Understanding ADHD - A Conversation with Stephen Hinshaw

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    • 00:01

      [MUSIC PLAYING]

    • 00:06

      HOWARD BURTON: What do you think of whenyou hear the acronym ADHD?Just another in a long line of pseudoafflictions that our overmedicated,label-hungry society throws on underperforming childrenand inattentive parents to mask falling standards?Or a genuine psychological conditionresulting from a combination of genetic and cultural factors?Well, scientific opinion is more convergent

    • 00:29

      HOWARD BURTON [continued]: than the popular press might lead you to believe.There's little doubt that ADHD is a real condition that existsthroughout the developed world.A condition that merits a comprehensive treatmentof medical and behavioral therapythrough diligent monitoring by physicians, parents,and educators.But there's also little doubt that ADHD is all-too-oftenboth overdiagnosed and underappreciated,

    • 00:51

      HOWARD BURTON [continued]: leaving a trail of frustration, miscomprehension,and all-too-often, over medicated children in its wake.Stephen Hinshaw is a clinical psychologist at UC Berkeley,and a world expert on ADHD.As Steve tells it, the first steptowards coming to grips with ADHD, like all mental illness,requires us to first develop our own understanding

    • 01:14

      HOWARD BURTON [continued]: by going beyond simplistic societal stereotypes.What are we talking about here?What is ADHD?And let's talk about what it is in an informal way,because I'm not asking you to boil it down to 30 seconds.

    • 01:38

      HOWARD BURTON [continued]: And then we can talk about diagnoses.We can talk about treatment.And then we can go on from there.But I think for a lot of people exactly like myself,there is a tremendous amount of confusion and misunderstandingas to what we're even talking about,right from the very beginning.So let's just start there.

    • 01:56

      STEPHEN HINSHAW: Well, part of the confusionis the alphabet soup nature of this.It's ADHD.No it's ADD.No, it would just be called hyperactivity or hyperkinesis.And back about 50 years or so ago,it was called minimal brain dysfunction.MBD.So I think we have to go back to compulsory education.What did we start to do?

    • 02:16

      STEPHEN HINSHAW [continued]: The first state in America was Massachusetts.And about 1830 we made kids go to school.And Europe had started to do this a few years before.Now for the first time, all kids-- not just the elite few--have to sit in uncomfortable chairs--

    • 02:32

      HOWARD BURTON: Really uncomfortable chairs, too.In the 1800s they were super uncomfortable.

    • 02:36

      STEPHEN HINSHAW: Not today's models.And do things that the human brain never evolved to do,which is learn to read.If you want to get a kid talking,you expose that could to a little bit of language.And the genetic programs in the brain take over.Everybody talks.If you try to get many kids to read, it's an act of God.It's a lot of work.

    • 02:57

      STEPHEN HINSHAW [continued]: Only very recently, the last secondbefore midnight in the evolutionary time clock,did we make everybody do this.In any species, it's a good thing to have diversity.If the climate changes, context changes,you want to have people who can not all be the same,because then some will survive in these changed times.There's a gene called the DRD4 gene.

    • 03:21

      STEPHEN HINSHAW [continued]: This is a gene that produces in its various alleles,or forms, more or less of a receptor for dopamine.Right in key parts of the brain thatcan give you a sense of reward, give youa sense of being focused.So what do we know?It's pretty interesting.Back 15,000 years ago-- we could point to the globe

    • 03:42

      STEPHEN HINSHAW [continued]: here-- in Asia, when the Bering Strait was not a strait,but a land mass, the frequency-- there'sa certain allele of this gene calledthe 7-repeat allele-- and people who have this form of the genetend to be explorers.They tend to be sensation-seekers.Today they like to ride on roller coastersand jump from planes.

    • 04:03

      STEPHEN HINSHAW [continued]: So what happened back then?There was a subset of the Asian population thatcrossed what is now the Bering Straitand went into modern-day Alaska, British Columbia, and soon down over the years into California and Central America,all the way down to South America.

    • 04:20

      HOWARD BURTON: Had it not been for this gene,we wouldn't have had people spreading out across the globe.

    • 04:23

      STEPHEN HINSHAW: That's right.There's a 3% frequency, genetic anthropologists can nowtell us, of this 7-repeat allele in the Asian society15,000 years ago, as you go into modern-day California, SouthAmerica, the gene allele frequency rises to 30% to 35%.So maybe ADHD isn't a disorder during those times,

    • 04:47

      STEPHEN HINSHAW [continued]: it's an exploratory gene.It's not a bad thing to have.But now in the last 150 years--

    • 04:52

      HOWARD BURTON: It's hard to explore whenyou're stuck in a chair and--

    • 04:54

      STEPHEN HINSHAW: You're stuck in a chair.So we could say, well, ADHD is just all cultural.These are perfectly good genes.And now we make every kid sit still,and so we call it a disorder.On the other hand, there's some evidencethat even back in the day, way before compulsory education--

    • 05:15

      STEPHEN HINSHAW [continued]: well, let's say you're a hunter-gather.So it's probably good for some peopleto be kind of calm and focused, and other peopleto be vigilant and looking out, many sensations.But there's only one arrow.And if you're impulsive and miss, there's the kill.There's the food for your tribe for a long time.

    • 05:36

      STEPHEN HINSHAW [continued]: Probably very severe forms of inattention and impulse controlproblems were always problematic.But today, even milder forms are problematicbecause of this culture of needing to pay attention.And increasingly over the last couple of decades,needing to achieve higher and higher.So all this is a long way of saying that we as a species

    • 06:02

      STEPHEN HINSHAW [continued]: have many differences.Some people are highly focused.Some people are restless almost by nature and impulsive.That might be good to have that variation.But over the last couple hundred years,and even the last couple of decades,people with those extreme forms of the inattentive, impulsiveside, that doesn't succeed very well these days.

    • 06:24

      STEPHEN HINSHAW [continued]: So we're really concerned that ADHD may be rising rightbefore our eyes, even in the last 10 years,in frequency, well above anythingthat anybody would have predictedeven a couple of decades ago because of academic pressures.But let's focus on ADHD and what it is.I gave some sort of genetic background.

    • 06:47

      STEPHEN HINSHAW [continued]: The symptoms today have to do with two main forms.Are you attentive versus inattentive?Are you highly organized versus disorganized?A. And B, are you controlled or impulsive?Are you pretty calm or are you restless and fidgety?So inattentive symptoms and hyperactive and impulsive

    • 07:08

      STEPHEN HINSHAW [continued]: symptoms.Those tend to fall out into two pretty distinct clustersmost of the time.So how do you know that this isn't justa three-year-old boy?All three-year-old boys have pretty rampant ADHD.That's the nature of three-year-old old boys.And a subset of girls, too.But what if you're well above the norm?You're in the 00 percentile even for a three or four-year-old

    • 07:30

      STEPHEN HINSHAW [continued]: boy.Or now in grade school, when these pressures are on,to sit still, what if you're much less attentive and muchmore impulsive than all but a few kids in your whole school?These are the kids who tend to get diagnosed with ADHD.There's no blood test.There's no brain scan.There's lots of research these days

    • 07:52

      STEPHEN HINSHAW [continued]: with structural and functional neuro imaging.And there are group differences.There are different brain structures and different brainprocesses in people with severe ADHD versus not.But neither for ADHD, nor for bipolar disorder, depression,schizophrenia, autism, we don't have a brain signature yetthat is highly diagnostic.The mean differences in research may, on the other hand,

    • 08:16

      STEPHEN HINSHAW [continued]: reveal false positives and false negatives one-on-one.Maybe in 30 to 50 years we'll havesome forms of this condition wherethere's a brain signature.That's the holy grail now.We're not quite there.And remember, even if we get more precise diagnostically,even if we get more precise brain scans,the symptoms of this condition play out in school.

    • 08:39

      STEPHEN HINSHAW [continued]: And when you've got to drive and pay careful attention,or when you've got to be in a relationship and reallylook to the other's needs.There's always a cultural aspect to howyou diagnose these symptoms, even though in extreme casesthere may be some real biological undercurrents.[Chapter 2.Clarifying Further: Definitions, Biology and Behavior]

    • 08:56

      HOWARD BURTON: I was fascinated by what I read in your bookabout the biological structure.Because as someone who comes at this from perhaps a morescientific persuasion, I was thinking,OK, I've heard this thing.I've heard ADHD.I hear all sorts of things that are bandied aroundin the press.

    • 09:11

      STEPHEN HINSHAW: Right.

    • 09:12

      HOWARD BURTON: In the public consciousness.If this is a developmental disorder, or condition,or something, there has to be some kind of explanationfrom a neurophysiological, biological perspective.

    • 09:24

      STEPHEN HINSHAW: There's a lot of fascinatingneurophysiological research.And so let's take one step back, and then we'll get to it.Is ADHD-- well, it's called attention deficit hyperactivitydisorder.It used to be called ADD-- attention deficit disorder.Is there really a deficit in attention?Well, cognitive psychologists will tell you thereare several forms of attention.There is sustained attention.

    • 09:46

      STEPHEN HINSHAW [continued]: If I drone on too long, you'll be asleep.And so maybe people with ADHD just fade out quicker.But there's good research that if you're looking at material,there's problems in the cognitive processing of peoplewith ADHD from the first second onward.So it's not just sustained attention over time.Maybe it's selective attention.Am I listening to your questions?

    • 10:08

      STEPHEN HINSHAW [continued]: Am I worried about my stomach growling?Or tomorrow's lecture?But I have to focus on you.Or let me give you a whole bunch of numbers.Six, eight, four, one, nine, seven.Could you say those backwards?So the longer I go, right?

    • 10:25

      HOWARD BURTON: I was trying to pay attention, because Ithought it was a test.

    • 10:28

      STEPHEN HINSHAW: It was a test.This is a potential capacity or load.And the more material anybody has to regurgitate,the harder it is.People with ADHD may have particular problemswith potential capacity and load.We're not even positive that ADHD is primarilyan attention deficit disorder, because of these various formsof attention.

    • 10:48

      STEPHEN HINSHAW [continued]: Maybe it's an inhibitory deficit disorder.One of the problems kids with ADHD have is,they go to birthday parties.It's really fun.They blow out the candles.But it's not their birthday party.Oh my God.I remember blowing out the candles at my birthday.It was so cool.And there was smoke.And everybody cheered.And there's stimuluses in front of me.

    • 11:09

      STEPHEN HINSHAW [continued]: There's the cake.And I forgot to remember that it's not my birthday.

    • 11:14

      HOWARD BURTON: You couldn't turn that off.

    • 11:16

      STEPHEN HINSHAW: Couldn't turn that off.So it's not so much a deficit of attention as inhibition.I've got to suppress that impulseto do something really cool in the service of longer termgains.Or maybe it's a disorder of intrinsic motivationand reward.What are most grade school kids have to do?

    • 11:37

      STEPHEN HINSHAW [continued]: Work for honor roll four months down the road.The most distant reward that an eight-year-old could ever have.Kids with ADHD are concerned about consequencesin the next five seconds, or five minutes.And there's pretty good evidence that ittakes a long time for most humansto develop that sense of intrinsic reward.

    • 11:59

      STEPHEN HINSHAW [continued]: But if you've got ADHD, it takes you a lot longer.May be related to dopamine neurotransmission.Because dopamine is the neurotransmitterin certain regions of the brain that give youthat sense of well-being and anticipatory pleasure, and oh,I've really done a good job now.So let's get into that, that's one of the theories.

    • 12:17

      HOWARD BURTON: Yeah.Let's get into that.But also I just want to add before-- that's also,it seems to me, linked to some of the behavioral techniquesas well.Because if you're talking about the ideathat somebody is looking for that satisfaction,goal-oriented behavior, a job well-done,focusing on a specific task and then getting that reward,

    • 12:41

      HOWARD BURTON [continued]: you can look at that neurophysiologicallyin terms of what's going on in your synapses.But you can also look at that as, let's isolate thatand try to build upon that so as to condition people.So you can see the link right therein terms of behavior and neurophysiology.

    • 12:57

      STEPHEN HINSHAW: Absolutely.So if we're talking-- if we jump to treatment.We say, well, we've got to replacethis deficit of dopamine.Give medications that do it.Or we can build in-- Rome wasn't builtin a day-- small, incremental steps.Reward those systematically.And then gradually taper the rewards in the waythat most kids don't need that precise a procedure.

    • 13:20

      STEPHEN HINSHAW [continued]: Kids with ADHD might.So behaviourally you might be able to shapelonger and longer delay without using a medication.So both in terms of causation and mechanisms and treatment,you can look to the brain.You can look to medication.Or you can look to social learning theory and behaviorand reward.It's a fascinating condition, because both ends alwaysget thrown in together.

    • 13:40

      STEPHEN HINSHAW [continued]: [Chapter 3.Diagnosis, Misdiagnosis, and Treatment]

    • 13:42

      HOWARD BURTON: Let's get into treatment now.So you've made a compelling case that there'ssomething interesting and there' certainly a lotrigorous going on neurophysiologically.But there's an awful lot that's going on,as you say, in terms of our culture, our conditioning,the interaction that we have.

    • 14:03

      HOWARD BURTON [continued]: So once someone is diagnosed with-- well,actually let me back up a little bit.So I'm a concerned parent.I have a child who I think might have ADHD,or maybe my teacher thinks he has ADHD, or what have you.So what happens next in terms of the diagnosis,

    • 14:24

      HOWARD BURTON [continued]: the diagnostic procedure?And how does that move forwards?Or at least, how should that move forward?

    • 14:29

      STEPHEN HINSHAW: Well, how should versus how doesis a big gap, which we talk about in the book.How should this work has been outlined very carefully by someof our big professional groups.The AAP-- the American Academy of Pediatrics.The AACAP-- the American Academy of Childand Adolescent Psychiatry, which is a mouthful.These are professional groups that commission research, talk

    • 14:53

      STEPHEN HINSHAW [continued]: to the best clinicians, look at the data,and say, what is it going to take to diagnosea kid with this condition?The long story short is, it's goingto take a long talk with the family about prenatal years,the first year of life, the second of life.Wat we call a developmental history.A lot of the symptoms we're talking about-- inattention,

    • 15:13

      STEPHEN HINSHAW [continued]: lack of focus, spacing out, impulsivity--are linked to depression.One of the cardinal symptoms of depressionis poor concentration.These symptoms are prevalent in kidswho've been maltreated-- physically or sexually abused,or neglected.These can be products of seizure disorders.You're going to have to do a lot of what the doctors callrule ins and rule outs.

    • 15:34

      STEPHEN HINSHAW [continued]: There's no substitute for a thorough history.This takes at least an hour.Parents and teachers both independentlyare going to have to fill out checklists, detailedratings of the kid's behavior.Obviously, if the clinician can make a school visit,that's all the better.Although that's often prohibitive.

    • 15:54

      STEPHEN HINSHAW [continued]: ADHD doesn't exist in the doctor's office waiting roomwhen the doctor is wearing a white coat.People with ADHD can get it togetherin a novel situation for 20, 30 minutes.ADHD occurs when you're doing homework,when you're on the soccer field, when the work gets harder,the day-to-day vicissitudes and pressures of performance.

    • 16:15

      STEPHEN HINSHAW [continued]: Right?So unless we get a history, and unless we get really good datafrom the people who see the individual as he or she worksand lives every day, ADHD is still a low tech diagnosis.It's a lot of information.Does your behavior, if you're the one I'm concernedabout, stand out in the 95th or 98th percentile compared

    • 16:38

      STEPHEN HINSHAW [continued]: to other males your age?Because girls are less active than boys.So we've got to take gender into account.And age is a big factor.How does all this work in practice?Way too much of the time, a childgets diagnosed with ADHD in the United Statesafter spending eight to 10 to 12 minutes in a pediatrician's

    • 16:59

      STEPHEN HINSHAW [continued]: office, with no history, no rating scales, no checklist,no norms, no nothing.And the prescription pad is written.So we're really convinced that some of this astronomicalrise across the last couple of decades in diagnosisis not necessarily because the environment's changing,our genes are mutating, that there's more real ADHD.

    • 17:24

      STEPHEN HINSHAW [continued]: ADHD'S in the news.There's a lot of incentive to get this diagnosis.And when it's made in a quick and dirty fashion like this,this is the price we're going to pay.

    • 17:31

      HOWARD BURTON: So I definitely want to get back to that.But let's go back to the more idealized casewhen we do have proper medical treatment, proper diagnoses,that's in accordance with professional opinionsof governing bodies who have thought long and hard about how

    • 17:53

      HOWARD BURTON [continued]: best to move forwards with this.So we've had at least an hour rigorous examination.We've had cross-referencing of independent reportsfrom parents, from independent reports from teachersand other individuals.

    • 18:08

      STEPHEN HINSHAW: And for an adult,from an employer or supervisor, or a spouse or partner.You've got to get information outside the person.

    • 18:15

      HOWARD BURTON: The big picture, and the big context.And then a diagnosis is made that this persondoes have this condition.What happens then?Or again, what should happen?Let's look more idealistically in terms of the treatmentand how should we proceed?

    • 18:31

      STEPHEN HINSHAW: Right.This is where there's real controversy and dividedopinion.Many European countries say what should happen thenis you try the systematic rewards.You get the parents engaged in parent management.They're going to break the skills down into small steps,provide reward charts at home, get the teachers consulted with

    • 18:52

      STEPHEN HINSHAW [continued]: to do the same thing, before you think of medication.The US-- now if you're a preschooler,behavioral treatments are preferred.But if you're a grade school kid and your ADHD is pretty severe,most of the professional associationswill say medication's the place to start.And then as needed, you're going to addthese behavioral treatments.So I was involved some years ago in a big study called

    • 19:16

      STEPHEN HINSHAW [continued]: the MTA-- the multi-modal treatmentstudy of children with ADHD.We had four arms of the treatment.About 150 kids get assigned to really carefully deliveredmedication.And we'll talk about this.The medications used for ADHD arestimulants, which enhance the effects of dopamine.The second group we said-- and we got

    • 19:39

      STEPHEN HINSHAW [continued]: informed consent, of course, from the families.We're going to ask you to keep your kid for the next 15 monthsoff all medication.And you're going to work hard in 35 parent management sessions.And we're going to send the psychologistinto your classroom a couple times a monthand meet with you and the teacher.We're going to create a summer program for your kid.Eight weeks, nine hours a day.

    • 19:59

      STEPHEN HINSHAW [continued]: We're actually going to have a counselor from that campserve as an aid in your child's classroomfor three months of the second school year.The most intensive behavioral, psychosocial treatment we know.The third condition was, let's put those together.That's the Cadillac, right?The fourth was, well that's our control group.What we wanted to say was, please

    • 20:20

      STEPHEN HINSHAW [continued]: do not help your children.We want to see them suffer.And we'll do our post assessment in 15 months.Ethically, you can't do that.So our control group was treatment as usual.So by the time this study ran in the late 90s,medication is getting more popular.Most of the kids in our control groupgot medication, the same treatment

    • 20:41

      STEPHEN HINSHAW [continued]: that kids in condition one-- medication only--condition three combined got.You'd think, that's a terrible control group.But let me tell you what happened.Our main outcome measure was thatafter a year and a quarter of treatment-- very intensive--the symptoms of ADHD as rated by parents and teachers,

    • 21:01

      STEPHEN HINSHAW [continued]: the medicine as we gave it, or the medicine as we gave itin combination with these intensive behavioral treatmentprocedures, quickly and reliably reduced those symptomsin the vast majority of cases, close to the normal range.The behavioral treatment was slower and not as effective.The community treatment that involved

    • 21:23

      STEPHEN HINSHAW [continued]: medication, but not the way we gave it--not with finding the right dose, spending a half hourwith the doctor every month.This is the usual pediatric standardof see a doctor every six months for nine minutes was the worst.Didn't do very well.So medication is not medication is not medication.It's how you diagnose, it's how you treat,

    • 21:44

      STEPHEN HINSHAW [continued]: it's how you monitor.But it was surprising and in some ways disappointing.All that reward-based behavioral treatmentdidn't add appreciably at all to the symptoms.But then we published another paper two years laterwhere we said, what might be more importantthan the symptoms is what about reading and writing?

    • 22:05

      HOWARD BURTON: Because these thingsdon't happen instantaneously.

    • 22:07

      STEPHEN HINSHAW: That's right.What about friendships and social skills at school?What about the parents' discipline styles?A lot of parents of kids with ADHDhave some of the symptoms themselvesbecause of genetic tendencies, and they're frustrated.Teaching the parents to be much more calm and responsive.So when our outcome measure wasn't just symptoms,but it was aggression and depression as well as academics

    • 22:32

      STEPHEN HINSHAW [continued]: and social skills and family discipline style,only the combination treatment reallyput a significant dent in that.Medication gets the kid's brain in better shape, if you will,to be amenable to all of the learningthat the teachers and families aredoing to try to get the kids intrinsic reward in place.

    • 22:51

      HOWARD BURTON: Which has a longer term effect.

    • 22:53

      STEPHEN HINSHAW: Which is what we're hoping has a longer termeffect.The problem with the long-term data from our studyis, we couldn't afford to treat these families for two or fiveyears.We stopped all the treatment and have been following them upover time through adolescence and even young adulthood.Once the treatment stopped-- either medication

    • 23:13

      STEPHEN HINSHAW [continued]: or this intensive combination treatment--the gains tend to erode.This wasn't a vaccine.Right?ADHD may be a longer term conditionthan many people have thought.In fact, we used to think 30 years ago ADD, hyperactivity,vanished when you hit puberty, because the kids weren'tfidgeting and squirming anymore.

    • 23:35

      STEPHEN HINSHAW [continued]: But the underlying attention problems and impulse controlsoften stay.And would we be surprised for the diabetes clinical trialif we said, well, we gave insulin very carefullyfor a year and a quarter.

    • 23:48

      HOWARD BURTON: Then we stopped.

    • 23:48

      STEPHEN HINSHAW: Then we stopped and the symptoms came back.We'd say, well, duh.ADHD may be more like diabetes than an infectious illness.It's going to take some sustaining treatment over time.[Chapter 4.Family Responsibilities and Subtleties of Medication]

    • 24:00

      HOWARD BURTON: I want to get to the adults in a momentthat you mentioned on several occasions.But it just seems there are two points thatare really worth highlighting that I certainlyhadn't thought of.One is that the behavioral conditioning, learningtechniques, working with the child in new ways, longer termissues, leads to I would imagine not only better structure,

    • 24:26

      HOWARD BURTON [continued]: some degree of intellectual coordination,goal planning, receiving, all the rest of that for the child.But it also drastically increases empathy.I would imagine that it would improve parenting skills.It's a hard thing to objectively say.

    • 24:47

      HOWARD BURTON [continued]: But certainly if you're spending a great deal of time and effortwith your child in all sorts of different ways,that would tend to make you much more adeptat being able to work with your child.And just you're spending much more time with your child.So there's this notion that the dynamics, the relationship,between the parent and the child will improve just

    • 25:10

      HOWARD BURTON [continued]: for the combined goal-sharing and effortsthat are going into that activity, I would think.So that's a huge additional benefit from that activity.

    • 25:18

      STEPHEN HINSHAW: And it's not just more time with the child,but it's more time and less yelling, and less emptythreats.You're going to be grounded for the next five years if youdon't-- parents of kids with ADHD get into these emptythreats because they're desperate.These are the kids back when they were young who gave upnapping before one year.These are the kids pulling down curtains in the house at 5:00

    • 25:40

      STEPHEN HINSHAW [continued]: in the morning when they're four.And have been already tossed out of two preschools.Parents are desperate.It must be my fault, because the clinicians often say, well, Idon't need to see the kid.I need to see you.It must be your marriage that's falling apart,or-- well, the marriage might be falling apartbecause of dealing with a kid like this.We know that from every twin study and adoption study done,

    • 26:03

      STEPHEN HINSHAW [continued]: the genetic undercurrent of ADHD is higherthan it is for schizophrenia or depression.About 80% of the reasons why some people are really focused,most people are in the middle, and some are really ADHD-like,those are 80% related to genes.

    • 26:24

      STEPHEN HINSHAW [continued]: So we don't want to blame parents, except for the genesthey transmitted to their kids for havingcaused the condition.But some people stop there and say, well, gee.All you can do is give medicine.Or maybe we can do gene replacement therapy the waywe can do with some neurological illnesses now.Obviously, we can't do that.What's the issue?Even though genes in early birth trauma or low birth

    • 26:47

      STEPHEN HINSHAW [continued]: weight, other biological factors may have been initial causes,how the family deals with the kid, how the family fights firewith fire versus taking a calmer, more rational, morestrict discipline approach with realistic limits,makes all the difference for outcome.Another reason why you can't separate biologyfrom the environment.

    • 27:08

      HOWARD BURTON: You make this distinction between blameand responsibility.

    • 27:10

      STEPHEN HINSHAW: That's right.

    • 27:10

      HOWARD BURTON: Just because it's not your faultdoesn't mean that you don't have some significant responsibilityto be involved in a constructive way.

    • 27:19

      STEPHEN HINSHAW: As a family, or whenyou're older or the adolescent or adult,getting treatment for yourself.

    • 27:23

      HOWARD BURTON: Exactly.The other point that you make repeatedly that I certainlyhadn't thought of is the distinctionbetween different ways of applying medication.So naively you think, well, you give the guy medication.OK.You either give medication or you don't give medication.The controversy or lack of controversy

    • 27:43

      HOWARD BURTON [continued]: surrounds the effectiveness of medication,whether it's the right thing to do,the wrong thing to do, and so forth.But at least in my mind, that's where it stops.There's a pill.You either give it or you don't.But it's much, much more complicated than that,as you had alluded to.There is a controlled way of giving the medication.There is supervision of the medication.There are questions of doses.It's a tremendously complicated issue.

    • 28:04

      STEPHEN HINSHAW: Much more complicatedthan most people give it credit for.So you could take two Tom Sawyer boys with ADHD, right?The sort of stereotype.They both weigh 64 pounds.And they both have the same symptoms.One boy requires one form of a stimulant at a very low dose.

    • 28:25

      STEPHEN HINSHAW [continued]: Another requires a different format five times the dose before you get the same effect.This is called pharmacogenomics.Maybe there are certain genetic differencesacross kids that predict not only their symptoms,but how they respond to medications.This is another holy grail we're going after.What it means right now is, the doctorhas to work in collaboration with the family

    • 28:47

      STEPHEN HINSHAW [continued]: in a controlled trial and error fashion.The first dose you give may be the wrong pill,may be the wrong dose.We've had kids come to the summer programs I run,which I've done for a long time, saying this medicine'sterrible for my kids.And at some of these summer programs,we do systematic trials.A week at dose A, a week at does B, a week on placebo.

    • 29:08

      STEPHEN HINSHAW [continued]: Some kids don't make it a week on placebo.You know in 10 minutes.So this lasts the whole time.And the parents say, we never thought,and our doctor never suggested, trying a much lower or muchhigher dose, or changing from medication form Ato form B. Makes all the difference in the world.[Chapter 5.Adult ADHD and Gender]

    • 29:26

      HOWARD BURTON: I wanted to ask a question about this conditionmanifesting itself in adults, and some of the differences.Because I think most people thinkADHD-- that's a kid who's out of control.Probably a boy.Running all over the place.OK.Give the kid some Ritalin.Or don't give the kid some Ritalin, or whatever it is.

    • 29:47

      HOWARD BURTON [continued]: And then eventually they'll grow out of it.

    • 29:49

      STEPHEN HINSHAW: That's right.

    • 29:50

      HOWARD BURTON: There's this naive notion about that.

    • 29:52

      STEPHEN HINSHAW: Well, that's the notionthat the pediatrics textbooks had 30, 35 years ago.Hyperkinesis is a benign conditionbecause it vanishes with puberty.What was the problem with that assertion?No long-term longitudinal followup studies.We now know that for both boys and girls--and here at Berkeley we've got the largest sample of girlswith ADHD in the world that we've

    • 30:13

      STEPHEN HINSHAW [continued]: been following systematically now 15 years--many over time, especially those who started outas the really rambunctious, fidgety, squirmy, hyper ones,the kids at 18 who literally jumped on the desksat our summer camps, could now sit.The hyperactivity's gone.

    • 30:33

      STEPHEN HINSHAW [continued]: But you ask, their minds are racing.Can't focus.You give tests-- sustained attention,impulsivity's still there.So 80% of kids well-diagnosed in childhoodcontinue to have full ADHD in adolescence.And somewhere, over 50% of these kidsstill have it as adults, meaning what?

    • 30:54

      STEPHEN HINSHAW [continued]: Well, some adults may, quote-- grow out of itif they find the right job and get skills.CEOs of big firms self-diagnosed with ADHD.Helps me be creative and think outside the box.Now, some of the CEOs have seven personal assistants.Right?

    • 31:10

      HOWARD BURTON: That helps too.

    • 31:11

      STEPHEN HINSHAW: That does help a lot.And some-- even of the self-professed ones--have had disasters on the job because theymade bad decisions.ADHD, the most florid symptoms tendto go away or go underground.Motor restlessness transmogrifiesinto cognitive restlessness.So now there's a growth industry,

    • 31:33

      STEPHEN HINSHAW [continued]: the biggest rise in diagnosis and medicationis for adults, not kids.And kids have almost kind of peaked in the United States.It's hard to diagnose ADHD in adults well because number one,you need to get some evidence that this person didn't wake upone day at age 34 with ADHD.If that's the case, what do you think as a clinician?

    • 31:55

      STEPHEN HINSHAW [continued]: What drugs have you been taking and where did youfall and injure your head?These symptoms don't come out of the blue.But you're going to have to go back in time-- of course,the diagnosis may not have been made in childhood.People didn't know about it.They thought it was a hoax or what have you.Parents are still alive, getting school records.And then second, what about on-the-job performance?

    • 32:16

      STEPHEN HINSHAW [continued]: What about relationships?And you've got to bring other people, justthe way you bring teachers into the assessment when it's a kid.When it's an adult, many adults with ADHDsay, well, I got a terrible boss.And yeah, I got treated badly.But there's not a lot of recognitionas to their role in the symptoms.

    • 32:31

      HOWARD BURTON: They've had 10 terrible bosses in a row.

    • 32:33

      HOWARD BURTON: That's right.That's right.There's a pattern there.Right.

    • 32:38

      HOWARD BURTON: A little bit about gender before we move on.So my understanding is that boys are far morelikely to be diagnosed with ADHD.But there is growing evidence that thereare many, many girls-- you had alluded

    • 32:58

      HOWARD BURTON [continued]: to it before-- who have ADHD.But the symptoms may be manifestedin somewhat different ways.And in your book you also point outthat-- I don't know if this is statistically true--but certainly there are many very tragic examplesof girls who haven't been diagnosed with ADHD properly,

    • 33:21

      HOWARD BURTON [continued]: or treated properly.It seems as if, if I'm reading whatyou were writing correctly, that the negative effectstend to be very, very dramatic for those girls whohaven't been properly diagnosed with ADHD,probably more statistically significant then for boys.Is that a fair assessment?

    • 33:40

      STEPHEN HINSHAW: Yeah.Let's talk about each point, because theseare really important points.So, is ADHD really more prevalent in boys than girls?Or do we just not recognize it?No.It's really more prevalent in boys.But so is autism.So is aggressive conduct disorder.So is Tourette's disorder.The first 10 years of life, neurodevelopmentally,are the risk period for boys.

    • 34:02

      STEPHEN HINSHAW [continued]: Sorry guys.The y chromosome isn't very big.It's only a few genes on it.It's not going to mask or cover for some flawin the x chromosome.And this is well-known.The second 10 years of life are the risk period for girls.Anxiety, depression, eating problems, cutting,suicidal behavior.That's another story.

    • 34:23

      STEPHEN HINSHAW [continued]: People thought when I was in grad schoolthat ADHD didn't really exist, or ADHD back thendidn't exist in girls, or it was really anomalous.Now we know that it's about 3 to 1.Autism is about 4 or 5 to 1.So maleness is a predictor of these developmental problemsfor a whole host of reasons.We set about-- my lab here at Berkeley,

    • 34:44

      STEPHEN HINSHAW [continued]: over 15 years ago-- to systematically studyADHD in girls, because we thought,we're getting referrals and we're getting calls.There's never quite enough to run a program.Let's run a program only for girls.We got NIMH, and the grant reviewers, the peer reviewers,to agree, best scored grant I've ever got.

    • 35:05

      STEPHEN HINSHAW [continued]: And so we got a big sample.140 girls with carefully diagnosed ADHD, againan 8 to 10 hour battery.Participated in one of three summer camps.And alongside them was an almost equally sized groupof typically developing girls from the same neighborhood,our control group built in.What have we learned?

    • 35:25

      STEPHEN HINSHAW [continued]: When we published our first papers in 2002, 12 years ago,on this condition in girls, that daywe doubled the world's literature,which is really kind of sad.It's not a huge sample.So very little systematically been done before.Second, we found that whether it wastheir attention, their academics, their social skills,

    • 35:48

      STEPHEN HINSHAW [continued]: how many friends they had, how many services they neededin school, how they did cognitivelyon a bunch of neuropsychological tests,they were systematically worse than the control group.Just like boys.

    • 35:59

      HOWARD BURTON: A real effect.

    • 36:00

      STEPHEN HINSHAW: A real effect.We got a big percentage of them to come back five years later.Some had scattered to the wind.It's a California sample.We found them.They found us.10 years follow-up happened then.So five years after that.95% retention rate we got back.Our staff are relentless.

    • 36:21

      STEPHEN HINSHAW [continued]: We never give up.

    • 36:22

      HOWARD BURTON: How did you get 95%?

    • 36:23

      STEPHEN HINSHAW: We never give up.And I'll tell you what.Facebook is a good way to track a longitudinal sample.You can privately friend a girl and not be publiclyon her wall, and stay in touch even if she's hada falling out with her family.

    • 36:34

      HOWARD BURTON: I didn't expect that with this conversation.I didn't expect that it would turn into an advertisementfor Facebook.But there you go.

    • 36:39

      STEPHEN HINSHAW: Social media helps longitudinal research.So, why am I saying this?If we had 50% of these young women back, they were girls.Now they're about in their early 20s.Well, you say the 50% are the ones who are doing best,are the ones who cared enough to come back.With 95%, pretty sure this is reliable.These girls with ADHD, now young women,

    • 37:02

      STEPHEN HINSHAW [continued]: they barely graduated from high schoolat the same rates as their control group,because their parents said, we carried her on our back.But they're the ones who are not goingto four-year schools or many community colleges,and their job vocational success is far lower.They continue to have the planning, sustained attention,

    • 37:25

      STEPHEN HINSHAW [continued]: executive function deficits, in some cases actuallygetting worse over time.Whereas the comparison group would get better.Most shockingly, we added measuresat this 10-year followup-- which we're doing nowin our current 15-year followup into the mid twenties--of things that aren't just symptoms of ADHD,

    • 37:46

      STEPHEN HINSHAW [continued]: but are symptoms of, have you thoughtyour life wasn't worth living?How strongly have you considered suicide?Have you ever made a serious suicide attempt?And separately, what about cutting, burning,self-mutilation, non-suicidal self-injurious behavior?The results were very alarming.

    • 38:08

      STEPHEN HINSHAW [continued]: Of the girls with ADHD 10 years earlier, who started offwith lots of impulsivity as well as inattention, 23% of themhad made a serious suicide attempt by the age of 20.

    • 38:20

      HOWARD BURTON: 23%.

    • 38:21

      STEPHEN HINSHAW: And 51% were actively,severely cutting, mutilating, burning themselves.

    • 38:28

      HOWARD BURTON: 51%.

    • 38:28

      STEPHEN HINSHAW: 51%.Now in our control group, it was 19%.That's the national average.There is a crisis of self-mutilationand cutting among teenage girls these days.But 2 and 1/2 fold higher in the girls with ADHD.So unlike boys, many of whom with ADHDgo on to delinquent careers and abuse substances, at least

    • 38:51

      STEPHEN HINSHAW [continued]: for a period of time, the girls with ADHDare taking it out against themselves.They feel socially isolated.They're not doing well in school.I mean, you can say for a boy, well, he's just all boy.A girl with ADHD is very atypicalcompared to other girls.These girls are internalizing it.And so one of our big interests in our 15-year followupis to see if through treatment or through maturation, if some

    • 39:14

      STEPHEN HINSHAW [continued]: of these self-destructive tendenciesare getting under control.[Chapter 6.Adderall for All?]

    • 39:18

      STEPHEN HINSHAW: I'm a Common Core fan.I think America needs better academic proceduresand standards and a explainable wayof teaching complicated concepts in math and history to kids.I'm not so sure that test scores should be the only wayto do that educationally.And our own research shows us thatthe unintended consequences for diagnosis of ADHD

    • 39:41

      STEPHEN HINSHAW [continued]: can be alarming.Now some people would say, so what?More kids get diagnosed, medicated, it helps everybody.In fact, why don't more kids get-- why don't more adultsget medicated?We're not doing very well achievement-wisein our society.So let's go to college.What do somewhere between 8% and 30%--

    • 40:03

      STEPHEN HINSHAW [continued]: if you believe the surveys, which I do--of college students now do?They take ADHD medications, even though they don't have ADHD.Study pills.Smart pills.Oh my God.My midterm is Friday.And I've got two term papers.So hey, I got a friend down the hall, a roommate,he's got Adderall or Concerta or Ritalin or Dexedrine.

    • 40:24

      STEPHEN HINSHAW [continued]: And I'll pop it.It doesn't seem to make me feel bad.In fact, I feel a little alert.Stayed up all night.I gave a talk a few months ago-- fall of 2013--at some wealthy public high schools in Marin County,just north of San Francisco.The school newspaper had done a survey.

    • 40:45

      STEPHEN HINSHAW [continued]: 12% of all ninth graders, and 40% of all 12th graderswere taking stimulants for SAT studying.In high school.

    • 40:52

      HOWARD BURTON: 40% of them.

    • 40:53

      STEPHEN HINSHAW: 40%.So, this isn't just in college anymore.So the question is, is this horrible?Or is this fine?I mean, think of fluoride.We put it in the water supply.Prevents tooth decay, right?Maybe we should put stimulants in the water supply.Get a little boost in dopamine level.You're going to stay up later, study harder.

    • 41:14

      HOWARD BURTON: You're trying to provoke me here.You're looking for a reaction.Cause I'm right on the edge of my seat.I'm ready to go.

    • 41:19

      STEPHEN HINSHAW: So, what do we know?Number one.It used to be thought that ADHD wassort of a magical paradoxical disorderbecause these are kids, when they took a stimulant theywould calm down.But everybody else would get sped up.Well, studies were done 30 years ago,

    • 41:40

      STEPHEN HINSHAW [continued]: you give perfectly normally developing kids stimulants,and what happens?They fidget less and they pay better attention.So maybe everybody's dopamine systemis enhanced a little bit with the stimulant.But what about college students who don't have ADHD?We know that the stimulants will help them focus and stay

    • 42:01

      STEPHEN HINSHAW [continued]: alert and stay up all night.Do they help learning?So we finally have some results on this from an important studypublished in 2013 by Ilieva, Boland, and Farah,back at the University of Pennsylvania.They got 46 college students-- not a hint of ADHD--who agreed to participate in a seven-week study,

    • 42:23

      STEPHEN HINSHAW [continued]: randomly assigning each week alternatingstimulant or placebo.And they gave-- now they didn't give every test every week.But they alternated 13 tests, not just to focusand being alert, but working memory, verbal fluency,but you're gonna really learn better.How many of those 13 measures did the college students

    • 42:48

      STEPHEN HINSHAW [continued]: without ADHD improve upon on the stimulant weeks comparedto the placebo week?Zero.There was a 14th measure, which was a simple one-item scaleeach week.How well did you do on your tests?And the college student said, I aced it this weekwhen they took their stimulant.So the implication is the stimulants

    • 43:09

      STEPHEN HINSHAW [continued]: are boosting false self-confidence.You think you're doing better because you're alert,and that boring material seemed interesting.So one of my colleagues, Jim Swanson,a psychologist at Irvine, has written on this.And it's pretty interesting.So forget ADHD, you have it or you don't.Let's look at the bell curve across the population.

    • 43:31

      STEPHEN HINSHAW [continued]: If you're at the far end of that curve,where you don't focus very well, medications help you.If you're in the middle of the curve-- most of us--medicine's a tiny benefit.They keep you up.But they're not helping you learn anything.If you're at the end of the curvewhere you're already over-focused,the stimulants make you worse.They get you over-focused.So they're not the panacea for learning.

    • 43:53

      STEPHEN HINSHAW [continued]: They're not the smart pills they were cracked up to be.That's number one.Number two.Why aren't stimulants in the water supply?Because they're addictive.The question is, how many people-- kids and adolescents--treated for ADHD and monitored wellby their doctor for medicines, become addicted?You look at the studies.

    • 44:15

      STEPHEN HINSHAW [continued]: There's very few reports of this.It seems vanishingly small.Probably one in 1,000.But what about the recent data on normally developingpeople-- college students, et cetera-- who take stimulants.10% to 15% chance of getting addicted.And the emergency department, ER visits,related to stimulants tripled in the last four years.

    • 44:36

      STEPHEN HINSHAW [continued]: [Chapter 7.International Effects]

    • 44:38

      HOWARD BURTON: You mentioned a couple of other countriesin passing.But for the most part, our discussionhas revolved around American policy.But you've also done quite a bit of work-- yourselfand with your colleagues-- lookingat how ADHD is handled around the world in other countries.And your assessment would be what,in terms of where the places are that have their act together,

    • 45:00

      HOWARD BURTON [continued]: that are doing things well.Where the places are that perhapsare a little bit further behind and needmore effort paid to this?

    • 45:08

      STEPHEN HINSHAW: Well, the first question is, does ADHD reallyexist around the world?Is this just an American phenomenon?And the answer is a resounding, itexists around the world where?In countries with compulsory education.Completely subsistence countries probably have bigger fishto fry than ADHD.

    • 45:24

      HOWARD BURTON: Sure.

    • 45:25

      STEPHEN HINSHAW: But once you startto require education-- and what'sremarkable is, a 2007 review of the world's literature-- it'sbeen replicated recently-- suggests that even though thereare slight differences in terms of which scale doesthis country use, or which measures does that country use,it's about 5% of kids around the worldwith compulsory education.Remarkably similar.

    • 45:46

      STEPHEN HINSHAW [continued]: It's the US that's the outlier with its 10%, 11% these days.So it makes you think that there is something biologicalabout 5% or so of kids who just don'tfit very well in our current educational system.So then the next part of your question is,who's doing a good job and who isn't?And it's a complicated story because of history

    • 46:07

      STEPHEN HINSHAW [continued]: and politics and economics.France has been on blog posts and articles.There's no ADHD in France.Well there must be.Let's look at their schooling.France has adhered to a very psychoanalytic model.

    • 46:21

      HOWARD BURTON: Same with autism, as well.

    • 46:23

      STEPHEN HINSHAW: Psychiatry.And they think it's all sort of early bonding problems.And current French practitioners and scientistsare thinking that that's been pretty misguided.Brazil-- we did an international workshopup here in Berkeley four years agoto try to get a sense of some high-rate countriesand low-rate countries.Brazil has traditionally for the last couple of decades

    • 46:44

      STEPHEN HINSHAW [continued]: had low rates of diagnosis and medication treatment.For many years there was politically repressive regimesin place.There was forced hospitalization and medicine.The public has understandably reacted against it.Now, ADHD can get diagnosed if you'rein an urban area, high income, health insurance.And it's only starting to catch on.

    • 47:06

      STEPHEN HINSHAW [continued]: Canada, in many ways, has the most progressive systemwhere diagnosis is taken very seriously.If there's somebody in the remote north of Canada,there can be teleconferences or experts flown into help with the diagnosis.Psychosocial to behavioral treatments

    • 47:27

      STEPHEN HINSHAW [continued]: for parents and teachers are taken as seriouslyas medications.Still, however, in Canada and in many other countries,whereas if you've got autism, youcan get special services at school,ADHD alone does not automaticallygenerate the special services.It's still a thought that well, it's just kids not trying hard.It's not really deserving of things.

    • 47:49

      STEPHEN HINSHAW [continued]: So we found in a paper that Scheffler and Idid-- he was the lead author, a few years ago--that if you plot about 100 countries on Earth,the economic well-being of the country-- sort of plota line-- is pretty correlated with how much ADHD

    • 48:09

      STEPHEN HINSHAW [continued]: is diagnosed, and how much medication is given.Sort of makes sense.Performance pressures.Economics.But there's a couple of countries like the USthat are way above the predicted line,and other countries like France that are way below.So it's not just economics.It's culture and values and how professionals are trained.[Chapter 8.The Stigma of Mental Illness]

    • 48:29

      HOWARD BURTON: Let me go back to the guy on the streetand skepticism that he might have, or she might have,about the existence of this thing.Oh well.It's just falling standards these days.You know, everybody's making excuses.Nobody takes responsibility.

    • 48:46

      STEPHEN HINSHAW: Everybody's got a disability.

    • 48:47

      HOWARD BURTON: Everybody's got something.Everybody's got this or that, or the other thing.Everybody should be on medication.It's an overmedicated society.It's a society filled with complainers.And what's interesting is that as you point out time and timeagain, this sentiment, which is in the public consciousness,is reinforced by not only wide pockets of the media,

    • 49:12

      HOWARD BURTON [continued]: but often the mainstream media.And you single out the New York Timesquite frequently for examples of publishing thingsthat not only seem to have an axe to grind,seem to have an agenda, but often govery strongly against prevailing scientific opinionand scientific dogma.So why is this?

    • 49:32

      HOWARD BURTON [continued]: I mean, why do you think that is?

    • 49:34

      STEPHEN HINSHAW: So, in the Times, across 2012 and 2013,some pretty good news stories about ADHD.But the opinion pieces, the Sunday Review, the op-eds,almost uniformly ridiculing, debasing.It's not a real condition.Medications are poisons.We just don't tolerate boyhood.Et cetera, et cetera.Just bad parenting.Stuff that any review of the scientific literature

    • 49:54

      STEPHEN HINSHAW [continued]: would tell you is not the case.We have to look to a concept called stigma.So, this is a big topic in social psychology.Racial prejudice has had the most ink on this.But what if you confess that you've got a mental illness?

    • 50:15

      STEPHEN HINSHAW [continued]: Why even hear the name?You're not stable.You're violent.You can't control yourself.You must have weak will or there'sa-- I may not express it, because I sort of know better,I might be minding my manners.But inside I feel you're not worthy.You may not even be fully human.So the stigma of mental illness is a topic

    • 50:36

      STEPHEN HINSHAW [continued]: I'm quite interested in.Wrote a book on this a few years ago called The Mark of Shame.And it turns out that if you had to pick the threethings, the three attributes in today's society,that people even consciously admit,much less what's really going on inside, will say,I don't want to be around those people.

    • 50:58

      STEPHEN HINSHAW [continued]: I stigmatize them.People with mental illness.People who abuse drugs.And people who are homeless.Those are the bottom three.And we tend to put those together.Sometimes they do actually go together.You must not have it together.Your parents must have been terrible parents.You're getting handouts SSI payments.

    • 51:18

      STEPHEN HINSHAW [continued]: You're violent.We have a big stereotype in the mediathat mental illness is always linked to violence.There's a few forms of mental illness that are.But the absolute fact is that peoplewith severe mental illness are far morelikely to be victimized by violencethan to perpetrate it themselves.Now we come to-- and this often occurs for somethinglike schizophrenia.

    • 51:38

      STEPHEN HINSHAW [continued]: You're psychotic.You're delusional.Nobody wants to be around somebody like that.Bipolar disorder.You're wacky.Just think of the words.You're loony.Looney Tunes.Children's cartoons are highly stigmatizing.But what about ADHD?These are kids who look pretty normal a lot of the time.They act normal at recess.

    • 51:59

      STEPHEN HINSHAW [continued]: But then in reading, they're not doing so well.So they're consistently inconsistent.It turns out that the stigma of milder, if you will,forms of mental disorder, or onesthat really fluctuate in their consistency, the stigmais really high.There's more stigma against high functioning autism-- what

    • 52:19

      STEPHEN HINSHAW [continued]: used to be called Asperger's, very smart kids whoact really weird-- then there is against the more prevalent,intellectually impaired kids with autism.You feel bad and sorry for them.But the other ones you think, they're just weird.

    • 52:31

      HOWARD BURTON: They're not trying.

    • 52:32

      STEPHEN HINSHAW: They're not trying.Or with ADHD.You got it together in period 2.What happened to period 4?It must just be bad effort or lousy parenting.So stigma's really high.

    • 52:42

      HOWARD BURTON: Right.And then they get it from the other side as you said.If somebody comes along and gives themironclad proof of some neurophysiological,then all of a sudden, they're deformed.They're less than human.They're all the rest of that.So you can't win, in a way.

    • 52:56

      STEPHEN HINSHAW: Well, we thoughtwe had the answer to stigma.So back in the '50s and '60s, whatwas the predominant mode of psychological and psychiatricthinking?Psychoanalytic.Psychodynamic.Poor early parenting leads to unconscious conflicts.And cure it with psychoanalysis, et cetera, et cetera.

    • 53:17

      STEPHEN HINSHAW [continued]: We shifted in the '70s, '80s, '90s to behavior genetics.Biological models.Schizophrenia has a substantial genetic liability,as we just said a minute ago.ADHD has an even higher genetic liability than that.Let's sell that to the public.Schizophrenia is a brain disease.ADHD is a dopamine disorder, or whatever we want to call it.

    • 53:39

      STEPHEN HINSHAW [continued]: The social psychologists will tell usthat if you're behaving deviantly,but I am the public now, and I think, oh, it'sbecause you couldn't help it.It's a biological cause.I'm going to forgive you.If I thought you just had weak personal character,I'll really blame you.The research is really interesting on this.

    • 54:01

      STEPHEN HINSHAW [continued]: Just published a few months ago the first sortof review of the world's literature on this topic.Take hypotheticals.Take experimental design studies,or just take people's general opinions.There's a group out there who have mental illness.And if I sort of program the research

    • 54:21

      STEPHEN HINSHAW [continued]: subjects to think it's because of biochemistry or becauseof genetic liability, almost uniformly the public will say,well, gee, I don't really blame that person or persons.So that's probably a good thing.But what also happens with the biogenetic attribution,I don't think you're ever going to get better.

    • 54:41

      STEPHEN HINSHAW [continued]: And I don't want to be around you.It's as though-- so, what happened in the forties?Never put cancer in an obituary.This was shameful.You put, died of natural causes or died of an unknown illness.Because we didn't understand cancer.Now we know that cancer is highly genetic in many cases.But it's cancer of-- it's a disease of your lungs

    • 55:02

      STEPHEN HINSHAW [continued]: or your liver or your pancreas.There's something about the biological ascriptionto mental illness where your whole behavior,your whole being, is flawed genes.I think what happens is we tend to think of the person as lessthan human.And once we dehumanize, harsh consequences.

    • 55:19

      HOWARD BURTON: Absolutely.Yes.

    • 55:21

      STEPHEN HINSHAW: Don't want to be around.It's called social distance.Social distance is increased, paradoxically,when we make a biogenetic ascriptionto that mental illness.We can't really afford to say it's all biologyor it's all made up.We can't afford to take the Scientologist perspectivethat all mental illness is bunk andthat all psychotropic medications have

    • 55:41

      STEPHEN HINSHAW [continued]: to be illegalized.These are complicated issues.Performance enhancement, whether it'sthrough medication or through beingable to afford an SAT tutor.Medications to control behavior.Those are fighting words, especially when it's kids.But then if you've grown up in a family like I have,with serious mental illness.My father's lifelong misdiagnosed bipolar disorder.

    • 56:04

      STEPHEN HINSHAW [continued]: Finally, after college, my helpinghim to get a correct diagnosis and get on Lithium.It was a lifesaver for a period of time.We have to be able to think that it's not just biological.And it's not just sociocultural.It's a complex amalgamation of the two, whichmakes it fascinating, but less easy to make a banner

    • 56:25

      STEPHEN HINSHAW [continued]: headline about.

    • 56:26

      HOWARD BURTON: Last question.You talk about social stigma of mental illness.You just mentioned your father, the other bookthat you had written, and one of the other booksthat you had written.Are you optimistic that society is slowly, by hook or by crook,

    • 56:48

      HOWARD BURTON [continued]: starting to develop more understanding, more tolerance,more appreciation, and compassion for sufferersof mental illness across the board?Are you seeing things moving in the right direction there?At least within an American context.

    • 57:06

      STEPHEN HINSHAW: Let's talk about the United States.Well, the first part of my answer is pessimistic.Sociologists have done surveys of people's attitudes--general public's attitudes-- toward mental illness,and social distance.Would you ride on a bus with a person like this?Would you let your daughter marry a person like this?For 50, 60 years, very similar.

    • 57:28

      STEPHEN HINSHAW [continued]: So we've got one of these rare occasionswhere we can look across time.The American public today knows vastly more, knowledge-wise,about mental illness than the '40s and '50s.I mean, there were no psychology courses in high schoolback then.Not many people went to college.There was a lot of mystification.

    • 57:48

      STEPHEN HINSHAW [continued]: So that's good news.But the bad news is that social distance, the American public'swillingness to interact with people's mental illness,has either stayed flat or gotten worse at the same timethat the knowledge has gotten better.Well, there's many reasons.Where did a lot of people with serious mental illnessused to be?

    • 58:09

      STEPHEN HINSHAW [continued]: 1955 is our peak year in America.Locked away in mental hospitals.And now where are they?In jails or on the streets and homeless.And so there's a sort of influx of very visible mental illnessthat leads to very bad stereotype.It's not just knowledge, it's attitude.It's belief and empathy.

    • 58:29

      STEPHEN HINSHAW [continued]: Personal contact is going to go a lot longerthan a course on the symptoms of mental illness.In fact, intriguingly, there are some middle school curriculabuilt into your health curriculum a uniton mental illness.Eighth graders learn a lot more about it.And they're more afraid of it.They say, I didn't know people with schizophrenia thoughtcrazy thoughts and heard voices.

    • 58:48

      HOWARD BURTON: So it's counterproductive.

    • 58:49

      STEPHEN HINSHAW: It can be counterproductive,unless you get people who've experienced schizophrenia,for example, to come in and--

    • 58:54

      HOWARD BURTON: Talk to them.

    • 58:55

      STEPHEN HINSHAW: --talk and say, I'm just like you.I've got my problems.Humanization is the way to go.And so the more optimistic part of all this is,just as with gay marriage where there's a big age divide,younger people in general in the United States are much morein favour than people above a certain age.For mental illness, we don't have the same national data

    • 59:16

      STEPHEN HINSHAW [continued]: as we do on gay marriage.But a lot of younger people are more open and willing.And the hope is that they're goingto grow into this sort of establishment whoare more willing to accept behavioral and emotionaldifferences.Now, a final point on this.I know how I could eliminate racial prejudice.

    • 59:39

      STEPHEN HINSHAW [continued]: Just make everybody's skin color the same as mine.Right?Obviously.You have to tolerate differences.With mental illness though, it's an illness.It's trickier.One of the best anti-stigma programsfor people with mental illness isfor them to get treatment and feel better about themselves,and have more productive lives.And that helps public attitudes.

    • 59:60

      STEPHEN HINSHAW [continued]: But in the same way, you can't treat somebodyfor racial difference.But still, people who get well-treatedfor serious mental illness are going to be different.We have to tolerate behavioral diversity too.So it's incumbent on both the health caresystem and people and families to get treatment and reimburseit.But also for us to decide as a society, what

    • 01:00:21

      STEPHEN HINSHAW [continued]: are the limits of behavioral diversitythat we want to tolerate, too?So it makes it fascinating.And I'm ultimately optimistic and pessimistic.Like many social causes, this isn'tgoing to go away with the next campaign in the next twoor three years.This is a lifelong battle.

    • 01:00:36

      HOWARD BURTON: Well, this has beena fascinating conversation.Thank you very much.

    • 01:00:39

      STEPHEN HINSHAW: Thanks so much.

    • 01:00:40

      HOWARD BURTON: I've really enjoyed it.It's been great.Thank you.[MUSIC PLAYING]

Understanding ADHD - A Conversation with Stephen Hinshaw

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Abstract

In conversation with Howard Burton, Professor Steven Hinshaw explains what ADHD is and how to diagnose and treat it. He explains common misconceptions about ADHD, and he describes the misdiagnoses that have led to those misconceptions.

Understanding ADHD - A Conversation with Stephen Hinshaw

In conversation with Howard Burton, Professor Steven Hinshaw explains what ADHD is and how to diagnose and treat it. He explains common misconceptions about ADHD, and he describes the misdiagnoses that have led to those misconceptions.

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