You’ve probably heard about the precipitous rise in diagnoses of ADHD in America the past few decades. What was once a rare mental illness has now become a common problem amongst children — particularly boys. Why the sudden spike? Are there really more people with ADHD or is something else going on?
My guest today has some possible answers to that question. His name is Steve Hinshaw and he’s a professor of psychology at UC Berkeley. In his book, The ADHD Explosion, Dr. Hinshaw gives the lay reader a crash course into ADHD and provides some insights as to why we’re seeing such a huge spike in the number of individuals diagnosed with it. We begin our conversation talking about what exactly ADHD is and how it impairs individuals. We then discuss the biological and environmental causes of ADHD, debunk some of the myths surrounding it, and discuss which treatments actually work.
Dr. Hinshaw then delves into his research which shows that the rise in ADHD is not because more people are actually developing it, but rather that cultural and economic forces in schools, corporations, and governments incentivize shoddy diagnoses. We also discuss the fact that ADHD medication is often used by people who don’t have ADHD in order to perform better, and whether it actually improves performance for these folks or not.
We end with a discussion about his new book, Another Kind of Madness, and the stigma of mental illness in America.
- What exactly is ADHD, and what does it feel like to have it?
- The adverse effects of having ADHD
- Why are the theories of ADHD’s origins so nebulous?
- The percentage of people in the US with a diagnosis, and how that number has exploded in the last decade
- How school achievement testing and educational policies have affected ADHD diagnoses
- What it takes to get an “official” ADHD diagnosis
- “Tom Sawyer” syndrome — what about the idea of “boys being boys”?
- How ADHD manifests differently in boys and girls
- How ADHD manifests in adulthood
- Treatments for ADHD, including those that don’t rely on medications
- How cognitive behavioral therapy, commonly used for depression treatment, can help ADHD
- What culture can do to counteract the ADHD explosion
- What happens to Average Joes who take stimulants like Ritalin and Adderall to simply be able to focus better
- The stigma of mental illness, and why it hasn’t gotten better over the decades
Resources/People/Articles Mentioned in Podcast
- The Fists of Teddy Roosevelt
- My podcast with Dr. Michael Gurian about raising boys
- My podcast with Steve Silberman about autism
- How No-Nonsense, Research-Backed Guide to Managing Male Depression
- How to Pull an All-Nighter
- Another Kind of Madness — Steve’s new book on the stigma of mental illness
I admittedly knew very little about ADHD before I read The ADHD Explosion. Steve does a great job explaining in layman’s terms what ADHD actually is. More importantly, he and his co-author deftly suss out what’s behind the precipitous rise in diagnoses in the past 20 years.
Connect With Stephen
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The Illustrated Art of Manliness. Father’s Day may be behind us, but that doesn’t mean our new book still wouldn’t make for a great gift for a loved one!
Read the Transcript
Brett McKay: Welcome to another edition of The Art of Manliness Podcast. Well, you’ve probably heard about the precipitous rise and diagnoses of ADHD in America in past few decades. What was once a rare mental illness has now become a common problem amongst children, particularly boys. Why the sudden spike, and are there really more people with ADHD or is something else going on?
My guest today has some possible answers to that question. His name is Steve Hinshaw, and he’s a professor of psychology at UC Berkeley. In his book The ADHD Explosion, Dr. Hinshaw gives the lay reader a crash course into ADHD and provide some insights as to why we’re seeing such a huge spike in the number of individuals diagnosed with it.
We begin our conversation talking about exactly what ADHD is and how it impairs individuals. We then discuss the biological and environmental factors that go into ADHD, debunk some of the myths surrounding it, and discuss which treatments actually work.
Then Dr. Hinshaw delves into his research, which shows that the rise of ADHD is not because more people are actually developing ADHD, but rather that there’s cultural and economic forces in schools, corporations, and governments that incentivize shoddy diagnoses.
We also discuss the fact that ADHD medications are often used by people who don’t actually have ADHD in order to perform better, and whether it actually improves performance for these folks or not.
We end our conversation discussing his latest book Another Kind of Madness, talking some memoir about his father and his mental illness, and it’s about mental illness in general and how we stigmatize it today, and what we can do to stop that.
If you know someone who has ADHD, this podcast will provide a lot of insight about a condition few really understand. After the show’s over, check out the show notes at aom.is/adhd.
Steve Hinshaw, welcome to the show.
Stephen Hinshaw: Thanks so much for having me on. I’m eager to get rolling.
Brett McKay: You co-authored a book called The ADHD Explosion. ADHD, it’s one of those things that has, I feel, is imbued in the popular culture. Everyone talks about it. People will flippantly say, “Oh, I’ve got ADHD,” because they’re having a hard time focus. I think it’s important. Let’s start off with definitions. Let’s be Socratic here. Let’s do what Socrates did and start off our conversation. What exactly is ADHD, and what does it feel like to have ADHD? Is it simply you can’t focus, or is it something more?
Stephen Hinshaw: Yeah, this is a great starting question. ADHD is the alphabet soup acronym for attention deficit hyperactivity disorder. Some years back, it was called ADD, attention deficit disorder. Some years before that, it was called hyperactivity or hyperkinesis, and back 60-plus years ago, it was called MBD, minimal brain dysfunction. It’s had a lot of name changes over the years, which I think adds to the confusion and mythology.
What is ADD or ADHD? Is it just “I spaced out. I couldn’t focus”? It’s actually much more than that. There’s a lot of theories about what goes on in the brains of people who have legitimate ADHD. Attention is part of the name of this, but it’s not simply an attention deficit. It’s not simply not paying enough attention. It’s the lack of ability to regulate attention according to what the situational demand is.
Many kids in classrooms or adults on the job have difficulty sustaining attention because someone else is calling the shots, and hard to keep your motivation up. But those same individuals, they get on a video game, for example, and there’s hyper focus. You can’t shut it off. Hours later, it’s like, where did the world go? It’s a myth to think that ADHD is just poor attention. It’s a dysregulation of the ability to pay attention.
That gets us into some of these other elements. Maybe it’s broader than attention. There’s these modules in our brain called executive functions, maybe what really separates us from the other primates and animals. You get up in the morning, 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 way I should have. I’ve gotta correct errors, and I’ve gotta suppress this distraction coming in and keep on track. I’ve got to hold things in memory, called working memory, the ability to remember short strings of data. All of these are executive functions. Another theory is that ADHD is really an executive function deficit, way beyond attention. It’s not how smart you are, but it’s your ability to navigate and follow a plan through a day and correct errors when they come in.
It may also be that, in another theory of ADHD, it’s your ability to inhibit a response that you’ve done a lot in the past. Kids with ADHD get into trouble a lot with their peers, not just at school. As I sometimes tell parents groups, these are the kids who, at the wonderful birthday party, blow out the candles, but then they remember, and all the kids tell them instantly, “It wasn’t your birthday. It was the other kid’s birthday.” Those candles were flaming, the cake icing was green and blue and looked beautiful, but it was very hard to inhibit that tendency to blow out the candles because you’ve done it before at your own birthday. Another theory of ADHD is if you have trouble suppressing or inhibiting these previously rewarded responses, you’ll never get a chance to pay attention well or use your other executive functions.
Finally, in the little mini-lecture here, another view, not incompatible with the first three, is that people with ADHD have trouble generating intrinsic motivation, always needing someone else to kind of lean on them, provide reinforcers, because probably there’s just not enough dopamine flowing in some of the dopamine circuits in the brain. We’ll talk about genes and brains in a little bit, I think. If you have that problem with gaining that intrinsic control of your motivation, you’re always kind of relying on the outside environment to set the agenda.
You put those things together, and for a person with ADHD, the world can often seem as a constant bed of noise. It’s hard to know wheat from chaff, figure from ground. What should I be paying attention to? What’s coming in? Of course, in today’s social media world, there’s stuff coming in all the time. Maintaining your goals, sticking with them, keeping that focus in the face of distractions, it’s hard for everybody these days, but if you’ve got ADHD, multiply that by 10 or 50, and I think that would be kind of a little worldview as to what it would be like day-to-day if you have this condition.
Brett McKay: Let’s talk about the adverse effects of this condition. We’ll unpack some more because there’s some other stuff you talked about. I’d like for our listeners to have an idea of how this negatively impacts individuals. Often when we talk about ADHD, it’s often focused on kids in school. I think we understand that.
Stephen Hinshaw: That’s right. We know that ADHD isn’t just a kid disorder anymore. It can last into adolescence and beyond. But you’re right, school is the place where this is often identified because if you have problems focusing and regulating attention, and inhibiting your impulses, and developing intrinsic motivation, schoolwork is a teacher yakking in front you and all these assignments, and it’s a morass, and it’s hard to sort it out.
The vast majority of kids and teens with ADHD are working behind their potential academically. Then moving up on the developmental scale, many adults with ADHD are underperforming at work and have checkered employment histories. Not because they’re not competent, not because they’re not smart, but because what do you have to do at work? You take that new job, and, boy, it didn’t go so well. Maybe you shouldn’t send that nasty email to your boss the first afternoon. You gotta keep it in check a little bit and wait and see how things go. If the immediate press of that negative experience motivates you to send you that email immediately, it gets you into hot water, so academics and vocational performance.
Number two, as I just mentioned a moment ago, people with ADHD have problems in interpersonal relationships. It’s not just not paying attention to school assignments. It may not be paying very good attention to one’s own behavior in a social setting, or paying enough attention to the facial emotions that you’re seeing from that person sitting across from you. Kids tend to dislike kids with ADHD more than they dislike kids with other behavioral and emotional problems because of that impulsivity, because those are the kids who let the soccer ball fly by them when they were goalie because they were more interested in the clover, or they blew out the birthday candles, even though it wasn’t their party; it was the other kid’s party. For adults, we know that people with ADHD have nearly double the divorce rate and real difficulty sustaining in relationships because of impulse control problems and sometimes anger management problems.
A third one is really crucial. People with ADHD, whether you’re 5 or 16 when you start to get that driver’s license, or well above, have massively high rates, more so than the rest of the population, of accidental injuries, car crashes, injuries at school or on the job. Preschoolers with ADHD have a higher death rate than other preschoolers. They climb on the wrong places and jump in front of cars. It’s not just the stereotype of “This is a fidgety, bothersome kid in a boring classroom, and it’s just a classroom issue.” If you’ve got severe ADHD, you’re going to have problems regulating your impulses and keeping yourself safe in a lot of different environments. School and job, social relationships, accidental injuries, to me, are some of the top three impairments, as we sort of call them in the lingo, that too often accrue from these symptoms.
Brett McKay: Okay. I’d like to, later on, delve deeper into the differences in how ADHD affects men and women. We’ll talk about that because I thought that was interesting.
As you were talking about what is ADHD, you said theory a lot, or we had this idea. Why is it sort of nebulous? Do scientists know for sure, or is it sort of like depression, where they think it’s this thing … it could be serotonin; it could be environment? Is that what’s going on with ADHD?
Stephen Hinshaw: We’ve made a lot of scientific progress over the last couple of decades to get far closer to some of the core genetics and biology of ADHD, and to what goes on in the environment that may trigger it too. Let me talk about that for a few minutes because the research is really interesting. Like depression, like schizophrenia, like bipolar disorder, like PTSD, all mental problems, behavioral and emotional problems, the brain’s a hugely complicated organ, a hundred trillion synapses firing all the time. We don’t yet have complete answers or cures, but we’re getting closer.
Number one, think of the people you know. Some are highly focused and regulated and conscientious. Others are, boy, a gnat comes in the next county, and that bug miles away has distracted you. Most of us are in between. Are genes mainly responsible for those differences in focus and concentration and attention, or environments? It turns out that genes are 80% responsible, about, for the differences between you and me and how focused and regulated we are. We know this from twin and adoption studies. Turns out that the symptoms of ADHD are more based in genetic liability and risk than is the case for depression. It’s up there with bipolar disorder and autism as three of the, what we call, most heritable or genetically vulnerable conditions.
However, the second I say that, this does not imply that early environments are not important. Prenatally, a host of toxic chemicals, cigarette smoke, alcohol, can also influence ADHD symptoms. Early child-rearing does not seem to be a big cause of ADHD. In fact, if you have the precursors of ADHD in your toddler years, you’re somewhat more ornery and intense. Parents tend to fight fire with fire and get controlling with the kid. The parents are responding to the kid’s “biological differences,” but those parental responses now pour a bit of gasoline on that fire, and we get a vicious cycle.
Parenting is not the cause of ADHD, but parenting getting locked into these negative cycles can clearly contribute to the worsening of ADHD and the addition of more aggressive behavior, sometimes depression. Parenting is a huge treatment-related factor. We don’t want to blame parents, maybe except through the genes they transmitted, but we don’t want to remove the responsibility from parents to get actively involved in family therapy, behavioral therapy, because that can make a big difference.
There’s a lot of interest these days in toxic chemicals, pesticides. We don’t have the definitive research yet, but it may well be that if you’re born with some of these genes that make you somewhat vulnerable to lapses in attention and concentration and self-regulation, you may be more susceptible than others to the early exposures you might get to toxic chemicals.
Let me mention quickly diet. 40, 50 years ago, everybody sort of thought that hyperactivity could be cured with an additive-free and sugar-free diet. That’s largely a myth, has been discounted. More recent good research does show that, especially some of the dyes and additives, and especially for kids under eight or nine years of age, they’re not the cause of ADHD, but if you’ve got the liability or vulnerability, they may add a couple of symptoms to the mix. Dietary treatments are not the core evidence-based treatment for ADHD, and I know we’ll talk about treatment in a few minutes, but it may be part of a holistic treatment plan.
Brett McKay: Okay. Well, your book is called The ADHD Explosion. Let’s talk about that. How many people would you say in America today have been diagnosed with ADHD?
Stephen Hinshaw: Well, this is a great question. We haven’t really known the answer very well until fairly recently because, unlike Europe, Scandinavia, other countries where there’s national databases of everybody from birth throughout their life and every medical record all put together, United States it’s much more hit or miss. About 15 years ago, the Centers for Disease Control and Prevention started to add to a big national survey of parents, the National Survey of Children’s Health, some questions about ADHD. This isn’t just people in clinics; this is 100,000 people every few years, random phone dialing, so it’s a representative sample.
What do we know? Back about 2003 or right around that time, about 7.5% of kids in the United States, as reported by their parents, had either received an ADHD diagnosis, or a health professional had told the parent, “Yes, your kid has ADHD.” Interestingly, that’s the world average. ADHD is not just an American thing. It’s in every country on the planet that has compulsory education. We’ll talk about education shortly, too. Somewhere between 5%, 6%, 7% is the world average in just about every country on earth, but in the U.S., the National Survey of Children’s Health was repeated five years later and then repeated five years after that. Between 2003 and about 2013, the last year we’ve got good data, ADHD diagnoses went up by 42% in kids. Now it’s not 7.5%; It’s closer to 11% of all kids between 4 and 17. Boys do get ADHD more than girls, so this means about 15% of all boys. And if you’re a boy above about 10 or so, these recent data, the most recent data we have suggests that almost 1 in 5, almost 20% have had an ADHD diagnosis.
Finally in a few states, often southern states, rates of ADHD diagnosis are even higher, and there’s a few states: Arkansas, North Carolina, even Indiana in the Midwest where about 1 in 3 teenage boys have received an ADHD diagnosis during their short lifetime.
Things are going up really fast. The United States is way above the world average now. This is probably not because ADHD-related genes have mutated in the United States in the last 15 years. Darwin would turn over in his grave; that genetics doesn’t work that way.
There’s something about the recognition of ADHD, or perhaps the shoddy diagnoses that we too often tolerate. Most kids with ADHD get diagnosed in a 10 or 12 minute office visit with a pediatrician.
And as Richard Scheffler, my co-author of The ADHD Explosion, he’s a great health economist, and I said in one of the key chapters, the regions in the U.S. where the rates of diagnosis have gone up the most explosively in the ADHD explosion, especially for kids near the federal poverty level, are those states that really push testing accountability in schools. Now accountability laws in schools really don’t have much of anything to do with ADHD, but those school districts in those states that really push achievement or bust are driving up very quickly high rates of ADHD diagnosis, in part because the districts want to get those kids treated so their test scores can improve.
And more cynically in some states, if you got an ADHD diagnosis for a kid, that kid was thrown out of the district’s test score pool, so there was a kind of insidious trying to get kids labeled to boost the district’s test scores. Educational policy boosts the district’s test scores. Educational policy may be artificially pushing up rates of ADHD in the United States beyond what they should be.
Brett McKay: What you’re saying there then is that maybe what’s going on, there’s not more kids with ADHD; there’s just more kids being diagnosed with ADHD because of these pressures from school system, et cetera.
Stephen Hinshaw: I’m glad you put it that way. So let’s play devil’s advocate. One causal factor for ADHD is being born at a very low birth weight, which is, of course, associated with preterm birth. The lower your birth weight, being born 28, 30, 32 weeks, rather than the full 40, is a risk factor for hyper activity and learning problems. At more severe low birth weight, cerebral palsy, Tourette’s disorder. Thirty years ago, most of those kids didn’t survive. But now with great neonatal intensive care units, more and more of these kids are surviving.
That may be a reason for at least a small increase in actual ADHD, the true prevalence. But what we were just talking about is what’s also called diagnosed prevalence. Maybe, I think and a bigger contributor, is more kids are getting diagnosed with ADHD artificially, again or as the result of pretty shoddy diagnostic processes, even though the true rate has probably stayed pretty much the same over the last decades.
Brett McKay: Let’s talk about how diagnoses should be made because I think that’s one thing you hear a lot of parents pushing back against nowadays in their schools that their counselor or school psychologist is saying, “Well, particularly with boys, your boy can’t sit still and focus and et cetera.” Most parents will be like, “Well, he’s acting like a boy. Boys like to move.”
Stephen Hinshaw: That’s right. He’s all boy, it’s the Tom Sawyer syndrome. Right, et cetera, et cetera.
Brett McKay: Right. Then there’s a pressure to get on the drugs so they can stay focused. What makes a true ADHD diagnosis? What is involved in order to make sure you’re actually being diagnosed correctly with ADHD?
Stephen Hinshaw: I’m glad you asked this because it’s a complicated answer, and it’s not a short answer because a proper diagnosis isn’t something done in a quarter of an hour. As with depression, schizophrenia, bipolar disorder, PTSD, we still don’t have a blood test, a biomarker, a brain scan that can unequivocally diagnosis any mental disorder. We’re just not that advanced in our science yet.
ADHD’s actually intriguingly a kind of low tech diagnosis, meaning the doctor, the psychologist, the clinician has to talk with the family, so we’re talking about child diagnosis now, for a long time first to get a developmental history. What was infancy like? What were the toddler years like? When did speech and walking come in? Has to get a birth history, et cetera, et cetera. Toxic drugs might’ve been used et cetera, et cetera too.
Beyond that are there other factors? Maybe this kid was maltreated. If you’ve been physically or sexually abused for a period of time, you may have lapses in concentration that may look like ADHD.
One of the core symptoms of major depression, and kids can get depressed, is poor concentration. That’s usually because you’re preoccupied with negative images of yourself. It’s different from ADHD, but the symptom’s the same.
So you have to do a big process of differential diagnosis, meaning a long talk with the family in a semi-structured way to rule out other things. Sometimes you’ve got to rule out a seizure disorder.
Then simultaneous with that, you’ve got to get parents and teachers to fill out quantified checklists of the symptoms of ADHD, the symptoms of depression, and other childhood disorders to get you a numerical score so you can compare that kid’s score to other kids in his or her region, to other boys and girls of a national sample. It’s not just, “Well, I think … ,” and any given teacher, any given year can say a certain percentage of kids are flaky or fidgety or unfocused, you want to get a couple of years worth of parent teacher ratings to make a statistical comparison to see is the kid way above the norms of what behavior and focused attention should be.
Then there can be cognitive testing, achievement testing. Is this the product of a learning disability? If you put this together, this is a several hour process at minimum. I have major federal research grants. We put kids and families through a 10 hour battery. Of course, no clinician can afford that; insurance won’t reimburse it. You’ve got to make darn sure that this kid is way extreme on inattentiveness, impulse control problems, for some cases overactive, fidgety behavior, and has objective information and a good history to make sure it’s ADHD and not one of the many other things just normally high temperament, abuse, maltreatment, a seizure disorder. You’ve got to rule those out to make sure that the diagnosis is accurate.
Once you do that and once you work with kids like this and teens and adults like this, and realize this isn’t just fidgety behavior, this isn’t just social constructivism 101, these are kids who get into serious trouble in school. These are kids who injure themselves. Sometimes the head injuries kids with ADHD receive exacerbates their symptoms, and you get into a vicious cycle. ADHD is serious business, but in our culture wars these days and because of the shoddy diagnostic practices we allow, social critics have a field day. Too many boys get diagnosed cursorally, and then they get put on ADHD drugs or medications, and we’re not dealing with societal problems. The reality is far more complicated than this, and it starts with a really good diagnostic work up.
Brett McKay: Yeah because I’ve heard instances of friends even who their diagnoses was they went and talked to their family doctor for 20 minutes, and then they got a prescription for ritalin.
Stephen Hinshaw: Which is too often the case, especially in the United States. We still have the highest medication rates in the world in the U.S. Other countries really emphasize other forms of treatment first. But I’ll tell you, the rest of the world is catching up, and healthcare is in crisis.
If you haven’t been following the news lately, both here and around the world, I think it’s a matter of pay now or pay later. If we invest in really careful diagnoses, so we catch the kids who really deserve a diagnosis and don’t over diagnose or under diagnose and give the right treatments at the right time, we’re saving families untold misery, and we’re saving countless billions in our economy years down the road, but that’s not often how it works in the health policy world.
Brett McKay: What it sounds like here, the diagnostic for ADHD should be very thorough and perhaps if a teacher or a counselor tells a parent like, “Your kid, I think, has ADHD. You might want to explore that, but don’t just rely on some sort of thumbnail sketch diagnoses.”
Stephen Hinshaw: Thumbnail sketch diagnoses lead to over diagnosis, of course, but also intriguingly, under diagnosis. The doctor might say, “Gee. He or she was sitting so nicely in the waiting room. It can’t be ADHD,” or, “Man, the parents report that he can play video games for eight consecutive hours. Well that might be hyper focus, the symptoms of ADHD.” You diagnose ADHD not in the waiting room or in the clinical exam room, you get information from school and soccer league and homework time out in the real world. That’s where the symptoms show up.
Brett McKay: Let’s talk about differences between male and females. We often think ADHD is a boy problem. And as you said earlier, boys typically get it more than girls. Is there a reason more boys get diagnosed than girls is ’cause just boy behavior, the Tom Sawyer stuff, is being diagnosed as ADHD when it’s not? But on the whole, boys have more ADHD more than girls. But let’s say the fathers out there who are listening who have daughters, and they have a daughter who’s just … You think “Oh, she’s just spunky or whatever,” but she might have ADHD. Is there a difference between how boys and girls manifest ADHD symptoms?
Stephen Hinshaw: Let’s start from ground zero here. ADHD, autism, very serious deficits in social communication abilities. Tourette’s disorder, the movement disorder with involuntary movements, most forms of learning disorders, aggressive conduct problems, all of the neurodevelopmental conditions that usually appear in the first decade of life, they’re all more prevalent in boys than girls at a rate of 2 to 1 for most learning disorders to 5 to 1 or more for autism and about 3 to 1 for ADHD.
Why? Well this would be a two hour seminar we don’t have time for. The Y chromosome doesn’t have any genes on it. If you’ve got 2 X’s, and you’re a girl, you get protection from a vulnerability on the X. If you’re a guy with an X and a Y, the Y doesn’t provide much protection. Boys are more vulnerable to all forms of life stress. Boys brains develop slower in the first few years of life than girls, et cetera, et cetera. Legitimately there’s more boys than girls not only with ADHD, but most of the other major conditions early in life.
Which led for too long, I learned in grad school some decades ago, that girls really don’t get ADHD, but that’s a myth too. Girls can and do get ADHD, and some of them look just like the most extreme boys, really impulsive, really fidgety, making poor decisions, terrible time focusing in school. For those girls, they tend to get rejected by their female classmates even more than boys with ADHD tend to get rejected by their male classmates because girls put such a premium on a good social relationships.
However, there is a difference. There’s a form of ADHD that’s more purely inattentive. You’re not wildly impulsive or fidgety. You just don’t focus very well in school or in social relationships. Girls more than boys tend to have this more purely inattentive form of ADHD on a relative basis. So if you’re a teacher, you know the kids who are obstreperous and ruining the learning of everybody else in the classroom. Those impulsive kids with ADHD get referred, and those tend to be boys more than girls. So it’s more likely that girls with this more purely inattentive form will get overlooked until later in the game, middle school or high school, and now the disorganization, and now the academic problems really become salient. There’s a couple of reasons why girls don’t get noticed. They do get ADHD less than boys, but they also tend, on average, to present with a form of it that’s less noticeable in the classroom.
Brett McKay: How does ADHD affect men and women later in life differently?
Stephen Hinshaw: Right, so we talked before about the myth that, again something I learned in grad school, ADHD is a pretty interesting disorder because it goes away once you hit puberty. Well in most of us whether we have ADHD or not, we don’t fidget. We’re not as motorically active in our teen years and adulthood as we were as kids, and that’s true for people with ADHD. But what’s missed is 80% of the time through adolescence and at least half the time through adulthood, the underlying executive problems and underlying inattention tend to persist well into adulthood.
Now do the symptoms show up identically all the time? No. It depends on are you self employed, or is a boss calling your shots? How supportive is your partner? ADHD is consistent in consistency, but for both men and women, vocational problems, relationship problems, and accidental injury rates are much higher than the norm. So you have to take into account that for adults, it’s not going to be fidgeting in a one room school house, it’s going to be doing impulsive things on the job or dangerous things behind the wheel. When we assess an adult with ADHD, get information not just from the person in the chair in front of us, but from parents, even though the adult doesn’t live at home anymore, partners, employers, et cetera to really get a thorough diagnostic picture.
Brett McKay: How is ADHD treated? Because I think oftentimes, people think, “Okay if you have ADHD, it’s an automatic ritalin prescription or some other stimulant.” Are there other treatments that work, that don’t rely on pharmaceuticals?
Stephen Hinshaw: Yeah, there are clearly two major forms of treatments that work. The stimulant medications, what’s a stimulant? Sort of a funny name. They should really be called SDRIs, selective dopamine reuptake inhibitors. We all know what SSRIs are, selective serotonin reuptake inhibitors. They prevent serotonin in the pathways in the brain where it flows from getting reuptaken into the neuron that’s just fired it out leaving more serotonin to do its work. The stimulants, ritalins and adderalls of the world, do the same thing, but for dopamine in the few pathways in the brain where dopamine fires. Those pathways have to do with what? Processing a reward, motivation, behavioral control. It may be that many people with ADHD, the genetics are pretty strong, as we talked about, don’t have as many active dopamine circuits, and the stimulants can help get those dopamine levels up to a more normative level and help behavioral regulation and focus.
The catch is a.) stimulants can be dangerous in terms of side effects. You can get addicted to them if you don’t have ADHD, and you just take them randomly. And second, stimulants don’t teach you academic work. Stimulants don’t teach you how to regulate your emotions better or make friends better. Stimulants may prevent some accidental injuries, but you still have to learn safe driving and safe job techniques.
At the very least for those people with ADHD who do show a good response to the medications, you’re not going to get a full response in terms of competencies unless you combine the stimulants with, for kids, behavioral parent training. The parents learn to set much better and clearer limits, getting the teacher onboard with delivering more rewards. For adults, cognitive behavioral therapy where you learn time management. One of the big problems for people with ADHD is you’re late for everything. You just don’t have that internal clock working well. Organizational skills, paying more attention to how you interact with others, cognitive behavioral therapies for adults, behavioral treatments, reward-based treatments for kids are a very viable alternative to stimulants. And for the vast majority of people with ADHD, you’re going to get the best benefit if medication is indicated and works by combining the meds with these behavioral and cognitive behavioral treatments for, again, the right holistic treatment packet.
Brett McKay: Is the treatment of ADHD similar to depression? I know some therapists or psychiatrists will begin with maybe cognitive behavioral therapy and see what they can do with that, and then if they don’t make any progress, they’ll add in the drugs, or do some therapists just go right to the drugs then add in cognitive behavioral therapy afterwards?
Stephen Hinshaw: Very good question. So it’s fairly easy for a doctor to pull out the prescription pad and write a script for methylphenidate, trade name ritalin, or amphetamine salts, trade name adderall, or any one of the stimulant medications. It’s harder to get the family engaged in parent management sessions, and to get in the school and work with the teacher, or to get adults to come in for cognitive behavioral therapy and organizational skills.
Stimulants are an easy first step, and in the United States, unlike just about every other country, stimulants are viewed as the first line treatment for kids and teens with ADHD. Most other countries say, “Let’s start with the behavioral management skill building first, and if they don’t work as well, then go to medications.” In the United States for preschoolers, for young kids, 3, 4, and 5 year olds, where ADHD can be a serious problem, these behavioral treatments are the first line.
I think it’s a matter of severity and safety. If you’ve got a kid with ADHD who’s really a risk physically to himself or herself, and you don’t have the time and wherewithal to get a behavioral program set up, it’s going to take a long time, medication may be your first option to at least get the symptoms under better control. But don’t make the mistake of thinking if they do, that that’s the total treatment. That’s the time to really, really add to the kick that’s needed by putting these other treatments, academic remediation, behavioral parent training in place.
Other countries, again, would say, “Let’s go to stimulants only if the other treatments don’t work first,” just the way you talked about for depression. But, again, if someone walks into your office, and you’re a clinician, with severe endogenous suicidal depression, you may not have the wherewithal to wait that person out for week after week of cognitive behavioral therapy. You may need to start medication soon, and then, again, depression’s another classic example. The best results for people with serious depression almost inevitably are going to come from combining antidepressant medication with cognitive behavioral therapy or interpersonal therapy.
Brett McKay: So going back to the title of the book, The ADHD Explosion, we talked about how this explosion is probably causing big factor is increasing education demands on children. So there’s the pressure on parents to diagnose their kid as ADHD so they can focus better, and they get drugs, et cetera. But also you’re seeing this, not just in school, but in corporations. I mean, we’re now competing with robots who don’t have to worry about focus or attention, et cetera.
Stephen Hinshaw: We’re not just competing with other countries; we’re competing with nanotechnology and robotics. Exactly. It’s true.
Brett McKay: There’s this culture, and people want the Limitless pill, like that movie Limitless, where they just have complete focus, et cetera. It sounds like you don’t think that’s a good thing because it stops people who actually have ADHD from getting the help they need, and getting people on powerful stimulant drugs that they don’t need is not good for them. What do we do as a culture? There are these increasing demands for more focus, more attention for longer periods of time, but how do we do that without saying, “Okay, just I’m going to say I have ADHD, so I can get the drug.”
Stephen Hinshaw: Yeah, there’s a big concern that many adults are going in for ADHD diagnosis to get this performance enhancement. Let’s totally start with devil’s advocate position. I’ve never had a cup of coffee in my life. Most everybody I know does. Well that’s a performance enhancer. Aren’t stimulants just like caffeine? What’s the big problem?
Number one, stimulants, if you don’t have ADHD, will keep you up later. Lack of sleep is one of the side effects. They will perhaps help you get that term paper that’s due tomorrow morning you’ve put off worked on all hours of the night. If you have ADHD, medications will actually help improve some crucial aspects of your learning. Again, they need to be combined with educational support to really get the maximum benefit.
If you don’t have ADHD, however, you’re just looking for that performance edge. How do the medications help your cognitive skills? The first big study on this was done couple years ago out at University of Pennsylvania where 42 typically developing college students without any ADHD went on a seven week long, some weeks on actual medication, stimulants, and some weeks on placebo, and each week got a partial battery of tests of verbal learning ability and working memory, cognitive functions. The answer on none of those 13 tests did the medications provide benefit for these typically developing college students. Whereas they would for people with ADHD.
The fourteenth scale, not a test, but a questionnaire used in the study was how well did you think you did on your test this week? It’s pretty easy to tell if you’ve had a stimulant versus placebo because of some of the side effects. There was a huge effect. People on the medication that week thought they were doing better on their tests. One of the conclusions of the study is if you’re a normal adult, stimulants are really good at boosting your false self confidence in your learning abilities.
The real downside though is if you have ADHD and get good medical care, and you’re an adult, the odds of your getting addicted to stimulants are very low. In fact, some of the genes for ADHD predict that you don’t really get a high from stimulants, you get a little bit more subdued. But if you’re the “average person” out there looking for a performance edge, and you start to take stimulants more and more, there’s about a 15% risk that you’ll get highly addicted to stimulants. That’s not a good picture. Two words: Breaking Bad, would give what happens when you get into meth addiction, for example.
I think we’re kidding ourselves as a society to think that if everybody just took stimulants, or we put them in the water supply the way we do fluoride, we’d be making America a much more economically viable country. I think it would be serious health risk, and it’s not doing what we really hope it would be doing.
Brett McKay: That’s interesting. I thought that was interesting that people thought they were performing better on the drugs, even though they weren’t because I can see how that would happen, you’re like, “Oh, I’m taking the pill, so I don’t have to really … ”
Stephen Hinshaw: “Taking the pill, the juices are flowing. I’m doing it right.”
Brett McKay: You don’t have to work as hard on this because the pill will do it, but it’s not. That’s interesting. Basically if you don’t have ADHD, taking a medication isn’t going to help. It’s just going to leave you feeling jittery and weird.
Stephen Hinshaw: I think it’s going to leave you jittery. It’ll keep you up later. Maybe you do it once or twice, if it’s life or death that you get the job done the next morning, but don’t think that you’re going to be neuro-enhanced permanently by taking stimulants. I think that’s a myth.
Brett McKay: Well this has been a great conversation. You got a new book out, Another Kind of Madness. This is a more personal book, much more personal book than The ADHD Explosion. Can you tell us about Another Kind of Madness and why you felt like you needed to write this memoir of mental illness in your family?
Stephen Hinshaw: Another Kind of Madness, this is a James Baldwin line from one of his masterpieces, Giovanni’s Room, where he talked about the madness of remembering too much or forgetting too much and another kind of madness. My editor and I, Karen of Saint Martin’s Press, my great editor, were discussing this year ago saying, “Well Another Kind of Madness, madness the archaic term for mental illness, is the stigma and shame surrounding mental illness. It’s worse in its consequences than ADHD or schizophrenia or bipolar illness because then it’s shameful, and you can’t talk about it, and you can’t get treated.”
The brief version is my sister and I growing up in Columbus, Ohio, our parents taught at Ohio State, years ago, kind of an idyllic childhood, right? Except that from time to time, dad, a very brilliant philosopher, would vanish for three or six or even twelve months at 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 one day without warning, no one could talk about it. His lead psychiatrist had told him, “If your children ever find out about your severe mental illness,” they thought it was schizophrenia. I later accurately diagnosed it as bipolar disorder. “They’ll be permanently destroyed. You and your wife can never discuss with your children the reasons for your disappearance.”
Would an oncologist tell a parent that the kids can’t know about the parent’s cancer? Well it’s unthinkable, but that was the state of some mental illness back then. It was so shameful that you couldn’t talk about it. So I, as a boy, took refuge in sports and in school and internalized, “Well it must’ve been my fault. Dad left. Maybe if I were a better son, maybe he’d come back sooner. Of course, we don’t want to talk about it and jinx it once he’s back in the home.”
It wasn’t until I was 18 coming back from the east coast from my first spring break from college, dad took me aside in his study at home, said, “Son, perhaps you should learn something of my life’s experiences,” and began to reveal at the age of 16, he thought he was saving the world from the growing Nazi threat in the 30s because he’d learned to fly. Well he was having a florid manic episode. Nobody knew. He got hospitalized in a brutal back ward for six months. Happened again after he finished grad school at Princeton studying with Albert Einstein and Bertrand Russell. So my dad was a brilliant philosopher, but when he went into severe bipolar episodes, he was almost given up for dead on back wards too many times.
Once my dad told me, what a surprise? I became interested in psychology sophomore year back at college. Maybe I could learn about kids and families and help solve mental illness. Later in my career, I dedicated my career to research and clinical work and teaching in this area, I became really interesting in stigma. Why is it still so shameful to even talk about, of course ADHD is in the news more, bipolar is in the new more. We as a society know a lot more of the symptoms of mental illness. Our mental health literacy’s high, but we actually have worse attitudes in many ways than back in the silent 1950s and 60s when I was growing up. We know more, but we’re more afraid of it. Medications are taboo. There but for the grace of God, go I. Most of the mental hospitals have been closed. So we confront severe mental illness on the streets of major cities with homeless muttering people who frighten us.
Another Kind of Madness is a deep memoir about my experiences growing up. My transformation once I learned the truth, but also interwoven through the text and the pages is a definition of this thing called stigma, and the urgent need why we need to reduce the stigma of mental illness. I think mental health disorders are the last frontier for human rights, and we’re cutting off our society at its knees, so to speak, by refusing to acknowledge mental illness. Cancer, you never had cancer in your obituary or your family member’s obituary, back in the 30s, 40s, 50s. It was a shameful disease that the person brought upon himself or herself. Cancer’s a cause. The NFL dudes and the pro golfers wear pink in the big tournaments and games because people talk about their experiences and their struggles.
If we can get personal narratives of everyday experiences of mental health, it won’t be last on the national agenda. That’s the reason for Another Kind of Madness, blending a really deep family narrative with the urgent need to reduce the stigma of all forms of mental illness.
Brett McKay: I thought it was interesting when you said that we know more about these mental illness, but there’s more of a stigma than there were 50, 60 years ago. Why do you think that is? Why do we still have more of a stigma than say the 1940s?
Stephen Hinshaw: Right. It’s the 64-jillion dollar question, right?
Here’s one partial answer. We know that, and some of the work we’re doing now is with high school and even middle school kids to increase mental health literacy. But the right way to do this is not to simply go in and teach, “This is what someone with schizophrenia looks like. Here’s their symptoms. Here’s bipolar disorder. Here’s PTSD. Here’s ADHD.”
They’re high school psychology courses. Now kids learn these symptoms and facts, but what they often learn is, “Oh, you mean someone with depression might get suicidal? Well why would you want to take your life? Oh, people with schizophrenia hear voices? That’s scary.”
Facts are good; we don’t want to have an ignorant culture. What needs to be taught is, “Many people with schizophrenia with the right treatment can lead successful lives. The same is true for bipolar disorder. The same is true for PTSD.” It’s contact. It’s opening up the shame and silence, coming out of the closet. It’s a kind of emotional knowledge about, “Yeah, there’s a lot of depression in my family,” or, “There’s eating disorders in some of the women relatives or friends of mine,” and, “People struggle with it, but can get better with treatment.”
The ultimate paradox is that if we still stigmatize it, we still have these primitive attitudes, people with mental health conditions pick up on the stereotypes. If you start to self-stigmatize, you feel you’re not deserving of treatment, you don’t get into it, or you drop out early, so now the vicious cycle continues.
The bottom line is we want to teach facts about mental health; we don’t want to be ignorant. But I think what we really need to enhance more is humanization and empathy and contact. That’s the knowledge, I think, that will help overcome stigma.
Brett McKay: Fantastic. Well, Steve Hinshaw, this has been a great conversation. Where can people go to learn more about your work and book?
Stephen Hinshaw: My last name is Hinshaw, H-i-n-s-h-a-w. Just google me, Stephen with a p-h Hinshaw. My author website is stephenphinshawauthor.com. I’m growing, even at my age, with social media, Facebook, et cetera, et cetera. Google me, [email protected], B-e-r-k-e-l-e-y.edu, is my main email address, and www.stephenhinshawauthor.com will get you into the many books I’ve written on these topics.
Brett McKay: Well, Steve Hinshaw, thank you so much for your time. It’s been a pleasure.
Stephen Hinshaw: This has been great and would love to come back any time and talk your ears off about all the other topics in mental health that are really important. Thank you so much.
Brett McKay: Like I said, with Steve Hinshaw and his book is The ADHD Explosion. It’s available on amazon.com and bookstores everywhere. Also check out his latest book Another Kind of Madness. It’s a memoir about growing up with his father who had a mental illness. Lot of great insights about how we stigmatize mental illness in America today, and what we can do about that. You can find out more information about the book also ADHDexplosion.com. Also check out our show notes at aom.is/adhd for links to resources where you can delve deeper into this topic.
Well that wraps up another edition of The Art of Manliness podcast. For more manly tips and advice, make sure to check out The Art of Manliness website at artofmanliness.com. If you enjoy this show, have got something out of it over the years, I’d appreciate it if you take one minute to give us review on iTunes or Stitcher or whatever other podcast thing you use to listen. Helps out a lot. As always, thank you for your continued support, and until next time, this is Brett McKay telling you to stay manly.