The Art of Manliness - #320： The ADHD Explosion

00:00:00.000 Brett McKay here and welcome to another edition of the Art of Manliness podcast.

00:00:17.980 Well, you've probably heard about the precipitous rise in diagnoses of ADHD in America the past

00:00:22.560 few decades. What was once a rare mental illness has now become a common problem amongst children,

00:00:27.100 particularly boys? Why the sudden spike? And are there really more people with ADHD or something

00:00:32.460 else going on? My guest today has some possible answers to that question. His name is Steve

00:00:36.400 Hinshaw and he's professor of psychology at UC Berkeley. In his book, The ADHD Explosion,

00:00:41.240 Dr. Hinshaw gives the lay reader a crash course into ADHD and provides some insights as to why

00:00:46.000 we're seeing such a huge spike in the number of individuals diagnosed with it. Now we begin our

00:00:50.220 conversation talking about exactly what ADHD is and how it impairs individuals. We then discuss

00:00:55.240 the biological and environmental factors that go into ADHD, debunk some of the myths surrounding

00:00:59.900 it, and discuss which treatments actually work. And then Dr. Hinshaw delves into his research,

00:01:04.660 which shows that the rise of ADHD is not because more people are actually developing ADHD, but rather

00:01:10.300 that there's cultural and economic forces in schools, corporations, and governments that

00:01:14.860 incentivize shoddy diagnoses. We also discuss the fact that ADHD medication is often used by people

00:01:20.180 who don't actually have ADHD or perform better, and whether it actually improves performance for

00:01:24.940 these folks or not. We're in our conversation discussing his latest book, Another Kind of

00:01:28.660 Madness, talking to a memoir about his father and his mental illness. And it's about mental

00:01:34.060 illness in general and how we stigmatize him today and what we can do to stop that. So if you know

00:01:37.860 someone who has ADHD, this podcast will provide a lot of insight about a condition few really

00:01:41.860 understand. After the show's over, check out the show notes at aom.is slash ADHD.

00:01:46.640 ADHD. Steve Hinshaw, welcome to the show.

00:01:53.420 Thanks so much for having me on. I'm eager to get rolling.

00:01:56.060 So you co-authored a book called The ADHD Explosion. ADHD, it's one of those things that has,

00:02:02.880 I feel, is imbued in the popular culture. Like everyone talks about it. People will flippantly

00:02:07.960 say, oh, I've got ADHD because they're having a hard time focused. I think it's important. Let's

00:02:12.840 start off with definitions. Let's be Socratic here, right? Let's do it like what Socrates did

00:02:17.080 and start off our conversation. What exactly is ADHD and what does it feel like to have ADHD? Is

00:02:24.440 it simply you can't focus or is it something more? Yeah, this is a great starting question. So ADHD

00:02:29.560 is the alphabet soup acronym for attention deficit hyperactivity disorder. Some years back, it was

00:02:38.040 called ADD, attention deficit disorder. Some years before that, it was called hyperactivity or

00:02:43.880 hyperkinesis. And back 60 plus years ago, it was called MBD, minimal brain dysfunction. So it's had a

00:02:51.380 lot of name changes over the years, which I think adds to the confusion and mythology. So what is ADD or

00:02:58.700 ADHD? Is it just I spaced out, I couldn't focus? It's actually much more than that. There's a lot of

00:03:07.280 theories about what goes on in the brains of people who have legitimate ADHD. So attention is

00:03:14.100 part of the name of this. But it's not simply an attention deficit. It's not simply not paying

00:03:20.340 enough attention. It's the lack of ability to regulate attention according to what the situational

00:03:27.040 demand is. So many kids in classrooms or adults on the job have difficulty sustaining attention because

00:03:35.860 someone else is calling the shots and hard to keep your motivation up. But those same individuals,

00:03:41.620 they get on a video game, for example, and there's hyperfocus. You can't shut it off. Hours later,

00:03:47.920 it's like, where did the world go? So it's a myth to think that ADHD is just poor attention. It's a

00:03:54.740 dysregulation of the ability to pay attention. So that gets us into some of these other elements.

00:04:00.180 Maybe it's broader than attention. There's these modules in our brain called executive functions.

00:04:08.020 Maybe what really separates us from the other primates and animals. You get up in the morning

00:04:13.180 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

00:04:19.360 way I should. I've got to correct errors and I've got to suppress this distraction coming in and keep on

00:04:25.300 track. I've got to hold things in memory called working memory, the ability to remember short

00:04:30.760 strings of data. All of these are executive functions. And another theory is that ADHD

00:04:36.040 is really an executive function deficit, way beyond attention. It's not how smart you are,

00:04:42.720 but it's your ability to navigate and follow a plan through a day and correct errors when they come in.

00:04:47.540 It may also be that in another theory of ADHD, it's your ability to inhibit a response that you've

00:04:57.160 done a lot in the past. So kids with ADHD get into trouble a lot with their peers, not just at school.

00:05:04.560 And as I sometimes tell parents groups, these are the kids who at the wonderful birthday party blow out

00:05:12.100 the candles, but then they remember and all the kids tell them instantly, it wasn't your birthday.

00:05:16.900 It was the other kid's birthday. Those candles were flaming, the cake icing was green and blue and

00:05:23.200 looked beautiful, but it was very hard to inhibit that tendency to blow out the candles because you've

00:05:28.780 done it before it's your own birthday. So another theory of ADHD is if you have trouble suppressing or

00:05:35.340 inhibiting these previously rewarded responses, you'll never get a chance to pay attention well or use your

00:05:42.060 other executive functions. Finally, in the little mini lecture here, another view, not incompatible

00:05:49.960 with the first three, is that people with ADHD have trouble generating intrinsic motivation,

00:05:57.280 always needing someone else to kind of lean on them, provide reinforcers, because probably there's

00:06:05.540 just not enough dopamine flowing in some of the dopamine circuits in the brain. And we'll talk

00:06:10.480 about genes and brains in a little bit, I think. But if you have that problem with gaining that intrinsic

00:06:17.520 kind of control of your motivation, you're always kind of relying on the outside environment to set the

00:06:22.660 agenda. You put those things together. And for a person with ADHD, the world can often seem as a

00:06:30.300 constant bed of noise. It's hard to know wheat from chaff, figure from ground. What should I be paying

00:06:37.900 attention to? What's coming in? And of course, in today's social media world, there's stuff coming

00:06:43.320 in all the time. Maintaining your goals, sticking with them, keeping that focus in the face of

00:06:49.640 distractions. It's hard for everybody these days. But if you've got ADHD, multiply that by 10 or 50.

00:06:56.020 And I think that would be kind of a little worldview as to what it would be like day to day if you have

00:07:02.560 this condition. And let's talk about the adverse effects of this condition. We'll unpack some more

00:07:07.280 because there's some other stuff you talked about. But I'd like for our listeners to have an idea of

00:07:10.480 how this negatively impacts individuals. Often when we talk about ADHD, it's often focused on kids in

00:07:16.960 school. And I think we understand that. That's right. And we know that ADHD isn't just a kid

00:07:21.820 disorder anymore. It can last into adolescence and beyond. But you're right. School is the place

00:07:28.120 where this is often identified. Because if you have problems focusing and regulating attention and

00:07:34.580 inhibiting your impulses and developing intrinsic motivation, schoolwork is a teacher yakking in

00:07:41.240 front of you and all these assignments. And it's a morass and it's hard to sort it out. So the vast

00:07:47.680 majority of kids and teens with ADHD are working behind their potential academically. And then

00:07:54.100 moving up on the developmental scale, many adults with ADHD are underperforming at work and have

00:08:02.740 checkered employment histories. Not because they're not competent, not because they're not smart,

00:08:06.820 but because what do you have to do at work? You take that new job and boy, it didn't go so well.

00:08:13.680 Maybe you shouldn't send that nasty email to your boss the first afternoon, right? You got to keep

00:08:19.400 it in check a little bit and wait and see how things go. But if the immediate press of that negative

00:08:26.180 experience motivates you to send that email immediately, it gets you into hot water. So

00:08:31.340 academics and vocational performance. Number two, as I just mentioned a moment ago,

00:08:37.060 people with ADHD have problems in interpersonal relationships. It's not just not paying attention

00:08:43.580 to school assignments. It may not be paying very good attention to one's own behavior in a social

00:08:50.340 setting or paying enough attention to the facial emotions that you're seeing from that person sitting

00:08:56.860 across from you. Kids tend to dislike kids with ADHD more than they dislike kids with other

00:09:04.420 behavioral and emotional problems because of that impulsivity. Because those are the kids who

00:09:09.440 let the soccer ball fly by them when they were goalie because they were more interested in the

00:09:13.940 clover or they blew out the birthday candles, even though it wasn't their party. It was the other

00:09:18.080 kids party. And for adults, we know that people with ADHD have nearly double the divorce rate and real

00:09:26.580 difficulty sustaining intimate relationships because of impulse control problems and sometimes anger

00:09:32.540 management problems. A third one is really crucial. People with ADHD, whether you're five or 16 when you

00:09:41.640 start to get that driver's license or well above, have massively high rates, more so than the rest of

00:09:49.220 the population of accidental injuries. Car crashes, injuries at school or on the job, preschoolers with ADHD

00:09:57.320 have a higher death rate than other preschoolers. They climb on the wrong places and jump in front of

00:10:02.800 cars. So it's not just the stereotype of this is a fidgety, bothersome kid in a boring classroom and it's just

00:10:10.340 a classroom issue. If you've got severe ADHD, you're going to have problems regulating your impulses and

00:10:16.840 keeping yourself safe in a lot of different environments. So school and job, social relationships,

00:10:24.340 accidental injuries, to me are some of the top three impairments, as we sort of call them in the

00:10:30.060 lingo, that too often accrue from these symptoms. Okay. I'd like to later on delve deeper into the

00:10:36.660 differences in how ADHD affects men and women. We'll talk about that because I thought it was

00:10:40.680 interesting. As you were talking about what is ADHD, you said theory a lot or like we had this idea.

00:10:48.320 Why is it sort of nebulous? Do like scientists know for sure? Is it sort of like depression where

00:10:52.880 they think it's this thing could be serotonin, it could be environment? Is that what's going on

00:10:57.480 with ADHD? We've made a lot of scientific progress over the last couple of decades to get far closer

00:11:04.320 to some of the core genetics and biology of ADHD and to what goes on in the environment that may

00:11:11.580 trigger it too. So let me talk about that for a few minutes because the research is really interesting.

00:11:17.020 Like depression, like schizophrenia, like bipolar disorder, like PTSD, all mental problems,

00:11:24.300 behavioral and emotional problems, the brain's a hugely complicated organ, 100 trillion synapses

00:11:29.340 firing all the time. We don't yet have complete answers or cures, but we're getting closer.

00:11:35.400 So number one, think of the people you know. Some are highly focused and regulated and conscientious.

00:11:41.920 Others are, boy, a gnat comes in the next county and that bug miles away has distracted you. And most

00:11:49.560 of us are in between. So are genes mainly responsible for those differences in focus and concentration

00:11:56.920 and attention or environments? It turns out that genes are 80% responsible about for the differences

00:12:04.880 between you and me and how focused and regulated we are. We know this from twin and adoption studies.

00:12:10.560 Turns out that the symptoms of ADHD are more based in genetic liability and risk than is the case for

00:12:19.060 depression. It's up there with bipolar disorder and autism as three of the, what we call most

00:12:25.860 heritable or genetically vulnerable conditions. However, the second I say that, this does not imply

00:12:32.280 that early environments are not important. So prenatally, a host of toxic chemicals,

00:12:40.560 cigarette smoke, alcohol can also influence ADHD symptoms. Early child rearing does not seem to be a big

00:12:50.040 cause of ADHD. In fact, if you have the precursors of ADHD in your toddler years, you're somewhat more

00:12:58.320 ornery and intense. Parents tend to fight fire with fire and get controlling with the kid. The parents are

00:13:06.480 responding to the kid's, quote, biological differences. But those parental responses now pour a bit of gasoline on

00:13:14.560 that fire and we get a vicious cycle. Parenting is not the cause of ADHD, but parenting, getting locked into these

00:13:22.900 negative cycles, can clearly contribute to the worsening of ADHD and the addition of more aggressive behavior,

00:13:31.940 sometimes depression. So parenting is a huge treatment-related factor. We don't want to blame

00:13:38.240 parents, maybe except through the genes they transmitted, but we don't want to remove the

00:13:44.240 responsibility from parents to get actively involved in family therapy, behavioral therapy, because that

00:13:50.240 can make a big difference. There's a lot of interest these days in toxic chemicals, pesticides.

00:13:55.960 We don't have the definitive research yet, but it may well be that if you're born with some of

00:14:03.180 these genes that make you somewhat vulnerable to lapses in attention and concentration and

00:14:08.420 self-regulation, you may be more susceptible than others to the early exposures you might get to toxic

00:14:15.020 chemicals. Let me mention quickly diet. 40, 50 years ago, everybody sort of thought that hyperactivity

00:14:22.020 could be cured with an additive-free and sugar-free diet. That's largely a myth has been discounted,

00:14:28.180 but more recent good research does show that especially some of the dyes and additives and

00:14:35.360 especially for kids under eight or nine years of age, they're not the cause of ADHD, but if you've got

00:14:42.160 the liability or vulnerability, they may add a couple of symptoms to the mix. So dietary treatments are not

00:14:49.600 the core evidence-based treatment for ADHD, and I know we'll talk about treatment in a few minutes,

00:14:54.180 but it may be part of a holistic treatment plan. Okay. Well, your book is called The ADHD Explosion.

00:15:01.540 So let's talk about that. How many people, when you say in America today, have been diagnosed with ADHD?

00:15:07.380 Well, this is a great question, and we haven't really known the answer very well until fairly recently,

00:15:13.720 because unlike Europe, Scandinavia, other countries where there's national databases of everybody

00:15:21.060 from birth throughout their life and every medical record all put together, United States,

00:15:26.660 it's much more hit or miss. But about 15 years ago, the Centers for Disease Control and Prevention

00:15:32.860 started to add to a big national survey of parents, a national survey of children's health,

00:15:39.820 some questions about ADHD. This isn't just people in clinics. This is 100,000 people every few years,

00:15:46.360 random phone dialing, so it's a representative sample. What do we know? Back about 2003 or right

00:15:54.880 around that time, about 7.5% of kids in the United States, as reported by their parents, had either

00:16:04.020 received an ADHD diagnosis or a health professional had told the parent, yes, your kid has ADHD.

00:16:09.820 Interestingly, that's the world average. ADHD is not just an American thing. It's in every country

00:16:17.600 on the planet that has compulsory education. We'll talk about education shortly, too. So somewhere

00:16:24.620 between 5, 6, 7% is the world average in just about every country on earth. But in the U.S.,

00:16:33.000 the National Survey of Children's Health was repeated five years later and then repeated five years after

00:16:38.100 that. Between 2003 and about 2013, the last year we've got good data, ADHD diagnoses went up by 42% in

00:16:49.320 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

00:17:00.720 girls. So this means about 15% of all boys. So this means about 15% of all boys. And if you're a boy

00:17:05.340 above about 10 or so, these recent data, the most recent data we have suggests that almost one in five,

00:17:14.900 almost 20%, have had an ADHD diagnosis. Finally, in a few states, often southern states, rates of ADHD

00:17:24.140 ADHD diagnosis are even higher. And there's a few states, Arkansas, North Carolina, even Indiana

00:17:31.080 in the Midwest, where about one in three teenage boys have received an ADHD diagnosis during their

00:17:39.320 short lifetime. Things are going up really fast. The United States is way above the world average now.

00:17:48.920 So this is probably not because ADHD-related genes have mutated in the United States in the last 15

00:17:57.360 years. Darbin would turn over in his grave. Genetics doesn't work that way. There's something about

00:18:03.860 the recognition of ADHD or perhaps the shoddy diagnoses that we too often tolerate. Most kids with

00:18:12.400 ADHD get diagnosed in a 10 or 12-minute office visit with a pediatrician. And as Richard Scheffler,

00:18:20.240 my co-author of the ADHD explosion, he's a great health economist. And I said in one of the key

00:18:26.160 chapters, the regions in the U.S. where the rates of diagnosis have gone up the most explosively in the

00:18:34.080 ADHD explosion, especially for kids near the federal poverty level, are those states that really push

00:18:42.300 testing accountability in schools. Now, accountability laws in schools really don't have much of anything

00:18:48.160 to do with ADHD. But those school districts in those states that really push achievement or bust

00:18:54.600 are driving up very quickly high rates of ADHD diagnosis, in part because the districts want to get

00:19:01.220 those kids treated so their test scores can improve. And more cynically, in some states,

00:19:07.080 if you got an ADHD diagnosis for a kid, that kid was thrown out of the district's test score pool.

00:19:13.080 So there was a kind of insidious trying to get kids labeled to boost the district's test scores.

00:19:19.400 Educational policy may be artificially pushing up rates of ADHD in the United States beyond what they

00:19:26.340 should be. So what you're saying there then is that maybe what's going on is really there's not more

00:19:31.080 kids with ADHD. There's just more kids being diagnosed with ADHD because of these pressures

00:19:36.400 from school systems, etc. Now, I'm glad you put it that way. So let's play devil's advocate.

00:19:44.320 One causal factor for ADHD is being born at a very low birth weight, which is, of course,

00:19:50.520 associated with preterm birth. The lower your birth weight, being born 28, 30, 32 weeks rather than the

00:19:58.700 full 40 is a risk factor for hyperactivity and learning problems at more severe low birth weight,

00:20:05.140 cerebral palsy, Tourette's disorder. 30 years ago, most of those kids didn't survive. But now with great

00:20:12.900 neonatal intensive care units, more and more of these kids are surviving. So that may be a reason for at

00:20:20.060 least a small increase in actual ADHD, the true prevalence. But what we were just talking about is

00:20:27.600 what's also called diagnosed prevalence. Maybe, I think, and a bigger contributor is more kids are

00:20:35.240 getting diagnosed with ADHD artificially, again, or as the result of pretty shoddy diagnostic processes,

00:20:42.120 even though the true rate has probably stayed pretty much the same over the last decades.

00:20:47.640 So let's talk about how diagnoses should be made. Because I think that's one thing you hear a lot

00:20:52.960 of parents pushing back against nowadays in their schools that they're a counselor or school

00:20:58.300 psychologist is saying, well, you're, particularly with boys, your boy can't sit still and focus and

00:21:05.200 et cetera. And, you know, most parents be like, well, he's just, he's being, he's acting like a boy.

00:21:09.680 Boys like to move. 1.00

00:21:10.900 That's right. He's all boy. It's the Tom Sawyer syndrome, right? Et cetera, et cetera.

00:21:15.320 Right. And then they're like, there's a pressure to get on the drug so they can stay focused,

00:21:19.140 whatever. So like what makes like a true ADHD diagnosis? Like what is involved in order to

00:21:23.920 make sure like you were actually getting diagnosed correctly with ADHD?

00:21:27.220 Yeah. I'm glad you asked this because it's, it's a complicated answer and it's a not,

00:21:31.360 it's not a short answer because a proper diagnosis isn't something done in a quarter of an hour.

00:21:36.700 As with depression, schizophrenia, bipolar disorder, PTSD, we still don't have a blood test,

00:21:42.980 a biomarker, a brain scan that can unequivocally diagnose any mental disorder. We're just not that

00:21:51.020 advanced in our science yet. So ADHD is actually intriguingly a kind of low tech diagnosis, meaning

00:21:58.560 the doctor, the psychologist, the clinician has to talk with the family. So we're talking about child

00:22:05.260 diagnosis now for a long time first to get a developmental history. What was infancy like?

00:22:11.660 What were the toddler years like? When, when did speech and walking come in? Has to get a birth

00:22:16.640 history, et cetera, et cetera. Toxic drugs might've been used, et cetera, et cetera, too. Beyond that,

00:22:24.100 are there other factors? Maybe this kid was maltreated. If you've been physically or sexually abused

00:22:31.040 for a period of time, you may have lapses in concentration that may look like ADHD.

00:22:36.940 One of the core symptoms of major depression and kids can get depressed is poor concentration.

00:22:41.980 That's usually because you're preoccupied with negative images of yourself. It's different from

00:22:46.540 ADHD, but the symptoms the same. So you have to do a big process of differential diagnosis,

00:22:52.400 meaning a long talk with the family in a semi-structured way to rule out other things.

00:22:58.600 Sometimes you've got to rule out a seizure disorder.

00:23:03.340 Then simultaneous with that, you've got to get parents and teachers to fill out quantified

00:23:10.780 checklists of the symptoms of ADHD, the symptoms of depression and other childhood disorders to get

00:23:18.340 you a numerical score. So you can compare that kid's score to other kids in his or her region,

00:23:24.600 other boys and girls of a national sample. It's not just, well, I think any given teacher in a given

00:23:32.560 year can say a certain percentage of kids are flaky or fidgety or unfocused. You want to get a couple

00:23:37.720 of years worth of parent and teacher ratings to make a statistical comparison to see is the kid

00:23:43.480 really above, way above the norms of what behavior and focused attention should be.

00:23:49.420 Then there can be cognitive testing, achievement testing. Is this a product of a learning disability?

00:23:59.520 If you put this together, this is a several hour process at minimum. I have major federal research

00:24:06.720 grants. We put kids and families through a 10 hour battery. Of course, no clinician can afford that.

00:24:11.440 Insurance won't reimburse it. You've got to make darn sure that this kid is way extreme on inattentiveness,

00:24:20.200 impulse control problems, for some cases overactive, fidgety behavior, and has objective information

00:24:27.960 and a good history to make sure it's ADHD and not one of the many other things, just normally high

00:24:35.200 temperament, abuse, maltreatment, a seizure disorder. You've got to rule those out to make sure that the

00:24:40.060 diagnosis is accurate. Once you do that, and once you work with kids like this, and teens and adults

00:24:46.680 like this, and realize this isn't just fidgety behavior. This isn't just sort of social constructivism

00:24:53.160 101. These are kids who get into serious trouble in school. These are kids who injure themselves.

00:24:59.700 Sometimes the head injuries kids with ADHD receive exacerbates their symptoms and you get into a vicious

00:25:05.720 cycle. ADHD is serious business, but in our culture wars these days, and because of the shoddy

00:25:12.740 diagnostic practices we allow, social critics have a field day. Too many boys get diagnosed

00:25:20.260 cursorily, and then they get put on ADHD drugs or medications, and we're not dealing with societal

00:25:26.740 problems. The reality is far more complicated than this, and it starts with a really good diagnostic

00:25:32.380 workup. Okay. Yeah, because I mean, I've heard instances of friends even who their diagnosis was,

00:25:37.660 they wouldn't talk to their family doctor for 20 minutes, and then they got a prescription for

00:25:41.940 Ritalin. Which is too often the case, especially in the United States. We still have the highest

00:25:47.460 medication rates in the world in the U.S. Other countries really emphasize other forms of treatment

00:25:53.840 first. But I'll tell you, the rest of the world is catching up, and healthcare is in crisis. If you

00:26:00.240 haven't been following the news lately, both here and around the world, and I think it's a matter of

00:26:06.860 pay now or pay later, if we invest in really careful diagnoses, so we catch the kids who really

00:26:12.940 deserve a diagnosis and don't over-diagnose or under-diagnose, and give the right treatments at

00:26:17.800 the right time, we're saving families untold misery, and we're saving countless billions in our

00:26:25.260 economy years down the road. But that's not often how it works in the health policy world.

00:26:29.580 Okay. So yeah, what it sounds like here, the diagnosis for ADHD should be very thorough. And

00:26:34.040 perhaps if a teacher or a counselor tells a parent, like, your kid thinks he has ADHD,

00:26:40.280 you might want to explore that, but don't just rely on some sort of thumbnail sketch diagnoses.

00:26:45.640 Thumbnail sketch diagnoses lead to over-diagnosis, of course, but also intriguingly under-diagnosis.

00:26:51.680 The doctor might say, gee, he or she was sitting so nicely in the waiting room, it can't be ADHD.

00:26:57.760 Or, man, the parents report that he can play video games for eight consecutive hours. Well,

00:27:02.120 that might be hyper-focus, one of the symptoms of ADHD. You've got to, you diagnose ADHD not in

00:27:07.900 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 0.98

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 0.99

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 0.86

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 0.99

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 1.00

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, 0.97

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

00:42:39.740 in your family.

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 0.98

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 0.75

00:48:21.820 treatment can lead successful lives. The same is true for bipolar disorder. The same is true for 0.95

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

00:49:23.520 more about your work and book?

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

00:51:14.840 manly.

The Art of Manliness - July 11, 2017

#320： The ADHD Explosion

Episode Stats

Summary

Transcript