A Whole Child Approach to ADHD with Dr. Phil Boucher

Debbie:
Hey Phil, welcome to the podcast.

Dr. Phil Boucher:
Thanks for having me. I’m excited to get to be here and to talk about ADHD and all the things.

Debbie:
All the things ADHD sounds like a good plan to me. I’m happy you’re here. And I would love it if you could kind of kick us off by just talking a little bit about who you are in the world, the lens through which you come to this conversation.

Dr. Phil Boucher:
So I’m a pediatrician in Lincoln, Nebraska. I grew up here in Lincoln and have been back here as a pediatrician for twelve or thirteen years now. I have a full kind of scope pediatric practice, but one of my specific areas of interest is ADHD, in part because I think that a lot of families have a lot of questions and concerns. And we kind of developed a different practice model where we have long visits with our families. And so for ADHD in particular, it gives us the time to really talk through all of the different aspects of ADHD, not just medications or not just, you know, like what the things that they’re doing wrong at school are, but really take a whole picture view of the child. And parents really like that. And I really like kind of diving deep into the weeds when it comes to ADHD evaluations and management.

Debbie:
I’m curious to know what was the appeal for you for ADHD? Like why did that become something you got really curious about?

Dr. Phil Boucher:
Yeah. So when I was kind of way back when I was in college, I was trying to decide, do I want to be a researcher or do I want to go into medicine? And the thing that I liked more about medicine, one is that like the problems to solve, you get a solution faster. And whereas research, it takes years and decades to, you know, make the experiments and run the studies and all those sorts of things. I like the more instant gratification. But I also like following kids over the long time and ADHD in particular allows me to put some interventions in place that we’re gonna see in the next days and weeks and then follow these kids over months and years and get to see the progress they make. So it kind of scratches both itches of I want to figure out what the problem is and then put some solutions in place and see what happens. And nowadays we have so many good tools that allow us to kind of objectively look at are things better for the child at home, at school, with their, you know, learning, with their curiosity, with their friendships, all those sorts of things, that it really fills the bucket for me of like, here’s some interventions we can put in place. And then we can see what happens. And it’s not going to take years for the study to come back to know if we’re on the right track.

Debbie:
Yeah. You know, as you’re talking, I’m like, this is such a good opportunity to really get into the weeds of like the experience from your lens because you know, we’ve obviously talked about ADHD a lot on this show over the past 10 years, but it’s often around very specific areas like sleep or movement or you know, the executive function. We talk a lot about that. But, you know, if we kind of look at the bigger picture, I’m thinking I’d love to even know, you know, when you’re working with a family, like is there a specific age where you start to recognize, this is, you know, what’s going on with the child? Like I think it’s always hard, when parents, especially if you’re working with them from the time they’re really little, parents are often confused, is this normal? Is this typical? Is this something going on here? So can you talk about that?

Dr. Phil Boucher:
Yeah, getting to work with children from birth through college age is really fun for me because we kind of get to see them as they grow and change. I think when I think about, okay, is this child on the ADHD trajectory? One is mostly do the parents have ADHD, whether it’s diagnosed or not, because that’s going to be one of the biggest things that as we watch the child grow, parents are bringing up things like they’re all over the place or they’re bouncing constantly. That so often leads to the conversation of, you know, were you like that as a kid? And do you have any diagnoses or take any medications on a regular basis? Where we could kind of tease that out a little bit because a lot of ADHD runs in families. And then it really depends more specifically on what flavor of ADHD we’re seeing, whether it’s the more hyperactive, which we usually see at the younger age, starting to kind of make itself known in those preschool and early elementary years, or if they’re more inattentive. And those kids will often make it through longer before it comes to attention, when we’re saying, okay, maybe this is actually what’s going on with your child that, you know, is bright but is really struggling with getting their teeth brushed and getting tasks done and all those different things. So one of the things that I really like about ADHD is that it looks very different for the child depending on a lot of different factors that come into play and what the parents have already figured out helps them to have more executive function, helps them to regulate more.

Debbie:
If we kind of zoom out and look at ADHD over maybe the past decade, you know, certainly in the adult space, like autism, we’ve seen, you know, the lost generation of all of ADHD women. And we’ve seen kind of a growing understanding, I think, of ADHD. And I still feel like it is one of the more maligned or most maligned of the neurodivergences. Like there’s still a lot of myths and a lot of stigma surrounding it. I’m just wondering, in the time that you’ve been really kind of exploring ADHD through the families you work with, have you seen a change in how it’s perceived in the world?

Dr. Phil Boucher:
Totally. I think that one of the things that you said there about like all of it’s a lot of moms that were not diagnosed in grade school, high school, you know, college, and realized in their thirties or forties this is what’s going on, then they’re looking at their child and be like, hey, those are the things that I faced as well. So I do think there’s a lot less stigma and there’s a lot more parents picking up on nuances. And I like to malign social media for all of the ills that it has caused for our society and continues to for both adults and for kids. But one of the things that I think it has helped make people aware of is kind of all of the different neurodivergences out there. One of the questions that I often ask, which I just asked yesterday of a mom who had come in with her child and was kind of suspicious of ADHD is what have you seen from, you know, being on your phone from time to time that makes you think he has ADHD? Or autism or this, you know, whatever it might be on your mind, like what are those things that you’ve realized could be indicators? And then let’s take those things and then one, figure out if that is really what we’re seeing here, or if that kind of that short Instagram reel or TikTok really kind of got the whole picture of the child. And two, does that make sense in the whole picture of the child for okay, yes, that aligns with ADHD or? Yeah, I mean a lot of kids do that. Like, you know, on social media, they make every little nuanced thing out to mean the whole picture. And oftentimes it’s us saying, well, yeah, a lot of kids when they’re young will flap their hands, but that doesn’t mean that all kids that flap their hands are autistic. So being able to work with families to tease those things out. And back to your original question after my long meandering here is that I think the stigma is less, and I think parents are more savvy about both picking it up. And wanting to get it addressed. So it’s not something where, like you said, the lost generation, where they’re dealing with this in their 20s, 30s, and beyond of now I understand my childhood and all the struggles that I had. They’re wanting to be proactive for their child and get the diagnosis, not so that they can medicate them and get them to sit still in class, but so that their child has a better understanding of themselves and their brain earlier than the parents experienced.

Debbie:
Yeah. Yeah. So I like that you, the way you talk about, you know, what a parent might learn through social media. It’s not like rejecting that, but it’s like, okay, this has brought something to your attention that we should explore. Let’s go deeper. And I really like that kind of using it, it could introduce some ideas and then you’re not rejecting that, but you’re saying, yeah, let’s look at this more closely and see if this actually fits. That’s really cool. So in terms of the way it shows up, I’d love to just, you know, if there are parents listening who have younger kids, I think there is that kind of stereotypical, like the disheveled, you know, kind of hyperactive little boy, right? Like that’s I think what comes to mind for a lot of us. But what are some indicators in addition to the, you talked about the parents’ own wiring, but what are some signs, especially with younger kids, that would indicate this looks like an ADHD kid to me.

Dr. Phil Boucher:
Right. So I think, you know, parents often ask when the child is two or three, I think they have ADHD. And I always say, guys, these are like typically three year olds have a short attention span. They bounce from thing to thing very quickly. And so I’m never saying, yeah, I think they have ADHD as a three year old. It’s really something that as they get closer to elementary school, that would be the earliest time where I would ever start to say, you know, I think you might meet the criteria for ADHD. Now that doesn’t mean we’re gonna start them on medications when they’re in preschool, because I think a lot of parents are wrapped up in if I have a diagnosis, I get medication, my kids sit still, that sort of thing. And they don’t want that, but they want to just better understand their child. Usually the hyperactivity is prevalent in that four, five, six area that’s outside of comparison to their peers. Yes, they love to run around and play, but they can also take a moment and have a little bit of focus time. And they can not blurt out answers right away. You know, if they’re asked something, they can take their turn. And if we’re really struggling with that, then that kind of raises at least a little bit of a flag. I think one of the misconceptions about ADHD is it’s all hyperactivity and inattention because those are the things when you fill out the forms, that’s what the bulk is asking about. But when I look at ADHD, the other two categories that are just as much of a thing are the emotional regulation or dysregulation and executive functioning. And so when we see the hyperactive child, I really, we know mostly what hyperactive children do because you can spot them from across the parking lot. But we often then will look at emotional regulation, meaning can they cope when something doesn’t go their way? Can they take turns? What do their meltdowns look like? Because all children melt down under some circumstances, but how do they compare to their peers? And then executive functioning. How are they able to get tasks done? Now I’m not going to give my five year old, you know, a three step instruction where they’re going to the garage and then they’re going to the attic and they’re going, like that’s not gonna go well. But can they do simple one step instructions most of the time without getting too distracted or off task? Can they, you know, plan to get their teeth brushed and their shoes on before school? And so when we look at ADHD at that young age, it’s often in comparison to their peers. Can they do these things that their typical peers would be able to do at least most of the time?

Debbie:
Yeah, that was a great description. And I am so happy you brought up emotional regulation because that is something that I think definitely, you know, when we were going through the evaluation process many, many years ago with my kiddo, that wasn’t really part of my understanding of what ADHD was. And I think it’s a huge piece that people don’t necessarily see. And it’s perhaps one of the most impactful, right, over the course of their life, that challenge with emotional regulation.

Dr. Phil Boucher:
For sure, because we can tamp down the hyperactivity. The hyperactivity, no matter what you do, you know, levels off as they reach puberty age and college age. We don’t see the same level of hyperactivity in a 15-year-old or a 25-year-old as we do in a five-year-old. Like those things, you know, simmer down over time. But the emotional regulation can really be stuck. And if we don’t recognize that, then we keep trying to parent them as if they are neurotypical, not realizing that it is their brain chemistry, their brain wiring that’s having an impact on their ability to cope with things that don’t go their way, to handle distress and disappointment and discomfort. And if we don’t realize that, then we parent them in a way that often leads to harsher punishments. And schools tend to approach them as the defiant child when in reality they’re just struggling to hold it together in a way that their peers are not.

Debbie:
Yeah. Okay, taking a deep breath there. Yes. So when you are working with a family who you suspect the child has ADHD, do you conduct the evaluations themselves? Do you refer out? What does that look like?

Dr. Phil Boucher:
So we typically do the evaluations ourselves, in part because it’s really hard to get like a neuropsychological test done. I mean, there’s long wait lists, and I think that pediatricians can accurately and confidently diagnose at least 90% of kids with ADHD. There are some where it’s subtle or there’s multiple things going on, and those are the perfect opportunity to pull a psychologist that can then go deeper on some of those things and tease out is this anxiety? Is this a degree of autism in here? Is there ADHD? Is there trauma? All of those sorts of things. But by and large, pediatricians are a great resource when it comes to diagnosing your child because you don’t have to wait 15 months to get in. It doesn’t have to cost thousands and thousands of dollars for an evaluation here in the US. When parents come in and they’re like, I think, you know, I’ve experienced enough, the teachers brought it up, I’ve seen these reels online, I think my child has ADHD. We kind of start with, well, let’s go back to the very beginning. And this is kind of my evaluation process, is go back to the very beginning. What was their birth like? What were their first years of life like? Because those things can have an impact on their brain wiring if they were preterm, if they had a lot of jaundice, if they had a number of health issues as a young infant, those things can predispose us to ADHD. What does the family history look like? Because that is, you know, if both parents have ADHD, then I’m gonna raise the likelihood of ADHD. If siblings have ADHD, same sort of thing. And then we really focus on what are the challenges that you’re facing. Because parents, when they come in with a child where they’re wondering if they have ADHD, have enough challenges, that that is kind of just where I start. Like, what are the hard parts of your day? Where are the struggles at school and at home? What does that look like? And then we kind of just let them unload. Here’s all the different challenges. We often excuse the child to go to the waiting room to, you know, read a book or play with the fish or color or something like that as they go through the challenges. Because we know kids with ADHD often have well, they have a ton of corrections. And then they also have self-confidence and rejection sensitivity. And hearing the laundry list of all the things that you’ve done in the past few months never feels good for anyone, let alone, you know, a young child that might have ADHD. As a complement to that, we really focus on, okay, what are we doing right now to help? And the things that I look at are sleep, like what’s their sleep like? Because oftentimes, and it’s not as much as Instagram or TikTok would make you think, getting their sleep doesn’t totally change their brain wiring, but it can play a major role in their hyperactivity, inattention, executive function, and emotional regulation. And so what does their sleep look like? Are they snoring? Are they restless? Is it tough to get them to go down to sleep? Are they up late? Are they tired during the day? Those are all areas that we kind of dive into and make sure that we have a good handle on their sleep and how that’s impacting things. And that’s one of the first areas that I really focus on before jumping into a huge evaluation process or, you know, starting medications is we’re gonna make sure our sleep is supporting our brain and our behaviors and connection and all those things. And then what is their diet like? Are they a picky eater? Do they eat a well-rounded, adventurous diet at least some of the time? Are they kind of in the middle where they’re kind of a typical American diet? And what role might that be playing? One of the things that parents often come in and say, like, I thought they might have ADHD. We took out dyes and they didn’t change at all. And I’d like that tracks, you know. Dyes, food dyes can make a small difference for a subset of children, but it’s not like social media would have you believe that we eliminated food dyes. And now they can focus and are, you know, up for a Nobel Prize and got a perfect score on their ACT. Like it’s not that much of a thing, but it’s often something that parents will try is like, well, let’s start here, start there, but I wouldn’t put all the eggs in that basket. And then have they worked with therapists or anyone like that in the past? Whether it’s an occupational therapist, whether it’s a speech therapist, whether it’s a behavioral therapist, finding out kind of what the big picture is of what they’ve done up until this point to try and get a handle on things. After we’ve kind of talked through all that, then we start with the plan of, well, let’s get some more data. And usually that looks like collecting more data from parents and from educators so that we have a bigger picture of what they’re like in a variety of settings. This time of year, when we’re, you know, recording this in August makes it a little bit challenging because it’s a brand new school year and teachers are just getting used to them. Everyone still has the wiggles. And so sometimes we’ll go back to the previous school year or we’ll take the information from the parent and be able to judge, I bet this is how school’s going because I trust that you’re kind of representing things. And we can do this even when we don’t have every single data piece in place. And so that’s kind of the start of our evaluation process.

Debbie:
Yeah, thank you for walking us through that. Super interesting. And, you know, as you were talking about sleep, we’ve covered sleep challenges on the show, you know, not just with ADHD, but with neurodivergence, you know, in general, as well as kind of circadian rhythm syndromes. And it’s such a complicated picture for a lot of our kids. And it made me wonder also, you know, that sleep can sometimes, as you said, like poor sleep habits can sometimes mimic some of the symptoms of ADHD, challenge with focus, or it might highlight what those challenges are. And I also was thinking, what about technology? So I don’t know what your thoughts are on that, but have you found, and I know it’s like correlation causation, like that’s not what I’m asking, but have you found that kids who spend more time on tech, that that can significantly ramp up ADHD symptoms or?

Dr. Phil Boucher:
No, I think like you said, poor sleep can, you know, amplify our ADHD signals that we’re seeing. And the same with too much screens. I think when they’re on their screens, and this is often a thing that parents tell me, and oftentimes they tell it as if like they could focus if they wanted, because they can play Minecraft for hours, but then when I ask them to unload the dishwasher, it you know takes them, you know, seventy-five minutes and seventeen different corrections to get them to do it. And so screens will give them the opportunity to really focus. And it’s not, you can’t extrapolate that then. Like if they can play Minecraft for three hours, then they should be able to practice piano for three hours because the screens are totally different when it comes to the way that they’re stimulating and all the dopamine release and everything along those lines. But kids that are on their screens more, especially late into the evening, have a tough time going to sleep. And kids that are on their screens more often will be very focused when they’re on their screens, and then they will be very dysregulated after screen time. The transition is a bear, the hours that follow are challenging. And so that is something that we always talk about and try and put boundaries in place really early in our conversation. Around here’s how we’re going to approach screens, knowing that your brain wiring may predispose you to having worse symptoms. We don’t have to do, you know, screen free, we don’t have to do a detox, but we are going to put some boundaries in place on the time of day, the location, and how much screen time compared to the other things like moving our body, getting outside when we’re able to, you know, having more real life connection rather than just living on our screens.

Debbie:
Okay, so when you are working with a family and you’ve kind of determined like, okay, this child has ADHD, this is what’s going on. I do want to talk about medication because I know that’s something a lot of parents have questions about. I know that in our family, we were very open to anything and we really let our kiddo kind of, you know, be involved in all of those conversations and we decided, you know, let’s explore lots of other things that we can do before we go down that road. But I’m curious, yeah, how do you kind of approach that? Where do you start with families in terms of changes you can make that could support a kid’s ADHD symptoms?

Dr. Phil Boucher:
This is my favorite thing to get into, and this is what we spend most of our time getting into. Actually, the medications are relatively easy compared to all of the other things that we do on the front end before getting to the point of adding on medications. And so what we typically do is at the first evaluation, I will usually check a little bit of lab work too. They’re again on in the social media makes it seem like I gave my kids some iron and they, you know, are writing their first novel. And it’s just not that powerful. But if certain minerals and vitamins are out of whack for our child, it can be difficult to make as much progress implementing everything else. So I will typically look at their iron level, their omega-3 level, their vitamin D level, their copper, and their zinc. And those are really the only things that have any evidence behind them as being helpful and making sure that we get those lined up as we’re kind of putting all these different things into place. If we don’t have enough iron available, no matter even how much medication we give our child, if their brain doesn’t have iron available to convert amino acids into dopamine, then we’re not gonna make as much progress. So that’s one area that we always focus on is like, let’s make sure our diet and nutrition are helping to improve things rather than making it harder to make progress. And then when it comes to kind of, okay, here guys, yes, he has ADHD. Here’s where we’re gonna start. We’re gonna focus on sleep and we’re gonna focus on getting restful, restorative sleep. And here’s the things we’re going to put in place. We’re going to turn screens off at 7:30 p.m. at the latest. We’re going to have a good consistent wind down routine, even if that means that we’re not going to be able to do the late night baseball practice or other thing on the schedule, because we know that, you know, having rest is much more important than the extra practices and things along those lines. We’re going to make sure that we don’t have screens or a lot of light in our bedroom so that we can get a good night’s rest. Those are kind of the sleep’s starting places. Diet and nutrition. Rather than like you have to put this into their diet or get this out of their diet, I focus on let’s make sure they’re getting enough protein in their diet, especially first thing in the morning. So one of the questions that I always ask the child, because they’re, you know, honest to a fault, what do you eat for breakfast every day? And it’s usually, you know, cereal or muffins or something along those lines. And I’m like, cereal is fine if we can add a bunch more protein. So, what sort of protein things could we add? My favorite snack, I’ve gotten into the bad habit of this, it’s not a bad habit, but I don’t need it, is a dollop of peanut butter on the side of my bowl of raisin bran crunch. It is delicious. It adds a bunch of protein. If kids are kind of in that cereal mindset, let’s add some protein to their cereal. Let’s get them some eggs or some bacon or some sausage or something like that. Protein is what helps keep our blood sugar stable during our day so that we are able to focus because our brain isn’t all over the place with our blood sugar going up and down because we had a huge glucose intake as we started our day and then it crashes at 10 o’clock and we’re so distracted because we’re hungry and our mind is all over the place. Protein also helps to fuel dopamine synthesis and all those other things that are important for focus. And then after school we’re gonna make sure that we get hydrated and we have some downtime. And we get more protein so that we have those energy reserves as we go into after school, evening, and bedtime. And so those are some of the first places when it comes to like the biology side of things that we put into place. I also spend a lot of time talking with parents about what are some things that we can do to make the difficult moments in your day easier. With kids with ADHD, mornings are tough, after school can be tough, and getting to bed can be tough. And so those are kind of places where I will talk through with them some specific interventions that are really tailored to their family. But one of the big things in the morning is the constant reminders to get teeth brushed, to get dressed, to get breakfast eaten, to get your shoes on, and those sorts of things. And so we talk through, okay, we need to put some visual reminders in that relieve you as the parent from having to be the one that is constantly nagging and reminding them constantly. They can read or they can look at pictures if they’re younger and they know here’s what I need to do before I leave my room in the morning. And one of the things that parents often get just a little bit off on is they’ll make a master checklist and put it on the fridge. And what I tell parents, I told a dad this yesterday and he was like, yeah, I need to do this for myself, is they’ll put the master checklist on the fridge when we’re not brushing our teeth and getting dressed at the fridge. We need to put the checklist where the point of performance is for children with ADHD because it is out of sight, out of mind if it is not there. And so we might have three checklists. We might have a getting ready checklist that goes in our bedroom so that when we get up, we get dressed, we brush our teeth, we, you know, make our bed or whatever kind of things we do first thing in the morning. And then we might have one on the fridge that’s related to eating breakfast, you know, drinking some water, whatever it might be. And then we might have one wherever our backpack and shoes are. And when we’ve done those at those places, it makes a big difference of actually having to do that. And then as the parent, I can rest assured that they’re seeing those different checklists. And I can ask about the checklist rather than did you brush your teeth? Did you get your morning checklist done? Which includes these four different, you know, sub-tasks under there. And just simple things like that as a start to the day. And then in the after school period of time, are we giving them some wind down time, some movement time, because they’ve been sitting still most of the day and they need to move their bodies. And in the US, we do not get enough recess. And so they’re sitting at their desks constantly. They need time to move their bodies. They need free play. We can’t just go, okay, I’m going to sign them up for all these activities and then just run to an activity where again they’re sitting there. They might be playing baseball or soccer or piano, but they’re performing. We need to have the time where they don’t have to perform, where they can just have a little bit of downtime to unwind, recharge, hydrate, and refuel. And if we’re not doing that, then we need to cut back on activities so that at least several days after school, we have that dedicated time to just wind down, connect, recharge. And then, like we talked about already, kind of the bedtime window routine so that again, we’re able to prepare for sleep. And so those are kind of the first line things that we make sure and put in place. Get their nutrition, get their sleep, get their movement. Those sorts of things make a big difference for families when it comes to the initial steps for managing and helping their child with ADHD to thrive.

Debbie:
Yeah. Super interesting. And I, you know, just a quick question on the lab work, because that, you know, we’ve talked with nutritionists on the show before. That’s a road we went down at one point. And zinc was something that came up as like a really, and I was like, but you know, for you mentioned iron, omega-3, vitamin D, copper, and zinc. Are those things that would need to be individually supplemented? Or is there like a multivitamin that like handles all of those?

Dr. Phil Boucher:
Right. I don’t do multivitamins much for ADHD because most kids either have a specific nutritional deficit or not. And I find that when we check the labs, both the child and definitely the parents are more motivated to correct that when you can see, my child’s ferritin is low and they’re so restless in their sleep, like their blankets and pillows are all over the place, their hair is always way more messed up in the morning than the average kid. If we give them iron, I noticed that their sleep was better, they’re less restless. And so when we can put those specific nutritional deficiencies in focus, then parents are more likely to continue because they actually see results rather than just take a multivitamin. It has kind of some of those different things. And most of the multivitamins out there don’t have enough if you’re deficient to supplement, like zinc in particular, none of the multivitamins, or if your child has a really low zinc level and zinc definitely plays a role in focus and attention. If their zinc level is low, just taking a multivitamin with a little bit of zinc isn’t going to be enough. And we’re gonna want to check it, we’re gonna correct it, see what we notice symptom wise, and then check it again to see if we’ve made some progress in repleting their low zinc level.

Debbie:
Yeah. Okay. Super, super helpful.

Dr. Phil Boucher:
It would be nice though if there was something like it’s, it’s just, I often send like here’s the three things that they need to take. They need to take iron, they need to take zinc, and they need to take omega threes. Here’s the three different ones. It makes for a few gummies or a few pills for the child to take, but in the grand scheme of things, most kids don’t mind and are able to do it and parents are kind of motivated to do it because they know that there’s something that’s contributing to their child’s struggles.

Debbie:
Yeah. So, all right. So I want to pivot just for a few minutes to talk about medication. And I want to approach it through the lens of what I heard. I don’t know if this is still the case, but you know, when my kiddo was younger, I knew of so many families for whom the school was the one pressuring the family. Like you need to get your kid on ADHD meds because it’s a management issue, they’re moving, they can’t focus, they’re disruptive, all of those things. And I always had such a knee-jerk reaction, like the school should not be dictating that your child is on meds. And especially if a parent has like a really strong, you know, it’s something some parents really grapple with and they have to really explore it to make sure this feels right for them. So I’m using that as an entry point. And I’d love to know your thoughts on meds and how they can be kind of folded into other interventions.

Dr. Phil Boucher:
I think medications for a lot of children with ADHD can be life changing. And so I don’t think that it’s something that we shouldn’t be a hard no. And it also shouldn’t be the first thing that we turn to when we make the diagnosis. And it does really bother me too when schools kind of pressure parents, like, hey, have you talked to your doctor about this? Have you talked to your doctor about this? The hidden message under there is like, when are they gonna get started on their medication? And so I always push back. I had a really interesting family about a year ago who had come in and their child had kind of been referred in by school. And I wrote a letter and I used AI to help me kind of generate like the text of the letter of here’s the things we should be doing in school to help the child to, you know, be able to focus, be able to get work done without being disruptive to others. And it, you know, talked about kind of the typical things that we talked about: moving their body more, being a helper, preferred seating, all those sort of things that we know make a difference for children with ADHD. And then I didn’t hear from them for a few months. And usually I would hear from them within a month or so of like, hey, school asked what we’re doing. And I reached out to the family. We do a lot of texting in our practice. So I was just like, hey, how’s things going? How’s school been? She’s doing great. Like, what happened? Did you guys go see somebody else? No, your letter was all we needed. Like, sometimes that’s all it takes. And it felt really good to be like, I made this letter. AI helped me write it, and that’s all it took for the school to actually take it seriously enough, which is also nice that that happened, but also unfortunate that like it took me writing a letter with basic, very basic like classroom management strategies for children with ADHD for them to get a handle on it. And she’s doing great now and she’s thriving in school and we haven’t done anything else for her except for one letter, one time that was like, hey, here’s what she’s facing and here’s how you can help. And that’s all it’s taken. Now that might not always be the case. At some point, it might be the case that we’ve maximized those sorts of things. We’re getting good sleep. We’re still struggling with emotional dysregulation, inattention, hyperactivity, those sorts of things. And then that becomes a time where, hey, you know, I want your child to enjoy learning. I want them to feel confident in themselves. I want them to be able to handle life’s ups and downs. And this is something that we need to put practices into place. We’ve optimized the other areas. And so I think that there’s a good reason that we should try a medication to help their brain wiring to support their ongoing skill development. And I always focus on how we can use the medication to help with skill building, with emotional regulation, with friendships and connection, rather than we’re gonna give you medication so your child will sit still and not bother their classmates or the teacher. And when parents kind of hear that and see that and see that focus, then they’re on board with trying a medication much more likely than if they feel pressured to do it by school, or if, you know, their sister-in-law is telling them, no, don’t do this, like it’ll take away their personality or turn them into a zombie. When they see we’ve put the effort in sleep, we put the effort in nutrition, we’re getting them movement, we’re doing all of these different things, we put all these things into place. And now the next step is medication. One of the things that we often, I compare it to is asthma. If your child has asthma, you’re gonna get them on allergy medicine. You’re gonna sleep with the windows closed. You’re going to make sure and do those allergy measures that you need to, you know, avoid an asthma exacerbation. But at some point, we might say, hey, we need to use one of those inhalers to get a better handle on your child’s asthma so that they can breathe easily. And in the same way, we’ll use medications to help them to think clearly, to focus, to regulate. And we wouldn’t say breathe harder to an asthmatic that’s in the midst of an asthmatic flare. So we shouldn’t say to a child, especially when we’ve put all the work in otherwise, that you know, you should just think harder or just try harder when we have really good interventions that are available to help that can be life changing.

Debbie:
Yeah. So one of the things you said that medication can be truly life-changing. When our family ultimately, including my child, we decided, okay, in high school, let’s explore this and see if this is beneficial for you. What I heard from other parents is like it should be, it shouldn’t be like, I think it’s working. It should be a significant difference. And I’m just wondering, you know, if you could speak to that and then how do you kind of begin that process of exploring medication with a child?

Dr. Phil Boucher:
Right. So I always tell parents, like, whichever medication we’re gonna use, you’re gonna notice a substantial difference in a month if we’re on the right medication at the right dose. And if it’s so subtle or you haven’t noticed anything, then we’re either on the wrong medication or we’re not at a dose because the medications that are out there do work. And it’s not just, yeah, the teacher said he just sits still and is quiet all day. It’s that they’re more regulated, they’re completing tasks more easily, they’re gaining that self confidence of like, I can do things without constantly being corrected. And so when I think about let’s add a medication on, by and large, most children with ADHD just across the board do well with stimulants. So stimulants are things like methylphenidate, which the one that most parents are familiar with from the 90s is Ritalin. There’s a lot more than just Ritalin nowadays, or with Adderall. And so those are kind of our typical two big classes of stimulants. Is the amphetamine salts, which is Adderall, or the methylphenidate, which is like Ritalin and Focalin and Concerta and things along those lines. There is another class of medications called alpha agonists. And I will use those specifically, mostly in hyperactive and impulsive younger kids, because those can help to insert a little bit of a break between thought of something, gotta do it. And so for those specific children, sometimes I will explore things like guanfacine or clonidine first. But by and large, most children respond well to stimulants. And so if you’re just kind of across the board looking at children and ADHD medications, most children are on stimulants. Most stimulants work pretty well. We usually start with a low dose. We take it first thing in the morning after we get up or have had breakfast. And then my goal is that they take one medicine per day and don’t have to do a bunch of other medications on top of that. So usually with the medications that we have now, when it comes to stimulants, we can take a dose in the morning and it lasts till that after school period of time. And then it starts to wear off in its effectiveness into the evening. And that’s kind of where we typically will start with medications and then kind of adjust them as we need depending on any side effects that they experience or if they’re working or not.

Debbie:
In terms of side effects, like whether or not it’s working, have you found that there are some people with ADHD for whom meds just simply aren’t effective or the negative side effects kind of outweigh any benefits they might have?

Dr. Phil Boucher:
Yeah, so some of the negative side effects that we will see in some kids, every kid that’s on a stimulant that’s at a therapeutic dose will have less of an appetite at lunch. And that’s usually not a big enough deal to say we can’t keep doing the medication. We just anticipate that they’re gonna eat a big breakfast and then they’re gonna be hungry after school and into the evening. But the stimulants typically suppress the appetite. So at lunchtime, you can pack a smaller lunch for them. You can tell the teacher, hey, they probably won’t eat that much lunch. We’re getting them fed on the other sides. In a good way and they’re growing fine and we don’t have any concerns there. If the medication is too high of a dose, sometimes you will see kids that are a little too locked in and they’re kind of not zombie-esque, but they’ll be really locked in on things. And we don’t want that. We want, I always tell parents like they should laugh at the same jokes, they should have the same energy, they should have the same personality and enjoyment of life that they would, whether they’re on medication or not. And sometimes if we’re taking the medication too late in the morning or it’s too strong, it will make it harder for them to sleep. And so that’s another thing that we always watch for too. Usually if we’re taking it when around the time that they get up in the morning and it’s wearing off before or around dinner time, that their sleep is not impacted in a negative way by it. Now, if they have anxiety as well, sometimes stimulants will worsen anxiety. So that’s something we watch for closely and talk about like, are they kind of a, you know, a straightforward ADHD, or is there the combination of both ADHD and some anxiety? And then we’re gonna use that as we kind of decide on medications and then watch that closely of is their anxiety a lot worse? Are they experiencing a lot more panic attacks or seeming more anxious while they’re on the medication? Well, then we’re gonna switch to a different one. There’s actually a couple of new classes of medications that I won’t get into today, but that can act both on the dopamine side of things, which is what we mostly think about when it comes to stimulants. But also on the serotonin side of things, which is one thing that we think about with anxiety and that kind of area. And so there are some medications that can now kind of address both of those. And so that’s kind of a cool new emerging area of non-stimulant medications, is some that can target both the ADHD side and the anxiety side.

Debbie:
Yeah, I feel like I just read something about that, that there are some combined with SSRIs so that is exciting. Cause we know, especially with neurodivergent kids, and I will just say like a lot of my listeners have kids who have multiple things going on, AuDHD, anxiety, depression, like there’s a lot of moving pieces. So that is exciting to think of not adding additional meds, but maybe there could be, you know, fewer meds that could cover or, you know, manage multiple symptoms.

Dr. Phil Boucher:
Yeah, I’ve had a lot of kids that have done really well with one of the medications that is both dopamine and serotonergic. And especially if they’re kind of the anxious ADHD type that has a lot of issues with emotional dysregulation, that those medicines can be really helpful for them. Cause you put them on a stimulant and they’ll sit still, but they’re super anxious. And you put them on a SSRI and they’re still having a lot of trouble with focus. But these combination medications, or they’re not combination medications, it’s one medication, but it acts on both receptors, can be really helpful when it comes to the emotionally dysregulated ADHD anxiety autism kind of phenotype.

Debbie:
Yeah. Yeah. Excellent. Okay. All right. We could just continue talking, but this has been super insightful. I really just appreciate, I feel like we covered so many different aspects of this experience. And again, it’s a conversation we haven’t really had in a very long time, especially for listeners with younger kids who are just kind of navigating this and realizing, this is what’s going on and how can we move forward? So is there anything that we didn’t touch upon that you think would be like an important takeaway or something you want to leave my listeners with.

Dr. Phil Boucher:
I think in the big picture, a lot of parents feel like they did something wrong because of the challenges that their child is presenting with. And as much as I like teaching parenting approaches and different ways to, you know, I like to teach authoritative parenting. I think a lot of times parents have been misled that like their big feeling kid or whatever the term is is their fault or that they should possess the ability to handle it. When we look at ADHD as a biological difference, we can release some of that guilt and tension that we have because we realize, like asthma, these are not all things that I have the power to control over, but there are a lot of different evidence-based things that we can put in place that will help our child. And so I always just encourage parents to not beat themselves up about their child and where they’re at right now, knowing that there’s a lot of things that we can put in place to help them to move forward and to get to a place of thriving.

Debbie:
Yeah. I love that. And obviously like y’all listening to this, you’re showing up, you’re doing this for your kids anyway. So I really appreciate that. So okay, I know you’ve got a Substack, Dear Parents, you have a thriving social media presence, and I’ll have an extensive show notes page, but where do you most like to engage with listeners?

Dr. Phil Boucher:
I really like my Substack. I think that would be the main place to send people. Yes, I do lots on Instagram, but I feel like the conversations are even deeper on Substack and it’s a little bit more of an intentional community rather than the really easy to scroll past social media. So Substack would be the main place to find me.

Debbie:
Okay. All right. So listeners, I will have a show notes page with all the resources we talked about, as well as some other conversations I’ve had about ADHD, if you want to dive deeper. And Phil, thank you. This has been super interesting. And like I said, we could have continued, but then I was going to start getting into let me ask you some personal advice. So we’re not going to do that, but thank you so much for this conversation.

Dr. Phil Boucher:
Thank you.