#320： The ADHD Explosion
Episode Stats
Summary
In this episode, Dr. Steve Hinshaw, co-author of The ADHD Explosion, gives the lay reader a crash course into ADHD and provides insights as to why we re seeing such a huge spike in the number of individuals diagnosed with it.
Transcript
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Brett McKay here and welcome to another edition of the Art of Manliness podcast.
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Well, you've probably heard about the precipitous rise in diagnoses of ADHD in America the past
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few decades. What was once a rare mental illness has now become a common problem amongst children,
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particularly boys? Why the sudden spike? And are there really more people with ADHD or something
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else going on? My guest today has some possible answers to that question. His name is Steve
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Hinshaw and he's professor of psychology at UC Berkeley. In his book, The ADHD Explosion,
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Dr. Hinshaw gives the lay reader a crash course into ADHD and provides some insights as to why
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we're seeing such a huge spike in the number of individuals diagnosed with it. Now we begin our
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conversation talking about exactly what ADHD is and how it impairs individuals. We then discuss
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the biological and environmental factors that go into ADHD, debunk some of the myths surrounding
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it, and discuss which treatments actually work. And then Dr. Hinshaw delves into his research,
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which shows that the rise of ADHD is not because more people are actually developing ADHD, but rather
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that there's cultural and economic forces in schools, corporations, and governments that
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incentivize shoddy diagnoses. We also discuss the fact that ADHD medication is often used by people
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who don't actually have ADHD or perform better, and whether it actually improves performance for
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these folks or not. We're in our conversation discussing his latest book, Another Kind of
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Madness, talking to a memoir about his father and his mental illness. And it's about mental
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illness in general and how we stigmatize him today and what we can do to stop that. So if you know
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someone who has ADHD, this podcast will provide a lot of insight about a condition few really
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understand. After the show's over, check out the show notes at aom.is slash ADHD.
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Thanks so much for having me on. I'm eager to get rolling.
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So you co-authored a book called The ADHD Explosion. ADHD, it's one of those things that has,
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I feel, is imbued in the popular culture. Like everyone talks about it. People will flippantly
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say, oh, I've got ADHD because they're having a hard time focused. I think it's important. Let's
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start off with definitions. Let's be Socratic here, right? Let's do it like what Socrates did
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and start off our conversation. What exactly is ADHD and what does it feel like to have ADHD? Is
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it simply you can't focus or is it something more? Yeah, this is a great starting question. So ADHD
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is the alphabet soup acronym for attention deficit hyperactivity disorder. Some years back, it was
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called ADD, attention deficit disorder. Some years before that, it was called hyperactivity or
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hyperkinesis. And back 60 plus years ago, it was called MBD, minimal brain dysfunction. So it's had a
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lot of name changes over the years, which I think adds to the confusion and mythology. So what is ADD or
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ADHD? Is it just I spaced out, I couldn't focus? It's actually much more than that. There's a lot of
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theories about what goes on in the brains of people who have legitimate ADHD. So attention is
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part of the name of this. But it's not simply an attention deficit. It's not simply not paying
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enough attention. It's the lack of ability to regulate attention according to what the situational
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demand is. So many kids in classrooms or adults on the job have difficulty sustaining attention because
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someone else is calling the shots and hard to keep your motivation up. But those same individuals,
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they get on a video game, for example, and there's hyperfocus. You can't shut it off. Hours later,
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it's like, where did the world go? So it's a myth to think that ADHD is just poor attention. It's a
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dysregulation of the ability to pay attention. So that gets us into some of these other elements.
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Maybe it's broader than attention. There's these modules in our brain called executive functions.
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Maybe what really separates us from the other primates and animals. You get up in the morning
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and there's a plan. I've got stuff to do and a kind of mental checklist. And oh, the plan didn't go the
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way I should. I've got to correct errors and I've got to suppress this distraction coming in and keep on
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track. I've got to hold things in memory called working memory, the ability to remember short
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strings of data. All of these are executive functions. And another theory is that ADHD
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is really an executive function deficit, way beyond attention. It's not how smart you are,
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but it's your ability to navigate and follow a plan through a day and correct errors when they come in.
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It may also be that in another theory of ADHD, it's your ability to inhibit a response that you've
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done a lot in the past. So kids with ADHD get into trouble a lot with their peers, not just at school.
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And as I sometimes tell parents groups, these are the kids who at the wonderful birthday party blow out
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the candles, but then they remember and all the kids tell them instantly, it wasn't your birthday.
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It was the other kid's birthday. Those candles were flaming, the cake icing was green and blue and
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looked beautiful, but it was very hard to inhibit that tendency to blow out the candles because you've
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done it before it's your own birthday. So another theory of ADHD is if you have trouble suppressing or
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inhibiting these previously rewarded responses, you'll never get a chance to pay attention well or use your
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other executive functions. Finally, in the little mini lecture here, another view, not incompatible
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with the first three, is that people with ADHD have trouble generating intrinsic motivation,
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always needing someone else to kind of lean on them, provide reinforcers, because probably there's
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just not enough dopamine flowing in some of the dopamine circuits in the brain. And we'll talk
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about genes and brains in a little bit, I think. But if you have that problem with gaining that intrinsic
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kind of control of your motivation, you're always kind of relying on the outside environment to set the
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agenda. You put those things together. And for a person with ADHD, the world can often seem as a
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constant bed of noise. It's hard to know wheat from chaff, figure from ground. What should I be paying
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attention to? What's coming in? And of course, in today's social media world, there's stuff coming
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in all the time. Maintaining your goals, sticking with them, keeping that focus in the face of
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distractions. It's hard for everybody these days. But if you've got ADHD, multiply that by 10 or 50.
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And I think that would be kind of a little worldview as to what it would be like day to day if you have
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this condition. And let's talk about the adverse effects of this condition. We'll unpack some more
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because there's some other stuff you talked about. But I'd like for our listeners to have an idea of
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how this negatively impacts individuals. Often when we talk about ADHD, it's often focused on kids in
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school. And I think we understand that. That's right. And we know that ADHD isn't just a kid
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disorder anymore. It can last into adolescence and beyond. But you're right. School is the place
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where this is often identified. Because if you have problems focusing and regulating attention and
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inhibiting your impulses and developing intrinsic motivation, schoolwork is a teacher yakking in
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front of you and all these assignments. And it's a morass and it's hard to sort it out. So the vast
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majority of kids and teens with ADHD are working behind their potential academically. And then
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moving up on the developmental scale, many adults with ADHD are underperforming at work and have
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checkered employment histories. Not because they're not competent, not because they're not smart,
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but because what do you have to do at work? You take that new job and boy, it didn't go so well.
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Maybe you shouldn't send that nasty email to your boss the first afternoon, right? You got to keep
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it in check a little bit and wait and see how things go. But if the immediate press of that negative
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experience motivates you to send that email immediately, it gets you into hot water. So
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academics and vocational performance. Number two, as I just mentioned a moment ago,
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people with ADHD have problems in interpersonal relationships. It's not just not paying attention
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to school assignments. It may not be paying very good attention to one's own behavior in a social
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setting or paying enough attention to the facial emotions that you're seeing from that person sitting
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across from you. Kids tend to dislike kids with ADHD more than they dislike kids with other
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behavioral and emotional problems because of that impulsivity. Because those are the kids who
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let the soccer ball fly by them when they were goalie because they were more interested in the
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clover or they blew out the birthday candles, even though it wasn't their party. It was the other
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kids party. And for adults, we know that people with ADHD have nearly double the divorce rate and real
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difficulty sustaining intimate relationships because of impulse control problems and sometimes anger
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management problems. A third one is really crucial. People with ADHD, whether you're five or 16 when you
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start to get that driver's license or well above, have massively high rates, more so than the rest of
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the population of accidental injuries. Car crashes, injuries at school or on the job, preschoolers with ADHD
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have a higher death rate than other preschoolers. They climb on the wrong places and jump in front of
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cars. So it's not just the stereotype of this is a fidgety, bothersome kid in a boring classroom and it's just
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a classroom issue. If you've got severe ADHD, you're going to have problems regulating your impulses and
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keeping yourself safe in a lot of different environments. So school and job, social relationships,
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accidental injuries, to me are some of the top three impairments, as we sort of call them in the
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lingo, that too often accrue from these symptoms. Okay. I'd like to later on delve deeper into the
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differences in how ADHD affects men and women. We'll talk about that because I thought it was
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interesting. As you were talking about what is ADHD, you said theory a lot or like we had this idea.
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Why is it sort of nebulous? Do like scientists know for sure? Is it sort of like depression where
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they think it's this thing could be serotonin, it could be environment? Is that what's going on
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with ADHD? We've made a lot of scientific progress over the last couple of decades to get far closer
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to some of the core genetics and biology of ADHD and to what goes on in the environment that may
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trigger it too. So let me talk about that for a few minutes because the research is really interesting.
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Like depression, like schizophrenia, like bipolar disorder, like PTSD, all mental problems,
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behavioral and emotional problems, the brain's a hugely complicated organ, 100 trillion synapses
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firing all the time. We don't yet have complete answers or cures, but we're getting closer.
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So number one, think of the people you know. Some are highly focused and regulated and conscientious.
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Others are, boy, a gnat comes in the next county and that bug miles away has distracted you. And most
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of us are in between. So are genes mainly responsible for those differences in focus and concentration
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and attention or environments? It turns out that genes are 80% responsible about for the differences
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between you and me and how focused and regulated we are. We know this from twin and adoption studies.
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Turns out that the symptoms of ADHD are more based in genetic liability and risk than is the case for
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depression. It's up there with bipolar disorder and autism as three of the, what we call most
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heritable or genetically vulnerable conditions. However, the second I say that, this does not imply
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that early environments are not important. So prenatally, a host of toxic chemicals,
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cigarette smoke, alcohol can also influence ADHD symptoms. Early child rearing does not seem to be a big
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cause of ADHD. In fact, if you have the precursors of ADHD in your toddler years, you're somewhat more
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ornery and intense. Parents tend to fight fire with fire and get controlling with the kid. The parents are
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responding to the kid's, quote, biological differences. But those parental responses now pour a bit of gasoline on
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that fire and we get a vicious cycle. Parenting is not the cause of ADHD, but parenting, getting locked into these
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negative cycles, can clearly contribute to the worsening of ADHD and the addition of more aggressive behavior,
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sometimes depression. So parenting is a huge treatment-related factor. We don't want to blame
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parents, maybe except through the genes they transmitted, but we don't want to remove the
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responsibility from parents to get actively involved in family therapy, behavioral therapy, because that
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can make a big difference. There's a lot of interest these days in toxic chemicals, pesticides.
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We don't have the definitive research yet, but it may well be that if you're born with some of
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these genes that make you somewhat vulnerable to lapses in attention and concentration and
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self-regulation, you may be more susceptible than others to the early exposures you might get to toxic
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chemicals. Let me mention quickly diet. 40, 50 years ago, everybody sort of thought that hyperactivity
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could be cured with an additive-free and sugar-free diet. That's largely a myth has been discounted,
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but more recent good research does show that especially some of the dyes and additives and
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especially for kids under eight or nine years of age, they're not the cause of ADHD, but if you've got
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the liability or vulnerability, they may add a couple of symptoms to the mix. So dietary treatments are not
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the core evidence-based treatment for ADHD, and I know we'll talk about treatment in a few minutes,
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but it may be part of a holistic treatment plan. Okay. Well, your book is called The ADHD Explosion.
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So let's talk about that. How many people, when you say in America today, have been diagnosed with ADHD?
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Well, this is a great question, and we haven't really known the answer very well until fairly recently,
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because unlike Europe, Scandinavia, other countries where there's national databases of everybody
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from birth throughout their life and every medical record all put together, United States,
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it's much more hit or miss. But about 15 years ago, the Centers for Disease Control and Prevention
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started to add to a big national survey of parents, a national survey of children's health,
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some questions about ADHD. This isn't just people in clinics. This is 100,000 people every few years,
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random phone dialing, so it's a representative sample. What do we know? Back about 2003 or right
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around that time, about 7.5% of kids in the United States, as reported by their parents, had either
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received an ADHD diagnosis or a health professional had told the parent, yes, your kid has ADHD.
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Interestingly, that's the world average. ADHD is not just an American thing. It's in every country
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on the planet that has compulsory education. We'll talk about education shortly, too. So somewhere
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between 5, 6, 7% is the world average in just about every country on earth. But in the U.S.,
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the National Survey of Children's Health was repeated five years later and then repeated five years after
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that. Between 2003 and about 2013, the last year we've got good data, ADHD diagnoses went up by 42% in
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kids. So now it's not 7.5%, it's closer to 11% of all kids between 4 and 17. Boys do get ADHD more than
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girls. So this means about 15% of all boys. So this means about 15% of all boys. And if you're a boy
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above about 10 or so, these recent data, the most recent data we have suggests that almost one in five,
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almost 20%, have had an ADHD diagnosis. Finally, in a few states, often southern states, rates of ADHD
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ADHD diagnosis are even higher. And there's a few states, Arkansas, North Carolina, even Indiana
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in the Midwest, where about one in three teenage boys have received an ADHD diagnosis during their
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short lifetime. Things are going up really fast. The United States is way above the world average now.
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So this is probably not because ADHD-related genes have mutated in the United States in the last 15
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years. Darbin would turn over in his grave. Genetics doesn't work that way. There's something about
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the recognition of ADHD or perhaps the shoddy diagnoses that we too often tolerate. Most kids with
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ADHD get diagnosed in a 10 or 12-minute office visit with a pediatrician. And as Richard Scheffler,
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my co-author of the ADHD explosion, he's a great health economist. And I said in one of the key
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chapters, the regions in the U.S. where the rates of diagnosis have gone up the most explosively in the
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ADHD explosion, especially for kids near the federal poverty level, are those states that really push
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testing accountability in schools. Now, accountability laws in schools really don't have much of anything
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to do with ADHD. But those school districts in those states that really push achievement or bust
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are driving up very quickly high rates of ADHD diagnosis, in part because the districts want to get
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those kids treated so their test scores can improve. And more cynically, in some states,
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if you got an ADHD diagnosis for a kid, that kid was thrown out of the district's test score pool.
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So there was a kind of insidious trying to get kids labeled to boost the district's test scores.
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Educational policy may be artificially pushing up rates of ADHD in the United States beyond what they
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should be. So what you're saying there then is that maybe what's going on is really there's not more
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kids with ADHD. There's just more kids being diagnosed with ADHD because of these pressures
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from school systems, etc. Now, I'm glad you put it that way. So let's play devil's advocate.
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One causal factor for ADHD is being born at a very low birth weight, which is, of course,
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associated with preterm birth. The lower your birth weight, being born 28, 30, 32 weeks rather than the
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full 40 is a risk factor for hyperactivity and learning problems at more severe low birth weight,
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cerebral palsy, Tourette's disorder. 30 years ago, most of those kids didn't survive. But now with great
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neonatal intensive care units, more and more of these kids are surviving. So that may be a reason for at
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least a small increase in actual ADHD, the true prevalence. But what we were just talking about is
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what's also called diagnosed prevalence. Maybe, I think, and a bigger contributor is more kids are
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getting diagnosed with ADHD artificially, again, or as the result of pretty shoddy diagnostic processes,
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even though the true rate has probably stayed pretty much the same over the last decades.
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So let's talk about how diagnoses should be made. Because I think that's one thing you hear a lot
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of parents pushing back against nowadays in their schools that they're a counselor or school
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psychologist is saying, well, you're, particularly with boys, your boy can't sit still and focus and
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et cetera. And, you know, most parents be like, well, he's just, he's being, he's acting like a boy.
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That's right. He's all boy. It's the Tom Sawyer syndrome, right? Et cetera, et cetera.
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Right. And then they're like, there's a pressure to get on the drug so they can stay focused,
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whatever. So like what makes like a true ADHD diagnosis? Like what is involved in order to
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make sure like you were actually getting diagnosed correctly with ADHD?
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Yeah. I'm glad you asked this because it's, it's a complicated answer and it's a not,
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it's not a short answer because a proper diagnosis isn't something done in a quarter of an hour.
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As with depression, schizophrenia, bipolar disorder, PTSD, we still don't have a blood test,
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a biomarker, a brain scan that can unequivocally diagnose any mental disorder. We're just not that
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advanced in our science yet. So ADHD is actually intriguingly a kind of low tech diagnosis, meaning
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the doctor, the psychologist, the clinician has to talk with the family. So we're talking about child
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diagnosis now for a long time first to get a developmental history. What was infancy like?
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What were the toddler years like? When, when did speech and walking come in? Has to get a birth
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history, et cetera, et cetera. Toxic drugs might've been used, et cetera, et cetera, too. Beyond that,
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are there other factors? Maybe this kid was maltreated. If you've been physically or sexually abused
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for a period of time, you may have lapses in concentration that may look like ADHD.
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One of the core symptoms of major depression and kids can get depressed is poor concentration.
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That's usually because you're preoccupied with negative images of yourself. It's different from
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ADHD, but the symptoms the same. So you have to do a big process of differential diagnosis,
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meaning a long talk with the family in a semi-structured way to rule out other things.
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Sometimes you've got to rule out a seizure disorder.
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Then simultaneous with that, you've got to get parents and teachers to fill out quantified
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checklists of the symptoms of ADHD, the symptoms of depression and other childhood disorders to get
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you a numerical score. So you can compare that kid's score to other kids in his or her region,
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other boys and girls of a national sample. It's not just, well, I think any given teacher in a given
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year can say a certain percentage of kids are flaky or fidgety or unfocused. You want to get a couple
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of years worth of parent and teacher ratings to make a statistical comparison to see is the kid
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really above, way above the norms of what behavior and focused attention should be.
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Then there can be cognitive testing, achievement testing. Is this a product of a learning disability?
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If you put this together, this is a several hour process at minimum. I have major federal research
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grants. We put kids and families through a 10 hour battery. Of course, no clinician can afford that.
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Insurance won't reimburse it. You've got to make darn sure that this kid is way extreme on inattentiveness,
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impulse control problems, for some cases overactive, fidgety behavior, and has objective information
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and a good history to make sure it's ADHD and not one of the many other things, just normally high
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temperament, abuse, maltreatment, a seizure disorder. You've got to rule those out to make sure that the
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diagnosis is accurate. Once you do that, and once you work with kids like this, and teens and adults
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like this, and realize this isn't just fidgety behavior. This isn't just sort of social constructivism
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101. These are kids who get into serious trouble in school. These are kids who injure themselves.
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Sometimes the head injuries kids with ADHD receive exacerbates their symptoms and you get into a vicious
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cycle. ADHD is serious business, but in our culture wars these days, and because of the shoddy
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diagnostic practices we allow, social critics have a field day. Too many boys get diagnosed
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cursorily, and then they get put on ADHD drugs or medications, and we're not dealing with societal
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problems. The reality is far more complicated than this, and it starts with a really good diagnostic
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workup. Okay. Yeah, because I mean, I've heard instances of friends even who their diagnosis was,
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they wouldn't talk to their family doctor for 20 minutes, and then they got a prescription for
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Ritalin. Which is too often the case, especially in the United States. We still have the highest
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medication rates in the world in the U.S. Other countries really emphasize other forms of treatment
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first. But I'll tell you, the rest of the world is catching up, and healthcare is in crisis. If you
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haven't been following the news lately, both here and around the world, and I think it's a matter of
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pay now or pay later, if we invest in really careful diagnoses, so we catch the kids who really
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deserve a diagnosis and don't over-diagnose or under-diagnose, and give the right treatments at
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the right time, we're saving families untold misery, and we're saving countless billions in our
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economy years down the road. But that's not often how it works in the health policy world.
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Okay. So yeah, what it sounds like here, the diagnosis for ADHD should be very thorough. And
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perhaps if a teacher or a counselor tells a parent, like, your kid thinks he has ADHD,
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you might want to explore that, but don't just rely on some sort of thumbnail sketch diagnoses.
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Thumbnail sketch diagnoses lead to over-diagnosis, of course, but also intriguingly under-diagnosis.
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The doctor might say, gee, he or she was sitting so nicely in the waiting room, it can't be ADHD.
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Or, man, the parents report that he can play video games for eight consecutive hours. Well,
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that might be hyper-focus, one of the symptoms of ADHD. You've got to, you diagnose ADHD not in
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the waiting room or in the clinical exam room. You get information from school and soccer league
00:27:13.540
and homework time out in the real world. That's where the symptoms show up.
00:27:18.020
Okay. Well, let's talk about differences between male and females. We often think
00:27:21.660
ADHD is a boy problem. And as you said earlier, boys typically get it more than girls. The reason
00:27:27.640
more boys get diagnosed than girls is because just boy behavior, the Tom Sawyer stuff is being
00:27:31.980
diagnosed as ADHD when it's not. But on the whole, boys have more ADHD more than girls. But let's say
00:27:39.280
the fathers out there who are listening, who have daughters, and they have a daughter who's just,
00:27:44.180
you know, he thinks, oh, she's just spunky or whatever, but she might have ADHD. Is there a
00:27:48.660
difference between how boys and girls manifest ADHD symptoms?
00:27:51.980
So let's sort of start from ground zero here. ADHD, autism, very serious deficits in social
00:28:00.680
communication abilities. Tourette's disorder, the movement disorder with involuntary movements.
00:28:08.080
Most forms of learning disorders, aggressive conduct problems, all of the neurodevelopmental
00:28:14.720
conditions that usually appear in the first decade of life. They're all more prevalent in boys and
00:28:19.940
girls at a rate of two to one for most learning disorders to five to one or more for autism and
00:28:26.840
about three to one for ADHD. Why? Well, this would be a two hour seminar. We don't have time for
00:28:32.400
the Y chromosome. Doesn't have many genes on it. If you've got two X's and you're a girl, you get
00:28:38.380
protection from a vulnerability on the X. If you're a guy with an X and a Y, the Y doesn't provide much
00:28:43.080
protection. Boys are more vulnerable to all forms of life stress. Boys brains develop slower in the
00:28:49.780
first few years of life than girls, et cetera, et cetera. So legitimately, there's more boys and
00:28:55.000
girls, not only with ADHD, but most of the other major conditions early in life, which led for too
00:29:01.620
long. I learned in grad school some decades ago that girls really don't get ADHD, but that's a myth
00:29:07.380
too. Girls can and do get ADHD and some of them look just like the most extreme boys, really impulsive,
00:29:15.720
really fidgety, making poor decisions, terrible time focusing in school. And for those girls, they tend to
00:29:24.760
get rejected by their female classmates, even more than boys with ADHD tend to get rejected by their male
00:29:30.560
classmates because girls put such a premium on a good social relationships. However, there is a
00:29:38.260
difference. There's a form of ADHD that's more purely inattentive. You're not wildly impulsive or
00:29:46.080
fidgety. You just don't focus very well in school or in social relationships. Girls more than boys tend to
00:29:53.860
have this more purely inattentive form of ADHD on a relative basis. So if you're a teacher, you know
00:30:01.860
the kids who are obstreperous and ruining the learning of everybody else in the classroom. Those impulsive
00:30:08.620
kids with ADHD get referred, and those tend to be boys more than girls. So it's more likely that girls
00:30:15.160
with this more purely inattentive form will get overlooked until later in the game, middle school or
00:30:20.740
high school. And now the disorganization and now the academic problems really become salient.
00:30:26.580
So there's a couple of reasons why girls don't get noticed. They do get ADHD less than boys,
00:30:32.240
but they also tend on average to present with a form of it that's less noticeable in the classroom.
00:30:38.440
Okay. And how does ADHD affect men and women later in life differently?
00:30:42.540
Right. So we talked before about the myth that, again, something I learned in grad school,
00:30:47.700
ADHD is a pretty interesting disorder because it goes away once you hit puberty. Well,
00:30:55.720
in most of us, whether we have ADHD or not, we don't fidget. We're not as motorically active in
00:31:01.900
our teen years and adulthood as we were as kids. And that's true for people with ADHD. But what's missed
00:31:07.520
is 80% of the time through adolescence and at least half the time through adulthood,
00:31:13.020
the underlying executive problems and underlying inattention tend to persist well into adulthood.
00:31:21.040
Now, do the symptoms show up identically all the time? No, it depends on are you self-employed or
00:31:27.520
is have a boss calling your shots? How supportive is your partner? ADHD is consistent in consistency,
00:31:34.300
but for both men and women, vocational problems, relationship problems, and accidental injury rates
00:31:42.000
are much higher than the norm. So you have to take into account that for adults,
00:31:48.420
it's not going to be fidgeting in a one-room schoolhouse. It's going to be doing impulsive
00:31:54.040
things on the job or dangerous things behind the wheel. So we've got to, when we assess an adult with
00:31:59.640
ADHD, get information, not just from the person in the chair in front of us, but from parents,
00:32:05.380
even though the adult doesn't live at home anymore, partners, employers, et cetera, to really get a
00:32:09.900
thorough diagnostic picture. Okay. How is ADHD treated? Because I think oftentimes people think,
00:32:15.060
okay, if you have ADHD, it's an automatic Ritalin prescription or some other stimulant.
00:32:18.920
Are there other treatments that work that don't rely on pharmaceuticals?
00:32:23.020
Yeah, there are clearly two major forms of treatments that work. The stimulant medications,
00:32:27.900
what's a stimulant? It's sort of a funny name. They should really be called SDRIs,
00:32:33.600
selective dopamine reuptake inhibitors. We all know what SSRIs are, selective serotonin reuptake
00:32:40.040
inhibitors. They prevent serotonin in the pathways in the brain where it flows from getting reuptaken
00:32:46.820
into the neuron that's just fired it out, leaving more serotonin to do its work. The stimulants,
00:32:52.280
Ritalins and Adderalls of the world, do the same thing, but for dopamine in the few pathways
00:32:57.800
in the brain where dopamine fires, and those pathways have to do with what? Processing of
00:33:03.100
reward, motivation, behavioral control. So it may be that many people with ADHD, the genetics are
00:33:13.020
pretty strong, as we talked about, don't have as many active dopamine circuits, and the stimulants
00:33:18.840
can help get those dopamine levels up to a more normative level and help behavioral regulation and
00:33:25.340
focus. The catch is, A, stimulants can be dangerous in terms of side effects. You can get addicted to
00:33:32.420
them if you don't have ADHD and you just take them randomly. And second, stimulants don't teach you
00:33:39.420
academic work. Stimulants don't teach you how to regulate your emotions better or make friends
00:33:45.740
better. Stimulants may help prevent some accidental injuries, but you still have to learn safe driving
00:33:51.040
and safe job techniques. At the very least, for those people with ADHD who do show a good response
00:33:59.200
to the medications, you're not going to get a full response in terms of competencies unless you combine
00:34:05.400
the stimulants with, for kids, behavioral parent training, the parents learn to set much better and
00:34:10.660
clearer limits, getting the teacher on board with delivering more rewards. And for adults, cognitive
00:34:16.680
behavioral therapy, behavioral therapy, where you learn time management. One of the big problems of
00:34:20.660
many people with ADHD is you're late for everything. You just don't have that internal clock working
00:34:25.800
well. Organizational skills, paying more attention to how you interact with others. Cognitive behavioral
00:34:32.980
therapies for adults, behavioral treatments, reward-based treatments for kids are a very viable
00:34:39.040
alternative to stimulants. And for the vast majority of people with ADHD, you're going to get the best
00:34:45.540
benefit if medication is indicated and works by combining the meds with these behavioral and
00:34:51.560
cognitive behavioral treatments for, again, the right holistic treatment package.
00:34:55.680
Is the treatment of ADHD similar to depression? I know some therapists or psychiatrists will begin with
00:35:02.060
maybe cognitive behavioral therapy and see what they can do with that. And then if they can't,
00:35:07.020
if they make any progress, then they'll add in the drugs or do some therapists just go right to the
00:35:11.900
drugs and then add in cognitive behavioral therapy afterwards? Yeah, very good question. So
00:35:16.240
it's fairly easy for a doctor to pull out the prescription pad and write a script for
00:35:21.380
methylphenidate, trade name Ritalin, or amphetamine salts, trade name Adderall, or any one of the stimulant
00:35:27.080
medications. It's harder to get the family engaged in parent management sessions and to get in the
00:35:33.540
school and work with a teacher or to get adults to come in for cognitive behavioral therapy and
00:35:37.640
organizational skills. So stimulants are a kind of easy first step. And in the United States, unlike
00:35:45.680
just about every other country, stimulants are viewed as the first line treatment for kids and
00:35:52.340
teens with ADHD. Most other countries say, let's start with the behavioral management, skill building
00:35:59.140
first, and if they don't work as well, then go to medications. In the United States, for preschoolers,
00:36:04.960
for young kids, three, four, and five-year-olds, where ADHD can be a serious problem, these behavioral
00:36:10.240
treatments are the first line. So I think it's a matter of severity and safety. If you've got a kid with
00:36:19.160
ADHD who's really a risk physically to himself or herself, and you don't have the time and wherewithal
00:36:27.340
to get a behavioral program set up, it's going to take a long time, medication may be your first
00:36:33.760
option to at least get the symptoms under better control, but don't make the mistake of thinking,
00:36:39.480
if they do, that that's the total treatment. That's the time to really, really add to the
00:36:46.080
kick that's needed by putting these other treatments, academic remediation, behavioral parent
00:36:51.780
training in place. Other countries, again, would say, let's go to stimulants only if the other
00:36:58.760
treatments don't work first, just the way you talked about for depression. But again, if someone walks
00:37:03.640
into your office near a clinician with severe endogenous suicidal depression, you may not have
00:37:09.720
the wherewithal to wait that person out for week after week of cognitive behavioral therapy. You may need
00:37:15.340
to start medication soon, and then again, depression's another classic example. The best results for people
00:37:21.500
a serious depression almost inevitably are going to come from combining antidepressant medication
00:37:28.640
with cognitive behavioral therapy or interpersonal therapy.
00:37:32.040
All right. So going back to the title of the book, The ADHD Explosion, we talked about how this
00:37:35.880
explosion is probably causing, a big factor is increasing education demands on children. And so
00:37:42.700
there's the pressure on parents to diagnose their kid with ADHD so they can focus better and they get
00:37:48.040
drugs, etc. But also you're seeing this not just in school, but in corporations. I mean, we're now
00:37:53.780
competing with robots who don't have to deal, worry about focus or attention, etc. So we're not just
00:37:59.520
competing with other countries, we're competing with nanotechnology and robotics. Exactly. It's true.
00:38:04.820
So there's this culture and, you know, people want to want the limitless pill, like that movie
00:38:09.540
Limitless, where they just have complete focus, etc. I mean, it sounds like you don't think that's a good
00:38:16.720
thing because it stops people who actually have ADHD from getting the help they need and getting
00:38:21.220
people on powerful stimulant drugs that they don't need is not good for them. So what do we do as a
00:38:26.400
culture, right? There are these increasing demands for more focus, more attention for longer periods
00:38:32.720
of time. But how do we do that without saying, okay, just I'm going to say I have ADHD so I can get
00:38:37.160
the drug? Yeah. And there's a big concern that many adults are going in for ADHD diagnosis to get
00:38:44.800
this performance enhancement edge. So let's totally start with devil's advocate position.
00:38:50.740
I've never had a cup of coffee in my life. Most everybody I know does. Well, that's a performance
00:38:55.680
enhancer. Aren't stimulants just like caffeine? What's the big problem? So number one, stimulants,
00:39:04.560
if you don't have ADHD, will keep you up later. Lack of sleep is one of the side effects.
00:39:09.260
They will perhaps help you get that term paper that's due tomorrow morning. You've put off,
00:39:15.760
worked on all hours of the night. But if you have ADHD, medications will actually help improve
00:39:24.980
some crucial aspects of your learning. Again, they need to be combined with educational support to
00:39:30.280
really get the maximum benefit. So if you don't have ADHD, however, you're just looking for that
00:39:38.760
performance edge. How do the medications help your cognitive skills? The first big study on this
00:39:45.240
was done a couple of years ago out at University of Pennsylvania, where 42 typically developing
00:39:52.180
college students without any ADHD went on a seven-week long, some weeks on actual medication
00:39:59.460
stimulants and some weeks on placebo. And each week got a partial battery of tests of verbal learning
00:40:06.300
ability and working memory, cognitive functions. The answer on none of those 13 tests did the
00:40:13.740
medications provide benefit for these typically developing college students, whereas they would
00:40:19.120
for people with ADHD. The 14th scale, not a test, but a questionnaire used in this study was how well did you
00:40:30.000
think you did on your test this week? It's pretty easy to tell if you've had a stimulant versus placebo
00:40:34.540
because of some of the side effects. And there was a huge effect. People on the medication that week
00:40:40.440
thought they were doing better on their tests. So one of the conclusions of the study is if you're a
00:40:44.900
normal adult, stimulants are really good at boosting your false self-confidence and your learning
00:40:50.320
abilities. The real downside though is if you have ADHD and get good medical care and you're an adult,
00:40:59.420
the odds of your getting addicted to stimulants are very low. In fact, some of the genes for ADHD predict that
00:41:06.660
you don't really get a high from stimulants, you get a little more subdued. But if you're the quote average
00:41:12.960
person out there looking for a performance edge and you start to take stimulants more and more, there's about
00:41:18.120
a 15% risk that you'll get highly addicted to stimulants. That's not a good picture. Two words, breaking bad
00:41:24.780
would give what happens when you get into meth addiction, for example. So I think we're kidding
00:41:30.520
ourselves as a society to think that if everybody just took stimulants or we put them in the water
00:41:36.520
supply the way we do fluoride, we'd be making America a much more economically viable country.
00:41:43.320
I think it would be serious health risk and it's not doing what we really hope it would be doing.
00:41:48.180
That's interesting. I thought that was interesting that people thought they were performing better
00:41:51.920
on the drugs, even though they weren't. Because I can see how that would happen. You're like,
00:41:55.440
oh, I'm taking the pill. So I don't have to really...
00:41:57.660
Taking the pill. I must be... The juices are flowing. I'm doing it right.
00:42:00.900
I don't have to work as hard on this because the pill will do it, but it's not.
00:42:05.440
All right. That's interesting. So basically, if you don't have ADHD,
00:42:09.060
taking a medication isn't going to help you. It's going to leave you jittery and feeling weird.
00:42:12.660
I think it's going to leave you jittery. It'll keep you up later. Maybe you do it once or twice
00:42:16.120
if it's life or death that you get the job done the next morning. But don't think that you're
00:42:20.800
going to be neuro-enhanced permanently by taking stimulants. I think that's a myth.
00:42:25.860
Well, this has been a great conversation. You got a new book out, Another Kind of Madness.
00:42:30.260
This is a more personal book, much more personal book than the ADHD explosion. He talks about
00:42:34.620
Another Kind of Madness and why you felt like you needed to write this memoir of mental illness
00:42:40.280
Another Kind of Madness. This is a James Baldwin line from one of his masterpieces, Giovanni's Room,
00:42:46.900
where he talked about the madness of remembering too much or forgetting too much and another kind
00:42:51.960
of madness. And my editor and I, Karen Wolny of St. Martin's Press, my great editor,
00:42:58.380
were discussing this year ago saying, well, another kind of madness, madness, the archaic term
00:43:03.200
for mental illness, is the stigma and shame surrounding mental illness. It's worse in its consequences
00:43:09.620
than ADHD or schizophrenia or bipolar illness because then it's shameful and you can't talk about it
00:43:14.720
and can't get treated. So the brief version is, my sister and I growing up in Ohio, Columbus, Ohio,
00:43:22.280
our parents taught at Ohio State years ago, kind of an idyllic childhood, right? Except that
00:43:27.660
from time to time, dad, a very brilliant philosopher, would vanish for three or six or even 12 months at
00:43:35.260
a time. But we didn't know where he went. We didn't know if he was alive or dead. When he'd come back
00:43:40.380
one day without warning, no one could talk about it. His lead psychiatrist had told him,
00:43:47.080
if your children ever find out about your severe mental illness, they thought it was schizophrenia,
00:43:51.280
I later accurately diagnosed it as bipolar disorder, they'll be permanently destroyed.
00:43:55.880
You and your wife can never discuss with your children the reasons for your disappearance.
00:43:59.980
Would an oncologist tell a parent that the kids can't know about the parent's cancer? Well,
00:44:05.140
it's unthinkable. But that was the status of mental illness back then. It was so shameful
00:44:09.420
that you couldn't talk about it. So I, as a boy, took refuge in sports and in school and internalized.
00:44:18.140
Well, it must have been my fault dad left. Or maybe if I were a better son, maybe he'd come back
00:44:23.140
sooner. And of course, we don't want to talk about it and jinx it once he's back in the home.
00:44:26.760
It wasn't until I was 18. Coming back from the East Coast for my first spring break from college,
00:44:33.000
dad took me aside in a study at home, said, son, perhaps you should learn something of my life's
00:44:38.200
experiences and began to reveal at the age of 16, he thought he was saving the world from the growing
00:44:44.620
Nazi threat in the 30s because he'd learned to fly. Well, he was having a florid manic episode.
00:44:50.120
Nobody knew. He got hospitalized in a brutal back ward for six months. Happened again after he finished
00:44:56.180
grad school at Princeton studying with Albert Einstein and Bertrand Russell. So my dad was
00:45:01.960
a brilliant philosopher. But when he went into severe bipolar episodes, he was almost given up
00:45:08.400
for dead on back wards too many times. Once my dad told me, what a surprise, I became interested in
00:45:15.820
psychology sophomore year back at college. Maybe I could learn about kids and families and help solve
00:45:21.240
mental illness. Later in my career, I've dedicated my career to research and clinical work and
00:45:27.640
teaching in this area. I became really interested in stigma. Why is it still so shameful to even talk
00:45:34.260
about, of course, ADHD is in the news more, bipolar disorders in the news more. We as a society know a
00:45:41.180
lot more of the symptoms of mental illness. Our mental health literacy is high. But we actually have worse
00:45:47.040
attitudes in many ways than back in the silent 1950s and 60s when I was growing up. We know more,
00:45:54.300
but we're more afraid of it. Medications are taboo. There but for the grace of God go I. Most of the
00:46:01.320
mental hospitals have been closed. And so we confront severe mental illness on the streets of major cities
00:46:06.980
with homeless muttering people who frighten us. Another kind of madness is a deep memoir about my
00:46:13.600
experiences growing up, my transformation once I learned the truth, but also interwoven through the
00:46:20.840
text and the pages is a definition of this thing called stigma and the urgent need why we need to
00:46:28.840
reduce the stigma of mental illness. I think it's really mental health disorders are the last frontier
00:46:33.500
for human rights. And we're cutting off our society at its knees, so to speak, by refusing to
00:46:41.600
acknowledge mental illness. Cancer. You never had cancer in your obituary or your family member's
00:46:46.900
obituary back in the 30s, 40s, 50s. It was a shameful disease that the person brought upon himself or
00:46:51.720
herself. Cancer is a cause. The NFL dudes and the pro golfers wear pink in the big tournaments and games
00:46:59.420
because people talk about their experiences and their struggles. If we can get personal narratives of
00:47:05.920
everyday experiences of mental health, it won't be last on the national agenda. So that's the reason
00:47:11.660
for another kind of madness, blending a really deep family narrative with the urgent need to reduce the
00:47:19.120
stigma of all forms of mental illness. I thought it was interesting you said that we know more about
00:47:23.840
these mental illness, but there's more of a stigma than there were 50, 60 years ago. Why do you think
00:47:29.660
that is? Why do we still have more of a stigma than, say, the 1940s? Right. I mean, it's the $64
00:47:36.620
jillion question, right? I mean, so here's one partial answer. We know that, and some of the work
00:47:44.140
we're doing now is with high school and even middle school kids to increase mental health literacy.
00:47:50.480
But the right way to do this is not to simply go in and teach, this is what someone with schizophrenia
00:47:55.480
looks like. Here's our symptoms. Here's bipolar disorder. Here's PTSD. Here's ADHD. There's high
00:48:00.900
school psychology courses now. Kids learn these symptoms and facts, but what they often learn is,
00:48:07.340
oh, you mean someone with depression might get suicidal? Well, why would you want to take your
00:48:11.940
life? Oh, people with schizophrenia hear voices? That's scary. Facts are good. We don't want to have
00:48:17.140
an ignorant culture, but what needs to be taught is many people with schizophrenia with the right
00:48:21.820
treatment can lead successful lives. The same is true for bipolar disorder. The same is true for
00:48:26.540
PTSD. It's contact. It's opening up the shame and silence coming out of the closet. It's a kind of
00:48:34.080
emotional knowledge about, yeah, there's a lot of depression in my family, or there's eating disorders in
00:48:39.620
some of the women relatives or friends of mine, and people struggle with it but can get better with
00:48:46.360
treatment. The ultimate paradox is that if we still stigmatize it, we still have these kind of
00:48:52.380
primitive attitudes. People with mental health conditions pick up on the stereotypes. If you start
00:48:57.980
to self-stigmatize, you feel you're not deserving of treatment. You don't get into it or you drop out
00:49:03.240
early, so now the vicious cycle continues. So the bottom line is we want to teach facts about mental
00:49:09.800
health. We don't want to be ignorant, but I think what we really need to enhance more is humanization
00:49:14.940
and empathy and contact. That's the knowledge I think that will help overcome stigma.
00:49:19.820
Fantastic. Well, Stephen Shaw, this has been a great conversation. Where can people go to learn
00:49:25.880
So my last name is Hinshaw, H-I-N-S-H-A-W. Just Google me, Stephen with a P-H, Hinshaw. My author
00:49:34.680
website is Stephen P. Hinshaw.com. I'm growing even at my age with social media, Facebook, etc., etc.
00:49:47.240
Google me, Hinshaw at Berkeley.edu, B-E-R-K-E-L-E-Y.edu is my main email address, and
00:49:57.360
www.stepenhinshawauthor.com will get you into the many books I've written on these topics.
00:50:04.640
Well, Steve Hinshaw, thank you so much for your time. It's been a pleasure.
00:50:07.300
This has been great, and would love to come back anytime and talk your ears off about all the
00:50:12.860
other topics in mental health that are really important. Thank you so much.
00:50:15.660
My guest is Steve Hinshaw, and his book is The ADHD Explosion. It's available on Amazon.com and
00:50:20.560
bookstores everywhere. Also check out his latest book, Another Kind of Madness. It's a memoir about
00:50:24.660
growing up with his father who had a mental illness. A lot of great insights about how we
00:50:28.520
stigmatize mental illness in America today and what we can do about that. You can find out more
00:50:32.020
information about the book also at ADHDExplosion.com. Also check out our show notes at aom.is
00:50:37.640
slash ADHD for links to resources where you can delve deeper into this topic.
00:50:41.380
Well, that wraps up another edition of the Art of Manliness podcast. For more manly tips and
00:50:57.680
advice, make sure to check out the Art of Manliness website at artofmanliness.com. If you enjoy this
00:51:02.140
show, I've gotten something out of it over the years, I'd appreciate it if you take one minute to
00:51:05.100
give us a review on iTunes or Stitcher or whatever podcast thing you use to listen. Helps out a lot.
00:51:10.360
As always, thank you for your continued support. Until next time, this is Brett McKay telling you to stay