Is My ADHD Real? with Stephen Hinshaw
Factually! with Adam Conover #116 August 3, 2021
Ever since he was diagnosed as a kid, Adam has wondered if ADHD is a serious psychological condition, or a false diagnosis pushed by an overzealous industry. This week Dr. Stephen Hinshaw, Professor of Psychology at the University of California, Berkeley is on the show to help answer these questions. You can check out his book The ADHD Explosion: Myths, Medication, Money, and Today’s Push for Performance at factuallypod.com/books.
Hear the Episode
Speaker 1 [00:00:00] Hello everyone, welcome to Factually. I'm Adam Conover, thanks again for joining me and listening to the show. I'd like to talk about something a little bit personal today. Maybe I've discussed this on the show before, but never in great length. It's something that's really a part of myself, something I've struggled with for a long time, let's just jump into it. As a kid, I was diagnosed with ADD, or attention deficit disorder. It was later called ADHD but I was diagnosed really early and they hadn't put in the 'H' yet. I was really an ADD hipster, I guess, whatever you want to call me. It's one of the most complicated things about me. And we're going to spend the whole episode today talking about it, so it's kind of a special one. It's a very special episode in these sort of sitcom 'Blossom' mold, I suppose. If you will. My main memory as a child was people telling me that I wasn't able to focus: my dad telling me, 'Focus on your objective,' which is an, an odd thing to tell a five year old. People would say, 'Adam, you're jumping out of your chair so much.' That kind of thing. I don't remember not being able to focus. I remember adults telling me that I couldn't, until eventually they said I was so disruptive that they took me to see a psychiatrist and that psychiatrist diagnosed me with ADD and they prescribed me Ritalin. And I took Ritalin for many, many years that I was in school. I actually don't remember that much about it, quite oddly. I think I stopped taking it at one point. Then a couple of years later when I was in college, I found for the first time I was actually starting to struggle to focus on things that I wanted to focus on. I was not able to do the reading that I wanted to do, even as much as I wanted to do it. So I went to see another psychiatrist and they confirmed my diagnosis and they gave me Adderall. I took Adderall for many years throughout college and in the years afterwards and let me tell you something, it did help me study in some ways. It helped me really focus on learning German, a little bit less so on reading philosophy. It also helped me a lot at focusing at playing video games and sweeping my dorm room floor at 2 A.M.. Adderall is a complicated drug. It's amphetamines for those of you who don't know, it's simply amphetamines. It has the effects that amphetamines do. It gives you trouble sleeping and it can make you a little bit obsessive. It's often prescribed to kids with ADD, and it often seems to work. But there are real drawbacks. About halfway through my 20's, I realized, 'Hold on a second. I'm taking all this Adderall. I'm taking all this amphetamine. I'm drinking, I'm smoking. These things are all creating a house of cards of substances. This is not going great for me.' And so I quit taking Adderall, and soon after that I quit smoking. Took me another 10 years to quit drinking and that's a whole other story you can hear about the episode we did on addiction. That episode is with Judith Grisel. We did that a few years ago, check out that episode if you'd like to hear about that part of my story. Suffice to say in my mid-twenties, I quit Adderall and I stopped thinking about ADD quite so much. The weird thing is that it's in the time since then, in the time since I quit, that everything good that I value in my life has happened. That's the time during which I built a career in comedy, during which I started doing standup, during which I started running my own television show and we made 60 plus episodes of TV. I'm working on a new show for Netflix now. I run a writers room. I get through all my emails. I do all this shit, right? And that makes me think, 'Well, hold on a second. What was this diagnosis? Did I really have something called ADD?' Or was this something that my parents, that a psychiatric industry, that a pharmaceutical industry pushed on me that I didn't really need? That didn't really reflect who I was. So I started looking into this recently, and what I found is that I was on the upswing of a massive ADD wave in America. It was a trend, just like I've talked about in my work so many times, an idea that swept the country and that changed the way that we treated many, many children in our society. ADD diagnoses increased massively in the 90's, and stimulant use in kids with ADD increased by four times from 1987 to 1996. It was in that early period that I myself was first diagnosed and prescribed a stimulant. It's indisputable that that rise in diagnoses and prescriptions was to some degree driven by the pharmaceutical industry and its relentless marketing of its drugs. So again, put all that together, and maybe I never really had ADD. Maybe it's not true about me. Maybe I should rethink this very deep part of my self conception. And then on the other hand, I try to sit down and write a script for a couple hours, or I try to sit down and read a book I'm interested in, or I try to sit down and watch a whole baseball game and I can't fucking do it. I can't do it. I am like a bird constantly alighting off of a wire over and over again, I gotta wait for myself to settle back down, peck a couple of words into that script until I fly off again and need to go make myself a sandwich or text a friend or something like that. In reality, I still do struggle with attentional issues every single day. So what is it? Is ADD real or is it fake? Is it a serious medical psychological condition or is it imposed upon us by the pharmaceutical industry and by frightened parents run amok? I've never known. The answer to this question is something that I have been puzzling through for years, and I continue to puzzle through and on the show today we have a wonderful expert who is going to help me confront some of these issues and help lay out the science of what we do and do not know about attention deficit disorder. So to that end, please welcome Stephen Hinshaw. He's a professor of psychology at Berkeley and the author of 'The ADHD Explosion: Myths, Medications, Money and Today's Push for Performance.' Please welcome Stephen Hinshaw. Steve, thank you so much for being here.
Speaker 2 [00:06:28] Glad to be here.
Speaker 1 [00:06:29] This is going to be an important interview for me, personally, because I was diagnosed with what was then called ADD at a young age. I think I was on the upswing of the big wave of it, and it was a diagnosis that I struggled with for many years. I have had many different relationships with it throughout my lifetime, and this is my first time speaking with an actual expert on the topic. Other than the various psychiatrists and people I've spoken to who are very eminent, they have training and everything. But this is my first time speaking with someone who has actually studied the issue on a wider scale. So thank you so much for being here.
Speaker 2 [00:07:11] Delighted.
Speaker 1 [00:07:13] Well, let's start with the basics. What is ADHD? It's a very misunderstood diagnosis and a lot of people would even say it doesn't even exist. So that's what a lot of people think. What is it? Does it exist?
Speaker 2 [00:07:28] Yeah, it really does exist. It's a reality. But like depression and PTSD and bipolar disorder, we don't have an exact brain scan or blood test that says 'you've got' it or 'you don't,' like cancer or coronary artery disease. So we rely on people's opinions about themselves and what other people say, especially about kids with ADHD. And we have some tests that are helpful. So let's get to the point, what is it? We human beings have a bunch of traits and a whole bunch of cognitive functions and a bunch of emotions and some key traits are first: how organized and attentive and focused are you on average, especially when the material is really boring or rote or it's really challenging or hard. Some people thrive on that. Most people are in the middle of the bell curve, and some people just find it really hard to focus and regulate all the attentional mechanisms in their brains to keep on track. The other big domain is how impulsive are you; doing things on the spur of the moment, not thinking it through before, which is also associated with how fidgety and squirmy and how physically or mentally restless you are. So we got this dimension, it's like a scale, of inattention and disorganization and we've got another scale of hyperactivity and impulsivity. Some people, mainly because of the genes that are inside their DNA that they're born with but also because of other influences, are really on the high end of lack of focus and/or on hyperactivity or impulsivity. And if such people have real problems at school, real problems at jobs, real problems in the workplace, real problems with relationships, we tend to diagnose them with this thing called 'attention deficit hyperactivity disorder.' Let's make an analogy in medicine: blood pressure. I might walk in and the doc puts the sphygmomanometer around my left arm and squeezes it and it comes out as 140 over 90. Well, that's borderline high and actually with the newer standards I might be considered to have mild hypertension. Probably diet and exercise, let's monitor it. Now if I walk into the doctor's office and I'm 300, over 200. If the doctor doesn't put me in the emergency room or get me on medications right away, we'd probably sue the doctor for malpractice. So, it's a matter of degree. A lot of people are sometimes focused and sometimes unfocused, especially if things are really boring or really challenging. But what if you're that way just about all the time and your symptoms are at the top of the chart? It's good for everybody to take risks every once in a while. But what if you're a kid and you take risks all the time, like 'The teacher won't catch me if I shoot that spitwad against her when she's turned her back to the chalkboard?' Or what if when I'm a teen, I don't resist the urge to try the next substance that's passed in front of me outside a middle school or high school? Or what if I just can't sit still and keep regulated? If you're at the high, high end of those continuum, ADHD (the thing we call being at the high end of the spectra) can be a real problem. It's hard to focus in class. It's hard to learn the stuff that other kids are doing, even though you might be smart. It's hard to keep out of trouble. And as we'll talk about, really high scores on these dimensions (especially if other risk factors are involved) can predict some really bad outcomes, like self-harm and suicidal thinking. And like huge rates of accidents and real difficulties getting your life together as an adult. So we're not just making up a new diagnosis because we have to diagnose everybody who's not conforming to societal norms. High ends of these problems are really serious stuff.
Speaker 1 [00:11:32] Yeah, that was gonna be one of my questions and you answered it. A lot of what it sounded like you were describing at the beginning are what we might call personality traits or they sound perhaps natural: being impulsive, not focusing on dense material, that sort of thing. And my question was going to be what makes it so that we need to call this a disorder or a psychiatric condition that might require medication or treatment or all these other things? And it sounds like that's your answer, is that these are approaching levels that we would call disability, I suppose.
Speaker 2 [00:12:06] Exactly, impairment or disability. So a big controversy is 'can you diagnose ADHD in a three or four year old in preschool?' Well, half the boys in the world at three and four, because boys brains are slower to develop than girls (and boys are kind of little monsters more than girls are), you can diagnose half the boys in the world with ADHD. But what if compared to other three year old boys or four year old boys, you're still at the 99th percentile? It's very likely you can't be in a preschool classroom. It's very likely you're going to aggress against other kids. You can't follow directions. You're not sleeping much. Your family is bending over backwards with everybody exhausted and there's potential for child abuse. There's potential for that kid to develop into a kid who's going to show a lot of signs of delinquency later on. So it's how severe are the problems and how much of a problem or disability do they incur, even under the best of circumstances?
Speaker 1 [00:13:06] OK, well, there's so many places we could start this and and for me, more than any topic, this is really hard for me to divorce from my own experience. But I just want to set the stage a little bit more before I get into that piece of it. Because ADHD is a very controversial diagnosis. It's been a cultural flashpoint. It seems to be different than a lot of other diagnoses that we have. For instance, it's one where the amount of diagnosis that we've had, in America specifically. It's not as common a diagnosis in the rest of the world. The amount of diagnoses that we've had in America specifically has gone up and up and up over recent years. It's very, very recent. Which is true of clinical depression, as you know, we've had a psychiatric revolution in our understanding of mental health. But you know, it feels like it's a more recent thing. We can look back at folks in the 19th century and say 'That author was depressed.' We have a little bit harder time seeing ADHD. It seems newer. The levels of medication, we're medicating kids with the disease at a very high rate or kids with the condition at a very high rate. And the medication itself is very directly a stimulant for most kids who take it. A stimulant that is basically a recreational drug given for pharmaceutical purposes. And so for all those reasons, people have a lot of questions about it. How do you view those? Are some of those questions legitimate? Are there real concerns there?
Speaker 2 [00:14:38] They're absolutely legitimate. There's a term in sociology called 'medicalization.' Problems that we had back in earlier times, now all of a sudden become a disease in a medical handbook or a psychiatric condition in a diagnostic and statistical manual because we don't have free will or volition anymore. Everything's a medical condition if you're off the norm and that's a legitimate criticism. On the other hand, let's take in adolescents and adults with bipolar disorder, Jekyll and Hyde, manias and high mood swings or real crashing lows. Well, we could sort of get to be armchair sociologists and say, 'Why would we diagnose anybody, because everybody fluctuates in mood?' Well, in fact, if you really have bipolar disorder where compared to your normal mood for a period of time, you're way above. You're giddy, et cetera, et cetera, but that turns into often hallucinations and delusions and reckless sexual behavior, reckless driving, reckless spending, people breaking their credit lines, and about 40 percent of people with bipolar disorder make a serious attempt on their lives. And about half of those 40 percent end up killing themselves.
Speaker 1 [00:15:54] I've known folks with bipolar disorder, and it's very frightening. It can be frightening for them and for their loved ones.
Speaker 2 [00:16:00] That's exactly right. But you think ADHD, it's school kids, it's the Tom Sawyer syndrome, right? It's not really serious.
Speaker 1 [00:16:07] Yes, it's Calvin from Calvin and Hobbes.
Speaker 2 [00:16:09] Exactly. But it's all a matter of degree and extreme and how you fit with the circumstances you're in. We know that 70 to 80 percent of kids with ADHD are going to have serious academic problems, again, even though they may not have a learning disability or even though they're in the high IQ range. We know that kids with ADHD are extremely disliked by their peer group. They're the kids who blow out the birthday candles at the birthday party but it's their friends birthday, not theirs, because they just couldn't resist the flaming candles on the cake. I've seen this happen.
Speaker 1 [00:16:45] I do relate to this as the things you're saying are pinging for me. But keep going, please.
Speaker 2 [00:16:50] Yeah. Even though we used to think, 'Well, you stop fidgeting when you're 12, ADHD is a time limited thing,' the underlying lack of self-regulation, the underlying disorganization; that persists much longer than the actual fidgeting and squirming and running around a room. So we know now, especially from Europe, where they've got data on every person among the millions of people in Scandinavia and in western European countries. Unlike the kind of chaos in the United States. People with ADHD have high risk for dying about 10 years earlier than they should. People with ADHD have high risk for suicide attempts, especially in girls and women as they grow up. People with ADHD have accidents in cars and on the job and have many failed relationships. It may not be as dramatic as the swings of bipolar disorder but despite the stereotype, ADHD can really wreck a lot of good things in your life. Now if it were all doom and gloom, why would ADHD still exist? If genes are responsible for extremes, wouldn't a natural selection have bred this out of existence? Well, there's pretty good evidence that some of the genes that predict having ADHD back in earlier times in human history, might have predicted your being an explorer. Maybe you were the one who moved in the wake of the earlier rounds of climate change, et cetera, et cetera. Maybe even back in hunter gatherer societies, it's good to be cautious but unless you're out there in the vanguard looking out for the next hunt, you're going to miss it. In any species that we know of, it's good to have diversity in genes. If everybody's the same and conditions change, the species is doomed. So ADHD is not all doom and gloom, but especially in the 20th and 21st century; where we put pressure on kids to achieve ever earlier and where you've got to be perfect and where jobs are scarce, et cetera, et cetera. The rates of diagnosis, the second part of your question, have gone up in part (and we can talk about this in more detail) directly related to academic pressures in different states and different communities. So ADHD has a biological aspect to it, but culture and expectations and social pressures have a lot to do with rising rates of diagnosis. In fact, the United States and Israel have the highest rates in the world at this point.
Speaker 1 [00:19:13] Yeah, and there's only a social explanation for why that would be the case, is that we treat this phenomena or this set of behaviors differently in the United States than other nations. And we could say, 'Well, they're behind the curve and they haven't gotten up to date with the science and all the great benefits that medication can bring,' or we could say 'Something in the United States is a little bit whack. So we've gotten something twisted and we're doing something strange to our own children,' or it could be both. But it is a little specific to the United States
Speaker 2 [00:19:48] So the Centers for Disease Control and Prevention, they've been doing surveys of diseases around the country for years and years and years. But only in the last 20 years have they started to ask, in these phone surveys of families across the country, about ADHD and autism, learning problems, et cetera, et cetera. In the most recent versions of these surveys (and this isn't just people in clinics, these are 100,000 randomly chosen families that are talking about their kids) in certain states if you're a boy over 10 (so you've had a little bit of history in grade school) in Alabama, is one, North Carolina, Arkansas and Indiana are others. Thirty percent of boys have received a diagnosis of ADHD.
Speaker 1 [00:20:33] Wow.
Speaker 2 [00:20:33] Now I don't like stigmatizing terms, but that's crazy. Something's wrong. The world average is about five to six percent of kids that have this condition, largely past though genes. Or even under the best of circumstances, they're really having trouble with self-regulation. 30 percent?! That's insane. In the book I wrote with Richard Scheffler, 'The ADHD Explosion,' Richard is a health economist here at Berkeley and I'm a psychologist. We found that those states and regions within states that do 'test scores or bust:' unless your public school district is getting those test scores higher and higher and higher, those are the places where the rates of diagnosis have gone to these insane levels. This is a new trend, ADHD used to be a white middle class boy thing. Now we know that girls get it (at half the rate of boys but they still get it) and for the first time now, black kids and kids of color are getting diagnosed more than white kids, which is partly because the science is catching up. But it's partly because, in federally funded title one public schools with these achievement pressures, the school administrators are desperate to get these kids help. Or until it became illegal a few years ago, if you diagnosed a kid in that public school district with ADHD, guess what? Next spring that kid was pulled out of your district's test score pool. You can improve your test scores in your district by diagnosing a kid with ADHD because their scores get pulled. So it's really political as well as biological.
Speaker 1 [00:22:12] Yeah. Well, let me raise the ante for you; so I've done a lot of thinking on this myself. Like I said, I was diagnosed at a young age. I was medicated. First my parents gave me medication, then I took medication myself in college because I was actually encountering, 'I want to do the work and I'm not able to do it.' And then I started taking Adderall. It actually did help me with some part of my schoolwork. Then, through my mid-twenties, I was still taking Adderall and I realized, 'You know what? This is leading to a whole lot of unhealthy behaviors. I'm drinking too much. I'm smoking too many cigarettes, and I don't feel that it's helping me with comedy,' which is what I was working on with writing and things like that. I stopped taking it. I started exercising. I quit smoking and my life got better. And then I went for 15 years having great success in my chosen field without any medication of any kind and I feel that I live very functionally. My affairs are in order. During the pandemic, I began to feel for the first time in many years 'I'm really having trouble and struggling with getting what I want to get done finished. I can't focus on a script, I can't focus on the writing I want to do.' So I got myself reevaluated. I was like, 'Let's see what medical science will give me today versus what I had when I was 11 years old.' And through that process, I had a whole battery of tests done, and I ended up thinking, 'You know what, I do have this condition.' I'd been wondering, 'Is it even real,' because I had been doing quite fine. But I got enough testing done. I talked with a wonderful psychologist who walked me through all of it and said, 'You score very well in these areas. You have a deficiency in this area. And based on your history, I can tell you're very high functioning, but you have ADHD.' So I believe that it's real. But however, on the other hand, I also started reading about the social history of ADD Reading about how it was a real thing that was diagnosed in kids. But what do we have? We have a diagnostic criteria that is in many ways subjective, where you ask kids a dozen questions or so, 'Do you have trouble sitting still? Do you have trouble focusing?' Very easy to say yes to that when the answer is a maybe or a no. Then you have a brand new pharmaceutical intervention that is being really pushed in massive amounts of advertising. Advertising which appealed directly to parent's own insecurity about their kids. 'Your child will sit still and do well in school, as you want them to, if you give them this drug.' You've got schools that started encouraging parents to take it, for the reasons that you said and then you've got, as in adulthood, the same pharmaceutical companies now marketing to adults. Adults around me at my age now, every day a new friend says, 'You know, maybe I have ADD. I don't know I was thinking about it. I'm having trouble with my writing and I went to a psychiatrist, I got a diagnosis, and I think I have it.' It's the BuzzFeed quiz-ification of the diagnosis. So I'm looking at all these qualities. As you said, no brain scan can tell you that you had it. It's subjective criteria. The drugs make anybody feel good. You give anyone Adderall and they're going to say, 'Wow, I feel better than I did before I took this' until they crash. It'll work equally on everyone in that way. And you've got this thing where diagnosing yourself fits our notions about ourselves, about our society. It gives people comfort. And so to me, I look at it and say, 'This is a recipe for rampant over diagnosis.' So even though it's real, to me I'm like, 'It almost looks like the vast majority of people who are taking these drugs maybe don't need to be taking them.' So it's very hard for me to know how to think about it. That's me laying out everything that I've learned so far. I'd love you to tell me what it looks like from your view, based on what I said.
Speaker 2 [00:26:13] Well, you raised a lot of really important points and let them see if I can address a few, one at a time.
Speaker 1 [00:26:18] I know that was a lot. So thank you.
Speaker 2 [00:26:20] But it's all important stuff. So in the book that Scheffler and I wrote a few years ago, 'The ADHD Explosion: Myths, Medication, Money and Today's Push for Performance.' There's a lot of myths out there, 'It isn't real.' 'It is about money and productivity in a capitalist or post-modern society, and so school pressures are there.' And you mentioned Big Pharma, the pharmaceutical industry. I love 'em and I hate 'em. The government doesn't fund enough to get cancer drugs or mental illness meds into the market, so the companies invest billions of dollars and they want to make it back and they want to keep their copyright and trade patent protection. They're getting a good return on their buck if they can market the medication well. And what really aided that (you hit on this a minute ago) was that in the olden days until about 1999, you'd see (if you open a medical journal) the big advertisements for doctors. 'Here's the newest pill for schizophrenia or for cancer or for diabetes or for bipolar disorder, ADHD.' As of 1999, there are what's called now DTCs: direct to consumer advertising. You see on late night TV or you see in Ladies Home Journal or TV guide, big ads for all kinds of medications, often for mental illnesses. How many countries on Earth allow direct to consumer ads? Two! The United States and New Zealand. The rest of the world says it's unethical.
Speaker 1 [00:27:55] And some of these ads are, look - so I recently read this book called 'ADHD Nation,' which is by a journalist about the history of ADHD, maybe you think this book's a crock of shit. I thought it was pretty good.
Speaker 2 [00:28:08] There's good and bad parts to it. I've read the book and I know the author, so.
Speaker 1 [00:28:12] Great. I figured you would, since you're in the field. But it's really a social telling of this story, and some of the ads that are reproduced in the book are a mother saying 'Thanks to Adderall XR, I'm proud of you. We can play a game. Good job on your homework.' It's specifically that the ad is targeted to a mom, and it is specifically making the promise that this ad will make your child a joy to be around and will make them better at their studies and turn them into the perfect kid you've always wanted. And it's impossible to look at this without saying 'This is grotesquely unethical and it's going to work like gangbusters.'
Speaker 2 [00:28:46] Well, there's another ad. I don't work for pharma, I don't consult with them, so I'm allowed to talk about it under what's called the Fair Use Doctrine, so I can talk about being a critic of these ads. There's another ad for an ADHD med with a smiling white mother and a smiling white seven or eight year old boy, and the mother says. 'When I see Jason when he's on his medicine, I see the real boy, not his ADHD' conveying (not very subtly) that the medicine will take away the stigma and shame. You'll see the real person emerging underneath if you get rid of those annoying symptoms. Now that's a huge assumption right there. And who wouldn't buy it?
Speaker 1 [00:29:33] Also, the way I look at disability has changed so much over the past decade. To the extent to which I think of myself as having a disability because of ADHD, I still wrestle with that. But using our contemporary understanding of this, what a horrible thing to say about your child who has a medical condition. To say, 'Oh, I don't see the real boy. This medical condition means it's not my real son. It's some sort of horrible Jekyll figure who I need to suppress.' That's an an awful thing to say.
Speaker 2 [00:30:08] And you talked about, obviously to for yourself and for many others, ADHD doesn't stop when you hit puberty as we used to think 30 years ago. So the newest of the strain of ads are for adults with ADHD because by far the fastest growing market share is for adults with ADHD meds. Kids with ADHD, more kids are diagnosed these days so more get medicated, for the last 20 years about 60 to 70 percent of kids with a diagnosis get medication. But if you're an adult who gets medicated or gets diagnosed, the rate of being medicated has gone up from about five percent to much, much higher levels. So that's where the market is. Adult women are the fastest growing market for sure. And there's a major ad for an ADHD med that shows pictures of adult women "If you have ADHD, are twice as likely to get divorced as the average woman and you're twice as likely or three times as likely to get depressed." So take the medication and you'll stay married and you won't get depression, which is totally simplistic. And again, these direct to consumer ads may be creating false markets. Now, the other side would say 'We've denied that girls or women get ADHD for so long, and we didn't deny that adults have it. Let's give them a fair shake at treatment' and maybe it reduces the stigma to see an ad out there in the real world, and it will certainly reduce prices because it's competition. It's a complete B.S. argument. It doesn't reduce prices at all, it raises prices because for 12 years after you get your drug approved, you can charge anything you want before they come to generics. Whether it is a good thing for somebody to say, 'You know, these mood swings of mine, maybe I do have this thing called bipolar disorder,' maybe that'll get somebody help they needed. But it's way too tempting to say, because everybody in the world has periods of not focusing, with a quick and dirty ad saying, 'If you don't focus, well, you've got ADHD' and people will doctor shop till they find a doctor that says, 'Yeah, you have it, and here's the prescription.'
Speaker 1 [00:32:17] And you don't have to shop far.
Speaker 2 [00:32:18] You don't have to shop far. And of course, what none of these ads talk about is, for people with legitimate ADHD who are clearly in the high percentile ranks. Who really do have problems because of this condition. Medicine can be very helpful, although there are ill effects, which we'll talk about. But by far, the best results come from combining medicine with, for a kid: behavioral programs, more structured home life, more frequent rewards in school, reducing homework into shorter bursts, et cetera, et cetera. And for adults with things like cognitive behavioral therapy and organizational skills therapy, where you're learning to control yourself, not just have your brain dopamine levels controlled by medication. But you'd think from the ads it's medication or bust.
Speaker 1 [00:33:06] Yeah. I want to ask you about the social model of disability and how much of this is us not having a societal model that fits what's really a natural difference in kids and neurodiversity and all that? I just want to ask, while we're on the topic of the pharmaceutical industry. A whole lot of my career as a comedian, I don[t know if you're familiar with my work, but I tend to tell a story that goes, 'Hey, capitalism created a false impression that we all need to do x y z. They bombarded us with an ad campaign until we all believed it. Listerine convinced us we all got to use mouthwash, even though there is no medical reason to use mouthwash.' And I look at my own history with this diagnosis, I think 'I was told there was something wrong with me as a kid.' I don't remember there being something wrong with me, I was told that there was something wrong with me as a kid. I went to a psychiatrist. I was given this medication. I don't really remember much about it. I've been wrestling with it on and off it. When I finally quit it, that's when every good thing in my life happened, right? And I've tried it again since and it hasn't helped me. I tried some medication and it hasn't actually helped me write. And in fact, all of that tracks with the beginning of a massive ad campaign on the part of the pharmaceutical industry and a mania for ADD, and so I look at it and I say 'It sounds like I could tell that same story about ADHD and the medications, that the whole thing is a con on the American public,' except for the fact that I also believe the condition really exists, right? Based on talking to you, based on knowing other folks with serious cases of ADD. And based on my own testing and me knowing where my limitations are, I believe there is a real difference in me and in other people that psychology and psychiatry can say something about. So how do I reconcile those two stories? That is what I've never been able to understand.
Speaker 2 [00:34:52] Yeah, I think it's the story of our age in many ways. Over medicalization, over selling people as commodities or people as biological vessels, that the only way to get normal is to take a pill that changes your brain chemistry. And there are realities to mental disorders like ADHD, bipolar disorder, PTSD. Sometimes medications are lifesavers, but let's consider the name ADHD: attention deficit hyperactivity disorder. You spelled ADD, attention deficit disorder. It's assuming that people have a deficit in their ability to pay attention. Well, if that's true, why do so many people with ADHD, when they find their groove or something really love, they can't get away from it for eight hours in a row? There's hyper focus, right? That's not an attention deficit. I think if I could do a couple of things, and I'm so glad you've appointed me czar, at least for the day. So I'll work on this.
Speaker 1 [00:35:53] Yeah, change the world for us. Tell us how to think about this.
Speaker 2 [00:35:57] I would change the way we talk about ADHD medicines and the name ADHD itself. ADHD is not a deficit in attention. It's a deficit in the ability to regulate your attention and regulate your working memory and regulate your inhibition. 'Should I do this or not?' It's a bigger issue in general, with self-control. Let's say, I'm a middle schooler, maybe math is my sweet spot and for algebra, if you could titrate the meds hour by hour, I don't need the meds at all. But in English lit reading long passages or long poems, I'm going wild. I can't sit still. The different structures we have going from a rote to a more challenging task, going from something you're naturally good at to something you're not. ADHD is a problem in regulating and shifting your effort as situations change. It's also a problem in being as intrinsically motivated as many people are. Little kids always need praise and rewards. Once they get skills, we assume that they're going to start to perform those tasks on their own. People with ADHD have this funny relationship with rewards, mainly because of dopamine in their brains, where they're going to take more structuring for longer periods of time to get good at stuff. Our human brains didn't evolve to learn to read. Did we have classrooms on the savannas of Africa 60,000 years ago? I don't think so. And now, in the last 200 years, this compulsory education is asking kids to do things that human beings never evolved to do. So it's a mismatch between our genetic makeup and these recent cultural adaptations. That doesn't mean that ADHD is totally a myth or totally a social construct. There's a reality in our current century and millennium and current social situation where if you don't learn good stuff in school and if you don't learn some self-regulation, you're in trouble. And there are some people, about five percent of kids around the world, who have extreme problems with this. But the jump to over medicalization, the jump to thinking you're wrong or your DNA is flawed. This doesn't decrease stigma, it increases it. It makes people think you're either neurotypical or your neuro deviant and there's something wrong with you. It's on a continuum. It's like the blood pressure example I gave 20 minutes ago. At some point, I may need for my hypertension, some meds. But then if I get on a really strong exercise program and change my diet, maybe I can take away the meds for my cholesterol or the blood pressure meds. Some people, as they get older, adolescence and adulthood, they find a job that's a good groove for them. Medicine that might have been helpful before may not be as much. But then if you change jobs or you go to grad school, a whole new set of demands come in. You may need to get back on the medications for a period of time to help you focus because it's a new situation. It's not all or none. That's my first czar thing. ADHD isn't an attention deficit, it's a larger deficit in self-regulation. Second, stimulants. That's the main meds that work for ADHD. Terrible term, everybody knows what an SSRI is: a selective serotonin reuptake inhibitor.
Speaker 1 [00:39:35] I kind of know what it is, but it's anti depression meds
Speaker 2 [00:39:38] There for anxiety and depression. The brain, there's a neuron in your brain and at the end of it, the axon squirts out serotonin that sits in this little minute gap called the synapse, and it hits the next neuron and makes that electric current go on in the next. The chemical makes the electricity go on and on and on. What's an SSRI do? Serotonin usually sits out there in that gap, does its thing on the next neuron and then gets reabsorbed back into the neuron that squirted it out, it's called reuptake. It should just be called uptake, but pharmacologists don't know grammar. What does Prozac do? What does Zoloft do? It keeps the serotonin out in the synapse longer. Because it doesn't let that first neuron soak it up back as fast. So the serotonin has more time to act and regulate the whole chain of neurons down the track. Helps a lot with depression and anxiety for many people. Is it a cure? No, but it can help. What's a stimulant? It's an SDRI. It's a selective dopamine reuptake inhibitor. So dopamine is in about six percent of the neurons in our brains, but it's in four really important pathways that have to do with your ability to move. Parkinson's disease is a loss of 90 percent of your dopamine containing neurons in a very deep brain area that leads to Parkinson's disease. Other areas or pathways that contain dopamine go from your frontal lobes, back into your midbrain and your thalamus and your striatum and your caudate, all these brain regions that help you regulate yourself. They help you focus. ADHD may be in some people through the genes that predisposed to it. You don't have the same amounts of the same regulation of dopamine in your brain when you're young, as other people do. So if you give the stimulant, there's that neuron in the path that squirts out dopamine, gets reabsorbed re-uptaken, but the stimulant stops that re-uptake and keeps the dopamine active a few seconds longer. That helps many people with ADHD regulate, but only for the few hours at a time when that medicines in your bloodstream and brain. Does it teach you how to read? No. Does it teach you how to get along with peers better? No. Does it teach you how to screenwrite or write comedy scripts or write psychology books? No. It's an adjunct. It may be, in many cases of properly diagnosed ADHD (like I said, most ADHD is diagnosed in kids in our country by a 10 minute visit to a pediatrician's office with no history, no rating scales, no nothing). So, of course, we're going to over diagnose, and the professional groups have standards for good diagnosis, but we don't pay for them with insurance so we don't enforce it. Those same doctors with the quick diagnoses, what's there in their treatment bag of tricks, a prescription pad? Medical doctors don't know how to do behavior therapy, cognitive behavior therapy, all the kinds of skill building that people with ADHD need. So no wonder a: we over diagnose and b: we over treat with meds. The meds, as SDRIs, they're actually stimulating the parts of the brain and brain pathways that help you regulate yourself better. If you're an adult without ADHD and you're going out to a party and people are having a lot to drink. I'm going to fall asleep. But if I take Adderall not for medical use, I can drink more without passing out. I can stay up all night before my midterm and study. Because whether you got ADHD or not, stimulants will keep you alert longer too because dopamine subserves alertness. If you're a young adult without ADHD and you start to use, in adolescence or adulthood, stimulants as party drugs or smart pills. People think they make everybody smarter and better students. There is a 15 to 20 percent chance you're going to get addicted to those medications.
Speaker 1 [00:43:55] Sorry, we have to take a really quick break. And we haven't, because this is fascinating. We're a back to stay right on this point. We'll be right back with Steve Hinshaw. Steve, we're back. We were talking about stimulant medications
Speaker 2 [00:44:18] SDRIs, my new name for them.
Speaker 1 [00:44:22] So they do this to dopamine in your brain. I think that's very helpful to hear that and to understand the neurochemistry of it and why it works. But however, I have taken many of these stimulants throughout my life. I took Adderall for probably six or seven years and a month ago, I took Vyvanse a couple of times because I want to see if it would help me write. I had such a striking experience because I took the Vyvanse and immediately I felt this feeling course through my blood. I could feel it on my fingers. And it was like, 'Oh, hello, old friend.' I hadn't felt this in 15 years, and I was like, 'Wow, I remember exactly what this felt like.'
Speaker 2 [00:45:00] It's like Adele. 'Hello, it's me.' Right?
Speaker 1 [00:45:03] Yeah, exactly. Yeah, very much so. You feel like fucking Popeye eating the spinach. It's just like, 'BAZOOM, here I go.' And then, as I remembered, about five hours later I started to feel kind of stretched out. I started to feel kind of thin. My heart was sort of racing oddly, I felt both tired and wired at the same time. Then that night, I had trouble falling asleep. It took me a long time to wind down. I got less of a good night's sleep than I did before. I was little bit tired the next day. I took the Vyvanse again. Vyvanse, by the way, same as Adderall. Just an extended release, right?
Speaker 2 [00:45:40] Slightly different way of getting the dopamine going, but the same thing essentially.
Speaker 1 [00:45:44] So I felt the boost again when I took it the next day, had even more trouble sleeping. Then day three, I woke up and I was like, 'I can't keep doing this' because first of all, it wasn't really helping me write. But also I was like, 'Wow, this affected my whole body as much as drinking a couple of shots of whiskey.' It makes you feel different in your brain, also makes you feel different in your heart and in your fingers and all over your body. It's that big of a change, almost. And to me, it just underlined, I understand that there are people - I was going and reading people on Reddit who have ADHD and they're like, 'Oh my God, I was suicidal and I started taking this stuff, and it really helped me out.' But for me, maybe the whole time I was taking it, it was really just giving me a boost. It was just giving me a recreational boost that I was enjoying. But was it helping or was I just getting all those other effects out of it? It is a weird thing to give kids amphetamines, is it not?
Speaker 2 [00:46:48] It's counterintuitive. Why would you speed up a person who's already hyperactive, right? Their brains must be different. Well, remember, stimulants is the wrong term. When they're used right for people who really need them, they stimulate the brain pathways that help keep you restrained. For you, it sounds like in your adult years now, you're getting kind of a euphoric effect and kind of a boost that isn't good for your health, isn't good for your heart, and you've learned to do the writing and your performance without it. People have a bell curve, a range of differences. Some people can't really survive without medication. Other people learn that as kids, it kept them in school and kept their game going but as adults they've learned other coping strategies. Does a person with diabetes always need insulin? Well, the brain's more plastic and fluid than the pancreas. So people might need to keep taking, for organs other than the brain, medication very regularly. The brain can adapt to learning. The brain changes and sprouts new neurons. As we learn, people who've really needed ADHD meds when they were younger may be able to learn the strategy. They don't need them anymore. But as I said a few minutes ago, other people, as they change jobs or go back to grad school or whatever they do in adulthood, may temporarily need those medications to help them cope with a new and strange situation. So every case is different. You can't believe the ads or the articles that say seventy two point eight percent of people improve. Everybody's different.
Speaker 1 [00:48:23] Well, and a lot of what you said makes sense to me because especially when I took it in college, it helped me with some things and not others. It helped me with anything that was to do with mental mechanics. It helped me when I was studying German at the time. It helped me do language exercises and later in life, my early 20s, I was doing web design and video editing: basically programing and stuff like that. And it really helped me with that, something that was very mechanical. It made me great at crossword puzzles. And in fact, I would have a problem because I would be unable to do my actual work sometimes because I would become so hyper fixated on solving a puzzle or a video game. And now (here's the weird thing) as an adult, I'm actually very good at doing all those mental mechanics things. I'm good at getting my inbox down to zero. I'm good at doing my taxes, I'm good at that sort of thing.
Speaker 2 [00:49:18] You've learned executive function, is the neuropsychological term
Speaker 1 [00:49:22] Due to the plasticity of the brain.
Speaker 2 [00:49:23] Can you get up in the day and plan and organize and regroup after a failure? And go 'I'm going to turn off that dinger so I don't get any more damn inbox messages right now.'
Speaker 1 [00:49:34] Yeah, I can mostly do those things now
Speaker 2 [00:49:37] Can you use those strategies of the day with or without medication, especially without? That's a large part of what ADHD is. People aren't very good at those executive function, seems like you've kind of taken a master class at that, which is great.
Speaker 1 [00:49:48] Somehow, I think I have built coping mechanisms in the right areas in my life. I don't use a To Do list excessively, but I do keep a list over here. I'm pretty good at keeping a calendar and et cetera. And so I feel that I've built a lot of coping mechanisms, but there's still a place where I feel a block at times. I want to be able to focus on a script or on a piece of writing or a piece of reading. Reading has always been one for me, especially in college, I would find myself unable (even when I was on the Adderall) to read for a long stretch with the speed that I wanted to without flitting away and coming back. And part of it for me has been getting more patient with myself in those moments. I've started to accept, 'You know what? For me, working on a script means I got to spend 10 hours trying, and I'm going to accept that six of those hours I'm maybe not going to get a lot done, and I'm going to fly away and come back and fly away and come back.' And eventually the bird eats the bird seed. You know what I mean?
Speaker 2 [00:50:47] You sound like me with my latest book. It's on the 14th draft of the first paragraph that I finally get what I want to say. And then I go for a good stretch of a few pages and it takes time
Speaker 1 [00:51:00] and writing is hell, is half of the problem.
Speaker 2 [00:51:02] That's right. But most of life isn't a speeded test. It's not like a typing test, you have to take how many words per minute. It's quality, it's effort, it's redrafting, and it involves all parts of your brain, not just the parts of your brain that are going to sit down and do something rote, which maybe stimulants will facilitate for a long period of time.
Speaker 1 [00:51:22] Yeah, but before we move off of medication. I understand that for me, maybe I don't need them right now in my life and I assume there are folks who have more severe difficulties than I do, where these medications can really help transform their lives. Is that not the case?
Speaker 2 [00:51:41] It's absolutely the case.
Speaker 1 [00:51:42] OK, well, so here's the thing that still concerns me, though. I have friends (again every day) who say, 'You know what? I'm having a little trouble writing too and I talked to a friend and they told me to go to their psychiatrist. Turns out I have A.D.D. and now I got these meds and guess what? I take them and I feel great.' And in the back of my mind, I go, 'Man, it just feels great to take those meds.' It just feels good. It feels good to snort a line of coke too, and hey, maybe nothing even wrong with you doing that but it doesn't mean it's medicine that you need. I still see that weird thing about this medication that doesn't happen with SSRIs really or with insulin, there can be this availability if some folks need them, but it's very easy for folks who don't to end up taking them and as you say, get hooked because they are simply; they are addictive drugs. When I quit taking Adderall, it took me a couple of weeks to get it out of my system and to stop craving it, and to stop feeling like I had to have it.
Speaker 2 [00:52:41] Well, right before our break, we were right in the middle of a point. So as I said, 15 or 20 percent of people; adults who want to super party or be a super student, will take stimulant meds and they're going to get addicted to them. If you're an adult with bona fide ADHD, and that doesn't mean a psychiatrist after a 10 minute interview says, 'You have it.' It takes a lot of work. You got to get report cards from grade school. You've got to do a lot of historical interviews. You've got to take a lot of tests. If a person has ADHD and some decade in our older years we'll have the genomics of this nailed down. If you've got a certain gene pattern that predicts ADHD (there's probably several that do), there's good evidence right now that many people with ADHD, if they take medication, they get not euphoric but a little bit more straight laced. Don't have any craving for it and are very unlikely to get addicted. So there may be a protective effect for some cases of ADHD against stimulants being drugs of abuse. But our diagnostic rates are so high and our diagnostic standards are so poor, it's hard to sort it out.
Speaker 1 [00:53:54] Yeah. If what you're saying is right, that if you don't have ADHD, you do the BuzzFeed quiz version and you went to the slightly sloppy psychiatrist and they just gave it to you and you started taking some and you're like, 'Whoa, amphetamines feel good to take.' Well, then you could end up getting addicted to amphetamines, which is a big problem.
Speaker 2 [00:54:14] That's a harm. It's a huge harm. And again, what we do, every medicine has side effects. Every medicine has beneficial effects or it wouldn't be approved. At the level of the population, the benefits for many people with ADHD versus (especially with the direct to consumer advertising and the disease mongering) getting people who don't need these meds at all potentially addicted? And it's a gray area. We need to take a good, hard societal look at this. Look at Oxy. Look at pain relievers, which 15 years ago, the medical profession said, 'We're under treating people in chronic pain. They have terrible quality of life.' And then we get advertisements for and billions of dollars from some companies into promoting Oxy and these synthetics.
Speaker 1 [00:55:03] That's a great comparison.
Speaker 2 [00:55:03] And we have huge rates of death. And so it's not all yes or all no, all black or white
Speaker 1 [00:55:10] Because there are still people who have that severe pain and need those drugs. And in fact, for some of those folks, the pendulum has now swung back so far the other way that those folks are now falsely labeled as drug seekers and they're not able to take the medication they need.
Speaker 2 [00:55:27] In the very, very last chapter of 'The ADHD Explosion,' published in 2014 right before the huge surge of opioid overdoses and deaths, Scheffler and I talked about this exact analogy between stimulus and pain medication.
Speaker 1 [00:55:44] Yeah. OK, well, let's move off of medication. I really want to talk about the social aspect of this because again, I was diagnosed at a young age. I certainly believe that I was posing a problem in the classroom. I was a smart kid. They bumped me up a year because they thought I was I was impulsive and I was causing disruption in the classroom. They're like, 'Maybe we should bump him up a year to see if he'll do a little better with a higher level and all that.' But eventually I was medicated and really after doing some therapy and things like that about these feelings, what it turned out to be to feel to me as I was really told that there was something wrong with me as a kid.
Speaker 2 [00:56:30] Which is a terrible thing to tell a kid.
Speaker 1 [00:56:31] Yeah. By adults and by other kids. As you said, I was ostracized. I had trouble getting along with other kids and et cetera. And now again, I'm an adult. I'm coping fine and I'm like, 'I don't think there was anything wrong with me then either.' I think I was posing a problem for adults sometimes, but I was also a child. How bad could it have been? You know what I mean? I was a little disruptive in class, what's the big fucking deal? And so how much of this, when we talk about the social model of disability (which we've talked about on the show) is in a lot of ways disabilities are only a problem because society hasn't accommodated them. Being in a wheelchair is really only a disability when there's cupboards that you can't reach and there's curbs you can't get over. And if we can accommodate those, then it goes from a disability to a difference and neurodiversity, as a movement, is part of that as well. So how much is that part of the story here that ADHD, for some folks, is just, 'Hey, this is just a different way that the brain works.' That, as you say, can have negative or positive effects. But hey, why don't we just accommodate it, especially for children instead of medicalising it, labeling it, medicating it to such a big degree?
Speaker 2 [00:57:50] So this is, I think, the question of our decade moving forward. Especially about neurodevelopmental disorders like autism and ADHD. The neurodiversity movement started some years ago, really from the autism community. Did Einstein have Asperger's, now called high functioning autism? Did Thomas Edison? Lots of very creative people, Elon Musk even self-professed on Saturday Night Life, et cetera, et cetera. So maybe being extremely male, analytic and focused and maybe not as caring about relationships or as attuned to them isn't an illness, it's just a set of traits. Maybe under certain circumstances - and there's a lot of great work in the disability community now about getting young people, young adults with autism spectrum disorders into tech jobs because they do them better than neurotypical people in many ways. I agree with that. What do you tell the parent of the five year old who's never spoken, has seizures, is mutilating or head banging and can't sit in a classroom for more than five minutes? Is that just a difference? I think it's a disorder, disease or something by then.
Speaker 1 [00:59:08] It's something that needs a more serious form of treatment.
Speaker 2 [00:59:12] It's what I said at the very beginning; it's all on a continuum. We don't have, on the bell curve of all the traits we humans have, a cutoff where you're this far out on the tail and beyond it; you're diseased or disordered and short of it, you're normal. It's just on a continuum. ADHD is exactly the same in that way. Could we just accommodate? Well, remember I mentioned early part of the interview; Hunter-Gatherer societies. Well, there would be no ADHD in such societies, right? Because there's no school and everybody's out either foraging or hunting or preparing food for the next week. And considering things like 'Do we get a monsoon or do we not?' But what if you're so impulsive and there's three arrows left and you misfire all of them and the tribe goes hungry for a wee? Maybe even in a non modern, post-modern industrial educational society, there's a limit over which being impulsive is a problem. So back 60,000 years ago on the savannas of South Africa, would we have given Adderall? I don't know for a kid like that.
Speaker 1 [01:00:24] Might've helped you run faster if you needed to get away from a lion.
Speaker 2 [01:00:27] But the argument today is, 'If we just could accommodate' if the schools of today weren't like the one room schoolhouses in rural America, mid eighteen hundreds or the British factory model. People could stand, people could choose activities. I think that's good for everybody, especially people with ADHD. Would it eliminate the individual differences? Would there be some people, even in a more modern fluid classroom that is activity based that are still going to have problems? At what point do you medicate? At what point do you accommodate? These are the questions of our era. It's not that I believe in the total social disability model, where if we just accommodated, there'd be no illness or no disease. I think that's an extreme. But I also don't believe that any time you're a couple of percentage points on the peak of the bell curve, you've got an illness. That's equally pernicious and it robs us of our humanity and it removes the diversity from our species that makes us thrive.
Speaker 1 [01:01:30] I agree with you entirely, and I would never argue that there's no such thing as a condition that requires true medical intervention. I believe the accounts that I read and the folks I know who say that these drugs have actually helped them. It's a little bit difficult for me to say myself because if you ask me at different points in my life, I would have said the drugs help me and asked me a little year later, I'd say, 'Actually, I think I'm hooked on something that's making making my life worse.' It's hard to know.
Speaker 2 [01:01:59] Yeah, I've only known you today, so maybe you developed enough skills that you really didn't need em anymore. Or maybe they did help you more than you now realize when you were in sixth grade or seventh grade. But after a while, you didn't need them as much anymore. Or maybe some milder accommodations to the classroom back then might have taken care of it. Life doesn't have a rewind, unfortunately, but the issues you raise in bringing up your personal accounts and the issue society faces now about painkilling medication and about stimulant medication or SDRI medication are huge, because it's going to determine the levels of productivity and happiness and thriving of everybody in society.
Speaker 1 [01:02:43] Yeah, but do you fear that? I agree with you that there's a happy medium there that we need to find. But to me, it feels like the end that we are on is that we are punishing too many kids, medicating too many kids. That when we catch a whiff of ADHD, we're assigning medication. We constructed a system where people are self-diagnosing as adults and receiving medication that they possibly don't need. That we have gone from not knowing this is a disorder to, you know -
Speaker 2 [01:03:18] Seeing it everywhere?
Speaker 1 [01:03:20] Yes and we need to pull it back. I feel like I see the direction we need to go. I'm not entirely sure about that because I'm no expert, but I'm curious what you see.
Speaker 2 [01:03:32] So when Scheffler and I were writing 'The ADHD Explosion' and going into the Centers for Disease Control data; it's called the National Survey of Children's Health and it's been repeated every few years. We broke it down state by state, region by region and we are not making up numbers here. There were regions in North Carolina, Arkansas and Indiana where 35 percent of the middle school boys had been diagnosed.
Speaker 1 [01:03:57] Jesus Christ.
Speaker 2 [01:03:58] It's crazy. It is not right. It is societal moors about medicalization run amok and I knew we were in serious trouble. And so a lot of the research I do now, the book writing I do now, the speaking I do now, is to right the ship. To demand appropriate diagnostic assessments and evidence based treatments and don't take the meds any more than you need to. It's also to remove the stigma. So the other topic, that if we had more time we'd talk about is: I grew up in a family with really serious mental illness. I grew up with a dad who had bipolar disorder from the time he was 16 till in his mid 50's, misdiagnosed as schizophrenia. He was absent for months or even a year at a time when I was a kid. I didn't know if he was alive or dead because the doctors told him and my mom back in Ohio (they both taught at Ohio State), 'If you ever tell your kids about your schizophrenia [or whatever mental illness it was, your hospitalizations] the kids would be permanently destroyed.' I grew up in an era where mental illness was so shameful that it could never be talked about. I thought it was my fault when my dad was gone, I internalized it. We've got to be open about our range of vulnerabilities, some of which are problems in living: some of which may border into or cross over into mental disorders. We need to be open about the best treatments because if we never talk about it and push it under the rug, everybody loses. If we over medicalise and anybody two percentage points above or below the mean is the victim of an illness, we dehumanize and we cut off our human potential. So I think these are the issues of our 21st century. In fact, when I get on my high horse, I say (and of course, not that we're perfect on racism, given the events of the last couple of years),
[01:05:49] Certainly not.
[01:05:51] But with civil rights, with women's rights, with sexual minority rights, transgender rights, the full rights of people with mental illness or neurodevelopmental disorders is one of the last frontiers for humanity. In order for people to live full lives, that means both not burying it and equally as much not seeing it everywhere and calling everybody deceased who doesn't fit a norm.
Speaker 1 [01:06:17] Yeah, the way people talk about mental illness is still as though someone's a criminal when they say, 'Oh, that person is mentally ill.' When people talk about social issues in Los Angeles, for instance where I live, they say that. 'Oh, there's mental illness on the streets.' Well, that means we should help folks, if they have an illness. But they mean it as, 'No, this is a dangerous thing that we need to be frightened of.' It's awful. Well, let me end here because we do need to come in for a landing. For the folks who are listening to this, of which I'm sure there are many, who are wondering (however old they may be, they're adults), 'Well, I have trouble focusing. I've wondered if I have ADHD' or 'I spoke to a psychiatrist and they said, maybe I did. Should I take medication?' Or 'I was diagnosed as a kid, how do I feel about that now?' Folks who find themselves in that same liminal space that I have so much. What do you suggest they do? How do you suggest they think about finding a solution that works for them so that they don't end up a) either ignoring a problem that might be real or b) taking fucking amphetamines that they might not need?
Speaker 1 [01:07:23] Yeah, it's a very good and fair question. And I would say even though, as you can tell, I'm very emotionally laden about the whole topic of mental illness and stigma to try to be a scientific and objective about yourself as possible. Don't just rely on your views. Ask your partner. Ask your friends. Ask your parents if they're still around from x years ago. Ask your workmates. Have people been saying on the job for the last 10 years, 'Adam, you're on the verge of being fired because you just don't listen to what anybody else says and I have to repeat four things after an office memo because you just don't get it?' That would be a sign, even though you think the boss hasn't told you how to do it right. That would be a sign that there may be an underlying ADHD issue there. Find somebody in your medical community or psychologist community who's an expert in diagnosing ADHD. Not just that they had six weeks of residency training on it years or decades ago. The more objective you can be with yourself. There's a few people who have been perfectly focused their whole lives, I've never met them but I'm sure there are. Everybody else fluctuates as situations change. ADHD is an extreme of such changes as situational demands ebb and flow. Get an objective diagnosis, do the testing. It's not going to take 15 minutes. It might take a couple of hours. You might have to fill out a checklist, have other people fill out checklists, get an honest opinion and then as you have done such soul searching in your adult life think: given what I've learned and my coping skills what kinds of treatments do I really benefit from and which might be harmful to me?
Speaker 1 [01:09:10] Yeah. To that point, the evaluation I had done as an adult was; I spoke with a woman for about with a psychiatrist for about two hours, about my personal history. Then they had me take an ADHD evaluation, a personality test that was like 400 questions, an IQ test, which I don't even particularly believe in. But once they explained to me what it was designed to evaluate and how they were using it, I did feel it was helpful. And then I talked to them more, and then they wrote an eight page report that synthesized all that information together. And then I was able to speak with her for another hour. We concluded, looking at all these things and putting them next to each other, 'Here's what we do feel. We can say that you have this and what's the next step.' And I found that a very responsible and helpful way to do it. It wasn't just half an hour.
Speaker 2 [01:10:02] This wasn't fly by night. This was an evidence based assessment but that doesn't mean that you're not part of the equation. You get to choose what to do with it, right?
Speaker 1 [01:10:10] Yeah. Yeah, and that's really wonderful. What are the things that, you say not everyone needs medication, right? It's helpful for some, but not for all. If folks have that evaluation, they say, 'I think I have it, but do I really need medication?' We don't talk enough about what are the other things that can be done.
Speaker 2 [01:10:31] So I'll start off with medication. Even if you do have ADHD, there's two main kinds of stimulants. There's the amphetamines: Adderall, Vyvanse, etcetera, and there's the methylphenidate class: Ritalin, Concerta, Focalin, and they are somewhat different chemically. They both do the same things. Nobody has a test to know whether you do best on Class A or B, and nobody knows which dosage. It may take you a few weeks or even months to figure out. 'Gee, I bombed on Adderall, but on Concerta [kind of a long acting form of Ritalin] I felt much calmer and better, and I didn't have the side effects.' And many people, especially adults, get overmedicated. Especially if they've got the form of ADHD that's more inattentive rather than rambunctious and impulsive. So be a scientist there, make sure you've got the right dose and the right kind of medication. But in terms of other treatments for kids: kids with ADHD don't do very well going into a therapist's office and sitting down and analyzing their dreams or analyzing their play. They need action oriented reward programs, meaningful consequences and the teaching of academic skills and organizational skills - this wide class of behavioral/parent training behavioral classroom management. As you get older, late adolescence and in adulthood: CBT cognitive behavioral therapy. How do you manage time? Many people with ADHD are bright and creative and a whole days gone by, and they think 10 minutes has gone by. There's a time management issue, but you can teach those skills. Organizational skills. Lots of people with ADHD get really frustrated when people don't like their ideas, and so there's anger management problems. There's effective psychological, cognitive behavioral treatments, both individual and group, that are evidence based. They really work for people with ADHD, whether you're on medications or not.
Speaker 1 [01:12:27] Got it. I feel that somehow, In my own life, I've been able to build that suite of tools. For the most part, I still struggle sometimes. I guess I should expect that we all will. It was so funny, taking the medication thIs the last time. I had this hope that I would take it, maybe I'll take it and I'll just have an easy day writing the script and it'll solve all my problems. And it didn't, and it's hard to give up that idea. That there's going to be some magic fix, but you can make progress if you do these things.
Speaker 2 [01:13:02] There's big progress, if you do these things. Slow and steady wins the race. Kids with ADHD, people say, 'I'm going to try this new reward chart at home and get the teacher on board' and the kids in reading circle and the kids are sitting there 20 minutes and that kid with ADHD sitting there for four. And so the first day of the program, they say, 'Well, we expect Billy to sit for 20 minutes.' No, the first day you expect to sit for six minutes and then eight and then 10. Slow and steady with ADHD wins the race. Small steps. You feel better about yourself. Other people around you see that you're working, and this is a long game. ADHD doesn't end when you're 12. That report you got, which sounds very thorough, you're going to have some of these underlying tendencies the rest of your life, unless some miracle occurs. But it's how you cope with them and how you deal with them, the kinds of skills you build. That's what it's all about.
Speaker 1 [01:13:55] Yeah. Well, thank you so much, Steve, for being on the show. The book is called 'The ADHD Explosion.'
Speaker 2 [01:14:02] 'The ADHD Explosion: Myths, Medication, Money and Today's Push for Performance.' Oxford Press 2014.
Speaker 2 [01:14:10] If you want to pick it up, you can get a copy at our special bookstore: factuallypod.com/books. And when you do, you'll be supporting not just this show, but your local bookstore. Steve, thank you so much for joining us on the show. Really can't thank you enough. This has helped me learn a lot about myself as well.
Speaker 2 [01:14:24] Well, thanks for the great questions, and it was a delight.
Speaker 2 [01:14:31] Well, thank you once again to Stephen Hinshaw for coming on the show, I can't thank him enough for helping me think through this. His book, once again, is called 'The ADHD Explosion,' and you can get it at our special bookshop factuallypod.com/books. That's factuallypod.com/books, and when you buy a book there you'll be supporting not just this show, but your local bookstore as well. Thank you so much, once again, for listening. I want to thank our producers, Sam Roudman and Chelsea Jacobson. Ryan Connor, our engineer. Andrew W.K., for our theme song. You can find me online at AdamConover.net or @AdamConover wherever you get your social media. If you have a comment on the show or a topic you'd like to see us cover, send me an email at Factually@AdamConover.net. I do read and reply to emails and thank you so much for listening. We'll see you next week on Factually.