Welcome to Where Parents Talk. My name is Lianne Castelino. Our guest today is a developmental pediatrician. His focus is on treating issues related to a child’s attention, behavior and learning ability through a blend of pediatric neurology, and pediatric psychiatry. Dr. Walt Karniski has been practicing for more than 40 years. He previously ran three independent schools, supporting children with ADHD, learning disabilities and anxiety. He’s also an author and a father of two. In 2022, Dr. Karniski published his first book, it’s called ADHD medication. Does it work? And is it safe? Dr. Karniski joins us today from Tampa, Florida. Thank you so much for being here.

Thank you for having me. Lianne. It’s a pleasure.

So much to delve into on this topic with you and your expansive background in this world of ADHD. But I’d like to sort of start by having you paint a picture for us. What does the face of ADHD look like in broad strokes currently, in North America?

Well, to begin with the prevalence of ADHD, meaning how frequently it occurs, it’s approximately 7%. That’s true, whether it’s the United States, Canada or other countries in the world, using different diagnostic techniques. Most studies have consistently shown that ADHD occurs in 7% of the population. That seems like a large number. I one time I visited my dermatologist, he wasn’t available. And they gave me a different dermatologist. And she walked in the room and says, Oh, Dr. Karniski, I see the your physician, what kind of medicine Do you practice? And I said, Well, I teach children with ADHD. And she said, Oh, that’s ADHD that’s over diagnosed, isn’t it? And I looked at her, I said, let me let me answer that question by asking you a question. What’s the incidence of skin cancer in adults over the age of 60? And she said, Oh, it’s about 25%. That’s it? Oh, that’s really high that must be over diagnosed? And she said, No, no, it’s not over diagnosed. It’s because people don’t put sunscreen on and they don’t take care of their skin. And they, Oh, wait a minute, I see what you’re trying to do. And basically, I think what’s happening is that the prevalence of the disorder does not tell you anything at all about the validity of that disorder. In other words, just because something occurs frequently doesn’t mean that it’s there isn’t that that it’s an inappropriate diagnosis. If you learn that six people on your block near your house all had leukemia, would you say leukemia is over diagnosed? Or would you worry about what’s in the water?

And you notice, yeah, go ahead.

And so So ADHD is diagnosed frequently, and accurately, most of the time. In some cases, it is over diagnosed. But in other cases, it’s under diagnosed. So children may be diagnosed and are diagnosed with it, but then not treated appropriately, either. I don’t know if that answers your question about the state of the of the art, but it gives us a good idea, I think.

Absolutely. And it is such an important starting point. When you’re talking about this particular disorder, attention deficit hyperactivity disorder, ADHD, is the diagnosis piece and there is no definitive one test that diagnosis ADHD, correct.

There are two things that make the diagnosis of ADHD difficult and you hit on the first one, and the most important No, there is no specific diagnostic test. And the other factor that’s just as important than a corollary to that is that every one of the behaviors that are criteria for diagnosing ADHD, difficulty focusing difficulty remembering, forgetting things easily disorganization. All of those behaviors are normal behaviors in everybody, if they occur once in a while. So everybody forgets something once in a while. Everybody gets distracted easily by something that especially if they’re looking working on something that is very intense. People forget things. They’re disorganized. And that doesn’t make them our doesn’t make them have ADHD. What makes ADHD is that when those behaviors are so frequent, that they interfere with a child or an adult ability to learn in school, to develop appropriate social relationships and to live the life that they want to live in if that can’t be done because of those behaviors, because they’re so frequent, then we’re dealing with a disorder. Before that, we’re only dealing with behaviors and not a diagnosed disorder. I don’t know if that if that’s clear or not.

It is. And I want to drill down on that notion of frequency that you’ve brought up in terms of the the number of times that this occurs as a as a behavior in your child, what are we talking about here? And where can a parent or a caregiver go to get accurately assessed?

Most parents will start with their pediatricians. However, most pediatricians feel comfortable diagnosing ADHD when it is clear cut and straightforward. But that’s only true about 30 or 40% of the time, and 70 or 80% of the time, it’s more complicated than that. And a specialist is needed. So the specialists can be physicians like a pediatric neurologist or pediatric psychiatrist, or they can be a psychologist, not an MD. They can’t prescribe medication, but a pediatric psychologist that can look at those behaviors, measure them independently, compare them to other children as well, and then write a report back to the doctor to explain his or her findings.

Dr. Karniski, can you take us through what the main causes of ADHD are?

There’s three ways to look at the cause of ADHD. First, let me let me describe something, imagine that you are a caveman living 100,000 years in the past. And you’re in a tribe of about 35 people, adults and children. And your job in the tribe is to get up every morning to go out and pick berries off of bush and bring them into the tribe for breakfast. So one morning, you’re hunched, hunched over this bush picking these berries and putting them in your leather pouch, and you hear a rustling in the bushes behind you. What should you do? What would you do,
oh, go and address it, see what it is.
And if it’s if it’s the wind, you’ll go back to picking the berries. And if it’s a saber toothed Tiger, then you’re going to either pull your knife or run. But in either case, that distraction of picking from the berries and being distracted by the sound behind you may have saved your life, increase the probability that you’re going to mate with somebody else in the tribe, and have lots of children that also carry that distractibility gene. So in one way of looking at ADHD, it is nothing more than an evolutionary process that at one point, saved lives, and was productive. What changed? Most children learned out of farm their parents farm by living in the farm, or by working in their father’s blacksmith shop. But things changed around the 19th century when societies demanded that all children must go to school and learn to read. And when that happens, some of those children who could have been leaders of their tribe had difficulty because they had excess distractibility. So you could say that they have a mismatch between their abilities and the world that they live in. If they had lived back 100,000 years ago, they would have been a leader of their tribe, but now they’re having difficulty in school. So one way of looking at ADHD is that it is a difference in a mismatch between a child and his environment. However, there’s other ways of looking at ADHD as well. And if you look at it neurologically, if you look at the brain, if children with ADHD, you will find that there are three areas of the brain that are smaller in children with ADHD compared to children who do not have ADHD. Those three areas of the brain the frontal cortex, the caudate nucleus, and the frontal cerebellar striations. Those three areas are are responsible for organization attention, focusing, remembering, memory, all of the symptoms of ADHD. And in children with ADHD, those areas of the brain are smaller than in children without ADHD. That doesn’t necessarily mean that that’s an abnormality. It just means that there’s a difference there. But it results in differences in behavior, and differences in success in school. The other thing that’s incredible about this, and this is something that I only learned about in the last five or six years, is that if you take those same children that were scanned, with brain scans as children to determine that those areas of the brain are smaller, if you look at them as adults, and scan those brains as adults, you find something very surprising. In those adults who had been on medication when they were children, those three areas of the brain are now regular size, the same size as than everybody else. But then those adults who had not been treated with medication, those areas of the brain are still smaller than the expected. So what that is telling us is that there are differences in the brain of people with ADHD, again, not saying that it’s an abnormality, that difference in brain size would have caused them to be successful as cavemen. But in our current day and age, it’s causing them to have difficulty in school. And then one final thing to look at, and that is, if you look at many different areas of functioning as adults, people with ADHD have more car accidents than people that ADHD, if they have a car wreck to be corrected in is more serious than if you don’t have ADHD. People with ADHD are more likely to be arrested.
Said they’re more likely to end up in jail and more likely to have a child born out of wedlock, they’re more likely to have been going bankrupt, they’re more likely to have health problems, they’re more likely to have difficulty with their jobs. The studies have shown that people with ADHD earn approximately $10,000 less per year than people who don’t have ADHD. And the amazing thing is that if you look at all those studies, every one of those that I just mentioned, had been studied, and had been proven to be true. However, if you if you look at those people who have been treated with medication, they have the same number of car accidents, the same number of bankruptcies, the same number, the same job performance, all of the same. Difficulties seem to be corrected by those adults who are treated with medication as children. And that’s pretty astounding to be able to reverse something like that 20 years later.

So let’s talk about the medication. That is, of course, the thrust of your first book. And certainly the title of your book could not be more clear. Why did you want to write this book?

When I see children with ADHD, I see a lot of pain. Not the kind of pain that a an orthopedic surgeon might see it with joint pain or whatever but psychological pain. I one time I saw a child and mother brought in a letter that he had written to his teacher, the day before he wrote this letter. He had gotten angry at his teacher and he told his teacher to shut up. And he felt bad about that. So the next morning, he wrote a letter to his teacher and handed it to her and he did this all on his own. His parents and teacher did not ask him or force him to do this. In in the letter he said, Dear Mrs. Smith, I am sorry, that I told you to shut up yesterday. Sometimes my brain just does things without my control and goes off on its own. I’m sorry. And I’ll be the best kid in your class from now on. That’s, that’s the kind of pain that I felt is present in all of the children that we see with ADHD. They may not recognize that it’s coming from a brain difference. But they do recognize that they’re having difficulties in school, with their peers and with that’s important.

Now over the course of your 40 plus years, having practiced you’ve seen in excess of 10,000 or so patients and dealt with them on this very topic is medication, the main treatment option for an individual with ADHD.

It is not the only treatment option. There are behavioral options, there are special education options. There are differences, things that the teacher can do in the classroom to help a child with ADHD. However, medication is the most effective. And without medication, many of those other behavioral treatments will not work. So for instance, tutoring or executive function training or cognitive training, all of those are touted as treatments for ADHD. And they do help considerably. If the child is not on medication, they have difficulty focusing attending and don’t respond to the treatments nearly as well as they do as if they’re on medication. So, yep, go ahead. It’s kind of like saying, you have an artist and he goes out out in the middle of the night and he tries to paint the background. And he can’t see anything, so he can’t paint it. He turns the lights on, puts his glasses on, and now he’s able to paint it and he uses those tools to help him perform the job that is necessary. I see a medication that same way as a tool that is necessary for children to perform appropriately. For that 7% of children who have that difficulty.
Within that world of medication for ADHD, which you have described as the most effective treatment option for these patients, there are multiple medication options.

How does one navigate that in terms of what is most effective within within those medications?

Oh, excellent question. And that’s really the thrust of the book that I wrote. Let me first ask you, how many medications have you heard of that are used to treat ADHD? Do you know? What would you get?

5-10

Okay, there’s actually 36 stimulant medications used to treat ADHD and 10 non stimulant medications used to treat ADHD. Of those 36 medications that are that are used. You probably heard the names of Ritalin, Vyvanse, Adderall, Concerta, metadata, and many other different medications. But what’s striking about all those 36 different medications is that they really represent only two specific chemical compounds, methylphenidate and amphetamine. And all 36 medications are some form of either methylphenidate, which is ritalin, metadata, Concerta or amphetamine, which is Adderall, Vyvanse and many other medications as well. But why are there so many different medications? When there’s really only two substances that have an impact on the brain? And the answer is that each there’s there’s two answers really. The first is the pharmaceutical companies produce many different versions of the medication, because they can charge more for a brand name than they can for a generic but in reality, those, those eight or 10 different medications that have methylphenidate in them are all the same thing. However, Ritalin last two and a half to three hours. Meditate lasts seven to eight hours. Concerta lasts 10 to 11 hours. Some of the preparations are liquid. Some of them are orally dissolving tablets. Some of them are chewable tablets. Two of the medications come in skin patches that you apply to the skin and it releases the medication slowly. So in the process at the drug companies making their extra money on the side and on the new medication. They have provided to us many different tools for helping treat children with ADHD. So for instance, a lot of side effects occur with Ritalin because it wears off so rapidly, and causes irritability and mood swings. Some of the newer medications wear off very gradually and don’t cause those mood swings. And yet the medication gets to the brain. It’s exactly the same thing from either source. It’s just that with Ritalin, you have to give three doses a day to get the same effect of Concerta with one dose a day. So That’s what we talk about that in the book some of the advantages and disadvantages of each medication. And in addition, how the physician chooses which medication of those 36 to use. And I don’t know if you want me to go into that, well, we’re gonna save that for the book.

But I will ask you this is taking medication to treat ADHD a life sentence? Or can a patient outgrow a ADHD?

I guess I repel a little bit at the word sentient life sentence. Because I see it as a miraculous treatment, if you will, and, and again, I deal with with so many children and story, it’s stuck in my mind, let me tell you a story about that. Specifically, I one time saw a 12 year old girl, brought in by her parents diagnosed her with ADHD, started her on medication. But the parents didn’t like the side effects. And they, within one week, stopped the medication. And then I they didn’t return. So five years later, six years later, I’m sitting in my office looking at my new patients that I’m going to see this morning, and I recognize the name of this 12 year old who’s now 18, or 19, becomes engraved in her by herself without her parents. She says I’m a bright girl. I’m doing really well in school, that I’m sorry, I’m a bright girl, but I’m not doing well in school. And I’m having difficulty focusing and concentrating. And I said to her, Well, what happened with when I saw you five years ago, you were on medication, and you seem to be doing really well with it. She said, Well, my parents didn’t like the way it worked. And they stopped the medication. But I’m now an adult. And I can make my own decisions. And I said, Well, what what is it that you would like to? Or why did we stop the medication when you were 12? He said, Well, better? chronicity I have to tell you that I really hated you when you prescribe that medication. You hated me why? Why? She said, because my friends told me that I wasn’t as much fun to be around. We used to joke and laugh and have a good time in school. But when I was on my medication, I was serious and got all my work done. Now, when I when I try medication, my friends tell me a more fun to be around on medication, because I listened to what they say I’m focused on what they say. And they say I’m a better friend. When I’m on my medication. When I’m off my medication, I am scattered, I go off in different directions, I don’t pay attention to what they’re talking about. So that 12 year old, what was the difference between the 12 year old girl and the 19 year old girl and how she responded to medication? Nothing. She responded to medication the same way. At both ages, what was different were the expectations of her friends. And so I guess my point here is that the children really need to be involved in the whole process, especially adolescent children need to be involved in the process of treatment so that the physician and the parents know what the medications doing, what the benefits are, what the side effects are. And they need to recruit that child to be an active participant in the treatment process.

Want to pick up on that idea of the safety of medication which is obviously one of the themes of your book, how safe is medication to treat ADHD?

I went to see my doctor the other day he started me on a medication. I won’t tell you what it was or anything but but he spent seven seconds telling me what the side effects that medication. I spend a half hour talking to parents about the side effects of medication not because they’re more serious or not, but because they’re all treatable. And the thing that I can say to you about the medications are is that there is no side effect. There are side effects from the medication but there is no side effect that is long lasting. It lasts beyond the time that the child is on medication. It no side effect that is permanent, and can’t be undone by simply stopping the medication. So let’s talk about what the side effects are. The two most common side effects are difficulty falling asleep and a decreased appetite. And both of those side effects are related to how much medication depressant in the body. So if you use a medication that is given at seven o’clock in the morning and wears off at 430, in the afternoon, by six o’clock that child is off medication and will not have that side effect. If the medication wears off before bedtime, in almost all cases, the child will have no difficulty falling asleep. So the side effects are directly related to how high the level of medication is in the brain, if at all. And those two two side effects, even though they’re the most frequent, are easily treatable. By paying attention to when the medication wears off, how long it lasts, how effective it is. Now, there’s other side effects as well. For instance, irritability is a common side effect. And, but But what we’ve found is the irritability is not really a side effect of medication, it’s a side effect of the medication wearing off. So a child could get a dose of Ritalin, that short acne medication that lasts about three and a half hours. It’s seven o’clock in the morning, by eight o’clock, it’s working well, he’s focused and attentive, by 930, it’s wearing off and he’s getting a little bit irritable. So he has to go to the office and take a second dose of medication. And he goes through that same process again. And the third time he goes through it. The medication is wearing off at 330 or four o’clock in the afternoon about the time he comes home from school. And all the parents see is an angry, irritable child. And they say I don’t want my child on this medication, he just makes him irritable. Well, what they didn’t see was how well he was doing when the medication was at its peak. They only saw it as it was wearing off rapidly. So if you switch that child to a medication that wears off rap wrote slowly, that side effect goes away. So every one of the side effects that I’ve just mentioned, appetite sleep irritability, are treatable, by paying attention to how the medications working or not working, and how long it’s lasting. And that’s true of the other side effects as well. But those are the three most common side effects.

In preparing for this interview, Dr. Comiskey, I personally was struck in the research about the consequences of not medicating a child or a patient with ADHD. Can you take us briefly through some of the consequences of not medicating a child?

Well, as I mentioned before, I mentioned some of the signs of success in adulthood. Being happy with your family, having a lot of friends, having a good job having a good income. And yet all of the studies have shown that those people who have ADHD and did not take medication have much greater difficulty in those areas. So they’re more likely to have car accidents, more likely to have to lose a job, they’re more likely to have job changes, they’re more likely to have a bad relationship with their family, they’re more likely to have been divorced or separated. They’re more likely to have a child born out of wedlock, they’re more, they’re more likely to abuse alcohol, or they’re more likely they children who have ADHD, smoke three years earlier than children who do not, or at least have their first cigarette, they’re more likely to abuse drugs. If if they’re not treated with medication as well, I would venture to say that there is no health problem in the United States that is pervasive as pervasive and as damaging to the development of a child than untreated ADHD. Yes, cancer is terrible. Yes, heart disease and stroke is terrible. But children have to live with this on a day to day basis. And they recognize the problems that they’re having. But they blame themselves. They don’t blame their brain like that child that who had to apologize to his teacher did he blame most children blame themselves. Most parents blame the children or they blame themselves for not being good parents. But in reality, we’re dealing with a medical condition that is treatable without any serious side.

Very quickly, Dr. Comiskey, I wanted to ask you one final question, adult diagnosis of ADHD is that on the upswing? Are you seeing more and more young adults and adults themselves being diagnosed with this disorder?

The answer is yes. But you have to remember that if a An 18 year old presents with the symptoms of ADHD, he or she had those symptoms. When he or she was five or six or seven. They just were not recognized as ADHD. And they were not treated appropriately. I recently, not recently, about four or five years ago, I had a 73 year old woman come in to see me. And she said, You know, I’ve been struggling all my life. I’m disorganized. I forget things easily. I’ve been divorced twice. And it’s due to my behavior of not remembering to do certain things. And so I wonder if I have ADHD. I sent her to the psychologist to work with us. We did the all the tests that we give them the children. She had a clear case of ADHD. And I met back with her and said, You know, I’m willing to start going medication, we have to talk about the implications of veteran and 70 through three year old woman and she said, No, doctor, I don’t really need to be treated for it. My life is pretty much pretty settled right now. I just wanted to know why I had so much difficulty in life. To me, that was I almost broke into tears when I heard that she had lived with this for 73 years, a treatment was available. And yet for one reason or another, she was unable to take advantage of that treatment. That’s that’s a sad situation.

It is. Dr. Walt Karniski, thank you so much for your time today developmental pediatrician and author of ADHD medication. Does it work and is it safe? We really appreciate your expertise on this topic.

Well, thank you for having me. I’ve thoroughly enjoyed it.