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Russell Barkley, Ph.D. - Guest
Russell Barkley, Ph.D. is the author of 12 Principals for Raising a Child with ADHD among several other works about ADHD and defiance in children and adolescents, and ADHD adults. Dr. Barkley retired as a Professor of Psychiatry and Neurology from the University of Massachusetts Medical Center and subsequently worked as a Professor of Psychiatry and Health Sciences at the Medical University of South Carolina. He is currently a Clinical Professor of Psychiatry at Virginia Commonwealth University Medical Center. Dr. Barkley continues to lecture widely and develop continuing education courses for professionals on ADHD and related disorders, as well as consult on research projects, edit The ADHD Report, and write books, reviews, and research articles. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton, Psy.D: (00:22)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco bay area and the director of the Institute for the Advancement of Psychotherapy. Today I’ll be speaking with Russell Barkley Ph.D., who is a psychologist and author of 12 Principles For Raising a Child With ADHD, and several other works about ADHD and defiance in children, adolescents, and adults. Russ retired as a professor of psychiatry and neurology from the University of Massachusetts medical center and then worked as a professor of psychiatry and health sciences at the medical university of South Carolina. He is currently a clinical professor of psychiatry at Virginia Commonwealth University medical center. And Russ continues to lecture widely and develops continuing education courses for professionals on ADHD and related disorders. He also consults on research projects, edits the ADHD report and writes books, reviews, and research articles. Let's listen to the interview. Hi, welcome Russ.
Russell Barkley, Ph.D.: (01:29)
Welcome. Thank you so much. Good to be here.
Dr. Keith Sutton, Psy.D: (01:32)
Yeah. Great. Well, I'm so glad I have the chance to interview you today. So, I was introduced to you back in my predoc. One of my clients came in for an assessment for ADHD. And my supervisor said, oh, I said, how do you do this assessment? He said, here you go listen to a two-day workshop on Russell Barkley. And so I listened to a seven or nine-disc series and it was just so much great information. I mean, particularly, I came into the field with my original focus on difficult adolescents and kind of out of control running away and so on. And so huge overlap of course, with ADHD and oppositional, and actually it's funny actually because now half my practice is children, adolescents, adults, and couples with ADHD.
Dr. Keith Sutton, Psy.D: (02:20)
And I wouldn't have known because way back in the beginning in undergrad, I was working on doing work-study for Bruce Pennington at the University of Denver, just entering in Wisconsin, hard sort kind of data. So, I got to see you speak at a Chad conference, and you and I have emailed a couple of times, I've kept my questions short, but I know you're the to go-to person around ADHD and kind of so up to date. So yeah, I'd love to hear about kind of, you know, a little bit about your story. Cause I was saying, I actually would like to hear your backstory of how you got into this area and also kind of what you're doing now and, and really kind of what you're seeing as the forefront of the field.
Russell Barkley, Ph.D.: (03:03)
Oh man, there's just so much going on, Keith, thank you so much for asking. I appreciate that. I mean, I've been at this for what, 44 years of clinical practice and that doesn't include all my, you know, graduate training and so forth though. I, you know, I got into the field after I got out of Vietnam. I was in the air force and Vietnam and I came back and spent a couple of years in North Carolina. And at that point, that's where I went back to college. I had left college early because I wasn't interested in going and I didn't like my major. And, of course, that was the draft. So if you left college, you were going to get drafted. So I enlisted in the air force, my preferred branch, having been raised in the air force. So my dad was a career officer.
Russell Barkley, Ph.D.: (03:43)
So after I got out, I was very interested in the sciences, particularly biology, and to some extent psychology. So I went to the University of North Carolina and I was sort of double majoring, but a lot more emphasis on psychology when I was there. But I knew to go to graduate school, you had to do something extra. So I started asking around mainly over at the medical center because no one in the department needed any assistance. There were plenty of students wandering around and a lot of people were saying we don't need any help. And I was going to volunteer 20 hours a week if that they wanted that. And they said, well, this guy just got a grant to study hyperactive children over at the child development center, why don't you go talk to him?
Russell Barkley, Ph.D.: (04:28)
And it was Don Ruth who was, you know, a recognized authority in hyperactive children at the time. He was the editor of the journal of abnormal child psychology for quite a while, so I went to Don and he said, sure, we could use the extra help. And so I loved it. I became his research assistant. I was observing and coding and you know, all these hyperactive children, which now are ADHD kids coming into his program, and he was doing drug research on methylate with them. He convinced me to do my honors thesis with him. So not only was I his research assistant, but he was also my supervisor for my honors program. So I did my first study on, you know, hyperactive kids and then did one on imitation learning in children and then went onto graduate school and just, you know, once you get onto it, I just fell in love with that.
Russell Barkley, Ph.D.: (05:21)
I thought these out of control kids were fascinating and I wanted to know more about them what's going on here. And so I stayed with it and then, you know, wrote a lot of reviews in graduate school on the topic and, you know, just got further into it. Did my masters, did my dissertation on drug studies with ADHD kids and then went on to specialize like you did in, you know, developmental disabilities and neurodevelopmental problems. And especially in neuropsychology out at the university of Oregon medical center and continued on from there. I got my first job as a neuropsychologist at Milwaukee children's hospital, went on to start the neuropsychology service there in both adult and child neurology. And after that went on to UMass medical school for 17 years as director of psychology there, but still, you know, developed clinics for ADHD, adults, ADHD, kids, and then continued, you know, doing my neuropsychology research and after retiring from there at, at early age of 52, I went to work at the medical school in Charleston, South Carolina.
Russell Barkley, Ph.D.: (06:27)
Oh, wow. I was doing some research on ADHD and driving and the effects of medications and alcohol on driving down there. And then of course about five years ago, moved up to Richmond to be near my grandchildren here. But, you know, continued, at least to work part-time and doing a lot of lecturing and writing and also consulting on other people's projects and grants and just continuing my own work. So, you know, it's been a long haul, but what keeps me fascinated, every time I think it's getting boring, there'll be some discovery or I'll discover something that just lights my curiosity up all over again. And to me, ADHD, because it's a problem with self-regulation by studying where self-regulation goes wrong in people with this disorder, you learn a lot about typical people, not just ADHD, because you have to know how normal develops so to speak.
Russell Barkley, Ph.D.: (07:24)
How does typical self-regulation emerge and what is ADHD doing to screw all that up and then what does that tell us about how to help these people? And so, you know, I've been working on that question since 1994, when I started writing my first theoretical papers on ADHD and executive functioning and then wrote two books on that. And, you know, just did a number of research papers as well on executive functioning. So that, that got me really into this. So that was number one, I've just been fascinated by what ADHD teaches us, not just about them, but about all people in general, not, not just them. The second thing of course is I got involved in longitudinal research and we of course followed a large group of ADHD, children to adulthood out in Milwaukee. So that was going on at the same time that I'm studying executive functioning.
Russell Barkley, Ph.D.: (08:16)
More recently have gotten involved in developing this new attention disorder and research on it called sluggish cognitive tempo, which is a, a group of people who get misdiagnosed as ADHD, because there's no place for them in the DSM. So they get called a D D or ADHD inattentive presentation, but they're not. And perhaps, you know, in, in this conversation, we can talk a little bit more about that because there is this new attention disorder and there's growing research on it. And we've just brought 12 of the leading researchers in the world together for a work group task force. That's going to summarize the research. Although there have been meta analyses and summaries we're going to rename the disorder because it's a very demeaning term. We don't like the term. It suggests slow. Wittedness sure, you know, kind of a stupidity if you will, but, and we don't mean that at all.
Russell Barkley, Ph.D.: (09:11)
And we didn't invent the term. It was invented in 1984 by a graduate student, working with Ben Lehe. But it's stuck and, we wanna get rid of it and move to something more benign. So, you know, the group is charged with not only surveying research, coming up with unanswered questions promoting awareness of S C T and then changing the name. And we hope to do all of that by the end of the year.But it, you know, it's well underway. We've had some meetings and we're all doing our little research reviews, so that's an interesting disorder in its own. Right. So, you know, there you have it, I mean, between longitudinal research and executive functioning theories and, you know, S C T and ADHD. And then most recently I stumbled into the health outcomes area in ADHD.
Russell Barkley, Ph.D.: (09:56)
So the last year or two, I've been working with Chad very closely to promote awareness of ADHD as a public health disorder because of all of the risks, we have been able to document in my longitudinal study and elsewhere on the impact of ADHD on early mortality, on all the increased medical problems from obesity to diabetes, to accidental injury, to suicide and homicide, and then my own research published just not even two years ago showing the first to show that ADHD shortens life expectancy by an average of about 12 to 13 years, which is worse than all of the other health concerns we have combined. So if you were to look at what does obesity do to life expectancy? What about alcohol? What about exercise and sleep and smoking and all the things we spend billions of dollars on, they don't come close to what ADHD does to shorten your lifespan. And that's because ADHD predisposes to all of them not just one of them. And so you know, I've been doing a lot of presentations lately between Chad and other organizations on the health consequences of this disorder and what we need to do about it. So there you go. That's that's where I came from, that's what I'm up to, and I'm still going.
Dr. Keith Sutton, Psy.D: (11:19)
The're doing a lot in retirement there .
Russell Barkley, Ph.D.: (11:21)
Yeah. Yeah. Well, I'm kind of semi-retired, but, you know, I have time for my grandchildren and golf, but no problem, no, I'm still writing and, and working and consulting. I'm just not doing the things at the medical center here that I don't want to do. So I can do that.
Dr. Keith Sutton, Psy.D: (11:35)
Wonderful. Thank you. So let's go to the sub, sluggish, cognitive tempo, and particularly, and actually, and even for a clarifying question that I have, right. Cause there, you know, that, I know you've talked a little bit about the ADHD combined type and there's that ADHD inattentive. And then there's the ADHD hyperactive impulsive and the right ADHD. Inattentive is what many people call a D D although that's not,
Russell Barkley, Ph.D.: (12:05)
They shouldn't.
Dr. Keith Sutton, Psy.D: (12:06)
Yeah. Right. And, you've talked about the sluggish cogniti and it particularly just for my clarification, right. Is a hundred percent of children, adolescent adults with ADHD, inattentive considered Southern cognitive tempo, or is there there a difference between those two?
Russell Barkley, Ph.D.: (12:25)
I think there's a, somewhat of a difference. It gets a little confusing. So I'll try to parse it up this way, right? If you were to take samples of ADHD, inattentive people, who are high in inattention, but have five or less of the hyperactive symptoms you, you wind up with about three groups of people. The first group of people you have are kids who started out as the combined type, who met all the criteria, but hyperactivity, declines, markedly in children over time. So by adolescence, many combined individuals are getting rediagnosed inattentive because they don't have six hyperactive symptoms anymore. They have five or four. So they're outgrowing the hyperactivity, but they're not outgrowing the combined type. That's just what combined type people do. And especially by adulthood, a lot of people called inattentive presentation are just former combined type that are grown up.
Russell Barkley, Ph.D.: (13:20)
And because the DSM overweights hyperactivity, which is a preschool aspect of the disorder, it looks like people are changing types and presentations, and they're not changing anything. They're just growing up as they want to do. That's, you know, that's a big chunk of people called inattentive presentation. They're really combined types.And that's how we should think of them. They're no different than anybody else, adults. Then you have a group of people who are mild combined presentations, so mild enough that they only have five hyperactive or even four hyperactive symptoms. So according to the gospel of the DSM five, these are inattentive presentations, but not really they're, you know, they're just milder variants of the combined type. They don't differ in any respect from fully combined type people at all. Just a little milder, you know, the one symptom of hyperactivity isn't going to change your clinical presentation.
Russell Barkley, Ph.D.: (14:19)
So if you get all of those people out of there, you're left with about 30 to 50% remaining of these intent onlys. And those are the SCT people. They do have high levels of inattention, but they have like no hyperactive symptoms, no impulsivity. They certainly have at least three or fewer of those symptoms, but usually none. When you pull those people out that's the SCT group. And then when you study them as to how they differ. They differ in many qualitative ways from ADHD at all, which is why we are now arguing that it's certainly a new attention condition and syndrome. Some of my colleagues on the task force would prefer not to call it a disorder, because they reserve that for the officially sanctioned DSM term.
Russell Barkley, Ph.D.: (15:16)
I don't happen to like Jerome Wakefield's definition of disorders, which are harmful dysfunctions and S C T certainly fits that. But you know, I'll go along with that, you know, if you wanna play the semantic game, it's a syndrome now, what is it about this syndrome? So I'll be very brief. These people are characterized by hypo activity. Not hyper, hypo. They're very passive lethargic, sluggish, slow moving. So there's a motor element just like there is in hype in ADHD, but in this case, it's the opposite motor element. These are very passive, somewhat withdrawn, slow moving, slow reacting, sluggish people often and sometimes sleepy as well. So we have this sluggish motor activity, then there's also an attention component. So just like ADHD, there's inattention. But in this case, the inattention is daydreaming, staring mind, wandering, unavailable, decoupled from the external environment.
Russell Barkley, Ph.D.: (16:15)
So you're gone, you're just out there in never land. People are saying to you, you know, earth to Steve or earth to us, you know, come back where, where, and, and you'll see them shake their head and say “oh, oh, what, what do you say”? So they miss a lot of what's going on around them. They make a lot of mistakes in their work, at school and in the office because they have this propensity to become preoccupied with mental content, which is where the daydreaming and the steering come in. We happen to think that there's a lot of mind wandering going on in these people. We haven't proven that yet, but we're getting close to that. So, you know, pathological mind wandering is probably not a bad way of thinking of these individuals.
Russell Barkley, Ph.D.: (16:56)
So where ADHD, people are overly coupled to the now and the moment and the exterior environment, which is where you get the distractability and the busyness and the engaging and the touching, S C T people are decoupled from the environment and they're too much in their head. So that's where you get the daydreaming staring. That's where you get the proneness to errors. They're not processing information accurately, mental confusion, mental fogginess, sluggish, responding to other people that's S C T, and maybe we'll change the name this year. So there's a lot about these people that's very different than ADHD. They have zero impulsivity. In fact, people with S C T are actually less impulsive than normal people. It's a negative relationship. They're less active than even typical people. They're prone to depression and anxiety, not to conduct disorder, oppositional disorder, drug use disorder, delinquency.
Russell Barkley, Ph.D.: (17:59)
They don't have a whiff of antisocial behavior or psychopathy about them. So the whole pattern of comorbidity is very different with them. About half of S C T people do have ADHD along with it and half don't. And our studies show that when the two disorders are comorbid, it's far worse than ADHD by itself. And the same with S E T you really don't want to have both of these attention syndromes going at the same time, and certainly some people do. We've also just discovered in the past year that this is the attention syndrome, most characteristic of autism, depression, and anxiety. So people who we think of as having more internalizing spectrum disorders are more likely to manifest this pattern of inattention. So if you had PTSD, if you had major depression, if you were anxious, but especially depression and autism this is really what you're doing.
Russell Barkley, Ph.D.: (19:04)
You're decoupling from the environment and, having an autistic grandson. I can vouch for that in spades. My difficulty with my grandson is not an ADHD. He doesn't have ADHD at all, right. He's just oftentimes gone, mentally checked out. There's a lot about them. They don't do well on ADHD meds. In fact, the more SCT symptoms you have, the worse you do on ADHD meds. They have the same prevalence as ADHD, about 5% of kids, five to 6% of kids. And a little bit less four, 5% of adults. The beauty of this disorder is there is no sex differences to speak of. We see it in males and females. There's also no decline with age. Like we see in ADHD, it is stable and permanent it's as stable as ADHD, if not more so and by adulthood, it's actually worse than ADHD in education, college and workplace settings, which we were shocked to find that in our study. So there's a lot going on, on this disorder right now as to what's the neurology of this. What's the neuropsychology of it. It's not really an executive function disorder, though. There's a little bit of working memory, organization problems linked to it. And what's going on in the mind of these people. Which is why we got real interested in pathological mind wandering as an analogous condition.
Dr. Keith Sutton, Psy.D: (20:32)
Cause I was thinking about, you know, oftentimes when I think of inattention, I don't remember if it's, I think it's something I listen to and you're talking that it's oftentimes it's maybe more with a ADHD combined or hyperactive impulsive. It's not that the person can't pay attention, they're having trouble inhibiting the impulse to not pay attention to one thing and focus on another.
Dr. Keith Sutton, Psy.D: (20:51)
But it sounds like you're saying this is like a little bit different because they're not necessarily impulsively like attending to something else. They're more almost like not having the drive to kind of focus on something. And instead of having that lack of drive and then just kind of having, you know, thoughts and kind of, yeah. That's not connected.
Russell Barkley, Ph.D.: (21:09)
Yeah. This, this is the kid
Dr. Keith Sutton, Psy.D: (21:11)
In the moment that's actually bringing their attention. It's actually kinda what's going on internally.
Russell Barkley, Ph.D.: (21:15)
Right? Right. No, I mean, this is your absentminded professor, daydreamy kid who just, he's not disruptive. He's a good kid. The parents report that the only trouble they have is they tend to be somewhat shy and reticent and less involved. They have friends, but not as many as people would like, they're quiet. So if you ever read the book quiet, you'll see that they're more introverted. Especially what parents are concerned about is they're failing at school. They do as badly at school as ADHD kids, but they're nice. And so they get referred two or three years later because, you know, it's the aggressiveness and the disruptive behavior of ADHD that gets you referred so quickly. You're just a, you know, difficult kid to manage. Whereas these kids are wonderful in the classroom, but they don't do anything, you know, and people wonder, do they have a learning disability? Or, why isn't this kid available? Is this high functioning autism, which it isn't of course. So, you know, there are a very unique group of kids in that sense, but as I said, you know, somewhat higher risk of depression and of somewhat anxiety, more depression, and overlap with autism.
Dr. Keith Sutton, Psy.D: (22:20)
That's a question I have too, because I think particularly with the inattentive ADHD, you know, so many things, you know, kind of can lead to an attention, depression, anxiety, you know, somebody not getting enough sleep, being spread too thin at work. All these kinds of things. And so, you know, how, how does that even really stand out from the, say anxiety versus anxiety avoidance and like, you know, this, this sluggish cognitive tempo,
Russell Barkley, Ph.D.: (22:50)
Well, what we've seen is that at least in my national surveys, the S C T people had slight increases in anxiety, but not a, high rate of diagnosis. They did have 25 to 30% had a diagnosis of depression, but again, 70% didn't. So, you know, you can't call this a proxy for depression, but it is the attention problem often seen with depression. And even if you don't have depression followed up 10 years later, which Lynn burns did in S C T children in Spain and it's also been replicated here early S C T is a predictor of later depression, even if you're not currently depressed. And that's because mind wandering is such that when people engage in mind wandering, although their mind is skipping from one thing to another, it tends to keep circling back to unresolved conflict. That's what typical people do.
Russell Barkley, Ph.D.: (23:40)
And that's what these mind wanderers do. And so you can see that unlike typical people, they're spending a lot more time in their head. And by doing that, they're spending a lot more time on their conflicts and problems and hurts and fantasies ruminating on. Well, some of it could be rumination. You know, we certainly see that, but, it's not so much an OCD type rumination as more of a depression type you keep coming back to these unresolved issues and problems. But also we see fantasy in these people. Some of them have a propensity for a very engaging fantasy life, almost a,novel in their mind, and they wanna get back to it and, and live that alternative life. And, you know, they're superheroes and they're beating up the bullies and they're solving their problems.
Russell Barkley, Ph.D.: (24:26)
And it makes 'em feel better. So, you know, it's like, there's three different groups of mind wanders, you know, there's the really O C D, who's obsessive, there's the depressive ruminator, and there's the fantasy engaging escape artist who is bored with what's going on around them and flights of fantasy into this alternative reality. And they all look the same. They're just not here. They're gone. So trying to find out how to help these people is going to be interesting because the ADHD treatments don't work.
Dr. Keith Sutton, Psy.D: (25:01)
I'm wondering too, like some of the kids that I work with and adults, you know, that the procrastination, the avoidance kind of coupled with the ADHD and the difficulty in initiating, I find that combination sometimes to be the most difficult, and maybe this is that piece. And oftentimes, sometimes I'm even using just exposure and sitting with the distress of starting something, because there is such a discomfort in trying to get going on something that's not very stimulating than the kind of, you know, urges to avoid and kinda get out of there. Because it's like disregulating.
Russell Barkley, Ph.D.: (25:34)
Well, you know, you just pointed out something that we found in all of our research. When we looked at items that identify S C T from ADHD, there were two that were described for both of them. They were not differentiated. So we took 'em off the symptom list because they were as common in ADHD as an S C T, and they were procrastination difficulties initiating work. And, low motivation. So difficulties completing work, but they're doing it in different ways. So when you study the manner in which they're having trouble with this, the ADHD person has trouble getting started and finds anything else around them that's more interesting. So the video game and I'm surfing and I'll check my phone and do my Facebook and check my Twitter feed and you know, they're procrastinating, but they're being captured by things around them.
Russell Barkley, Ph.D.: (26:29)
Now they also engage in some mind wandering and especially I'm wondering and especially if they have S C T with their ADHD, now you're going to see both of these, but they're not starting. And then they're looking for anything else more fun or interesting to do, like getting a coffee or, you know, going to do something else. You know, even, spinning in their chair, at least that's what the kids were doing that we studied. But low motivation doesn't finish assignments, finds it difficult to initiate their work, hence the procrastination. But when you look at them and when we've done interviews with the families of the kids and with the adults, the S C T person has checked out, they're still sitting there in front of the computer, or in front of the paper, whatever they're doing.
Russell Barkley, Ph.D.: (27:16)
But they're not there. I mean, you know, they'll be staring at the book they're supposed to be reading, but it's like you and I, sometimes when we read, we mind wander and we catch ourselves and come back to the story and maybe go back to the top of the page, but we start to free associate to content. Well, they've done that in spades. They're just gone, but they're sitting there passively, mentally checked out. The ADHD person is not sitting there like that. They're usually fidgeting, you know, fidling with things, touching things, doing something else, you know,
Dr. Keith Sutton, Psy.D: (27:52)
Almost sounds like an associate state almost.
Russell Barkley, Ph.D.: (27:54)
Yes. Very, very much so. In fact, we, took a look at that because one of the two questions came up, a couple years ago is this hypersomnia because these people sometimes report sleepiness and the answer is no, but about 20% of them do qualify for daytime sleepiness, sleeping difficulties. But it's not a proxy for hypersomnia. And then the other one of course is, as I mentioned, it's not a proxy for depression either. So even though they're prone to depression, it's not depression. So it's not these other explanations that people worried about. And we looked at anxiety, well, they, very few of them have enough anxiety to qualify for an anxiety disorder. And if they have it, it really is more related to depression than to fearfulness and worry. But you know, that, that could be the case too. We're not seeing a signal for Frank anxiety disorder at the clinical level, even though there's a little element of that as there is an introverted people where there's a little element of anxiety.
Dr. Keith Sutton, Psy.D: (28:59)
Yeah. It's almost like I see a lot of the anxiety avoidance, but not necessarily the anxiety worry. But kind of fearfulness or so precisely avoidance of potential distress, especially connected to, you know, something that might require focus or tension.
Russell Barkley, Ph.D.: (29:15)
Yeah, indeed, indeed. So it's a fascinating group of people that we're publishing more and more on. And as I said, we now have a task force on this. And my hope is that maybe when DSM six becomes available there will be enough research to convince them to put it in as, you know, an alternative attention disorder. We'll see.
Dr. Keith Sutton, Psy.D: (29:36)
And I wanted to get some of your thoughts. You know, one of the things that I see, especially with my adults with ADHD, is that shame tends to be one of the biggest difficulties. And oftentimes when I'm working with parents, you know, one of the things I say is, you know, our goal is to help build resilience and to kind of get them through their childhood without a great deal of shame, because oftentimes kids with ADHD are getting in trouble 10 times more they're, you know, again, the disconnect between the how and the, what they know what to do, but they're not actually putting it into action. So oftentimes people are frustrated with them. They're getting frustrated with their self. And there's recently, you know, kind of, there's been talk about the, rejection sensitivity disorder.
Russell Barkley, Ph.D.: (30:19)
Yeah. Not really a disorder a once again, but yeah.
Dr. Keith Sutton, Psy.D: (30:23)
Yeah. But it's interesting because I think that this is a core piece for adults with ADHD, this shame aspect and actually one of the, so we have the Bay Area Center for ADHD. One of my clinicians just kind of informally gave an internalized shame questionnaire to all of his clients, ADHD and found that adults with ADHD tended to have the highest level of internalized shame, even more than the the adults with childhood physical, sexual abuse, trauma clients.
Russell Barkley, Ph.D.: (30:51)
Yeah. No question, no question.
Dr. Keith Sutton, Psy.D: (30:52)
About your thoughts about that.
Russell Barkley, Ph.D.: (30:54)
Well, yeah, there's no doubt both our, our longitudinal studies and our cross-sectional studies of adults with ADHD show that there's a growing pattern of demoralization as a result of repeated failure experiences over time, such that by adulthood rates of anxiety disorders are more than doubled. And they are correlated with the length of time. ADHD goes untreated and that's true. Even in adulthood, if you look at every four year period of follow up adults with ADHD who stay out of treatment, have increasing risk for anxiety such that by the time we see these people in their thirties and forties over almost half of them have an anxiety disorder, which is not the case in children that we see, but there's this growing risk for anxiety demoralization, to some extent depression although it tends to be more of a milder DYS IMIA than, you know, full-fledged depression though, that can be there too.
Russell Barkley, Ph.D.: (31:52)
But looks like S C T is the predictor of the depression part sure. Of ADHD, but you're right. And I'm not saying that there isn't, you know, this rejection sensitivity issue that they have. But you know, again, if we're not going to call S C T a disorder yet, cause it's not official, then we can't call rejection sensitivity. That right. There is no doubt that two things conspire to make them, you know, ashamed and hurt. Number one is the growing rate of failure in their life. Both letting themselves down, not accomplishing the goals they had hoped to accomplish by certain times. So those are self determined goals, but also the failure that they experience in school, college, work, peers, marriages I mean, you know, there's no domain of life unaffected by ADHD in some way or another.
Russell Barkley, Ph.D.: (32:44)
So there's that shamefulness that they have. Plus on top of that, the second thing that I wanted to mention is of course, the contribution of others around them to the shaming, which is viewing ADHD as a moral failure, you know, you could do this, you could wake up and smell the coffee and change yourself. You're just not motivated. You're a lazy layabout near do well. And God, you have no idea. Or maybe you do of how often people with ADHD hear that. From others, these are people who don't get the neurobiology of this disorder and place it within the realm of moral judgment. And so they've been, I don't wanna say bullied, but certainly brow beaten by others around them for their lack of success and follow through and forgetfulness and so on.
Russell Barkley, Ph.D.: (33:36)
And now let's take those two, let me add another third thing to this, you know, pot of stew that we've created here. And the third part of the recipe is these people have very impulsive emotions. They react very quickly, more so than other people do. It's not a mood disorder, it's impulsive, emotional reactions to provocations. So they're reacting emotionally to the failure, to the shaming, to the demo, to the moral judgements of other people. And they're regretting it. So now you've got this layer of regret sure. Of how I acted. “God, I wish I hadn't said that I, you know, blew my, you know, my cork at my boss. And now I don't know if I got a job” and you know, it's the emotion regulation piece of ADHD is the single best predictor being fired from a job. It's a single best predictor of how few friends you're going to have in life. The best predictor of whether you're going to be divorced and also intimate partner violence and aggression within intimate cohabiting relationships. It also predicts road rage. So you can see where the emotional aspect is going to create even further demoralization and rejection and shaming. So it doesn't just arise from one source. It's a multi-source problem. But by the time you and I see these people, you know, they're in a deep, dark place, they really are.
Dr. Keith Sutton, Psy.D: (35:02)
And I think too, that, you know, oftentimes people get into a shame spiral, they mess something up, they feel bad, then they don't wanna deal with it because that feels worse. But then they end up doing something else. Like the person gets a parking ticket and they feel bad, they just kinda ignore it. And then they get more and more until the car gets booted. Because kind of sitting with that and like, “oh, I messed up”, you know, ends up feeling so bad and goes to that. Therefore. No good. And so kind of, oftentimes I work with my clients around, you know, the antidotes, a shame is integrity, taking responsibility, you know, kind of making amends, learning, making it right. And then taking the next step in the, again for a lot of people with ADHD, because they're falling off that horse, you know, 10 times more that resiliency gets depleted very quickly and it's hard to keep getting up and fixing all the, you know, mistakes or whatever, because they're messing up one half standard deviations more than the average person kind of by definition.
Russell Barkley, Ph.D.: (35:55)
Well, that that's an important piece and I'm glad you pointed that out. So one of the parts of clinical practice, what that we tell people you have to go right up front when the diagnosis is made is ownership of the disorder. And, you know, Adam Levine has a great YouTube. He created for Shire pharmaceuticals, which is now TETA. But you know, Adam Levine, you know, the guy on the voice and, you know, the lead singer in guitars for Maroon Five as a raging adult with ADHD, and he talks about it. He's very open about it. You know, Michael Phelps and Justin Timberlake and Simone Biles and all these celebrities, just Google, ‘ADHD successories’ and you're going to see some really, you know, very accomplished people, but they will tell you that, you know, step one in getting to where they are and the success that they have is not denying this, but owning it and getting it managed and taking responsibility, being responsible doesn't mean you get everything right.
Russell Barkley, Ph.D.: (36:48)
It means you own it all, you know, the wars all, okay. “I messed up. I didn't get there on time. I promised you I'd do this and I didn't” and you know, try to get it right the next time, what am I going to do? So that doesn't happen the next time that's integrity, that's responsibility. And we have to make that distinction because some patients think that what you're talking about is being successful. No, I'm talking about owning who you are in spades. And to me that is step one in the road to recovery, is ownership. I own it it's me and I make mistakes. So what, I try to get it right the next time. And I create scaffolding around me and, you know, support services and artificial, you know, means of organizing my environment.
Russell Barkley, Ph.D.: (37:35)
And I take my medication to try to come to grips with this. And, and you'll you talk to these people, there's a great documentary that was just finished. It's being shopped to Amazon and Netflix. I, you know, was lucky to be one of the experts that they interview, but it's called the disruptors and they have taken these people from Justin Timberlake and Simone Biles and highly accomplished people, the owner of, you know, Jet Blue and, you know, celebrities. And so Howie Mandel's in it too, but they talk about their childhood. They also follow five families about how hard it is to be with ADHD and to help an ADHD child and the exhaustion of parenting. But they also weave in and out the success stories, which are often successful in non-traditional pursuits in life. The traditional paths are usually not where ADHD people make it, it might be an acting or videography or in, you know, being a chef or in the culinary arts, or maybe in the military. But you know, these are people who are actors, comedians, athletes, Olympians, and who are quite successful. So watch for that, The Disruptors, it's probably going to wind up on one of the major streaming channels, if not PBS.
Dr. Keith Sutton, Psy.D: (38:49)
Yeah. Yeah. And I think too that, you know, Ilove working with kids, adolescents, adults, couples with ADHD, because with intervention so much can change just medication and behavioral interventions around executive functioning and you know, all that kind of helping to understand that kinda shame avoidance kind of cycle and helping shift that with the cognitive behavioral therapy. And also I integrate a lot of EMDR. Because many of my adults with ADHD have experienced trauma from, you don't know how many EMDR I've done at an IEP meeting where you know, that they kind of get the sense that I'm broken. I'm bad, I'm not smarter, so on. But then, you know, oftentimes can really flourish with those supports and accepting and understanding and shifting. And there's actually a great little metaphor that Grace Friedman, she wrote a book for teams.
Dr. Keith Sutton, Psy.D: (39:38)
She was a teenager just a little e-book, it's at Addie team.com and she uses a metaphor of how when she was playing soccer, she was put in the goalie position, but she didn't really wanna be in that position. She wasn't in the right gear in some and getting pulled. And her dad said, you know, you really have to suit up for the game you're in. And she uses that metaphor of kind of understanding that you have ADHD and then beginning to actually suit up for that game. And really kind of dealing with that rather than just kind of turn the quote unquote, “be neurotypical” and kinda ignore the, the ADHD and the effects of “don't be neurotypical” because let me tell you, you're just going to keep hitting your head against the wall.
Russell Barkley, Ph.D.: (40:15)
That doesn't mean you can't go to law school or be a doctor or physician or, you know, the usual educational pathway into success. But for ADHD people, it's almost always, I don't wanna say always, but most of the time it's going to be nontraditional and they might be the entrepreneurs. They might own their own businesses. They might, you know, be a builder in construction. They might be like Thai Pennington who destroys and rebuilds houses for a living or, you know, or Glen Beck, the, you know, the disruptor and commentary. If you look at them or Michael Phelps, you know, the most decorated Olympian in history, that's all nontraditional. Simone Biles talks very openly the gymnast about her successes and her trials. You know, when Michael's out of the pool, he's, you know, he has to watch it because he's got DUIs and lots of other problems and he has to deal with.
Russell Barkley, Ph.D.: (41:03)
So these are people that can inspire you. To have hope that there's lots of other roads to successful fulfilling lives that don't necessarily involve a lot of advanced education to get there. And that, like you said, suit up for that game. Let's take a look around, I talk about it in my book, The 12 Principles For Raising a Child With ADHD, and one of those principal principles, we call the keys to success. Step one of the keys to success is you and your loved ones need to help you identify, what are your aptitudes? What are your strengths? You know, where are you clever? Where do you love engaging the task, the activity, and, you know, it might be technology, it might be standup comedy, it might be acting ,you know, it could be writing poetry for all I know, but, or you just love, you know, taking movies, you're going to be a videographer.
Russell Barkley, Ph.D.: (41:57)
You know, you wouldn't believe how many people in the video field are ADHD. So, you know, and also cooking, you wouldn't know believe how many chefs are ADHD. It's just unbelievable. So I tell them, would you just look around at what are you good at? And then do what Michael Phelps mom did for him. You find community resources that promote that aptitude to get you that 10,000 hours of practice that you know, are often talked about to become expert in that area. And you know, okay, we'll get you through school. C’s are good enough. We're going to, you know, we need to get you through school as best we can, but we are going to promote that aptitude, find the resources to further develop it. We are in your corner. We are your safety net. You know, the unconditional regard that we have for you.
Russell Barkley, Ph.D.: (42:45)
There's a great interview with Michael Phelps mom, and also with Ty Pennington's mom in Attitude Magazine. You have to go back and Google it about 10 years ago, but boy, they will tell you what they had to do to get this kid to where he is now, this success story. I mean, people don't realize Richard Branson who's adult ADHD was in jail, right? In London. What was he doing as a teenager? He was pirating the Beatles music and selling digital copies and he got caught and convicted and his parents had the second mortgage to house and get him out of jail and send him to Vermont to a private school. That's where he started to find his entrepreneurial niche.
Dr. Keith Sutton, Psy.D: (43:27)
Yeah, there's a great, podcast that I like, how I built this with Guy Ross and where he interviews different founders of different companies. And just so interesting to see, hear their path in their career, which oftentimes was not the straight and narrow that oftentimes many families think they have to get these grades go to these Ivy league schools and therefore this and that, you know, oftentimes people have these security roots and really kind of creat that support. And you even kind of mentioned in your book about kind of not engineering your kids, but more shepherding. I want you in the last little bit to kind of take a moment to just kind of talk a little bit about diagnosis. Because I know this is always a big question. I was recently kind of contacted by somebody doing an article for web MD on right now, especially with the pandemic.
Dr. Keith Sutton, Psy.D: (44:10)
And a lot of folks looking for assessment is this ADHD. And so on, especially this has been such a hard year for so many kids and families and remote learning and particularly, you know, an additional piece to this too, that I have a question of is I know that in the original kind of research in, in diagnosing ADHD, it was looking at the six out of nine symptoms. And that, that I, I heard in one of your talks at that place, the kids at the 93rd percentile or one and a half standard deviations above the meme, mostly on boys between I think it was six and 16 or so. Right. That's right. And I was almost wondering about if we did another kind of study like that now, would it actually shift, has the culture shifted at all? Where like, you know, more people are more inattentive, but more kids so on because of our fast paced society, internet, things like that, or would it still be kind of, again, that 93rd percentile would be that six out of nine still, or might be seven out of nine or five out of nine kind of because ultimately the rate of ADHD by definition should be about 7%.
Dr. Keith Sutton, Psy.D: (45:17)
Yeah. Based on that definition.
Russell Barkley, Ph.D.: (45:23)
That's correct. Well, I think, boy, there's a lot there to unpack, but let me get right to the more obvious one, which there is research where we've gone out and renormed the DSM items like George Dupal just renormed it, about four or five years ago on boys and girls, right after the DSM five came out, they took their old ADHD scale, reup, updated it, renormed it. And you know, as far as they're able to determine along with other international studies, that number still fits. So we haven't really seen, despite people thinking that with all the screen time and technology and now with COVID, as well as difficulties that people have had with sleeping, you know, we should see in more inattention and more ADHD. Well, we're not, I mean, you know, we're certainly seeing more inattention, but you know, inattention is not clinical ADHD. Those are two different things. And, you know, nobody's that severe from COVID, from the lockdown and the technology rising up to the level of an ADHD clinical diagnosis.
Dr. Keith Sutton, Psy.D: (46:23)
So somebody might have the symptoms right. In a significant range, but because it's not having the consistent history then precise, wouldn't actually be considered ADHD itself, even though it may look like it.
Russell Barkley, Ph.D.: (46:33)
ADHD doesn't mean that some cases that were marginally ADHD might not have moved a symptom or to during the pandemic over into the clinical range. But you know, the typical person didn't go all clinical just because of inattention and sleep, and worry, and so on. So the fact is it looks like six still is fine. DSM four for children and adolescents. What isn't fine is after that, because our studies show from 18 to 29, it should be five and beyond 30 and up, it should be four. And that's what we recommended to the DSM committee for DSM five. And what they did was kind of like a split the baby, you know, Solomon's decision. They didn't allow four, they gave five. So that's why DSM five says when you see somebody 18 and older use five. But you really should use four because that's the level of deviance for them.
Dr. Keith Sutton, Psy.D: (47:29)
That's what places are at that 90%.
Russell Barkley, Ph.D.: (47:31)
Yeah. Yeah. Precisely. So we really haven't seen that. The other thing, when you mention prevalence, although ADHD is around five to 7%, it's not as high as the CDC keeps saying it is. And, you know, the journalists keep trumpeting the CDC figures, but the CDC figures are junk. And that's because they're based on one question on a national survey, not a thorough evaluation, not do you meet DSM? The one question is, “has your child, or have you ever been told your child might have ADHD by a healthcare professional?” My God, you'll blow the lid off a prevalence if that's your only question, but that's what the CDC did.
Dr. Keith Sutton, Psy.D: (48:06)
I'm interviewing Steve hi on his book, ADHD explosion. And really,
Russell Barkley, Ph.D.: (48:11)
Yeah. And, and part of that is, you know, the CDC not doing its job with careful dag, you know, whenever we go out and use the DSM and I just, you know, normed my own adult rating scales and child scales on executive functioning, you know, back just to what seven, eight years ago. And you know, we still find that number is fine. And only about 5 to 6% of children qualified for the diagnosis when you use all the criteria. Now, if you start waving criteria, you know, like you don't have to have the full six and doesn't have to have six months and, you know, you don't have to have impairment, you know, then yeah, you're going blow the roof off prevalence, but then is that really ADHD you're talking about? Yeah. Right. You know, or is that just part of the normal spectrum of, you know, because ADHD is a spectrum disorder like autism is.
Russell Barkley, Ph.D.: (49:03)
So where along the spectrum are you drawing a line and the CDC, you know, drew a very low bar for this, whereas the DSM draws a very high bar. Um, and, and to me, the prevalence remains at that five to 7% figure when you do full clinical evaluation. So now there's been no increase in ADHD that we've seen in terms of prevalence. Yes. Now there has been an increase in referral and diagnosis. Yeah. But that's just good public health. You know, more people hear about ADHD, more people come in and we want that, you know, especially girls and women, the, the biggest increases by the way, are girls, teens and adults mm-hmm . And guess what, 20 years ago, those were the underdiagnosed populations. Even more so than boys for males. The diagnosis has actually been flat for a decade. The rate of, of medication used the rate of diagnosis has been flat now in the, the most recent surveys. So we're doing a pretty good job. We're reaching about 80% of the boys.
Dr. Keith Sutton, Psy.D: (50:01)
When I think the, the, the big piece too, at least when I am assessing an adult with ADHD, if my parents are alive, I always want to talk to their parents. Cause those childhood symptoms are such the biggest differential of whether it's not ADHD. Cause clearly things can, can, can score in a positive range on a questionnaire for ADHD symptoms, although not necessarily be due to that. So that kind of establish, and like you're saying in the past, when some of these adults were children, there wasn't as much kinda good, um, you know, services or awareness or so on or parents about bringing them in and getting, getting assessment.
Russell Barkley, Ph.D.: (50:35)
Yeah. No, that's, that's very true. It's very true. So I don't think we need to worry so much about the DSM for kids, but we do have worry about it for adults because the bar is set just a little too high. I recommend clinicians do two things. Use four on each list as you're cutoff and ignore the content in the parentheses. The parenthetical clarifications were never tested, never evaluated as good symptoms. My daughter-in-law Laura analysis, a psychologist, she and I just finished a study. That's coming out next month showing that the clarifications barely correlate with the items they're supposed to clarify. Right? Some of them are more related to anxiety mm-hmm . Um, but what they've done is to create eight or nine additional symptoms by putting those clarifications in there and then they didn't readjust the threshold mm-hmm so it's easier to qualify for a diagnosis of ADHD now because you've got all those clarifications that can count as symptoms, even if the original symptom isn't endorsed. So, you know, watch it, we show that you can almost double the rate of adult ADHD, particularly for the inattentive presentation. If you start counting the parentheses the clarification. So I'm telling people to ignore those until we learn more about 'em because I, I think they're bad news. Yeah,
Dr. Keith Sutton, Psy.D: (51:53)
Definitely. Well, Hey, thank you so much for this conversation today. It's always Keith, my pleasure taking, hear what you're doing and um, yeah, I I've got your book and it looks really great. The recent one on the principles the raising child with ADHD, um, keep up all the great work and thanks for taking the time to speak with me today.
Russell Barkley, Ph.D.: (52:13)
Thanks. I'm still going. So hopefully got a few more years left in me before I finally pull out of this. But thanks again. It's been an honor to be in your program. I appreciate it.
Dr. Keith Sutton, Psy.D: (52:22)
Great. Thank you. Well, take care. Appreciate it.
Russell Barkley, Ph.D.: (52:26)
Yeah, you be well, bye.
Dr. Keith Sutton, Psy.D: (52:28)
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Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco bay area and the director of the Institute for the Advancement of Psychotherapy. Today I’ll be speaking with Russell Barkley Ph.D., who is a psychologist and author of 12 Principles For Raising a Child With ADHD, and several other works about ADHD and defiance in children, adolescents, and adults. Russ retired as a professor of psychiatry and neurology from the University of Massachusetts medical center and then worked as a professor of psychiatry and health sciences at the medical university of South Carolina. He is currently a clinical professor of psychiatry at Virginia Commonwealth University medical center. And Russ continues to lecture widely and develops continuing education courses for professionals on ADHD and related disorders. He also consults on research projects, edits the ADHD report and writes books, reviews, and research articles. Let's listen to the interview. Hi, welcome Russ.
Russell Barkley, Ph.D.: (01:29)
Welcome. Thank you so much. Good to be here.
Dr. Keith Sutton, Psy.D: (01:32)
Yeah. Great. Well, I'm so glad I have the chance to interview you today. So, I was introduced to you back in my predoc. One of my clients came in for an assessment for ADHD. And my supervisor said, oh, I said, how do you do this assessment? He said, here you go listen to a two-day workshop on Russell Barkley. And so I listened to a seven or nine-disc series and it was just so much great information. I mean, particularly, I came into the field with my original focus on difficult adolescents and kind of out of control running away and so on. And so huge overlap of course, with ADHD and oppositional, and actually it's funny actually because now half my practice is children, adolescents, adults, and couples with ADHD.
Dr. Keith Sutton, Psy.D: (02:20)
And I wouldn't have known because way back in the beginning in undergrad, I was working on doing work-study for Bruce Pennington at the University of Denver, just entering in Wisconsin, hard sort kind of data. So, I got to see you speak at a Chad conference, and you and I have emailed a couple of times, I've kept my questions short, but I know you're the to go-to person around ADHD and kind of so up to date. So yeah, I'd love to hear about kind of, you know, a little bit about your story. Cause I was saying, I actually would like to hear your backstory of how you got into this area and also kind of what you're doing now and, and really kind of what you're seeing as the forefront of the field.
Russell Barkley, Ph.D.: (03:03)
Oh man, there's just so much going on, Keith, thank you so much for asking. I appreciate that. I mean, I've been at this for what, 44 years of clinical practice and that doesn't include all my, you know, graduate training and so forth though. I, you know, I got into the field after I got out of Vietnam. I was in the air force and Vietnam and I came back and spent a couple of years in North Carolina. And at that point, that's where I went back to college. I had left college early because I wasn't interested in going and I didn't like my major. And, of course, that was the draft. So if you left college, you were going to get drafted. So I enlisted in the air force, my preferred branch, having been raised in the air force. So my dad was a career officer.
Russell Barkley, Ph.D.: (03:43)
So after I got out, I was very interested in the sciences, particularly biology, and to some extent psychology. So I went to the University of North Carolina and I was sort of double majoring, but a lot more emphasis on psychology when I was there. But I knew to go to graduate school, you had to do something extra. So I started asking around mainly over at the medical center because no one in the department needed any assistance. There were plenty of students wandering around and a lot of people were saying we don't need any help. And I was going to volunteer 20 hours a week if that they wanted that. And they said, well, this guy just got a grant to study hyperactive children over at the child development center, why don't you go talk to him?
Russell Barkley, Ph.D.: (04:28)
And it was Don Ruth who was, you know, a recognized authority in hyperactive children at the time. He was the editor of the journal of abnormal child psychology for quite a while, so I went to Don and he said, sure, we could use the extra help. And so I loved it. I became his research assistant. I was observing and coding and you know, all these hyperactive children, which now are ADHD kids coming into his program, and he was doing drug research on methylate with them. He convinced me to do my honors thesis with him. So not only was I his research assistant, but he was also my supervisor for my honors program. So I did my first study on, you know, hyperactive kids and then did one on imitation learning in children and then went onto graduate school and just, you know, once you get onto it, I just fell in love with that.
Russell Barkley, Ph.D.: (05:21)
I thought these out of control kids were fascinating and I wanted to know more about them what's going on here. And so I stayed with it and then, you know, wrote a lot of reviews in graduate school on the topic and, you know, just got further into it. Did my masters, did my dissertation on drug studies with ADHD kids and then went on to specialize like you did in, you know, developmental disabilities and neurodevelopmental problems. And especially in neuropsychology out at the university of Oregon medical center and continued on from there. I got my first job as a neuropsychologist at Milwaukee children's hospital, went on to start the neuropsychology service there in both adult and child neurology. And after that went on to UMass medical school for 17 years as director of psychology there, but still, you know, developed clinics for ADHD, adults, ADHD, kids, and then continued, you know, doing my neuropsychology research and after retiring from there at, at early age of 52, I went to work at the medical school in Charleston, South Carolina.
Russell Barkley, Ph.D.: (06:27)
Oh, wow. I was doing some research on ADHD and driving and the effects of medications and alcohol on driving down there. And then of course about five years ago, moved up to Richmond to be near my grandchildren here. But, you know, continued, at least to work part-time and doing a lot of lecturing and writing and also consulting on other people's projects and grants and just continuing my own work. So, you know, it's been a long haul, but what keeps me fascinated, every time I think it's getting boring, there'll be some discovery or I'll discover something that just lights my curiosity up all over again. And to me, ADHD, because it's a problem with self-regulation by studying where self-regulation goes wrong in people with this disorder, you learn a lot about typical people, not just ADHD, because you have to know how normal develops so to speak.
Russell Barkley, Ph.D.: (07:24)
How does typical self-regulation emerge and what is ADHD doing to screw all that up and then what does that tell us about how to help these people? And so, you know, I've been working on that question since 1994, when I started writing my first theoretical papers on ADHD and executive functioning and then wrote two books on that. And, you know, just did a number of research papers as well on executive functioning. So that, that got me really into this. So that was number one, I've just been fascinated by what ADHD teaches us, not just about them, but about all people in general, not, not just them. The second thing of course is I got involved in longitudinal research and we of course followed a large group of ADHD, children to adulthood out in Milwaukee. So that was going on at the same time that I'm studying executive functioning.
Russell Barkley, Ph.D.: (08:16)
More recently have gotten involved in developing this new attention disorder and research on it called sluggish cognitive tempo, which is a, a group of people who get misdiagnosed as ADHD, because there's no place for them in the DSM. So they get called a D D or ADHD inattentive presentation, but they're not. And perhaps, you know, in, in this conversation, we can talk a little bit more about that because there is this new attention disorder and there's growing research on it. And we've just brought 12 of the leading researchers in the world together for a work group task force. That's going to summarize the research. Although there have been meta analyses and summaries we're going to rename the disorder because it's a very demeaning term. We don't like the term. It suggests slow. Wittedness sure, you know, kind of a stupidity if you will, but, and we don't mean that at all.
Russell Barkley, Ph.D.: (09:11)
And we didn't invent the term. It was invented in 1984 by a graduate student, working with Ben Lehe. But it's stuck and, we wanna get rid of it and move to something more benign. So, you know, the group is charged with not only surveying research, coming up with unanswered questions promoting awareness of S C T and then changing the name. And we hope to do all of that by the end of the year.But it, you know, it's well underway. We've had some meetings and we're all doing our little research reviews, so that's an interesting disorder in its own. Right. So, you know, there you have it, I mean, between longitudinal research and executive functioning theories and, you know, S C T and ADHD. And then most recently I stumbled into the health outcomes area in ADHD.
Russell Barkley, Ph.D.: (09:56)
So the last year or two, I've been working with Chad very closely to promote awareness of ADHD as a public health disorder because of all of the risks, we have been able to document in my longitudinal study and elsewhere on the impact of ADHD on early mortality, on all the increased medical problems from obesity to diabetes, to accidental injury, to suicide and homicide, and then my own research published just not even two years ago showing the first to show that ADHD shortens life expectancy by an average of about 12 to 13 years, which is worse than all of the other health concerns we have combined. So if you were to look at what does obesity do to life expectancy? What about alcohol? What about exercise and sleep and smoking and all the things we spend billions of dollars on, they don't come close to what ADHD does to shorten your lifespan. And that's because ADHD predisposes to all of them not just one of them. And so you know, I've been doing a lot of presentations lately between Chad and other organizations on the health consequences of this disorder and what we need to do about it. So there you go. That's that's where I came from, that's what I'm up to, and I'm still going.
Dr. Keith Sutton, Psy.D: (11:19)
The're doing a lot in retirement there .
Russell Barkley, Ph.D.: (11:21)
Yeah. Yeah. Well, I'm kind of semi-retired, but, you know, I have time for my grandchildren and golf, but no problem, no, I'm still writing and, and working and consulting. I'm just not doing the things at the medical center here that I don't want to do. So I can do that.
Dr. Keith Sutton, Psy.D: (11:35)
Wonderful. Thank you. So let's go to the sub, sluggish, cognitive tempo, and particularly, and actually, and even for a clarifying question that I have, right. Cause there, you know, that, I know you've talked a little bit about the ADHD combined type and there's that ADHD inattentive. And then there's the ADHD hyperactive impulsive and the right ADHD. Inattentive is what many people call a D D although that's not,
Russell Barkley, Ph.D.: (12:05)
They shouldn't.
Dr. Keith Sutton, Psy.D: (12:06)
Yeah. Right. And, you've talked about the sluggish cogniti and it particularly just for my clarification, right. Is a hundred percent of children, adolescent adults with ADHD, inattentive considered Southern cognitive tempo, or is there there a difference between those two?
Russell Barkley, Ph.D.: (12:25)
I think there's a, somewhat of a difference. It gets a little confusing. So I'll try to parse it up this way, right? If you were to take samples of ADHD, inattentive people, who are high in inattention, but have five or less of the hyperactive symptoms you, you wind up with about three groups of people. The first group of people you have are kids who started out as the combined type, who met all the criteria, but hyperactivity, declines, markedly in children over time. So by adolescence, many combined individuals are getting rediagnosed inattentive because they don't have six hyperactive symptoms anymore. They have five or four. So they're outgrowing the hyperactivity, but they're not outgrowing the combined type. That's just what combined type people do. And especially by adulthood, a lot of people called inattentive presentation are just former combined type that are grown up.
Russell Barkley, Ph.D.: (13:20)
And because the DSM overweights hyperactivity, which is a preschool aspect of the disorder, it looks like people are changing types and presentations, and they're not changing anything. They're just growing up as they want to do. That's, you know, that's a big chunk of people called inattentive presentation. They're really combined types.And that's how we should think of them. They're no different than anybody else, adults. Then you have a group of people who are mild combined presentations, so mild enough that they only have five hyperactive or even four hyperactive symptoms. So according to the gospel of the DSM five, these are inattentive presentations, but not really they're, you know, they're just milder variants of the combined type. They don't differ in any respect from fully combined type people at all. Just a little milder, you know, the one symptom of hyperactivity isn't going to change your clinical presentation.
Russell Barkley, Ph.D.: (14:19)
So if you get all of those people out of there, you're left with about 30 to 50% remaining of these intent onlys. And those are the SCT people. They do have high levels of inattention, but they have like no hyperactive symptoms, no impulsivity. They certainly have at least three or fewer of those symptoms, but usually none. When you pull those people out that's the SCT group. And then when you study them as to how they differ. They differ in many qualitative ways from ADHD at all, which is why we are now arguing that it's certainly a new attention condition and syndrome. Some of my colleagues on the task force would prefer not to call it a disorder, because they reserve that for the officially sanctioned DSM term.
Russell Barkley, Ph.D.: (15:16)
I don't happen to like Jerome Wakefield's definition of disorders, which are harmful dysfunctions and S C T certainly fits that. But you know, I'll go along with that, you know, if you wanna play the semantic game, it's a syndrome now, what is it about this syndrome? So I'll be very brief. These people are characterized by hypo activity. Not hyper, hypo. They're very passive lethargic, sluggish, slow moving. So there's a motor element just like there is in hype in ADHD, but in this case, it's the opposite motor element. These are very passive, somewhat withdrawn, slow moving, slow reacting, sluggish people often and sometimes sleepy as well. So we have this sluggish motor activity, then there's also an attention component. So just like ADHD, there's inattention. But in this case, the inattention is daydreaming, staring mind, wandering, unavailable, decoupled from the external environment.
Russell Barkley, Ph.D.: (16:15)
So you're gone, you're just out there in never land. People are saying to you, you know, earth to Steve or earth to us, you know, come back where, where, and, and you'll see them shake their head and say “oh, oh, what, what do you say”? So they miss a lot of what's going on around them. They make a lot of mistakes in their work, at school and in the office because they have this propensity to become preoccupied with mental content, which is where the daydreaming and the steering come in. We happen to think that there's a lot of mind wandering going on in these people. We haven't proven that yet, but we're getting close to that. So, you know, pathological mind wandering is probably not a bad way of thinking of these individuals.
Russell Barkley, Ph.D.: (16:56)
So where ADHD, people are overly coupled to the now and the moment and the exterior environment, which is where you get the distractability and the busyness and the engaging and the touching, S C T people are decoupled from the environment and they're too much in their head. So that's where you get the daydreaming staring. That's where you get the proneness to errors. They're not processing information accurately, mental confusion, mental fogginess, sluggish, responding to other people that's S C T, and maybe we'll change the name this year. So there's a lot about these people that's very different than ADHD. They have zero impulsivity. In fact, people with S C T are actually less impulsive than normal people. It's a negative relationship. They're less active than even typical people. They're prone to depression and anxiety, not to conduct disorder, oppositional disorder, drug use disorder, delinquency.
Russell Barkley, Ph.D.: (17:59)
They don't have a whiff of antisocial behavior or psychopathy about them. So the whole pattern of comorbidity is very different with them. About half of S C T people do have ADHD along with it and half don't. And our studies show that when the two disorders are comorbid, it's far worse than ADHD by itself. And the same with S E T you really don't want to have both of these attention syndromes going at the same time, and certainly some people do. We've also just discovered in the past year that this is the attention syndrome, most characteristic of autism, depression, and anxiety. So people who we think of as having more internalizing spectrum disorders are more likely to manifest this pattern of inattention. So if you had PTSD, if you had major depression, if you were anxious, but especially depression and autism this is really what you're doing.
Russell Barkley, Ph.D.: (19:04)
You're decoupling from the environment and, having an autistic grandson. I can vouch for that in spades. My difficulty with my grandson is not an ADHD. He doesn't have ADHD at all, right. He's just oftentimes gone, mentally checked out. There's a lot about them. They don't do well on ADHD meds. In fact, the more SCT symptoms you have, the worse you do on ADHD meds. They have the same prevalence as ADHD, about 5% of kids, five to 6% of kids. And a little bit less four, 5% of adults. The beauty of this disorder is there is no sex differences to speak of. We see it in males and females. There's also no decline with age. Like we see in ADHD, it is stable and permanent it's as stable as ADHD, if not more so and by adulthood, it's actually worse than ADHD in education, college and workplace settings, which we were shocked to find that in our study. So there's a lot going on, on this disorder right now as to what's the neurology of this. What's the neuropsychology of it. It's not really an executive function disorder, though. There's a little bit of working memory, organization problems linked to it. And what's going on in the mind of these people. Which is why we got real interested in pathological mind wandering as an analogous condition.
Dr. Keith Sutton, Psy.D: (20:32)
Cause I was thinking about, you know, oftentimes when I think of inattention, I don't remember if it's, I think it's something I listen to and you're talking that it's oftentimes it's maybe more with a ADHD combined or hyperactive impulsive. It's not that the person can't pay attention, they're having trouble inhibiting the impulse to not pay attention to one thing and focus on another.
Dr. Keith Sutton, Psy.D: (20:51)
But it sounds like you're saying this is like a little bit different because they're not necessarily impulsively like attending to something else. They're more almost like not having the drive to kind of focus on something. And instead of having that lack of drive and then just kind of having, you know, thoughts and kind of, yeah. That's not connected.
Russell Barkley, Ph.D.: (21:09)
Yeah. This, this is the kid
Dr. Keith Sutton, Psy.D: (21:11)
In the moment that's actually bringing their attention. It's actually kinda what's going on internally.
Russell Barkley, Ph.D.: (21:15)
Right? Right. No, I mean, this is your absentminded professor, daydreamy kid who just, he's not disruptive. He's a good kid. The parents report that the only trouble they have is they tend to be somewhat shy and reticent and less involved. They have friends, but not as many as people would like, they're quiet. So if you ever read the book quiet, you'll see that they're more introverted. Especially what parents are concerned about is they're failing at school. They do as badly at school as ADHD kids, but they're nice. And so they get referred two or three years later because, you know, it's the aggressiveness and the disruptive behavior of ADHD that gets you referred so quickly. You're just a, you know, difficult kid to manage. Whereas these kids are wonderful in the classroom, but they don't do anything, you know, and people wonder, do they have a learning disability? Or, why isn't this kid available? Is this high functioning autism, which it isn't of course. So, you know, there are a very unique group of kids in that sense, but as I said, you know, somewhat higher risk of depression and of somewhat anxiety, more depression, and overlap with autism.
Dr. Keith Sutton, Psy.D: (22:20)
That's a question I have too, because I think particularly with the inattentive ADHD, you know, so many things, you know, kind of can lead to an attention, depression, anxiety, you know, somebody not getting enough sleep, being spread too thin at work. All these kinds of things. And so, you know, how, how does that even really stand out from the, say anxiety versus anxiety avoidance and like, you know, this, this sluggish cognitive tempo,
Russell Barkley, Ph.D.: (22:50)
Well, what we've seen is that at least in my national surveys, the S C T people had slight increases in anxiety, but not a, high rate of diagnosis. They did have 25 to 30% had a diagnosis of depression, but again, 70% didn't. So, you know, you can't call this a proxy for depression, but it is the attention problem often seen with depression. And even if you don't have depression followed up 10 years later, which Lynn burns did in S C T children in Spain and it's also been replicated here early S C T is a predictor of later depression, even if you're not currently depressed. And that's because mind wandering is such that when people engage in mind wandering, although their mind is skipping from one thing to another, it tends to keep circling back to unresolved conflict. That's what typical people do.
Russell Barkley, Ph.D.: (23:40)
And that's what these mind wanderers do. And so you can see that unlike typical people, they're spending a lot more time in their head. And by doing that, they're spending a lot more time on their conflicts and problems and hurts and fantasies ruminating on. Well, some of it could be rumination. You know, we certainly see that, but, it's not so much an OCD type rumination as more of a depression type you keep coming back to these unresolved issues and problems. But also we see fantasy in these people. Some of them have a propensity for a very engaging fantasy life, almost a,novel in their mind, and they wanna get back to it and, and live that alternative life. And, you know, they're superheroes and they're beating up the bullies and they're solving their problems.
Russell Barkley, Ph.D.: (24:26)
And it makes 'em feel better. So, you know, it's like, there's three different groups of mind wanders, you know, there's the really O C D, who's obsessive, there's the depressive ruminator, and there's the fantasy engaging escape artist who is bored with what's going on around them and flights of fantasy into this alternative reality. And they all look the same. They're just not here. They're gone. So trying to find out how to help these people is going to be interesting because the ADHD treatments don't work.
Dr. Keith Sutton, Psy.D: (25:01)
I'm wondering too, like some of the kids that I work with and adults, you know, that the procrastination, the avoidance kind of coupled with the ADHD and the difficulty in initiating, I find that combination sometimes to be the most difficult, and maybe this is that piece. And oftentimes, sometimes I'm even using just exposure and sitting with the distress of starting something, because there is such a discomfort in trying to get going on something that's not very stimulating than the kind of, you know, urges to avoid and kinda get out of there. Because it's like disregulating.
Russell Barkley, Ph.D.: (25:34)
Well, you know, you just pointed out something that we found in all of our research. When we looked at items that identify S C T from ADHD, there were two that were described for both of them. They were not differentiated. So we took 'em off the symptom list because they were as common in ADHD as an S C T, and they were procrastination difficulties initiating work. And, low motivation. So difficulties completing work, but they're doing it in different ways. So when you study the manner in which they're having trouble with this, the ADHD person has trouble getting started and finds anything else around them that's more interesting. So the video game and I'm surfing and I'll check my phone and do my Facebook and check my Twitter feed and you know, they're procrastinating, but they're being captured by things around them.
Russell Barkley, Ph.D.: (26:29)
Now they also engage in some mind wandering and especially I'm wondering and especially if they have S C T with their ADHD, now you're going to see both of these, but they're not starting. And then they're looking for anything else more fun or interesting to do, like getting a coffee or, you know, going to do something else. You know, even, spinning in their chair, at least that's what the kids were doing that we studied. But low motivation doesn't finish assignments, finds it difficult to initiate their work, hence the procrastination. But when you look at them and when we've done interviews with the families of the kids and with the adults, the S C T person has checked out, they're still sitting there in front of the computer, or in front of the paper, whatever they're doing.
Russell Barkley, Ph.D.: (27:16)
But they're not there. I mean, you know, they'll be staring at the book they're supposed to be reading, but it's like you and I, sometimes when we read, we mind wander and we catch ourselves and come back to the story and maybe go back to the top of the page, but we start to free associate to content. Well, they've done that in spades. They're just gone, but they're sitting there passively, mentally checked out. The ADHD person is not sitting there like that. They're usually fidgeting, you know, fidling with things, touching things, doing something else, you know,
Dr. Keith Sutton, Psy.D: (27:52)
Almost sounds like an associate state almost.
Russell Barkley, Ph.D.: (27:54)
Yes. Very, very much so. In fact, we, took a look at that because one of the two questions came up, a couple years ago is this hypersomnia because these people sometimes report sleepiness and the answer is no, but about 20% of them do qualify for daytime sleepiness, sleeping difficulties. But it's not a proxy for hypersomnia. And then the other one of course is, as I mentioned, it's not a proxy for depression either. So even though they're prone to depression, it's not depression. So it's not these other explanations that people worried about. And we looked at anxiety, well, they, very few of them have enough anxiety to qualify for an anxiety disorder. And if they have it, it really is more related to depression than to fearfulness and worry. But you know, that, that could be the case too. We're not seeing a signal for Frank anxiety disorder at the clinical level, even though there's a little element of that as there is an introverted people where there's a little element of anxiety.
Dr. Keith Sutton, Psy.D: (28:59)
Yeah. It's almost like I see a lot of the anxiety avoidance, but not necessarily the anxiety worry. But kind of fearfulness or so precisely avoidance of potential distress, especially connected to, you know, something that might require focus or tension.
Russell Barkley, Ph.D.: (29:15)
Yeah, indeed, indeed. So it's a fascinating group of people that we're publishing more and more on. And as I said, we now have a task force on this. And my hope is that maybe when DSM six becomes available there will be enough research to convince them to put it in as, you know, an alternative attention disorder. We'll see.
Dr. Keith Sutton, Psy.D: (29:36)
And I wanted to get some of your thoughts. You know, one of the things that I see, especially with my adults with ADHD, is that shame tends to be one of the biggest difficulties. And oftentimes when I'm working with parents, you know, one of the things I say is, you know, our goal is to help build resilience and to kind of get them through their childhood without a great deal of shame, because oftentimes kids with ADHD are getting in trouble 10 times more they're, you know, again, the disconnect between the how and the, what they know what to do, but they're not actually putting it into action. So oftentimes people are frustrated with them. They're getting frustrated with their self. And there's recently, you know, kind of, there's been talk about the, rejection sensitivity disorder.
Russell Barkley, Ph.D.: (30:19)
Yeah. Not really a disorder a once again, but yeah.
Dr. Keith Sutton, Psy.D: (30:23)
Yeah. But it's interesting because I think that this is a core piece for adults with ADHD, this shame aspect and actually one of the, so we have the Bay Area Center for ADHD. One of my clinicians just kind of informally gave an internalized shame questionnaire to all of his clients, ADHD and found that adults with ADHD tended to have the highest level of internalized shame, even more than the the adults with childhood physical, sexual abuse, trauma clients.
Russell Barkley, Ph.D.: (30:51)
Yeah. No question, no question.
Dr. Keith Sutton, Psy.D: (30:52)
About your thoughts about that.
Russell Barkley, Ph.D.: (30:54)
Well, yeah, there's no doubt both our, our longitudinal studies and our cross-sectional studies of adults with ADHD show that there's a growing pattern of demoralization as a result of repeated failure experiences over time, such that by adulthood rates of anxiety disorders are more than doubled. And they are correlated with the length of time. ADHD goes untreated and that's true. Even in adulthood, if you look at every four year period of follow up adults with ADHD who stay out of treatment, have increasing risk for anxiety such that by the time we see these people in their thirties and forties over almost half of them have an anxiety disorder, which is not the case in children that we see, but there's this growing risk for anxiety demoralization, to some extent depression although it tends to be more of a milder DYS IMIA than, you know, full-fledged depression though, that can be there too.
Russell Barkley, Ph.D.: (31:52)
But looks like S C T is the predictor of the depression part sure. Of ADHD, but you're right. And I'm not saying that there isn't, you know, this rejection sensitivity issue that they have. But you know, again, if we're not going to call S C T a disorder yet, cause it's not official, then we can't call rejection sensitivity. That right. There is no doubt that two things conspire to make them, you know, ashamed and hurt. Number one is the growing rate of failure in their life. Both letting themselves down, not accomplishing the goals they had hoped to accomplish by certain times. So those are self determined goals, but also the failure that they experience in school, college, work, peers, marriages I mean, you know, there's no domain of life unaffected by ADHD in some way or another.
Russell Barkley, Ph.D.: (32:44)
So there's that shamefulness that they have. Plus on top of that, the second thing that I wanted to mention is of course, the contribution of others around them to the shaming, which is viewing ADHD as a moral failure, you know, you could do this, you could wake up and smell the coffee and change yourself. You're just not motivated. You're a lazy layabout near do well. And God, you have no idea. Or maybe you do of how often people with ADHD hear that. From others, these are people who don't get the neurobiology of this disorder and place it within the realm of moral judgment. And so they've been, I don't wanna say bullied, but certainly brow beaten by others around them for their lack of success and follow through and forgetfulness and so on.
Russell Barkley, Ph.D.: (33:36)
And now let's take those two, let me add another third thing to this, you know, pot of stew that we've created here. And the third part of the recipe is these people have very impulsive emotions. They react very quickly, more so than other people do. It's not a mood disorder, it's impulsive, emotional reactions to provocations. So they're reacting emotionally to the failure, to the shaming, to the demo, to the moral judgements of other people. And they're regretting it. So now you've got this layer of regret sure. Of how I acted. “God, I wish I hadn't said that I, you know, blew my, you know, my cork at my boss. And now I don't know if I got a job” and you know, it's the emotion regulation piece of ADHD is the single best predictor being fired from a job. It's a single best predictor of how few friends you're going to have in life. The best predictor of whether you're going to be divorced and also intimate partner violence and aggression within intimate cohabiting relationships. It also predicts road rage. So you can see where the emotional aspect is going to create even further demoralization and rejection and shaming. So it doesn't just arise from one source. It's a multi-source problem. But by the time you and I see these people, you know, they're in a deep, dark place, they really are.
Dr. Keith Sutton, Psy.D: (35:02)
And I think too, that, you know, oftentimes people get into a shame spiral, they mess something up, they feel bad, then they don't wanna deal with it because that feels worse. But then they end up doing something else. Like the person gets a parking ticket and they feel bad, they just kinda ignore it. And then they get more and more until the car gets booted. Because kind of sitting with that and like, “oh, I messed up”, you know, ends up feeling so bad and goes to that. Therefore. No good. And so kind of, oftentimes I work with my clients around, you know, the antidotes, a shame is integrity, taking responsibility, you know, kind of making amends, learning, making it right. And then taking the next step in the, again for a lot of people with ADHD, because they're falling off that horse, you know, 10 times more that resiliency gets depleted very quickly and it's hard to keep getting up and fixing all the, you know, mistakes or whatever, because they're messing up one half standard deviations more than the average person kind of by definition.
Russell Barkley, Ph.D.: (35:55)
Well, that that's an important piece and I'm glad you pointed that out. So one of the parts of clinical practice, what that we tell people you have to go right up front when the diagnosis is made is ownership of the disorder. And, you know, Adam Levine has a great YouTube. He created for Shire pharmaceuticals, which is now TETA. But you know, Adam Levine, you know, the guy on the voice and, you know, the lead singer in guitars for Maroon Five as a raging adult with ADHD, and he talks about it. He's very open about it. You know, Michael Phelps and Justin Timberlake and Simone Biles and all these celebrities, just Google, ‘ADHD successories’ and you're going to see some really, you know, very accomplished people, but they will tell you that, you know, step one in getting to where they are and the success that they have is not denying this, but owning it and getting it managed and taking responsibility, being responsible doesn't mean you get everything right.
Russell Barkley, Ph.D.: (36:48)
It means you own it all, you know, the wars all, okay. “I messed up. I didn't get there on time. I promised you I'd do this and I didn't” and you know, try to get it right the next time, what am I going to do? So that doesn't happen the next time that's integrity, that's responsibility. And we have to make that distinction because some patients think that what you're talking about is being successful. No, I'm talking about owning who you are in spades. And to me that is step one in the road to recovery, is ownership. I own it it's me and I make mistakes. So what, I try to get it right the next time. And I create scaffolding around me and, you know, support services and artificial, you know, means of organizing my environment.
Russell Barkley, Ph.D.: (37:35)
And I take my medication to try to come to grips with this. And, and you'll you talk to these people, there's a great documentary that was just finished. It's being shopped to Amazon and Netflix. I, you know, was lucky to be one of the experts that they interview, but it's called the disruptors and they have taken these people from Justin Timberlake and Simone Biles and highly accomplished people, the owner of, you know, Jet Blue and, you know, celebrities. And so Howie Mandel's in it too, but they talk about their childhood. They also follow five families about how hard it is to be with ADHD and to help an ADHD child and the exhaustion of parenting. But they also weave in and out the success stories, which are often successful in non-traditional pursuits in life. The traditional paths are usually not where ADHD people make it, it might be an acting or videography or in, you know, being a chef or in the culinary arts, or maybe in the military. But you know, these are people who are actors, comedians, athletes, Olympians, and who are quite successful. So watch for that, The Disruptors, it's probably going to wind up on one of the major streaming channels, if not PBS.
Dr. Keith Sutton, Psy.D: (38:49)
Yeah. Yeah. And I think too that, you know, Ilove working with kids, adolescents, adults, couples with ADHD, because with intervention so much can change just medication and behavioral interventions around executive functioning and you know, all that kind of helping to understand that kinda shame avoidance kind of cycle and helping shift that with the cognitive behavioral therapy. And also I integrate a lot of EMDR. Because many of my adults with ADHD have experienced trauma from, you don't know how many EMDR I've done at an IEP meeting where you know, that they kind of get the sense that I'm broken. I'm bad, I'm not smarter, so on. But then, you know, oftentimes can really flourish with those supports and accepting and understanding and shifting. And there's actually a great little metaphor that Grace Friedman, she wrote a book for teams.
Dr. Keith Sutton, Psy.D: (39:38)
She was a teenager just a little e-book, it's at Addie team.com and she uses a metaphor of how when she was playing soccer, she was put in the goalie position, but she didn't really wanna be in that position. She wasn't in the right gear in some and getting pulled. And her dad said, you know, you really have to suit up for the game you're in. And she uses that metaphor of kind of understanding that you have ADHD and then beginning to actually suit up for that game. And really kind of dealing with that rather than just kind of turn the quote unquote, “be neurotypical” and kinda ignore the, the ADHD and the effects of “don't be neurotypical” because let me tell you, you're just going to keep hitting your head against the wall.
Russell Barkley, Ph.D.: (40:15)
That doesn't mean you can't go to law school or be a doctor or physician or, you know, the usual educational pathway into success. But for ADHD people, it's almost always, I don't wanna say always, but most of the time it's going to be nontraditional and they might be the entrepreneurs. They might own their own businesses. They might, you know, be a builder in construction. They might be like Thai Pennington who destroys and rebuilds houses for a living or, you know, or Glen Beck, the, you know, the disruptor and commentary. If you look at them or Michael Phelps, you know, the most decorated Olympian in history, that's all nontraditional. Simone Biles talks very openly the gymnast about her successes and her trials. You know, when Michael's out of the pool, he's, you know, he has to watch it because he's got DUIs and lots of other problems and he has to deal with.
Russell Barkley, Ph.D.: (41:03)
So these are people that can inspire you. To have hope that there's lots of other roads to successful fulfilling lives that don't necessarily involve a lot of advanced education to get there. And that, like you said, suit up for that game. Let's take a look around, I talk about it in my book, The 12 Principles For Raising a Child With ADHD, and one of those principal principles, we call the keys to success. Step one of the keys to success is you and your loved ones need to help you identify, what are your aptitudes? What are your strengths? You know, where are you clever? Where do you love engaging the task, the activity, and, you know, it might be technology, it might be standup comedy, it might be acting ,you know, it could be writing poetry for all I know, but, or you just love, you know, taking movies, you're going to be a videographer.
Russell Barkley, Ph.D.: (41:57)
You know, you wouldn't believe how many people in the video field are ADHD. So, you know, and also cooking, you wouldn't know believe how many chefs are ADHD. It's just unbelievable. So I tell them, would you just look around at what are you good at? And then do what Michael Phelps mom did for him. You find community resources that promote that aptitude to get you that 10,000 hours of practice that you know, are often talked about to become expert in that area. And you know, okay, we'll get you through school. C’s are good enough. We're going to, you know, we need to get you through school as best we can, but we are going to promote that aptitude, find the resources to further develop it. We are in your corner. We are your safety net. You know, the unconditional regard that we have for you.
Russell Barkley, Ph.D.: (42:45)
There's a great interview with Michael Phelps mom, and also with Ty Pennington's mom in Attitude Magazine. You have to go back and Google it about 10 years ago, but boy, they will tell you what they had to do to get this kid to where he is now, this success story. I mean, people don't realize Richard Branson who's adult ADHD was in jail, right? In London. What was he doing as a teenager? He was pirating the Beatles music and selling digital copies and he got caught and convicted and his parents had the second mortgage to house and get him out of jail and send him to Vermont to a private school. That's where he started to find his entrepreneurial niche.
Dr. Keith Sutton, Psy.D: (43:27)
Yeah, there's a great, podcast that I like, how I built this with Guy Ross and where he interviews different founders of different companies. And just so interesting to see, hear their path in their career, which oftentimes was not the straight and narrow that oftentimes many families think they have to get these grades go to these Ivy league schools and therefore this and that, you know, oftentimes people have these security roots and really kind of creat that support. And you even kind of mentioned in your book about kind of not engineering your kids, but more shepherding. I want you in the last little bit to kind of take a moment to just kind of talk a little bit about diagnosis. Because I know this is always a big question. I was recently kind of contacted by somebody doing an article for web MD on right now, especially with the pandemic.
Dr. Keith Sutton, Psy.D: (44:10)
And a lot of folks looking for assessment is this ADHD. And so on, especially this has been such a hard year for so many kids and families and remote learning and particularly, you know, an additional piece to this too, that I have a question of is I know that in the original kind of research in, in diagnosing ADHD, it was looking at the six out of nine symptoms. And that, that I, I heard in one of your talks at that place, the kids at the 93rd percentile or one and a half standard deviations above the meme, mostly on boys between I think it was six and 16 or so. Right. That's right. And I was almost wondering about if we did another kind of study like that now, would it actually shift, has the culture shifted at all? Where like, you know, more people are more inattentive, but more kids so on because of our fast paced society, internet, things like that, or would it still be kind of, again, that 93rd percentile would be that six out of nine still, or might be seven out of nine or five out of nine kind of because ultimately the rate of ADHD by definition should be about 7%.
Dr. Keith Sutton, Psy.D: (45:17)
Yeah. Based on that definition.
Russell Barkley, Ph.D.: (45:23)
That's correct. Well, I think, boy, there's a lot there to unpack, but let me get right to the more obvious one, which there is research where we've gone out and renormed the DSM items like George Dupal just renormed it, about four or five years ago on boys and girls, right after the DSM five came out, they took their old ADHD scale, reup, updated it, renormed it. And you know, as far as they're able to determine along with other international studies, that number still fits. So we haven't really seen, despite people thinking that with all the screen time and technology and now with COVID, as well as difficulties that people have had with sleeping, you know, we should see in more inattention and more ADHD. Well, we're not, I mean, you know, we're certainly seeing more inattention, but you know, inattention is not clinical ADHD. Those are two different things. And, you know, nobody's that severe from COVID, from the lockdown and the technology rising up to the level of an ADHD clinical diagnosis.
Dr. Keith Sutton, Psy.D: (46:23)
So somebody might have the symptoms right. In a significant range, but because it's not having the consistent history then precise, wouldn't actually be considered ADHD itself, even though it may look like it.
Russell Barkley, Ph.D.: (46:33)
ADHD doesn't mean that some cases that were marginally ADHD might not have moved a symptom or to during the pandemic over into the clinical range. But you know, the typical person didn't go all clinical just because of inattention and sleep, and worry, and so on. So the fact is it looks like six still is fine. DSM four for children and adolescents. What isn't fine is after that, because our studies show from 18 to 29, it should be five and beyond 30 and up, it should be four. And that's what we recommended to the DSM committee for DSM five. And what they did was kind of like a split the baby, you know, Solomon's decision. They didn't allow four, they gave five. So that's why DSM five says when you see somebody 18 and older use five. But you really should use four because that's the level of deviance for them.
Dr. Keith Sutton, Psy.D: (47:29)
That's what places are at that 90%.
Russell Barkley, Ph.D.: (47:31)
Yeah. Yeah. Precisely. So we really haven't seen that. The other thing, when you mention prevalence, although ADHD is around five to 7%, it's not as high as the CDC keeps saying it is. And, you know, the journalists keep trumpeting the CDC figures, but the CDC figures are junk. And that's because they're based on one question on a national survey, not a thorough evaluation, not do you meet DSM? The one question is, “has your child, or have you ever been told your child might have ADHD by a healthcare professional?” My God, you'll blow the lid off a prevalence if that's your only question, but that's what the CDC did.
Dr. Keith Sutton, Psy.D: (48:06)
I'm interviewing Steve hi on his book, ADHD explosion. And really,
Russell Barkley, Ph.D.: (48:11)
Yeah. And, and part of that is, you know, the CDC not doing its job with careful dag, you know, whenever we go out and use the DSM and I just, you know, normed my own adult rating scales and child scales on executive functioning, you know, back just to what seven, eight years ago. And you know, we still find that number is fine. And only about 5 to 6% of children qualified for the diagnosis when you use all the criteria. Now, if you start waving criteria, you know, like you don't have to have the full six and doesn't have to have six months and, you know, you don't have to have impairment, you know, then yeah, you're going blow the roof off prevalence, but then is that really ADHD you're talking about? Yeah. Right. You know, or is that just part of the normal spectrum of, you know, because ADHD is a spectrum disorder like autism is.
Russell Barkley, Ph.D.: (49:03)
So where along the spectrum are you drawing a line and the CDC, you know, drew a very low bar for this, whereas the DSM draws a very high bar. Um, and, and to me, the prevalence remains at that five to 7% figure when you do full clinical evaluation. So now there's been no increase in ADHD that we've seen in terms of prevalence. Yes. Now there has been an increase in referral and diagnosis. Yeah. But that's just good public health. You know, more people hear about ADHD, more people come in and we want that, you know, especially girls and women, the, the biggest increases by the way, are girls, teens and adults mm-hmm . And guess what, 20 years ago, those were the underdiagnosed populations. Even more so than boys for males. The diagnosis has actually been flat for a decade. The rate of, of medication used the rate of diagnosis has been flat now in the, the most recent surveys. So we're doing a pretty good job. We're reaching about 80% of the boys.
Dr. Keith Sutton, Psy.D: (50:01)
When I think the, the, the big piece too, at least when I am assessing an adult with ADHD, if my parents are alive, I always want to talk to their parents. Cause those childhood symptoms are such the biggest differential of whether it's not ADHD. Cause clearly things can, can, can score in a positive range on a questionnaire for ADHD symptoms, although not necessarily be due to that. So that kind of establish, and like you're saying in the past, when some of these adults were children, there wasn't as much kinda good, um, you know, services or awareness or so on or parents about bringing them in and getting, getting assessment.
Russell Barkley, Ph.D.: (50:35)
Yeah. No, that's, that's very true. It's very true. So I don't think we need to worry so much about the DSM for kids, but we do have worry about it for adults because the bar is set just a little too high. I recommend clinicians do two things. Use four on each list as you're cutoff and ignore the content in the parentheses. The parenthetical clarifications were never tested, never evaluated as good symptoms. My daughter-in-law Laura analysis, a psychologist, she and I just finished a study. That's coming out next month showing that the clarifications barely correlate with the items they're supposed to clarify. Right? Some of them are more related to anxiety mm-hmm . Um, but what they've done is to create eight or nine additional symptoms by putting those clarifications in there and then they didn't readjust the threshold mm-hmm so it's easier to qualify for a diagnosis of ADHD now because you've got all those clarifications that can count as symptoms, even if the original symptom isn't endorsed. So, you know, watch it, we show that you can almost double the rate of adult ADHD, particularly for the inattentive presentation. If you start counting the parentheses the clarification. So I'm telling people to ignore those until we learn more about 'em because I, I think they're bad news. Yeah,
Dr. Keith Sutton, Psy.D: (51:53)
Definitely. Well, Hey, thank you so much for this conversation today. It's always Keith, my pleasure taking, hear what you're doing and um, yeah, I I've got your book and it looks really great. The recent one on the principles the raising child with ADHD, um, keep up all the great work and thanks for taking the time to speak with me today.
Russell Barkley, Ph.D.: (52:13)
Thanks. I'm still going. So hopefully got a few more years left in me before I finally pull out of this. But thanks again. It's been an honor to be in your program. I appreciate it.
Dr. Keith Sutton, Psy.D: (52:22)
Great. Thank you. Well, take care. Appreciate it.
Russell Barkley, Ph.D.: (52:26)
Yeah, you be well, bye.
Dr. Keith Sutton, Psy.D: (52:28)
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