By Gene Beresin, Executive Director and Khadijah Booth Watkins, Associate Director

Posted in: Multimedia, Podcast

Topics: ADHD

Welcome back to a new season of Shrinking it Down: Mental Health Made Simple!

For our back-to-school season opener, we are joined by Dr. Tony Rostain for a deep dive on how ADHD changes from teen to adulthood. They break down the importance of early intervention, the benefits of school accommodations, and why anxiety and other co-occurring conditions can be common in children and teens with ADHD.  If you want to understand ADHD better and hear what actually helps, this episode’s for you.

Media List

• Anthony L. Rostain, MD, MA (Cooper University)
• The Adult ADHD Tool Kit (Taylor Francis)
• CHADD – Children and Adults with Attention Deficit Disorder
• ADDA – Attention Deficit Disorder Association
• Make America Healthy Again (MAHA) (Department of Health and Human Services)
• Including Disability and Belonging in Diversity, Equity and Inclusion (MGH Clay Center)

Episode Transcript

SPEAKERS: Gene Beresin, MD, MA; Khadijah Booth Watkins, MD, MPH; Anthony Rostain, MD, MA

[INTRO MUSIC PLAYS]

Gene 00:29

Welcome back to Shrinking it Down: Mental Health Made Simple, I’m Gene Beresin.

Khadijah 00:34

And I’m Khadijah Booth Watkins.

Gene 00:35

We’re two child and adolescent psychiatrists at the Clay Center for Young Healthy Minds at the Massachusetts General Hospital.

Khadijah 00:43

And so, you may have heard people say that kids just grow out of ADHD, or they outgrow the symptoms, but the reality is, that’s really not that simple. And so, you know, we’re going to talk a little bit about that today. And so, while some of the restlessness and some of the motoric stuff kind of settled down, some of the other challenges still persist, like, you know, focusing and challenges with time management and some of the other kind of executive functioning skills, and they might actually get harder with age. So, we’re going to kind of get into that a little bit today,

Gene 01:13

and here to help us understand and prepare for this transition from childhood to adult. ADHD is Dr. Tony Rostain. Now let me begin by saying that I’ve known Tony. How many years? Tony?

Dr. Tony Rostain 01:26

50 years.

Gene 01:27

50 years. Okay, he’s one of my oldest and dearest friends, and the guitar player and singer and harp blues harp player and our band, Pink Freud and the Transitional Objects. And he’s, well, he’s nationally recognized as an expert in life stand lifespan neurodevelopmental diversity in psychiatry, and that’s his clinical and research focus has been on ADHD, autism, learning disabilities and related conditions. So, Dr. Rostain is also an accomplished author, co-writing the adult ADHD Toolkit and Cognitive behavior therapy for adult ADHD, which are two essential guides for managing adult ADHD and his book, The stressed years of their lives offers crucial insights for parents navigating the mental health challenges During the college years. So hey, it’s great to have you here. Tony,

Dr. Tony Rostain 02:23

it’s so wonderful to be here. I always enjoy my time with all of you whenever I get a chance to, I love, I love listening to your podcast. By the way, Shrinking it Down is just an amazing show. In fact, I was talking to a group of pediatricians last night about it, because Dr. Beresin, you came to our pediatric group in February, and they were saying that it was one of the most impactful sessions they’d had in in years. Wow, and it was a wonderful and they they’re now starting to come to the center. So, you built a new audience for yourself.

Gene 03:01

Well, we’ve got a resource, and it’s a useful one, but let’s so, you know, there’s a lot of confusion out there about ADHD. So, can you define ADHD? And, you know, people still call it add. So can you define it and tell us something about it, and so that the audience can kind of know where we’re at.

Dr. Tony Rostain 03:24

I mean, ADHD has been in the news a lot, right? People saying we don’t know what it is, or it’s being over diagnosed. Well, let’s get down to the basics. First of all, ADHD is not one thing. It’s a set of traits or characteristics that impair people in their ability to get things done every day, and it presents differently throughout life. We have a set of symptoms that are that we call the core symptoms of ADHD, and they’re divided into two big groups. One has to do with attention and concentration and organization and being able to plan and do things fairly efficiently. And the other set of symptoms that make up what we know is ADHD are the hyperactive and impulsive, not being able to sit still, having to do things all the time, having impulsive control problems. So those two, if you will, categories, the hyperactivity, impulsivity and the attention difficulties together make up what we call ADHD. We sometimes use add, for short, just because we don’t want to add that H. And the other thing is that we often see people who don’t have the hyperactive so we might say, oh, you have ADD. In the old days, we used to say you had attention deficit disorder with or without hyperactivity. That got changed, not important. There were pluses and minuses to that. But what I like to say to my patients and families is that your child is a person with their own temperament, with their own skills, with their own resources. But what’s getting in the way of basically getting the job done, whatever that happens to be, schoolwork, relationships, managing themselves. These symptoms get in the way, and when they get impaired enough, we call it a diagnosis. There are, by the way, some people who have symptoms of ADHD, but are not impaired. So that becomes a discussion. Do you treat it? Do you not treat it? The key here is when it’s causing impairment and when it’s developmentally interfering with what we would expect someone of that, of that, of a particular age to be able to do. That’s when we take the diagnosis seriously and try to do something about it.

Khadijah 05:44

So, when does ADHD usually present? You know, parents and even sometimes my own family members will ask, you know, is it ever too early to consider that you know, my child has ADHD? You know, when should they be reaching out to their pediatrician or to their school? Well,

Dr. Tony Rostain 05:58

first of all, I think from the time any parent notices a child has difficulty with either motor over activity and or impulsivity or difficulty sustaining attention for their age group, it’s worth discussing it now, we don’t tend to make the diagnosis as we’re not. We’re reluctant to make the diagnosis between age four before age four or five, because we know a lot more about the disorder and how to treat it. Whereas, if your two- or three-year-old is running around a lot, what are you going to do about that? Well, we might still say they’re exhibiting the symptoms. How do we help manage that behavior? How do you and in that case, most of the intervention has to do with environmental restructuring and monitoring, redirecting, helping the child calm down if they’re having trouble calming down. And yeah, in extreme cases, I have seen children two or three years old come to me for help. And I would say that most pediatricians don’t feel comfortable, but child psychiatrists tend to be more comfortable trying to sort out what’s happening here, what’s happening neurodevelopmentally, because, again, we think of this as either a dysregulation of certain centers of the brain that help us control our behavior. So, it’s a tough call on that one, I would just say being mindful that this child is showing signs of dysregulation of attention and behavior, but we’re not going to call it until we really think that if the child reached roughly age three or four. There is a whole literature now on preschoolers with ADHD, again, we know that for them, the best approaches tend to be behavioral. Medications are not as effective. And before we go any further, I want to say another thing add is not Adderall deficiency disorder, which some teenagers or adults who try Adderall and say, oh, it helps me focus. I must have ADHD No, because turns out that some of these medications can help anyone stay focused, right? We’ll get to medications later, but I think the earlier you notice a problem and ask for help about it, the better, so that the parent doesn’t feel like they’re a bad parent, but mainly no this child’s nervous system is wired differently and needs an environment that can help them channel their energy and minimize the negative interactions that often occur because when a child is not behaving in a way that is expected. One thing we do often is to re balance people’s expectations. Like you don’t expect a three-year-old to be able to play quietly on their own for a half an hour. They do need some of them really need constant accompaniment, if you will, and attention. But I have had kids come to me who failed out of it, failed out of preschool, so to speak, as I’m sure you have seen, and that’s a terrible, you know, that’s a terrible feeling for the parents, and it’s usually because the child is, we would call it, their nervous system is not yet ready to sit in in a place, In a playroom with other kids and interact on their own. They need much more.

Gene 09:26

Okay, well, let me I want to ask you three questions, and if you forget them, I’ll remind you. Okay, so the first one is, you talked about differences in age, but since we’re talking about the transition from childhood to adulthood. One question is, is there a difference between, say, teenagers or middle school kids with ADHD and adults? That’s question one second. We often hear about executive functioning, and we hear so much. About this. So, I’d like you to talk a little bit about executive functioning between teens and adults. And the third question is, if there’s an early effort to treat ADHD, and we’ll we can talk about their associated conditions, because I know that we’re going to get into this the package deals with ADHD, but does it help lessen the severity in adulthood if there’s an intervention or treatment in, say, in this the middle school or teenage years? So

Dr. Tony Rostain 10:37

Well, you know, you’re asking really important questions, and in fact, right now, the science is learning much more about the developmental trajectory. Let’s start with that one. What’s the developmental trajectory of kids who when their children are diagnosed with ADHD? It turns out that there’s no one path from ADHD in childhood through to adulthood for a for a certain group of kids with treatment, they improve, and they stay improved, and they actually, often times it’s not so much. They grow it. They learn to cope with it better, and their course is fairly smooth. There are another group where they get better for a while, and then they get worse. And then there’s a third group that are just difficult to treat because their symptoms persist in a very relentless way through childhood, into adolescence and into adulthood, and those are the ones that we would call the more persistent forms of ADHD. So, I don’t You can’t predict, by the way, with a child’s behavior at age 10 which of those pathways they’re going to follow. Another interesting feature is that in recent years, we’ve seen what we were calling later onset ADHD, where the child does fairly well until, say, high school, and that’s when it begins to manifest. So, no single path, there is definitely evidence that early intervention mitigates, modifies the outcomes in the positive direction, because that’s where you get both improvements in the child’s performance in school, which is a big one. I mean, not being able to function in a classroom and having to be in special ed, that is a major, major setback for a child and for a family. So, your goal, our goal in treating is to minimize impairment, maximize functioning, and help the child, however they are, navigate what we call progressively more environmental demands on the child’s cognitive abilities, emotional maturity, social interactional ability,

Gene 12:49

and what about executive functioning?

Dr. Tony Rostain 12:52

Okay, so that that’s exactly where I was going. So, when you’re little, everything’s structured for you. You go, you can wake up, you know, parents get you breakfast, get you ready for school. Little by little, parents expect kids to be able to do that on their own. And I would, by the way, I like to go beyond executive function and talk about the notion of self-regulation, because self-regulation means you not only are able to carry out, quote, The Daily activities more and more on your own. Get up, get dressed, you know, fairly efficiently. Get ready for school, go to school, handle those demands and plan, increasingly, how you’re going to manage different challenges that come along as you get older. You’re expected to do more and more of that on your own. So those we would call the tasks of everyday living, planning, remembering to do things, prioritizing and not avoiding or procrastinating too much. The other component, though, of ADHD, which is not in the diagnosis, but which becomes very important clinically, is this notion of emotional regulation or so? That’s why when I say self-regulation, I’m not just talking about being able to carry out activities of daily living and or tasks like doing your homework or learning how to play the guitar or the piano or whatever. It’s also being able to regulate your emotional state, including your motivational state, so kids with ADHD need a lot more support to maintain motivation when they’re finding things that are difficult for them to do. As you get older, you’re expected to do all of this on your own without constant rewarding, encouraging and quote external motivators, right? Well, people with ADHD, because of the circuitry that’s involved in ADHD, not only have trouble focusing, but they also have trouble sustaining motivation when they’re not feeling rewarded. And that’s something that’s both. Has been underappreciated in the past, but is now coming front and center, because it turns out that the two most important prognostic features of ADHD that spell whether you’re going to have an easier, harder time making that transition to adolescence and adulthood, is the ability to stay to manage your executive skills, to apply them to daily life and handle your emotional state. And we find when we see kids that they’re often either anxious, they get angry, they get frustrated, they give up and they get depressed.

Gene 15:38

What about low What about low self-esteem, you know, I and that’s what I’ve seen. I think that should be a diagnostic criterion for ADHD, because I have not seen one kid or adult that doesn’t feel bad about themselves because they can’t do what they’re expected to do.

Dr. Tony Rostain 15:57

Well, I’m so glad you. I’m so glad you went into this. Now this is the other important this is a bias in the way we diagnose ADHD. ADHD is diagnosed on base of behavior, observed stuff. We don’t really talk about the subjective internal experience of being someone with ADHD. People with ADHD feel lousy about themselves. Often, they feel this low self-esteem, and that low self-esteem is based on the fact that they can’t predict one moment to the next, whether they’re going to be able to get the job done, whether the world is going to be easy for them to navigate or not. So, they don’t feel self a sense of self efficacy, right? So, this is important. Self-efficacy is a concept that developed by Dr Albert Bandura, and it’s basically, how well do you feel you can do something like, if you put me in front of a guitar, I think, Oh, I’m pretty good at the guitar, but if you told me to play an oboe, I’d have no sense of faith that I could play the oboe because I don’t know how to play the oboe. So, we have a sense of ability self-efficacy in different arenas of our lives. None of us is good at everything, certain things we’re better at than others. With people with ADHD though, even things they learn to do, they often cannot reliably perform at the moment they’re supposed to. So, what Bandura referred to this was regulatory self-efficacy, the ability to regulate your level of motivation and strategies when you’re faced with a situation that’s challenging. Interesting concept. I mean, I’m a little nerdy about this, because I really see this as a central feature of the people I work with. They don’t believe they can trust themselves. The internal belief in your ability to do things is impaired. That’s where their low self-esteem comes. Because they don’t, they might have studied that spelling test and known all the words on the spelling test, they get into the exam, but it blanks out. I knew I knew it at home. How come I don’t know it know I played the piano really well in the rehearsal. I go to the performance, I stall out, I get distracted. So, they develop this negative self-concept. You know you were saying this gene that the subjective state. I’ll tell you some of the things we’ve learned talking to teens and adults. Number one, intense frustration with themselves. Why can’t I do this? Intense disappointment in themselves? I’m a failure. Intense fear of the future. I’m never going to do well, and that becomes a vicious sight. And yes, I would say they’ll also say things like, I’m not smart, even though they are, they don’t think they are. So, I’m not popular. Now it’s, it’s many of them and do experience social rejection. So once again, they feel like what’s wrong with me, and that’s where I think parents, teachers and clinicians all need to listen to what’s going on with the young person and not just see their behavior and say, Oh, they’re acting out too much, or they’re not sitting still, or they’re not doing their homework. Let’s get into that. Let’s see why. And when you ask a kid, why don’t you want to do your homework? I hear this every day. How come you didn’t do your homework? I’m too tired. I’m done. I hate it. That’s actually a reflection of the brain that’s tired because this add brain just sitting in school and getting through the day their gas tank is empty, so we want to help them understand it. It’s not your fault. Maybe you need a break. Maybe you need to get, you know, in in some motivation to do your work like. Or having someone sit in this you know, it’s interesting. Lately, we’re learning having someone sit in the room, like with college students, we’re doing this a lot now. It’s called doubling you sit in a room with someone else who’s studying your stuff is better. Just they don’t even have to be doing the same work you’re doing. Just sitting in the same room with someone else keeps you focused, keeps you motivated. So especially if we, if you want to talk about executive functioning, I my favorite discussion lately has been with because we’ve been doing a lot of work with college students, and how to help them is that they tend to they tend to procrastinate a lot and a lot of avoidance behavior. They don’t know how to control distractions, so they have the notifications. And you know, if you tell most people like your phones are distracting, like, right? Isn’t it true that we’re all facing some add like challenges, but with people with ADHD, they really don’t know how to ignore the phone. That’s modification. So hey, move that phone out of reach, because if the phone is near you, and you have ADHD, you’re going to keep looking at it, and you’re not going to get the work done. You need other things we worry about, poor time estimation. It’s known that people with ADHD have a really poor sense of time, which is why they’re always late, which is why they’re always struggling, rushing at the end, missing assignments, missing deadlines. We also know that they don’t sleep regularly. And so, if I were to say, you know, diet and sleep and exercise. You know, that’s the three-legged stool of every healthy behavior we have to reinforce that healthy behavior, getting enough sleep, eating right, taking care of your body’s needs, and exercise. So, a lot of the time, what happens is that this, this the college student may have in high school, had a lot of scaffolding, a lot of people helping them, reminding them, parents, telling them, you know, keep going. You can do it. But in college, you got to do it on your own. Very, very difficult. So those are some of those executive functioning skills are precisely the target of our work with college students with ADHD.

Khadijah 22:27

Well, I’m so glad we spent so much time talking about the executive function or the self-regulation, especially the self-esteem aspect of it. You know, we talk so much as providers about the risk to treatment, but we don’t talk enough about the risk to not treatment. And I think the self-esteem is a huge one. And I tell parents all the time, imagine, you know not feeling good about yourself, and imagine always being reprimanded and always being told you’re not working hard enough and it’s out of your control, and how that’s going to impact them emotionally and going forward. And so, I think it’s really important for us to remember as providers, to make sure we talk about the risk to not treatment but going back to executive functioning. You know, are there strategies parents can take to support their kids, like, is there anything they can do to, you know, maybe diminish the symptoms of ADHD, or help them build those skills and strategies they need to organize and manage their time? You know, do you have any tips that they might get to use at home, like, schedules, you know, you talked about the body doubling, but something they do to improve the attention and executive functioning.

Dr. Tony Rostain 23:30

So, you got to like again. We can break it down a little bit, but let’s start with something as simple as self-control, in terms of setting limits on yourself and on your what you’re doing, and not just going for the shiny object, but staying on the task. That’s less reinforcing. It seems to me that one thing that we teach everyone how to do is getting yourself into a situation, creating an environment where you’re likely to be able to successfully sit down and study so making sure that in that study area, I mean, I always like having a place where you can sit and focus without the phone, without the without the phone distracting you being in A well hydrated and well fed so you’re not hungry, being able to set aside the time that it takes ahead of time, and most of all, having the materials you need right there with you so you can do what you gotta do, having so that’s just with respect To setting aside toss, how about being able to not, not go with your urges? I think you then set up the time, the structure of our work for 20 minutes, and then I’ll take a 10-minute break, if that’s as far as the 20 minutes is what you can do without. That urge to get up. So instead of trying to study while you can’t, because you want to get up, you actually, which it’s called chunking, you break the task down. So, let’s say you had a chapter to read, and it’s got four parts. So, you read the first section. I’ve read that first section. I take a break, come back to the second section, because taking the break allows your brain to reset. And instead of being distracted, you can, at that point, say, I’m giving my brain a chance to do something different for a while, and then I’ll come back to what I’ve got to do. Okay? I also think parents need to give young people a chance to practice getting their getting to bed on time. How are you going to set up your bedtime schedule so that you don’t stay up too late? That’s a huge one, okay? Because the number one problem that we know is going on is that young people want to stay up late, they want to hang out with their friends. So, what I say is, okay, instead of doing that, after your folks get to sleep, why don’t you set up your social time and set it up with your friends. You’re going to play with them, or you’re going to join up with them. You’re going to do the video game thing, or the texting thing from, say, eight to nine, alright, and then at nine you start to wind down, or if it’s from nine to 10, at 10 is time to go to bed. You don’t stay up till 11 O’clock doing your homework. And then after your folks go to sleep, spend till 1am hanging out with friends. So that time management is a real skill. I have to say, time management, if I could ask parents to think this through with their teenagers, is, let’s look at time as you your time, is you? How do you spend you? Where do you put you? Okay, where is you going to be between these different times? Because the more you can get them to be aware of the time that they’re spending doing things, the better they’ll be able to make decisions about it. And the reason that time management so poor, I think, is number one, they get sucked into things and out their awareness of what time is goes away. And I think the devices and the device makers and the platforms that are out there are programmed with algorithms to seduce us into getting sucked in. And the second is to literally have external reminders, okay, beepers. And there’s a thing called the Pomodoro, which we use a lot. It’s a little tomato that you set, and it goes off after 20 minutes. And those external signals, because remember, internal signals of time, of being hungry or sleepy, people with ADHD, those internal signals don’t reliably go off. So, we try to say, externalize the reminders, and it shouldn’t be a parent’s nagging, because that just creates an angry emotional state for the parent and the kid. Like, if the parents nagging their kid, like, wait, wait, what are you to do? I always say, hold on. That itself is a bad pattern, because you’re coming at them angry and they’re coming at you, then they’re going to come back defensive, if you set it up more objectively, like, oh, let’s set up some timers. That are the guideposts. The last concept I want to introduce here is because many years ago, my colleague Russ Ramsey and I wrote a paper called ADHD as an implementation disorder. And what we mean by that is most people with ADHD know what they need to do, but they have trouble implementing it. And what you need when you have trouble implementing it are the guardrails, the external cues, the external reinforcers that keep you going. And that’s why that external thing could be something like a timer or, you know, a computer reminder. And then the other is having someone around you who guides you, like when you get stuck, which is why add coaching is so helpful. You know, the best thing that coach we’ve learned now that with good coaching, you don’t even need to. You don’t need as much. You really don’t need to do it all yourself. If you check in with your coach, who’s helping you to stay focused at a certain time, what the coach does is say, where did you get off your track? Where you get back on track? How can I get you back on track?

Gene 29:36

so, to go to the coaching issue? I think that’s great what parents can do. But sometimes parents need help from professionals. And the question, the question is, is that What? What? What services can parents and caregivers use, for coaching, for tutoring, for executive functioning, monitoring, for collaborative problem solving, speech and language.

Dr. Tony Rostain 30:00

I mean, are there all of the above? Well, okay, let’s start with when you’re young, occupational therapy does a lot of that in schools. They have, they have sometimes now periods set aside for kids where they go to it’s not just study hall. You don’t used to be study hall. You’d sit in study hall. What would you do you fool around if you wanted to study you would study kids with ADHD instead of getting general study hall, go to an organizational skills coach in the school. So I would, I would say that schools need to start to take that seriously, as well as after school homework clubs and hope, like we found at Children’s chop, just creating a an expectation that homework time is dedicated time in someone’s life, and having someone other than parents is preferable. But if it is parents, parents have to adopt a very much coaching strategy, not a I’m not making you do this. I’m helping you do this. I’m here to help you do it. I’m not doing it for you, and I’m certainly not going to nag you. I’m here to coach you when you’re stuck, mostly to remind you to that you know you can like you can say, motivate. I think the motivational enhancement. The third thing you mentioned, which is tutoring. See, tutoring for academic skills is vital. Unfortunately, in our society, tutoring is not paid for by anybody. It’s gotta be done. People have to pay out of pocket for tutoring if their kid needs it, which I think is again a big disadvantage to for people with learning difficulties. So, but tutors are worth it, because, you know what, they’re not just tutoring around a particular subject. They’re also using motivational enhancement techniques; rewards and they’re teaching strategies. They’re not just teaching the subject. They’re teaching how do you approach the problems? And they teach strategies, whether it’s around reading or math, writing, what have you then the last thing you’re saying is parents themselves need support. I think the parents of kids with ADHD have one of the toughest jobs on Earth. If they themselves have ADHD, it’s even harder, and a lot of them do fairly sizable number of parents of kids with ADHD will have their own ADHD, and they need to get they need care, to take care of themselves and take care of that ADHD. So, we have plenty of opportunities then you obviously, I think working with a therapist on the one hand, if the child is having emotional difficulties, or if the parent and the child are having interactional difficulties, there are ways to solve those. You mentioned, collaborative problem solving. I actually think the model of collaborative problem solving can be applied also to problem solving when it comes to couples or intimate relationships, couples therapy, but that’s for adults with ADHD. I generally ask, when I work with adults with ADHD, I always bring in their partner and talk about how the relationship is going, because the partner can be helpful, or the partner can be, you know, in a conflictual relationship, and they may be there feeling overburdened, so they need to come up with a way to resolve that. And lastly, I think online resources are amazing nowadays. There are some wonderful groups of organizations, Chad and Ada, that have, you know, support groups. And I think support groups gets at this idea of isolation. And why am I this way? There’s a lot of not only support in terms of strategy, but in terms of companionship, like you are not alone, because that’s the thing I worry about the most with any young person with any, any difficulty with, with life. Add being one of the most common but there are other kinds of disorders people have that make them feel different from others. And we want to make that loud and clear. You’re not alone. Lots of people have to struggle with this. And you know, it’s hard, it is hard to live with, whatever you’re living with, but we want to make it easier, and we want to be not feel like you know it’s all your fault and you’re no good because you don’t meet the expectations. You’re not meeting others’ expectations and or your own. So how do you modify the expectations so you’re more likely to succeed?

Khadijah 34:41

But I think that talking about the emotional challenges is really a good segue into talking about, you know, some kids will have emotional challenges that are secondary to, you know, the low self-esteem, or the external kind of pressure that’s being put on them, or the feeling of, like you said, of isolation and loneliness, about feeling like they’re the only one. But then, you know, I wonder, in your experience, are there other co-occurring conditions that usually kind of go along with ADHD? I know Gene mentioned, like package deals, you know, are there associated with ADHD?

Dr. Tony Rostain 35:14

Yes, yes, yes. So, so that’s the other thing we can’t ignore. Is that when you have trouble meeting expectations your others, of others and of yourself, and this negative self-esteem that builds up or this never get negative self-perception. Oftentimes you get tremendous anxiety and tremendous emotional turmoil, distress. So, we do see all kinds of problems, like eating disorders, eating disorder highly associated with ADHD anxiety disorders, especially social anxiety, mood disorders, especially including, by the way, not just depression, but even bipolar disorder. You know, we when a child comes to see me, or an adolescent who has a quote the complaint of ADHD, we always have to do a close looking for this co-occurring condition. I’d say lately, I’m really concerned about bullying and cyber bullying and trauma from being different. And it isn’t necessarily trauma, like you were assaulted, but just being chronic. You know, the microaggressions that people with developmental differences have, like this has been my latest thing is, it’s a trans diagnostic. It crosses over, add autistic spectrum, learning disabilities, any of the people with neurodevelopmental disorders experience the world, which is an ableist world, they’re always feeling one down. They’re always feeling that they don’t fit in, or that people don’t see how hard it is for them, and that, over time, becomes a source of growing alienation. And I would say, I mean, I’ve had patients come in and say they feel like the world is out to get them and it they’re not paranoid. It’s actually the case that they’re always being criticized rejected. So that social rejection, I feel is critical for parents to be aware of, if your child having trouble making and keeping friends, that, to me, is a psychiatric emergency, because the children who are most isolated and who feel the least supported by their own peers have, I think, become seriously at risk for both self-harming behaviors and yeah, major depressive disorder.

Gene 37:50

So Tony, just to speak to some of this, a question came up in a recent school evaluation team about whether the child was really struggling with ADHD or anxiety, and as you know, as you’ve noted, you know, there are a number of occurring conditions such as depression or anxiety, but you know, as, as we say in pediatrics, not all the wheezes is asthma, right? Okay, so how do we determine whether the disturbance in attention, focus, executive functioning, is ADHD, or is it another disorder, like post-traumatic stress disorder? Is it an anxiety disorder? Is it some other neuropsychiatric disorder, and how does this affect an individual educational plan? How do you sort that out?

Dr. Tony Rostain 38:46

Well, you first have to gather as much data as you can from as many sources, right? So, the individual, the family, the teachers, maybe extended family, have observations to share. Sometimes it’s not an either or it’s a this. And okay, so anxiety though, that we see in what I would call the regular anxiety we see with ADHD kids, tends to come from fear of failing in an in a social setting. Feel it fear, fear of failing at school, at home or with others. And so, they become so preoccupied with failing that they have trouble paying attention. And the attentional difficulties that creates this sense of fear about the future so intertwined that I could not discriminate between them, okay? Because when you talk to the child and you but here’s one thing that I like as a little pro, so you’re distracted in class, right? Yeah. Okay. What are you thinking about when you’re distracted? Well, I’m thinking about I’d rather be outside. Playing, you know, or I’m thinking about what I’m going to do later when I, you know, go home and the video game I like, or I’m hungry, I’m thinking about what I want to eat. Those are not anxious distractions. Those are what I would call kind of pleasant, or just your what I would call all of us have those distractions, and they just have a kind of a wandering mind. But if they say to you, hey, I’m afraid I’m going to fail that test, or I can’t help but think that when I leave school here, no one’s going to want to walk home with me those scenarios which are very negative and catastrophic. That, to me, is anxiety speaking loud and clear. The hallmark of anxiety disorder, subjectively is the sense that something terrible is going to happen and there’s nothing you can do about it, to the point, by the way, where some kids actually experience panic, right? They’re actually panicking about these, the test tomorrow, and you could, you know, like, and we all have bad dreams, some of the perennial dream of, I showed up at the test and I wasn’t studying for it, right? But with this, with kids with ADHD, they not only have the dream, but they also actually can’t study the night before. They are literally melting down with anxiety about it, and they can’t face it. So, I would say that untreated ADHD is often leads to anxiety. If you treat it earlier, the anxiety can be modified a little bit. The other thing is you ask about family history. I mean, we have to go back to the genetics of this, which becoming more and more fascinating is that anxiety is not as inherited as ADHD is. ADHD is highly inherited. Anxiety less so, but if there’s a strong family history of anxiety disorder, and if other members in the family are anxious all the time, checking constantly about things, not being able to really focus because their mind is wandering to distressing threats, then I’d say that, you know, you have someone with a primarily an anxiety disorder who happens to have trouble with focusing. Okay? And that that doesn’t solve all the dilemmas we have. Like, because clinical work requires a constant testing hypothesis, gathering data and then asking, like, I have listened. Kids have told me this. They’ve said to me, you know, I think, I think I have ADHD, even though they’ve come to me being treated for anxiety disorder, and I go, well, what makes you say that? And they go, because, actually, the only things I’m worrying about are the things that I’m having trouble focusing on. I say, okay, and maybe you’re making a case that your anxiety is related to your difficulty with folks?

Khadijah 43:04

Well, this has been really, really great, I guess one more or less, if we can do quick question. You know, there’s so many people involved with our kids as they progress from childhood to teenage years, what are some of the most common struggles that persist into adulthood? And are things like accommodations in higher education or even in the workplace, you know, helpful? Or do they even exist?

Dr. Tony Rostain 43:25

Well, you know, I’m glad you brought that up. I really think that we’re living at a time right now where there’s a lot of misinformation being spread about mental health disorders and about what people need to do better in life who have them undeniably a positive environment. A positive social environment is a huge predictor of either success or not when you have any kind of challenge, like ADHD having schools that are inclusive, having a community that is inclusive, having families that believe in you, are really important as starting points from there you mentioned accommodations. Right now, in the United States, people are being threatened with their accommodations being removed because there’s this misinformation being spread that we’ve over scaffolded kids, that we’ve done too much for them, that we’re giving them an excuse not to work hard. That is a total mischaracterization. It’s because of our efforts to be inclusive that now around 5% of college students have ADHD at least maybe even more. In some studies, those college students do need the accommodations, but that’s a cost to someone right. Right, and this remains to be seen. What you just asked is, is to me, where parents and people with ADHD as a as communities have to join with clinicians to say we will not be denied our rights to equal opportunity. It isn’t. It isn’t like we don’t have a right to a thing. We have the right to have an opportunity to perform to our best, and we know that with accommodations, people with ADHD can succeed. They still have to work. They still have to make the effort. They still need treatment. And by the way, that’s a whole other discussion about the vilification of our treatments, medications, and all of that distortions. If you read the MaHA report, which I’m in the process of not I’ve read it a few times now, I’m trying to teach medical students about it and residents, it totally distorts what we’re doing in child psychiatry to make it look like we’re over medicalizing children and over or over medicating children. That isn’t the problem. The problem is that we don’t have enough supports in place for people with ADHD to succeed, enough tutors, enough coaches, enough accommodations in school and in the workplace. And I believe that should be you know, what we should be calling for, instead of getting into arguments about is ADHD real or not? To me, that’s a red herring. It’s real. We just have to figure out, how do we maximize people’s ability in to live a good life and to contribute to society?

Khadijah 46:41

So, in closing, we like to ask each other personal questions. So, for today, the personal question is, you know, whether or not you have ADHD, you know, what do you struggle with in your own life in terms of being able to keep focused and keep your attention? You know what kinds of things derail you and how do you stay on track? So, let’s start with let’s start with you. Gene.

Gene 46:57

Oh man. Okay, so I take on too much. I take on too much of everything. I have a hard time saying no. And so, you know, checking on my email, checking on the text from the family, checking, I mean, usually it’s digitally related, you know, and it’s, it’s, it’s distracting. But what gets me is that it could be, you know, I keep saying to myself, it could be something important. And if I get, you know, four or 500 600 emails a day, which I do, maybe there’s 10% or 5% that are really important, and the others I just have to scroll through. But I get distracted, and it’s just, you know, it’s, it’s, it derails me.

Khadijah 47:50

How do you get on track? How do you get back on track? Or have you figured it out?

Gene 47:57

I try to minimize, I try to, I try to minimize my use of looking at email to a limited amount of time during the day.

Khadijah 48:10

How about you, Tony?

Dr. Tony Rostain 48:11

well, that’s beautiful. I was going to say the same thing. I think that we’re still learning to live with this new technology. I would say my biggest distraction is worrying about how I’m going to get everything done. And, like, I wake up at four in the morning sometimes, and I go, oh my god, I forgot to do this, and I have to go back to bed, and I can’t. And I, and I used to, like, you know, get upset with myself. Now, what I’ve learned to do is, if I wake up at four in the morning and I’m like waking up, I first thing I do is I go breathe. Then I think about the thing I needed to do. I figure out when I’m going to do it later today, and that brings down my heart rate and my breathing look a little bit. Then I just decide I’m just going to rest, even if I can’t sleep, I’m going to rest and see what happens. And within a few minutes, I start to drift off again, because I just enjoy the sense of my bed and lying there and basically not engaging in the anxious going around and round and round. Instead, I’m just focusing on the sensory experience I’m having. And if I don’t fall back fully asleep, at least I have what I call a restful period before I have to get up at five, you know, at 515 so that’s my way of coping with I definitely agree with you, Gene. I say no. I say no very rarely, and I’m learning to practice saying no, that’s my

Gene 49:45

and Khadijah, how about you?

Khadijah 49:47

I mean, I would have to agree, emails are probably the bane of my existence, along with progress notes. But I’m going to talk about something else that I feel like that has been getting me off track, which is, like these audio books that I listen to, which is maybe to come. The fact that I’m distracted and distressed by emails, and so sometimes it’s hard for me to stop. And so, what I’ve done because it almost feels like an escape, so what I’ve done is I’ve either set myself a time limit, but then sometimes it’s really hard to stop, so then I just kind of go the extra mile and delete the app. So, it’s an extra step for me to reload it, and then in that moment that I have to think about, like, do I really want to do this? Because I really need to have other things I need to do. So, I think the things that I’ve been getting distracted by lately are really these audio books, and that’s how I kind of try to combat it.

Gene 50:31

This is great. And so Tony, we there’s a lot more to talk about, and maybe we should have a part two about this, even though this was a this was a long one, but I think we should really talk about treatment and about the misinformation, about ADHD and about how accommodations can be incorporated into school plans and the community programs. And there’s so much more that we need to do from kind of a social, emotional learning standpoint that we’re just not doing it.

Dr. Tony Rostain 51:01

But I just want to say that people with disabilities, they just want to be treated like everybody else. They don’t want to be seen as a burden, and they also don’t they want to be respected. And what we do now in this society is we make people feel worse about whatever with them, and that’s something that I think parents, people, we as clinicians, see this every day, that the world out there is hard and it’s getting harder. Because i the other thing I want to talk about is the possibilities, the good things, as well as the dangers of the internet for people. Because look, I mean, my kids get to find my patients, get to find community in that world. But there’s also mean spiritedness, you know, and that part, they’re very vulnerable to. They’re very vulnerable. So, I think you’re right. We ought to talk some more about changing the vibe from a hostile world in which people tear each other down, which I believe is being hated and abetted by a number of forces and players in the in the in the world stage, and instead argue that, no, that’s not what humans need. We need to create community, and we need to be able to really respect diversity, right? Ultimately, value the diversity, belonging and inclusion are the probably the most important pieces of the puzzle that we in psychiatry need to talk be talking about.

Khadijah 52:33

We wrote a blog on diversity and incorporating how we don’t do enough to think about people who have challenges like ADHD and other things, and how they really need to be included, it is overlooked,

Dr. Tony Rostain 52:45

that’s right?

Gene 52:46

And know from a political standpoint.

Khadijah 52:48

Oh boy.

Gene 52:49

I’m not going to, I’m not gonna go on a rant. I think, I think both, I think on both sides of the fence, which tend to be a hostile interchange, everybody wants to feel belonging and community.

Dr. Tony Rostain 53:00

Exactly.

Gene 53:05

and a part of something. I mean, its common ground, whether you’re on the right or on the left or wherever you are on the spectrum. Everybody wants that sense of feeling that they’re important and that they count and that they’re heard and that they’re seen.

[OUTRO MUSIC STARTS]

So, you know, maybe we need to, kind of like, you know, look more at that. Anyway, for those of you at home, if you like what you’ve heard today, consider leaving us a review. And as always, we hope that our conversation will help you have yours. I’m Gene Beresin.

Khadijah 54:05

And I’m Khadijah Booth Watkins. We’ll see you next time you time.

[OUTRO MUSIC ENDS]

Episode music by Gene Beresin

Episode produced by Spenser Egnatz