ADHD in Children with Dr. Stephen Faraone

Stephen Faraone is a Distinguished Professor and Vice Chair for Research in the Departments of Psychiatry and Neuroscience at SUNY Upstate Medical University in New York. He is a highly cited researcher and also Senior Scientific Advisor to the Research Program in Pediatric Psychopharmacology at the Massachusetts General Hospital and a lecturer at Harvard Medical School.  He is Program Director for the educational websites www.adhdinadults.com and www.ADHDevidence.org and President of the World Federation for ADHD.  Prof. Faraone has been ranked as a highly cited researcher in the top 0.01% of scientists across all fields and in 2023 ranked as the 80th best scientist in the world, and 57th best in the United States, according to Research.com. He is a recipient of numerous awards including the Lifetime Achievement Award from the International Society of Psychiatric Genetics and the Paul Hoch Award from the American College of Neuropsychopharmacology. 

Dr. Steve Faraone discusses various aspects of Attention Deficit Disorder with Hyperactivity, including its genetic component, misconceptions about its causes, and the role of stress in its development. He explains the importance of executive functioning and the criteria for diagnosing ADHD according to the DSM-5. Dr. Faraone also highlights the long-term effects of untreated ADHD and the benefits of medication in managing the disorder. He emphasizes the challenges faced during transition periods and the need for comprehensive treatment approaches that address social components. Additionally, he discusses the formation of the World Federation of ADHD and the issues surrounding the World Health Organization's recognition of ADHD medications. The conversation covers topics such as political influence on medications, the perception of ADHD as a disorder, focusing on strengths, and ADHD resources.

• ADHD is just one aspect of a person's identity, and individuals with ADHD have many other positive qualities.
• Medication works well but you also have to improve life skills that may have been missed in early development.
• Political influence can impact the availability and accessibility of medications.
• ADHDEvidence.org is a valuable and highly credible resource for evidence-based information on ADHD.

Chapters

00:00Introduction and Background

02:26Misconceptions about ADHD

05:15Genetic Component of ADHD

06:31The Role of Stress in ADHD

08:57Executive Functioning and ADHD

12:33DSM-5 Criteria for ADHD

18:25Long-Term Effects of Untreated ADHD

20:46Benefits of Medication for ADHD

23:29Transition Periods and ADHD

25:58Age Requirement for ADHD Diagnosis

28:21Survey Questions for ADHD Diagnosis

30:11Executive Functioning and Treatment

36:30Social Component of ADHD

40:35World Federation of ADHD

42:55Issues with the World Health Organization

44:44Political Influence on Medications

45:41ADHD as a Disorder and Positive Aspects

46:48Focusing on Strengths and ADHD Resources

47:27Closing Remarks and ADHD Evidence Website

Transcript

Tom (00:15.68)
All right, well, welcome, Dr. Frone, to the Clear Health podcast. I really appreciate you taking out your time to actually speak with me. From everything that I read about you, I assume that you're really busy with all of your contributions to the clinical world.

So I just kind of wanted to start off talking about how you actually got into studying ADHD because you have a long, very long history of it. And sometimes people don't always stick to it. They don't always stick to the original thing that they wanted to study.

Steve Faraone (00:51.249)
I do.

Steve Faraone (00:58.447)
It's very true. It's very true. So for me, it happened in the early 1980s. I was... No, actually mid 1980s, I should say. I was a postdoc in a program in psychiatric epidemiology and genetics at Harvard Medical School. And at that time, I was working... My mentor was a man who was studying schizophrenia and bipolar disorder. And we were doing genetic studies, epidemiologic studies of those disorders.

And then one day we got a request from a colleague at the Mass General who was studying ADHD to help him out with the genetic epidemiology of a project that he wanted to get funded from the National Institutes of Health. So I took a look at his papers and what he proposed. It was intriguing, really interesting. And I started to delve a little bit more into ADHD than I had in the past and just became very intrigued with the disorder.

And the fact that relatively little was known about it compared to other psychiatric problems, particularly in adults. In general, kind of child psychiatry has a leg behind adult psychiatry in terms of the research effort that's been devoted to it. And back in the 80s, there was relatively little known about it. There were a lot of misconceptions about ADHD. Some people still thought it was caused by parents and not knowing how to parent their kids and things of that sort. So I basically changed my...

Tom (02:21.238)
Mm -hmm.

Steve Faraone (02:26.641)
I didn't change so much to my methodological approach. I still continue to do a lot of work in psychiatric genetics and in clinical epidemiology, but I turned my focus to primarily ADHD, although I did continue to work in other areas as well, but ADHD has really been my primary focus for about 30 years now.

Tom (02:45.646)
Oh, very nice, very nice. So I know you had you mentioned that the focus kind of started more, you know, onto children. And then you said something about how it wasn't caused or isn't caused by the parents. And I think that's something really important that I find in my clinical practice that the parents are almost kind of looking for.

either that, oh yeah, you did cause it, or you didn't cause it because it's kind of this kind of guilt around their child having a problem. Can you kind of explain a little bit more about that?

Steve Faraone (03:20.881)
Yeah.

Steve Faraone (03:28.721)
Absolutely. But if you think about it, there's a lot of information out there that tells parents how to be a good parent. There are books about it. There are podcasts about it. There are TV shows about it. And parents, especially, I mean, I was a young parent once and when you start out as a young parent, you've never done it before. So it's a totally new job that you weren't particularly well trained for. And yeah, if you have a child that has problems, it's natural to think, did I do something wrong with this child?

Tom (03:38.766)
Yeah.

Steve Faraone (03:56.057)
And it's sometimes very frustrating to parents who maybe have three kids and one child's not doing well. They still tend to think, how did I treat that? I mean, I can learn parents saying that. How did I treat Johnny differently than Jane? What was different? I can't put my finger on it. Because there's a natural thought that it's natural for people to think that parents have a huge impact on the development of their child. And yes, parents are important, but there are other factors that determine the child's course in life besides the parental.

Tom (04:28.078)
Right, right, yeah, and there is a large, I know, genetic component to ADHD, you know, across multiple genes and multiple loci. And it's kind of difficult to explain genetics to a parent. And as far as how it contributes to ADHD and also the other comorbid,

Steve Faraone (04:55.567)
Mm -hmm.

Tom (04:55.882)
psychiatric problems that may come along with it. So how would you kind of explain that to a parent? If they're looking for an alternative answer, what would you kind of tell them?

Steve Faraone (05:15.025)
Well, what I tell them are the facts, essentially, what the evidence is that's been collected over decades. And I explain to them that this is not something that I did just one study and made a conclusion or my opinion, that there are literally hundreds of studies of genetics of ADHD. And when you put those all together, as I did in a recent review paper, you come up with a conclusion that roughly 75 to 80 % of ADHD is due to genetics. The rest is due to effects of the...

obviously the environment. And what that means is that because most of it is due to genetics, that the role that the parent actually could play is by definition small to begin with because there's not a lot of room for parental effects on the child's disorder.

Tom (05:46.828)
Mm -hmm.

Tom (06:01.486)
Right, yeah, yeah, that's a really good point that there is, you know, there is the effects of the environment, which can play some small part, but, you know, it is a more small part than it is a large part. And one of the things that's been interesting to me is the effect of stress on the development of these

Steve Faraone (06:16.913)
Exactly. Exactly.

Tom (06:31.982)
these traits in ADHD. In other words, of course, the more stress they have, it seems like that they can manifest these traits a lot more, which is interesting, because sometimes more stress can cancel out other thoughts in the brain or other actions arising, but it seems like stress kind of amplifies.

Steve Faraone (06:36.325)
Mm -hmm.

Steve Faraone (06:45.017)
Yeah.

Tom (07:00.652)
you know, these traits for ADHD.

Steve Faraone (07:02.769)
Yeah, so there's two ways to think about the effects of stress. Let's talk first about stress as a, think about it as an initial cause. Like genes are initial cause, genes come before everything else, so we know they're an initial cause of the disorder. We do know that extreme emotional and nutritional deprivation very early in life can lead to symptoms syndromes that are essentially ADHD.

lead to a diagnosis of ADHD. These are, of rare events. We're talking about very extreme conditions. The classic work was done in some studies by British researchers using, studying kids that were raised in orphanages in Romania where literally they were left in cribs with almost no food, no human contact. It was awful, awful, awful conditions. These kids had very high rates of ADHD and other neurodevelopmental problems. So there's that kind of extreme stress is

Tom (07:31.502)
Mm -hmm.

Tom (07:51.15)
Oh wow.

Steve Faraone (07:59.867)
cause of ADHD. Now, that's the only stressor that we can really say it seems to be a cause of the disorder. On the other hand, there's stress that occurs after the child has the disorder. Stress is something that fluctuates in one's life. We all experience that. And one way, one conceptualization of ADHD, which I'd like to share with people, is to think about ADHD as a disorder.

Tom (08:09.324)
Mm -hmm.

Steve Faraone (08:28.241)
which primary feature is the inability to self -regulate a person's behavior, their attention, and their ability to respond to impulses. And also a difficulty in regulating their emotions. Most of us can self -regulate. We might think we want to do something or say something, let's say we're in a conversation and we're upset with somebody, but we'll talk ourselves down. We won't do it. We'll self -regulate our emotions. We'll calm down, but we'll talk to ourselves.

Tom (08:56.396)
Mm -hmm.

Steve Faraone (08:57.873)
A child with ADHD is more likely to get into a fight because they impulsively, they act without thinking, they're not self -regulating. Now, in our daily lives, we are in different environments that have different requirements for self -regulation. So if I'm sitting at home watching television, there's no requirement really for self -regulation. It's very simple, low stress environment. If I'm sitting here doing a podcast with you,

I need to self -regulate. I can't just get up and go through the refrigerator and get a drink or get some potato chips because I'm talking to you and you're expecting me to give you answers, not to be walking off and so forth. As those demands for self -regulation increase, environments get more stressful and difficult for people with ADHD and those environments will tend to elicit more symptoms of the disorder.

Tom (09:30.478)
Right, yeah. Right. Mm -hmm.

Tom (09:49.678)
Yes, yeah, yeah, definitely. You know, my three year old would just walk off in the middle and you know, I don't think he has ADHD and you know, yet. But there is something to say that there is a, you know, regulatory kind of, I guess, act you would say like, when I'm in my clinic and I'm talking with my patients, they can,

kind of drift off sometimes. Or a lot of times they'll pull out their phone and I've often thought about, hey, should I ask them to put it away? Or is there a way I can be more entertaining to them and actually really engaging them and getting them to listen can be a really difficult thing.

Steve Faraone (10:41.627)
It becomes a teachable moment in a way because there you're absolutely observing an inability to self -regulate that the person's experiencing. Here they're seeing you, they're seeing a doctor who's going to help them and then they're being distracted by something else. And so they're not actually benefiting from you the way they might benefit from you because of their lack of self -regulation. I want to get back to something you said because the listeners might be like this to know about this.

You mentioned that, yeah, my three -year -old will just walk off in the middle of a conversation or so forth. And some people will say, well, yeah, that's just normal kid behavior. Why is something like that ADHD? And the point you were making was that it's normal for a three -year -old. It's not normal for a 12 -year -old. Or it's not normal for a 25 -year -old. And so what people tend not to understand is that when an expert is making the diagnosis, they're looking at the person's behavior.

Tom (11:19.574)
Mm -hmm.

Tom (11:26.902)
Right.

Steve Faraone (11:35.729)
with respect to what's expected for their age level. What do we expect from a 10 -year -old, a 12 -year -old, a 25 -year -old, or the 50 -year -old? We don't expect, if a 50 -year -old is acting like a three -year -old, that could be a problem. It usually is a problem. If a three -year -old is acting like a three -year -old, that's fine. And they can be running around, climbing on furniture, doing all sorts of behaviors that we might think diagnose ADHD in a 10 -year -old, but not in a three -year -old. That's it.

Tom (11:48.558)
Yes, yeah, yeah

Tom (12:04.206)
Right, right, yeah, yeah, most definitely. Very age -dependent. And that kind of brings me to the criteria for ADHD, like the DSM -5 criteria for ADHD. It does list out things for inattention or hyperactivity and impulsivity, but something interesting, and I couldn't...

I didn't realize this until like maybe a month ago where it doesn't speak to the emotional component really with ADHD. Meaning that I noticed that there are.

Steve Faraone (12:43.313)
Mm -hmm.

Tom (12:49.23)
There are things that says like, you know, often losing things necessary for task and activities and then easily distracted and forgetful and daily activities. There isn't a component that says, you know, has increased anxiety around social situations or in classroom situations, you know, and things like that. Do you know why that might be? Why they might have left those out?

Steve Faraone (13:05.905)
Mm -hmm.

Steve Faraone (13:15.857)
I do. I do. It's a great question because when the DSM -5 was being created, I knew the people who were responsible for developing the new criteria. The same was true for the DSM -4. When the criteria developed, the people, the committee that puts them together, they reach out to the community and they ask us, what do you think? What should we do? We send them papers. We send them articles, we say. And I had it at the time of DSM -5.

Tom (13:42.54)
Mm -hmm.

Steve Faraone (13:46.257)
me and some other colleagues had written papers that essentially suggested that symptoms of emotional dysfunctional emotional self -regulation ought to be in the criteria, especially for adults, because what the research shows is that as a person with ADHD gets older, they get less hyperactive and impulsive. They continue to be attentive and you tend to see more symptoms of emotional dysregulation. So the committee, all very good people, and I know this is not a criticism of them. They're very good people that did the right thing.

They decided they couldn't add, they shouldn't add symptoms of emotional dysregulation because they were worried that some clinicians would have a hard time distinguishing ADHD's emotional dysregulation from the kind of dysregulation we've seen other disorders like oppositional dysphonia disorder or depression or anxiety. And they thought because of the concern of kind of muddying the distinction, they decided against that. I would have done it, you know,

I still would have argued for it because I think that that distinction can be made and we need to teach people better how to do it. But it is what it is. And when I lecture to the clinicians about ADHD, especially in adults, I'll say to them, if you have a case on the borderline and you're not really sure about the diagnosis, take a look at the emotional symptoms. And if they have a lot of emotional symptoms of ADHD, then even though it's not a DSM criterion, that might in your clinical formulation tip.

the scales in favor of an ADHD diagnosis.

Tom (15:19.47)
Right, right, yeah. And that's what I kind of look for. And I was doing it kind of without necessarily thinking about it in the moment, but then when I would go back and review the case and review their situation, I would look for it. And it's very interesting that you talk about how that they were concerned, the committee was concerned about,

not being able to tease out those details, especially with things like generalized anxiety disorder. And one of the things that I found is helpful is using the survey questions that like in the Connors fourth edition, right? Like in these other kind of testing that's used for ADHD, my current...

favorite one is the Connors fourth edition, simply because I can use it to talk to the child, the parent, as well as the teacher, because I really try and survey all of them and then do a repeat follow -up after treatment in about six months or so. Do you, how do you, or what do you look for,

in a survey like say the Connors, what would you be looking for to have included in those that's important to you?

Steve Faraone (16:57.489)
Well, once using a rating scale, it really depends upon the goal of the rating scale. So if there are... like to... For your listeners who don't understand what I mean by that, a rating scale is just a series of questions that a parent or a patient responds to, either by the clinician asking them or by the parent filling a format or the adult patient filling out a form. Now, these rating scales, there's really two types. So the one we call narrow band is a very narrow focus on one thing, like ADHD.

And so many people will give the parent or patient an ADHD rating scale to get an initial sense of what are the main symptoms of the person. I do want to emphasize that rating scales aren't meant to diagnose the disorder. They're meant to be a guide for the clinician to ask questions and to fully understand the patient's clinical picture. And then there's broader band rating scales, which cover more than ADHD. A good example would be child behavior checklist or the BASC behavior assessment scale for children. These scales...

Tom (17:27.822)
Mm -hmm.

Steve Faraone (17:57.201)
will measure multiple aspects of a child's functioning and can be used to give hints, if you will, about whether the child has more than one disorder. So you'll ask about ADHD symptoms, depressive symptoms, anxiety symptoms. And that can be useful for monitoring children with ADHD because we know they're high risk for other disorders later in life. And so if they periodically are given a broadband rating scale, it can alert the clinician to be worried about an emergence of a new disorder.

But there are lots of good rating scales out there, for sure.

Tom (18:32.078)
Yeah, and that was, you know, that's why I looked for certain ones that included those other things like, you know, like you're saying, like oppositional defiant and cognitive disorder. I think that sometimes people may think that ADHD isn't such a big deal. Like it doesn't. It's like, OK, you know, they can't pay attention that well. And then, you know, they may think that, well, I couldn't pay attention. Well, what's what's kind of the.

big deal about my child having ADHD. And I think it's important to point out that there is a progression that starts in childhood and can lead up to, you know, cognitive disorder and oppositional defiant and lead to things that are, you know, could be illegal in nature and very harmful to, you know, individual human beings as well as society sometimes.

Steve Faraone (19:27.067)
Absolutely. ADHD predicts bad things that will happen in the future. Not for every person with ADHD. There are some kids with what I call simplex ADHD, relatively mild, and they will only have ADHD. But even those kids, they're going to suffer from failing in school because they can't pay attention in school. They're going to have problems perhaps getting along with friends because of their behavior, noise, and irritates their friends. And that's huge in a child's life if they can't integrate into a peer group.

And then if they have a more severe case of ADHD, yes, they can develop these other conditions. Substance use disorders are worrisome. Kids will start drinking alcohol and take drugs at a young age, getting involved in, you mentioned, antisocial behaviors, becoming depressed. And even, although it's relatively rare, later in life, there's now very good data to show that people with ADHD are at increased risk for dying early, mostly due to accidents and suicide.

Tom (20:07.66)
Mm -hmm.

Steve Faraone (20:27.441)
So the idea that it's a mild condition, society shouldn't worry about it is really wrong because if you don't worry about it until it becomes very, very serious, it's too late. You can't, you know, you can still, once somebody is a substance abuse, well, yes, you can treat substance abuse, but the treatments aren't very good. You're much better off preventing it by treating it early. And we do know that early treatment, and this again, there are studies that show this early treatment of ADHD with the current treatments that are available.

Tom (20:46.166)
Right.

Steve Faraone (20:56.419)
reduces subsequent risks for developing substance use disorders, reduces risk for criminality, reduces almost all of the adverse outcomes for ADHD.

Tom (21:08.31)
Yeah, that's a very interesting point that if you treat with medications, because, I mean, of course, parents are worried about starting medications, you know, that in actuality, it prevents substance use disorder, because one of their concerns is that, oh, my child's gonna become addicted to, you know, Ritalin or something along those lines, like a stimulant. But in fact, it prevents, you know, future possibility.

Steve Faraone (21:35.289)
Exactly. Exactly. And they don't become addicted to their therapeutic drug because when the drugs are taken therapeutically, it doesn't have addictive potential. And as you said, it's just the reverse. It protects them against substance abuse. It protects them against drug abuse.

Tom (21:37.838)
of it.

Tom (21:49.198)
Yeah. Yeah. Very, very interesting conversations I've had in my clinic about it.

Steve Faraone (21:56.977)
Well, there's a lot of misinformation out there on the internet about drugs for ADHD and you shouldn't give drugs to kids and the child's brain is developing, so giving them a drug like Ritalin is not going to be good for their brain. There's no data to suggest that that's true. I mean, that's actually, in fact, it's just the opposite. These brains are not developing normally, and that's why they need to have medication. They need to have medication to get them back on the right course. And by the way, when people have done imaging studies and they've looked at...

Tom (22:23.084)
Mm -hmm.

Steve Faraone (22:26.929)
They find small but reproducible differences between kids with and without ADHD or adults with and without ADHD. What they find is that those brain differences are not caused by the medication, they're just actually part of the disorder that explains to some degree why some people have ADHD and some people don't. One more point about parents that are worried about side effects of medication. There's...

If you're faced with the decision, do I give the child medication or not? You have to balance two competing risks. One risk is the risk for side effects that you most people get. Most people think about the risk. People don't think about as a risk of not medicating my child. And that risk is very high. That's the risk of your child eventually abusing substances, not developing a good peer group, doing worse in school and many, many more. So it's up to every parent to make that decision. I'm not dictating what one should do, but you can't ignore.

the risks of not treating a condition.

Tom (23:29.422)
Yes, yeah. And, you know, it's, it's when I have parents in, you know, in an exam room and I realized that, oh, these are really good parents. They, they brought their child up really well and they provided them lots of love and comfort. But now the child has reached a transition point where the parent can no longer provide that support. For instance, as they get closer to high school, they,

Steve Faraone (23:56.313)
Mm -hmm.

Tom (23:59.246)
hit a point where they need their executive functions operating optimally to achieve their own goals. And it's kind of then that this ADHD arises and causes significant problems for them.

Steve Faraone (24:16.081)
That's right, transitions are very difficult because as I was saying before, you've got the brain's ability to self -regulate on the one hand and the self -regulatory challenges of the environment. And during a transition, what happens is the child loses the parental regulation that's been helping them out. And then they're thrown into an environment which requires a lot more self -regulation than they're used to. And they can, I mean, literally they can fall apart and do very poorly in school.

And sometimes ADHD will emerge later on because it may have been always there, but because if they had a helicopter parent, let's say, my friend and I like to call it social and emotional intellectual scaffolding. The parents and the teachers put up a scaffold that holds up the child. And then when that scaffolding is gone, because they go take a job or they go to college, the ADHD emerges full blown and people think, oh, this ADHD is strange. It just started when they were 20 years old. Well, it was always there. It's just that the scaffolding held them together.

Tom (24:57.006)
Yes. Yeah.

Tom (25:16.142)
Yeah, and that's kind of, I know there were some age limits, you know, or in the diagnosis, there is like a certain age at which you have to say, hey, they had ADHD. Yeah, age 12. Thank you. And it's interesting that that's there to me because sometimes,

Steve Faraone (25:32.977)
Yes, age 12. Yes. Yeah.

Tom (25:45.742)
in practice, it's hard to go back to that age and discover what was exactly going on with them. Can you speak a little bit about that kind of age requirement there?

Steve Faraone (25:58.001)
Absolutely. It's one of my favorite topics. So before the DSM -5, we had DSM -4, which there the age limit was seven. You had to have symptoms before the age of seven. A number of us, including myself, I did a whole series of studies which basically showed that that age seven criterion was not valid and that later on sets in adolescence were clearly valid. And so when the DSM -5 committee reviewed the literature, there was substantial data up to about age 12. And so they raised it to age 12.

Tom (26:06.958)
Yeah.

Tom (26:21.518)
Mm -hmm.

Steve Faraone (26:28.017)
Now, many of us, including myself, make the point that age 12 is still arbitrary. It's less arbitrary because it's based on available data. But anybody in the field of neuroscience knows there's no switch in the brain that turns off at age 12. It says you can't develop ADHD. So it is what I call a diagnostic hack in the sense that it's put there because people who, one of the things when the committee is developing a diagnostic system, they're thinking, how is this going to be used out in the world?

real world and how can we avoid as many wrong diagnoses as possible? And I think what the committee was concerned about was that if you drop the agent onset criterion, there'd be many, many cases being diagnosed in adulthood without any reference to childhood. And that would increase the number of inappropriate diagnosis of ADHD. Now, again, there's no proof that that would actually happen, but that was the concern. So that's why this kind of hack is...

Tom (27:04.206)
Right.

Steve Faraone (27:27.473)
put into diagnostic criteria because it kind of, it makes, it's sort of, you know, as you know, as a clinician, it forces you to think about their childhood, even when you can't, and then when you can't document it, and you frequently can, right? A 40 year old comes in, you know, with no data from parents or anything like that. And we know, by the way, from, we know from prospective data that if you follow kids up in childhood into adulthood, when they're adults, you ask them about their childhood, they don't remember.

Tom (27:35.382)
Mm -hmm.

Steve Faraone (27:55.025)
They typically don't remember their ADHD symptoms. They're very bad. They have very bad recollection. And you know that. So as a clinician, you're not going to deny treatment to somebody because they have a bad memory, which is part of having ADHD. But it does create a conundrum. And my advice is always for clinicians about diagnosing ADHD without a documented childhood onset is just to be cautious. It's to be cautious because that's where you need to do a little bit more work. Maybe you want to.

Tom (27:57.262)
Right, right.

Tom (28:07.126)
Yeah, yeah.

Tom (28:21.39)
Mm -hmm.

Steve Faraone (28:23.461)
Especially if someone has a later onset, hopefully they have lots of symptoms of the disorder, lots of impairments. It's not just a mild subthreshold case. You want to be sure it's not somebody that's a drug seeker who really just wants to get Adderall or Ritalin to sell to somebody else, which does happen, unfortunately. But caution is warranted in those cases.

Tom (28:40.332)
Yes, yeah.

Yeah, and I mean, for me, I'm definitely more on the cautious side. I'm lucky enough to have a clinic where I can spend an hour with my patients and talk to them and really understand, you know, one from a physiologic standpoint that they're not suffering from any other, you know, other conditions that may mimic ADHD. And so I can go through all of that with them.

Steve Faraone (28:53.905)
Oh, that's great. That's great.

Steve Faraone (29:07.737)
Mm -hmm.

Tom (29:13.486)
And then also it gives me a chance to try out certain other medications that aren't stimulants, you know, and see, okay, does this, does this work for them? Or does it change anything for them at all? Because I mean, nine times out of 10, they're, they're more worried about the stimulant than other medications. You know, it's just, I guess it's a little bit of a stigmata, but also,

Steve Faraone (29:24.997)
Mm -hmm.

Steve Faraone (29:39.633)
Yep.

Tom (29:43.148)
Realistic too, I think. Whenever parents present an office with their child, they usually have three concerns. One, how do I help my child at home? How do I help them at school? And then they will say, I've heard about these executive functions. What are those? That's usually the three different.

kind of questions they have. Can you kind of explain a little bit about the executive functioning for my audience?

Steve Faraone (30:21.677)
Absolutely, absolutely. So the term executive dysfunction is used by neuropsychologists to describe functions of the brain and brain does many things, but one of the things the brain do is helps us think, helps us organize the world around us. And there is these executive functions are basically cognitive skills, mental skills that allow us to essentially self -regulate, that allow us to control.

coordinate our other cognitive abilities and our behaviors. It's kind of like the master control of the brain. It puts, because there's a part of the brain, as you know, you have a part of the brain that controls your vision, what you're seeing. You have a part of the brain that helps you read. You have a part of the brain that is involved in your emotions. All these different, many parts of the brain are getting lots of information and the brain is trying to decide what to do with that information in terms of behaving. It's the executive functions that put it all together.

These executive functions occur in a part of the brain called the frontal lobes at the very front of the, where your forehead is basically is where your frontal lobes are. And it's believed that ADHD occurs because there's difficulty with other parts of the brain communicating with their frontal lobes and leads to a breakdown in executive dysfunction.

Tom (31:39.606)
Mm -hmm. And how do you approach improving these areas?

Steve Faraone (31:50.065)
Well, that's a... You're asking all the great questions. Yeah, yeah, yeah. No, it's a perfect question. So in the current approach to ADHD, the first approach to treatment is a medication for ADHD, of which there are now many. And patient or end -to parent discuss with the doctor which is the most appropriate form. The goal, first goal is to get the patient stabilized on a medication. By stabilized, I mean...

Tom (31:51.788)
That's a big question.

Steve Faraone (32:19.273)
the medication has gotten to an adequate dose, it's controlling symptoms, and if there are any side effects, they're controlled as well. At that point, after the clinicians have, you know, the specific psychiatrist, although nowadays a lot of nurse practitioners are doing, are prescribing, once the prescriber gets to the point where they feel they have optimal symptom control for the medication, the next step is to see, well, what else is not going right in this child's life? Are they completely 100 % okay?

And it depends on the person. There are some people who are just with the medication, things are fine. There's nothing else that they need. But it's not always the case and it varies. So it'll frequently happen with, for example, in the case a parent will come in, they'll accept the medication treatment. The prescriber does a good job. Parent will come back and say, everything's wonderful. And because things have changed dramatically, the parent's very happy because these medications are very, very effective. And then what happens maybe like a few months later, they come back and say, well, you know, I kind of noticed that...

Tom (33:13.206)
Mm -hmm.

Steve Faraone (33:17.251)
he or she is not really doing as well in school. They're having some problem with their friends. And what happens then is that they've kind of realized that the first tremendous effect is sort of the medications. While it was very reassuring to them because it really, in some ways, was life -saving, it didn't do everything. And then, so the prescriber has to always be kind of looking for what are the additional problems that are emerging after the initial treatment. And that's when you think about...

adding on other treatments, psychological treatments, behavioral treatments that might help. So, to get back to executive functions, this is particularly an issue for older adolescents and adults. We have, I say we meaning as a field, the field has developed a specialized cognitive behavior therapy for adolescents and adults. And for the listeners, cognitive behavior therapy is a therapy that...

Tom (34:11.116)
Mm -hmm.

Steve Faraone (34:16.081)
It's a very focused therapy that deals with how the patient is thinking and how the patient uses their thoughts to regulate their behaviors. And for a person with ADHD, it's like teaching them how to self -regulate, teaching them life skills so they can organize their life better and do better at whatever they want to do better at. It's not telling them that you have to do one thing. It's saying you want to be the best salesperson ever? Okay, here's how you can help regulate your life. Because...

Although the medicines are extremely effective One phrase I like I know who said it first, but it's the phrase that you know pills don't provide skills The pills do is that they provide yeah Well, they provide the ability of the brain to self -regulate but they're not going to make up for all the skills a person has missed and so Could be a child who's maybe they're treated at the age of seven, but they've had ADHD since four So for half their life, they haven't really been learning the right skills or an adult may have not been treated for most of their life

Tom (34:57.486)
Oh, that's a good one.

Steve Faraone (35:16.305)
So typically, life skills need to be taught in some setting. For the adolescent, older adults, it's cognitive behavior therapy. For kids, it's usually family behavior therapy is the method that's used. And that's a method where the parent learns methods that they can use to help their child learn to be better socialized.

Tom (35:39.47)
Yeah, and I think that's a good point that there is a social component to it because I think sometimes when they're growing up, they lose it because they're not able to either function well in class and then some of them get ridiculed by their peers. Yeah, and they lose that, that.

Steve Faraone (36:00.311)
Absolutely. Oh, that's a huge problem. That's a huge problem.

Tom (36:07.534)
I guess that period in their life where it's very important to have that social interaction. And that's very interesting you talk about how they build that back up with them. And it's one of the things I suggest too is like, hey, can they get into sports? Is there a sport they like? Simply because it contributes to that social component a lot.

Steve Faraone (36:25.521)
Mm -hmm.

Steve Faraone (36:30.641)
Yeah, that's a great idea. And it's also sports tend to be very well structured. So it's easier for them to learn what to do because the environment there is particularly well structured. They have a coach telling them to do this and do that. Absolutely. People tend to think of kids as being not knowing a lot because they are learning a lot about the world. But kids know a lot about what it means to be a kid. And they know what the kids know what appropriate child behavior is. And they can spot a child that's not doing the right thing very easily.

Tom (36:42.572)
Mm -hmm. Mm -hmm.

Steve Faraone (37:00.337)
and those kids get ostracized. They figure it out very quickly. In fact, one of my colleagues many years ago, he used to do studies in a special summer camp for kids with problems and mostly many of them had ADHD. But some did, so it was a summer camp and a group of kids with ADHD came to this camp and he gave them therapy as part of the camp experience. He told me once that, he asked me, he how long do you think it takes?

Tom (37:01.294)
Yes.

Tom (37:14.732)
Hmm.

Steve Faraone (37:28.561)
the kids without ADHD to know to pick out who the kids are that have ADHD. I said, I have no idea. He said, only by lunch at the second day of camp, they figured out which of the kids have ADHD. Because kids are very sensitive to kids that behave differently. And they can be, look, kids can also be very mean to kids that are different and very difficult. And that creates all sorts of adverse outcomes in children that are different. It's sad, but it's...

Tom (37:41.784)
Yes. Yes.

Steve Faraone (37:58.705)
It's a real aspect of childhood that, again, parents have to be concerned with when they're figuring out, should I treat or not treat the disorder? I have to say another thing about the decision about treating and not treating, because it also, the very fact that many people think this way, it's another sign about how mental disorders are stigmatized in our society. Because most parents don't think about this unless they come from some special religion that forbids treatment.

Tom (38:06.606)
Yeah.

Steve Faraone (38:27.281)
Most parents, if the doctor says, your child has cancer, we need to give them these really horrible treatments that are going to cause all sorts of terrible side effects, but will save their life. Most parents will say yes. Your child has diabetes. Doctor says, you need to take insulin. Parents will say yes. If it's a medical disorder, and I'm using air quotes here that you can't see, most parents are going to be like, well, sure, you know, to treat them. They'll ask about the side effects. They'll be concerned. They'll do due diligence. But when it comes to psychiatric,

Tom (38:39.596)
Mm -hmm.

Steve Faraone (38:56.593)
It's a different game. They're like, and partly it's because they don't really believe it's a problem deep down and they're resistant to it for that reason.

Tom (39:01.518)
Yes. Yeah.

Tom (39:06.574)
Yeah, it's a very interesting thing. Sometimes I compare it to back pain where people do not believe that another person can be suffering so much because they've never been through it themselves. And it's like a, once they have it, it's like this switch. They immediately become empathetic and they say, oh, you know, I understand what you're going through.

Steve Faraone (39:20.721)
Yes.

Tom (39:33.23)
And I think it's very hard, especially with the psychiatric disorders, because I've had people ask me, you well, aren't they just, you know, lazy? Like, aren't these are just lazy people, right? You know, and I'm like, no, if you have this disorder, you would have these similar, you know, traits and things going on in your life. And to speak to the kids in finding out other kids with problems, I used to be a camp counselor too.

Steve Faraone (39:42.353)
Yeah, that's right.

Tom (40:03.662)
And there would be, you're right, like your friend was exactly right. It was almost like clockwork. Like the next day during recess or some free play, they would immediately start picking on those kids with problems. And they can be pretty vicious. Like parents, some parents were not able to observe their kid interacting with another child that had a problem.

Steve Faraone (40:19.217)
Yep. Yeah.

Tom (40:31.47)
and they can do some pretty good damage even as kids. So can you talk a little bit about how you created or why you created or I guess why the World Federation of ADHD was brought together? I know it's a big problem, but can you talk about that a little bit?

Steve Faraone (40:35.473)
That's right. That's right.

Steve Faraone (40:57.371)
Sure. So in general, professionals like myself and yourself, we like to go to professional meetings to learn more about the problems we deal with and to also meet other people who are working on similar problems, the network as they say. And so in the ADHD world, there actually weren't very many specialty societies for a long time. The Europeans had a group called the Unithiates.

It was only in the past maybe 10 years now there's an American group which I belong called American Professional Society for ADHD and Related Disorders that meets once a year. And the World Federation was a, and I wasn't part of the original group that put it together, but the group that put it together had the idea that it would be good to have an organization devoted to ADHD that was brought together people internationally so we could share.

what people were doing in China, in Africa, United States, Brazil, et cetera, about ADHD. So we could all learn together. And that we could also deal with problems that were international problems. Like we've been trying to deal with the World Health Organization, for example, in the last few years about an international issue that we think they're not doing a good job on and we want them to do better. And that's why we felt there was a need for a world organization. They asked me about...

Tom (41:59.118)
Hmm.

Steve Faraone (42:23.633)
I think seven years ago now to become the president of the organization to help move that initiative forward. And I will be president until I think next year, my terms, my second term ends and then we'll turn to someone else and then we'll take over and continue with that mission.

Tom (42:40.878)
And you had mentioned that there is a problem that they're not addressing, that the World Health Organization is not addressing, or that you think they could do a little bit better on. Can you speak to that a little bit?

Steve Faraone (42:55.889)
Oh, sure. So the World Health Organization has a list that they generate. It's called the List of Essential Medicines for Children. And what this list is, it's a list that they decide are medicines that every health care system should have available for their patients. The problem we have is that there is no medication for ADHD on that list at all. Even though...

We have now tried twice by sending them lots of documentation about the efficacy of these medications and the low rates of side effects, et cetera. Literally like talking about a 200 page document with more details than anybody really ever would want to read about methylphenidate, just one of the drugs, methylphenidate, which has been used, by the way, for decades. It was first used in the 1960s in the United States and is now being used around the world for decades.

Tom (43:41.742)
Wow, yeah.

Steve Faraone (43:53.073)
For complicated reasons, the World Health Organization still refuses to put it on the list of essential medicines. The reason is essentially they're being influenced by a very small group of people who, again, have stigmatizing views about ADHD and the medications for ADHD. And it becomes, because the World Health Organization is in some degrees a political organization, it's a political decision as opposed to a correct medical decision. It's a real problem because what it means is that there are some countries,

Tom (43:58.668)
Hmm.

Steve Faraone (44:23.289)
where they have national health plans and if a medication is not on that list no one in that country can get that medication at all. Even if they can afford to buy it they can't they just can't get it because it's not on the list and so it's a huge huge problem not to have a medication for ADHD on the list especially when we have many that work very very well.

Tom (44:31.212)
Oh wow.

Tom (44:44.59)
Yes, yeah, that is that does sound like a big problem. And I've I think I've run across that list before. When I took some natural disaster courses and where, you know, it's like this country, you know, they need these medications and it's like you're saying, it says here's a list for them. But that's that's very interesting. There is a lot of, you know, political influence on.

Steve Faraone (44:57.071)
Mm -hmm. Yeah.

Tom (45:13.9)
certain areas of medicine that simply just does not need to be there. Nutrition, our nutrition is the same thing in America, it's heavily influenced. And so I really feel for you there trying to get that through. Well, I think that kind of...

Steve Faraone (45:18.641)
Exactly, exactly.

Tom (45:41.518)
covers mostly everything I wanted to talk about. And I know your time is limited and I really, sure, sure, sure, sure.

Steve Faraone (45:49.457)
Let me say two things, two more things. Because I do like, because I know that parents will listen to this, people with ADHD will listen to this. And when you learn about ADHD, you do learn about a lot of the negative aspects of the problem, because it is a disorder. And by definition, if it's a disorder, it's a problem. And you hear, oh, ADHD is associated with this. ADHD leads to this bad outcome. I always want people with ADHD to understand that ADHD is just one.

aspect of their person. It is not the defining aspect of their person. There are many, anyone with ADHD has many other aspects about them, many of which are very positive. You might have artistic talent. You might have a special skill in a certain area. You might be a very funny person. Who knows? We're all very different. So you shouldn't let a negative view of ADHD kind of drag you down and make you think that you're somehow less of a person because of that, because everybody's got problems. Some of us have back problems. Some have diabetes. You just have ADHD.

Try to, while it's important to treat your ADHD, also learn about your strengths, focus on those strengths, and use those to make your life better. So I also mentioned that I do curate a website called ADHDEvidence .org, where I provide evidence -based information to people interested in ADHD. Totally free, there's no paywall, I don't even ask for your email address. Take a look, you might like it, many people seem to do. We've had the, I think we're...

close to getting to 50 ,000 visits in the first year of operation or so. So with that, I think I'll bid you goodbye, Tom, unless you have any last words.

Tom (47:27.662)
That is a perfect ending. I really appreciate that website is fantastic. Everyone should go check it out. It is really great. But I thank you so much for being on the podcast. It's been a great talk with you and I look forward to reading more papers that you publish.

Steve Faraone (47:48.209)
Thanks very much for talking to you. Take care.

Tom (47:50.178)
Alright, good talking to you too.