- [Dr. Borenstein] Welcome to "Healthy Minds," I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence, With help, there is hope.

(gentle music) Today on "Healthy Minds..." - All too often, the diagnosis gets made after a few short minutes with a general pediatrician, or for an adult, with a general practitioner without the specialty training to really know this is going to take some time.

- So as is the case with other psychiatric or medical conditions, it needs a careful evaluation to make that diagnosis.

That's today on "Healthy Minds."

This program is brought to you, in part by, the American Psychiatric Association Foundation and the John and Polly Sparks Foundation.

(gentle music) Welcome to "Healthy Minds," I'm Dr. Jeff Borenstein.

ADHD, what do you need to know as a parent, other family member, teacher, what do you need to know about this condition?

Today I speak with leading expert, Dr. Steven Hinshaw, about ADHD.

(gentle music) Steve, thank you for joining us today.

- My pleasure.

- I'd like to jump in and ask you to describe the symptoms of ADHD.

- ADHD is the somewhat awkwardly named condition, called attention deficit hyperactivity disorder, and that name betrays that there are two main features or dimensions, attentional, organizational problems on the one hand, and hyperactive and impulsive behaviors and symptoms on the other.

In the first realm, distractibility, not following through, doesn't seem to hear all the directions that have been said, a lack of focus, and in the second, doing things without thinking them through, all the way to interrupting a lot or in, more boy than girl cases, actual fidgeting, squirming, on the move behavior.

In an interesting way, ADHD is a misnomer.

It's really not a deficit in attention as much as a problem in regulating attention and regulating your impulse control as situations and tasks change.

So one of the cardinals of ADHD is a kind of consistent inconsistency, in kids, teens, and adults having to constantly readjust your motivation and your effort as you go from algebra to French, or as you go from a casual conversation at work to meeting with your boss, and in different aspects of a close relationship.

- And as you're pointing out, sometimes somebody with ADHD can be very good at being hyper-focused on a particular activity.

- Well, that's another great reason why we shouldn't probably think of it as an attention deficit.

Many people with florid ADHD, once they're in the groove, once it's a task that they're really good at, have strong intrinsic motivation for, where did lunch go, where did dinner go, where did any breaks go?

So it's that hyper-focus exemplifies how do you regulate and control your attention and other aspects of motivation and cognition as the task changes.

- Tell me a little bit about how a diagnosis is made and typically what age can a diagnosis be made?

- So the mean age at which, in the United States and probably most of the rest of the world, a kid gets diagnosed, is early elementary school for boys and late elementary or even middle school for girls.

And this is because now, even though signs might have been present from the preschool years, with a formal curriculum, teachers are often the ones to notice, most of the other kids in class can follow multi-part directions, but this particular child has real difficulty.

There's a lot of rule-ins and rule-outs.

So the quick answer to your question is all too often the diagnosis gets made after a few short minutes with a general pediatrician, or for an adult, with a general practitioner without the specialty training to really know this is going to take some time.

- So as is the case with other psychiatric or medical conditions, it needs a careful evaluation to make that diagnosis.

- Without a careful evaluation, just to give two examples, way more boys got the diagnosis than girls, back in the day, because we emphasized only that fidgeting overactive behavior.

And in parallel, girls got missed, both because of the belief that girls really didn't have ADHD, but also because girls are more likely than boys to show these more exclusively inattentive forms of the condition, which takes really careful observation to review.

It's not as salient as a boy is running around a classroom.

- I want to delve into this difference between boys and girls.

This is an area of research that you've been a leading person on.

Tell us about those differences.

- If we think of what we call neurodevelopmental disorders, autism spectrum, ADHD, Tourette, very early onset conduct disorder, there are more cases in boys than girls.

Now, when I went to school some decades back, we thought it was 10 to one, 15 to one, 20 to one.

We know now it's closer to around 2 1/2 to one for ADHD, three to one for autism, four to one for Tourette.

The developing brain, if it's been in a boy, with an XY chromosome, has been secreting a lot of androgens prenatally, and that creates a biological male.

It also, frankly, slows brain development for the early years of life.

So it's a little wonder that boys are more susceptible than girls to some of these neurodevelopmental conditions.

But if you look closely, and it may be the less salient or less disruptive impulsive behaviors, many girls have been suffering in silence, not understanding two part directions, not reading social cues well in their teachers, or their peers, or their parents, and the diagnosis can get delayed because it may take until middle school or after for the symptoms to really become apparent.

- So once a diagnosis is made, what happens next?

And I know it's age related, so tell us for a younger child and then maybe for an adolescent older child, what happens after the diagnosis?

- What happens after the diagnosis actually differs around the world.

In most countries, the first line of treatment is considered to be behavioral, environmental, reward-based interventions, especially for younger kids.

People with ADHD, at that age, at any age, have trouble developing intrinsic motivation for tasks that don't come easily.

So it may take a more structured reward program, very clear instructions, successive approximations, the fancy name for small steps, to build success.

And if those programs aren't working right, mainly delivered by parents and teachers, we might consider some of the ADHD medication.

- So the first part that you just described really is coaching the parents and teachers as to how to best help the child.

- That's right.

As kids get older, into their teen years and adult years, cognitive behavior therapy, CBT, once the brain is more mature, you can start to do self-regulation.

But in the early years, it's really an environmental treatment, regularize the rewards, regularize the expectations, Rome wasn't built in a day, and very clear, non-emotionally given consequences when the mark hasn't been met.

If those aren't going as well as they should, there's a range of ADHD medications, largely the stimulants and some non-stimulant alternatives.

In the United States, all that's true in the preschool years, but starting in grade school, medication is often viewed as the primary treatment to begin with, but as we know from many years of research, the best dose and the best delivered medication, followed carefully, combined with these behavioral and eventually cognitive behavioral treatments has a far greater chance of yielding the best results.

- I'd like you to talk a little bit, and you make an important about the combination, not just one thing alone, I'd like you to talk a little bit about the medicine.

'Cause often parents, understandably, are anxious about giving a child medicine.

What do you say to a parent under those circumstances?

- So I'd like to say a lot of things and we take it kind of slow.

The main medications for ADHD are called stimulants, which is a really a bit of a misnomer.

Let's call them what they are.

SDRIs, selective dopamine reuptake inhibitors.

Most everybody knows what an SSRI is.

A selective serotonin reuptake inhibitor.

Keep serotonin in the synapse active for a little bit longer, helping to regulate the serotonin system, helping with depression and anxiety, et cetera.

An SDRI does the same thing, it allows dopamine to stay in the synapse a little bit longer, helping to regulate the few dopamine pathways in the brain that are essential for self-regulation and motor control.

And these pathways in the brain go from the midbrain up to the frontal lobes.

If we can get dopamine flowing more regularly, motivation increases, attention can increase, and people are less prone to do impulsive things.

There's other non-stimulant ADHD medications that work more on norepinephrine.

We could get into more detail later if we want to, that don't have the same side effect profile of appetite suppression.

They have their own side effect profile.

Those work better than placebo, but on average, the stimulants give you a little more of an attentional boost overall.

But the main point is, no doctor knows, no scientist knows, if you're diagnosed with ADHD, do you start with one of the two main types of stimulants, the amphetamine group or the methylphenidate or Ritalin group, and at which dosage.

It takes some cautious trial and error, an experimental trial with each child, to see.

Now the stimulants are short enough acting, this can be done in a few weeks, not the many, many months it might take with other forms of medication.

- I want to shift gears a little bit and ask you about what are the risks associated with not treating ADHD?

What happens to a child and an adolescent if it's untreated?

- There's a myth running around that ADHD is really a hidden gift.

If we just had classrooms that allowed people to stand and not sit all the time, and if we just tailored education more individually, ADHD would vanish.

Now, it is true that a flexible classroom, although one with a lot of structure at the same time, in terms of expectations, can help people with ADHD.

But it's a mistake to think that ADHD is always a hidden gift if we just recognize the person's talents and fast speed and scanning the environment well.

For both boys and girls and therefore, men and women, as people age, academic performance is one of the major areas of impact.

Whether there's a specific reading or math disorder or not, if you're not following directions well and you have trouble completing homework, your grades are going to suffer.

And about 80% of youth with ADHD have related academic problems.

Another key area is in the social world, especially if you're pretty ornery and impulsive and not reading cues well, tend to be less well liked than kids with autism spectrum disorders or depression or anxiety.

So the social world is a big area as well.

So it can lead to kind of a snowball of lowered self-image, poor academic performance, problems with adults and peers, and the lack of regulation actually can have more of an impact for an adult because once you're in secondary school or beyond or in the workforce, you don't have that one teacher a day guiding you.

It's really up to you to regulate yourself.

- I want to follow up a little bit on the issue of girls and something that you've spoken about, which is the triple bind, and ask you to describe that so that the people watching can understand what you're referring to.

- So 14 years ago, I wrote a book called "The Triple Bind," and it didn't have terribly much to do with ADHD.

It really had to do with, in our studies of girls over the years, looking at our neurotypical comparison girls who didn't seem to have neurodevelopmental disorders.

But the premise is this, for time immemorial, girls are raised to be the nurturers, the caregivers.

Now we have more gender parity in those roles in many Western countries than we did before, but it's still the norm.

Now, girls are getting the opportunity, and with the clear expectation that they're going to be academically and athletically quite successful.

So already there's a bit of a bind if you're sprinting down the finish line on the track and your competitor in the next lane stumbles, do you compassionately help her?

Well, if you do, you lose the race.

So how do you be super nurturant and super competitive at once?

And the third aspect of the triple bind, which we learned about from focus groups and studies of culture, and interviewing a lot of girls and women, the pressure is to do all these things.

If a girl, turning into a young woman, also has the neurodevelopmental challenge of ADHD, where it's hard to regulate yourself, one plus one might equal four.

And we have seen that this combination of the social expectations and pressures that are damaging to many girls throughout development, if there's a neurodevelopmental condition involved too, can be particularly pernicious.

- I want to shift gears a little bit and talk about the use of the ADHD medications, the stimulants, really not for somebody with ADHD, but being used by people to study or focus without such a diagnosis.

I'd like you to speak about that.

- This has become a big problem for one simple reason.

There's many reasons.

When I was in grad school, we learned that ADHD was a boy thing, not a girl thing, and it really pretty much ended when you hit puberty.

It didn't last into adulthood.

We now know, from countless follow-up studies, that even though the fidgeting, squirming activity may go underground as you get older, the underlying problems in self-regulation don't go away in the majority of cases and may persist.

So this means, fast forwarding, there are many college students or young adults in the workforce with stimulant medication prescriptions in their medicine cabinet, in the dorm room or in the apartment.

And with the lore that abounds out there that, "Huh, I'm in college, I'm a junior, I've got to get my GPA up, that midterm is tomorrow.

I guess I could take a stimulant and pull an all-nighter."

And there's, again, a kind of lore that stimulants are smart pills.

They're going to increase your intelligence.

Now let's make a distinction.

If you have well diagnosed ADHD, the medicines do help your focus.

You don't want to take 'em too late or you will stay up too late, but unless you want to study all night, and they do aid, not perfectly, they don't normalize, they help your working memory, they help your ability to regulate and focus on a task and learn new material.

But what if you're neurotypical?

You really don't have any ADHD, but you have this assumption, "It's a smart pill, it'll be my way to a 4.0 grade average."

It's been very difficult over the last 10 years, since this became a hot issue, to do a controlled trial for non ADHD individuals of some days on medicine and some days on placebo because of some of the health concerns.

But several of these studies have been done now, and to cut to the chase, on the best of these studies that measure different aspects of learning and memory and acquiring new knowledge, on the week that you take the stimulant and you get a bunch of these tests, and then alternating week you get a placebo, there is hardly any significant effect at all.

But there is a measure that shows a big effect, which is the questionnaires at the end of the week saying, "How do well do you think you did on the test?"

Pretty much known to individuals that they got a stimulant during the week felt a little different than a placebo.

And almost exclusively the neurotypical adults say, "Well, I aced the test this week.

I mean, I was on the medications, I did great."

So the conclusion from this research is stimulants are pretty good for neurotypical individuals at boosting your false confidence and your learning ability.

You're not learning better, but you think you are.

And here's the coupe de gras, if you have carefully diagnosed ADHD and you're followed from childhood to adolescence to adulthood, and you've got a practitioner who really stays on top of you, partly because of that, and partly because of probably some genetic protection, you're very unlikely to get addicted to stimulants.

But if you're a neurotypical young adult or adult, without ADHD and occasionally use stimulants not only as smart pills, but sometimes as party pills, what's one use of stimulants in clubs and raves, and in the college scene, you're drinking a lot at a bar, you're going to pass out, but if you take stimulants, you'll stay awake longer and get drunker.

You know, it's very dangerous.

About 20% of adults who start to use stimulants as smart pills or party pills become addicted to stimulants versus a far lower, under a percent of individuals with ADHD.

So it is dangerous game and you're kidding yourself.

- Extremely important point.

So it's safe to take under the auspices of a careful treating physician, but to abuse it, to misuse it, puts you at great risk.

- At very great risk.

- I'd like you to look into the camera and tell a parent who's concerned that maybe their child has ADHD, maybe the teacher brought it up to them, what should they do?

- So this is the 64 jillion dollar question.

There's a lot in the media, there's a lot on the web.

The myth that ADHD is just labeling of poor classrooms or the myth that it's always a hidden gift.

So what I would tell a parent is, number one, do you trust the practitioner that you're going to see?

Are they experienced in assessing and treating ADHD?

Number two, if the evidence starts to mount that maybe from a family history, ADHD is one of the most heritable, in other words, genetically vulnerable conditions we know of, it's in the class with autism spectrum and bipolar disorder.

More than 80% of the risk is because of the genes you inherit, not the way you're raised, in particular.

So, but if you're getting that sense from the clinician, are you also getting the sense that the clinician isn't going to, first and foremost and only, pull out a prescription pad and write a prescription for a medication?

The best ADHD treatment plans are really holistic.

Aerobic exercise is an evidence-based treatment for ADHD.

It's not as good as the behavioral treatments or as medication.

Avoiding a lot of additives in the diet.

A lot of ADHD dietary treatments can be fatty and not very helpful.

There's a lot of trials now about mindfulness and other forms of meditation.

The evidence-based treatments are the behavioral, reward-based, positive parenting, and positive classroom interventions, in combination with the right dose of medication.

So I would say to parents, maybe you're worried that ADHD is over-diagnosed, and it certainly can be.

It also tends to still be underdiagnosed in girls.

And maybe you're worried that getting your kid on medications is somehow poisoning their brain.

I mean, there's a lot of lore out there that this is somehow unethical.

What about your kid's asthma, or what about your kid's cancer, would you forego the chance to try?

So one of the things I say a lot to families is if the diagnosis has been made well, would you consider a trial?

Doesn't mean you've given your kid a lifetime sentence of medication, but you will know in a few weeks, with a good physician and mental health team monitoring this, whether the medication's working or not.

So it may be worth that chance.

- It sounds like one thing to look for in treating professional is that they're not just writing a prescription and handing it to you, and that's it, that they are combining this with other behavioral approaches, coaching the parents, doing work with the child, et cetera, not just writing a prescription.

- Very much so, and a point I want to emphasize is, in these coaching style, behavioral, environmental, school and home interventions, a thing that can get overlooked is finding the kids or teens or adult's strengths.

Look around and see what your kid really enjoys.

Find ways to encourage that alongside the skills they need to develop in self-regulation, and math, and English, and everything else.

Because too many home-based conversations between parents who often have ADHD themselves 'cause of the genetics and kids, and teachers and kids is, "You didn't do this."

The kid internalizes, "I'm a failure at this," and it gets into a negative spiral.

A strengths-based approach can lead to that positive, virtuous cycle, which is where you want to see the kids going.

- Steve, I'd like you to tell us about some of the long-term effects of ADHD.

- More data are emerging that ADHD may rob people of the years they stay alive.

Often through poor health habits, often through unhealthy eating, clearly through accidental injuries, which data around the world are converging is a big problem for people with ADHD.

So we've known for some time now that schizophrenia might, on average, take 20 years off a person's lifespan.

Severe bipolar disorder, probably in that ballpark too.

And ADHD, which is often considered mild, people with ADHD don't hear voices, they're not psychotic, they can function well in many aspects of life, but there's hidden costs to impulsivity, and hidden costs to a lack of planning, and hidden costs to carrying around the burden that you've never quite lived up to your potential, and some of those relate to health behaviors.

So ADHD may well be one of those conditions where, if we're just talking about the nuts and bolts of life expectancy, 10 or more years may be lost, on average.

- Very important point about life expectancy and also quality of life that untreated ADHD can have a negative impact on both.

But with treatment, those negative impacts can be reversed.

- That's clearly the key point.

- Steve, I want to thank you for all the work that you've done in this field for all the people that you've helped over the years, and thank you for joining us today.

- What a pleasure to have had this opportunity.

Thanks so much.

(gentle music) - If your child is experiencing symptoms that may be related to ADHD, don't let your child suffer in silence.

Seek help.

Remember with help, there is hope.

(gentle music) Do not suffer in silence.

With help, there is hope.

(gentle music) This program is brought to you, in part by, the American Psychiatric Association Foundation, and the John and Polly Sparks Foundation.

(gentle music)