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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This podcast is brought to you by PAR. PAR offers the SPECTRA Indices of Psychopathology, a hierarchical-dimensional look at adult psychopathology. The SPECTRA is available for paper and pencil assessment or administration and scoring via PARiConnect. Learn more at parinc.com\spectra. For a limited time, you can get one free administration and score report for the SPECTRA on PARiConnect by calling PAR at 855-856-4266 just mention promo code S-P-E-C.

[00:01:00] Hey, welcome back everyone. Thank you as always for being here and for listening. Hey, as we continue to head into the summer, I am working on lining up my guests for the next several months. And in the meantime, I’m going to share with you a replay of an episode that I did, Gosh, it was a few years ago now with Dr. Joel Nigg.

We talked about a lot of the content in his book, Getting Ahead of ADHD. And you’ll hear in the introduction a little bit more detail about the episode content. So I will not go into that in as much detail here, but suffice it to say that we cover a number of topics related to ADHD and ADHD assessment. So there’s a lot to take away from this. Even if you heard it the first time around, I think there’s still a lot of relevant information here. And if you did not hear it the first time around, then there is plenty to work with. Just starting from the [00:02:00] ground up.

If you have not checked out the CE credits available, most of the clinical episodes of The Testing Psychologist podcast are available for CE credits. There is a link in the show notes. CE credits are provided through athealth.com. You can go to athealth.com and just search The Testing Psychologist and find any number of clinical episodes there for CE credit. So check that out if you need some CEs here as the year comes to an end. 

I’m not sure why, for some reason, our licenses always reset in August. So for us here in Colorado, we’re hitting that final push to get our CEs. And if you’re in that boat athealth.com can help you out.

All right. Without further ado, let’s transition to my episode with Dr. Joel Nigg.

Welcome to The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Today, I’m talking with Dr. Joel Nigg, a prolific researcher in the ADHD field. He was kind enough to sit down and talk with us about a lot of content from his latest book called Getting Ahead of ADHD. But we also get into many, many related topics to ADHD, things like diet, exercise, sleep, screen, time, marijuana use assessment recommendations. We talk about all sorts of things. So this is definitely one you want to stick around for.

Just a little about Joel. This is another one of those bio’s that’s really challenging to summarize effectively, but I will give it a shot. So he earned his bachelor’s [00:04:00] from Harvard back in 1980, went on to get a master’s in social work, and then a Ph.D. from the University of California, Berkeley.

Joel is currently a very active researcher. He has over 200 scientific publications and has been cited over 15,000 times in the literature. Like I said, he authored a book about a year ago called Getting Ahead of ADHD: What Next-Generation Science Says about Treatments That Work—and How You Can Make Them Work for Your Child. And he also has a previous book called ADHD: What Goes Wrong and Why which is aimed at students and professionals.

Since 2008, Joel has been the Director of the Division of Psychology and professor in Psychiatry and Behavioral Neuroscience at Oregon Health & Science University. He directs their ADHD program and maintains and conducts and directs a large-scale federally funded research from [00:05:00] NIH on a variety of projects, all centered around ADHD. Let’s see. What else is important? Joel is also a licensed psychologist, so he has the clinical side to back up the research side as well.

I think you’re going to enjoy this. He was a great interviewee. I took away many things from this conversation and I think that you will too. All right on to our interview with Dr. Joel Nigg.

Like you heard an intro, today, I’m talking with Dr. Joel Nigg. I think this is going to be a great interview. I heard Joel probably six months ago, I don’t know, on the attitude webinar, the live webinar, and was super impressed. I went and looked up his book and we’re going to be talking all about ADHD research and where things are, where things are headed. He’s got a lot to say.

Joel, as you heard, he is a professor at Oregon Health Sciences University. He’s also a licensed psychologist. NIH-funded researcher. And we’re really fortunate to have him. So [00:06:00] Joel, welcome to the podcast.

Dr. Nigg: Thanks, Jeremy. Happy to be here. 

Dr. Sharp: Yeah. Thanks for making the time. I’m excited for this one. Let’s just start. This is how we do. Maybe talk about what you’re doing day-to-day, how you got here, and how you got interested in ADHD.

Dr. Nigg: Well, right now most of my time is actually spent on research on ADHD. I hear at OHSU we’ve got a large cohort of kids. By large, there are 1400 kids that we initially recruited and assessed. And then we’re following longitudinally about 550 of them. And we see them every year. So we’re up to 10 years of follow-up now funded for that. And so this is going to span and a leg design age 7 to 20.

Part of the goal there is integrating multi-level measures, genetics, brain imaging, physiology, neuropsychology, cognition, and emotion regulation, clinical features, treatment to figure out the moderators [00:07:00] and features over time and solve the problem with prediction algorithms of how do you know which kids are really going to get better on their own and which kids really are going to get in trouble and need more active intervention?

Part of our idea is that it’s hard to predict the future now with these kids. And so, this is one of the arguments about whether we’re both over-treating and under-treating ADHD because we can’t guess the future very well for these kids. Obviously, we know bad things lead to bad things, but beyond that, we don’t know very much about how differentiates.

So that’s one big priority, but I’ve got multiple grants now. We have a mother-infant cohort study to look at the early origins of ADHD. And, and like I mentioned in the genetics and imaging offshoots, so it’s a busy, busy time with a lot of collaborators, a lot of meetings. But we put out about 10 papers a year. We’re pretty busy and productive too.

Dr. Sharp: Oh my gosh. It certainly sounds like it. Well, it sounds like you’ve got a pretty wide breadth of research going on. You’re touching a lot of areas. 

Dr. Nigg: We do. And I’ve been very interested in that gene [00:08:00] environment interplay. That’s part of the book you mentioned, we’ll come back to that around environmental stuff. But we also think about that in relation to genetics, and then what’s the phenotype. What is ADHD? We’re very interested in that. So yeah, I’ve been tracking this now, Jeremy for 25 years doing research in this field.

Dr. Sharp: How did you get into it? Why ADHD? 

Dr. Nigg: It was kind of happenstance. I started out as a clinical social worker working with adults in a psychiatric hospital and I just got so curious, what was the early childhood like, how did this develop when they were kids and I got interested in kids who might have problems later, and pretty soon I was doing research on kids.

When I was in graduate school, I just was really interested in this problem the integration of neuropsychology and family context and these areas that are often just different, seem like different fields, but how do they go together? And I just have the opportunity to do that with ADHD. And it’s clearly common, everybody has questions about it. So it was something that [00:09:00] just seemed important to study. And I just studied. And I liked the kids. I really enjoyed working with these kids. So that helped.

Dr. Sharp: Nice. Wow. And so here you are. That’s your life these days it sounds like. A lot of research and certainly the book as well. We talked about maybe just jumping in and really starting with that question, like you said, of what is ADHD and how are you conceptualizing it these days?

Dr. Nigg: That’s really a big topic right now for me and for the field. And it’s got two parts. What is the actual condition or syndrome or phenotype? Is it an executive function disorder, et cetera? Is it a neural developmental problem? But then the other is the causal structure of it.

I’m going to start with the cause and structure then back up to the phenotype. As most of your listeners probably know that for much of the 20th century, we had a contest between those in the biological field who thought that ADHD was [00:10:00] early brain injury and those in a more psychodynamic field who thought it was an unresolved neurotic conflict, and so on.

And then we moved into this biogenetic descriptive phase with the DSM–III and DSM–IV. And really in the 90s, maybe even the 80s and certainly the 90s we moved towards genetics in all of psychiatry and a real interest in… And I think even because of the twin studies, there’s even today, a lot of belief that ADHD is just genetic and that there’s not as much room for the environment.

And I think what’s really happened in the last 5 or 10 years is a recognition that the environment is extremely important in ADHD. And that we have to figure out how that goes with the genetics rather than the other way round. That’s been a big development for us.

So when I counsel parents, I really talk about that balance that on the one hand, you didn’t cause the struggle [00:11:00] because there is some sort of a liability here that’s genetic, or there may be some early injuries. On the other hand, the environment does play a role in maintaining this condition, making it go in certain directions once it’s there. And that’s where we’re getting caught in a negative parent-child interchange or having an unhealthy lifestyle may end up being more important for these kids than for others. So, try to get that integration going, and we’ll talk more, I’m sure today about the specifics there.

And then as far as what is the syndrome, as I think most of your listeners are aware of, the most important change in DSM for ADHD was that it went from a behavioral problem to a neural developmental problem. And that’s not without its own controversy. But then, are we back to minimal brain dysfunction? What does that mean? We’ve really focused on is getting beyond the idea of just cognitive and attention problems to the idea of self-regulation. That really helps clinicians and parents recognize that the emotional problems of ADHD kids are really soon to be part of it.

[00:12:00] It’s not that jeez, I can’t decide if it’s ADHD or anxiety disorder or ADHD or depression. The child that has tantrums or is over-reactive emotionally, that really is part of that larger self-regulation picture. So really thinking almost, this is self-regulation disorder, if you will, that encompasses emotion and cognition and behavior. And that helps to frame it for parents and put it together. And I think it helps diagnostically to think about when it really is a comorbid versus it’s just ADHD.

Dr. Sharp: Yeah, for sure. I forget when I ran across that. It’s been two years. I forget who said it, but once I started to wrap my mind around that concept that ADHD really is about self-regulation, that opens some doors, certainly because then you get those kids from an assessment standpoint who are emotionally dysregulated and recognize that that’s just part of the ADHD a lot of the time and [00:13:00] it’s not necessarily in the diagnostic criteria, right?

Dr. Nigg: That’s exactly right. It’s not. And that’s one of the directions we may go in DSM-VI is to modify that if we get the courage to change the criteria, we’ll see. It’s hard to do that for a lot of reasons. 

Dr. Sharp: Oh my gosh. Yes. So let me back up a little bit. At this point, just reflecting the state of the research, would you say that it’s pretty well-identified that there are structural differences and even genetic components to ADHD that we can settle on in addition to environmental stuff? You’re smiling. Let’s open that.

Dr. Nigg: I’d say we’re pretty close to having a consensus on some of the brain features in the syndrome at the group level. We still can’t see it on an individual kid. And there’s still controversy about even the specific brain findings, how important are they compared to what we’re going to discover in the future because [00:14:00] the technology of brain imaging is evolving so rapidly and we’re thinking about the brain so differently than we did even a few years ago.

There’s so much more attention now to the dynamic interplay of brain networks and circuits and much less attention to the static functioning of one brain node or one brain locus. On the stroke on the structural side of that, we have clear evidence of ADHD, again, at the group level, there are slight changes. The cortex is smaller. Some subcortical regions are smaller. And so on. What that means functionally is still how to integrate that with the functional conductivity findings is still a work in progress.

So I would say we have got so-called consensus descriptions of this in the literature, but I’m not sure that consensus is really there on it or that it will stay the same. And so, it’s not sort of settled science in certain is exactly what that brain circuit is. Even though it is clear evidence that at a group level you see brain alterations in kids with ADHD as a [00:15:00] group, the genetics is sort of similar.

We just had a paper published, not us, but the field this, this week, it came out, but it’s been known for about a year by those of us in the field with the first proven genetic findings in ADHD, the first reliable genome-wide hits in ADHD of about a dozen low PSI in a large sample of about 30,000 individuals. And so that just tells you that yes, we can definitely prove genetic role in ADHD, but there are no genes of large effect except in very rare cases.

So again, we’re not going to have… we’re a long way from genetic diagnostics except in rare cases where you might genotype. So, I would say that the challenge here is, again, the distinction between that group level and that individual clinical level. Their parents will say, well, can I get a brain scan or can I get a genetic test? And getting that [00:16:00] nuance of no, it’s at a group level, but it’s a subtle effect, it’s a population effect, we don’t have good enough science yet or good-enough tools to see it in the individual. So the genetic or brain test isn’t worth your money unless there are additional findings that would justify that.

Dr. Sharp: Yeah, I got you. Well, so maybe that answers the question. I know there are folks out there in various places who would say the ADHD is not “real.” How do you answer that question? Or if you ever confront that?

Dr. Nigg: Yeah, we confront it all the time. Books have been written by philosophers on what we mean by real here. I think about it in two ways in my mind. And now I’ll translate that into what I would say to parents. But from the point of view of the clinician thinking about it in their mind, the old philosophical argument going back to the enlightenment is, are we carving nature? Does nature really have these conditions in it and we’re discovering them, or are we creating these [00:17:00] conditions as a method to help us work on what the problem is?

And for a long time, of course, it was thought that biology essentially was convenient taxonomy, not nature’s taxonomy. With the evolution of genetics and the development of these fields, there’s a closer belief that some of those taxonomies in biology now are actually really there in nature. Any culture, any science, any civilization would eventually discover them. Whereas with something like ADHD and most psychiatric illnesses, there would be a lot of different ways to slice the pie. And it’s pretty clear that what we’re doing here is we’re inventing constructs to overlay on human experience in order to help us organize our perception as we organize the study of it.

So in that sense, ADHD is not something in nature that we’re discovering. A different culture, a different history, an alternative universe on the earth might just develop a different idea than [00:18:00] ADHD of what’s there. So in that sense, it’s not “real”. We’re not discovering a real disease. It’s not malaria. That’s really there. It would be discovered by any science in any culture eventually.

On the other hand, something is really troubling these kids. They’re clearly really dysfunctional. They really have a problem. And there really is a biological substrate to it or a biological component to it. So in that sense, it is real. There’s a real impairment. There’s a real problem. It’s not just imagination of the clinician or the imagination of the teacher that there’s something wrong. And that there is a component that is in the child, at least in a significant number of cases.

So what it really boils down to is, is the problem in the child, or is the problem in the people around the child? Of course, many of the children will tell you the problem is the people around them. And many parents and teachers may be overeager to blame the child, but really what we’re seeing in our research is that, for many of the subgroups of kids, large, sub-groups, where you can see that there are differences in the [00:19:00] child, they have different neuro-psychological functioning, they have disturbing emotion regulation. They have differences in brain imaging at the group level. There are other subgroups we can see with machine learning that nothing is different about them. They really biologically or neuro-biologically look the same as typical kids.

And so, we’re hopeful that with our research, we could eventually differentiate groups of kids where there is a biological component even if it’s subtle which may reflect an early injury, perinatal injury or an extreme genotype or a sensitivity to the environment that has led them to have a disruption. And others for whom it really is an extreme temperament, there’s no need to call it a disorder or there’s something else in the child environment fit that should be addressed instead.

And I think that that differentiation is really the sense of real and not real that we want to get to where there really is something in the child that’s legitimate to say, this is the condition in the child, carried by the child, the child brings it with them and is causing them problems [00:20:00] to a large enough extent that it’s legitimate to say they have a disease or disorder or a condition and not merely society over pathologizing normal child behavior.

I think we can be confident that that release for some of these children, that is the case. Our goal and our science is to identify those kids more accurately. And then the clinician’s challenge is to say to parents, we know that that there is a condition where some kids do have either a subtle neural injury or an extreme genotype or some other disruption in them that is making it hard for them to function in the world and to adapt at least in our society as it’s currently constructed and that therefore we need to help them. We also know that there are others that we can’t always pick them out where it really is that maybe we’re overreacting to a child’s exuberance.

And I think even today with their tools, the clinicians can probably tell those apart. It’s sometimes hard to break the news to the parent. But I [00:21:00] think you can probably tell them apart reasonably well. But we can’t prove that scientifically yet. And that’s what I’d like to get to. I don’t know if that’s helpful, but that’s how I think about it.

Dr. Sharp: Absolutely. For me, I think about a lot of the past guests that have been on here. We’ve talked about the neurodiversity paradigm, which I would imagine you might be familiar with that whole idea like you said of, is it just a bad person-environment fit and we’re calling that ADHD versus how much of this is actually happening? I’m not sure what the word is. It’s an aid to some degree.

Dr. Nigg: Somehow in the child. Yeah, that’s right. I think it’s legitimate to say that both things are probably happening and there’s a little bit of everybody can be a winner and get a prize here, but that also means it’s an oversimplification to wrap it all up and say, [00:22:00] it’s all bogus. It’s not. We know for sure that there are kids with neuro-biological injuries in the population. And some of those we can already see even on ultrasound at birth or later on brain imaging, but they’re subtle. Others are too subtle to pick up in an individual yet, but eventually, we probably will. And others probably do meet the criteria of, we got overexcited with our diagnosis.

Dr. Sharp: Sure. Well, that’s maybe a nice segue into the whole diagnostic process. A big part of our audience, I think, is clinicians who are practicing. Assessors. I know there’s a lot that goes into this, but how does all this inform the assessment process from your perspective? We have cognitive measures and we have behavioral measures and we have an interview and we have observations.

Dr. Nigg: That’s right. We have our tool kit and what’s the right way to use it. And especially with increasing cost pressures on everybody for keeping [00:23:00] these assessments brief, one of the big questions that’s kind of a spin of what you’re asking is when is it okay to do a brief assessment? And when should you really do a lot more? How do you know when it’s easy versus a hard case before you do all of it?

The first thing that I bring to the assessment is the knowledge that with everything we just said about, is it real, or is it not real? There is a tremendous risk for kids in the ADHD population. They’re triple the risk of serious head injury. They’re double the risk of puncture wounds. They’re going to die earlier and have the worst health outcomes. They’re a greater risk for addiction, greater risk of going to jail, failing school, getting divorced later. The list of poor outcomes and the multiplication of risk is rather daunting.

And so the first piece of this is to take ADHD very seriously and to help the parent understand that if your child does fall into this population, it’s a serious matter that requires some real reflection. And it means your child’s got a lot of additional risks. You want to really think about what [00:24:00] that means for how you’re going approach it and not brush it all off.

So a lot of times for us, the first piece is just helping the parents see that it’s an important matter to get right. And it’s worth assessing it carefully and not just doing it off the couch. You know, sort of motivating more thoughtful look. That said, if the question becomes then triple, A, do I have enough criteria to meet the diagnosis for billing? And that’s trivial in a way, although it matters. It matters to schools. It matters to parents. It matters to judges. It matters to insurance companies and therefore matters to our listeners.

At the same time, is the severity enough that we should intervene? And then, what’s the right intervention And that’s where I think the additional evaluation can be helpful. So to get the criteria right, I do think it’s important to follow the DSM pretty carefully. That means taking seriously the need for that second informant, the [00:25:00] teacher. The rating scales on paper are pretty good at reproducing what you’re going to get out in an interview.

The problem is the black Swan. The problem is the teacher that fills the rating scale differently than they really think because they don’t want to hurt the parents’ feelings or because they are really can’t cope with this child for some reason. And it’s because of a different reason than the child. And you only find the black swans by talking to the person. And so, you may talk to the teacher and find out that no, I told you what I thought in the ratings. I can reiterate it now. And you say, okay, in this case, I wouldn’t have had to call the teacher, but every 1 out of 5 or 1 out of 10, you’re going to find a teacher who says, oh no, no, the parent is completely right. This child has got serious problems. I just didn’t want to hurt their feelings. And that’s why I marked zero on the rating scale. You don’t want to miss those.

So I have found it invaluable to talk to the teacher. And then also with the teacher, you get the nuance that the problem really is that he’s [00:26:00] being bullied or the problem early is that he’s got this one friend in the class that he can’t stop goofing around with. And you really get a sense of what the behavioral correction in the school is versus no, we need an aid in here, knowing how big of that. I think that’s not discoverable necessarily on a rating scale.

So I’m a big believer that the teacher interview is going to give you the qualitative information you need. And of course, for a psychologist, this is not need to be said, but I think for the pediatricians or other clinicians that don’t have time it’s a much bigger challenge, but it’s very important to have that normative rating scale, those national norms.

Part of the philosophy of disorders is that it’s statistically extreme. It’s not the only definition. Obviously, that statistically extreme things are normal or don’t concern us in albinoism and so on. We’re not going to call that a disease or disorder, but you don’t want to call it a disorder if it’s normal. In this case, now, you might, [00:27:00] for some things, I mean, if the whole population has malaria, if they still have malaria, but in this case, part of the definition of ADHD is that the behavior is outside the normal range.

You can’t tell that just by the symptom count, you have to also have the normative rating scale and show at least. And then the promise how to combine it. Parent and teacher both gave you some elevated scores and that’s where it’s important. Remember, the DSM is not the 10 commandments on snow and handed down. It is a guideline for clinicians. The six symptom cut off, or the five symptom cutoff for those over 17 is a guideline. This is where a clinician should really be looking to find their decision point. But knowing if you have exactly six symptoms is hard and all.

For real symptoms from the parent and for additional real symptoms from the teacher with some impairment, six symptoms, I think the answer is yes, but some people would argue about that. So that’s where the judgment comes in. And when we review papers [00:28:00] from the research field is always a question of how did you actually count your six symptoms? There’s a lot of ways to do it.

So, I think the way that I advise clinicians to do it in the DSM text, which I had a big hand in writing actually points this out, you want to really see, you want to be convinced that there’s something going on in both settings. And then both interviewers are seeing it, even if you can’t quite get six symptoms from both reporters. And if you have six total and you’re convinced that there’s really a problem there, and there’s some impairment, then you pretty much probably have this kid in the population that’s at risk and you know that you’re now in this decision point of it may be legitimate to give them a disorder and intervene. 

Dr. Sharp: Got you. Sorry, to just get real practical, do you have any favorite rating scales that stand out?

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Dr. Nigg: It’s a tough call because a lot of people use the Vanderbilt because it’s free and it’s almost identical to the ADHD rating scale. The DHD rating scale does have national norms and how important is it to have the exact wording and the exact structure to affect those scores is always, I guess psychologists do always know that that’s a whole literature. And so, what I don’t like is using the Vanderbilt to just count symptoms and not think about the norms.

I think that the ADHD rating scale is pretty affordable. I think the Connors actually has better [00:31:00] norms and more differentiation of domains that can be very helpful. So I tend to like to use the Connors and the ADHD way to scale together and see if there are seeing cutoffs in at least one of those sets of norms in addition to an argument that there’re six symptoms or very close to six symptoms and that there’s impairment.

The other nice thing about the Conners is it gives you a positive and negative bias score, which is not very often helpful, but occasionally it’s helpful. It’s I always like to have a broadband scale, so you don’t miss a mood disorder.

And so here’s where the CBCL or even the strength and difficulties questionnaire is helpful. The strength and difficulties questionnaire is close to free. They’ve now got a small charge on it, but it’s a lot cheaper than the CBCL. CBCL has better American norms and more items. So you’re going to get more differentiation, but it’s a lot more expensive.

So for clinicians that can bill for it and some can’t, and then the CBCL is probably a better choice. [00:32:00]For those that can’t bill for it or that think that the parent isn’t going to have the literacy or the patients to do the log CBCL, then the SDQ is the adequate substitute. They are adequate, not as good but adequate norms for the United States. And you can at least get a sense of whether they’re in a clinical range there. And that does help you miss. If you see the G the emotion score or the anxiety score is a lot higher than attention and hyperactivity score, that may be a warning flag that this really is a primary emotional anxiety disorder, and not just emotional features with ADHD. I want to see that profile. Again, the profile analysis isn’t well-validated, it’s another piece of evidence to consider. 

Dr. Sharp: Yeah, I hear you. So thinking about it, I’m not going to necessarily touch the cognitive side, I know that that’s a big can of worms to open and cognitive lots of ADHD, but I feel like you really speak a lot to that. Like you said, the environmental influence, [00:33:00] which makes me think of the interview, right? So what kind of things might we need to ask about that? Well, I’ll just leave it at that. What should we be asking about in an interview that either are or are not obvious? 

Dr. Nigg: Yeah, let me comment on that. Let me say a word about cognitive testing though first.

Dr. Sharp: Sure.

Dr. Nigg: I did skip over that I realize. I do carry out a neuropsychological battery a percentage of the time on these kids. Not so much to figure out if they have ADHD, but to make sure that I understand that the cognitive profile. I think it’s one thing that psychologists can offer, but other disciplines can’t offer as easily in terms of, there’s really low alertness, low arousal, there’re really problems with response inhibition, interference control.

I really do think in my experience, talking to special ed teachers or talking to parents, that can really help parents and teachers to think in a more creative way about what is happening for that child. And again, help reduce the blame. [00:34:00] You know, they’re not filtering very well. They’re getting too much information coming in and that’s why they’re shutting down or they’re really not very alert. They have low arousal and we need to look at why that is. And that’s where it’s going to help to do some of these behavioral interventions for that around more frequent changing, or shorter tasks or whatever it may be.

So I think that it really can help with the functional plan. It’s not diagnostic. And so the differentiation I will give it to parents and to other clinicians is, let us do the battery so we can form an appropriate intervention plan because ADHD, part of the message in the book and part of my theme song is that ADHD is not a one size fits all. It’s a really heterogeneous group of kids that every clinician knows that already, but I think this really helps capture the heterogeneity a little bit.

So I will do the full neuropsychology battery in some instances, especially if this child has already failed in treatment and it’s really not clear what’s going on, but not [00:35:00] when it seems straightforward and I don’t think there’s a major school problem or a major. That’s kind of a judgment call, but I think again, one that’s familiar to us. So I think it’s legitimate to do it sometimes. And you may get a comorbid learning problem. Obviously, there’s something there too.

As far as the environment, I think that probably there’s a number of common blind spots that used to really be very common, I think are less common now as the word has gotten out, but one obviously wants to sleep. We actually did a webinar, I think, as you know on that just last week on attitude again. So ask them about sleep.

American Academy of Sleep Medicine has got a really nice, short, valid sleep questionnaire on it that you can download and use. I can make it available. I think it’s free. We will give that and that’ll just flag that there’re real sleep problems. Of course, in the interview, you want to ask briefly about sleep quality, whether they seem tired, then in your observation of the child, notice if they seem sleepy.

I think that the clinicians probably do that instinctively, but that’s a very important thing to focus on for a minute. and [00:36:00] reconsider, am I missing a potential sleep problem here? Keep in mind that although indigenous sleep disorders are relatively rare, even in kids with ADHD, that these behavioral ready-to-sleep problems, where the child isn’t getting good sleep because they won’t go to bed, the parent has given up on bedtime.

You don’t want to miss that and find out that Jeez, I don’t know when they’re going to bed. I don’t know when they’re awake or not. We’ve given up on that especially with teenagers that can happen. If you miss that, obviously, you’re going to feel kind of foolish if it turns out that that he’s not paying attention because he didn’t sleep.

The other one for adolescents is drug use. And those that don’t have training in addiction assessment can often be too easily brushed aside a simple declaration by the parent that he wouldn’t use drugs. And so more careful evaluation of that with the teenager, I think is really important to determine if they are doing anything.

I have found the teens to be surprisingly for us right on that. [00:37:00] You always have a dilemma, of course, of whether that’s going to be privileged information or not. And of course, usually, you’re not going to want to make it privileged just because you don’t want your hands tied to what you’re doing. In that case, the teens may not be forthcoming, but I think it’s important to try and to investigate that and not overlook that entirely, and to put in your report that you attempted that, and it came up empty or came up with something very mild and maybe it’s underreported. 

Dr. Sharp: Can I ask a side question with that?

Dr. Nigg: Yeah.

Dr. Sharp: We live in a state where marijuana is legal. All I can’t remember, is Oregon the same?

Dr. Nigg: Yea, Oregon is the same.

Dr. Sharp: Right. So, we get a lot of teens, I don’t know if they used this necessarily gone up, but the maybe perception that it’s okay has gone up.  I wonder how you talk to teens about that, or if you talk to teens about that? How do you say, hey, this really isn’t that great for you? [00:38:00] You might want to pull off a little bit.

Dr. Nigg: Yeah, it’s a key issue. We have that issue too here. It’s getting endemic in the high schools now because it’s legal and it’s everywhere and it’s a major concern for everyone. What I have told teens is that if your problem is attention or motivation, this is a commonly known side effect and you should rethink it.

And also, we don’t know that it’s safe in teenagers’ brains. We actually don’t know that in adults’ brains either, but, but in teens’ brains, we really don’t know it. And so you are taking a risk with your brain development and your future potential. And so, I will give them that information and urge them to take it more seriously. You need to cut it out.

The big challenge as you know very well it’s like video gaming addiction. That’s their peer culture. And so, it’s very hard for them to give that up, but I think it’s important and incumbent on us to give them that [00:39:00] information.

Dr. Sharp: Sure.

Dr. Nigg: And sometimes parents too because sometimes parents underestimate it.

Dr. Sharp: Oh yeah.

Dr. Nigg: I’ve had parents who know their kids smoke pot and aren’t worried about it, you know? 

Dr. Sharp: Oh sure, yeah. What other things should we be looking for in the interview that might not be obvious?

Dr. Nigg:  The other one that, and again, maybe some of this is obvious, but I think the overall emotional climate in the home is very important. And thinking about the role of stress and emotional disruption, one conceptualization that I found helpful, and I read about this a lot in the book is this concept of extreme sensitivity to your environment. That is the ADHD child in some way, somebody that can be thought of as very sensitive to what’s around them?

So they may be very perceptive of beauty and very reactive to something wonderful exuberant about that, but equally reactive and sensitive to stress and [00:40:00] conflict and toxic emotions. And so, these are often not the individuals who can let it roll off their back when somebody says something that upsets them or does something that they think is unfair. And of course, with the children’s behavior and the children’s being provocative, for a lot of reasons, as your listeners know all too well, you often end up with a home environment where there’s substantially intense, emotional expression going on.

And it would be helpful if it was more mellow in terms of this whole literature and expressed emotion and literature on stress and coping. And the idea that maybe the ADHD kid is a more sensitive person, not in the sense of fragile although sometimes they are fragile, but in the sense of very attuned and reactive.

I have to be careful with this analogy, but one analogy that helps some people is that, did you ever notice that when you’re stressed out, your dog is restless? Do you ever notice that when you’re frantic, your [00:41:00] dog can’t relax? And you think to yourself, I’ve had this happen to me. Why is my dog underfoot running around at the very moment when I don’t want him to be doing that because I’m frazzled?

Well, he’s reacting to me. He’s reacting to my vibes. And children are the same way. And I think ADHD children are especially that way. And again, I don’t take the analogy too far. Our children are not pets and they’re not dogs, but there are a hundred reasons why that’s not a valid analogy, but for this particular angle, I think it’s helpful to remember that the children really can pick up on the subliminal that’s going around them.

They’re very, very attuned to this. They’re not necessarily conscious of it. They’re not necessarily thinking that you’re stressed, but they’re reacting viscerally to it. And we can see that even in our research. We can see the heart rate changes. The blood pressure changes in kids even when they’re shown an emotionally arousing picture, two people arguing in a picture.

And so, I think that’s something that is important to look at is what’s the emotional intensity in the home. And is it stress level for the family or the [00:42:00] parents they’re super overwhelmed and super stressed out? 

Dr. Sharp: Yeah. How do you ask about that? Or how do you assess that?

Dr. Nigg: I started approaching that with parents around their own level of feeling overwhelmed and needing support. How are you doing? How’s your support going? How are you getting along with each other? And I normalize it. I tell parents it’s very common when children are struggling or a special needs for parents to find that on each other’s case about things. That’s just human nature.

Your resources are depleted. You’re depleted and you’re starting to not be at your best. How is that going for you guys? And what kind of supports do you think you’re going to need? And again, I normalized, most parents in this need some other support, either more friends, more time, more break time, something to help them cope with it.

It’s just an unusually hard situation. And that’s usually enough to help parents acknowledge at least to some extent. Sometimes as again, as your listeners know, sometimes there’ll be disguised [00:43:00] or displaced. I don’t do it anymore, but I used to just fly off the handle all the time. I interpret that as you, you might still flap if they handle it in time. And so, let’s talk about your stress level. Unless something has changed legitimately convinces me that’s no longer true. So I’ll accept that it used to happen more and it sounds like it’s improving, but maybe it’s still time to make sure it continues to improve and continue to give more support.

So I think that that can be helpful too. Most people are overstressed these days. And so, the trick is to figure out that this is sufficiently overstressed, that it’s really bothering the parents and they’re really feeling it. And it’s surprising how often there’ll be. One of the parents really resents that the other one is working so much. And it’s true. They are working more and they’ll admit it, but they have to, they feel like for various reasons. 

And then talking about the trade-off there. I understand that you feel like you have to. Financial pressures are real for all of us, at the same time your child is attuned to this. And so, what are [00:44:00] we going to do? We have a dilemma. And then just do some problem solving and thinking about this. Maybe there’re some ways we can offer this, at least, even if we can’t change the workload.

Dr. Sharp: Got you. Yeah. So just getting in there explicitly, I think in normalizing, it makes sense.

Dr. Nigg: The normalizing really helps cause it is pretty common for ADHD families.  

Dr. Sharp: Yeah. Now, do you ask about, I think this is good, this is actually getting into some of the things that you write about, but in terms of influences on ADHD. I get a lot of questions about screen time. Do you assess screen time?

Dr. Nigg: Yes. We do assess screen time. We just ask about it. We ask about how much screen time they’re spending, when they’re doing it, is it at bedtime, for example, or is it during meals just to get a sense of the ubiquitousness? A real issue, of course, is the addictive-like behavior that they just can’t handle it when you limit it.

And that’s the red flag. It’s turned into the [00:45:00] fight of the century about video time. And it’s becoming almost in some ways, the most common complaint of parents. It’s replaced other common complaints of video game overuse or addiction. So yeah, we definitely assess that. It’s a common problem.  And for teen boys, especially, it’s a very common problem.

Logistically that’s supported, even though it’s not only teen boys. And so that that’s a key issue and we do talk about it. And we talk about with parents the fact that it disrupts sleep in that last hour before bedtime. We talk about the dilemma that it’s sometimes it’s the social network for the child, but it also is competing with other social opportunities that would be just as important for them. It may not be all or nothing by getting some rebalancing, maybe there needs to be some other, maybe we don’t need to take it away completely, but maybe we need to balance it out.

And then this goes to the health stuff. We haven’t talked about exercise and diet yet, [00:46:00] but you’re going to have some de-stressing time. If you’re going to have some downtime at the end of the day screens, if you’re going to get exercise, for young kids, if you’re going to have some play time so that they can actually exercise their fantasy life and their creativity, and you’re going to have some family time and get to bed on time, you shouldn’t have a lot of time to be on the screens.

And so it should be able to put reasonable limits of an hour a day or whatever it may be. And of course, books have been written now on how much screen time is the right amount. But once we’re past an hour a day, it’s hard for me to see how there’s time for the other important health behaviors, you know, getting the homework done.

So one strategy there, there are strategies we can get into, but what one strategy is to is for parents is to say that, homework and playtime and exercise are the priorities and healthy supper and getting to bed on time and no screen time for an hour before bed. If you can do all that and get an hour on the screen, fine. [00:47:00] If not, let’s make up for on the weekend and give you some weekend time.

The educational value is there for the right kind of programs. But the obvious, as I write about the risks of the screen time in terms of exposure to violent content and explicit content and the inability of the child or the youth to really handle that and integrate that in a mature way, I hate to say it, but I know there’s some conscientious video game developers out there, but I don’t think it’s getting enough attention and parents have to monitor this.

Dr. Sharp: Sure. Yeah, I’m with you on that. So let me ask you a question that people ask me a lot which is, is screen time causing more ADHD?

Dr. Nigg: That’s a great question. We have one metal analysis on that that I think is robust and it’s now four or five years old. So it’s already outdated because obviously behavior patterns have changed dramatically just in five years.

But at that time there were real, but small effects on attention problems. What [00:48:00] you would see is that kids who were on the screens more had a slightly elevated detention process, but the effect was rather statistically very small. So the population significance, but not a very big individual significance.

That said, what we are seeing now in literature is a concern about emotional unhappiness in relation to screen time that kids who are on the screens too much are more stressed. They’re they’re more reactive. They’re more anxious, more depressed. They feel worse and this gets to anxiety about social exclusion. It may get to the over arousing nature of the material on the screens. And there’s still not enough good experimental evidence to say if this is causal or correlational, but we do know casually that there’s good correlation, causal experimental of that, that aggressive behavior gets worse with a group with violent content.

So it stands to reason that with over rousing content, you can some of this emotional dysregulation. So I [00:49:00] do think it’s plausible, not yet proven, but plausible that it may not be having a big effect on more ADHD, but it may be having effect on the emotional dysregulation features in kids with ADHD and giving them more challenges there.

Dr. Sharp: Yeah, I get that. So a little bit ago, you mentioned diet. I feel like this is a huge area that parents will ask about, you know, pop culture. There’s a lot out there. There’s a history of mixing up ADHD and diet. So I feel like there’s a lot to sort through there. Where are we at currently in terms of diet and its effect on ADHD?

Dr. Nigg: Yeah.  This is where I think, again, this is, as you point out, it goes back to the 30s in terms of hypothesis and it was a popular topic in the 70s and 80s. It kind of died out for a while. It’s coming back now both as a common question and with new data, and this is where we’ve had a bit of a sea change, I think in just the last 5 or 6 years [00:50:00] where the field has really shifted his perspective now to recognize that the dietary effects are real.

Again, they’re small. Diet is not just the sole explanation and the cases where diet is going to cure ADHD are very rare, but the cases that will benefit from diet improvements and a healthier diet are probably more common. We estimated that maybe again, this literature is thin, but still believe it or not, but we estimate that about 30% of kids with ADHD might benefit from significant attention to their nutritional and diet intake. And I’ll say more about the specifics of that in a second. We do know from random experiments studies that there is a causal effect of certain unhealthy dietary factors on symptoms of ADHD. And again, the effect size is not huge.

If you think of a medication effect as a 100, the diet effect might be a 20. So, [00:51:00] it’s not as or 25. So it’s 1/5 to 1/4 as big as a medication effect. And that may give you a sense of, you know, if you gave a medication, you might change a Connor score from a 65 down to a 55. Whereas if you do a dietary change, you might change that Connor scores from a 65 down to a 62. And so you’re going to have some effect and some benefit, but it’s not going to be for most kids on average, not going to cure it. It’s not going to be, but it may allow you to give a lower dose of medication or it may in combination for their other health behaviors take the edge off a little bit. And occasionally, you’ll get a strong response where a kid has got some kind of food sensitivity that’s been undetected.

Then in terms of specifics, the culprits that have been studied are food colorings, food preservatives. And so that’s led to this concern about food additives. But as far as I can tell from looking at this literature very closely, it’s unusual for a child to react to only [00:52:00] one thing. More commonly, there are kids who are just sensitive to elements in the diet. And so, it means that if you take away the food additives, you’re probably also taking away lots of other unhealthy things because to do that in real life, you have to get rid of a lot of processed food. And that just makes food healthier in a number of ways.

So we do ask about diet. We ask about junk food. We ask about healthy food and soft drinks and sodas and things. And we do include in our routine recommendations that if there’s looking a little bit expensive involved, it costs more to eat healthy, unfortunately, but if you can eat fresh food, work on dietary changes little by little reduce the processed foods a little by little, it’s gradual, get rid of some of the drinking your calories, some of that kind of stuff, it’s going to be another health behavior that will help.

And I use the analogy with parents. If your child has asthma or you have high blood [00:53:00] pressure or obesity, overweight, it’s always a combination of multiple lifestyle health factors to help combat that and to minimize the need for medications and drugs to solve it.

In ADHD, it probably won’t be enough to do those things, but it should help somewhat. And that may be a nice compliment to your standard care and reduce that need a little bit. And occasionally, you’ll get a big benefit. So we do counsel parents to do the waterfront and give a child every chance.

Dr. Sharp: Yeah, is it enough of a concern that you would recommend that parents maybe seek out functional medicine or a blood panel or something like that? I mean, is there a way to test those sensitivities to those different?

Dr. Nigg: Yeah, testing sensitivities is not dependable for ADHD kids. Obviously, an allergist can do an allergy test and that is sometimes worth doing if you have other allergy symptoms. But unfortunately, the allergy test findings don’t seem to correlate with the ADHD food sensitivities very well. [00:54:00] So, I would tend to attempt to advise the allergy testing if you have other signs, atopy, and other things that could be allergic and the allergist thinks that’s worth doing the testing then yes.

Think about food allergies as part of that, for sure. But I think a bigger thing that a blood test will do is show if there is anything that’s low, low iron, low thing, low vitamin D, even low omega-3, that it’s not standard of care. We guys have to stress that. Standard of care is not a blood panel for ADHD. And that’s partly because these are still considered to be a minority of kids and therefore the hit rate isn’t considered high enough. And that’s why it’s not standard of care to justify the cost. And the majority of kids who have, you won’t find anything.

But I do know clinicians, holistic psychiatrists, I guess you say that will combine a blood panel just to make sure that they aren’t missing a nutritional value. And I don’t think that’s wrong. It [00:55:00] just has to be… I always had to footnote that it’s not standard of care. Insurance might not pay for it, but I don’t think it’s a terrible thing to do. You don’t to miss the low vitamin D or miss the low iron if they are.

And usually, a good physician should detect other symptoms of that problem. But ADHD is subtler than some of the physical symptoms. And we know that from like the lead work and some of the other physical, physical contributors. The other big one here is omega-3. We do know that omega-3 supplementation does help. Again, the effect is modest. It’s about 20 or 25 on my scale of 100 with medication being an effect of 100.

So it’s not going to be the solution, but if something else that’s generally safe at the doses that you’re going to get. And it may provide some partial relief, and that we know that it’s causal and that effect is there even though it’s modest. We don’t [00:56:00] know if that’s only in kids who have low levels to start with, however. So again, I will usually tell parents, go ahead with the omega-3 supplements, the official oil, or now the LG based seemed to be the way to go because they don’t have any of the contaminants of the fish oil, but there’s a variety of these holistic products that are getting better.

Again, it’s a cost factor. If you can get it from food with eating more walnuts and macro and sardines and low on the food chain fish, and the occasional high in the food chain fish with high omega-3, then food is always better than supplements if you can do it, but supplements are a way to do it if you can’t get the food in. So what we do for those that are interested in healthy behaviors, we do think these. So basically, the omega-3s and healthier diet are the two big ones that we go with. And then we tell parents, don’t worry about most of the other dietary supplements unless you’ve got low blood levels.

Dr. Sharp: Got you. While we’re talking about supplements, I want to jump back to the sleep topic. Do you have some reflection of the research on [00:57:00] Melatonin and its safety? Its efficacy? 

Dr. Nigg: Really great question. It’s surprising how many parents are not giving their kids Melatonin. So there’s a lot to say about this. And I put a whole section of the book on it for that reason. Point number one is for kids who really do have a Circadian rhythm disorder, sleep-wake phase offset disorder. And if it doesn’t respond to behavioral intervention, melatonin isn’t an effective intervention. And that’s about the only time though that it’s the right intervention. And even then it should be done with medical supervision.

The two big things that parents don’t realize about melatonin is over-the-counter supplements have way too high of a dosage compared to what the clinical dose would be. And second of all, it’s a hormone. And so, it’s powerful. It can do stuff to the child’s other hormones. And so, with babies, [00:58:00] it’s a total no-no because they’re still training their bodies to sleep. And you’re gonna really mess up their system.

With adolescents, we don’t know what the interaction is very well with other adolescent hormones that are very busy during that time and melatonin is in the mix. And so, what’s it gonna do to their brain development? I don’t want to be histrionic about this, but it’s just unknown.

And so, I really coach parents that melatonin is not to be taken lightly. It isn’t over the counter, but it is a hormone. It is overdosed on the supplements. So I would only use it if you’ve got your physician’s oversight on it and you understand why you’re using it. It does help you fall asleep, but it doesn’t help you stay asleep. It does have side effects you have to watch out for including, it can have a morning hangover. You can have night sweats. You can have other side effects.

To use it properly, you’re actually supposed to take it a few hours before bedtime. It’s supposed to help [00:59:00] help the melatonin ramp up in anticipation of sleep, not as a sleeping pill right at bedtime. So there are correct use practices, but the biggest issue is getting a safe not a safe, but a recommended dose and then understanding that you’re messing with hormones here. So use it with caution, under medical instructions.

I’m very cautious on it. Usually, if there’s a sleeping problem, the first line of attack is behavioral. There are very good behavioral strategies again, as many of your listeners are well aware for treating sleep as a behavior problem and in approaching it that way. And if that hasn’t been done well with professional oversight and a good counselor, that should really be tried first. And I really push parents on that because of the the frequency with which that will be sufficient in the unknown risks of melatonin.

Dr. Sharp: Sure. That’s a great answer. I appreciate you delving into that. I get that question so much. 

Dr. Nigg: Yeah, we YouTube.  

Dr. Sharp: Well, I feel like we’ve covered a lot of bases in terms of environmental factors [01:00:00] different things that might be part of the picture here. I do want to ask you just a little bit about recommendations and what’s helpful for ADHD, but other environmental pieces we didn’t really talk about or that interplay between genetics and environment. Anything to touch on there before we move on?

Dr. Nigg: Yeah, we talked about stress but not about trauma.

Dr. Sharp: Oh yes, of course.

Dr. Nigg: I would flag for your clinicians not to forget to evaluate for emotionally traumatic events. And it’s not just early abuse. Think about whether that bullying is really rising to the level of the child is really deeply frightened or whether that parent loss of temper is really deeply fragmenting the child to the point where it’s approaching a trauma reaction, or you really have had a traumatic event, there was a serious car accident there wasn’t abuse. And are you seeing a situation that requires a trauma-based cognitive-behavioral intervention and not just an ADHD-focused intervention?

And I think that again, there’s [01:01:00] more trauma consciousness now. So probably most of your clinicians have thought about this, but it’s just a reminder that not to overlook this, it’s a historical oversight in the field. Books on ADHD and articles, we haven’t integrated that with the addiction literature or the trauma literature.

The other piece I would say is that I think the gene-environment is going to grow as a focus. We’re going to learn more about environments. We haven’t talked about environmental pollutants and toxicants, but it’s another area to be mindful of. If the family lives in old housing, these things are factors. It’s a common anxiety for parents now. Unfortunately, there’s not a lot you can do, except try to remove the exposure, but healthy food, stress reduction, exercise, all interact. And so if there’s been some negative input from any of these sources doing what you can, may benefit exercise can undo some of the effects of stress in the body and in the brain and so on and helps to improve your [01:02:00] appetite and previous sleep.

So I do think this healthy lifestyle deserves more attention. The trick is not to make it a panacea or not to pretend it can be instead of the proper professional oversee. 

Dr. Sharp: Right. Well, and maybe that’s a nice transition to recommendation kind of stuff. What, in addition to a healthy lifestyle, good diet, regular sleep schedule, those kinds of base factors that we covered. What medication, behavior therapy, other things?

Dr. Nigg: Yeah, I think from there probably, I’m not sure that the state of the art of the recommendation panel has changed much in 20 years. Unfortunately, we did have the big MTA study you know, now almost a generation ago that continues to be mined with long-term outcomes.

There’s a number of findings from that that I think have been overlooked and there are some good summaries in the literature that I’ve noted and in the book, but recently, but  I do generally recommend that we get some counseling going at the very least to help [01:03:00] with coping skills for the family. It may be parent counseling more than child counseling depending on the pattern of course, but can we reduce the emotional intensity in the home? Can we improve the positivity in the home?

Some of these things that we know are partial drivers of worsening the condition and making it unpleasant for everyone. Can we restore some of what parents really want, which is positive relationship with their child and then the communication skills, and so on. We know that those interventions aren’t necessarily going to improve the ADHD symptoms, but they’re going to improve a lot of the functional problems around emotional regulation, oppositional behavior, and so on. That’s often the leading edge problem

For hyperactivity and attention, there’s still nothing better than stimulant medications. The important point here is to really make sure that the protocols are followed. We have treatment protocols, the Texas algorithm, and other algorithms that recommend the sequence of meds to try.

And the most common mistake we see on the medication front is that [01:04:00] clinicians depart from the algorithm based on their gut feeling. And it’s an elementary mistake. And so really pushing back for a second opinion if they’re not on the algorithm and use the algorithm is to start with a straightforward methylphenidate or Adderall trial. And when that doesn’t work,  adjust the dose, when that doesn’t work, try the other one. And when that doesn’t work, then get creative.

Usually, you don’t think of work by that point, the most common mistakes on medication are infrequent follow-up. There should be intensive follow-up, weekly or every two weeks until we’re confident of the dose, and that it’s working or not working. Not every six months.

And then we also know that pairing although the effect of the ADHD symptoms of medication alone is equal to the effect of an intensive psychosocial intervention, the chances of the child would get better is maximized by doing both. And the final wrinkle there that I’ll mention is if a child does have substantial anxiety, the benefits of medication are less likely and so [01:05:00] stimulants. And so that’s when you might want to really look at let’s start with some behavioral interventions and cognitive-behavioral interventions to help that anxiety come down, not put so much faith in the stimulus this time. And if we can’t get anywhere, then we’ll think about the right pharmacology.

That’s just one of the interesting findings from the MTA. The other big MTA finding goes back to parenting. Meds work the best when you can reduce negative parenting. So you really want that combo of reduced the hostile critical and shakes, interchange. That’s all it usually all about parents dress, pairing up being overwhelmed, and then their meds are going to work better and you get the best effect.

So that’s really the mix that we want. And that’s some of the nuances in the MTA findings that I think has been missed in some of this so much.

Dr. Sharp: Okay. That’s good. Yeah, those are some things that it’s nice to highlight.

Dr. Nigg:  Yeah. And then don’t overlook the school plan. Don’t overlook doing something with the classroom.

Dr. Sharp: Sure. Yeah, this was great. Let me throw a curveball at you before we wrap [01:06:00] up here. You mentioned ODD.  I’m trying to think how to ask this question. there’s just a lot of discussion around like is ODD a separate disorder? How does that fit into this whole picture? And is that a different class of kids that we’re talking about? Is there different brain stuff going on? I don’t know. Do you have thoughts on ODD and its role as a diagnosis?

Dr. Nigg: Oh boy. Yeah. That is a curveball. I want to jokingly say that I have to go now. I think it’s a very important issue. Certainly in the Survey literature, we can find kids who seem to be severe oppositional defiant and really don’t meet the criteria for ADHD just like we can find aggressive kids who don’t really have ADHD, but have other stuff going on in terms of the history of conflict or hostility or callous-unemotional features, and so on. The [01:07:00] the angry element.

The things about ODD I think to know is that most of the time ADHD is there also, especially in younger children, but it does mean elevated risk for future conduct problems in a subset of those kids. And so, this is the group of kids where you really want, again, pay attention to. Are we getting into a negative, hostile interchange in the home? They’re going to be teaching this kid to be coercive in their exchanges with people. And that that’s really what we don’t want to have happened because that’s what escalates. And so that’s where the parenting becomes a more important, parent counseling cause more important.

So, we do want to, if the ODD is there, put a lot more emphasis on the importance of parent guidance, parent counseling, and behavioral management curriculum. And again, Barkley’s curriculum is very good. There’s a number of very good curriculum here for oppositional defined kids, forehand. McMahon’s curriculum is very good. So that’s standing programs there and books that I think are very well-proven as effective to helping reduce these behaviors.

So yes, identify the ODD. Yes, put a greater [01:08:00] emphasis then on adding in or doing instead of the parent behavioral guidance with the programs around reducing those behaviors for the parents. Don’t forget that the first step in those programs is reestablishing positivity between parent and child as a basis. You don’t launch it immediately to harsh punishments or something. So getting that order of sequence right and really following that curriculum.

Conceptually, there is a higher risk in a subset for depression. And so with the ODD, we want to make sure we’re not missing a mood disorder or depression. It’s been disproven that it’s bipolar. So that was a myth for a while that these kids have bipolar or the DMDD diagnosis in DSM-V was created to save us from over-diagnosing bipolar disorder.

Most of the DMDD kids are severe ADHD, ODD as well. And we don’t know yet if they need a different pharmacology. Those trials are underway. And we’ll know more soon about whether an SSRI or something that should be considered when they really have DMDD. [01:09:00] What we’re seeing in our research is, and I talk about this too in the book, is that there is a group of kids with statistically who, it doesn’t overlap perfectly with ODD, who really are the kids with the severe tantrums. We call them the severe irritable kids. Extremely angry, blow up and can’t calm down, the irritable kids. And probably a lot of these kids might meet DMDD, but they don’t all have ODD. A lot of the ODD kids aren’t like this.

And these are the kids that we’re really seeing are the ones with the poor long-term outcomes. And so, we are encouraging clinicians now, even though our research is still just research, it hasn’t been accepted by the field. It’s still intuitive enough and has some empirical support that if there’s extreme explosive, extreme irritability, that’s almost the real trigger even more than the ODD for saying we have to intervene here to try to change the course of development. 

Dr. Sharp: Yeah. Okay. Let [01:10:00] me ask, what interventions do you recommend for those kids? Anything off the top?

Dr. Nigg: Well, that’s what we’re going to. Again, the parent guidance to get changes interchanges. If it’s really a child with a lot of anger management, and I said, adolescent, we might go in and try to work on the anger management with the kid, but we don’t have good empirical support to know. There are new interventions coming out, Federalist and counseling, around this that are looking good. So I think this is a place for your audits to really watch the literature and go to their workshops every year for CE’s to find out what the latest is.

There’s new treatment. They’re coming out almost annually now with because clinicians already focused researchers who develop new behavioral treatments are really interested in this problem of the kind of angry and defiant, explosive adolescent. And I think we’re getting some really good family-oriented interventions that are getting away from, you know, with younger kids, you can work on this costs-benefit behavioral [01:11:00] stickers. That stuff’s not going to work with these teens. And so you really have more creative interventions that are working now that are coming out. So I think that is a place where there’s new stuff to identify. And maybe we do a whole session on that sometime, or I can offline recommend some sources. 

Dr. Sharp: Sure. Well, I think that leads well into kind of a wrap-up of people want to learn more about all of this, any of this. I will certainly have your book in the show notes. It’s called Getting Ahead of ADHD: What Next-Generation Science Says about Treatments That Work―and How You Can Make Them Work for Your Child. I’ll put that in there. Other resources and places that could be helpful for people to look on this topic?

Dr. Nigg: We’ll give you our web link where we have some material and there are some other web pages that other researchers have that are loaded with resources. So we’ll give you a couple of those to put up there. 

Dr. Sharp: Okay, fantastic. I appreciate it. And if anybody wants to reach out to you, are you open to that? If so, how do people get in touch with you?

Dr. Nigg: You can go to my website that’ll give you [01:12:00] joelniggphd.com and put in a query there. I’ll try to respond to them. It’s hard for me because I get so many, so I can’t promise to, but I will try to, and if I get repeat questions about a topic, I will do a blog on it. And so you can sign up there and track a little bit of it. So yeah, feel free to try to reach me there and I’ll respond if I can. I just, for obvious reasons, can’t promise that I will, but I’ll do my best. 

Dr. Sharp: Of course. Well, thanks for being open to it. Well, this has been fantastic. I am so appreciative of your time. I have taken away at least 3 or 4 little things, and I’m going to go dig into and can apply with our next interview. So just thanks so much. I’m really appreciative that you were willing to spend some time with us.

Dr. Nigg: Pleasure, Jeremy. And best of luck to you and your listeners. 

Dr. Sharp: Yeah. Thank you.

All right y’all. Thanks so much for tuning into this episode. If it was your second time around, I hope you got a nice refresher and maybe learned a couple of new things. And if it was your first time around, [01:13:00] I hope that you took away a lot of helpful information about ADHD.

Like I said, at the beginning, if you need some CE credits, the vast majority of the clinical episodes are available for CE credits through athealth.com. Just search for the testing psychologist and you can find short CE quizzes for most of the clinical episodes for a pretty reasonable price.

I hope you are all doing well. If you have not subscribed or followed the podcast, it’s a great time to do that. Like I said, it helps spread the word about the podcast and just expose this content to more folks who might want to hear it. So always grateful for that. Thank you so much for those of you that have left reviews recently. I really appreciate that as well.

Hope that you are all heading into summertime, I think is where we’re at on the release schedule. Summer is coming. And in the meantime, I [01:14:00] will be working on more business and clinical episodes. I will see you this upcoming Thursday for another business episode.

All right. Take care, y’all.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between the host [01:15:00] or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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