Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
ADHD: Diagnosis, Management and Real-World Strategies
Unlock the secrets of ADHD with guest Dr. Michael Manos and gain a comprehensive understanding of this genetic condition that affects so many lives. In this enlightening episode, Dr. Manos shares his expertise on how ADHD manifests differently in brain function and about the gender disparities in ADHD diagnosis and treatment.
Managing ADHD behaviors effectively is crucial for improving quality of life, and Dr. Manos provides valuable strategies and tips. Tune in for a wealth of knowledge and actionable advice that can help individuals with ADHD thrive.
Welcome to the Fit, Healthy and Happy Podcast hosted by Josh and Kyle from Colossus...
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Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, and I'm back in the Sunflower House for a new episode with a guest, dr Michael Manos. He is a PhD and he is an expert in ADHD attention deficit hyperactivity disorder. Dr Manos is the former head of the Center for Pediatric Behavioral Health in the Children's Hospital at Cleveland Clinic and he is the founding clinical and program director of Pediatric and Adult ADHD Center for Evaluation and Treatment. And Dr Manos is adjunct faculty at Case Western Reserve University College of Medicine Department of Psychiatry University College of Medicine Department of Psychiatry and he's an associate professor at the Cleveland Clinic Lerner College of Medicine and he's got special interest and expertise in both children and adults with ADHD, behavioral pediatrics, clinical behavioral pediatrics, family management, as well as pharmacotherapy research, and he has written and presented several hundred scientifically based papers on ADHD. Welcome, dr Manos.
Speaker 2:Hi, Dr Thacker. Thank you for the invitation to be here.
Speaker 1:Well, it is wonderful to have you to be here. Well, it is wonderful to have you. As our Sunflower House listeners know, my major area of expertise is in midlife women's health and menopause and hormones, and I have a lot of women come to me for inattention and brain fog, and sometimes that is menopause. Sometimes they have new diagnoses of ADHD themselves or they think they may have it after their children or teenagers are diagnosed with it. So can you tell our listeners what is ADHD and what causes it?
Speaker 2:So ADHD is a genetic condition and so it's handed from parent to child and it tends to occur certainly in families. So ADHD is a distinct difference in two kinds of attention in the brain. So I do want to emphasize that for many people ADHD is not a disorder. It's not like a, a viral infection where there is something wrong with an individual. It's actually a difference in how the brain functions. And because it is a genetic condition, it certainly doesn't have necessarily a cause, other than if you consider some individuals, such as evolutionary, who consider that ADHD has been selected for through natural selection and evolution.
Speaker 1:Fascinating. Why is that?
Speaker 2:Yeah, that's actually the question, and what's interesting is that, because the brain is adapted to the environment through natural selection, when all of us lived in a very dangerous world, a world where hunter-gatherer tribes were necessary in order to enhance survival, hunters were the ones who could be diagnosed with ADHD, because their brains were highly attuned to the external world and they were highly reactive to the external world, and so just by their ability to recognize danger and adapt to danger, they kept people alive, so evolution selected for it.
Speaker 2:They kept people alive, so evolution selected for it. What's also interesting is that following the ice age, people lived on farms and now a brain that could wait a long time for something to happen, like seasons changing or plants growing. Now a different brain was selected for in evolution. Now a different brain was selected for in evolution, so farmer brains became more prevalent. And if you consider many of the adult tasks in our world today, where things are relatively safe, that the farmer brain largely is the brain that reacts better to, say, school tasks or work tasks, as opposed to the ADHD brain, which largely reacts to incurring stimuli.
Speaker 1:You know it's interesting that you talk about the school brain. You know it's interesting that you talk about the school brain. I'm the mother of three sons and I noticed early on, especially when I would volunteer in schools, that it seemed like schools were better set up for girls. And of course I'm a female myself. But even I felt like I had more of that male brain and wanting to move from task to task or be hands-on or be more physically active instead of sit quietly and write neatly. Are there gender differences with ADHD, and is the school environment not as good for someone who's more wired to be sensitive to all the stimuli?
Speaker 2:Well, if you ask most kids, do they like doing school tasks? They're going to tell you no, they don't. So school tasks themselves certainly may have something inherent in them that make them a little less invigorating. So girls with ADHD are diagnosed less than boys with ADHD, by a factor of about three to one three boys to one girl than boys with ADHD by a factor of about three to one three boys to one girl. And ADHD in girls is a little more difficult to recognize because there are expectations, societal expectations that apply to child behavior, that are allowed more grace in girls, for example, so what things are allowed more grace in girls.
Speaker 2:Well, boys are highly recognized because of their overactive behavior. A girl with ADHD who has overactive behavior may be considered just more social, or they may be considered just more talkative, as opposed to a boy, who may be more aggressive and more intrusive in school activities. So the ratio of boys to girls tends to be three to one, and girls also tend to have societal expectations that preclude a diagnosis of ADHD, and so there is a very interesting statistic that, by a factor of about three to one, girls and women are provided with antidepressants or anxiolytics before they're provided treatment for ADHD, whereas boys it's the opposite.
Speaker 1:Now, is that because girls are being underdiagnosed, or are boys being overdiagnosed, or are there sex hormonal differences in the brain that affect the expression of the symptoms of ADHD?
Speaker 2:No, it's not a question of being over or underdiagnosed, or over and under or undertreated or mistreated, and or over and under or under treated or mistreated. The paper that we publish in the Cleveland Clinic Journal of Medicine has been very well received, actually worldwide, and it's very interesting because we address that very question overdiagnose and over treated or misdiagnose and mistreated. Boys tend to be more easily recognized, especially in childhood, because of their hyperactive and impulsive behavior, whereas girls' behavior is generally excused or allowed to be there. It's not necessarily recognized as being problematic, and girls tend also to internalize. When they accrue negative attention for, say, being distracted in school, they tend to make themselves wrong or they tend to be critical of their own behavior and of themselves, as opposed to boys, who may be more accustomed to acting out or being more aggressive.
Speaker 1:And maybe we should back up a little bit and you can tell us the common symptoms of ADHD, as opposed to some people are just telling me they only have ADD, they're not really hyperactive, and how would someone know if they have this condition or how?
Speaker 2:would a parent know if his or her child or grandchild has ADHD? Or four diagnoses for ADHD ADHD inattentive type, adhd hyperactive, impulsive type, adhd combined type, which is both of those. Then there is a third kind of ADHD called unspecified type, and I've used it only very rarely with people who do show intruding symptoms in their lives and their lives are actually impacted by these symptoms, but they don't necessarily meet full symptom criteria. In a child, we're looking for at least six of nine behaviors that are associated with inattention and or six of nine behaviors associated with hyperactivity impulsivity. It's either one of those categories that there needs to be a clustering of at least six symptoms. In an adult, we're looking for a clustering in either one or both categories, of at least five symptoms.
Speaker 1:And what are those classic symptoms?
Speaker 2:Inattention, distractibility, disorganization, starting tasks and not finishing them, leaving tasks incomplete. The biggest problem that people with ADHD have is this notion of incompletion. Somebody says they're going to do something and they do not do it. They leave the task incomplete. This is, of course, very obvious in childhood, where children are expected to complete schoolwork and finish it and turn it in the next day, complete an entire test. So children have tasks that they are assigned by adults and typically there is what occurs in childhood.
Speaker 2:Social scaffolding is very prominent, so you have parents and teachers who are keeping track of the child's ongoing performance in school and subsequently, that ongoing performance is monitored continually. When you are an adult, things change and adults are expected to be self-responsible and they are expected to identify the task and complete the task. They're not expected to be reliant on social scaffolding, on parents or others to tell them what to do. However, that certainly is built into certain occupations. If you're at the executive of a company, then certainly you have people around you who will allow you or assist you to structure the day and to do the tasks that need to get done, but in childhood that's not always available, unless you have a very loving parent.
Speaker 1:Wow. And so how would a parent know if their child has it? If they're just concerned about the symptoms, would a general pediatrician be the one to make the diagnosis? You know one thing I just feel like I just see at least children like of my grandparents, my grandchildren's age. It just seems like they're more medicalized than like maybe my kids were, and they seem to be more medicalized than like maybe my kids were, and they seem to be more medicalized than like I was as a child. So I don't know if it's just we're better at diagnoses or are we just less tolerant of certain behaviors, being a scatterbrained or a silly head or, you know, just being a child?
Speaker 2:Well, I think that we have given a name to a body of behaviors that, when they cluster, they interfere with a child's life. They interfere with the child's responsibilities at home and in school and they certainly interfere with an adult's responsibilities unless there is a very notable scaffolding. But adults also learn all kinds of new behaviors in order to manage the behaviors that are problematic in ADHD.
Speaker 1:So I'm not quite sure if I'm answering your question properly, but nevertheless so do you think we're just better at diagnosing it, or do you think that maybe older parents and overworked teachers are less able to support the child? I mean, do you think there is some over diagnosis of of this, or do you think there's actually under diagnosis and not enough, not enough treatment or enough people that specialize in this, or is it regionally?
Speaker 2:dependent, right understood, and I don't think we are over diagnosing by any means, and I think actually that we are under diagnosing and because of that, many kids, and girls especially, are experiencing failure where they don't need to experience failure. They are more interested in watching the squirrel climbing the tree than they are in doing the math homework or finishing their test in school, and so they are considered to be scatterbrained or they're considered to be frivolous and they, they really don't care. Sometimes we even call kids lazy, and that is one of the most absurd descriptions of a child. I have never, ever, met a lazy child ever, and there is a lot of avoidance. There are certain tasks that children will avoid and adults will avoid. However, that doesn't mean that they're lazy. So I think that the real concern here with ADHD is what is it that is the cause of, or the instigating factor that leaves a task incomplete?
Speaker 1:We are listening to Dr Michael Manos, a PhD and expert in child and adult ADHD, in the Speaking of Women's Health podcast, and I'm your host, dr Holly Thacker, and we're talking about behaviors that can indicate a condition which is treatable, and the suffering and the problems and the misunderstandings that can go along with it.
Speaker 3:Hello, you just listened to part one of this podcast episode on ADHD with our guest Dr Michael Manos of the Cleveland Clinic. In the original recording of this podcast interview, dr Thacker interviewed Dr Manos entirely. However, we had a bit of a technical glitch in the second half where it did not record the second part of the interview. So I will be hosting this re-recording of the second part of the podcast episode with Dr Manos. My name is Leigh Klecker and I am the producer of the Speaking of Women's Health podcast. I am the producer of the Speaking of Women's Health podcast. So first thank you, dr Manos, for taking time in your busy schedule to re-record this part of the podcast episode, and we did hear a lot of important information in the first part with Dr Thacker. But I'd like to start this portion of the interview discussing academics and the connection to performance in school and ADHD. So, generally speaking, do most children with ADHD not perform as well in school?
Speaker 2:So that's a very good question. To perform well in school requires certain fundamental behaviors that often are not available to a child with ADHD. So, for example, staying in seat, sitting still and paying attention to one source of information, like the teacher, is a fundamental part of being successful in school. So many children with ADHD, whether they are of the inattentive type or hyperactive impulsive type, tend to have difficulty staying seated and being able to attend to one voice source, for example, like the teacher, and so children often miss things in school. And on top of that, let's say, there is silent work being done, like a worksheet a child is to complete at the desk. Worksheets are often very unstimulating and not very activating to attention not very activating to attention so children tend to get distracted or drawn away from tasks much more easily than when you have ADHD, than a child who does not have ADHD.
Speaker 3:Okay.
Speaker 2:So ADHD can clearly interfere with functioning in school.
Speaker 3:Mm-hmm. And if someone is doing well in school and getting good grades, does that usually eliminate the fact that they have ADHD?
Speaker 2:No, in fact, that's very insightful of you to ask, because people with ADHD, who have higher IQs or manage information much more effectively, can pay attention for perhaps a quarter of the time that another student must pay attention to for the whole time. So many kids who are bright tend to perform quite well in school and in fact do quite well even through high school. So they breeze through school and get good grade point averages. Then they go on to college and realize that the workload in college is far more demanding than the workload in school, so subsequently they begin to require more assistance in completing the schoolwork that before came so easily to them. So just performing poorly in school is not an indicator of ADHD at all.
Speaker 3:Okay, okay, so well then, how do clinicians test for ADHD?
Speaker 2:There is really only one way of knowing whether ADHD is present, and that is doing a concerted, semi-structured interview related to the description of behavior. What does the child do? So? For example, in our office, this conversation takes anywhere from 40 minutes to an hour and a half, depending on what's occurring for the child. So one asks how does the child behave at home and how does the teacher report the child behaves at school? It's important to address this kind of functioning across settings home, social network. Has there been trauma in the child's history? Is there difficulty in school? And so asking about behavior across settings is very important to do.
Speaker 3:And while you're doing that testing, is it usually with the parent in person, the child in person and maybe someone like you mentioned, either a teacher or another person in their relationship or social world, or is it just with the child?
Speaker 2:No, it should never just be with the child and in fact it's best to begin the interview with a parent, and we always do testing here and in that testing. The examiner is the one who does the interview with the child. But a detailed, systematic inquiry as to the child's behavior in multiple settings is critical. And who knows the child best but parents and teacher? Right Now we typically do not directly interview teachers, but we get teacher input by asking them to complete several different rating scales scales.
Speaker 3:Okay, okay, so what is the prevalence?
Speaker 2:of ADHD here in these states compared to the rest of the world. So there are a variety of different estimates of prevalence, and in the United States the childhood prevalence is considered to be about 11%. Worldwide prevalence of ADHD is rated from 4.7 to 7.2%, so there are very, very many people with ADHD children and adults.
Speaker 3:So why do you think that here in the US the percentage is higher compared to the rest of the world?
Speaker 2:That's a very good question, and I know some people have cracked jokes about it that what attracted people to an unknown territory like the United States from the very beginning was that they had that restlessness associated with ADHD. So they came to the US. Now some people think that it's kind of funny to also joke that Australia has a very high prevalence of people with ADHD because Great Britain sent all of their criminals to Australia. Now I don't know if that's something you want to say in there, but nevertheless it's an interesting anecdote that people bring up. Yeah, why the prevalence of ADHD in the United States is so high? I don't know of anybody who's given a satisfactory explanation other than that somehow it's in our gene pool.
Speaker 3:Interesting. So can the condition, the ADHD. Can it be correctable, manageable, Is it lifelong? Does the brain sort of develop and help people maybe outgrow it later in their life?
Speaker 2:ADHD does not go away and people do not outgrow it. So when I was in graduate school, we were always told that adults don't get ADHD and that it's a childhood condition. But that's absolutely not the case. What happens is that over time, hyperactive and impulsive behavior tend to tone themselves down or to be less observable. But inattention does not go away and many times people experience comorbidity like depression or anxiety comorbidity like depression or anxiety. So ADHD is a lifelong condition and doesn't go away.
Speaker 3:Huh, well, I know just from working with Dr Thacker for such a long time. You know we have. She has noticed and I've heard from you know, in our meetings, that more and more women are coming in and getting a ADHD diagnosis, even, you know, up to midlife. So maybe back when you know, when they were younger or you know, as you mentioned, you know, during their younger school age they didn't really notice it. They did well in school and then as they've gotten older, you know it's sort of now become more of an issue for them in their adult life.
Speaker 2:So my wife is very fond of telling me that women are smarter than men anyway. So that's why? So women being smarter tend to find it easier I shouldn't say easier they tend to be more successful in getting through school and subsequently, the detriment of ADHD. The problem that it poses in living everyday life doesn't show up oftentimes until women have children and are the primary caretakers of children, because when you have children in the household, suddenly the demand of life gets exponentially bigger.
Speaker 3:Oh yes, very overwhelming. I have three at home and two boys who are very well, I'd have to say, one more restless than the other and for a long time. I would ask, you know, his pediatrician teachers. I've had him tested but you know what's kind of come back is just, this is his personality. He's not diagnosed with ADHD, he's just has a. You know he's an energetic, rambunctious young man. He's 14 now and I'm hoping, as he gets older, this, that frontal lobe part of his brain, will keep developing and he'll be able to sort of. You know, relax a little bit.
Speaker 2:Well, so you're bringing up something very interesting when you talk about frontal lobe bit. Well, so you're bringing up something very interesting when you talk about frontal lobe dominance, and that is that there are two distinct kinds of attention. One kind of attention is called automatic attention, and in the ADHD brain, automatic attention is exceptionally strong. People with ADHD tend to notice things far more than most other people with ADHD tend to notice things far more than most other people, so automatic attention is very strong in the person with ADHD. Directed attention, however, is the kind of attention you use when you have to do something that is of low interest, like doing taxes or completing boring schoolwork. Directed attention is the kind of attention that is quite effortful. You have to force yourself to use it. Automatic attention is a kind of attention that is just there. It's applied to things that are interesting, and automatic attention is attracted to any change in the environment around us.
Speaker 2:So many times, some people have extrapolated that the historical significance of ADHD is that when we all lived in hunter-gatherer tribes, hunters were the ones who had ADHD, because their brains were the kind of brains that noticed things that other people didn't notice, and subsequently they were successful at hunting and providing sustenance to people in hunter-gatherer tribes. The ice age, when people settled down and lived on farms, a different brain that could sustain attention for a longer period to watch plants grow or wait for seasons to change became predominant. So evolution selected for that brain, which would explain why in some cultures there is a lower incidence of ADHD and in some there's a higher incidence of ADHD.
Speaker 3:That's really interesting. So let's talk a little bit about medication and if there's any side effects to those. So can some ADHD medications cause other symptoms or side effects, like we've talked about depression briefly, you know, especially if children have been on these medications for, you know, most of their developmental years.
Speaker 2:So again I want to be clear that I do not practice medicine and I don't give medical advice, but I have conducted clinical trials of medicine for about the past 30 years, so I'm fairly familiar with how these medicines work. And what medicine simply does is provide greater access to directed attention, and directed attention is moderated by language. For example, if you have to go to the store and get milk, eggs and butter, you say to yourself I'm going to get milk, eggs and butter, and so you do that. When you walk into the store, you are speaking to yourself or using language to orient yourself to what it is that you're there for. So milk, eggs and butter, so you can go down the aisles and get milk, eggs and butter. But let's say you happen to walk down the cookie aisle and you see Oreos. Oreos may attract your attention, and so you get Oreos too, which is not milk, eggs and butter.
Speaker 2:But language is what sets human beings apart in terms of their managing themselves and their directing their own behavior. We use language to direct our own behavior, and language is a directed attention task. Consider the tasks that are assigned in school. The teacher says children, sit down and do this worksheet. Here's how you do the worksheet and then she reviews the directions for the worksheet. Those are language-directed behaviors, and language-directed behaviors are what are difficult for a child or an adult with ADHD to use. So what occurs in the immediate environment, the attraction of what's occurring around the person, is often far more powerful than the language that we're using to regulate or self-regulate our own behavior.
Speaker 3:Mm-hmm. Okay, so it seems that more young people and I know this just because I do have three school-age children are being diagnosed with either an anxiety disorder or ADHD. So is there a connection between the two, adhd and anxiety?
Speaker 2:So again, that's a very astute question. That is, that people get anxious when they leave things incomplete. It's more obvious in adulthood that when an adult leaves something incomplete, there always is a reaction to it, and incompletion is actually a broken agreement. You said you were going to do something and you didn't do it. That is the biggest problem that adults with ADHD have. Leaving something incomplete, a broken agreement, will always result in anxiety or depression of some kind. Very few people can ignore broken agreements and there may be a variety of reactions to that, but nevertheless, you cannot ignore a broken agreement, and so people who leave things incomplete consistently and systematically often are anxious and can get depressed as well depressed as well.
Speaker 3:That's really interesting because my son last year transferred schools in the middle of high school and it was a big you know change for him. He went from being a you know a student who had no problems and you know, to trying to keep up with all the school work and I think it led to a little bit of anxiety because he was he was having you know, doing half a worksheet, trying to turn it in and and you know new grading scale and everything in the school, yeah. So, while it's really interesting that you say that and it kind of makes sense to what he was, what was happening in his life last year.
Speaker 2:Well, again, remember that school tasks are largely farmer brain tasks and I'm not diagnosing your son, of course. Yeah yeah, people who have very sensitive attention that reacts to things that occur around them are going to do just that. They're going to react to the things that occur around them rather than to the thing that's sitting in front of them, that they are directed via language to do.
Speaker 3:Sounds like him. Yeah, okay, so we talked again a little bit about the medication. But does the ADHD medication it allows the person to focus better on the task at hand correct usually?
Speaker 2:Yes. So the American Academy of Pediatrics has as its gold standard the use of the stimulants for treating ADHD. All the stimulants do is improve directed attention, so a person can use language effectively to complete the tasks that are extant in their world. So pharmacotherapy is a very effective strategy for treating ADHD because it improves directed attention. Many kids, for example, whose attention is automatically drawn to things that are external to them rather than to the instructions that may be given to them, that they need to repeat to themselves to put their behavior under the control of those instructions. Many times that cannot be available to a child, and what medicine does in strengthening directed attention is allow the child to use language or instruction more effectively to self-regulate. That's, in essence, what it does.
Speaker 3:That's, in essence, what it does. Okay, so, other than medication, are there any other say, like at-home tips or steps that a person or a child can do instead of taking medication? To kind of get that focus.
Speaker 2:Well, for example, we have at the Cleveland Clinic a summer treatment program. At the Cleveland Clinic, a summer treatment program the summer treatment program is considered to be the best behavioral program for kids with ADHD that there is. There is nothing better than the STP, and what the STP does is to provide contingent acknowledgement of appropriate behavior, and contingent the technical word is punishment, but the contingent withdrawal of reinforcement or withdrawal of points for negative behavior. And so by reinforcing appropriate behavior, you strengthen the presence or the activation of appropriate behavior for children.
Speaker 2:So many times we live in I mean, most of us live in this culture, so this culture tends to be a punitive culture. The cop doesn't stop you and give you a $20 bill when you're going the speed limit. The cop stops you when you're not going the speed limit or going over the speed limit, and so you are punished for that. So, as a result, we live in a punitive culture and we're so subsequently accustomed to punishing the things that kids do. So a child will lose his iPad for two or three days if he doesn't do what his parents tell him to do right now, and so that kind of thing is not particularly effective. But when you also show appropriate behavior and that appropriate behavior can result in a positive consequence, then appropriate behavior tends to consistently improve over time, which is what we find in the summer treatment program, treatment program. So there absolutely are behavioral programs and there are a number of different parent trainings and parent behavioral programs that can be very effective.
Speaker 3:Okay, can people find any of this? Maybe in a book, you know? If they don't have maybe the time or the resources to do, you know, a professional treatment, is there anything at home that parents can do?
Speaker 2:Well. So we often recommend that parents use the book One, two, three Magic. One, two, three Magic, we feel is probably the best way of managing behavior in the household that there is, and it also indicates how to increase positive behavior and increase compliance at home, but essentially for teenagers also, there's a 123 Magic for Teens that incorporates and includes the teenager in the management of behavior in the household, which is very important for a teenager's autonomy.
Speaker 3:Yeah, absolutely. That's great. I'm going to look into that book myself, because my second follow-up question was you know, is it too late after maybe they hit a certain age?
Speaker 2:But you know. So if there's a teenage version, that's great. I think that'd be really helpful the kinds of things that they may do and revise how they do things in the household to avoid having to rely on directed attention. So putting things in the physical environment, like a shared to-do list, for example, can be a helpful thing. Now, to-do lists don't get something done. To-do lists only indicate what needs to get done. It's the action towards the task that gets the task done. So adults themselves can use behavioral strategies to improve the concerns that they have for themselves.
Speaker 3:Right, I love that shared to-do list and I think that'd be really helpful for a lot of households, even if you are empty nester and your kids are grown or you don't have children. But I mean, I feel like, speaking as a woman, we take on we tend to take on a little bit more around the house and work and maybe are raising children or helping with grandchildren and it can get overwhelming and I know probably a lot of arguments are why am I the one always cleaning the bathroom or vacuuming or going to the grocery store? So I think that's a really helpful tip.
Speaker 2:I'm going to start that. The bad question to ask is why am I always the one?
Speaker 3:Yeah, I mean, yeah, it's very common, it is.
Speaker 2:It's useful to come to agreements and to agree that you are going to complete agreements, that you're going to adhere to them and bring integrity to the agreements, because an agreement not kept can be a true source of problems itself, right. So if you are going to agree to make agreements and to keep your agreements, then keeping agreements becomes the sole source of planning between two people.
Speaker 3:Yeah, that's great. So we talked about the non-stimulant treatments and so that's really helpful. I wanted to follow up a little bit on the medicine, really quick on does, and I'm thinking this more specifically well, not just for children, because so many adults have issues, you know, falling asleep. But do you need to take the medicine while you're sleeping, or is it better for that drug to maybe be taken early in the morning, so then it's out of your system by the time you're trying to fall asleep at night?
Speaker 2:It should always be taken early in the morning, according to physicians, because the stimulants are in the system for between six and 13 hours and then they're out of the system, so when a person sleeps and they can interfere with sleep even if they're out of the system. So it's important to use medicine in an appropriate way and follow the doctor's orders when they're taken. The immediate release stimulants last between three and four hours. The extended release stimulants can last between six and 13 hours.
Speaker 3:Wow. Do you think the screen time use in young people and adults is bad for the brain or that brains need more directed attention because our screen use is disrupting that in some way?
Speaker 2:So saying something is bad for the brain is going a little bit too far for me to comment on, but I do not think screen time is helpful to a person with ADHD. But I do not think screen time is helpful to a person with ADHD, and the simple reason is that screen time activates automatic attention. It's interesting sorts of other activities that are in the corner of the screen or not. You know they attract your attention. Screen time activates automatic attention, and you know as well as I do that all of our attention cannot be activated solely by something that's interesting, and in fact, much of what we do in fact most of what we do during the day is simply not interesting, and so the brain has to get, or the brain can get accustomed to doing directed attention tasks.
Speaker 2:If the brain gets accustomed to only being activated by interesting things, which is what screen time does, then that is a very difficult thing to overcome, and in fact, many of the screens that kids are accessing these days have built into them something that shows up as interesting every 30 seconds, and when the brain is activated by something every 30 seconds, a person begins to expect that that's the way it's supposed to be.
Speaker 2:And so if the mom says, go scrub the toilet right now, and there's nothing interesting about scrubbing a toilet whatsoever, and there's nothing interesting about scrubbing a toilet whatsoever. So having to go do that task becomes it's like being in a desert and there's nothing there that can be activating and even the threat of a punishment if you don't do it is not activating enough to make a person do it. So screen time gets children used to having automatic attention constantly activated, as if that's what's supposed to be. And yes, it would be ideal if everything was interesting all the time, but it's never going to be interesting all the time, at least not in the world that we live in right now. Yeah, so I discourage unmanaged screen time as strongly as I can discourage it in that the American Academy of Pediatrics says by age six, an hour of screen time a day is the maximum. And then, as you go up into adolescence, screen time becomes much more difficult to manage. But there still should be limits to screen time.
Speaker 3:Absolutely. I mean it's difficult, but I wholeheartedly agree with you. I mean we've tried to kind of, you know, not give those phones. We've never even actually had an iPad in our house, so but as long as we could get away with it, you know so because and now I just they're just I'm talking to them and they're on their phones and I'm like, put it down and look me in the eyes because you're not focusing on me. Number one, don't tell me you are, because I don't believe you.
Speaker 2:Well, and even when you look at being an adult situation, like if you go out to dinner at a restaurant, if you look at tables of individuals two individuals sitting with each other, both- of them on their phones two individuals sitting with each other, both of them on their phones. Screen time is becoming truly intrusive into our modern world, and I, for one, just find it really difficult to accept.
Speaker 3:I agree, I mean you're so right. I mean I don't get to go out to eat too often, but when I do, I can't believe how many people are just sitting there on their phones together rather than talking. You know, it's it. Culture's really changed in the last you know decade.
Speaker 2:My dear, my own dear wife gets mad at me because I don't answer her when she calls on my cell phone, and she's used to it by now though, so so it's not that much of a problem, and she knows how to reach me if she needs to. So, at any rate, screen time is a major problem today.
Speaker 3:Yeah, I agree. Well, I don't want to keep you too much longer. We're wrapping up here. I guess my last question would be, if there's I know this is going to be a big one but any connection to the COVID-19 pandemic and that impact on the children's brains who were, and adults who were, forced to work from home or stay home, maybe spending a lot of time on screens or, you know, working virtually, children virtually during school. Do you think that's any connection to increases in ADHD and, you know, these other learning disorders?
Speaker 2:So I've not read any active research that took the COVID infection as being indicative or intrusive in people with ADHD, other than that, when kids were at home, they have more access to screens and their brains are more accustomed to doing what's entertaining to them as opposed to doing what is required of them. That certainly is a possibility, but as far as COVID is concerned, regarding impacting ADHD directly, I don't know of evidence that indicates that.
Speaker 3:I mean I just know I can say I definitely in my older children. Just, you know, doing school online for a year did not help them with their grades or anything like that. So I know we've seen it. I mean, that's just my personal opinion, so I'm sure other parents you know as well. Yeah, but are there any other final thoughts before we wrap up our interview that you'd like to share with our audience?
Speaker 2:Well, I think the final thing that I would really like to say is that a person may have ADHD, that does not mean that their life is limited in any way, and, in fact, many very successful people have ADHD and would be diagnosable ADHD. I mean, if you consider people who are on television or screen, there are many people who are very high energy and who would, some who have admitted and been diagnosed that they have had ADHD or are diagnosed with ADHD, and there are many, many people with ADHD who are highly successful. There are many, many people with ADHD who are highly successful. And so I'll just give you a perfect example.
Speaker 2:When I married my dear wife, she had a little three-year-old boy named Michael. Michael was the most hyperactive child you have ever seen in your life, and at the time I was working at the University of Hawaii and Melissa and I lived in Hawaii and Michael would do anything if we took him to the airport on a Saturday so he could lay in the grass by one of the biggest runways and feel those planes land. So I set up a marble system for him where he earned marbles for appropriate behavior, and when he cashed those marbles in, the thing that he invariably wanted to do was to go to the airport on a Saturday, and if you're living in Hawaii, why do you want to go to the airport?
Speaker 1:on Saturday.
Speaker 2:But we took him to the airport on Saturday and he lay in the grass and could feel those huge 747s landing. And Michael is 39 years old now. What do you think he does?
Speaker 3:for a living. I see a pilot.
Speaker 2:Oh my gosh, he's a pilot. He flew for Pacific Northwest. It was a freight company and they transferred freight from Guam to the United States and to Hawaii. And one time he was flying one of those big planes and he was landing in Guam and the front landing gear did not descend, and so he had to fly around for a while and get rid of some of the fuel, and then he landed that plane. It stayed exactly in the middle of the runway. Nobody was hurt, nothing was damaged. He told me that when he landed that plane, he was so hyper-focused on the instrument panel that nothing else got in, and so people with ADHD can perform exceptionally well in circumstances that many of us would consider pretty concerning.
Speaker 3:Yeah overwhelming for sure. That's a great story. I actually also did the marble jar with my three children a rewarding system.
Speaker 2:I did.
Speaker 3:I think I probably found it online and they could earn something, and a lot of times it would be like can we go to the zoo on the weekend or something fun, rather than maybe a toy. So I agree with that. Well, thank you, dr Manos, for joining us on the Speaking of Women's Health podcast again, and thank you to our listeners for tuning in to another episode. We're so grateful for your support and hope you will consider supporting the podcast and sharing it with others. And to catch all the latest from the Speaking of Women's Health podcast, you can subscribe for free on Apple Podcasts, spotify TuneIn or wherever you listen to podcasts. So thank you again and we will see you next time in the Sunflower House. Be strong, be healthy, be in charge.
