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Stephen Hinshaw, Ph.D. - Guest
Dr. Hinshaw is known for his work in developmental psychopathology, clinical interventions with children and adolescents, and mental illness stigma. He is currently a Professor of Psychology at the University of California, Berkley and the University of California, San Francisco. Dr. Hinshaw has authored over 370 articles and chapters as well as 12 books, including, Another Kind of Madness: A Journey through the Stigma and Hope of Mental Illness , The Triple Bind: Saving our Teenage Girls from Today’s Pressures with R. Scheffler, and The ADHD Explosion: Myths, Medications, Money, and Today’s Push for Performance. Dr. Hinshaw’s research efforts have been recognized by many awards including the James McKeen Cattell Award from the Association for Psychological Science (2016) which is the highest award to honor a lifetime of outstanding contributions to applied psychological research. |
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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 therapist 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 talking with Steven Hinshaw, PhD who is known for his work in developmental psychopathology clinical interventions with children, adolescents, and his work in mental illness stigma. He's currently a professor of psychology at the University of California, Berkeley and the University of California, San Francisco. Steve has authored over 370 articles in chapters, as well as 12 books, including: A Another Kind of Madness, A Journey Through The Stigma, and Hope of mental illness, The triple bind saving Our Teenage Girls from Today's Pressures and the ADHD explosion myths, medications money, and today's push for performance. Steve's research efforts have been recognized by many awards, including the James McKeen Catel award from the Association of Psychological Science, which is the highest award to honor a lifetime of outstanding contributions to applied psychological research. Let's listen to the interview. So welcome Steve.
Dr. Steven Hinshaw, PhD: (01:32)
Nice to see you again, Keith.
Dr. Keith Sutton, Psy.D: (01:34)
Yeah. Good to see you. So, gosh, I forget how we originally got connected. I know I was having those dinners at my home, some time ago or, or I'd have psychiatrists and researchers and authors and therapists and educational therapists who all worked with folks with ADHD come to my house and we kind of talk about what's going on in the field. And then I've gotten to see you teach at Berkeley, you know, some of your courses and you've come into a talk for the Association of Family Therapists in Northern California. Right, so, I just really love your work and I wanted to invite you on and, you know, hear, your story and about your work and what you're working on now. But yeah, let's first start off and find out a little bit about your, you know, how'd you get to doing what you're doing.
Dr. Steven Hinshaw, PhD: (02:20)
Well, how I got to do what I'm doing is part of the meta story about where I think this conversation will go. I grew up in the Midwest Columbus, Ohio. My dad was a philosophy professor. My mom was a lecturer in English, my little sister, and I had this kind of idyllic life. We lived across the river from Ohio state. We'd go to Ohio stadium and watch the might Buckeyes play. And faculty were over for dinner and play reading group, but dad would disappear. I mean, literally for three months, six months, or at one point I was in third grade a year at a time as though abducted by aliens, he was gone. I knew from the look I'm on mom’s face, I couldn't ask. There was no letters, no phone calls, no postcards. And then months later, or again, at one point a year later, one morning I'd wake up and dad was cooking breakfast, but I knew I couldn't really ask where he'd been because it might jinx, whatever had happened and he go away again.
Dr. Steven Hinshaw, PhD: (03:20)
And, and when he was back, he was super warm, very calm philosopher helped me with stuff I was dealing with. And I had no idea what this was all about until I went away to college back east, came back home for my first spring break, and dad pulled me into his home study and said, son, perhaps this time you learned a bit about my life. So in that 40 minute, first talk, we had the first of many for the next 25 years as long as he lived, I learned that he'd been diagnosed with schizophrenia when he was 16. And he had jumped off the roof of the family home in Pasadena, California, thinking he had sprout wings. So he could save the free world from Hitler and Mussolini and ended up in a back ward of a county hospital, given up for dead thinking the Nazis had poisoned the food supply. He went from 180 to 117 pounds was basically given up for dead. And then miraculously recovered went back the finished a senior year at Pasadena high, but the family didn't talk about it cause they didn't want to spoil or jinx his recovery. He went on grad school in philosophy during world war II. He couldn't go overseas cuz he was four F he'd been in a “loony bin”, which is what they called them back then for six months when he was a teenager, he studied in grad school with Albert Einstein and Bertrand Russell. He was a very brilliant philosopher. And he thought at the, in the mid forties, he could predict the end of world war II via telepathy, clearly he was becoming psychotic again. When he was shipped over to Philadelphia state hospital by Barry, as it was known where he still in another six month basically chained sometimes to his bed, beaten by staff and inmates.
Dr. Steven Hinshaw, PhD: (05:09)
His brother went to visit him from Washington DC every Sunday, cuz he feared that my dad hadn't had enough company on his Southern California hospitalization got a day pass for dad, once and took him out to get a meal, first meal, outside this massive institution. And my dad shouted him in German and in English saying I'm being held at a concentration camp in German, take me back. The guards will shoot us. You're a collaborator. And my uncle, decades later when I got to know him, when I was in grad school in Southern California said, boy, I guess with schizophrenia, you had delusions that are, you know, it didn't make any sense to me. So when I started the second sort of phase of my career, really studying the stigma against neurodevelopmental disorders and all forms of mental illness started to write about this.
Dr. Steven Hinshaw, PhD: (05:59)
I found some books on mental hospitals in America, including a photo essay of by Barry State Hospital, the year that my dad was there and the year after. And the photographs showed triple bunk beds in a windowless room that looked just like the liberation of the camps that they a cow book involved and conscientious objectors at the hospital who smuggled out photographs showed the shallow graves and the beatings and starvations. So at some metaphorical level, the closest thing we had in the United States to concentration camps were the big state pit state hospitals of the day. So once my dad came out of the closet, to me, I changed my major to psychology, wanted to get my dad diagnosed. Right, right. I didn't think he had schizophrenia, I thought he had something called manic depression.
Dr. Keith Sutton, Psy.D: (06:49)
Yeah.
Dr. Steven Hinshaw, PhD: (06:50)
And both I had a mission in life, but I was also terrified cuz I didn't tell a soul. Roommates, other family members, girlfriends, not, professors, I wouldn't be fit to be a clinical psychologist, with a crazy father. So after years of getting dad diagnosed correctly and got lithium and finally opening up myself, I've had this wonderful career in Developmental Psychopathology and Child and Developmental psychology study causes of and treatments for child disorders, but also really taking on the more open I got. Why do we still blame people in families for mental illness? Why is it, why do we know so much more about mental illness than in the fifties and sixties? But our attitudes are absolutely frozen. Many social issues have seen great change in attitudes, not mental illness. So I've had this dual career in Child Adolescent Clinical Psychology and the stigmatization of mental illness really spurred by my dad's and many other family members experiences with pretty serious mental illness.
Dr. Keith Sutton, Psy.D: (07:53)
Yeah. And you talk about this in the, your book the, Another Kind of Madness.
Dr. Steven Hinshaw, PhD (7:58) : Yes.
Dr. Keith Sutton, Psy.D ( 7:79): And, and I think this is such a huge piece. And even I actually was just watching the Oprah and, Prince Harry apple special today about again, trying to break down stigma because there's so much stigma around mental health and about feeling like, oh, I don't wanna share that. Or if people knew that they would think I was bad or broken or like you're even saying. You're in a graduate school at this high level of achievement and still, you know, feeling, Ugh, somebody needs.
Dr. Steven Hinshaw, PhD :(08:26)
Better not talk about it. Right? I mean, isn't it a sign of strength to get your card tuned up or to go to your periodic doctor's visit or your pediatric visit. But it's a sign of weakness to admit you've got a mental or moral flaw. There's something wrong with you, wrong with your family. Even the thought that really took over the National Institute of Mental Health in the eighties and nineties, if we can just call mental illness, a brain disease, a disease like any other. Well you attribute it to something that the person couldn't control. It's a medical illness. Well the stigma should go away. Right? Well not so fast.
Dr. Keith Sutton, Psy.D: (09:05)
Not so much.
Dr. Steven Hinshaw, PhD: (09:05)
We hold the person less blame worth, but we think the person is hopeless and probably violent, when it comes the behavior that defies social norms, it's not the bad old days of the schizophrenogenic mother or the refrigerator parents or the more recent genetic days that it's all in flawed genes. It's a combination of vulnerability, life choices, culture, experience just in the way that heart disease or cancers are not fully genetic and not fully experiential. They're a complex combination of both. And I'll just say one more thing. Cancer. So in a passage late in another kind of madness, I, I kind of raise a point for the reader. What would we say today about an oncologist who told a parent as my father was told in the fifties and my mother, if your children ever learn of your mental ill illness and hospitalizations, they'll be permanently destroyed.
Dr. Steven Hinshaw, PhD: (10:08)
You're never allowed to talk. The doctor's orders were silence. So what if a, an oncologist today told the mom or dad, if your children ever learn about your cancer, they'll be permanently destroyed. It's verboten. Well, cancer back in the thirties, forties, fifties, and even sixties in the last century was so stigmatized that if you're a grandpa or your great aunt died of cancer in the obituary, you always put died of an unknown illness, died of natural causes. Everybody knew that cancer was a psychosomatic illness that you brought upon yourself because you was fundamentally lost a will to live.
Dr. Keith Sutton, Psy.D: (10:44)
I didn't know that.
Dr. Steven Hinshaw, PhD: (10:45)
And now today, breast cancer's a cause for women, prostate cancer’s a cause for guys, we wanna find a cure we support. And the irony is that mental illness is now an some ways the cancer of a century ago. We still don't really believe it's an illness. We still don't really well, we do believe well, is it animal spirits? Or you just have a weak, moral character, but you're weird and you might be contagious and we wanna keep our distance. We got a long way to go, Keith.
Dr. Keith Sutton, Psy.D: (11:16)
Yeah, definitely. Well, you know, I wonder, go to the earlier work that you did. And particularly, I mean, I think, and tell me, I actually don't know all the history that did you start out in your research with ADHD or how did you get there? I mean, I know the MTA study, that's kind of my beginning of the story that I have for you.
Dr. Steven Hinshaw, PhD: (11:36)
So in college I went up to Northern New England, New Hampshire and worked at summer camps and I came to direct a summer camp, a residential camp for kids with autism spectrum disorders and serious emotional disturbance and learned a lot about close observation and working with families to get their kids back home. And spent three years doing that ran a day school for kids in, in Massachusetts. Massachusetts had the first state legislation that mandated a free and appropriate education to everybody, regardless of specialties. It was a forerunner of the federal, what now we call IBEA. And went to grad school thinking I would learn a lot more about outpatient residential treatment and about kids with neurodevelopmental disorders and probably go off now with an advanced degree doing studies in those settings. But what I realized was there's a whole world out there of genes and family therapy and clinical trials and dissemination studies, which were kind of new and still growing at the time.
Dr. Steven Hinshaw, PhD: (12:39)
And I just got a hunger to learn. It turned out that by pure luck, one of the professors at UCLA was studying what was then called hypokinesis in boys. And ran day, summer camps, and I'd run camps before to see if the setting, the kind of classroom activities, the kind of playground activities, the demands on a kid would change both the kid's behaviors and how medications might affect those behavioral changes. So I got immersed in such research, did my dissertation on treatments and came away with sort of a track record of ADHD. Both clinical studies and longitudinal studies and even a little bit of EPI. And when, as an assistant professor up at Berkeley, this call came out well over 30 years ago now to apply for a major study to look at kids with of course. What was then called by then, ADHD, boys and girls, to see if regular community care, a very intensive family and school behavioral therapy program really well delivered stimulant medications, or a combination of both would provide optimal outcomes.
Dr. Steven Hinshaw, PhD: (13:51)
So I didn't think I would get the grant. I was the youngest investigator, but I had done that dissertation, back in grad school, on treatment which everybody told me not to do. Why are you gonna do it treatment? It'll never work. And so sometimes being stubborn and doing what you really want to do is a good thing. So I had a track record and I became part of this big multicenter study with about 600 kids across the country. Wow. 300 comparison kids without ADHD, finding that in the short run medications really help the behaviors. The combined treatment really helps the academics and the social skills and the parenting, but we still don't have the magic bullets, I don't think there is any bullets, to keep the kids as they turn into teenagers and young adults on the right track. And this got me thinking a lot more about doing lifespan longitudinal research. We'd always have girls apply to our summer camp programs. Never enough to really get a sufficient sample size. So I, 1995 wrote a grant to the national Institute of Mental Health and said, I think girls really can and do have ADHD, we want to do the largest study of this sample. And we started.
Dr. Keith Sutton, Psy.D: (15:03)
Oh, well now before we get into the, the B girls study, right. Is that nickname?
Dr. Steven Hinshaw, PhD: (15:08)
B Gals.
Dr. Keith Sutton, Psy.D: (15:09)
That's it? The MTA, I mean, one of the things that really struck me from the MTA and this was actually, in workshop from barley that in talking about it is that. You know, that, that there was so much cream and given, I think there was, a one-on-one eight in the classroom. There was meetings with the teachers, and the parents, and the therapist. There was like family counseling, individual counseling.
Dr. Steven Hinshaw, PhD: (15:29)
35 sessions of being behavioral parent management. Exactly.
Dr. Keith Sutton, Psy.D: (15:32)
Yeah, there was a, there was a summer, intensive summer camp, like hours a day, like more treatment that you could ever put together in yourself. And that, you know, despite all that, the medication was still the most significant aspect of the ADHD symptoms themselves.
Dr. Steven Hinshaw, PhD: (15:50)
If the symptoms, the symptoms themselves.
Dr. Keith Sutton, Psy.D: (15:51)
And then all, and then the therapy really helped with the relationships with the family, with anxiety, with social, with all these other kind of aspects. And so that, you know, oftentimes when I'm talking to families about this, that yes, medication is so important. And that's, you know, and something to look at and we work through feelings around that in combination with the therapy and really that work because it's, you know, the way I think about it is, you know, kids with ADHD, it's, you know, that they, they, they, they know what they need to do, but they have such a hard time putting into action. Really, I wanna help them get through their childhood without a great deal of shame because there's so much frustration cuz they know I should be able to do this, but then that's right. Screw it up and, and feel bad. And what's wrong with me and get angry and oppositional at times or depressed or anxious. Yeah.
Dr. Steven Hinshaw, PhD: (16:42)
So if you do twin and adoption studies and review the many that have been done with ADHD, certainly any behavior that you or I, or exhibit is all a part of our gene and all a part of our experiences we learned in high school biology. The phenotype is the genotype is expressed by experience. But if we're looking at me very unfocused, and you super focused there's differences, right?
Dr. Keith Sutton, Psy.D: (17:07)
Yeah.
Dr. Steven Hinshaw, PhD: (17:08)
The differences between people in their ADHD is 80% because of genes, not environments. It's higher than the genetic relatedness or what we call heritability for schizophrenia. It's up there with bipolar disorder and autism spectrum. So the stereotype is meds are the only things that work maybe someday we'll know the many genes that contribute do gene therapy. I think that's hundreds to years off if ever.
Dr. Steven Hinshaw, PhD: (17:37)
But the medications, which if you get the right dose and the right kind of formulation and it takes a lot of work, can really pretty quickly suppress those impulsive symptoms and help the kid focus better. That's great, but those symptoms remit to baseline the day you stop taking the medication and as the old adage, no skills just with pills. The medicine gets your body and brain in the right attunement to learn, but you've gotta learn behavioral control and emotion, regulation and academics and social skills. And that's where the intensive behavior therapy, the family counseling, the coordination between parents and school, the summer program was to really do some intensive academic behavioral remediation. If you want to go holistic, if you want to improve academics, social skills, get parents in a much more positive and consistent frame of parenting. The medicines alone just don't do that. So the combinations are best guess, but as we've learned from further follow up ADHD, doesn't go away at 13. The way I learned in grad school, it doesn't go away at 33 or 53 or 83 either. So we've gotta look lifespan in long term.
Dr. Keith Sutton, Psy.D: (19:01)
Well into that fact too, again, with the high readability that oftentimes when you have a kid with ADHD, you have a parent with ADHD. Absolutely. And if you're doing all these behavioral intervention, creating structure, being organized and so on can be difficult. That's why, yeah. I really am, always interested in working with the family kind of helping the, I think this takes us to the next subject of, particularly of your book, the ADHD explosion. Is, you know, around all the kind of variability in diagnosis rates and you looked at different, you know, states and on, and, and kind of rates of, of diagnosis. And you know, I think that that is oftentimes a concern of folks, of concern, of overdiagnosis concerns of under diagnosis, concerns of a, 15 minute pediatrician appointment and then being prescribed medication for, you know, an eight year old or so on or.
Dr. Steven Hinshaw, PhD: (19:49)
Or a four year old, right.
Dr. Keith Sutton, Psy.D: (19:51)
Four year old. Yeah.
Dr. Steven Hinshaw, PhD: (19:52)
So I have a lot to say about this. ADHD is a lot like depression, and bipolar disorde,r and schizophrenia, and autism spectrum. We don't have a brain scan or a blood test that can definitively tell us you got it or you don't the way you can with cancer. Et cetera, et cetera. Does that mean as some critics say, well, the mental illnesses don't exist. No, it's just, we don't have enough knowledge. And the brain is hugely complex. If you have chronic schizophrenia, you can do an MRI and see literally some holes in the brain, the cortex is eroding, but for most functional cases of depression, ADHD, schizophrenia, autism. Yes, there's some hints that there's some brain pathways and subtleties that are a skew, but we don't know A, if that's the full story and B if it's a pure genetic anomaly or it's early experiences interacting with such genetic vulnerability.
Dr. Steven Hinshaw, PhD: (20:54)
So what do we do? We know, and the American Academy Pediatrics, the American Academy of Child Adolescent Psychiatry have published 20 years ago, 10 years ago, recently guideline to say, we can't do a good job of diagnosing ADHD, 10 or 12 minutes in a pediatrician's office. We're gonna need to get a really good developmental history from the parents. We're gonna need a medical exam. Some forms of absent seizures, look a lot like the inattentive form of ADHD, hypothyroidism. And there's a lot of medical rule outs. We're gonna need to get good rating scales from parents and teachers so we can compare those to national norms. We might need to do some testing. Now, one on one computerized tests of attention are not the gold standard for ADHD because some kids with really bad ADHD can focus pretty well. For 20 minutes, one on one in front of a computer screen, some perfectly neurotypical kids may have problems.
Dr. Steven Hinshaw, PhD: (21:57)
We put all this information together and we get our best estimate. This is gonna take a couple of hours minimum. The problem is many general practitioners are not trained in this . And even if they are, you don't get reimbursed for it. So that's number one. Number two, some of our colleagues around the world have been doing large scale epidemiologic studies in every continent except Antarctica, which doesn't have enough people permanently living there. What's the prevalence of ADHD in kids and teenagers around the world. Amazingly, it's about five to 6% everywhere. Very few exceptions. Now within Germany or Australia or China, different regions have very different rates because of the quality of practice. But the worldwide rate is sufficiently similar. It makes you think there's a certain percentage of kids. Who've got this genotype that makes it harder for them to focus, especially when they have to sit in schools, which only happened in the last couple hundred years of human history.
Dr. Steven Hinshaw, PhD: (23:11)
So what do we do with all of this? We know that genes matter. We know that some district, some state, some regions are really concerned about school achievement. So Richard Scheffler, the great health account anonymous and public health professor at UC Berkeley. And I teamed up in this big book on ADHD to try to figure out why do North Carolina, Arkansas, Indiana have three times as many kids diagnosed with ADHD as California, Nevada. And that's the truth. This isn't just a, you know, it's not a fraction of a percent, is it that there's more Hispanic kids out west and more black kids in the south? You put that in the equation. It answers only a tiny fraction of this difference. Well, is it now it in cancer, I'm being a little detailed here. You can measure the number of cancer doctors in an area, and that's pretty correlated with a number of cancer patients in an area mm-hmm cause the doctors go to cancer clusters and patients move to where the doctors are.
Dr. Steven Hinshaw, PhD: (24:17)
We found a zero association between the number of pediatricians or Child Adolescent Psychiatrists, county by county across the U.S and the rates of ADHD diagnosis. So when Professor Sheffler first met me almost 20 years ago, he was giving a talk. And I'd said that the cause of ADHD, tongue and cheek is compulsory education. Well it isn't really, but it it's the factor that unleashes it, right? It puts these kids in the crucible attention is of a premium and as a health economist, he said, I think of ADHD as a condition of productivity and performance. So I'm guessing that in those regions that really put a premium on test scores, we're gonna find higher rates of a ADHD diagnosis. So we did a lot of detective work. We found, don't bore you to tears with it.
Dr. Steven Hinshaw, PhD: (25:15)
But many states have instituted a policy called consequential accountability. You know, what on earth does that mean? It means state by state and the seventies, eighties, nineties, you, your public school district is only gonna get funded. And we're not gonna write you up in the paper or put you in receivership the way California did with the Oakland district some years ago. If your test scores are either going up or they've met this threshold, you're good. But if not, there's consequences. So there's consequences for the accountability of the kids, reading and math and science course, right? A bunch of states pass such a legislation. And then little known is the fact that when no child left behind became federal law, George Bush two's first major piece of domestic legislation in 2002, it made consequential account the law, the land for the remaining 21 states.
Dr. Steven Hinshaw, PhD: (26:12)
So this is what a scientist licks his or her job. We got a natural experiment. Mm-hmm we didn't randomly assign states to these laws. That would be interesting to do if you could do it. But we saw 30 states that did this and about 20 that did it all at once later, the states that suddenly got consequential accountability in their early two thousands, the poorest kids in those states, the ones closest to the federal poverty level within two years had a 60% greater chance of being diagnosed with ADHD compared to kids in the states that had already passed those laws or kids in private schools in the same states.
Dr. Keith Sutton, Psy.D: (26:52)
Cause if they didn't have a diagnosis, they would, they would then get counted against the funding.
Dr. Steven Hinshaw, PhD: (26:57)
Exactly. And it's so part of it is that superintendent says, we've gotta get the kids test scores up, let's get 'em diagnosed and treated for gosh sake. However, until this became illegal in 2011, there was another clause. If your kid gets diagnosed with ADHD, well, that's a special ed kid. Guess what? Next spring? And the standardized test scores, we throw those kids scores out of the equation.
Dr. Keith Sutton, Psy.D: (27:23)
Yeah, they don't count.
Dr. Steven Hinshaw, PhD: (27:24)
They don't count. So it was gaming the system to get test scores up. So ADHD is very biological. It has a lot to do with family interactions and it has a lot to do with school policy. It's not either or, it's all of these thrown together in this complicated mixture.
Dr. Keith Sutton, Psy.D: (27:40)
Yeah. And I think, you know, the way I've thought about it, two is it, from what I had learned that, you know, the, the original diagnosis of six out of nine symptoms place the kids at the 93rd percentile. Right. So essentially one and a half standard deviations above the mean, which would mean then the population is about 7%.
Dr. Steven Hinshaw, PhD: (27:58)
If it's normally distributed, which is, should be six, 7%. That's right.
Dr. Keith Sutton, Psy.D: (28:02)
Oh yeah. And then it, what ends up happening is that. Some kids are overdiagnosed. And particularly to the frontal lobe it's the first thing to go and kids are depressed or anxious. Trauma didn't get enough sleep or so on. But then on the other hand, there's a lot of concern about diagnosis and then not as much training as like, as you were saying, and you get underdiagnosed, that's why you get a lot of, of adults coming in.
Dr. Steven Hinshaw, PhD: (28:25)
Absolutely.
Dr. Keith Sutton, Psy.D: (28:26)
We, you know, for the way we do it through our center for ADHD, we contact the parents of those adults. I've had parents I've talked to in their eighties of an adult, you know, in their, in their forties. And particularly that, you know, that, that those childhood symptoms are the biggest differential. Cuz like you're saying, even with the computerized test, somebody may be positive for ADHD, but then you have to go back to your clinical interview, is that due to depression, anxiety, you know, all these kind of things. And is there's that childhood history.
Dr. Steven Hinshaw, PhD: (28:56)
There's a lot of rule outs and there's a lot of in the fancy lingo, comorbidity. You can have ADHD and be depressed Yep. Or have an autism spectrum disorder or have bipolar disorder. And so it's not as simple as it seems, most kids in the world who have ADHD, not just the ones in clinics, but they're even under identified as of yet have more than one other disorder too. It means that we've got, I think we pay now pay now or later.
Dr. Steven Hinshaw, PhD: (29:30)
We do a solid assessment now or we'll pay later by missing the kids who could have used help or over diagnosing kids who really didn't need all of the medication of the special treatment. And the, the only solution is better education of healthcare professionals and reimbursing the legitimate cost of doing it. Right. And speaking of under diagnosis, another thing I learned in grad school, girls don't get ADHD.
Dr. Keith Sutton, Psy.D: (29:58)
Yeah.
Dr. Steven Hinshaw, PhD: (29:59)
They are depressed they have conduct is so they they're they're anxious. And certainly that can be true. Autism, Tourettes, many forms of learning disorder, early onset conduct disorder, ADHD. These are neurodevelopmental disorders. They occur in the first 10 years of life. Often they persist. All of them they're are more boys than girls. Autism, It's about five to one. Tourette's about five to one very severe early disorder, about seven to one. ADHD, It's about two and a half boys for every girl. But until clinicians started to recognize that girls really could have ADHD. It was about 10 to one. Cause if you were a girl, you'd get diagnosed with some cause you really couldn't have ADHD. So finally I think the practice is caught up with the truth that girls don't have ADHD as much as boys, a, b: they tend to have the more purely inattentive variation variant of ADHD.
Dr. Steven Hinshaw, PhD: (30:59)
Although girls can certainly be hyperactive and impulsive two and C, unless we diagnose carefully, maybe not exist insist on the running around a classroom, but being hyper verbal or impulsivity, more choosing A on every multiple choice answer rather than, uh, some of the boys impulsivity, which is much more behavioral. Girls with ADHD are at very high risk, as we've learned from some of our studies, which we can talk about in a moment for serious outcomes, like self harm, self injury, unplanned pregnancy, and we're doing girls and families intergenerationally and disservice unless we diagnose accurately and get treatment.
Dr. Keith Sutton, Psy.D: (31:43)
Yeah, definitely. And do you think that, I mean, that difference for girls, um, is, is that all due to kind of, you know, socialization, gender socialization, is there anything kind of, um, neurologically different about what leads to a different manifestation of ADHD?
Dr. Steven Hinshaw, PhD: (32:02)
Yeah, it's it, nobody's quite sure my belief is, although I don't have enough data to prove this. That in utero and in the perinatal period, right after, after birth for a while, and even in the infancy and toddlerhood boys' brains are more vulnerable than girls' brains to a whole host of insults from toxin to low birth weight, all kinds of insults that can happen. So boys in this first 10 year of life period, are likely to have ADHD and autism and these other conditions more than girls now in the second 10 years of life, girls shoot ahead with anxiety, depression, cutting eating disorders. So there's kind of a tale of two sexes here. But I think it's not girls for autism, ADHD have such different genes. It, I think there are similar genetic variations, but boys may actually be more vulnerable to a host of psychosocial problems, trauma problems, um, other biological insults early in life. That doesn't mean that girls can't have them. And in fact, when girls have these conditions, they can be quite serious.
Dr. Keith Sutton, Psy.D: (33:18)
Definitely. So talk a little bit about the, the be gal study and, and this kind of, you know, focus, and you know, as you're following the girls, through development.
Dr. Steven Hinshaw, PhD: (33:30)
So we got this big grant in 1995. NIMH believed us. We can do this study. Now we've got a recruit, a big sample of girls. Can we do it? And think back to 95 listeners, we had voicemails and we had fax machines. stuff like that. The first day we had I'd given talks in elementary schools, we'd gone to Kaiser and all the pediatric practices around put some ads in the Chronicle, in the Oakland tribute, the phone rang off the hook, the answer machine filled up. We got well over a thousand inquiries. Did a lot of careful screening teacher ratings, parent ratings, preliminary interviews. And then we ended up assessing the final participants for 10 hours. We, we took this really seriously. And got a sample of 140 girls with ADHD. About two thirds of them have what we call the combined presentation or type they're very inattentive.
Dr. Steven Hinshaw, PhD: (34:30)
And they're pretty sometimes ornery and impulsive and hyperactive too. And about a third were more purely inattentive. The more Spacey maybe more easily mistaken for anxiety or depression. And, and then a almost equal size number of girls with neurotypical development. They didn't have these same problems. Put them all together, summer camp one year and then another group in a summer camp. So, so we could study them, not just in a lab or a clinic, but as they were on the softball field and in reading class and all kinds of things. We learned a ton. We learned that girls with ADHD when they're in grade school have many of the same problems as boys. In fact, they are even less liked by other girls than boys with ADHD are disciplined by other boys. Cause for girls, relationships are everything. A guy can kind of be whatever Spacey or running rush through things.
Dr. Steven Hinshaw, PhD: (35:31)
And it's like, ah, he's all boy. So we, we only could get that first grant for five years at a time. That's the way the federal government works. So we had to publish a lot, show the government we're ready to do adolescent follow up. And then a late adolescent follow up when they were about 20. And then we did one when they were about 26. We're now involved in our fifth wave when they were in their thirties. And this is where things got interesting. First of all, how do you follow up a sample like this? Yeah, this is Northern California. Russ Barkley has followed his samples in Wisconsin for decades. Cause nobody ever leaves Milwaukee. very few do like my classmates in Columbus, Ohio 98% of them stayed. So we told each family back in the late nineties when they came to their summer camps that even though we couldn't guarantee it, we wanted them and their daughters to be in our study, the rest of their lines.
Dr. Steven Hinshaw, PhD: (36:29)
And in fact, after the summer camps, we could get calls to our project line, say, what is that lifetime study happening professor? Well, we get our grant. And so the families had the expectation. Yeah. The summer camps were free of charge. You treat families. Well you give back, we wrote reports on every participant . So we've had 93 to 95% of the participants back. 16 years later. So cuz if you do a, still have to come back, guess guess what's up with the half you haven't seen, right? Yeah. I it's not representative. So here's the short headline version. Girls with ADHD are a lot like boys with ADHD, they're reading and math problems continue whether or not they have a formal reading or math disorder. The inattention, the impulse, but girls, especially in math, their scores into their twenties in math are, shockingly low.
Dr. Steven Hinshaw, PhD: (37:28)
And of course math is the stereotyped field of study that girls aren't supposed to do well in and get anxious about. And more advanced math takes these executive and planning skills that a lot of, of kids with ADHD black. So that's number one. Number two, the girls didn't end up in juvenile hall or related facilities to the extended boys. Not shocking. Some of the girls had antisocial behavior. Number three, they didn't have as much substance abuse as the boys so maybe girls get kind of a hall pass. Number four, we started measuring in late adolescence and have continued things like cutting burning self-injury self harm NSSI. Nonsuicidal self-injury your intent isn't to end your life, but you're doing some just things to yourself to either relieve emotional pain or to temporarily escape the problems you're having. Yeah. Or to distract you a lot of theories about why this happens.
Dr. Steven Hinshaw, PhD: (38:32)
In fact, the girls with ADHD, especially if they had both impulsivity and inattention, when they were girls mm-hmm 51% were engaged in moderate to severe self injury at the age of 20. 50% now 15 to 20% of our comparison girls were too is what the national average is. This has become an epidemic parents of teenage girls out there know sadly and beyond cutting self-harming a quarter of the girls with this combined form of ADHD had attempted to end their lives by their twenties and about 6% or 7% of the comparisons. Again, that seems like a high rate, one outta 16, typically developing girls, but that's sadly the national average, the girls with inattention only were somewhere in between. So we believe that if you're a girl with ADHD, especially if you're impulsive and with the many studies we've done to see what tracks here, what happened between childhood and adolescence that mediates this low academic achievement, poor executive functions.
Dr. Steven Hinshaw, PhD: (39:54)
Intriguingly poor father daughter connections rather than poor mother daughter connections. There's something about a girl. Who's got the challenges of ADHD? If she doesn't have a dad, strongly standing beside her and behind her, that seems to be a pretty big predictor for us. And finally we have tracked over time, physical abuse, sexual abuse, and neglect. Our sample is professors, kids, and executive kids all the way down to public assistants. It's very ethnically homogeneous or heterogeneous. In terms of life experiences, the girls with ADHD when they were girls in teens who had been physically abuse, sexually abused and or neglected either alone or in combination, their suicide rate was 35% by the mid twenties. So the genes that predisposed to this disorganization and this impulsivity and inattention and poor self-regulation when there's been early trauma, you put one and 1,and 1 together it's biology and experience that predicts the really difficult outcomes. Finally, by the mid to late twenties, just under half of the girls with ADHD had had one or more unplanned pregnancies compared to our comparison group of neurotypicals. What happens if you have an unplanned pregnancy, do you terminate, do you deliver before time? Do you have enough support? We know, as you mentioned, apply a few minutes ago, given the genetics of ADHD, a parent, a biological parent who has a kid.
Dr. Steven Hinshaw, PhD: (41:42)
With ADHD has a 35 to 45% chance of having ADHD himself or herself, whether it's been diagnosed or not.
Dr. Steven Hinshaw, PhD: (41:51)
Kids with ADHD, I often say require some real, super parenting, but if you can't balance your checkbook too well, and you lose your temper at work and you've had a history of ADHD and all its ramifications, that kid is gonna challenge you in the ways they're kind of your so spot. So getting families assessed parents themselves for depression and ADHD and getting treatment for themselves is often a huge step to helping remediate their daughter's course.
Dr. Keith Sutton, Psy.D: (42:20)
Definitely now I, and I kinda remember, from a talk, I think I was at, that you did at Chad, for the conference was around that the, the girls had also started cutting earlier or the non, the self-harming. Yes. and then also I think, was there also eating disorders, particularly I think bulimia.
Dr. Steven Hinshaw, PhD: (42:44)
Very interesting in the teen years, our sample with ADHD didn't have pronounced rates of anorexia interval. So there were some, but some of our comparisons did, but the impulsive binge eating the bulimic symptoms appeared faster and stronger than in our comparison group. But if you go out over time, I'm making a graph over time in front of my eyes here, a number of our comparison girls had developed these same disorder symptom. So it ended up not being a significant difference by their twenties. Yeah. We're not saying that girls don't have that risk if they've got ADHD, but it was the self injury, unplanned pregnancy. And even though most of our girls with ADHD graduated high school, as the parents will tell you, carrying their daughters on the, their back, over the postsecondary education, the multiple community colleges with one or two credits and lots of grades of Fs and the job firings and the tardiness at work and unemployment. These girls know that they're women, too many of them are really personally and sort of vocationally, they have challenges they've not been prepared to deal.
Dr. Keith Sutton, Psy.D: (44:02)
Yeah. And oftentimes too, for many women, especially in heterosexual relationships, when they have families or kids of their own, oftentimes a lot of the demand falls on their shoulders. That's right. Able to deal with all the emails from the schools and the kids.
Dr. Steven Hinshaw, PhD: (44:16)
Oh, absolutely.
Dr. Keith Sutton, Psy.D: (44:17)
Like that, which oftentimes, and kind of more those yeah. Heteronormative kinda stereotypical well.
Dr. Steven Hinshaw, PhD: (44:23)
And, just think of the pandemic recently. How does any parent teach their young kids? I think Keith you've had some personal. On zoom and, and what if your kid has ADHD and what if you're trying to hold down a job remotely or in person, and you've got ADHD yourself, this is not a happy ticket.
Dr. Keith Sutton, Psy.D: (44:43)
Yeah. And I mean, I think too, we were talking about this earlier for our center. We've got the, the referrals have just skyrocketed, you know, and, and, and particularly, you know, I found this also in some of the couples therapy I was doing, not even related to ADHD as the kids were home, the parents started realizing and, and the parents were describing it. I was saying, huh, like, has this been going? I'm like, oh yeah, the teacher's been talking about this for years.
Dr. Steven Hinshaw, PhD: (45:05)
That's right now we see it.
Dr. Keith Sutton, Psy.D: (45:06)
Then we actually started doing the ADHD evaluation. And it did that there, that kid actually did have ADHD. And we were able to diagnose and figure out what was going on. But you know, these kind of situations, which the pandemic has just totally brought this. I mean, and it's also a lot of folks confused cuz they're, the kids are having such a hard time focusing and paying attention and readjusting back to school that the parents are wondering is this ADHD but then when we look at the history pre pandemic, that those symptoms weren't necessarily there. But you know, again, the frontal lobe is the first thing to go. So, you know, attention, concentration, focus, you know, all of that is out the window when things aren't going, right. It's been a big, big question for people and big concern. So, you know, tell me a little bit about what you're working on now. I mean, what's what what's your area of interest is. I know that the, the latest thing that I knew that you were working on was around this work around stigma. Yeah.
Dr. Steven Hinshaw, PhD: (46:06)
So, you've known me a while. I've known you. I, I don't do one thing very well. I like to different things, and of course you don't want to be a dilatant and have the doll crashing down. But so our girls and our boys and girls in the MTA have grown up, so I've gotten much more into adult forms of ADHD and what that means. And we'd like to get funding to look at the, especially the B gals who are parents themselves and help us any generational stuff. We've been doing other studies of adults with ADHD in the community, slowed down by the pandemic, looking at EEG signals and looking at ways for them to develop their own focusing skills. Maybe not as opposed to medication, but in addition to yeah.
Dr. Keith Sutton, Psy.D: (46:54)
Do you mean neurofeedback?
Dr. Steven Hinshaw, PhD: (46:56)
So not so much neurofeedback, but with a collaboration I've been developing now cuz neurofeedback hasn't really done as well as it should against the proper controls of sort of fake neurofeedback. But other means of self-regulation. So next show I'll talk about that more so.
Dr. Steven Hinshaw, PhD: (47:16)
But as you just noted, I've been really interested in both the history of the cross-cultural differences in the shameful amounts of, and what we can do about it. Issue of the stigma of neurodevelopmental conditions like ADHD and autism, mental disorders like bipolar disorder, depression, schizophrenia, PTSD, anxiety, you name it. And so I've written, you mentioned another kind of madness, a journey through the and hope of mental illness was my attempt to really give our family story, to put and you know, stories better than statistics to sort of change people's minds and hearts. And we gotta do a lot more of that, but I've been really interested in why we know more as a society factually about mental illness, but sometimes know more actually increases stigma, especially in high school students. So I've really been interested in the development of kids with disorders in high school, but just typical kids in high school.
Dr. Steven Hinshaw, PhD: (48:23)
This is when attitudes consolidate. This is when prejudices and stigma really, you know, have sticking power. So colleagues in other parts of the country have pride curricula where you take over a health class in a high school for a semester and you have the schizophrenia module and the bipolar module and the ADHD module and the autism module. And boy, by the end of the term, the kids ACE their test, they know symptoms. And they're more fearful of and want to keep greater distance from all of those conditions. Cause you've learned, wait a minute. Some people with major depression are so depressed. They want to end their lives. Well, that's the most selfish thing I've ever heard people with schizophrenia hear voices. That's the last thing I wanna do. People, the ADHD can't focus. It fact are fine. We want to have a literate society.
Dr. Steven Hinshaw, PhD: (49:15)
But when the facts reinforce the very stereotypes that are the basis of stigma, the kind of education, and this is what we're doing in many high schools throughout the country now with sort of stigma reduction groups. Is focusing on speaker series. People with lived experience of mental illness coming in mindfulness, meditation apps. Self-disclosure lobbying the school administration that if a kid in that school ends his or her life by a suicide, we can maybe have an assembly. We can't keep this under the road. We don't want to glorify things. The kids through bring change to mind a nonprofit right here in the bay area, founded by Glen close 11 years ago now. And I'm the scientific advisor helped bring this curriculum to them. But the point is, it's not a curriculum where day one week one and week two, you learn lessons. The kids design their own anti-stigma programs. Based on this platform of videos and resources, because if they're not motivated to get this information spun in their own ways, it'll just be like book learning and maybe learning the wrong facts.
Dr. Steven Hinshaw, PhD: (50:31)
And colleagues of mine in other places in Canada and, down in Southern California are starting this now, even in grade school and middle school. In the way that non-binary gender and sexual minorities status, isn't something you just learn about by, you know, Willie nilly and high school on your own. So the idea is let's confront the fact that mental illness is pretty darn prevalent. Can be very impairing, but it's not them. It's not this strange, weird group of people out there it's you it's me. It's our family members. It's our best friends. It's the people. And we all lose if we keep these barriers up. So I'm very interested in whether over the next 10 years, the high school kids in the middle school, kids who go through these programs might become the adults of the future and start to say, stigma's an old person's term. We don't believe in that anymore.
Dr. Keith Sutton, Psy.D: (51:31)
Yeah. Oh, that would be great. Yeah. Yeah. I think that, you know, it sounds great though, the work that you're doing and I know I actually have a lot of, we have, folks that, that volunteer as non-clinical interns for us. And a lot of the folks that have come to us actually, and a theme that I'm seeing a lot in these undergraduate students is wanting to also work against, stigma in, minority populations.
Dr. Steven Hinshaw, PhD: (51:54)
Absolutely.
Dr. Keith Sutton, Psy.D: (51:54)
In many of the populations that they grew up in because there there's, even more stigma in, in some of their cultures. And so that aspect of kinda bringing, you know, addressing stigma from a multicultural perspective,
Dr. Steven Hinshaw, PhD: (52:08)
It it's huge. Keith. I mean, people say, well, you know, if you, you go to a, a non-Western society, you, you go to east, if you will, um, all the way to Asia. Well, those are collective of societies. They don't have stigma. Well in India with dowry systems, if the girls or woman's space, family has mental illness, they're unacceptable. They're untouchable the suicide rate in Japan, especially among business men is incredible and women. Those more business men and women in Japan. The pressures are so strong. So stigma is expressed differently in different cultures, but it knows no cultural balance stigma's high in every culture we've ever studied.
Dr. Keith Sutton, Psy.D: (52:49)
Definitely. Well, Hey Steve, thank you so much for taking the time today. This is always great. And it's great to hear about your work and I'm always wanting to, to get it out there. And I am so appreciative of the work you're doing on stigma, because we can know all these great things and, you know, important facts about, you know, diagnoses and treatment and so on. But if people are scared to you identify the right treatment, then its no good.
Dr. Steven Hinshaw, PhD: (53:15)
And, and I'm gonna say two things. I always have to end my little lecture here. So big study done the national comorbidity study years ago, still very valid the average time. And this is not with the clinical samples, just a representative sample of thousands of adults across the country between understanding that you maybe you've got some symptoms and, and getting assessed and treated the average in America's 10 years. That's a decade of lost time.
Dr. Keith Sutton, Psy.D: (53:43)
Yeah.
Dr. Steven Hinshaw, PhD: (53:44)
So that's number one. Number two, man how are we gonna fight stigma? Public campaigns enforce the Americans with disabilities act, make sure parody happens. People speaking out their stories, but right up there is making sure people get evidence based treatment.
Dr. Keith Sutton, Psy.D: (54:04)
Yeah.
Dr. Steven Hinshaw, PhD: (54:04)
What really change the tide, if you will, on the stigma against HIV, the antiretrovirals and the new waves of treatments that make HIV a lifelong livable with, but not fatal illness. And once we can get better treatments and more people have access to them, that's the other side of the coin. Yes, we have to have more tolerant attitudes, but we need treatments to,
Dr. Keith Sutton, Psy.D: (54:26)
And more people trained in those treatments.
Dr. Steven Hinshaw, PhD: (54:28)
More people trained in this dissemination you and I develop a great treatment. It's gonna take us 20 years to get it out to market.
Dr. Keith Sutton, Psy.D: (54:35)
Yeah. Yeah, definitely. Well, thank you so much. I really appreciate your time today. And this is really important work. It's always a pleasure talking with you.
Dr. Steven Hinshaw, PhD: (54:44)
Well, thanks for your great questions and all the work you do. Keith.
Dr. Keith Sutton, Psy.D: (54:47)
Take care. Bye-bye
Dr. Keith Sutton, Psy.D: (54:49)
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Welcome to therapy on the cutting edge, a podcast for therapist 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 talking with Steven Hinshaw, PhD who is known for his work in developmental psychopathology clinical interventions with children, adolescents, and his work in mental illness stigma. He's currently a professor of psychology at the University of California, Berkeley and the University of California, San Francisco. Steve has authored over 370 articles in chapters, as well as 12 books, including: A Another Kind of Madness, A Journey Through The Stigma, and Hope of mental illness, The triple bind saving Our Teenage Girls from Today's Pressures and the ADHD explosion myths, medications money, and today's push for performance. Steve's research efforts have been recognized by many awards, including the James McKeen Catel award from the Association of Psychological Science, which is the highest award to honor a lifetime of outstanding contributions to applied psychological research. Let's listen to the interview. So welcome Steve.
Dr. Steven Hinshaw, PhD: (01:32)
Nice to see you again, Keith.
Dr. Keith Sutton, Psy.D: (01:34)
Yeah. Good to see you. So, gosh, I forget how we originally got connected. I know I was having those dinners at my home, some time ago or, or I'd have psychiatrists and researchers and authors and therapists and educational therapists who all worked with folks with ADHD come to my house and we kind of talk about what's going on in the field. And then I've gotten to see you teach at Berkeley, you know, some of your courses and you've come into a talk for the Association of Family Therapists in Northern California. Right, so, I just really love your work and I wanted to invite you on and, you know, hear, your story and about your work and what you're working on now. But yeah, let's first start off and find out a little bit about your, you know, how'd you get to doing what you're doing.
Dr. Steven Hinshaw, PhD: (02:20)
Well, how I got to do what I'm doing is part of the meta story about where I think this conversation will go. I grew up in the Midwest Columbus, Ohio. My dad was a philosophy professor. My mom was a lecturer in English, my little sister, and I had this kind of idyllic life. We lived across the river from Ohio state. We'd go to Ohio stadium and watch the might Buckeyes play. And faculty were over for dinner and play reading group, but dad would disappear. I mean, literally for three months, six months, or at one point I was in third grade a year at a time as though abducted by aliens, he was gone. I knew from the look I'm on mom’s face, I couldn't ask. There was no letters, no phone calls, no postcards. And then months later, or again, at one point a year later, one morning I'd wake up and dad was cooking breakfast, but I knew I couldn't really ask where he'd been because it might jinx, whatever had happened and he go away again.
Dr. Steven Hinshaw, PhD: (03:20)
And, and when he was back, he was super warm, very calm philosopher helped me with stuff I was dealing with. And I had no idea what this was all about until I went away to college back east, came back home for my first spring break, and dad pulled me into his home study and said, son, perhaps this time you learned a bit about my life. So in that 40 minute, first talk, we had the first of many for the next 25 years as long as he lived, I learned that he'd been diagnosed with schizophrenia when he was 16. And he had jumped off the roof of the family home in Pasadena, California, thinking he had sprout wings. So he could save the free world from Hitler and Mussolini and ended up in a back ward of a county hospital, given up for dead thinking the Nazis had poisoned the food supply. He went from 180 to 117 pounds was basically given up for dead. And then miraculously recovered went back the finished a senior year at Pasadena high, but the family didn't talk about it cause they didn't want to spoil or jinx his recovery. He went on grad school in philosophy during world war II. He couldn't go overseas cuz he was four F he'd been in a “loony bin”, which is what they called them back then for six months when he was a teenager, he studied in grad school with Albert Einstein and Bertrand Russell. He was a very brilliant philosopher. And he thought at the, in the mid forties, he could predict the end of world war II via telepathy, clearly he was becoming psychotic again. When he was shipped over to Philadelphia state hospital by Barry, as it was known where he still in another six month basically chained sometimes to his bed, beaten by staff and inmates.
Dr. Steven Hinshaw, PhD: (05:09)
His brother went to visit him from Washington DC every Sunday, cuz he feared that my dad hadn't had enough company on his Southern California hospitalization got a day pass for dad, once and took him out to get a meal, first meal, outside this massive institution. And my dad shouted him in German and in English saying I'm being held at a concentration camp in German, take me back. The guards will shoot us. You're a collaborator. And my uncle, decades later when I got to know him, when I was in grad school in Southern California said, boy, I guess with schizophrenia, you had delusions that are, you know, it didn't make any sense to me. So when I started the second sort of phase of my career, really studying the stigma against neurodevelopmental disorders and all forms of mental illness started to write about this.
Dr. Steven Hinshaw, PhD: (05:59)
I found some books on mental hospitals in America, including a photo essay of by Barry State Hospital, the year that my dad was there and the year after. And the photographs showed triple bunk beds in a windowless room that looked just like the liberation of the camps that they a cow book involved and conscientious objectors at the hospital who smuggled out photographs showed the shallow graves and the beatings and starvations. So at some metaphorical level, the closest thing we had in the United States to concentration camps were the big state pit state hospitals of the day. So once my dad came out of the closet, to me, I changed my major to psychology, wanted to get my dad diagnosed. Right, right. I didn't think he had schizophrenia, I thought he had something called manic depression.
Dr. Keith Sutton, Psy.D: (06:49)
Yeah.
Dr. Steven Hinshaw, PhD: (06:50)
And both I had a mission in life, but I was also terrified cuz I didn't tell a soul. Roommates, other family members, girlfriends, not, professors, I wouldn't be fit to be a clinical psychologist, with a crazy father. So after years of getting dad diagnosed correctly and got lithium and finally opening up myself, I've had this wonderful career in Developmental Psychopathology and Child and Developmental psychology study causes of and treatments for child disorders, but also really taking on the more open I got. Why do we still blame people in families for mental illness? Why is it, why do we know so much more about mental illness than in the fifties and sixties? But our attitudes are absolutely frozen. Many social issues have seen great change in attitudes, not mental illness. So I've had this dual career in Child Adolescent Clinical Psychology and the stigmatization of mental illness really spurred by my dad's and many other family members experiences with pretty serious mental illness.
Dr. Keith Sutton, Psy.D: (07:53)
Yeah. And you talk about this in the, your book the, Another Kind of Madness.
Dr. Steven Hinshaw, PhD (7:58) : Yes.
Dr. Keith Sutton, Psy.D ( 7:79): And, and I think this is such a huge piece. And even I actually was just watching the Oprah and, Prince Harry apple special today about again, trying to break down stigma because there's so much stigma around mental health and about feeling like, oh, I don't wanna share that. Or if people knew that they would think I was bad or broken or like you're even saying. You're in a graduate school at this high level of achievement and still, you know, feeling, Ugh, somebody needs.
Dr. Steven Hinshaw, PhD :(08:26)
Better not talk about it. Right? I mean, isn't it a sign of strength to get your card tuned up or to go to your periodic doctor's visit or your pediatric visit. But it's a sign of weakness to admit you've got a mental or moral flaw. There's something wrong with you, wrong with your family. Even the thought that really took over the National Institute of Mental Health in the eighties and nineties, if we can just call mental illness, a brain disease, a disease like any other. Well you attribute it to something that the person couldn't control. It's a medical illness. Well the stigma should go away. Right? Well not so fast.
Dr. Keith Sutton, Psy.D: (09:05)
Not so much.
Dr. Steven Hinshaw, PhD: (09:05)
We hold the person less blame worth, but we think the person is hopeless and probably violent, when it comes the behavior that defies social norms, it's not the bad old days of the schizophrenogenic mother or the refrigerator parents or the more recent genetic days that it's all in flawed genes. It's a combination of vulnerability, life choices, culture, experience just in the way that heart disease or cancers are not fully genetic and not fully experiential. They're a complex combination of both. And I'll just say one more thing. Cancer. So in a passage late in another kind of madness, I, I kind of raise a point for the reader. What would we say today about an oncologist who told a parent as my father was told in the fifties and my mother, if your children ever learn of your mental ill illness and hospitalizations, they'll be permanently destroyed.
Dr. Steven Hinshaw, PhD: (10:08)
You're never allowed to talk. The doctor's orders were silence. So what if a, an oncologist today told the mom or dad, if your children ever learn about your cancer, they'll be permanently destroyed. It's verboten. Well, cancer back in the thirties, forties, fifties, and even sixties in the last century was so stigmatized that if you're a grandpa or your great aunt died of cancer in the obituary, you always put died of an unknown illness, died of natural causes. Everybody knew that cancer was a psychosomatic illness that you brought upon yourself because you was fundamentally lost a will to live.
Dr. Keith Sutton, Psy.D: (10:44)
I didn't know that.
Dr. Steven Hinshaw, PhD: (10:45)
And now today, breast cancer's a cause for women, prostate cancer’s a cause for guys, we wanna find a cure we support. And the irony is that mental illness is now an some ways the cancer of a century ago. We still don't really believe it's an illness. We still don't really well, we do believe well, is it animal spirits? Or you just have a weak, moral character, but you're weird and you might be contagious and we wanna keep our distance. We got a long way to go, Keith.
Dr. Keith Sutton, Psy.D: (11:16)
Yeah, definitely. Well, you know, I wonder, go to the earlier work that you did. And particularly, I mean, I think, and tell me, I actually don't know all the history that did you start out in your research with ADHD or how did you get there? I mean, I know the MTA study, that's kind of my beginning of the story that I have for you.
Dr. Steven Hinshaw, PhD: (11:36)
So in college I went up to Northern New England, New Hampshire and worked at summer camps and I came to direct a summer camp, a residential camp for kids with autism spectrum disorders and serious emotional disturbance and learned a lot about close observation and working with families to get their kids back home. And spent three years doing that ran a day school for kids in, in Massachusetts. Massachusetts had the first state legislation that mandated a free and appropriate education to everybody, regardless of specialties. It was a forerunner of the federal, what now we call IBEA. And went to grad school thinking I would learn a lot more about outpatient residential treatment and about kids with neurodevelopmental disorders and probably go off now with an advanced degree doing studies in those settings. But what I realized was there's a whole world out there of genes and family therapy and clinical trials and dissemination studies, which were kind of new and still growing at the time.
Dr. Steven Hinshaw, PhD: (12:39)
And I just got a hunger to learn. It turned out that by pure luck, one of the professors at UCLA was studying what was then called hypokinesis in boys. And ran day, summer camps, and I'd run camps before to see if the setting, the kind of classroom activities, the kind of playground activities, the demands on a kid would change both the kid's behaviors and how medications might affect those behavioral changes. So I got immersed in such research, did my dissertation on treatments and came away with sort of a track record of ADHD. Both clinical studies and longitudinal studies and even a little bit of EPI. And when, as an assistant professor up at Berkeley, this call came out well over 30 years ago now to apply for a major study to look at kids with of course. What was then called by then, ADHD, boys and girls, to see if regular community care, a very intensive family and school behavioral therapy program really well delivered stimulant medications, or a combination of both would provide optimal outcomes.
Dr. Steven Hinshaw, PhD: (13:51)
So I didn't think I would get the grant. I was the youngest investigator, but I had done that dissertation, back in grad school, on treatment which everybody told me not to do. Why are you gonna do it treatment? It'll never work. And so sometimes being stubborn and doing what you really want to do is a good thing. So I had a track record and I became part of this big multicenter study with about 600 kids across the country. Wow. 300 comparison kids without ADHD, finding that in the short run medications really help the behaviors. The combined treatment really helps the academics and the social skills and the parenting, but we still don't have the magic bullets, I don't think there is any bullets, to keep the kids as they turn into teenagers and young adults on the right track. And this got me thinking a lot more about doing lifespan longitudinal research. We'd always have girls apply to our summer camp programs. Never enough to really get a sufficient sample size. So I, 1995 wrote a grant to the national Institute of Mental Health and said, I think girls really can and do have ADHD, we want to do the largest study of this sample. And we started.
Dr. Keith Sutton, Psy.D: (15:03)
Oh, well now before we get into the, the B girls study, right. Is that nickname?
Dr. Steven Hinshaw, PhD: (15:08)
B Gals.
Dr. Keith Sutton, Psy.D: (15:09)
That's it? The MTA, I mean, one of the things that really struck me from the MTA and this was actually, in workshop from barley that in talking about it is that. You know, that, that there was so much cream and given, I think there was, a one-on-one eight in the classroom. There was meetings with the teachers, and the parents, and the therapist. There was like family counseling, individual counseling.
Dr. Steven Hinshaw, PhD: (15:29)
35 sessions of being behavioral parent management. Exactly.
Dr. Keith Sutton, Psy.D: (15:32)
Yeah, there was a, there was a summer, intensive summer camp, like hours a day, like more treatment that you could ever put together in yourself. And that, you know, despite all that, the medication was still the most significant aspect of the ADHD symptoms themselves.
Dr. Steven Hinshaw, PhD: (15:50)
If the symptoms, the symptoms themselves.
Dr. Keith Sutton, Psy.D: (15:51)
And then all, and then the therapy really helped with the relationships with the family, with anxiety, with social, with all these other kind of aspects. And so that, you know, oftentimes when I'm talking to families about this, that yes, medication is so important. And that's, you know, and something to look at and we work through feelings around that in combination with the therapy and really that work because it's, you know, the way I think about it is, you know, kids with ADHD, it's, you know, that they, they, they, they know what they need to do, but they have such a hard time putting into action. Really, I wanna help them get through their childhood without a great deal of shame because there's so much frustration cuz they know I should be able to do this, but then that's right. Screw it up and, and feel bad. And what's wrong with me and get angry and oppositional at times or depressed or anxious. Yeah.
Dr. Steven Hinshaw, PhD: (16:42)
So if you do twin and adoption studies and review the many that have been done with ADHD, certainly any behavior that you or I, or exhibit is all a part of our gene and all a part of our experiences we learned in high school biology. The phenotype is the genotype is expressed by experience. But if we're looking at me very unfocused, and you super focused there's differences, right?
Dr. Keith Sutton, Psy.D: (17:07)
Yeah.
Dr. Steven Hinshaw, PhD: (17:08)
The differences between people in their ADHD is 80% because of genes, not environments. It's higher than the genetic relatedness or what we call heritability for schizophrenia. It's up there with bipolar disorder and autism spectrum. So the stereotype is meds are the only things that work maybe someday we'll know the many genes that contribute do gene therapy. I think that's hundreds to years off if ever.
Dr. Steven Hinshaw, PhD: (17:37)
But the medications, which if you get the right dose and the right kind of formulation and it takes a lot of work, can really pretty quickly suppress those impulsive symptoms and help the kid focus better. That's great, but those symptoms remit to baseline the day you stop taking the medication and as the old adage, no skills just with pills. The medicine gets your body and brain in the right attunement to learn, but you've gotta learn behavioral control and emotion, regulation and academics and social skills. And that's where the intensive behavior therapy, the family counseling, the coordination between parents and school, the summer program was to really do some intensive academic behavioral remediation. If you want to go holistic, if you want to improve academics, social skills, get parents in a much more positive and consistent frame of parenting. The medicines alone just don't do that. So the combinations are best guess, but as we've learned from further follow up ADHD, doesn't go away at 13. The way I learned in grad school, it doesn't go away at 33 or 53 or 83 either. So we've gotta look lifespan in long term.
Dr. Keith Sutton, Psy.D: (19:01)
Well into that fact too, again, with the high readability that oftentimes when you have a kid with ADHD, you have a parent with ADHD. Absolutely. And if you're doing all these behavioral intervention, creating structure, being organized and so on can be difficult. That's why, yeah. I really am, always interested in working with the family kind of helping the, I think this takes us to the next subject of, particularly of your book, the ADHD explosion. Is, you know, around all the kind of variability in diagnosis rates and you looked at different, you know, states and on, and, and kind of rates of, of diagnosis. And you know, I think that that is oftentimes a concern of folks, of concern, of overdiagnosis concerns of under diagnosis, concerns of a, 15 minute pediatrician appointment and then being prescribed medication for, you know, an eight year old or so on or.
Dr. Steven Hinshaw, PhD: (19:49)
Or a four year old, right.
Dr. Keith Sutton, Psy.D: (19:51)
Four year old. Yeah.
Dr. Steven Hinshaw, PhD: (19:52)
So I have a lot to say about this. ADHD is a lot like depression, and bipolar disorde,r and schizophrenia, and autism spectrum. We don't have a brain scan or a blood test that can definitively tell us you got it or you don't the way you can with cancer. Et cetera, et cetera. Does that mean as some critics say, well, the mental illnesses don't exist. No, it's just, we don't have enough knowledge. And the brain is hugely complex. If you have chronic schizophrenia, you can do an MRI and see literally some holes in the brain, the cortex is eroding, but for most functional cases of depression, ADHD, schizophrenia, autism. Yes, there's some hints that there's some brain pathways and subtleties that are a skew, but we don't know A, if that's the full story and B if it's a pure genetic anomaly or it's early experiences interacting with such genetic vulnerability.
Dr. Steven Hinshaw, PhD: (20:54)
So what do we do? We know, and the American Academy Pediatrics, the American Academy of Child Adolescent Psychiatry have published 20 years ago, 10 years ago, recently guideline to say, we can't do a good job of diagnosing ADHD, 10 or 12 minutes in a pediatrician's office. We're gonna need to get a really good developmental history from the parents. We're gonna need a medical exam. Some forms of absent seizures, look a lot like the inattentive form of ADHD, hypothyroidism. And there's a lot of medical rule outs. We're gonna need to get good rating scales from parents and teachers so we can compare those to national norms. We might need to do some testing. Now, one on one computerized tests of attention are not the gold standard for ADHD because some kids with really bad ADHD can focus pretty well. For 20 minutes, one on one in front of a computer screen, some perfectly neurotypical kids may have problems.
Dr. Steven Hinshaw, PhD: (21:57)
We put all this information together and we get our best estimate. This is gonna take a couple of hours minimum. The problem is many general practitioners are not trained in this . And even if they are, you don't get reimbursed for it. So that's number one. Number two, some of our colleagues around the world have been doing large scale epidemiologic studies in every continent except Antarctica, which doesn't have enough people permanently living there. What's the prevalence of ADHD in kids and teenagers around the world. Amazingly, it's about five to 6% everywhere. Very few exceptions. Now within Germany or Australia or China, different regions have very different rates because of the quality of practice. But the worldwide rate is sufficiently similar. It makes you think there's a certain percentage of kids. Who've got this genotype that makes it harder for them to focus, especially when they have to sit in schools, which only happened in the last couple hundred years of human history.
Dr. Steven Hinshaw, PhD: (23:11)
So what do we do with all of this? We know that genes matter. We know that some district, some state, some regions are really concerned about school achievement. So Richard Scheffler, the great health account anonymous and public health professor at UC Berkeley. And I teamed up in this big book on ADHD to try to figure out why do North Carolina, Arkansas, Indiana have three times as many kids diagnosed with ADHD as California, Nevada. And that's the truth. This isn't just a, you know, it's not a fraction of a percent, is it that there's more Hispanic kids out west and more black kids in the south? You put that in the equation. It answers only a tiny fraction of this difference. Well, is it now it in cancer, I'm being a little detailed here. You can measure the number of cancer doctors in an area, and that's pretty correlated with a number of cancer patients in an area mm-hmm cause the doctors go to cancer clusters and patients move to where the doctors are.
Dr. Steven Hinshaw, PhD: (24:17)
We found a zero association between the number of pediatricians or Child Adolescent Psychiatrists, county by county across the U.S and the rates of ADHD diagnosis. So when Professor Sheffler first met me almost 20 years ago, he was giving a talk. And I'd said that the cause of ADHD, tongue and cheek is compulsory education. Well it isn't really, but it it's the factor that unleashes it, right? It puts these kids in the crucible attention is of a premium and as a health economist, he said, I think of ADHD as a condition of productivity and performance. So I'm guessing that in those regions that really put a premium on test scores, we're gonna find higher rates of a ADHD diagnosis. So we did a lot of detective work. We found, don't bore you to tears with it.
Dr. Steven Hinshaw, PhD: (25:15)
But many states have instituted a policy called consequential accountability. You know, what on earth does that mean? It means state by state and the seventies, eighties, nineties, you, your public school district is only gonna get funded. And we're not gonna write you up in the paper or put you in receivership the way California did with the Oakland district some years ago. If your test scores are either going up or they've met this threshold, you're good. But if not, there's consequences. So there's consequences for the accountability of the kids, reading and math and science course, right? A bunch of states pass such a legislation. And then little known is the fact that when no child left behind became federal law, George Bush two's first major piece of domestic legislation in 2002, it made consequential account the law, the land for the remaining 21 states.
Dr. Steven Hinshaw, PhD: (26:12)
So this is what a scientist licks his or her job. We got a natural experiment. Mm-hmm we didn't randomly assign states to these laws. That would be interesting to do if you could do it. But we saw 30 states that did this and about 20 that did it all at once later, the states that suddenly got consequential accountability in their early two thousands, the poorest kids in those states, the ones closest to the federal poverty level within two years had a 60% greater chance of being diagnosed with ADHD compared to kids in the states that had already passed those laws or kids in private schools in the same states.
Dr. Keith Sutton, Psy.D: (26:52)
Cause if they didn't have a diagnosis, they would, they would then get counted against the funding.
Dr. Steven Hinshaw, PhD: (26:57)
Exactly. And it's so part of it is that superintendent says, we've gotta get the kids test scores up, let's get 'em diagnosed and treated for gosh sake. However, until this became illegal in 2011, there was another clause. If your kid gets diagnosed with ADHD, well, that's a special ed kid. Guess what? Next spring? And the standardized test scores, we throw those kids scores out of the equation.
Dr. Keith Sutton, Psy.D: (27:23)
Yeah, they don't count.
Dr. Steven Hinshaw, PhD: (27:24)
They don't count. So it was gaming the system to get test scores up. So ADHD is very biological. It has a lot to do with family interactions and it has a lot to do with school policy. It's not either or, it's all of these thrown together in this complicated mixture.
Dr. Keith Sutton, Psy.D: (27:40)
Yeah. And I think, you know, the way I've thought about it, two is it, from what I had learned that, you know, the, the original diagnosis of six out of nine symptoms place the kids at the 93rd percentile. Right. So essentially one and a half standard deviations above the mean, which would mean then the population is about 7%.
Dr. Steven Hinshaw, PhD: (27:58)
If it's normally distributed, which is, should be six, 7%. That's right.
Dr. Keith Sutton, Psy.D: (28:02)
Oh yeah. And then it, what ends up happening is that. Some kids are overdiagnosed. And particularly to the frontal lobe it's the first thing to go and kids are depressed or anxious. Trauma didn't get enough sleep or so on. But then on the other hand, there's a lot of concern about diagnosis and then not as much training as like, as you were saying, and you get underdiagnosed, that's why you get a lot of, of adults coming in.
Dr. Steven Hinshaw, PhD: (28:25)
Absolutely.
Dr. Keith Sutton, Psy.D: (28:26)
We, you know, for the way we do it through our center for ADHD, we contact the parents of those adults. I've had parents I've talked to in their eighties of an adult, you know, in their, in their forties. And particularly that, you know, that, that those childhood symptoms are the biggest differential. Cuz like you're saying, even with the computerized test, somebody may be positive for ADHD, but then you have to go back to your clinical interview, is that due to depression, anxiety, you know, all these kind of things. And is there's that childhood history.
Dr. Steven Hinshaw, PhD: (28:56)
There's a lot of rule outs and there's a lot of in the fancy lingo, comorbidity. You can have ADHD and be depressed Yep. Or have an autism spectrum disorder or have bipolar disorder. And so it's not as simple as it seems, most kids in the world who have ADHD, not just the ones in clinics, but they're even under identified as of yet have more than one other disorder too. It means that we've got, I think we pay now pay now or later.
Dr. Steven Hinshaw, PhD: (29:30)
We do a solid assessment now or we'll pay later by missing the kids who could have used help or over diagnosing kids who really didn't need all of the medication of the special treatment. And the, the only solution is better education of healthcare professionals and reimbursing the legitimate cost of doing it. Right. And speaking of under diagnosis, another thing I learned in grad school, girls don't get ADHD.
Dr. Keith Sutton, Psy.D: (29:58)
Yeah.
Dr. Steven Hinshaw, PhD: (29:59)
They are depressed they have conduct is so they they're they're anxious. And certainly that can be true. Autism, Tourettes, many forms of learning disorder, early onset conduct disorder, ADHD. These are neurodevelopmental disorders. They occur in the first 10 years of life. Often they persist. All of them they're are more boys than girls. Autism, It's about five to one. Tourette's about five to one very severe early disorder, about seven to one. ADHD, It's about two and a half boys for every girl. But until clinicians started to recognize that girls really could have ADHD. It was about 10 to one. Cause if you were a girl, you'd get diagnosed with some cause you really couldn't have ADHD. So finally I think the practice is caught up with the truth that girls don't have ADHD as much as boys, a, b: they tend to have the more purely inattentive variation variant of ADHD.
Dr. Steven Hinshaw, PhD: (30:59)
Although girls can certainly be hyperactive and impulsive two and C, unless we diagnose carefully, maybe not exist insist on the running around a classroom, but being hyper verbal or impulsivity, more choosing A on every multiple choice answer rather than, uh, some of the boys impulsivity, which is much more behavioral. Girls with ADHD are at very high risk, as we've learned from some of our studies, which we can talk about in a moment for serious outcomes, like self harm, self injury, unplanned pregnancy, and we're doing girls and families intergenerationally and disservice unless we diagnose accurately and get treatment.
Dr. Keith Sutton, Psy.D: (31:43)
Yeah, definitely. And do you think that, I mean, that difference for girls, um, is, is that all due to kind of, you know, socialization, gender socialization, is there anything kind of, um, neurologically different about what leads to a different manifestation of ADHD?
Dr. Steven Hinshaw, PhD: (32:02)
Yeah, it's it, nobody's quite sure my belief is, although I don't have enough data to prove this. That in utero and in the perinatal period, right after, after birth for a while, and even in the infancy and toddlerhood boys' brains are more vulnerable than girls' brains to a whole host of insults from toxin to low birth weight, all kinds of insults that can happen. So boys in this first 10 year of life period, are likely to have ADHD and autism and these other conditions more than girls now in the second 10 years of life, girls shoot ahead with anxiety, depression, cutting eating disorders. So there's kind of a tale of two sexes here. But I think it's not girls for autism, ADHD have such different genes. It, I think there are similar genetic variations, but boys may actually be more vulnerable to a host of psychosocial problems, trauma problems, um, other biological insults early in life. That doesn't mean that girls can't have them. And in fact, when girls have these conditions, they can be quite serious.
Dr. Keith Sutton, Psy.D: (33:18)
Definitely. So talk a little bit about the, the be gal study and, and this kind of, you know, focus, and you know, as you're following the girls, through development.
Dr. Steven Hinshaw, PhD: (33:30)
So we got this big grant in 1995. NIMH believed us. We can do this study. Now we've got a recruit, a big sample of girls. Can we do it? And think back to 95 listeners, we had voicemails and we had fax machines. stuff like that. The first day we had I'd given talks in elementary schools, we'd gone to Kaiser and all the pediatric practices around put some ads in the Chronicle, in the Oakland tribute, the phone rang off the hook, the answer machine filled up. We got well over a thousand inquiries. Did a lot of careful screening teacher ratings, parent ratings, preliminary interviews. And then we ended up assessing the final participants for 10 hours. We, we took this really seriously. And got a sample of 140 girls with ADHD. About two thirds of them have what we call the combined presentation or type they're very inattentive.
Dr. Steven Hinshaw, PhD: (34:30)
And they're pretty sometimes ornery and impulsive and hyperactive too. And about a third were more purely inattentive. The more Spacey maybe more easily mistaken for anxiety or depression. And, and then a almost equal size number of girls with neurotypical development. They didn't have these same problems. Put them all together, summer camp one year and then another group in a summer camp. So, so we could study them, not just in a lab or a clinic, but as they were on the softball field and in reading class and all kinds of things. We learned a ton. We learned that girls with ADHD when they're in grade school have many of the same problems as boys. In fact, they are even less liked by other girls than boys with ADHD are disciplined by other boys. Cause for girls, relationships are everything. A guy can kind of be whatever Spacey or running rush through things.
Dr. Steven Hinshaw, PhD: (35:31)
And it's like, ah, he's all boy. So we, we only could get that first grant for five years at a time. That's the way the federal government works. So we had to publish a lot, show the government we're ready to do adolescent follow up. And then a late adolescent follow up when they were about 20. And then we did one when they were about 26. We're now involved in our fifth wave when they were in their thirties. And this is where things got interesting. First of all, how do you follow up a sample like this? Yeah, this is Northern California. Russ Barkley has followed his samples in Wisconsin for decades. Cause nobody ever leaves Milwaukee. very few do like my classmates in Columbus, Ohio 98% of them stayed. So we told each family back in the late nineties when they came to their summer camps that even though we couldn't guarantee it, we wanted them and their daughters to be in our study, the rest of their lines.
Dr. Steven Hinshaw, PhD: (36:29)
And in fact, after the summer camps, we could get calls to our project line, say, what is that lifetime study happening professor? Well, we get our grant. And so the families had the expectation. Yeah. The summer camps were free of charge. You treat families. Well you give back, we wrote reports on every participant . So we've had 93 to 95% of the participants back. 16 years later. So cuz if you do a, still have to come back, guess guess what's up with the half you haven't seen, right? Yeah. I it's not representative. So here's the short headline version. Girls with ADHD are a lot like boys with ADHD, they're reading and math problems continue whether or not they have a formal reading or math disorder. The inattention, the impulse, but girls, especially in math, their scores into their twenties in math are, shockingly low.
Dr. Steven Hinshaw, PhD: (37:28)
And of course math is the stereotyped field of study that girls aren't supposed to do well in and get anxious about. And more advanced math takes these executive and planning skills that a lot of, of kids with ADHD black. So that's number one. Number two, the girls didn't end up in juvenile hall or related facilities to the extended boys. Not shocking. Some of the girls had antisocial behavior. Number three, they didn't have as much substance abuse as the boys so maybe girls get kind of a hall pass. Number four, we started measuring in late adolescence and have continued things like cutting burning self-injury self harm NSSI. Nonsuicidal self-injury your intent isn't to end your life, but you're doing some just things to yourself to either relieve emotional pain or to temporarily escape the problems you're having. Yeah. Or to distract you a lot of theories about why this happens.
Dr. Steven Hinshaw, PhD: (38:32)
In fact, the girls with ADHD, especially if they had both impulsivity and inattention, when they were girls mm-hmm 51% were engaged in moderate to severe self injury at the age of 20. 50% now 15 to 20% of our comparison girls were too is what the national average is. This has become an epidemic parents of teenage girls out there know sadly and beyond cutting self-harming a quarter of the girls with this combined form of ADHD had attempted to end their lives by their twenties and about 6% or 7% of the comparisons. Again, that seems like a high rate, one outta 16, typically developing girls, but that's sadly the national average, the girls with inattention only were somewhere in between. So we believe that if you're a girl with ADHD, especially if you're impulsive and with the many studies we've done to see what tracks here, what happened between childhood and adolescence that mediates this low academic achievement, poor executive functions.
Dr. Steven Hinshaw, PhD: (39:54)
Intriguingly poor father daughter connections rather than poor mother daughter connections. There's something about a girl. Who's got the challenges of ADHD? If she doesn't have a dad, strongly standing beside her and behind her, that seems to be a pretty big predictor for us. And finally we have tracked over time, physical abuse, sexual abuse, and neglect. Our sample is professors, kids, and executive kids all the way down to public assistants. It's very ethnically homogeneous or heterogeneous. In terms of life experiences, the girls with ADHD when they were girls in teens who had been physically abuse, sexually abused and or neglected either alone or in combination, their suicide rate was 35% by the mid twenties. So the genes that predisposed to this disorganization and this impulsivity and inattention and poor self-regulation when there's been early trauma, you put one and 1,and 1 together it's biology and experience that predicts the really difficult outcomes. Finally, by the mid to late twenties, just under half of the girls with ADHD had had one or more unplanned pregnancies compared to our comparison group of neurotypicals. What happens if you have an unplanned pregnancy, do you terminate, do you deliver before time? Do you have enough support? We know, as you mentioned, apply a few minutes ago, given the genetics of ADHD, a parent, a biological parent who has a kid.
Dr. Steven Hinshaw, PhD: (41:42)
With ADHD has a 35 to 45% chance of having ADHD himself or herself, whether it's been diagnosed or not.
Dr. Steven Hinshaw, PhD: (41:51)
Kids with ADHD, I often say require some real, super parenting, but if you can't balance your checkbook too well, and you lose your temper at work and you've had a history of ADHD and all its ramifications, that kid is gonna challenge you in the ways they're kind of your so spot. So getting families assessed parents themselves for depression and ADHD and getting treatment for themselves is often a huge step to helping remediate their daughter's course.
Dr. Keith Sutton, Psy.D: (42:20)
Definitely now I, and I kinda remember, from a talk, I think I was at, that you did at Chad, for the conference was around that the, the girls had also started cutting earlier or the non, the self-harming. Yes. and then also I think, was there also eating disorders, particularly I think bulimia.
Dr. Steven Hinshaw, PhD: (42:44)
Very interesting in the teen years, our sample with ADHD didn't have pronounced rates of anorexia interval. So there were some, but some of our comparisons did, but the impulsive binge eating the bulimic symptoms appeared faster and stronger than in our comparison group. But if you go out over time, I'm making a graph over time in front of my eyes here, a number of our comparison girls had developed these same disorder symptom. So it ended up not being a significant difference by their twenties. Yeah. We're not saying that girls don't have that risk if they've got ADHD, but it was the self injury, unplanned pregnancy. And even though most of our girls with ADHD graduated high school, as the parents will tell you, carrying their daughters on the, their back, over the postsecondary education, the multiple community colleges with one or two credits and lots of grades of Fs and the job firings and the tardiness at work and unemployment. These girls know that they're women, too many of them are really personally and sort of vocationally, they have challenges they've not been prepared to deal.
Dr. Keith Sutton, Psy.D: (44:02)
Yeah. And oftentimes too, for many women, especially in heterosexual relationships, when they have families or kids of their own, oftentimes a lot of the demand falls on their shoulders. That's right. Able to deal with all the emails from the schools and the kids.
Dr. Steven Hinshaw, PhD: (44:16)
Oh, absolutely.
Dr. Keith Sutton, Psy.D: (44:17)
Like that, which oftentimes, and kind of more those yeah. Heteronormative kinda stereotypical well.
Dr. Steven Hinshaw, PhD: (44:23)
And, just think of the pandemic recently. How does any parent teach their young kids? I think Keith you've had some personal. On zoom and, and what if your kid has ADHD and what if you're trying to hold down a job remotely or in person, and you've got ADHD yourself, this is not a happy ticket.
Dr. Keith Sutton, Psy.D: (44:43)
Yeah. And I mean, I think too, we were talking about this earlier for our center. We've got the, the referrals have just skyrocketed, you know, and, and, and particularly, you know, I found this also in some of the couples therapy I was doing, not even related to ADHD as the kids were home, the parents started realizing and, and the parents were describing it. I was saying, huh, like, has this been going? I'm like, oh yeah, the teacher's been talking about this for years.
Dr. Steven Hinshaw, PhD: (45:05)
That's right now we see it.
Dr. Keith Sutton, Psy.D: (45:06)
Then we actually started doing the ADHD evaluation. And it did that there, that kid actually did have ADHD. And we were able to diagnose and figure out what was going on. But you know, these kind of situations, which the pandemic has just totally brought this. I mean, and it's also a lot of folks confused cuz they're, the kids are having such a hard time focusing and paying attention and readjusting back to school that the parents are wondering is this ADHD but then when we look at the history pre pandemic, that those symptoms weren't necessarily there. But you know, again, the frontal lobe is the first thing to go. So, you know, attention, concentration, focus, you know, all of that is out the window when things aren't going, right. It's been a big, big question for people and big concern. So, you know, tell me a little bit about what you're working on now. I mean, what's what what's your area of interest is. I know that the, the latest thing that I knew that you were working on was around this work around stigma. Yeah.
Dr. Steven Hinshaw, PhD: (46:06)
So, you've known me a while. I've known you. I, I don't do one thing very well. I like to different things, and of course you don't want to be a dilatant and have the doll crashing down. But so our girls and our boys and girls in the MTA have grown up, so I've gotten much more into adult forms of ADHD and what that means. And we'd like to get funding to look at the, especially the B gals who are parents themselves and help us any generational stuff. We've been doing other studies of adults with ADHD in the community, slowed down by the pandemic, looking at EEG signals and looking at ways for them to develop their own focusing skills. Maybe not as opposed to medication, but in addition to yeah.
Dr. Keith Sutton, Psy.D: (46:54)
Do you mean neurofeedback?
Dr. Steven Hinshaw, PhD: (46:56)
So not so much neurofeedback, but with a collaboration I've been developing now cuz neurofeedback hasn't really done as well as it should against the proper controls of sort of fake neurofeedback. But other means of self-regulation. So next show I'll talk about that more so.
Dr. Steven Hinshaw, PhD: (47:16)
But as you just noted, I've been really interested in both the history of the cross-cultural differences in the shameful amounts of, and what we can do about it. Issue of the stigma of neurodevelopmental conditions like ADHD and autism, mental disorders like bipolar disorder, depression, schizophrenia, PTSD, anxiety, you name it. And so I've written, you mentioned another kind of madness, a journey through the and hope of mental illness was my attempt to really give our family story, to put and you know, stories better than statistics to sort of change people's minds and hearts. And we gotta do a lot more of that, but I've been really interested in why we know more as a society factually about mental illness, but sometimes know more actually increases stigma, especially in high school students. So I've really been interested in the development of kids with disorders in high school, but just typical kids in high school.
Dr. Steven Hinshaw, PhD: (48:23)
This is when attitudes consolidate. This is when prejudices and stigma really, you know, have sticking power. So colleagues in other parts of the country have pride curricula where you take over a health class in a high school for a semester and you have the schizophrenia module and the bipolar module and the ADHD module and the autism module. And boy, by the end of the term, the kids ACE their test, they know symptoms. And they're more fearful of and want to keep greater distance from all of those conditions. Cause you've learned, wait a minute. Some people with major depression are so depressed. They want to end their lives. Well, that's the most selfish thing I've ever heard people with schizophrenia hear voices. That's the last thing I wanna do. People, the ADHD can't focus. It fact are fine. We want to have a literate society.
Dr. Steven Hinshaw, PhD: (49:15)
But when the facts reinforce the very stereotypes that are the basis of stigma, the kind of education, and this is what we're doing in many high schools throughout the country now with sort of stigma reduction groups. Is focusing on speaker series. People with lived experience of mental illness coming in mindfulness, meditation apps. Self-disclosure lobbying the school administration that if a kid in that school ends his or her life by a suicide, we can maybe have an assembly. We can't keep this under the road. We don't want to glorify things. The kids through bring change to mind a nonprofit right here in the bay area, founded by Glen close 11 years ago now. And I'm the scientific advisor helped bring this curriculum to them. But the point is, it's not a curriculum where day one week one and week two, you learn lessons. The kids design their own anti-stigma programs. Based on this platform of videos and resources, because if they're not motivated to get this information spun in their own ways, it'll just be like book learning and maybe learning the wrong facts.
Dr. Steven Hinshaw, PhD: (50:31)
And colleagues of mine in other places in Canada and, down in Southern California are starting this now, even in grade school and middle school. In the way that non-binary gender and sexual minorities status, isn't something you just learn about by, you know, Willie nilly and high school on your own. So the idea is let's confront the fact that mental illness is pretty darn prevalent. Can be very impairing, but it's not them. It's not this strange, weird group of people out there it's you it's me. It's our family members. It's our best friends. It's the people. And we all lose if we keep these barriers up. So I'm very interested in whether over the next 10 years, the high school kids in the middle school, kids who go through these programs might become the adults of the future and start to say, stigma's an old person's term. We don't believe in that anymore.
Dr. Keith Sutton, Psy.D: (51:31)
Yeah. Oh, that would be great. Yeah. Yeah. I think that, you know, it sounds great though, the work that you're doing and I know I actually have a lot of, we have, folks that, that volunteer as non-clinical interns for us. And a lot of the folks that have come to us actually, and a theme that I'm seeing a lot in these undergraduate students is wanting to also work against, stigma in, minority populations.
Dr. Steven Hinshaw, PhD: (51:54)
Absolutely.
Dr. Keith Sutton, Psy.D: (51:54)
In many of the populations that they grew up in because there there's, even more stigma in, in some of their cultures. And so that aspect of kinda bringing, you know, addressing stigma from a multicultural perspective,
Dr. Steven Hinshaw, PhD: (52:08)
It it's huge. Keith. I mean, people say, well, you know, if you, you go to a, a non-Western society, you, you go to east, if you will, um, all the way to Asia. Well, those are collective of societies. They don't have stigma. Well in India with dowry systems, if the girls or woman's space, family has mental illness, they're unacceptable. They're untouchable the suicide rate in Japan, especially among business men is incredible and women. Those more business men and women in Japan. The pressures are so strong. So stigma is expressed differently in different cultures, but it knows no cultural balance stigma's high in every culture we've ever studied.
Dr. Keith Sutton, Psy.D: (52:49)
Definitely. Well, Hey Steve, thank you so much for taking the time today. This is always great. And it's great to hear about your work and I'm always wanting to, to get it out there. And I am so appreciative of the work you're doing on stigma, because we can know all these great things and, you know, important facts about, you know, diagnoses and treatment and so on. But if people are scared to you identify the right treatment, then its no good.
Dr. Steven Hinshaw, PhD: (53:15)
And, and I'm gonna say two things. I always have to end my little lecture here. So big study done the national comorbidity study years ago, still very valid the average time. And this is not with the clinical samples, just a representative sample of thousands of adults across the country between understanding that you maybe you've got some symptoms and, and getting assessed and treated the average in America's 10 years. That's a decade of lost time.
Dr. Keith Sutton, Psy.D: (53:43)
Yeah.
Dr. Steven Hinshaw, PhD: (53:44)
So that's number one. Number two, man how are we gonna fight stigma? Public campaigns enforce the Americans with disabilities act, make sure parody happens. People speaking out their stories, but right up there is making sure people get evidence based treatment.
Dr. Keith Sutton, Psy.D: (54:04)
Yeah.
Dr. Steven Hinshaw, PhD: (54:04)
What really change the tide, if you will, on the stigma against HIV, the antiretrovirals and the new waves of treatments that make HIV a lifelong livable with, but not fatal illness. And once we can get better treatments and more people have access to them, that's the other side of the coin. Yes, we have to have more tolerant attitudes, but we need treatments to,
Dr. Keith Sutton, Psy.D: (54:26)
And more people trained in those treatments.
Dr. Steven Hinshaw, PhD: (54:28)
More people trained in this dissemination you and I develop a great treatment. It's gonna take us 20 years to get it out to market.
Dr. Keith Sutton, Psy.D: (54:35)
Yeah. Yeah, definitely. Well, thank you so much. I really appreciate your time today. And this is really important work. It's always a pleasure talking with you.
Dr. Steven Hinshaw, PhD: (54:44)
Well, thanks for your great questions and all the work you do. Keith.
Dr. Keith Sutton, Psy.D: (54:47)
Take care. Bye-bye
Dr. Keith Sutton, Psy.D: (54:49)
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