The future of ADHD

0:00This is Stanford Engineering's The Future of Everything, and I'm your host Russ Altman. I thought it would be good to revisit the original intent of this show. In 2017, when we started, we wanted to create a forum to dive into and discuss the motivations and the research that my colleagues do across the campus in science, technology, engineering, medicine, and other topics. Stanford University and all universities, for the most part, have a long history of doing important work that impacts the world. and it's a joy to share with you how this work is motivated by humans who are working hard to create a better future for everybody.

0:37In that spirit, I hope you will walk away from every episode with a deeper understanding of the work that's in progress here and that you'll share it with your friends, family, neighbors, co-workers as well. ADHD really is a serious condition and it can be debilitating and can get a lot of strain on an individual who has it and there are very significant studies over the years that are large prospective studies that showed that ADHD is associated with higher bad outcomes, including mortality. And so they are more likely to get into car accidents. They're more likely to be injured in general. They're more likely to have drug abuse, alcohol abuse problems, mental health issues, incarceration, holding a job, right?

1:23Employment issues of educational. Of course, I didn't mention problems and not completing school or education. So it is a very serious condition and it's a lifelong condition.

1:38This is Stanford Engineering's The Future of Everything and I'm your host Russ Altman. You know if you're enjoying the show or if you like to listen to it we really would love it if you would rate and review it. Rating and reviewing we like to get a 5.0 if we deserve it. reviews tell people why you like it or why you don't like it. It's really useful and it helps grow the show. It also helps us get feedback from you. So thanks very much for doing it. Rate and review. Today, Yair Bannett from Stanford University will tell us that attention deficit hyperactivity disorder can be diagnosed in young children and it's super important to do so so you can implement treatments to help them avoid the lifetime risks that come with that disease.

2:19It's the future of ADHD. Today we are continuing our new feature, The Future in a Minute. At the end of my interview with Yair, I'll ask him a few rapid questions, he'll give a few rapid answers, and that'll be it. Before we get started, another reminder, we love it when you rate and review. It helps us, it helps the show, it feeds the algorithm. Thanks for doing it.

2:47ADHD or attention deficit hyperactivity disorder is a disease that we've seen diagnosed much more in the last couple of decades. Developmental behavior pediatricians are the specialists who study this disease and who understand how to diagnose it, how to treat it, and why it's so important to treat. It's difficult to diagnose, especially in small children, but it is possible and recognizing the disease early allows physicians to start treatments, both medical treatments, drugs, as well as non-pharmacological treatments that can really improve the life and the future of the patient who suffers from ADHD.

3:25Well, Yair Bannett is a developmental behavioral pediatrician at Stanford University and an expert at ADHD. He saw it as a primary pediatrician in the clinics, and then he made it his research passion. He'll tell us about ADHD, its symptoms, its treatments, and what the future is like. Yair, why did you decide to study ADHD, especially in children who are pretty young? Well, thank you for having me, Russ. It's great to be on the podcast. And I'd like to say that initially I started being interested in ADHD as a primary care pediatrician. When I first trained as a resident, I didn't have a lot of exposure to developmental and behavioral problems.

4:08But then as a pediatrician, as a PCP in the community, I noticed that parents often came to me with these concerns for ADHD and other developmental concerns. And so I started learning more and more about developmental behavioral pediatrics, and I decided I want to specialize and know how to support children who have these challenges. Okay, great. So I think what we should do to start is establish some of the baseline, basic facts about the disease. So first of all, we called it ADHD, but it is attention deficit hyperactivity disorder. Tell me if I'm wrong. And could you give a little picture about like, what are the symptoms?

4:48What's known about the causes? Where are we with this disease right now? Absolutely. So ADHD is a very common condition and the prevalence varies. Also, I talk about the United States, but it even varies within the United States. And somewhere between 8 to 10 % of children get diagnosed with ADHD. That is pretty high prevalence. And the symptoms we're talking about, the core symptoms, are hyperactivity and impulsivity, as well as inattention. Those are the core symptoms. And as anything in the DSM, the manual that defines this condition, there has to be a functional impairment. So it's not enough to only have these symptoms, right?

5:32All of us sometimes are inattentive or have a lot of energy, but it has to be impairing. It has to prevent you as a child or as an adult from doing what you need to do. And another stipulation is that it has to occur in at least two settings. So it can't just be at home that you're presenting with these symptoms. It has to be at least in two settings. And again, for children, typically the two settings would be home and school. So that's really interesting. And in my lifetime, my impression is that the frequency of diagnosis has gone way up. And I'm sure we'll talk about that. But let me dive a little bit into those.

6:08You said hyperactivity is one of the, and attention deficit, it's in the title. Where do we get our baselines from? And how does a parent know if what they're seeing is at a normal level? Because, you know, these can be kids and like kids are crazy. but and how can they figure out and how does the clinician figure out if this level of activity is dysfunctional? What are the, can you give a little bit more about the signs that they see, maybe typical situations that a parent or a teacher might find themselves in? Yeah, that's a great question. I would say, and it also ties to your first question around why I chose to focus on young children, because I think that's where it becomes the hardest to distinguish, right?

6:53Because they're always bouncing around. And so, yes, I think that the answer, the short answer is it's very hard to distinguish. And I think that's part of the controversy around ADHD that exists where people, some people will say, oh, it doesn't even exist. There's no sort of thing. It's just kids being kids. And I think as, you know, as experts in the field, we all agree that's not true. And it's a spectrum like many other things. And so for parents, for especially first time parents, it is pretty much impossible to distinguish and know. And that's where they go to the pediatrician and say, hey, I'm not sure, is this normal or not?

7:29And that's exactly what happens often. That's what happened in my office as a PCP where I said, okay, I want to get more training and understand how to distinguish when it is within the realm of normal, let's just watch and wait or give minimal supports versus more. And so again, it's a type of a condition that Where the diagnosis relies on behavioral observations, on reporting, subjective reporting from the parents, from teachers often. And all of these vary, right? So sometimes you might have one type of parent or one type of teacher that will report things. And then another parent or another teacher will report very differently, right?

8:08So you can imagine how inaccurate it might be. And so we have to, again, as experts, we have to use our clinical judgment many times, use our own observations as well in the clinic to make a decision. Now, what do we understand about the causes of disease? You know, there's always nature versus nurture. There's a million other things, of course. But do we think this is fundamentally an inborn feature of the patient, of the child? Or is this something that is a response to environmental conditions? And I understand completely how this is a very sensitive issue because you don't want to tell a parent you created an environment that created this disease, right?

8:45I mean, this is a very difficult, I'm guessing, assessment. That's right. That's right. So we do know for sure over the past few decades, the data is gathering, you know, to clearly say there are inborn differences in children with ADHD. We know there are genetic components to it. We know that there are differences in the brain structure of individuals with ADHD. And so, yes, the answer is it is something that is inborn. At the same time, as with all of these conditions, including autism, for example, which is another condition that we see frequently in our specialty, the answer is yes, the environment can also have an influence.

9:29We don't know yet to what extent, I would say. But in ADHD specifically, you know, there's this whole question around, for example, screen time and how much of that's influencing. And so, again, the answers are not there yet. But I would say for certainly we can we always assure parents that, you know, it's nothing that you did wrong, typically, unless it's a very extreme case. Most likely it is the way the child is born and we can just try to adapt the household. And maybe this household needs to be a little bit different. And so the environment is not only a part of the problem, potentially, it actually a lot of times is a part of the solution.

10:08Great. So a few more questions, because this is really, really very helpful. You made a very intriguing side comment that the prevalence may be different in different, not only in different parts of the world, but in different parts of the United States. Talk to me about what's known about that, because that sounds really interesting. Yeah, so the CDC, the Center for Disease Control, has a prevalence rate that it publishes. And the last time I looked, it looks like the West Coast specifically, and we are in California now, has lower prevalence compared to the East Coast. Those are kind of, I would say, the two extremes in terms of the prevalence, where it's the lowest around the West Coast and it's the highest, I would say, in the northeast of the United States.

10:54And that has been true for a while. And I don't know to say, again, I'm not an epidemiologist. It's hard for me to say, you know, the reasons behind it. I'm not sure anyone does know. But, you know, there's this argument always about how much of it is true prevalence versus just, you know, higher detection in certain areas. There are cultural aspects to it as well. One of the things we know is that in Hispanic patients, the prevalence is lower, for example. And one of the thoughts would be that, you know, in certain cultures, maybe there's just more tolerability for a wider, you know, presentation of behavior and development.

11:37So what about on the global scene? So I know you, I think you mentioned that you practiced in Israel for many years as a primary care physician. Did you see a similar syndrome there? And what do you know about other cultures and other continents? Yeah, I would say that, yes, to your question about Israel, it is very similar prevalence to the United States. And many other, I would say, westernized countries, we find pretty similar prevalence. I think it becomes harder in other countries where maybe the monitoring also of these conditions is not as accurate or as robust. And it's just harder to know the real prevalence.

12:13so again it's really hard to tease out how much is just it's about the monitoring and being able to give a good number versus maybe like we said earlier differences and cultural perceptions yes yes um and then i also wanted to get a sense for the natural history um you're you're dealing with children and obviously and we're going to talk about treatments of course that's i'm sure people are very interested in that i am very interested in that but before we get to treatments if untreated or if if it's not a recognized can you give us a sense for what what is the natural history? What is the type of life and the type of challenges that a patient might have over time?

12:48Yeah. So this is a great question. I think this is, again, one of the areas where there are large misconceptions about ADHD. So I'm glad to have the opportunity to answer that. I would say, first, one of the things we know is that ADHD is a lifelong condition. It was originally thought to be not too long ago. It was thought to just be a childhood disorder. And what happens is children at some age eventually stop bouncing around. And so you don't see adults, you know, bouncing around typically, right? But many of these adults who had ADHD and were bouncing around still have ADHD, even though they're not bouncing around.

13:23So that's one important thing to know. And the second part is that ADHD really is a serious condition, and it can be quite debilitating, and it can create a lot of strain on an individual who has it. And there are very significant studies over the years that are large prospective studies that showed that ADHD is associated with higher bad outcomes, including mortality. And so they are more likely to get into car accidents, they're more likely to be injured in general, they're more likely to have drug abuse, alcohol abuse problems, mental health issues, incarceration, holding a job, right, employment issues, educational, Of course, I didn't mention problems and not completing school or education.

14:08So it is a very serious condition and it's a lifelong condition. And so that I would say the natural history before we'll talk about treatment, like you said, but I'd say the natural history can be quite grim. And again, it is a wide spectrum. So obviously there are many people who have ADHD and certainly thrive, but it can be quite debilitating. And what is our ability? So now I'm very interested, what is our ability for adult physicians to recognize ADHD and make that diagnosis later in life? I'm imagining that it's more difficult. You're kind of attuned to it. There are parents who are worried.

14:43There may be teacher reports. You're a pediatrician. And I know you might not see 18-year-olds or 30-year-olds or 50-year-olds. So how good are we in our primary care for adults in recognizing this disorder? Yeah. So I would say it's hard to recognize, especially now adults these days, typically what we hear in clinic because they bring their children who have ADHD, right? So as I mentioned, there's a genetic component. So I do get to see them in the office as parents, not as the adult pediatrician or the adult physician. But to answer your question, what we mostly see is adults saying, oh, you know, I think I had ADHD, you know, but I've never been diagnosed.

15:26And one of the criteria actually in the DSM for diagnosing ADHD is that the symptoms have to appear before age 12. So the idea, again, is that to talk about ADHD, we're talking about something that emerges in childhood. Because if it's something else that emerges only in adulthood, likely it's something else. I see. Oh, that's an important distinction then. So they'll have to be going back and thinking about what life was like before they were 12. So as an adult, they would have to talk to their parents, people who remember them, and kind of there would be a little bit of archaeology going on there to figure out if in retrospect, that could have been what was happening.

16:04That's right. And there is also better recognition of adults with ADHD today. I do know that from also just from reading the literature and speaking with people, certainly more adults now going back and saying, yes, I wasn't recognized when I was a kid, but it is clear that I had ADHD and I still do. and I learned that I can take medications that can help me function better at work, for example. Great. Okay, good. So now let's get into treatments because, of course, people always think about pills, but I know that you've looked into both medications but also non-medication treatments. So where are we with treatments?

16:42So yeah, there are two types of treatment for ADHD. There are the medications that most people know about, and there are also non-pharmacological interventions that are mostly for younger children, that most of the research is done on younger children for that. and so when we speak with families especially of young children we talk about these two arms of treatment and ultimately for most children we want them to receive both so that is the gold standard is to eventually hopefully you'll be getting both medication treatment and also behavioral interventions so that's i would say an overview of kind of the types of treatment we can go dive deeper into it this is the future of everything with russ altman we'll have more with Yair Bannett next.

17:45Welcome back to the future of everything with Russ Altman. I'm speaking with Yair Bannett from Stanford University. In the first segment, we got a great tutorial on ADHD, ADHD, attention deficit hyperactivity disorder, its symptoms, a little bit about its causes, and we're about to start understanding what are the treatments, do they work, and why are they important. Don't forget, at the end of the conversation, we're going to have the future in a minute where I'll ask Yair some quick questions and get his off-the-cuff answers. Yair, you mentioned that there were both pharmacological and non-pharmacological treatments.

18:21Let's start out with the pharmacology. What are the drugs that we use and how do they work? What should we know about them? Great. So we use generally two types of medications. The most longstanding medication that's been around for almost 100 years now is in the category of stimulant medication. So the name of the family are stimulants. The common names you may have heard of are Ritalin and Concerta and Adderall. And so those medications are very safe to use in children. we know that they have a really significant benefit short term for sure. And immediately once you start using the medicine, you see reductions in hyperactivity impulsivity and increases in attention.

19:02I think there's a lot of confusion because they're called stimulants. So maybe you can address that. People thinking, why would you give some kid who is hyperactive a stimulant? Yeah, so it is true. And the effect varies depending on the person. So a person without ADHD might become more stimulated. But what's interesting is, and again, this was a discovery that would just happen. It's not, you know, people just tried it out and saw it had an amazing effect. And so what we see is that the stimulants actually create more focus. There isn't, I think the mechanism of action is not entirely understood, I would say.

19:40But we do see that children who use stimulants typically have a large positive effect on the core symptoms of ADHD, I would say probably close to 80 % of children have a positive effect. That's great. And that's, so that's the first class is the stimulants. That's right. So the stimulants, again, have a very strong positive effect on the symptoms. We also know from recent research, and this is very interesting, I think not many people know about this, but we do know that it also carries benefits, long-term benefits. And this is just emerging now because it's so hard to do these longitudinal studies.

20:15But there are really strong studies showing that people who are taking these medications long-term are less likely to have those bad outcomes I mentioned earlier, including incarceration, including drug abuse, alcohol abuse, and those kinds of bad outcomes, getting into car accidents. So I think that's a really important thing to know about it because when people think about weighing the pros and cons of trying these medications, I think everyone agrees there are short-term benefits, but not everyone knows that there are actually long-term benefits as well. And that implies, just to make a point of it, that some of these drugs you might be on either for life or for a very long time.

20:56Is that right? That's right. And these medications are very easy in the sense that you can stop and start whenever you want. There actually isn't even a ramp up period like many other medications or psychopharmacological medications. So yeah, it's true. And once the child grows older, he or she become the person to decide also, right? For example, in college or later in life, do they want to take it? And when do they want to take it? And they can choose to take it on certain days or just before specific events like tests and things like that. Oh, that's great. Oh, okay. And I think you said there were another class.

21:34That's right. The second class of medications are called non-stimulants. The most common ones for that are alpha agonists, as well as ademoxetine. And the non-stimulant medications work a little bit differently on the brain, but they have also a smaller effect compared to the stimulants. And so they reduce the hyperactivity and the impulsivity, but they don't as much increase the attention. Okay. And do you tend to use these together or is it one or the other? So in some children may use them together. For most, it's one or the other. I would say that we're looking into using non-stimulants for younger children more often because they have less of a different side effect profile.

22:17So one of the issues with stimulants is that a lot of times the main side effect is reduction of appetite, but it can also have other problems like maybe sleep problems or irritability, especially in young children. So that is why a lot of times for younger children, we use non-stimulants. Gotcha. Okay. So let's move to the non-pharmacological. I know that you've done some work in these. And so what are the things other than the medications that can help in ADHD? Yeah. So there is really strong evidence to show that when parents or caregivers participate in what's called parent training and behavior management, and they apply some strategies to modify the environment, as I mentioned, and also learn how to manage specific behaviors, there is improvement both in the symptoms, but more in the environment of the home or the chaos in the home.

23:10Homes are typically chaotic when there's a child or children with ADHD. And so that becomes better once those behavioral interventions are applied. So just to dive in a little bit, because I'm intrigued by this, you're a physician, what is the prescription for a chaotic home? Like, give me some examples of what you might ask a parent to consider. Yeah, so that's a great question. And this is something that, again, we're hoping that pediatricians can also consult parents on, not only developmental pediatricians. And the simple things we talk about are, first of all, making sure that you have a strong connection, building a strong connection with the child.

23:47That's the foundation, really. And you want to have a positive, strong connection with the child. And then on top of that, then you layer some structure, some reward system. One of the principles is called positive discipline. We don't want to punish them and say, oh, you know, you were bad and you get punished, but rather catch them when they're good. You want to identify when they're behaving well, when they're not, you know, getting up from the table every second or not yelling or not interrupting. Oh, you did a great job there and build a system of rewards. Those are just a few of the principles.

24:24There are also things related to structuring the routines also. So things are anticipated and there's some visual aids. Also, for example, morning time is usually difficult, getting organized in the morning. So there are different techniques like that that can help. And have they been studied? Like, are they working? Yes. So there are studies that show, again, that when you take that type of intervention, you can see improvements in the behavior as well as in the environment of the home, the quality of life of the family. Great. So the last few minutes, I wanted to ask, because I know that you're using a variety of methods to assess the quality of care, because, of course, the pediatricians who are specializing in this disease are, as you said, they're using medications.

25:09They might be making prescriptions about a less chaotic home. How do you know if it's all working? Yeah. So what I've focused on, and again, I came to this area of developmental pediatrics after several years of being a PCP, of being a primary care pediatrician. And my passion grew when I realized that we're not doing a great job in offering the right treatments always or even knowing what the right treatments are. And one thing I didn't mention is that most children with ADHD are managed by their primary care pediatrician. And so that's why once I came to Stanford and specialized in developmental behavioral pediatrics, I decided to focus my research and my career on helping to support PCPs to know how to provide better care for children.

25:55Because they're on the front lines and there are probably not enough specialists like you to go around for all the amount of kids with the disorder. Yeah, so that's why I chose ADHD, because it's so prevalent and it's clear to everyone that PCPs should be managing it. And indeed, they are. They're managing most kids. And so the way I've done it is my team has been looking at electronic health records. And we've been using, I started looking at natural language processing back in 2017 when my mentor offered it. And I said, oh, that sounds interesting. and then this big AI boom came about. And so now we're using large language models and having really a great success in identifying what treatments are being offered.