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Pediatric neurologist Paige Kalika discusses her article, “Why ADHD kids struggle and how we can truly help,” sharing insights from her perspective as a pediatric neurologist and parent of a child with ADHD. She outlines compassionate ways to talk to children about ADHD, starting by validating their efforts (“Are you trying harder?”) and explaining that ADHD affects focus, not intelligence or worth. Paige emphasizes the importance of diagnosis as a tool to counteract negative self-labels (“lazy,” “bad”) that children internalize, reframing ADHD as having a brain that works differently, using analogies like the “Ferrari brain with bicycle brakes.” The conversation addresses common parental concerns about medication, countering the “natural vs. unnatural” debate and explaining medication’s role in addressing neurotransmitter differences, comparing it to “glasses for the brain” or a “bag with a hole” for scattered thoughts (“marbles”). Paige offers practical advice on finding the right medication, stressing that the goal is to empower “neurospicy” children to understand their unique brains and thrive.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Paige Kalika. She’s a pediatric neurologist. Today’s KevinMD article is “Why ADHD kids struggle and how we can truly help.” Paige, welcome back to the show.

Paige Kalika: Thank you so much. It’s a pleasure to be here.

Kevin Pho: All right, so tell us what your latest article is about.

Paige Kalika: Well, just like it says in the title: We’re talking about ADHD kids and how we can help, and this is a topic that’s very near and dear to my heart because these are such good kids and they tend to be very misunderstood kids because either we have the classic ADHD hyper kids—they’re troublemakers, they’re bouncing off the wall. They’re too much. They’re too much all the time, and that’s a problem. Or it’s the opposite. They’re the daydreamers, the space cadets. They’re lost in space. And oh, if you could just—and for both of them—if you could just activate your potential, you could do so much. So these kids are constantly being told, try harder, try harder.

The thing that I always ask the kids in front of their parents when I see them in the office is: Are you trying harder? And every kid says yes. They’re all trying harder and they’re all frustrated because nobody gets it. And these kids are hearing this message from the parent, the people who love them the most. Parents, teachers, family members. Tutors, therapists: Try harder. You’re not good enough. Even though you’re not using those exact words. That’s what they’re hearing. They’re hearing, well, I’m trying harder. There’s something wrong with me. I’m dumb, I’m lazy, I’m a problem. And that’s what they internalize.

So I just think it’s so important to get these kids early to say: No, there’s nothing wrong with you. You have an excellent brain. It’s a wonderful brain. Your brain works differently though. And if we can understand how your brain works, we can help you understand how to use this awesome brain of yours to be who it is you’re going to be.

Kevin Pho: So expand on that in terms of the effect that scenario has on the ADHD children. So from the vast majority of kids that you talk to and you ask that question, are you trying harder and being told, like you said, from the whole cadre of loved ones, that they may not be trying hard enough. Like how does that affect them, not just at that moment, but moving forward as well?

Paige Kalika: That’s the whole point. It affects them tremendously. These kids, and we see this in the studies, I always tell my families my job is evidence-based medicine. So when you come to me, we’re going to talk about evidence, what the evidence shows is going on with these kids now and in the future. And what we see is these kids really feel this sensation of not being enough, that they’re not good. And this starts early. You can sit down and ask any kindergartener or first grader, “So, who’s the smart kid in your class? Who’s the funny kid?” They’ll tell you. “Who’s the bad kid? Who does the teacher need to keep talking to?” They’ll tell you that too. They know, and if they’re the bad kid, they know and they internalize that, and it is so hard to shake that feeling. You know, after years of being externally and internally labeled as the bad kid, the troublemaker, the daydreamer. This follows them, and these kids turn up in my office at five years, six years, 10 years, 15 years, feeling inadequate, feeling self-conscious, feeling anxious.

This is not the only reason, but one of the reasons these kids tend to have a lot of overlap with anxiety, depression, other mental health conditions over time, because they’ve grown up internalizing this message that they hear from all of these loved, trusted adults. You’re not trying hard enough, you’re lazy. And they think it’s true and it’s really hard to shake them out of that. You know, you can say, “No, you’re good,” but, you know, how can an hour in the office with me compete against all these years of hearing this from your teachers and parents?

Kevin Pho: So what’s the answer? Let’s say we identify kids who are prone or diagnosed with ADHD at an early age. So you as a pediatric neurologist, short of wholesale societal changes, like what can you do if you identify these children at an early age?

Paige Kalika: Well, unfortunately, wholesale societal changes seem to be coming, but in the wrong direction. So the important thing is what you said. Early diagnosis, picking up these kids early before they’ve had a chance to internalize these very, you know, bothersome, troublesome internal messages that they’re not enough, to say: No, you’re good, you’re strong, you’re smart. But what you need to know is that your brain works a little bit differently. What works for other kids may not work well for you, and that’s OK.

Unfortunately, school tends to be kind of a one-size-fits-all phenomenon, unless we as parents, teachers, doctors, therapists, go in and make it different with an IEP, Individualized Educational Plan, or a 504 plan to get the right kind of accommodations. But that’s what these kids need. We need to say: OK, what do you need to succeed? Sometimes it’s just changing the environment. It’s saying: OK, oh, you’re distracted by everyone around you. OK, here, let’s sit you at the front. Oh. Do you need more time for your tests? OK, we can put that in the plan. Do you need a quieter environment? That can be another big one. So identifying what they need really can help put them on the pathway to success, but also empowering them.

To advocate for themselves to say: I need more time. I need a quieter environment. Because sometimes we’ll have these accommodations written into their 504 plan or IEPs which are legal documents with the school saying these children must be accommodated, but for whatever reason they’re not getting them. Sometimes it’s because the school is being obstructionist, but often it’s because the teacher’s expecting the student to speak up and say, “Hey, do you remember I need this?” And that doesn’t always happen.

Some kids are mature and, you know, confident enough to speak up, but others aren’t. I don’t know that I would’ve been confident enough to speak up when I was, you know, in elementary or middle school or high school. Probably not. I think I would’ve just suffered and gone with it, which is why I try to tell kids how to advocate for themselves, but also to tell their parents that these are still kids and we need to be their voices sometimes. So that’s the first step. I tell the parents, we have to make sure that the school is on our side. What can we do at school to make sure that the environment is conducive to learning? And this follows through to at home. What can we do at home?

Some kids with ADHD really need quiet, you know, a lot of structure to get their work done. You know, they can’t have their siblings running around in the background screaming and watching TV. Other times, there are some kids who actually need that level of background noise. They need to go from one thing to the next and we need to figure out what they need. It’s again, not one size fits all.

So that’s the first step, making sure that, one, we identify what’s going on, and two, trying to fix as much of the environment as we can to allow these kids to grow and flourish. It’s like saying: OK, we have a garden full of roses, but this one is an orchid. What does this orchid need to grow that, you know, they’re not getting, that’s not the same as the roses? So you have to figure out what kind of flower you have.

Kevin Pho: Well, those who aren’t familiar, tell us more about what an IEP or—was it the 504 plan? What a 504 plan is.

Paige Kalika: Well, these are pretty much… This goes back to my previous song about the language of medicine. This is very much the language of pediatrics and especially pediatric neurology. So these are plans put into place through the public school system. They’re legal documents putting down exactly what kind of accommodations children with specific needs or disabilities should have provided to them in order to make sure that they are learning in the least restrictive environment. That’s the term that you’ll hear thrown around a lot: least restrictive learning environment, which is what keeps, you know, kids with maybe mild behavior concerns from being thrown in a self-contained classroom from the mainstream classroom, because that’s a very restricted environment.

I absolutely have patients who need that. When we say “self-contained classroom,” that may sound very bad, but no, really what it means is that they’re in a small class with a much lower student-to-teacher ratio. Usually there are additional teachers, additional support, and for some kids, this is amazing. They need that. For other kids, maybe it’s too much. No, these are kids who need to be in the mainstream class. The ones we think of as regular, normal classes where they’re, you know, in the regular classroom setting with a regular teacher. But getting additional help. So what these plans do is delineate what these kids need.

They tend to come in two varieties. One is a 504 plan. This is kind of like the first step. And the next one is the IEP, Individualized Educational Plan, which tends to be a little more intensive. The way I learned the difference between them is that a 504 plan can set accommodations, but an IEP also sets goals. So let’s say we just want to have extended testing time. We want fewer distractions and preferential seating, you know, in the classroom setting. A lot of times we can do that with just a 504 plan, but if we have a child who needs that, plus they also need speech therapy or occupational therapy. Or if they need to have time in the ESE class where they get more one-on-one support for that, you might want the IEP. Because that’s going to put the goals into place.

For both of these, the schools will set up a meeting with the parents, the teacher, the ESE specialists, any therapists or specialists involved with the school who can provide, you know, additional support. And you sit down and you hammer out a plan. Now, for the most part, the plan itself is pretty boilerplate. The wording is very similar. It’s just figuring out which specific interventions and accommodations you’re going to include for each student. But these are very important because we’ve seen that having these kinds of accommodations is very important to helping these kids flourish.

And I said before, this is a legal document. So this becomes very, very important when our kids do standardized testing. Now, regardless of how you feel about standardized testing, this is very, very important to the school system. And whereas your teacher may be nice and let you have, you know, extra time to finish the test and to sit off in the corner to do your tests just for normal tests, when it comes time for standardized test season. Things are very regulated and unless you have a 504 plan or an IEP, you cannot have extra time. You cannot sit in a different area. You cannot have any accommodations unless it is in your plan. So if we want kids to be able to perform to their potential on these standardized tests, which are very, very important to the school, you want to make sure that they have the best chance, and that means that we have to make sure that they have these legal protections in the form of these standardized documents.

Kevin Pho: So you mentioned the importance of course, of the environment. So it sounds like educating the parents and extended families around these children is just as important, right?

Paige Kalika: Oh, so much. Because, one, these parents can be very, very frustrated. You can love your child more than anything in the world and still want to scream when you’ve been doing homework with them for three hours at night. And I can speak from experience. It is very frustrating and despite what I’m saying here, I have to, you know, stop myself from saying, try harder. I know she’s trying harder, but it’s 10 o’clock at night and we need to do the work. It’s very hard. So yes, the parents need and deserve a lot of support because this isn’t easy for anyone. Sometimes you have to tell the parents. He’s not doing it to you, he’s just doing it. This is how his brain works. He’s not bad, but we have to remember that he’s a kid and he’s doing his best right now.

So there’s a lot of education that we have to give the parents and a lot of support. And also we have to remember that ADHD is very strongly heritable. So I tell my families, I learned a great saying when I moved down to Florida: You don’t get apples from a mango tree. So you start shaking the family tree. You see who falls out. A big part of my ADHD evaluation of the first visit, you know, I’m taking history, I’m learning more about the kids. It’s more than… you know, there are a lot of reasons someone can be distracted and hyper, so you want to know more about what’s going on, but you also want to know about the parents. So I always say, “Who do they take after? Who are they like?” And almost every single family will have at least one person. “Oh, he’s just like me.” “Oh, he’s like my husband.” “Well, my brother…” “Well, my father…” There’s always someone in the family. And the funny thing is if you have enough people in the family like that, that’s your normal. That’s normal for you. You’re like, “Oh, but everyone’s like this. This isn’t a problem.” Or “Yeah, we’re all just dumb like that.” No, you’re not just dumb like that. You’re just all wired differently and you need to remember that and we need to say: OK, well, what’s going to work for your kid and what can also work for you?

I have so many parents who at the first visit with me, they say, “Well, I was never diagnosed. But…” I’m like, “Uh huh,” and a fair amount of them over time say, “You’ll never believe it. I went to go see the doctor and I have a diagnosis now.” I’m like, “Yeah, I know, I know.” And it’s actually very empowering for them because these parents heard the same thing that their kids are hearing now: You’re not enough, you’re not trying hard, you’re lazy, you’re not motivated. And to be told, you know, even 10, 20, 30 years later. No, actually, you’re not lazy, you’re not bad. Your brain works differently and you’ve got a great brain. Here are some ways to help you learn. Here are things that can help you succeed, and it’s a relief. It’s a relief to know that you know you’re not bad. They aren’t, they’re good parents and they’re trying their best even when things are rough, because even parenting a neurotypical child is, you know, not always easy, but when you got a neurospicy kid, that’s hard. And when you’re a neurospicy person yourself, you know, you can clash.

So, it’s really important to tell the parents and also tell the parents, talk to your parents. Talk to the family members. You know, you want to reinforce the messages that you’re sending your kids and everyone around you that, yeah, your brain works differently and that’s OK. We’re going to figure out how we’re going to help, what’s going to help this, you know, awesome brain of yours work better.

The example I tell the kids that they seem to really like is you have a Ferrari brain with bicycle brakes. So a Ferrari is an awesome car, expensive car. It’s a race car. So you’ve got this awesome fast brain. But it’s got bicycle brakes so the brakes don’t work so well. So, OK, how are we going to learn to drive this awesome Ferrari brain of yours? And part of it is saying: OK, we work on the environment, we make sure we have the right accommodations, we have the right support. And then sometimes we have to say: Well, what else does this Ferrari brain need?

And another thing you’ll hear me tell my families all the time is, you know, if you can’t make your own neurotransmitters, store-bought is OK. We know that ADHD brains are wired differently. And when I say wired differently as a neurologist, I really mean that a lot of it comes down to how the brain is functioning on this chemical level. We know that their neurotransmitters, these chemical messengers in the brain work a little differently. And that’s what a lot of the medications we use for ADHD target now.

Are the medications perfect? I wish they were perfect. It’s not a one-size-fits-all deal. I tell parents it’s like going shoe shopping. You may know that you’re a size eight, but not every size eight is going to fit you. You gotta try ’em on. “This one’s too tight.” “This one pinches.” “This one you had to break it in.” “This one? Perfect right out of the box.” We want perfect right out of the box, but we’re not always going to get it.

And also, everyone looks at me when we talk about medication because no one likes medicine. We don’t like the idea of medicine. We feel like bad parents for even considering medicating our child. And I’m like, “OK, this is like glasses.” If your child is nearsighted, and I’ll do this in front of the parents because I’m very nearsighted. I will take off my glasses. I’m like, “I can’t see.” I’m like, “Try harder,” and I will lean in real close and pretty much have my nose touching the monitor because that’s as close as I need to be. I’m really, really nearsighted and I’m like, “This is me trying harder.” Now. Can I get by like this? Yes. 200 years ago, I wouldn’t have had a choice. So, can I survive? Yes. Can I thrive? Not really. I’m working harder than most other people. I’m going to give myself a headache by the end of the day. And trust me, you do not want to see me drive without my glasses. It’s not going to happen. It’s a bad idea. I put on my glasses, oh, look at me. I’m 20/20. It doesn’t mean that every set of glasses is going to work, that my prescription is going to be right. You gotta give it a chance to settle, and then if it doesn’t work, you go back and say, “Hey Doc, this prescription doesn’t work for me. You gotta fix it.” So we work with it.

And again, just like glasses, we don’t always need to wear our glasses. There are some people who only need glasses for reading. You only need glasses for driving. And there are people who, they need their glasses, but maybe they’re a little vain, they don’t want to bother and they get by without their glasses. And then there’s me, I wear my glasses because I need my glasses because I need to see. So that’s how I describe it to families. And sometimes that seems to help. Other times families are like, “No, no, no, we’re not medicine people.” It’s amazing. I’ve been practicing over 14 years now, and I’ve never met any “medicine people.”

But everyone is “help my children” people. We are all “how can I help my kids?” people. So the other thing I’ll tell them is: OK, we all like the idea of natural. Natural feels good, but natural doesn’t mean good. You know, poison ivy, lead and bears are natural. That doesn’t mean we want them to happen to us. On the other hand, air conditioning, we live in South Florida, and no one wants to live down here without our AC. So AC is not natural, but most of us feel that it is good for us. So I’ll tell the parents, look, as a doctor, natural versus unnatural is not a helpful category for me. But as parents, I know that this is for you, so, OK, we’ll talk about our natural things first. What’s natural? Helping the environment. You know, making sure that the school is on our side, giving the kids the right support. Do they need tutoring? Do they need therapy? What else can we do to help support them?

And after that, if we still need help and most of the time we still need help, then we say: OK, let’s talk about medicine. I always say, I am not going to sneak into your house at six in the morning and sneak pills into your kids because that’s creepy and illegal. And if I do it for you, I have to do it for everyone. But this is an option we have, and let’s talk about it if we need it. And usually after we’ve tried everything natural, the families will be more conducive to listening because these are good parents who love their kids. They’re trying to figure out the best way to parent these kids who don’t quite fit the usual template. And you know, I tell the parents, look, we’ll try different things until we figure out what helps the most.

Kevin Pho: We’re talking to Paige Kalika. She’s a pediatric neurologist, and today’s KevinMD article is “Why ADHD kids struggle and how we can truly help.” Paige, let’s end with some take home messages that you want to leave with the KevinMD audience.

Paige Kalika: I know I’ve said it before, but I’ll say it one more time because it’s so important. These are good kids. Make sure they hear that message from you because they’re getting bombarded with negative messages all day long, and that turns into negative self-talk. So make sure that they hear that they’re good, they’re smart, they’re strong, and that their quirky brain chemistry is a strength, not just a weakness that just like everyone else, they’re going to learn how to use their brains and they’re going to do amazing things in life.

And as parents, teachers, doctors, therapists, anyone involved with these kids, you are there to support them, to figure out how to help them to grow into the amazing, happy, healthy, independent people that they’re going to be.

Kevin Pho: Paige, as always, thank you so much for sharing your perspective and insight and thanks again for coming back on the show.

Paige Kalika: Thank you. It’s a pleasure.