Navigating ADHD Care – A Practical Guide for Adults with ADHD – Stephen V Faraone PhD

Show Introduction and Guest Welcome 0:00

The following program does not offer personal medical advice. Please consult your doctor before using any treatment or product we cover. Welcome to GoToHealth Media with your host, Jonathan Marks. We provide a welcoming environment where experts educate you on important health topics, answer your questions, and provide information from which you can benefit in consultation with your doctor. You can visit and subscribe to the show at gotohealthmedia.com. And now here is Jonathan Marks. Hey everyone, this is Jonathan Marks.

Welcome back to Go To Health Media. Remember, you can watch us on our website and I encourage you to subscribe so you don't miss a show at gotohealthmedia.com. You can also watch us on YouTube and you can listen to us on eight podcast networks. So today's show is about adult ADHD. If you think you have ADHD or you know someone who might have ADHD or who you know has ADHD, I highly recommend this show for you. Why? Because we're talking with a good friend of mine, Steve Ferrone, PhD. He's a distinguished professor at SUNY Upstate Medical University.

Steve and I worked together for 10 years. We created the website adhdinadults.com, which I highly recommend that you visit. There's a lot of great information there. We trained 33,000 health professionals about how to diagnose and screen and treat ADHD, and we also achieved almost 1 million views on YouTube about ADHD in adults. I've done a previous show with Steve on adult ADHD. You can watch this on our website at gotohealthmedia.com.

Adult ADHD Diagnosis Over Time 2:00

And today we're talking about Steve Farone's new book. It's called Navigating ADHD Care, a Practical Guide for Adults with ADHD. And given Steve's long history in researching ADHD and ADHD treatment, he really brings to this book a tremendous amount of knowledge about what works in good care and what doesn't work. And you'll learn more about that in this interview. So without further ado, let's get together now with Stephen V. Ferrone, PhD. So welcome back to the show, Steve Ferrone. It's nice to have you back.

How are you today? I'm doing great, Jonathan. Thanks for having me on your show. Appreciate it. Good. So really excited about this new book, Navigating ADHD Care, a Practical Guide for Adults with ADHD. So before I ask you about the book, Steve, let me ask you first a little bit of history. How's diagnosis and treatment of ADHD, especially in adults, changed over the last few years? Let's go back to a few decades ago first, because in the 1960s and 70s and 80s, it was not diagnosed in adults at all.

In the 1990s, a few of us began to notice that this did indeed occur in adults, and we started programs of research and clinical care to help adults with ADHD. It's only really been in the 21st century that the diagnosis of ADHD in adults has been accepted by the professional community. The most dramatic change in recent years for adults has been for the first time in the official diagnostic manual that's used to diagnose ADHD. We have diagnostic criteria that are a little bit different for adults than they are for children.

Some of us think they should be even more different for adults, but it's a good step in the right direction. For example, perhaps the most important one is that whereas kids with ADHD have to have at least six symptoms of the disorder to be diagnosed, If you're an adult, you only need five symptoms of the disorder. Okay. And there are very good reasons for that, which we can't go into here. That's one example of how the diagnostic criteria have evolved to be more friendly, if you will, to adults with ADHD.

Got it. So tell me, what are those five symptoms so that our listeners can possibly identify this in themselves or in a loved one? It's a great question. It's not that there are only five symptoms for ADHD. There are actually 18 total symptoms that are considered criteria for ADHD. Nine of them have to do with being inattentive, being distractible, not being able to pay attention, losing your keys, things like that. The other nine are symptoms of hyperactivity or impulsivity. Hyperactivity in kids is just running around climbing on furniture.

In adults, it's more kind of being uncomfortable. in situations where you have to stay seated for long periods of time. Impulsivity is just what you think it is. It's acting without thinking. If you're an adult kind of blurting out something in the middle of a conversation when it's not the right time to speak. If you're a child that's running into the street to chase a ball, not looking for cars, that sort of thing. So it's any five of those. You have to have five of the inattentive symptoms or five of the hyperactive impulsive symptoms to meet the criteria for diagnosis.

Symptoms and Screening in Adults 5:14

Got it. And are we being more successful at diagnosing adults with ADHD? Because in the work you and I did before, what I remember is that it was first diagnosed in overactive or hyperactive boys. And when they calmed down, everybody thought, oh, well, the ADHD has gone away. And it wasn't until your research and the research of your peers that we learned that ADHD is really a lifelong condition. So how are we doing in terms of diagnosing and screening for ADHD these days? In the USA, we're doing much better than we had been.

If we look at the latest data from the Center for Disease Controls, it shows that the rates of ADHD diagnoses are approaching what I would expect based on epidemiologic data. So we know from epidemiology data that about 5% of adults should have ADHD. And currently, that's about as many as are being treated in the United States. Now, there is an age-dependent decline in the prevalence of diagnosis because the disorder tends to go away with age. It starts in childhood, and little by little, the prevalence goes down.

So by, say, late 50s, early 60s, we only expect about 2% of adults will have ADHD. Oh, really? So I didn't know that. Yeah. Another really important feature about the diagnosis is that it's frequently missed in girls because girls are inattentive and they're not disruptive like boys. Boys are running around, hyperactive, they have lots of energy, climbing on furniture. They bother other people. When you're a child, you can refer to treatment if you're bothering someone else. When you're an adult, you refer yourself to treatment when you're having problems.

What happens in adulthood is that some women who may have had ADHD their entire life, hit their 20s, 30s, and they realize something's wrong, and they may have heard something on a podcast or read something in a newspaper or a magazine, and they refer themselves for treatment. And now we're finding that in adulthood, the treatment rates for adults, I'm sorry, the treatment rates for women are about the same, which is really good news, which means we're probably not under diagnosing ADHD in females in adulthood.

We still are in childhood though, so we need to catch them earlier, a better job treating them. And I recall that a lot of adults realize they may have ADHD when they have kids who get diagnosed with ADHD and they say, you know, I was like that myself, maybe I should get checked out. Is that true? That's right. We know ADHD is a genetic disorder in part. It's about, roughly speaking, 80% genetic in rough terms. And because of that, many parents of kids with ADHD will also have ADHD themselves. And that's how we first, when I say we, meaning my colleagues when I was at the Mass General, we noticed parents coming in that said exactly that.

You know, I'm just like my kid. Do you think I have ADHD? And in many cases, they did. Yeah. Now ADHD is coexistent or comorbid with lots of other conditions.

Comorbid Conditions and Missed Diagnoses 8:12

And sometimes I think doctors can have trouble diagnosing ADHD because they're really focused on the other conditions such as, and you can list them off for me, but I'm just thinking anxiety, depression. Tell us more about that. Absolutely. I mean, anxiety and depression are the major ones. There's also substance use disorders are fairly common. And the problem that occurs in the clinical context, now remember that most adults with ADHD have to be treated in primary care, not by specialists, meaning psychiatrists, because there's just not enough psychiatrists to treat the millions of adults with ADHD.

What happens frequently is that sometimes people come, first of all, let's put it this way, an adult with ADHD who doesn't know about the disorder We'll get to a point where they get anxious or depressed in part because of their ADHD. They're not achieving as well as they might in life. And because of that, they start to experience symptoms of anxiety and depression. Then you also have an underlying biological depression that we know is associated with ADHD. The doctor sees that they diagnose depression or anxiety, they treat it.

And because they're not well-trained for ADHD, they tend not to notice the ADHD. And so we have noticed that ADHD can go undiagnosed in primary care because of doctors not understanding that people who are depressed and anxious. So we tell doctors actually when we treat them, when we educate them, take a look at your patient's with anxiety and depression, we're not doing very well despite your treatments. Those treatment non-responsive people may very well have ADHD. And that does help some doctors transition into a better understanding of the disorder.

And what are some of the treatments that are effective for adult ADHD? What are the options that people have to consider and doctors have to consider? Sure. So there's two sets of evidence-based treatments. There's psychopharmacology or medication, and there's psychosocial or psychological therapies. The only well-validated psychological therapy is cognitive behavior therapy. That's a therapy where the The psychologist typically sits down with the patient and teaches them life skills to help them understand how they're thinking, how they're behaving, how the two are connected, and how they can learn more about themselves and change their behavior to control their symptoms of ADHD.

Got it. So it really is like training. It's exactly right. It's training people in life skills that they need. Now, research shows that cognitive behavior therapy, or CBT as we call it, is somewhat effective when used by itself, but it's most effective if it's coupled with medication treatments. Because the medication treatments are more effective on a, if you will, affecting the scale that we use in research. Medication treatments are more effective than the cognitive behavior therapy treatments.

Now, there are many choices of medications we could go into if you'd like, stimulant medications, non-stimulant medications, et cetera, but many choices of effective medications for adults with ADHD.

Treatment Options for Adult ADHD 11:16

And I know you've done research as well on more natural treatments like diet and exercise. What's the effect of those and what have you found? What does the evidence show? So my research has basically been looking at other people's research and kind of summarizing it and communicating to the public about what it means. Essentially, there's no diet that improves ADHD. Exercise, there's some data that suggests it might help with ADHD symptoms, but not dramatically so. And so what I usually tell people with ADHD or providers that treat ADHD is that everybody should have a good diet.

Everybody should exercise for all sorts of reasons, but it is not a good idea to promote these ideas these methods as ways to effectively treat the disorder. There are no way replacements for treating the patient with medications and or cognitive behavior therapy. Okay, good. Now, you've just written this book, Navigating ADHD Care, a Practical Guide for Adults with ADHD. What motivated you to write the book, Steve? What's in the book that we need to know and that people will learn? Well, the book derives from a project we call the Quality Measures Project, which I got together a group of nine experts in adult ADHD, psychologists, psychiatrists, people in primary care that treat ADHD on a regular basis.

And we asked the question, what are the major activities that a provider, a psychiatrist, a treater should engage in with their patients to create a quality care environment for that patient. So the result of that quality care initiative was essentially to kind of provide a rough, if you will, guideline for doctors and psychologists on What are appropriate approaches? And what I thought was, we're trying to teach this to doctors and other health care professionals, but patients really ought to know about these quality measures because they can look at what their doctors are doing.

They can read the book and say, hey, this is what they're supposed to be doing. And they can see how the two mesh. And that might help them communicate with their doctors about what they want. It might help them perhaps choose another provider if they think that they need another provider. And so explain for us what you mean by quality measures. What does that mean? A quality measure is used in healthcare to come up with a well-defined metric to evaluate the quality of care provided by providers.

For example, one of our quality metrics is something like the doctors should be screening for ADHD in their patients. We can then find out, we can look into medical records, we can see our doctors doing that. Another quality measure is the doctor explaining the pros and cons of different medications.

Diet, Exercise, and Non-Medication Approaches 14:05

Is the doctor doing that? We can go to the record. In fact, we did that. We actually went into the medical records of maybe 70,000 patients with ADHD, and we looked for evidence of our quality care measures in these medical records. This was all in primary care now, not psychiatrists, but primary care specialists, primary care physicians or nurse practitioners. And we found that many of the quality measures were not being achieved in many of the medical records, which suggested that these quality, if you will, behaviors on the parts of healthcare providers were not being done appropriately.

Got it. So you did these, you researched these quality measures and you've used that to train healthcare professionals about diagnosing and treating ADHD. And now you've published this book, really outlining these measures for the public so that the public can learn what good ADHD care looks like. Yes. Exactly. And the book basically is a detailed explanation of what's in the, we wrote a paper for professional journal that most patients won't read because it's difficult to understand that kind of jargon that we use.

So I've translated that into something that patients can understand. Wonderful. So this really is for the public and having them better understand what does good care look like if you have ADHD.

Why the New ADHD Care Book Matters 15:31

That's right. Good. And life is complicated enough if you have ADHD. Exactly. And understanding what good care looks like is an important quality to have. Tell us a little bit about your website, ADHDEvidence.org. So I created ADHDEvidence.org about five years ago or so as a method to communicate to the public evidence-based research about ADHD. And its kind of cornerstone feature is what we call the international consensus statement on ADHD, which was published in a professional journal. But it is open access, so it's available to everybody at the journal publisher, but also at my website.

I also have several hundred blogs now that describe not my opinion about ADHD, but They're basically snippets that describe results of research projects that are fairly impressive about ADHD, and they cover everything from genetics to treatment to diagnosis, so people can get a sense of what's the latest and greatest information about ADHD. And then there are some resources for people to download for free, such as 370 slides that people can use to educate other people about ADHD or to learn themselves about details about ADHD.

Good. And I'm going to go back like 10 or 15 years. You taught me about evidence-based medicine and give us a short treatise on what evidence-based medicine is because you're calling your website ADHDEvidence.org. So tell us about evidence-based medicine. Evidence-based medicine is the approach that says health care providers should use the best quality evidence that's available when choosing a diagnostic method, a treatment method, or any method that they use in their health care. And there's what we call the evidence-based pyramid.

So the very top of the evidence-based pyramid there, for example, for treatment studies would be meta-analyses, which are pros-analyses of many, many, many randomized controlled trials. high quality trials for say medications for ADHD. That's the highest level of evidence. Where at the bottom, the lowest level of evidence is some doctor wrote a case report that said, you know, I tried this medication for somebody with ADHD and it worked. Now that's interesting, but it's not really very solid evidence because there's no controlled trial.

There's only one observation. And as we move up the evidence-based period, there are higher and higher, better and better levels of evidence.

Quality Measures and Evidence-Based Care 17:58

So we encourage any healthcare provider to choose the best level of evidence. Now this means it has to be randomized controlled trial. It just means if there is, you want to use that instead of something that's lower down the evidence hierarchy. Got it. And this evidence, as you're saying, comes from trials and comes from research. It's not just somebody's opinion or something you read on the internet. There's actually been research done. on large groups of people. Essentially it mostly comes from research.

The best evidence comes from research on large groups of people. There's another level of evidence which is you get a group of experts together and the group of experts says this is something you should do. That is a level of evidence that even though there may be no studies around it, if that's the best thing you have as a practitioner, well that's fine because you're dealing with somebody who's had a group of people who have come up with what they think is the best approach. That's sometimes seen in treatment guidelines, where there's no data to actually guide a decision.

Experts get together and say, based on our clinical experience, here's what you should do. Got it. Good. So what question haven't I asked that I should have asked, or what message would you like to leave people with before we end our interview today? Well, I guess the main message here is that ADHD, whether it's children or adults, is a disorder that can be readily treated, easily treated. There are very effective medications. There's cognitive behavior therapy for adults. And that not getting it treated in an evidence-based way is only delaying The time in which the patient will be experiencing all sorts of impairments in their everyday life that could be solved if they only were to take an appropriate treatment.

Many people are afraid of medication treatments. They're afraid of engaging mental health professionals for all sorts of reasons, mostly related to stigma, how other people will think about them. But I urge people to say, treatment for many adults with ADHD is literally life-changing in a way that is amazing. And so let's give it a try. Try it for a month or two. If you don't like it, you can always stop it. Good. And Dr. Ferrone is providing us a practical guide for adults with ADHD so you know what good treatment looks like.

Thanks for being with us today, Steve. It's so good to have you back on the show. Thank you, Jonathan. Great to be here. Take care. So we've been talking with Steve Ferrone, PhD. He's a distinguished professor in the departments of psychiatry and neuroscience and physiology at SUNY Upstate Medical University, and he's also a vice chair for research in the department of psychiatry. He's recently published a book, a new book, called Navigating ADHD Care, a Practical Guide for Adults with ADHD.

ADHDEvidence.org and Final Takeaways 20:48

And if you have ADHD or you know someone with ADHD, I highly recommend this book. And I also recommend that you visit Steve's website, which is ADHDEvidence.org. And you can also find Steve Farone on LinkedIn. He publishes a lot of very informative articles. And you can follow him there to be best updated about ADHD. Thanks again, Steve. Thank you, Jonathan. It was good to see you. And remember, you can watch us on our website at gotohealthmedia.com. You can watch us on YouTube. You can also listen to us on eight podcast networks.

We'll see you again next time. And as we say at the end of every show, what do we say? Repeat it with me. Go to health. Take care. We'll see you again next time. Bye bye. for tuning in this week to Go To Health Media. Be sure to join Jonathan Marks and another health expert next time. You can also catch the program on your favorite podcast platform. Until our next show, be sure to visit us on the web at gotohealthmedia.com and elevate your life.