Behind the Stigma
Hosted and produced by Seiara Imanova, a PhD student from University of Birmingham, Behind the Stigma is a pioneering podcast that bridges the gap between the general public and the fields of Psychology, Psychiatry and Mental Health.
Each episode offers a deep dive into cutting-edge research, featuring conversations with leading experts and top researchers in the field. Take a listen, as we uncover the science, challenge misconceptions, and bridge the crucial gap between academia and the everyday.
Behind the Stigma
Attention Deficit Hyperactivity Disorder with Dr. Stephen Faraone
In this week's episode, I speak to one of the world's most influential psychologists and researchers on ADHD, Professor Stephen Faraone.
We go into defining ADHD , the role of executive functions and the differences in cognitive processes between individuals with and without the disorder. We also discuss the impact of social media on ADHD awareness and insights into the genetic components of ADHD, such as twin studies, genome-wide association studies, and the polygenic nature of the condition. Dr Faraone tackle the crucial topic of ADHD medication like Adderall, and Ritalin, and other non-drug interventions. Finally, we go into his work and his contributions in the field.
The ADHD Evidence Project: https://www.adhdevidence.org/
Twitter: https://twitter.com/StephenFaraone?s=20
Profile: https://researchers.mgh.harvard.edu/profile/14559688/Stephen-Faraone
Hey everyone and welcome back to another episode on the Behind the Stigma podcast. I'm your host, ciara Minova, and in this week's episode, our topic of discussion is ADHD attention deficit hyperactivity disorder. Our guest speaker today, who I'm honored to have on the podcast, is Dr Steve Farone. Dr Farone is an American psychologist who has worked mainly on attention deficit hyperactivity disorder and is considered one of the most influential psychologists in the world. Dr Farone studies the nature and causes of mental disorders and childhood and has ongoing research in psychiatric genetics, with a current focus on applications of data-driven computational models, including classical machine learning and deep learning.
Speaker 1:In 2002, dr Farone was inducted into the Chad Hall of Fame in recognition of outstanding achievement in medicine and education research on attention disorders. He's also received many other awards, such as the Lifetime Achievement Award in 2018 and in 2019 he received the Paul Hawke Award from the American Psychopathological Association, to name a few. I mean how impressive, because this list could go on and on. What an honor to have him here with us today. Dr Farone, welcome. Thank you so much for your time and joining us.
Speaker 2:Happy to be here. Ciara, Thanks for being interested in ADHD.
Speaker 1:Thank you Honestly. I'm truly excited for this discussion because ADHD is quite a complex disorder, in a sense that there's many factors that contribute to it, much like most psychiatric conditions, but it's also quite controversial in the field as well. So I want to approach this episode from many different angles from symptoms to genes to brain morphology so that we can hopefully get a full circle of understanding of the condition. But let's start with the most obvious and basic questions, as it'll set the precedent to understanding the rest of the conversation as well, which is what is ADHD, its symptoms and how it shows up in a person. And maybe you can briefly just mention the history of it, as I'm aware was first known as ADD and then it changed in the field, and clearly people showed these symptoms even before the recognition in the medical literature as well.
Speaker 2:So I could talk a lot about that. So first of all, you just first about the definition. So it's important people understand that ADHD is defined by three sets of symptoms. In attention just what it sounds like. People have a difficult time paying attention, they're distractible, they're looking at the window and they should be looking at the classroom, school board or focusing on something else. That's the first set. Second set is impulsivity. Impulsivity acting without thinking, doing things without considering the consequences. The child who runs out into the street, chases the ball and doesn't look for cars coming by That's an impulsive reaction. The adult who's having a conversation just blurts out something before someone's finished That's impulsive conversation. Hyperactivity the third set Hyperactivity is in kids. It's basically means running around, climbing on furniture, being much more active than the typical child, for that child's age.
Speaker 2:In adolescence, and adulthood, hyperactivity tends to diminish, and we don't see adults running around and climbing on furniture in the boardroom. What we do see, though, is adults who have a difficulty in situations where they have to remain seated or remain still. These people, if they have to be in a meeting where they're seated, they'll be uncomfortable, or they get up and pace around, and so forth. History is actually pretty important for people to know, because a part of the stigma of ADHD is around this weird concept that it was invented in the United States because it was some kind of cabal between doctors and pharmaceutical companies to drug kids. You read about this on the internet.
Speaker 2:ADHD was. if you go back into what we'll call medical writings, the first description of something we might recognize as ADHD actually goes back to the ancient Greeks in 500 BC. Hippocrates actually has some written texts where there's descriptions of kids that we might think of as ADHD. But fast forward, the first description in medical literature what we would consider a medical textbook occurs in the late 18th century in both Germany and Scotland at around the same time. These are very clear descriptions in medical books of kids that have what we undoubtedly would call ADHD, so it's been with us for quite a long time.
Speaker 1:Yeah, that's super interesting. In terms of adult impulsivity, would you say things like impatient, like waiting for waiting in a line or, let's say, driving very recklessly. Would that be considered a form of impulsivity?
Speaker 2:So being impatient is an example of impulsivity, because you, for example, just leave a line and run off being frustrated and not do what you need to do Absolutely Driving impulsively. We know that people with ADHD are at higher risk for car accidents than people with ADHD, and part of that is in intention. If you're not paying attention to the road, you're looking at your cell phone, you're going to get into an accident. Part of it is impulsivity You cut a car off too soon and you get into trouble that way, absolutely.
Speaker 1:Very interesting. So, dr Farron, how did you come about studying ADHD? What made you interested in this topic?
Speaker 2:Well, it's a good question. I like to tell young people that they're starting their careers that you kind of never know where your career is going to go when you're starting out, because there are many influences that will occur. So I was a back about what? 35 years ago I was a psychology intern at Brown University Medical School And I joined a group that was.
Speaker 2:After my internship I did a post-doctoral fellowship, joined a group that was doing psychiatric epidemiology and genetics. After that I joined the faculty at Harvard Medical School where at the time I was actually starting out studying schizophrenia and bipolar disorder. And then I met a colleague from the Massachusetts General Hospital, professor Biederman, who was needed some help with some work. He needed some help in my area specialty genetics and epidemiology with some work he was doing in ADHD, and I agreed to help him and became intrigued with the disorder and then ended up working with him at the Massachusetts General Hospital in his clinic and also working in collaborative research together. So I became interested because I became introduced to the disorder and the needs for research by a colleague who had started to study it before me.
Speaker 1:It's absolutely amazing And you're absolutely right in saying we actually never know where we end up in the field, right? I started off with being interested in psychology and neuroscience and ended up in philosophy of psychiatry. I've noticed that's where my interests go. So you're right, the door is always so open. Well, you just gave us a definition of ADHD. In particular, it's symptomology, so the characteristics that may arise in someone, as you said, the impulsivity, the inattention. But I want to focus now on the cognition or the cognitive processes that someone with ADHD might have, so, in particular, what we know in the field as executive functioning, so the ability to task, which decision make. I'll let you get into the definition here. Now, there have been a number of studies that have looked at the ADHD brain. I believe you've published a few yourself, and meta analysis as well, that looked into executive functioning. So I guess my question here is firstly, what consists of executive functioning and does ADHD impact executive functioning from so-called healthy control? So basically, people that don't have ADHD.
Speaker 2:Okay, great questions. So the executive functions are those functions of the human brain that basically, essentially control all the other functions of the human brain. That's why it's called the executive. It's like an executive Right. They're controlling and managing everything else. They are executive functions help to organize ourselves in time and space so that we can complete goal. Directed activities Involves things like working memory, being able to remember things that you need to do, things like planning, things like abstracting information from whatever you're reading or whatever you're observing. Executive functions are very important in many areas of our life. They are the brain functions that separate us from other animals, for sure. Now, in ADHD, we know from you mentioned the meta analysis that I did with Eric Wilk and others that clearly shows that people with ADHD are more likely to have executive function deficits than people with ADHD. But not everybody with ADHD has executive function deficits.
Speaker 2:And this is actually I'm going to. You brought this up because there are. We talked about before the symptoms of ADHD and every person with ADHD has some of those symptoms And that's what we call them. We call them diagnostic criteria. There are other features, we call associated features, that people with ADHD are at risk for having. Executive functions are one of them. But we shouldn't confuse that with executive dysfunction. Is ADHD. If somebody could have executive dysfunction and not have ADHD.
Speaker 1:Very interesting. I don't quite remember the study that I read, but it said that essentially, as we grow older, so kids that may show symptoms of ADHD when they're younger, once they reach, let's say, adolescence, the brain changes, our hormones change And so it could happen that they may have been, may have shown the symptoms of ADHD or may have been ADHD, but as they grow into adolescence, something changes. Have you seen, you know, with your current like knowledge of it, have you seen such changes happen quite frequently?
Speaker 2:Well, we know now from a very big research literature that has studied ADHD children over time, where they've literally followed them over time and see what happens to their ADHD. We know that about two roughly two thirds of kids who have ADHD will continue to have ADHD as young adults, but one third will desist. Their ADHD will go away. What's happening there? Well, one of the clues is was seen in longitudinal studies of brain functioning One of the best ones done by Philip Shaw at the National Institute of Health, and what Dr Shaw found was that over time, those kids who were mid of their ADHD symptoms also showed changes in their brain.
Speaker 2:Their brains were becoming more typical, more like the average person as opposed to a person with ADHD. When they started that in childhood they had we called I don't like to call them brain anomalies, i call them brain differences because they're. There's small brain differences between people with and without ADHD that are very evident in childhood but tend to diminish as people age And if they go, if they get small enough. We think that's one of the reasons why ADHD remits in some people in adulthood.
Speaker 1:Do you mind giving in a few examples of what would be the difference between someone who? is there any brain differences in someone with ADHD or without? both in childhood or adulthood or adulthood? Excuse me.
Speaker 2:Sure. So I was part of a big mega analysis involving several thousand children and adults with ADHD and people with ADHD as well. It was a very big study combining neuroimaging samples from around the world Neuroimaging meaning studies which actually took pictures of the brain, in this case, with looking at brain structure. Differences in brain structure Right, make a long story short. What that study showed was that in childhood you could document small differences when you have lots of data, like we did, in certain areas of the brain, particularly the frontal cortex, the prefrontal cortex that controls the executive functions, right, but also in what we call lower areas of the brain that are more deeply embedded in the brain, subcortical regions, which are connected to the frontal cortex, which we know are involved in regulating behavior.
Speaker 2:And remember, adhd is a you can think of it as a disorder of self-regulation, the inability to self-regulate important behaviors. We think that circuits between these subcortical structures and the prefrontal cortex are involved in the self-regulation and therefore in ADHD. Now, we don't have any definitive pathophysiology for the disorder, but we have these little clues. I do want to emphasize that the differences are small. If you were to show the brain scan of anybody with ADHD to a radiologist, they wouldn't see any difference in the brain from a so-called normal person. Brain difference is a tiny, with the only exception being someone who has suffered a traumatic brain injury and gotten ADHD because of that. Then their brains might show a very clear pathology, but in 99.9% of cases nobody would even notice it on a brain scan.
Speaker 1:I think I do remember reading something about the default mode network and then the task network being correlated with someone who has ADHD, whereas they're actually supposed to be anti-correlated.
Speaker 2:Okay, So let's talk about that, because that's another good source of data. We have less data in this area, but the data that are out there are suggesting. It's more suggestive that We'll bring back up a second for your listeners. The default mode network in the brain describes the activity of the brain when the brain is at rest. So when you're sitting around at rest, daydreaming, meditating, your brain is essentially at rest, but your default mode network is activated, meaning that if we would scan your brain at that time, we would see activity that corresponds to that relaxed brain. Now, when the brain has to do a task, it switches out of the default mode network and it goes online. It goes into an active network, an executive control network, to complete a task, And some of the data that are out there suggest that the ADHD brain has difficulty going online when it needs to and sometimes goes offline when it should be online. So that's a good way to think about the ADHD brain as regards to the default mode network.
Speaker 1:Very well said. Yeah, i love that. You explained it much more eloquently than I could, so thank you for that. In my intro I did mention that ADHD does have a bit of controversy in the field, where some worry of overdiagnosis, other think because it can be comorbid with other psychiatric conditions, it can be incorrectly diagnosed And of course there's some that don't believe it exists at all. Right, but that's a whole another conversation. But to approach some of these in a nutshell firstly, how does a clinician or a psychiatrist diagnose ADHD? And then how would you recommend clinicians and even individuals for themselves to be confident in knowing that their diagnosis is accurate and, for example, not some other diagnosis, and when and if they should seek a second opinion or just know that all the other options have been ruled out and that their diagnosis is most accurate?
Speaker 2:Sure, Sure, Number one the diagnosis can only be based on an interview of the patient, sometimes with other people, like a parent or a partner for an adult, an informant, someone who knows the patient. But it can only be based on that clinical interview where the clinician goes through and queries the person about the symptoms of ADHD. So if your doctor spends time with you talking about these symptoms and determines that you have them to a degree that is extreme we say extreme for one's developmental level. That means in simple language, that means more extreme than you'd expect for your age group, than you would say the person has ADHD. You know that the doctor is making a mistake. If they're.
Speaker 2:For example, if they just give you a little form, paper and pencil, form and they say fill this out and you just check off some symptoms to find ADHD, that's wrong, It's not the right way. That is not the correct way to diagnose ADHD. If they have, you take a neuropsychological test or some kind of weird computer-based test and use that test to say you have ADHD. That's wrong. That is not and I'm talking about not my opinion, I'm talking about what is written in any treatment guideline for ADHD in either the USA or Europe or Australia or anywhere You do not use these tests to diagnose ADHD. You can use them to collect extra information for the diagnosis based on the interview.
Speaker 1:I think this is such important information. This was bear in mind. This was through an online therapy application, but they're all like clinical psychologists. A friend of mine got diagnosed by literally just doing one test. They gave them a questionnaire and then, based on that, they actually got the diagnosis. I think what you're saying is so important that it's actually it should be more of an interview, rather than just giving one simple test and then determining whether you are diagnosed in the condition. It's always good to have a more thorough examination, rather just more surface level right?
Speaker 2:Absolutely. I'll tell you exactly why. that is because the diagnosis not only requires that you have a certain set of symptoms. You have to establish that the symptoms are causing the person some impairment in their life. You have to establish that the symptoms and the impairments don't just occur in one place. If you only have ADHD when you're at work or you only have ADHD with you when you're with your family or at school, that's not ADHD. that's something that's situation-specific that the doctor would have to figure out. Very important We also have an agent onset criteria in that it has to start before the age of 12. And so one has a document for an adult that's symptoms onset early. Now we can have a big discussion about that. That's a complicated point. but that's the reason why you don't use these simple checklists. They're very useful to screen people. So if you have a big patient load in the primary care office, you might get everybody to this test and then the people who have high scores. then you bring them in and say I'd like to talk to you about these symptoms. Let me.
Speaker 2:I didn't answer your question about other psychiatric problems. We call them comorbidities, other disorders that a person might have When I was being trained. we're talking like 40 years ago. I guess in graduate school we were taught that you always try to differentiate. Is it ADHD? Is it depression? Is it depression? Is it autism? Is it this? or is it that It would turn out to be the incorrect belief that all psychiatric disorders are independent of one another?
Speaker 2:What we found and I say we meaning the field, not just me, although I did contribute to this over those last three, four decades is that comorbidity meaning two disorders occurring together, is very common in both childhood and adulthood. So if a person has ADHD, they're much more likely to eventually become depressed than somebody who doesn't have ADHD, and vice versa. So these days we don't tell clinicians to rule out ADHD. if the person is depressed, we tell them to document all the disorders that the person has and then, after you document them, then you come up with a treatment plan based upon the differential severity of the disorders. So it's not so much.
Speaker 2:The biggest mistake is not so much you've kind of diagnosed somebody with ADHD who's really depressed and you should just treat the depression. The big mistake is not to recognize that the person has two disorders that need treatment, and a good example would be sometimes I lecture primary care doctors who have very little training in ADHD and sometimes someone will say, well, i don't have any ADHD people in my practice. And I'll say well, you do. I guarantee you do because, first of all, the base rate of ADHD in adults is about at least 5%. Number one, number two, you probably. I say, do you treat people with depression and anxiety? I say yeah. I say to some of those people not do well in their medication, they say, yeah, i bet that among those people, take a closer look at those people, but many of them will have ADHD And that's why they're not responding to their medications, because you've only treated part of their problem, not the entire problem.
Speaker 1:It's great also to see how the field has evolved. Think of the fact that two disorders could coexist. It's good to see that it's kind of broadened and there is a depth of understanding that we could have multiple for example, adhd and anxiety, but also like being on the spectrum of autism, and it helps right. It helps with intervention. It helps to understand the person as an individual and how best to help them. Another thing you said which absolutely blew my mind was that check if the symptoms only show up in a certain area of your life. Do you show ADHD symptoms just at school or just at work or just at home? Because if that's the case, then clearly there's something else going on there. What is that environment that you're in that is creating these symptoms? So yeah, i just found that so mind blowing. That's right.
Speaker 2:I will add that there are some environments. Well, let me add two things, right.
Speaker 2:Well, i guess we'll get to genetics later, so I'm not gonna talk about that, but you wanna talk about genetics and comorbidity, but there are some environments where people with ADHD will show a diminuation of their symptoms And this has to do with a concept that's popular on the internet among people with ADHD. It goes under the term hyper focus, where people with ADHD will say well, you know, i have ADHD, but sometimes I can really focus and maintain concentration, not be impulsive and don't seem to have ADHD, like if I'm playing a video game I really like, and it's always. this hyper focus always occurs in very high reward situations And that's a way those are the only kinds of environments we know where the symptoms of ADHD will tend to go away when there are rewards that are very we use the term salient. the rewards are very powerful, meaning that they're frequent, they come to you very quickly and there's something that you really like.
Speaker 2:People with ADHD are not good at waiting for rewards. If you try to reward them by saying, hey, if you study in high school, you're gonna do well in college and get a good job, that future reward for them has no impact, whereas for other people it has a big impact. they'll respond to that. And if you don't understand the concept of delay of reward, look up the marshmallow test on YouTube and you'll see some very good examples of that.
Speaker 1:Oh, so interesting, Do you think? some of the kids that did not wait? they were diagnosed with ADHD later on.
Speaker 2:Absolutely yeah. So in that marshmallow test it's not a diagnosis of ADHD. I would bet that, yeah, among the kids that didn't, that couldn't wait, and they ate the marshmallow right away, more of those would have ADHD than the group that waited.
Speaker 1:Yeah, you mentioned the internet, so I couldn't help but bring this up. I do wanna talk a little bit about Gen Z and just the younger generation and the way the diagnosis has impacted them. So there was a statistics in 2022 that showed the ADHD hashtag. So if you look at the ADHD hashtag on TikTok, it had about 14.5 billion views and the ADHD awareness hashtag had also some number in the billions as well. Now, of course, that's great.
Speaker 1:Awareness is great, because a lot of these videos are about removing the stigma and the shame around ADHD. but of course, much like anything, it comes with its challenges, because a lot of young people are now actually turning to TikTok for advice. They are reading these messages as actual mental health help instead of going to a licensed or a clinical psychologist, et cetera. And the most most crazily, perhaps, is that they're self-diagnosing, saying that oh, this sounds exactly like me, so I must have ADHD. So and a lot of these clips are like well, some of them are like actual conditions talking about the diagnosis, but a lot of them are comedy skits or like memes or funny videos of this is how you do, this is what your ADHD brain does, and things like that. Now, obviously, as someone who's dedicated their life's work to this and knows so much on this topic, i'm just curious to know your thoughts on this. I'm not sure if you're on TikTok, dr Farron, but I presume you are aware of this to an extent.
Speaker 2:I'm not on TikTok. You can follow my blogs on. I tweet at my blogs periodically a few times a week on Twitter. I love it, but not on TikTok yet at least.
Speaker 1:Yeah, well, I mean, academic Twitter is awesome, but, yeah, I just want to know what do you think? Do you think this era, is this going in the right direction? Because sometimes I worry about this over diagnosis, self-diagnosis, excuse me, and just the way that it's been perceived on social media.
Speaker 2:Well, number one. I think anybody that's trying to fight stigma is doing a great job on TikTok and they should continue to do that. That's super important. Oh yeah, awareness is very important too. It's great that TikTok promotes awareness.
Speaker 2:But for people who are consuming this information, they have to remember that if they they have to remember, they have to learn how to evaluate what they're hearing about. So if they, for example, here's someone TikTok and that makes them think they have ADHD, well then yeah, by all means go to your doctor and say, hey, i heard this, i think I might have ADHD. Could you evaluate me And then find out what the doctor says? And you might find out. The doctor says you don't have ADHD.
Speaker 2:Because, honestly, there are people on TikTok who kind of don't know what they're talking about and they're not experts, they're people. They might be people with ADHD, but a lot of times, a person with ADHD will talk about other aspects of their life and act as if that's their ADHD. Well, no, that's just them as a person, because we're all people. We all do many, many things have multiple facets to us and when you talk about everything in your life as being your ADHD, it can confuse people because they think like, for example, i've heard I've done some ask me anything sessions on Reddit and a common question I get there is it has to do with the question of gender dysphoria. Is that? is that you know?
Speaker 2:I've heard that gender dysphoria is part of ADHD and that's because someone on TikTok said, oh, I have ADHD and I have gender dysphoria, and the casual listener makes the leap to think, oh, gender dysphoria is a good thing. They're correlated, yeah.
Speaker 2:No, it's not this is just somebody who happens to have gender dysphoria. It's not, but it's not ADHD, great point. That's where the problem lies. And then the other part of the problem is when people use TikTok to promote misinformation. When they, for example, promote some treatment for ADHD that they, oh, this is a great treatment. I tried this, you know special probiotic drink and it cured my ADHD. That's just a bunch of BS. You should definitely not get treatment advice from TikTok. That you should get from your health professional.
Speaker 1:Absolutely. yeah, thank you for that, and you're so right in saying that sometimes it's great that people share personal experiences, but sometimes we take personal experiences as the experience and the only experience and definition, whereas people with ADHD it can appear differently in different people to an extent, right. So, yeah, it's very important to just be mindful of the information that we receive and just fact check always And, like you said, if we are suspicious that we may have the diagnosis, to actually go to a practitioner and a clinician to get that confirmed.
Speaker 2:Absolutely, and this doesn't play TikTok, it apply. There are popular books written by people about ADHD. Frequently a question's about Gabor Mate, who writes a lot about ADHD as a website about it, and what I tell people is well, what I do is when I hear about somebody who's a new name in the world of ADHD, i go to the National Library of Medicine and I say, has this person ever written anything that's been published in a journal reviewed by experts? And I can't find anything by him. There may be something I couldn't find, anything that he's written that's been peer reviewed and published. He's written popular books. He probably gives a good talk, engaging person And what we have, the problem that we have.
Speaker 2:In fact, i was just talking to a medical student today who said, oh, he read this great book by Gabor Mate who said that attachment problems are a real cause of ADHD And that's basically a BS. I mean, there's not a lot of data that says that attachment problems are a major cause of ADHD? They may contribute in a small way, but hey, we got some guy out there blaming parents for not attaching well to their kid And that just causes more problems. So what I would tell people and this is something I'm pretty serious about because I have my own website called ADHDevidenceorg And the goal there is to promote evidence-based information about ADHD. And when we say evidence-based, we mean based upon the best evidence available, which is typically through research.
Speaker 2:I tell people I talk to your audience listening here it's we're all very impressed with somebody who's entertaining and engaging and they're good speakers And you know they're more impressive than a nerdy professor. You're like, oh, is this guy? what does this guy really know? He's not telling jokes. He's not making me laugh. You know he's not doing a little dance. I mean, how could it? why should I believe him? The answer is you need to, especially when it comes to your healthcare. Okay, it's not entertainment. Okay, healthcare is very serious. You need to find the best evidence available and use that. Don't base it on whether you like the person. In fact, if you really like that person and they're really engaging, you might even be a little suspicious of them, because they're trying to get to you via their high level of interpersonal skill as opposed to giving you solid information. So go to pugmedgov Yes, pugmedgov. You can search the National Library of Medicine to find out if somebody who says they're an expert really is an expert.
Speaker 1:Thank you, dr Perron. I gotta be honest, i've read some of his books, one of them being When the Body Says No. There's a lot of you know, interesting, anecdotal, you know kind of data based on his journey as a physician. However, they're not peer reviewed. you know academic research. They're more, i guess, based on his personal life experiences. It's very interesting because I've never thought of it from that perspective.
Speaker 2:So yeah, i don't and I should say I don't discount personal life experiences, what people with ADHD have to say about the disorder. But I want people to understand, you know, when we talk about evidence, the lowest level of evidence is personal life experience. It doesn't mean it's meaningless, it just means it's the lowest level we have. And so if my personal, if someone says their personal life experience says that eating donuts is good for ADHD, well you know, maybe it is. But guess what? There's a lot. There's other evidence that's much stronger that says that other things are better for treating ADHD. So be very careful when you're making healthcare decisions based upon low levels of evidence. They're not meaningless And sometimes clinical observations by doctors, life experience by patients and in fact in my career, sometimes just simple observations where there was no evidence, have led me and colleagues to make important discoveries for ADHD that we could then document in research. But you have to take it through those phases. If you don't go that far, you're just kind of basically making an educated guess.
Speaker 1:Right, a huge assumption based on one experience, or one or two experiences. They're kind of in line with this. There's actually a very interesting book called Stolen Focus. He's a journalist, i think his name, johan Hari, and he basically just travels around the globe and he meets, like different experts, investigating why we've lost our focus, and basically the gist of this book is that our issue is rooted deep within the society that we live in. I guess a very similar message to like Gabor Mati, and I guess one of the main things that he talks about is that it's, of course, the use of smartphones, like TV, tablets and all of this that is creating this disorder essentially. So I'm very curious to know your thoughts.
Speaker 2:Yes, Yeah, i tell you right away. So this guy, this is somebody who does not know any. He does not know the evidence, but ADHD. So I would say, if smartphones goes ADHD, why is the prevalence of ADHD the same around the world? If you take a study that's done in Africa, where people don't have smartphones, how come they have ADHD too? So interesting, how come the prevalence of ADHD has not changed?
Speaker 2:If you look at scientific studies well-done studies look at the real prevalence of ADHD in populations over the last six. I think it goes back at least six decades or so. The prevalence has not changed over time. It's been fairly constant. It's fairly constant around the world. Where there are higher rates, it's not in the United States, it's in places like the Middle East. And even those rates we're not sure that they're actually higher because there's studies, there's very few studies, so there's no.
Speaker 2:Adhd is not culture bound. And the genes we know that, the genes that are responsible for ADHD. We did a study, the group of us that does genomics. Actually it was done by my colleagues in Barcelona, but they asked me to help them with it. What they found is that the risk genes for ADHD have been around since the Paleolithic times, because we have DNA samples that have been available enough from the Paleolithic and the Andrithal samples And you can show that they've been slowly been being removed from the population because ADHD is not adaptive for survival, but they've been with us for quite a long time. So this idea that it's modern society no, it used to be, it used to be.
Speaker 2:Tv causes ADHD, adhd. Pretty soon it's going to be oh, chat, jpt causes ADHD. The only thing is it's causing ADHD. No, it's been with us for quite a long time. It's going to be with us for a while. This stuff is just, it's speculation, it's entertainment, but it's just entertainment, and keep that in mind that when you read these books, you might get some insights from somebody that help you think about your life. That's great. I'm not arguing against that, but don't use it. Don't think that it's serious evidence that you should make important health care decisions. Bye.
Speaker 1:Let's actually talk about genes, since we spoke about symptomology and a bit about cognitive processes. So I know that twin studies there have been a lot of twin studies that show that there's a very strong genetic component of ADHD And obviously there's a number of ways that we can look at the genetic contribution, like through candidate genes, And then there's also the genome-wide association studies. So for today, or take it as you wish, but I was hoping to focus a little bit on GWAS, So kind of what it is, what it looks at, and do we have enough SNPs to identify ADHD or what is the current literature about the genes of this condition?
Speaker 2:Yeah, I'll tell you all about that. It's one of my favorite areas.
Speaker 2:Yay, i think contributed a lot to that. You mentioned the twin studies. I think there are 38 twin studies And for the public that's listening, twin studies were in the past used to get an idea of how genetic, if you will, what's the strength of the genetic component for disorder? Because identical twins have a hundred share their genes 100% of the time, whereas non-identical twins are just like regular siblings. They only share half their genes. So what it turns out to be that the biggest risk factor for ADHD is having an identical twin who has ADHD, and it leads us to estimate that the heritability of the disorder is about I think it was 76% in my last review of that And that means that about 76% of ADHD can be counted for by genes in the genome, along with the way they interact with the environment. So fast forward to the era of DNA studies, where nowadays we can take a blood sample and we can assay your DNA and we can look at. Sierra mentioned SNPs. These are simply measures of your genome, all along the genome, and what the GWAS studies have told us one of the most fascinating, i think the most fascinating thing we've learned from the GWAS studies is that ADHD is highly polygenic And what that means is that it's not one gene that causes ADHD, or two or three or 10 or even a hundred.
Speaker 2:In the last GWAS we published this came out in January of this year we now estimate that there are over 7,000 areas of the genome that contain risk. We call them alleles, which are versions of genes. Risk alleles for ADHD 7,000. You can think about it as 7,000 risk genes for ADHD. That's a lot. It means that what happens is we don't know how many a person needs to have, but is some threshold. Maybe a person has to have a hundred or 200, maybe they have to have 200 plus an adverse environment, because we also think that some environmental circumstances also accumulate to cause ADHD. Extremely important finding for the field You mentioned can we use genes to say who has and who doesn't doesn't have ADHD?
Speaker 2:And the answer is we can't use the genome to predict very accurately yet, because we can create a risk score it's called a polygenic risk score. so I could you know if, sierra, if you give me a blood sample, i could tell you, or you could go to 23andMean. 23andmean would tell you that your risk score for ADHD is such and so high. Low in between. That risk score is not useful for making very accurate predictions, but it is very useful for teaching us about the genomics of psychiatric problems, and one of the very interesting things we've learned is that a person's genomic risk for ADHD is significantly correlated with their genomic risk for autism, their genomic risk for depression, their genomic risk for bipolar disorder, genomic risk for anxiety disorders, even their genomic risk for schizophrenia. Now, when I say correlated with, i mean if you have a lot of ADHD genes, some of those genes also cause depression. Some of those genes also cause anxiety, and this is one of the reasons to go back to diagnosing people with two disorders.
Speaker 1:This is one of the reasons why Comorbidity yeah.
Speaker 2:Comorbidity is real because part of it not all of it part of it is due to shared genetic risks. Now it even gets even more fascinating, because we tend to think of genes on the one hand and environment on the other hand, and that these are two separate areas of our existence. Well, in terms of that, that's not true, because there is this pervasive phenomena that is called gene environment correlation, and what that means is that people, based on their genes, choose specific environments. Yeah, that might sound weird, fascinating, but it's not, because if you have genes, for example, that are promoting you to risk taking, you're more likely to put yourself in risky situations. A friend of mine did a study of, did a twin study of veterans that had been served in the US military during the Vietnam era, and in his twins that he found that, essentially, willingness to put yourself in a combat situation was partly heritable, partly driven by your genes. Whether you decided to go back to Vietnam for a second and third tour of duty was partly driven by your genes, and this actually makes a lot of sense to me, because there are genes that are associated with risk taking, bravery, the features of you consider the ideal soldier that have led these people. So what that also leads to is that these are people that put themselves in traumatic situations, and so some of them come back with post-traumatic stress disorder, which is partly driven by their genome and obviously also driven by the fact that they were in a traumatic situation.
Speaker 2:Now talk about children. Colleagues of mine have done genomic studies where they take kids not kids with ADHD, just kids from the population at large, anybody. They could have ADHD, but most of them don't And they measure their genome and they get their risk for ADHD. And what do they find? They find that the child's genomic risk for ADHD predicts whether they've been physically or sexually abused, whether they live in impoverished environments and other environmental risks for psychopathology. And so this is gene environment correlation. It doesn't mean genes explain everything, but it means that if somebody has ADHD, many of them actually end up having a. We think of it as a double hit. The genes that they have are causing the disorder, but it's putting them in environments that are making their lives worse for sure.
Speaker 1:I had spoken to Professor Thalia Eley from Kings College London and she also studies epigenetics And it's super fascinating. It's exactly as you said. So if you're genetically susceptible to be antisocial, you seek people or environments where you are alone, and so that kind of enhances that behavior, and so it's like you said. It's like a double, double edge sword, right?
Speaker 2:I do want to also emphasize that I'm not saying that genes are destiny. Right, if you have a certain degree of change, you're destined to have this kind of life. That's not the case. You keep people. You can take charge of your life. You can control your life and move it in a better direction. We sometimes geneticists, sometimes talk about the reaction range of a genetic predisposition, that if you have a genetic problem, it means that you can end up higher or low for certain features, that antisocial behavior based upon what you do and the actions that you take and the kinds of or your parents take. Right, whether, if your parents let you allow you to be exposed to antisocial environments, you're more likely to end up down an antisocial pathway.
Speaker 1:Right. But as you said, if anything can actually help you, it can push you to do the opposite. Right. If you know you're susceptible to being antisocial, you can put yourself out there and do the opposite.
Speaker 2:Yeah, no, it has to do with health management. Think of ADHD. I like to think of ADHD like hypertension. Let's say you come from a family that's had multiple elders die of strokes or heart attacks because of hypertension. You know you're at risk for hypertension. If you take it seriously and you watch your diet and you exercise and you do what your doctor says, you can avoid having those strokes. You can avoid having heart attacks. You control it. The same is somewhat true for ADHD. It doesn't nap by diet, but there are other methods to improve your ADHD symptoms via appropriate treatment.
Speaker 1:Absolutely, dr Farron. I am wary of time. However, i feel like it won't be an episode about ADHD if we don't talk a little bit about medication, in particular ADHD medications. We know the most common prescribed drugs for ADHD are obviously stimulants Methylphenidate like retolin, concerta, and then amphetamines like Adderall. I guess my first question to start off is how do stimulants actually work in the brain? Then we know that amphetamines can have high propensity for addiction abuse. They can also have some other side effects For both adults and kids. Could there be a potential, a long-term potential, of it being I wouldn't say the word dangerous, but having immense side effects?
Speaker 2:Stimulant medications work in circuits in the brain that are controlled by a neurochemical called dopamine. By modulating dopamine transmission, they improve one's ability to regulate one's behavior. Non-stimulants like etymoxetine or guanfacine or clonidine those work primarily in the neuroadrenergic system. The neuroadrenergic system is also involved in the self-regulation of behavior and attention. That's why they work, although they're not as effective. The targets in the brain of these chemicals are very well known, but we're not going to go into those neurobiology details here. In terms of addiction amphetamine, adderall, the Gaterall or methylphenidate think Ritalin or Concerta these are addictive drugs, which is why they're We talked about it they're scheduled by the DEA and the FDA and they're controlled substances. If they're taken inappropriately, they can lead to addiction. The therapeutic use of these medications, however, does not lead to addiction. There have been now many, many, many studies and meta-analyses of these studies that show not only that, it's very clear that therapeutic use doesn't cause addiction. there's even evidence to indicate that therapeutic use prevents addiction, which makes sense because if your ADHT is under control, you're less likely to impulsively take a drug for the first time. you're less likely to put yourself in a situation where you might be exposed to drugs for the first time. Medications are not going to cause when they use therapeutic. they're not going to cause addiction. As regards other side effects, the side effects of these medications are very well known and they're all written out in the labels of the medications. They're essentially minor side effects that typically will go away in the first few weeks of treatment. If they don't go away, your physician or nurse practitioner will switch you to another medication where you likely won't have those side effects. In rare cases it's hard to control some of these side effects. We're talking here now about things like insomnia, not eating enough, not feeling yourself, losing your enthusiasm happens with some people on stimulant medications. Typically, these can be dealt with by changing the dose or changing the medication.
Speaker 2:The fact that patients need to be screened by their physician to see if the medication is appropriate is one of many reasons why people with ADHT medications should not divert their medications to other people. This is a problem we have particularly in adolescents and young adults, although it happens at all ages. Sometimes it's the parents of kids with ADHT. They will give the medication to someone else. Typically it's for what we call performance enhancement. It's to stay up late to study because they think they'll do better on a test if they're taking an ADHT medication, which is basically wrong. We found studies that we've done is that people who misuse these medications for performance enhancement aren't actually doing any better because they're using these medications. Some kids take misstates late to party because the counter defects of alcohol. This is a big mistake because if you haven't been screened for these medications, they could cause harms that you're not expecting to occur.
Speaker 2:The worst track of course, to take is to take these medications and try to snort them or inject them. I know I'm not going to probably convince some students, particularly in colleges, to have the idea that, well, because this is a prescribed medication, it's okay, it's better than street medication. It doesn't mean it's any safer to snort or to inject. It can still cause huge problems. The FDA and DEA they track emergency room visits. I've written papers about emergency room visits of people who have used amphetamine and methylphenidate. They can be very serious health outcomes for these people when they're misusing and abusing these medications. I just don't do it. Don't think they're safe because a doctor prescribed it to your friend Absolutely.
Speaker 2:You're always safe and taken therapeutically.
Speaker 1:Definitely That's such important advice as well. Dr Frohn, you also write about non-stimulants for ADHD. Maybe we can also briefly just quickly talk about non-drug interventions for ADHD, like CBT or even EMDR, impulse control, things like that. What are your thoughts on these methods? Do you think these methods work? Do they depend on the severity of the symptom or the person, et cetera? Sure.
Speaker 2:First we'll start with the non-stimulants. These are the ones that work in what we call neurogenetic circuits of the brain. They are effective in some people, but the effect of this is not as good as the stimulants. When I say not as good, i mean that fewer people will respond to the non-stimulants compared to the stimulants. Some people do very well and it's a very good alternative for people to consider, because then they don't have to worry about the headaches of getting it. When you get a controlled substance described by your doctor, you have to go visit them more frequently and there are other headaches involved with getting that. Not to mention that, as you may have heard, we ran out of Adderall in the United States this year because the amount that is made by the manufacturers is controlled by the DEA. If the DEA doesn't allow them to make enough in any given year, basically the pharmacy is run out. That's what happened this year or, i'm sorry, it happened last year and caused a big problem. But that doesn't happen with the non-stimulants, because they're not controlled substances. Now, in terms of non-pharmacologic treatments, they're not considered to be what we call first line treatments, because they're not as effective by far. You mentioned a few treatments like EMDR and Pulsavity, something or other. Those have not been studied sufficiently in ADHD. I would not recommend them.
Speaker 2:The only what we call psychological treatments that have been well documented for ADHD. For kids it would be what we call family behavior therapy, which is essentially teaching parents how to parent in a way that's more effective for a child with ADHD. That can be effective in some cases, but it's not dramatically effective. It's nowhere near as effective as the medications. Some people prefer to try that first because they'd rather not be on medications. I tell people, if you have to do that pathway first, just don't do it for too long. If it's not working after a few months put your child on medication, because we know that works very well for most kids. Lots of other things have been tried and studied. Well, i'm sorry I didn't mention for adults. For adults, the only psychological treatment that has documented to work is cognitive behavior therapy. I mean we call that CBT, i don't mean any CBT. Cbt is specifically designed for people like ADHD. There are programs that were developed by Mary Salento at NYU I think she's now in Hofstra. Steve Salento, who was at MGH, now somewhere in Florida. Susan Spirch, now still at Harvard. You want to find a CBT therapist who knows about how to deal with ADHD.
Speaker 2:As far as other non-pharmacologic treatments, interestingly there have been a lot of studies of omega-3 fatty acid supplements, particularly those that have a higher EPA-DHA ratio. What those studies show in a big meta-analysis, which is a pool analysis of many studies, is that there is a real effect of omega-3 on reducing symptoms of ADHD. It's actually effective. The problem is that it's not very effective. On a scale of 1 to 10, we'll say a stimulant drug is a 9, 8 or 9. A non-stimulant drug is maybe a 6. Omega-3 is about a 2. It's possible that a very small group of people might do very well on omega-3. That's happened, well documented. I say the same thing If you're going to try it, don't try it for very long and while it's not working.
Speaker 2:Especially those parents out there who, because of the internet, are so afraid to put their kids on ADHD medications, will remind you that many of them the stimulant medications have been around and approved for ADHD for decades or more than 50 years. Ritalin was approved in the 1960s. The first emphatomy was actually used in 1937, although they weren't used regularly until the last 40, 50 years, there's been extensive use of these medications. They're even used in the elderly. My dad was 90 years old. He had dementia. He took Ritalin just to help him stay awake. They give stimulants to even some of the most vulnerable people, the elderly. Remember that when you Don't, when you're afraid of giving medication because of its side effects, just remember that not giving your child medication also has side effects and those side effects are the effects of untreated ADHD. And If you have a five year old and you delay treatment for two, three years, that means you know you basically a third of their life, half, more than half their life in school, has been, has been untreated and that's means they're not learning enough, they're not developing socially enough and you're denying them that privilege. It's a big mistake.
Speaker 2:I tell you a personal story. Friend of mine called me up and said he said hey, you know, you know a lot of the ADHD. He says my daughter, my grandson, i'm pretty sure he has ADHD. My daughter, for the last year and a half, two years, has been taking him to this doctor who gives him all these supplements And this treatment and these, all these alternative treatments and nothing seems to be working. And she keeps trying and trying and doesn't want to do medication.
Speaker 2:Would you talk to her? I talked to her. What did I say? Basically said look, i understand I fully respect your right to choose the treatment for your child, but you are exposing him to lots of adversity that he doesn't have to be exposed to. I Understand you're concerned and a little bit afraid of what medications might do. But let me suggest this Get a prescription for the medication.
Speaker 2:You don't have to take it. You don't have to give it to your child for the rest of his life. You can give it to him for one day, two days. If you see some problems you don't like, you can stop right away. But give it a try. I would suggest you at least try for a week or so before you give up.
Speaker 2:She called me back. She did that, got the prescription, called me back a week later and said oh my gosh, i wish I had done this two years ago Because it was child, was night and day. All of a sudden he could attend in school, he wasn't causing havoc in the home, the parents could parent effectively. Interestingly, studies figment done showing that when you give I think this was done with methylphenidate, which is also known as Ritalin. Right, i'll consider when you give kids a stemming medication, the the parents parenting behavior improves. They become better parents when the child is medicated.
Speaker 2:That's strange reason. Reason is because the child is becoming like an average child. They're not frustrated all the time, so they actually have the bandwidth to parent appropriately. So look, i'm not trying to sell medication, i'm just saying it works. This is again. This is I'm a psychologist. I wish Psychological therapies work better and I and psychological therapies are good for lots of things. Right, they're good for lots of residual problems and families that are not the medications can't deal with. They're especially good for adults Who have never been treated because, as we say, pills don't replace skills and you can frequently, psychological treatment can help you develop skills that you never developed during your life as a child, not a lesson because of your ADHD. But don't think that these other treatments, except in rare circumstances, are gonna solve your problems.
Speaker 1:They won't would you say for someone who's hesitant With ADHD medication, but they do want to give it a shot, would you advise to start with small doses and then increase, or, if small works for them, just keep it at that.
Speaker 2:Or okay, so number one. just everybody knows I'm a psychologist, i don't yeah right, i do know a lot about them.
Speaker 2:They can exact. I know a lot of psychiatrists. I've studied it intensively for 30 years, so here's what I'll tell you. But it's not personal advice to any individual, it's just general information and that is a typical advice, for We call it tight-trading medication.
Speaker 2:That means giving medication to a patient for the first time. Is you always start low? We say start low and go slow. You started a low dose and you gradually increase the dose. When do you stop increasing the dose? typically the dose is.
Speaker 2:Most guidelines would say increase the dose Until side effects emerge that are a problem, which case you would stop, or maybe even or lower the dose, or you've achieved sufficient amount of efficacy that medication is working as good as well as it can work. So that's so. Yeah, starting low is perfectly sensible, but I wouldn't stop at the lowest dose because You want, you want to wait, you want to get as high as you can so that your ADHD is Completely under control. What happens to some people is they they do stop at a lower dose. They say, hey, this is really great because the stimulant medications have a fairly quick effect and When people respond, they notice the change in there and themselves or their child and sometimes They stop too soon because of that initial change. But what happens later on is maybe a few months later They realize there are the problems that I still have That were relatively minor But now they seem more serious because the more serious problems they've been taken care of and some cases Increasing the dose then helps to get rid of those problems.
Speaker 1:Yeah, very good advice. Thank you for that, dr Farone. As we come close to the end of this episode, i want to talk about the ADHD evidence project that you have founded, which, honestly, for those listening, if you're interested in ADHD or are going, you know, want to go into in thorough detail. I highly recommend you have a look at this website. It has everything from like blogs to presentations, to studies, to health, everything, everything. But I'll let dr Farone perhaps go into that. Why have you founded the ADHD evidence project and maybe a little bit about its mission.
Speaker 2:So the mission is simple, is to provide evidence-based information to people With ADHD or their loved ones to help them make better decisions in their life about their own health care or to learn about ADHD in a way From a place that they can be sure is based on the best evidence available. That's the mission. It started with What we call the international consensus statement on ADHD. This was a publication as published in a scientific journal that I organized. I think we had 87 people, like I organized, 87 people from around the world. They were identified as experts by the various regional ADHD associations from around the world to participate in Writing this consensus statement. And it's a consensus statement.
Speaker 2:It's a special one. It doesn't just mean things that we all agreed on. It means items that were well documented in the scientific literature. There's 208 statements. It's relatively easy to follow back is a very nice summary at the very beginning. If you don't read 208 statements, you can just look at the summary Basics from there, and then, after I did that, i realized there was a real need for kind of Maintaining the evidence base because it's increasing every day. I mean people are publishing articles every day about ADHD And so I do blog on a regular basis.
Speaker 2:Amazing bad ADHD. Also for those people who are interested in educating others about ADHD, i have a slide set. I think it's over 350 slides PowerPoint slide deck Free of charge, everything's free. By the way, there's no paywall. I know that BS, you know you just use it or you don't, but there are these free slides. So people want to educate me ADHD. Take a, take the slides, use them freely And teach other people about what we know, what the evidence says about ADHD true academic I'm professor for because all of the information that you give, as you said, it's free.
Speaker 1:There's no pay for my monthly subscription and or, you know, join my masterclass and you'll find out all you need. All the research that you've done, all the hard work is Genuinely you know, for the people and I just think that's absolutely amazing. So thank you for that. Thank you, dr. For as a final question, what's next in your already extremely impressive academic journey? I know you do have an upcoming book, the Misunderstood mind, adhd in the 21st century, coming up, so exciting. Can you tell us a little bit about it?
Speaker 2:Well, the book itself is it's it's it's possibly that we can be done. It's a. It's a project I'd like to do. I'm trying to raise funds for it because I the only way I can do it is I need to have a professional writer Help do the research for it. I really want to be. What I want to be is a very in-depth look at how The media, including the internet, has stigmatized ADHD and created this to be the most misunderstood Disorder ever in psychiatry. But yeah, it's actually a lot, a lot of work, because I, as I said, i like to get these things right.
Speaker 2:I want to, you know, do it a deep dive into the research, not just not just give my opinion. So that might happen, depending upon if there's enough interest in, if there's enough interest in the book we get enough donations, will do that. But otherwise, in my career Right now, my research is is focused on trying to develop better Ways to predict not only the onset of ADHD but also the onset of future problems and people with ADHD, and We're using some of the more advanced machine learning methodologies applying to medical record data, also to genomic data, to do that, and that's we'll see. It's a it's a very tough problem to solve. We're hoping, you know, maybe the next ten years will will be have some ability to make good predictions about ADHD.
Speaker 1:Is there any place people can donate for, for the, for the upcoming book?
Speaker 2:they go to the website, you'll see a donation button on the page that talks about the book. I don't get enough donations. I'll just use those donations to support the website.
Speaker 1:Definitely, dr Frohn. This has been nothing short of amazing. What an honor to have you learn from you and listen from you today. Thank you so much for your time and expertise and for all your work in the field. I'm sure so many of the listeners are going to learn so much from you as I did, so appreciate your time.
Speaker 2:Hey, thanks for caring about ADHD. I really appreciate that. Thank you.
Speaker 1:Thank you everyone for tuning in and listening. If you did like this episode, please do support us by sharing some of your favorite episodes or subscribing through your favorite podcast hosting site to keep up to date with our Future episodes. I will be linking Dr Frohn's details to this episode description along with his website, though do go check it out further if interested. Thank you again and we'll catch you in the next episode. You.