​Inattentive ADHD Is A Whole Different Disorder & The Task Force To Address It

[Music] Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up today on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training and evidence-based models, including family systems, cognitive behavioral therapy, emotionally focused couples therapy, eye movement desensitization reprocessing, motivational interviewing, and other approaches through live in-person and online trainings, on-demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in evidence-based approach. 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To learn more about trainings, treatment, and employment opportunities, please go to sfip.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training and evidence-based treatment. BACC is a 501-C3 nonprofit, so all donations are tax deductible. They'll be speaking with Russell Barkley, PhD, who is a psychologist and author of 12 principles for raising a child with ADHD, and several other works about ADHD and defiance in children, adolescents, and adults. Russ retired as a professor of psychiatry and neurology from the University of Massachusetts Medical Center, and then worked as a professor of psychiatry and health sciences at the Medical University of South Carolina. He is currently a clinical professor of psychiatry at Virginia Commonwealth University Medical Center, and Russ continues to lecture widely and develops continuing education courses for professionals on ADHD and related disorders. He also consults on research projects, edits the ADHD report, and writes books, reviews, and research articles. Let's listen to the interview. Okay, well, hi, welcome, Russ. Welcome. Thank you so much. Good to be here. Yeah, great. Well, I'm so glad I have the chance to interview you today, so gosh, I was introduced to you back in my pre-doc. One of my, one of the clients came in for, and wanted a assessment for ADHD, and my supervisor said, oh, I said, how do you, you know, how do you do this assessment? He said, here you go. Listen to a two day workshop on Russell Barkley. And so I listened to a seven or nine disc series, and it was just so much great information. I mean, particularly my, I came into the field with my original focus on a difficult adolescents and kind of out of control running away, and so on. And so, huge overlap, of course, with ADHD and oppositional. Sure. And actually, it's, it's funny actually, because now half my practice is children adolescents, adults, and couples with ADHD. And I wouldn't have known, because way back in the beginning, in undergrad, I was working on the, doing work study for Bruce Pennington. Oh, yeah. Good guy. I got, and, obviously, Denver just enter, you know, entering in Wisconsin hard sort, you know, kind of data. Right. So. But anyway, so, yeah, and I got to see you speak at a chat conference, and you and I've emailed a couple times with, I've kept my question short, but I know you have a whole two person around ADHD and kind of so up to date. So, yeah, I'd love to hear about kind of, you know, a little bit about your story, because I was saying, I actually have a back story of how you got into this area, and also kind of what you're doing now and, and surely kind of what you're seeing is the, for part of the fields. Oh, man, there's just so much going on. Thank you so much for asking. I appreciate that. I mean, I've been at this for what 44 years of clinical practice, and that doesn't include all my, you know, the graduate training and so forth. I thought, you know, I got into the field. After I got out of Vietnam, I was in the Air Force in Vietnam, and I came back and spent a couple years in North Carolina. And at that point, that's where I went back to college. I had left college early because I wasn't interested in going, and I didn't like my major. And of course, that was the draft. So, if you left college, you were going to get drafted. So, I enlisted in the Air Force, my preferred branch, having been raised in the Air Force. So, my dad was a career officer. So, after I got out, I was very interested in the sciences, particularly biology and to some extent psychology. So, I went to the University of North Carolina, and I was sort of double majoring, but a lot more emphasis on psychology when I was there. But I knew to go to graduate school, you had to do something extra. So, I started asking around mainly over at the Medical Center because no one in the department needed any assistance or plenty of students wandering around. And a lot of people were saying, we don't need any help, and I was going to volunteer 20 hours a week if that they wanted that. And they said, well, this guy just got a grant to study hyperactive children over at the Child Development Center. And why did you go talk to him? And it was Don Ruth, who was recognized as an authority in hyperactive children at the time. He was editor of the Journal of Abnormal Child Psychology for quite a while. But so, I went to Don, and he said, sure, we could use the extra help. And so, I loved it. I became a research assistant. I was observing and coding, and all these hyperactive children, which now are 80 HD kids coming into his program. And he was doing drug research on methylphenidate with them. And he convinced me to do my honors thesis with him. And so, I don't know, it was his research assistant. He was my supervisor for my honors program. So, I did my first study on hyperactive kids, and then did one on imitation learning in children. And then went on to graduate school. And just, you know, once you get on to it, I just fell in love with that. I thought these out of control kids were fascinating. And I wanted to know more about the what's going on here. And so, I stayed with it, and then, you know, wrote a lot of reviews and graduate school on the topic. And, you know, just got further into it. Did my master's, did my dissertation on drug studies with ADHD kids. And then went on to specialize like you did in, you know, developmental disabilities and neurodevelopmental problems, and especially neuro psychology. Out of the University of Oregon Medical Center and continued on from there. I got my first job as a neuropsychologist at Milwaukee Children's Hospital when I'm to start the neuropsychology service there in both adult and child neurology. And after that went on to UMass Medical School for 17 years as director of psychology there. But still, you know, developed clinics for ADHD adults, ADHD kids, and then continued, you know, doing my neuropsychology research. And after retiring from there at your early age of 52, I went to work at the Medical School in Charleston, South Carolina. And I was doing some research on ADHD and driving and the effects of medications and alcohol on driving down there. And then, of course, about five years ago, moved up to Richmond to be near my grandchildren here. But, you know, continued, at least to work part time and doing a lot of lecturing and writing and also consulting on other people's projects and grants. And you're just continuing my own work. So, you know, it's been a long haul, but it keeps me fascinated. Every time I think it's getting boring, there'll be some discovery or I'll discover something that just lights my curiosity up all over again. And to me, ADHD, because it's a problem with self-regulation, by studying where self-regulation goes wrong in people with this disorder, you learn a lot about typical people, not just ADHD, because you have to know how normal develops, so to speak, how does typical self-regulation emerge? And what is ADHD doing to screw all that up? And then what does that tell us about how to help these people? And so, you know, I've been working on that question since 1994 when I started writing my first theoretical papers on ADHD and executive functioning. And then wrote two books on that and, you know, just did a number of research papers as well on executive functioning. So, that got me really into this. So, that was number one. I've just been fascinated by what ADHD teaches us, not just about them, but about all people in general, not just them. The second thing, of course, that got involved in longitudinal research, and we of course followed a large group of ADHD children to adulthood out in Milwaukee. So, that was going on at the same time that I'm studying executive functioning. And then more recently, have gotten involved in developing this new attention disorder and research on a called sluggish cognitive tempo, which is a group of people who get misdiagnosed as ADHD, because there's no place for them in the DSM, so they get called ADD or ADHD in a tentative presentation, but they're not. And perhaps, you know, in this conversation, we can talk a little bit more about that because there is this new attention disorder and there's growing research on it, and we've just brought 12 of the leading researchers in the world together for a workgroup task force that's going to summarize the research, although there have been meta-analyses and summaries. We're going to rename the disorder because it's a very demeaning term. We don't like the term. It suggests slow-wittedness, you know, kind of a stupidity, if you will, but and we don't mean that at all. And we didn't invent the term. It was invented in 1984 by a graduate student working with Ben Lehi, but it stuck. And we want to get rid of it and move to something more benign. So, you know, the group is charged with not only surveying research, coming up with unanswered questions, promoting awareness of SCT, and then changing the name. And we hope to do all of that by the end of the year. But, you know, it's well underway. We've had some meetings, and we're all doing our little research reviews. So that's an interesting disorder in its own right. So, you know, there you have it. I mean, between longitudinal research and executive functioning theories and, you know, SCT and ADHD. And then most recently, I stumbled into the health outcomes area and ADHD. And so the last year or two, I've been working with Chad very closely to promote awareness of ADHD as a public health disorder because of all of the risks we have been able to document in my longitudinal study in elsewhere on the impact of ADHD on early mortality, on all the increased medical problems from obesity to diabetes to accidental injury to suicide and homicide. But, and then my own research published just not even two years ago showing the first study to show that ADHD shortens life expectancy by an average of about 12 to 13 years, which is worse than all of the other health concerns we have combined. So if you were to look at what does obesity do to life expectancy? What about alcohol? What about exercise and sleep and smoking and all the things we spend billions of dollars on, they don't come close to what ADHD does to shorten your lifespan. And that's because ADHD predisposes to all of them, not just one of them. And so, you know, I've been doing a lot of presentations lately between Chad and other organizations on the health consequences of this disorder and what we need to do about it. So there you go. That's where I came from. That's what I'm up to. And I'm still going like the other day. Yeah, well, kind of semi-retired, but you know, I have time for my grandchildren and golf, but now I'm still writing and working and consulting. I'm just not doing the things that the medical center here that I don't want to do. So I can do that. Yeah. Wonderful. Thank you. So let's go to the sub-Sological Cognitive Tempo. And particularly, and actually, and even for clarifying questions I have, right? Because they're, you know, they're talking a little bit about the, you know, there's the ADHD combined rape. And there's the ADHD inattentive sub, sorry. And then there's the ADHD hyperactive in pulse. And the ADHD inattentive is what many people call ADD, although that's right. They shouldn't. And you've talked about the sluggish Cognitive Tempo. And it's particularly just for micrification. Right. He's 100% of children adolescents adults with ADHD inattentive considered sluggish Cognitive Tempo. Or is there a difference between those two? I think there's a, there's a somewhat of a difference. It gets a little confusing. So I'll try to parse it up this way. If you were to take samples of ADHD inattentive people who are high in intention, but have five or less of the hyperactive symptoms, you wind up with about three groups of people. The first group of people you have are kids who started out as the combined type, who met all the criteria. But hyperactivity declines markedly in children over time. So by adolescents, many combined individuals are getting redignoses inattentive because they don't have six hyperactive symptoms anymore. They have five or four. So they're outgrowing the hyperactivity, but they're not outgrowing the combined type. That's just what combined type people do. And especially by adulthood, a lot of people called inattentive presentation are just former combined type that are grown up. And because the DSM overweight type of activity, which is a preschool aspect of the disorder, it looks like people are changing types and presentations. And they're not changing anything. They're just growing up as they're wanting to do. So that's, you know, that's a big chunk of people called inattentive presentation. They're really combined types. And that's how we should think of them. They're no different than anybody else. Then you have a group of people who are mild combined presentations so mild enough that they only have five hyperactive or even four hyperactive symptoms. Okay, so according to the gospel of the DSM five, these are inattentive presentations, but not really. They're just milder variants of the combined type. They don't differ in any respect from fully combined type people at all. Just a little milder, you know, one symptom of hyperactivity isn't going to change your clinical presentation. So if you get all of those people out of there, you're left with about 30 to 50% remaining of these inattentive onies. And those are the SCT people. They do have high levels of inattention, but they have like no hyperactive symptoms, no impulsivity, certainly have at least three or fewer of those symptoms, but usually none. And when you pull those people out, that's the SCT group. And then when you study them as to how they differ, they differ in many qualitative ways from ADHD at all, which is why we are now arguing that it's certainly a new attention condition and syndrome. Some of my colleagues on the task force would prefer not to call it a disorder because they reserve that for the officially sanctioned DSM term. I don't. I happen to like Jerome Wakefield's definition of disorders, which are harmful dysfunctions and SCT certainly fits that, but I'll go along with that. You know, if you want to play the, you know, the semantic game, it's a syndrome. Now what is it about this syndrome? So I'll be very brief. These people are characterized by hypoeactivity, not hyperhypother very passive, lethargic, sluggish, slow moving. So there's a motor element just like there is a hype in ADHD, but in this case, it's the opposite motor element. These are very passive, somewhat withdrawn, slow moving, slow reacting, sluggish people, often at some time sleepy as well. So we have this sluggish motor activity. Then there is also an attention component. So just like ADHD, there's an attention, but in this case, the intention is daydreaming, staring, mind wandering, unavailable, decoupled from the external environment. So you're gone. You're just out there in Never Neverland. And you know, you know, people are saying to you, you know, earth to Steve or earth to Russ, you know, come back where, and you'll see them shake their head and oh, what do you say? So they miss a lot of what's going on around them. They make a lot of mistakes in their work at school and in the office because they have this propensity to become preoccupied with mental content, which is where the daydreaming and the staring come in. We happen to think that there's a lot of mind wandering going on in these people. We haven't proven that yet, but we're getting we're getting close to that. So you know, pathological mind wandering is probably not a bad way of thinking of these individuals. So where ADHD people are overly coupled to the now and the moment and the exterior environment, which is where you get the distractibility and the busyness and the engaging and the touching. SCT people are decoupled from the environment and they're too much in their head. Yeah. And so that's where you get the daydreaming staring. That's where you get the pronus to errors. They're not processing information. Accurately, the mental confusion, mental fogginess, sluggish responding to other people. That's SCT. And maybe people change the name this year. So there's a lot about these people that's very different than ADHD. They have zero impulsivity. In fact, people with SCT are actually less impulsive than normal people. It's a negative relationship. They're less active than even typical people. They're prone to depression and anxiety, not to conduct disorder, oppositional disorder, drug use disorder, delinquency. They don't have a whiff of antisocial behavior or psychopathy about them. So the whole pattern of comorbidity is very different with them. But about half of SCT people do have ADHD along with it and have don't. our studies show that when the two disorders are comorbid, it's far worse than ADHD by itself. And the same with SET. You really don't want to have both of these attention syndromes going at the same time. And certainly some people do. We've also just discovered in the past year that this is the attention syndrome most characteristic of autism, of depression and anxiety. So people who we think of as having more internalizing spectrum disorders are more likely to manifest this pattern of inattention. So if you had PTSD, if you had major depression, if you were anxious, but especially depression and autism, this is really what you're doing. You're decoupling from the environment and having an autistic grandson, I can vouch for that in spades. The difficulty with my grandson is not an ADHD, isn't of ADHD at all. He's just oftentimes gone mentally checked out. So there's a lot about them. They don't do well on ADHD meds. In fact, the more SET symptoms you have, the worse you do on ADHD meds. They have the same prevalence as ADHD, about 5% of kids, 5 to 6% of kids, and a little bit less, 45% of adults. The beauty of this disorder is there's no sex differences to speak of. We see it in males and females. There's also no decline with age, like we see in ADHD. It is stable and permanent. It's as stable as ADHD if not more so by adulthood. And by adulthood, it's actually worse than ADHD in education, college, and workplace settings, which we were shocked to find that in our study. So there's a lot going on on this disorder right now, as to what's the neurology of this, what's the neuropsychology of it? It's not really an executive function disorder. There's a little bit of working memory organization problems linked to it. What's going on in the mind of these people, which is why we got real interested in pathological mind wandering as a analogous condition. Yeah, because I was thinking about, you know, often I think of an attention. I don't remember if it's I think it's something that I listen to it and you're talking about it's sometimes it's maybe more with ADHD, combined or hyperactive, impulsive. It's not that the person can't pay attention. They're having trouble inhibiting the impulse to not pay attention to one thing and focus on another. So it's not like you're saying this is like a little bit different because they're not necessarily impulsively like attending to something else. They're more almost like not having the drive to kind of focus on something and instead of having that lack of drive and then just kind of having, you know, thoughts and kind of, yeah, that's not effective. Yeah, this is a key point in the moment that's actually bringing their attention. It's actually kind of what's going on internally. Right, right. No, I mean, this is your absent-minded professor, Daydreamy kid who just he's not disruptive. He's a good kid. The parents report that the only trouble they have is they tend to be somewhat shy and reticent and less involved. They have friends, but not as many as people would like. They're quiet. So if you ever read the book quiet, you'll see that they're more introverted. But especially what parents are concerned about is our failing at school. They do as badly at school as ADHD kids, but they're nice. And so they get referred two or three years later because you know, it's the aggressiveness and the disruptive behavior of ADHD that gets you referred so quickly. You're just a difficult kid to manage. Whereas these kids are wonderful in the classroom, but they don't do anything, you know, and people wonder, do they have a learning disability or why isn't this kid available? Is this high functioning autism, which it isn't, of course. So, you know, there are a very unique group of kids in that sense, but as I said, you know, somewhat higher risk of depression and of somewhat anxiety, more depression and overlap with autism. That's a question I have, too, because I think particularly with the inattentive ADHD, you know, so many things, you know, kind of lead to an attention to depression, anxiety, you know, and somebody not getting enough sleep being spread to finite work, being all these kinds of things. And so, you know, how does that even, yeah, how does that even really stand out from the, say, anxiety versus anxiety avoidance and, you know, this, this luggage on the tempo? Well, what we've seen is that at least in my national surveys, the SCT people had slight increases in anxiety, but not a high rate of diagnosis. They did have 25 to 30% had a diagnosis of depression, but again, 70% didn't. So, you know, you can't call this a proxy for depression, but it is the attention problem often seen with depression. And even if you don't have depression, followed up 10 years later, which Len Burns did in SCT children in Spain, and it's also been replicated here, early SCT is a predictor of later depression, even if you're not currently depressed. And that's because mind wandering is such that when people engage in mind wandering, although their mind is skipping from one thing to another, it tends to keep circling back to unresolved conflict. That's what typical people do, and that's what these mind wanderers do. And so, you can see that, unlike typical people, they're spending a lot more time in their head, and by doing that, they're spending a lot more time on their conflicts and problems and hurts and fantasies. Yeah, well, some of it could be rumination. You know, we certainly see that, but it's not so much an OCD type rumination as more of a depression type. You keep coming back to these unresolved issues and problems. But also, we see fantasy in these people. Some of them have a propensity for a very engaging fantasy life, almost a novel in their mind, and they want to get back to it and live that alternative life. And, you know, they're superheroes and they're beating up the bullies and they're solving their problems. And it makes them feel better. So, you know, it's like there's three different groups of mind wanderers. You know, there's the really OCD, you know, who's obsessive. There's the depressive ruminator. And there's the fantasy engaging escape artist who, you know, is bored with what's going on around them, and flights of fantasy into this alternative reality. But they all look the same. They're just not here. They're gone. So, you're trying to find out how to help these people is going to be interesting because the ADHD treatments don't work. I'm wondering, too, like some of the the kits that I work with in adults, you know, that the procrastination, the avoidance kind of coupled with the ADHD and the difficulty in initiating, I find that combination sometimes to be the most brutal. And maybe this is that piece. And oftentimes, sometimes I'm even using just the exposure and sitting with the distress of starting something because there's such a discomfort in trying to get going on something that's not very stimulating. Then that kind of, you know, urges to avoid and kind of get out of there. It's like this regulating. Well, you know, you just pointed out something that we found in all of our research. When we looked at items that identify CT from ADHD, there were two that were described for both of them. They were not differentiated. So, we took them off the symptom list because they were as common at ADHD as an SCT and they were procrastination, difficulties initiating work, right? And low motivation. So, difficulties completing work. But they're doing it in different ways. So, when you study the manner in which they're having trouble with this, the ADHD person has trouble getting started and finds anything else around them that's more interesting. So, the video game and I'm surfing and I'll check my phone and do my Facebook and check my Twitter feed. And, you know, so they're procrastinating, but they're being captured by things around them. Now, they also engage in some mind wandering. And especially if they have SCT with their ADHD, now you're going to see both of these. But they're not starting and then they're looking for anything else more fun or interesting to do, like getting a coffee or, you know, going to do something else or, you know, even, you know, spinning in their chair or whatever, but at least that's what the kids were doing that we studied. But low motivation, doesn't finish assignments, finds it difficult to initiate their work, hence the procrastination. But when you look at them and when we've done interviews with the families of the kids and with the adults, the SCT person has checked out. They're still sitting there in front of the computer. Or in front of the paper, whatever they're doing. But they're not there. I mean, you know, they'll be staring at the book they're supposed to be reading. But it's like you and I sometimes when we read, we mind wander and we catch ourselves and come back to the story and maybe go back to the top of the page. But we start to free associate to content. Well, they've done that in spades. They're just gone. But they're sitting there passively, mentally checked out. The ADHD person is not sitting there like that. They're usually fidgeting, you know, fiddling with things, touching things, but doing something else, you know. And what's something like a dissociative state monster? Yes, yeah, very, very much so. In fact, we took a look at that because one of the two questions came up a couple years ago. Is this hypersomnia? Because these people sometimes report sleepiness. And the answer is no. But about 20% of them do qualify for daytime sleepiness sleeping difficulties. But it's not a proxy for hypersomnia. And then the other the one, of course, is, as I mentioned, it's not a proxy for depression either. So it's, you know, even though they're prone to depression, it's not depression. So it's not these other explanations that people worried about. And we looked at anxiety. Well, they very few of them have enough anxiety to qualify for an anxiety disorder. And if they have it, it really is more related to depression than to fearfulness and worry. But, you know, that could be the case, too. We just not, we're not seeing a signal for Frank anxiety disorder at the clinical level, even though there's a little element of that, as there is an introverted people, where there's a little element of anxiety. Yeah, it's almost like I see a lot of the anxiety avoidance, but not necessarily the anxiety worry. Yeah, kind of fearfulness or so. Precisely. A avoidance of the control distress, especially connected to, you know, something that might require, yeah, focus or attention. Indeed. Indeed. So it's a fascinating group of people that were publishing more and more on. And as I said, we now have a task force on this. And my hope is that maybe when DSM 6 becomes available, there will be enough research to convince them to, to put it in as, you know, alternative attention disorder. We'll see. And I have a one to get some of your thoughts. And one of the things that I see, especially with my adults with ADHD is a shame tends to be one of the biggest difficulties. And often, sometimes when I'm working with parents, I'm, you know, one of the things I say is, you know, our goal is to help build resilience and to kind of get them through their childhood without a great deal of shame, because oftentimes kids with ADHD are getting in trouble, 10 times more. They're, you know, again, the disconnect between the hell and the what they know what to do, but they're not actually putting it into action. So oftentimes people are frustrated with them, they're getting frustrated with their self. And there's recently, I've, you know, kind of, there's been talk about the reject rejection sensitivity disorder. Yeah, we're not really a disorder. Yeah, but it's interesting, because I think that this is a core piece for adults with ADHD, the shame aspect. And actually, one of the, so we have a, the Bay Area Center for ADHD, one of my clinicians, just kind of informally if the internalized shame questionnaire to all of his clients, ADHD and not. And even, you know, found that adults with ADHD tended to have the highest level of internalized shame, even more than the, the adults, when child's physical sexual abuse, trauma clients. Yeah, no question. No question. I wonder how your thoughts about that. Well, yeah, there's no doubt of both our longitudinal studies and our cross-sectional studies of adults with ADHD show that there's a growing pattern of demoralization as a result of repeated failure experiences over time, such that by adulthood, rates of anxiety disorders are more than doubled. And they are correlated with the length of time ADHD goes untreated. And that's true, even in adulthood, if you look at every four-year period of follow-up, adults with ADHD who stay out of treatment have increasing risk for anxiety, such that by the time we see these people in their 30s and 40s, over almost half of them have an anxiety disorder, which is not the case in children that we see, but there's this growing risk for anxiety, demoralization, to some extent depression, you know, although it tends to be more of a milder dysthymia than full-fledged depression, though that can be there too. But it looks like SCT is the predictor of the depression part of ADHD. But you're right. And I'm not saying that there isn't, you know, this rejection sensitivity issue that they have. But you know, again, if we're not going to call SCT a disorder yet, because it's not official, then we can't call rejection sensitivity. There is no doubt that two things conspire to make them, you know, ashamed and hurt. Number one is the growing rate of failure in their life, both letting themselves down, not accomplishing the goals they had hoped to accomplish by certain, you know, times. So those are self-determined goals, but also the failure that they experience in school, college, work, peers, marriages. I mean, you know, there's no domain of life unaffected by ADHD in some way or another. So there's that shamelessness that they have. Plus on top of that, the second thing that I want to dimension is of course the contribution of others around them to the shaming, which is viewing ADHD as a moral failure, you know, you could do this, you could wake up and smell the coffee and change yourself. You're just unmotivated. You're a lazy layabout nearer to well. And God, you have no idea, or maybe you do, of how often people with ADHD hear that from others. These are people who don't get the neurobiology of this disorder and place it within the realm of moral judgment. And so they've been, I don't know if they bullied, but certainly brow-beaten by others around them for their lack of success and follow through and forgetfulness and so on. And now let's take those two and let me add another third thing to this, you know, pot of stew that we've created here. And the third part of the recipe is these people have very impulsive emotions. They react very quickly, more so than other people do. It's not a mood disorder, it's impulsive, emotional reactions to provocations. So they're reacting emotionally to the failure, to the shaming, to the moral to the moral judgments of other people. And they're regretting it. So now you've got this layer of regret of how I acted. God, I wish I hadn't said that. I blew my, you know, my cork at my boss. And now I don't know if I got a job. And you know, the emotion regulation piece of ADHD is the single best predictor being fired from a job. It's a single best predictor of how few friends you're going to have in life. It's the best predictor of whether you're going to be divorced and also intimate partner violence and aggression within intimate cohabiting relationships. It also predicts road rage. So you can see where the emotional aspect is going to create even further demoralization and rejection and shaming. So it doesn't, it doesn't just arise from one source. It's a multi source problem. But by the time you and I see these people, you know, they're in a deep dark place they really are. Yeah. And I think too that, you know, often, people get into a shame spiral. They mess something up. They feel bad. Then they don't want to deal with it because that feels worse. But then they end up doing something else like the person gets a parking ticket and they feel bad. They just kind of ignore it. And then they get more and more until the car gets booted. Right. Because kind of sitting with that and we often messed up, you know, ends up feeling so bad and goes to that therefore I'm no good. And so kind of often times I work in the plants around, you know, the antidote to shame is integrity, taking responsibility, you know, kind of making a man's learning, making it right and then taking the next step in the right direction. Exactly. For a lot of people with ADHD because they're falling off that horse, you know, 10 times more resiliency gets depleted very quickly and it's hard to get getting up and fixing all the, you know, mistakes or whatever because they're messing up one house standard deviations more than the average person kind of by definition. Well, that's an important piece. I'm going to point it that out because one of the parts of clinical practice that we tell people you got to do right up front when the diagnosis is made is ownership of the disorder. And you know, Adam Levine has a great YouTube. He created for Shire Pharmaceuticals, which is now tequila. But you know, Adam Levine, you know, the guy on the voice and you know, the lead singer and guitarist for maroon five is a raging adult with ADHD and he talks about he's very open about it. You know, Michael Phelps and Justin Timberlake and Simone Biles and all these celebrities, just Google ADHD success stories and you're going to see some really, you know, very accomplished people. But they will tell you that, you know, step one in getting to where they are and the success that they have is not denying this but owning it and getting it managed and taking responsibility. Being responsible doesn't mean you get everything right. It means you own it all. You know, the words and all, okay, I messed up. I didn't get there on time. I promised you I'd do this and I didn't and you know, try to get it right the next time. What am I going to do so that doesn't happen the next time? That's integrity. That's responsibility. And we have to make that distinction because some patients think that what you're talking about is being successful. No, I'm talking about owning who you are in spades. And to me, that is step one in the road to recovery is ownership. I get it. I own it. It's me and I make mistakes. So what? I try. I try to get it right the next time. And I create scaffolding around me and, you know, support services and artificial, you know, means of organizing my environment and I take my medication to try to come to grips with this. And you'll you talk to these people. There's a great documentary that was just finished. It's being shopped to Amazon and Netflix. That I was lucky to be one of the experts that they interview, but it's called the disruptors. They have taken these people from Justin Timberlake and Simone Biles and highly accomplished people, the owner of, you know, Jet Blue and you know, celebrities and so how he man dels in it too. But they talk about their childhood. They also follow five families about how hard it is to be with ADHD and to help an ADHD child and the exhaustion of parenting, but they also weave in and out the success stories, which are often successful in non-traditional pursuits in life. - Sure. - The traditional paths are usually not where ADHD people make it. It might be in acting or videography or in, you know, being a chef or in the culinary arts, or maybe in the military, but, you know, these are people who are actors, comedians, athletes, Olympians, and who are quite successful. So watch for that, the disruptors. It's probably gonna wind up on one of the major streaming channels, if not PBS, and perfect. - Yeah, and I think too that, you know, I love working with kids that are less to build couples with ADHD because with intervention, so much can change just medication and behavioral interventions where I'm executive functioning, and, you know, all that kind of helping to understand that kind of shame, avoidance kind of cycle and hoping to shift that with the cognitive behavioral therapy, and also I integrate a lot of EMDR, that's something that my adults with ADHD have experienced trauma from, you don't know, how many EMDRs I've done on an IEP meeting where, you know, that they kind of get the sense that I'm broken, I'm not smarter or so on, but then, you know, oftentimes can really flourish with those supports, accepting and understanding and shifting, and there's actually a great little metaphor that Grace Friedman, she wrote a book for teens, and she was a teenager, just a little ebook, it's at AdiTeam.com, and she uses a metaphor of how when she was playing soccer, she was putting the goalie position, but she didn't really want to be in that position, she was like the right gear and someone getting pummeled, and her dad said, "You know, you really got to suit up for the game you're in." And she uses that metaphor of kind of understanding that you have ADHD and then beginning to actually suit up for that game, and really kind of dealing with that rather than just kind of, the photocopy neurotypical and ignore the ADHD and the effects of ADHD. - Precisely, yeah, don't be neurotypical, because let me tell you, you're just gonna keep hitting your head against it. - I know, yeah. - That doesn't mean you can't go to law school or be a doctor or physician, or the usual educational pathway in this success, but for ADHD people, it's almost always, I don't wanna say always, but most of the time, it's gonna be non-traditional, and they might be the entrepreneurs, they might own their own businesses, they might be a builder in construction, they might be like Ty Pennington, who destroys and rebuild houses for a living, or Glenn Beck, the disruptor and commentary. If you look at them, or Michael Phelps, the most decorated Olympian in history, but that's all non-traditional. Simone Biles talks very openly, the gymnast about her successes and her trials. When Michael's out of the pool, he has to watch it because he's got DUIs and lots of other problems that he has to deal with. But these are people that can inspire you to have hope that there's lots of other roads to successful fulfilling lives that don't necessarily involve a lot of advanced education to get there. And that, like you said, suit up for that game. Let's take a look around. I talk about it in my book, the 12 principles for raising a child with ADHD. And one of those principles, we call the keys to success. And step one in the keys to success is you and your loved ones need to help you identify. What are your aptitudes? What are your strengths? Where are you clever? Where do you love engaging the task, the activity? And it might be technology. It might be stand-up comedy. It might be acting. It could be writing poetry for all I know. But, or you just love taking movies. You're going to be a videographer. You wouldn't believe in it. People in the video field are ADHD. So, you know, and also cooking. How many-- you wouldn't believe how many chefs are ADHD. It's just unbelievable. So I tell them, would you just look around at what are you good at? And then do what Michael Phelps mom did for him. You find community resources that promote that aptitude to get you that 10,000 hours of practice that are often talked about to become expert in that area. And, you know, OK, we'll get you through school. C's are good enough. We're going to, you know, we need to get you through school as best we can. But we are going to promote that aptitude, find the resources to further develop it. We are in your corner. We are your safety net, you know, the unconditional regard that we have for you. There's a great interview with Michael Phelps mom. And also with Ty Pennington's mom in Attitude Magazine. You have to go back and Google it. It's about 10 years ago. But, boy, they will tell you what they had to do to get this kid to where he is now. This is a story. I mean, people don't realize Richard Branson, whose adult ADHD was in jail, right? In London, what was he doing as a teenager? He was pirating the Beatles music and selling digital copies. And he got caught and convicted. And his parents had the second mortgage to house and get him out of jail and send him to Vermont to a private school. And that's where he started to find his entrepreneurial niche. Yeah, there's a great podcast that I like about how I built this with Guy Ross and where he interviews different founders of different companies. And just so interesting to see here, their path in the career, which oftentimes was not the straight and narrow that often times many families think they have to get these grades because of these Ivy League schools and therefore this. But, and that, you know, oftentimes, yeah, people have these securities roots and really kind of creating that support. And you even kind of mentioned in your book about kind of not engineering your kids, but more shepherding. Hey, I want you in the last little bit of, you know, kind of take a moment to just kind of talk a little bit about diagnosis. I know this is always a big question. I was recently kind of contacted by somebody doing an article for WebMD on right now, especially with the pandemic. And a lot of folks looking for assessment is this ADHD and so on, especially that this has been such a hard year for so many kids and families in remote learning. And particularly, you know, an additional piece to this too that I have a question of is I know that in the original kind of research in diagnosing ADHD, it was looking at the six out of nine symptoms and that that I heard in one of your talks at that place, the kids at the 93% trial are one and a half standard deviations above the mean mostly on boys between, I think it was 16 or so. Right. That's right. I was almost wondering about if we did another kind of study like that now, would it actually shift? Has the culture shifted at all? Where more people are more inattentive or more kids so on because of our fast-paced society, internet, things like that. Or would it still be kind of again that 93% trial would be that six out of nine still, or might be seven out of nine or five out of nine kind of, because ultimately the rate of ADHD by definition should be about 7%. Yeah. Right. It's on that definition. So, yeah. Anyway, that's correct. Well, I think, boy, there's a lot there to unpack, but let me get right to the more obvious one, which is there is research where we've gone out and re-normed the DSM items like Georgia Dupal just re-normed it about four or five years ago on boys and girls right after the DSM five came out. They took their old ADHD scale, re-updated it, re-normed it. And as far as they're able to determine, along with other international studies, that number still fits. OK. So, we haven't really seen, despite people thinking that with all the screen time and technology, and now with COVID, as well as difficulties that people have had with sleeping, we should see more inattention and more ADHD. Well, we're not. I mean, we're certainly seeing more inattention. But, you know, inattention is not clinical ADHD. Those are two different things. And, you know, nobody's that severe from COVID, from the lockdown and the technology, rising up to the level of an ADHD clinical diagnosis. So, somebody might have the symptoms, right, in a significant range, but because it's not having the consistent history, then it's going to be considered ADHD itself, even though it may look like ADHD. Doesn't mean that some cases that were marginally ADHD might not have moved a symptom or two during the pandemic, over into the clinical range. But, you know, the typical person didn't go all clinical just because of inattention and sleep and worry and so on. So, the fact is, it looks like sixth still is fine for children and adolescents. What isn't fine is after that, because our studies show from 18 to 29, it should be five, and beyond 30 and up, it should be four. And that's what we recommended to the DSM committee for DSM five. And what they did was kind of like a split the baby, Solomon's decision, they didn't allow four, they gave five. So, that's why DSM five says, when you see somebody 18 and older, use five, but you really should use four, because that's the level of deviance for them. - That's what places are that, that 90% of them? - Yeah, precisely. So, we really haven't seen that. The other thing when you mention prevalence, although ADHD is around five to seven percent, it's not as high as the CDC keeps saying it is. And the journalists keep trumpeting the CDC figures, but the CDC figures are junk. And that's because they're based on one question on a national survey, not a thorough evaluation, not do you meet DSM. The one question is, has your child, or have you ever been told your child might have ADHD by a healthcare professional? My God, you'll blow the lid off a prevalence if that's your only question, but that's what the CDC did. - I'm interviewing Steve Hinchon, as well as ADHD Exploration and Religious Community. - And part of that is, you know, the CDC not doing its job with careful dying. You know, whenever we go out and use the DSM. And I just, you know, normed my own adult rating scales and child scales on executive functioning, you know, back just to what, seven to eight years ago. And, you know, we, we still find that number is fine. And only about five to six percent of children qualify for the diagnosis when you use all the criteria. Now, if you start waving criteria, you know, like you don't have to have the full six and doesn't have to have six months. And, you know, the, you don't have to have impairment. You know, then, yeah, you're going to blow the roof off a prevalence. But then is that really ADHD you're talking about, right? You know, or is that just part of the normal spectrum of, you know, because ADHD is a spectrum disorder like autism is. And so where along the spectrum are you drawing a line? And the CDC, you know, drew a very low bar for this. Whereas the DSM draws a very high bar. And, and to me, the prevalence remains at that five to seven percent figure when you do full clinical evaluation. So no, there's been no increase in ADHD that we've seen in terms of prevalence. Now, there has been an increase in referral and diagnosis. But that's just good public health. You know, more people hear about ADHD, more people come in and we want that, you know, especially girls and women. The biggest increases, by the way, are girls, teens and adults. And guess what? 20 years ago, those were the underdiagnosed populations, even more so than boys. For males, the diagnosis has actually been flat for a decade. The rate of drug medication use, the rate of diagnosis has been flat now in the most recent surveys. So we're doing a pretty good job. We're reaching about 80% of the boys. When I think of the big piece to you, at least when I'm assessing an adult with ADHD, if I'm for a lie, I always want to talk to their parents because those childhood symptoms, which are such the biggest differential of whether it's not ADHD. Because clearly things can can can can score in a positive range on the questionnaire for ADHD symptoms, although not necessarily be due to that. It's so that kind of established and like you're saying in the past, when these adults were children, there wasn't as much kind of good, you know, services or awareness or so on or parents and actually about bringing them in and getting the assessment. Yeah, no, that's very true, it's very true. So I don't think we need to worry so much about the DSM for kids, but we do have to worry about it for adults because the bars set just a little too high. I recommend clinicians do two things. Use four on each list as your cutoff and ignore the content in the parentheses. The parenthetical clarifications were never tested, never evaluated as good symptoms. My daughter, Laura now says a psychologist, she and I just finished a study that's coming out next month, showing that the clarifications barely correlate with the items they're supposed to clarify. Some of them are more related to anxiety. But what they've done is to create eight or nine additional symptoms by putting those clarifications in there, and then they didn't readjust the threshold. So it's easier to qualify for a diagnosis of ADHD now because you've got all those clarifications that can count as symptoms even if the original symptom isn't endorsed. So watch it. We showed that you can almost double the rate of adult ADHD, particularly for the inattentive presentation. If you start counting the parentheses, the clarifications. So I'm telling people to ignore those until we learn more about them because I think they're bad news. Yes. Definitely. Well, hey, thank you so much for this conversation today. It's a list for you. I'm glad you can hear what you're doing and yeah, I've got your book and it looks really great. The recent one on the principles of raising child with ADHD. Keep up all the great work and thanks for taking the time to speak with me today. Thanks. I'm still going. So hopefully got a few more years left in me before I finally pull out of this. But but thanks again, it's been an honor to be in your program. I appreciate it. Great. Thank you. We'll take care. Appreciate it. Bye. Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapy on the cutting edge.com and click on the link for CE. 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