there that do specialize in ADHD and work primarily with adolescents and children. So when you do--you know when you"re searching out a specialist I would you know call them and I would say you know do you have a lot of expertise in this area? I mean that's a fine question to ask any professional and someone who you know is versed in the topic then will tell you and if they"re not you know hopefully they"ll be ethical enough and say you know I really--I really don't know that topic but I can refer you to somebody else.

Interviewer: Right.