This week, we’ve got an incredible guest, Dr. Stephen Faraone, one of the world's foremost experts on ADHD.
Let me just give you a quick rundown of just how influential Dr. Faraone is:
He has authored over 700 journal articles, editorials, chapters, and books
Listed as the eighth-highest producer of High Impact Papers in Psychiatry from 1990 to 1999 as determined by the Institute for Scientific Information (ISI).
In 2005, the ISI listed him as the second-highest cited author in the area of ADHD.
In 2019 and 2020, his citation metrics placed him in the top 0.01% of scientists across all fields.
In 2002 he was inducted into the CHADD Hall of Fame
Currently, Dr. Faraone serves as a distinguished professor of psychiatry, physiology, and neuroscience at SUNY Upstate Medical University and president of the World Federation of ADHD.
So yeah, this guy knows what he’s talking about when it comes to ADHD and if you only listen to one episode of the podcast this year, I’d suggest this one.
One of the focal points in this conversation is the ADHD Evidence Project, which Dr. Faraone started to help fight misinformation about ADHD and give free access to the information we have about ADHD. On the site - which can be found at ADHDevidence.org - you can find the International Consensus Statement, which provides 208 statements strongly supported by ADHD research. In the episode we get more into what went into the process of making the statement and the standards of research.
In the episode, we also discuss evidence-based treatments, debunk common myths, and discuss what really works when managing ADHD.
William Curb: Well, I guess the best place to start here then would be kind of about this adhdevidence.org. And can you tell me a little bit more about that site and your involvement in it?
Dr. Faraone: Sure. Number one, I'm in charge of it. I, as the one that had designed and came up with the idea, I was concerned that there was a lot of misinformation about ADHD in all, all media, from print media to the internet. We all know that, right? And I wanted a place to present and organize evidence-based information method disorder. It started with the international consensus statement on ADHD, which, which was, I designed for the same reasons. I did this as, in my role as president of the World Federation of ADHD. I got together all the ADHD associations from around the world and it wouldn't believe it, but they're all around the world.
We convened a group of about 87 authors to put together a set of evidence-based statements about ADHD. That was published in a scientific journal, but it's also posted at the website for people to use. It's also placed for educational resources. So people who want to educate with ADHD can download totally free of charge. I think I have 370 odd slides derived from the consensus statement about ADHD. Everything on the website is free. There's no paywall. I don't even ask for email addresses. The goal there is to get people connected with evidence about the disorder.
William Curb: What constitutes evidence and this expert opinion that people tend to really be seeking out? You know, I say people seek out expert opinions, but that's not always the case.
Dr. Faraone: Well, it's true. And partly it's because I think our educational system hasn't done such a good job teaching us when we're young, meaning in grade school, how to evaluate evidence. We haven't'really been taught that. And partly it's because most of us grew up in an age where we didn't have so much misinformation out there. And so evidence was kind of obvious. If it was written in a textbook, we thought, okay, this is probably accurate, even though maybe it wasn't always accurate. I like to tell when people ask me that evidence, there's a few ways to look at that. One way is how do you evaluate an expert?
Somebody is, you know, up there talking about ADHD or they have a webpage of ADHD. How can you tell if they're an expert? Well, there's a few things you can do. One, you can go to expertscape.com to look at their rankings of the experts. That's one place to go. Another is you can go to the US National Library of Medicine at pubmed.gov, and you can look up whether that person has ever published anything about ADHD in a scientific journal. And why should it be in a scientific journal? Because scientific journals are reviewed by other people to make sure that the information is correct. That's very different from a book.
Right? You can go on Amazon and buy lots of books from people about ADHD. But those books are just written by somebody. They're published. They're out there to make money. They're never not necessarily reviewed by other people for the accuracy of their evidence. So pubmed.gov is a good way to evaluate somebody. We can also talk about different kinds or different fuel rules of evidence in behavioral sciences. So for example, somebody might talk about a patient they had and say, oh, I thought this patient, and this makes me think that ADHD is actually causes gender dysphoria.
Well, that's one experience, one patient that's considered like the lowest level of evidence possible. And this is, we could call the pyramid of evidence. You go from simple, single observations to systematic studies, the clinical trials, and then to big meta-analysis clinical trials. And some of this I describe on my website, I have a new video actually that describes all of this for people to take a look at.
William Curb: Yeah, one thing I like to say is that an anecdote doesn't tell you much about ADHD and a bunch of anecdotes doesn't make anec-data.
Dr. Faraone: I love it. That's great.
William Curb: Because it's like, you need to go beyond what's just that first level. I mean, it's a great starting place to be like, oh, is this a thing? Should we look into it more? But beyond that, it's hard to make actual observations.
Dr. Faraone: The other point I make to people all the time is I would say when you evaluate the expertise, if somebody comes across as very likable and charismatic, I'd be a little suspicious about those people. I mean, people like me, we're kind of nerdy academics. You know, we get professorial, we talk about meta-analysis, we talk about clinical trials. People's eyes start to glaze over. They'd rather have somebody telling a engaging story about a patient.
And to convince them that something. And you know what? That might be entertaining, just like TikTok is entertaining. But as far as teaching you anything but ADHD, it's basically BS. And really shouldn't even be considered unless you can see what that person says documented in the peer reviewed scientific literature.
William Curb: So one of the things that I was noticing about the ADHD evidence was the criteria to be included on there. Because there were very large studies or only meta-analysis was included. What led to that decision? And then also what counts as a very large study?
Dr. Faraone: Good question. So we struggled with this point because we there's lots of information about ADHD. And we want to curate the best documented results that are out there. And as we say in the consensus statement, if something's excluded from that, it doesn't mean that it's not correct. It just means that the data level hasn't risen to the level, the level of certainty that we are considering in that document. How large was a large study? We say that it's in the paper. I think we say 2000 participants.
William Curb: Okay.
Dr. Faraone: Is that I recall, but I'd have to go back to actually check that to be sure. And why are large studies important? Because somebody publishes on a smaller study, you can find something that's maybe not true because small studies frequently produce false positive findings.
William Curb: Yeah, one of the things I was finding though, when looking into very large studies too, is the like reliance on survey data and less ethical researchers that can kind of do the P-hacking stuff to find relevance where there isn't any.
Dr. Faraone: Absolutely. You raise a good point. This gets back to what we talked about before, which was what are the different levels of evidence in behavioral science? If we talk a little bit about a clinical trial, what we have, what's called a randomized controlled trial where people are randomized to get a treatment or not to get the treatment.
And then we follow them and we see if the treatment works. That's an experiment. And because it's a controlled experiment, we can draw very strong inferences about the results. On the other hand, somebody does a very large survey, even this large, 2000, 3000, 10,000, it's a survey of a population. It's not a controlled study. And because it's not controlled, it's subject to something in science, we call a confound. Like a confound is something which can occur in that data set that makes the finding spurious, makes the finding wrong.
I can give you a great example actually, which is coming out of the last few years for at least a decade or more. There have been data from very big studies that show there's an association in the population between mothers who smoke during pregnancy and the occurrence of ADHD in their offspring. The kids are more likely to have ADHD than mothers who don't smoke. Now that association has been confirmed by meta-analyses and very big studies. It's a real association in the sense that if you were to do another study, you would find it again.
It's replicable. The question is, does maternal smoking cause ADHD? That's a different question. Fact that they go together in a population, they could go together because of something else. And in fact, what researchers have discovered, and I'm not going to give you all the details of how they discovered it, but when we use what's called a genetically informed research design, it turns out that the reason why mothers who smoke are more likely to have kids with ADHD is that mothers who smoke are more likely to have ADHD than other mothers. And so they're transmitting ADHD via their genes and not via smoking.
William Curb: Well, that is very interesting. Like I've never seen that in being like, it's interesting to have that environmental factor have such a big effect. But that totally makes sense that it's, well, we have so much data that shows that people who have these risk factors for ADHD also, you're more likely to be a smoker if you have ADHD, so then you're more likely to give someone ADHD.
Dr. Faraone: That's right. So even though these associations exist in the population, I have to be very careful about asserting causality. That's what we've done. We really know very little about environmental causes of ADHD because most of these studies, no, actually all of them really, environmental causes are not experimental. They're just observational studies that are subject to potential confounds.
William Curb: Yeah, absolutely. This also goes back to why it's so important to direct people who are doing the peer review research to look at this because it's so hard as a casual reader to make those inferences and figure it out that, oh, yeah, that isn't a causal relationship. It's just a correlational one.
Dr. Faraone: Exactly. Exactly.
William Curb: I was interested kind of if I don't know if you'd have anything to say about because I was looking at the environmental factors, if that has something to do with, do we think there's like some like epigenetic component where it's like this gene expression that's causing these increased diagnosis with those environmental factors?
Dr. Faraone: People who believe that the environment plays a strong role believe that the environment changes gene expression by epigenetics, which of course, we know that epigenetics is real and that that occurs. But at this point, no one's ever documented and the potential environmental cause that actually changes gene expression and leads to ADHD. And one reason that another reason that's difficult is that we know from twin studies that the heritability of ADHD is about 80 percent, which means that most of the causes of the disorder can be attributed to our genome as opposed to what's happening in the environment.
William Curb: And I could see it there being like a lot of like, there's both. Like if you have the genes that for ADHD and then you have the environmental factors that would increase the likelihood, you have the genes that are there and then the gene expression that's making it happen.
Dr. Faraone: That's been a working hypothesis for a long time. And I would say there are two environmental events that I think pretty convincing to me as causes of ADHD. One of them is exposure to very extremely deprived environments as a baby. And when I say extremely deprived, these were the studies that were done, were done in these orphanages in Romania during the Chichescu regime, where kids were just basically left in cribs. They were hardly fed any food. They had no emotional support.
They were never picked up, never cuddled all their anything like that. Emotionally and nutritionally deprived. These kids grew up to have many kinds of problems, including ADHD, which interestingly were somewhat reversible when the kids were adopted later in life into homes in the United Kingdom. That's one environmental cause. The other one would be head injury, that we know that traumatic brain injuries can lead to ADHD. And there, the risk is fairly high. It's like a sevenfold, five to sevenfold risk, increased risk. If you have had a traumatic brain injury.
William Curb: That always seemed interesting to me too, because I'm like, this seems like is this actually ADHD or is it just something that has the exact same symptom profile as ADHD? And so we might as well call it ADHD.
Dr. Faraone: Well, the way that I think about it, and many of my colleagues think about mental health problems in general, that's ADHD, is if a person meets the criteria for the disorder based upon the symptoms that they have, who would diagnose the disorder? Now, if somebody happened to have an after traumatic brain injury, that would be noted, obviously in the medical record, that's the case. But we wouldn't deny somebody treatment for ADHD because it was subsequent to a traumatic brain injury, for example.
William Curb: Yeah, I just was thinking purely in the terms of like what would be the most effective treatments for someone with the different causal effects, I guess.
Dr. Faraone: Exactly.
William Curb: We have both like straight misinformation about ADHD and also misleading information about ADHD, which is also very hard with this looking through things through this evidence based lens, because there is stuff that is maybe promising, but not there yet for in terms of treatment. And then there's also stuff that's just pure quackery. I feel like it's very hard for people to parse out that difference between just straight, this is wrong, and this is just misleading me a little bit.
Like specifically, the one I was looking at recently was this effect of citric acid on stimulant medication. Like I will see stuff being like this makes this completely ineffective or there's absorption rate differences. And my first step was going to talk. I have a friend that's a bio mathematician that works in the pharmaceutical industry. And I was like, hey, what can you tell me about these? Like just look at the information that comes with your pills. They'll tell you exactly what you need to know. And I was like, that's a fair answer to that question.
Dr. Faraone: That's right. Look at the package insert. All those that very hard to read text. That's so small.
William Curb: Yeah. And doing stuff. I was like, OK, I can see that there is some interaction that could occur, but it seems like it's not clinically significant, but it is something that if you are having some problems with your medication, maybe you should look into. But it's often presented in this light of this is something you have to worry about. Don't drink OJ with your simulant medication in the morning.
Dr. Faraone: There's no question that citric acid does interact with. With stimulants can reduce their efficacy. And some prescribers recommend don't drink OJ. Don't have grapefruit and so forth. I don't give medical advice to people. So I'll leave that to the physicians. But I have a child with ADHD now an adult. And I definitely did not want him to have any OJ with his breakfast when he was taking his stimulant medication.
William Curb: Another interesting one there is the artificial food colorings, which seems to have some effect for some people, but not...
Dr. Faraone: I can tell you about those data because we did review those. First of all, all the artificial food coloring data was collected in kids who were exposed to lots of artificial food colors. So and what that was, though, they just find is that when kids are exposed to artificial food colors, if you put them on a food color free diet, the findings are really interesting. Now, the parents rate them as having lower ADHD symptoms, but the teachers don't. Now, one way of looking at that, which is the way that is probably the more common way to look at it, is that when you put an ADHD kid on a diet, a new diet, the parents know about the new diet.
They have to because they're implementing the diet. Right. So we say that they're not they're not blind to the treatment. They know the child's getting a treatment. We know that when parents know about a treatment, they're more likely to see improvements than when they don't know they're getting a treatment. The teachers, on the other hand, are actually blind to the treatment. They don't know that the child is being treated or not.
And so most of my colleagues would really say the teacher data is more informative there because the teachers don't know what treatment the child's getting. So I would say that the artificial food coloring data are very weak at best. I also say that we don't really need artificial food colors. I mean, it's just they're basically not necessary. Although I don't advise people to remove them from a diet. It's not going to be harmful to the child to remove them from their diet. It might be difficult for the parent to remove them, which is something else to consider.
William Curb: Yeah, because I was surprised when I looked at the data and saw like any effect at all, because my initial gut reaction was it wasn't going to have an effect because I had looked at like where the initial recommendations came from. And I was like, oh, that's really old data that wasn't really founded on anything. So then when I was like, oh, there are some people are seeing an effect. I was like, oh, that's interesting, but it does seem to be like even in cases where it is measured, it isn't a significant factor.
Dr. Faraone: When the effects appear to be real, they're small. They're not a replacement for the medication effects, which are always that's the other thing. The medication effects are always much larger than these other effects that people are always looking for something, whether it be a diet or meditation or homeopathy, something simpler, less dangerous, if you will, because people fear medication and the medications.
But even when they seem to be effective and again, most of them, the only supplement or diet that's been shown to be effective or treating ADHD symptoms is omega three fatty acids. There's a pretty consistent finding there. But the effect is very small. It's about 20 percent of what you get from a stimulant medication. This is why they're not prescribed or not recommended because most people won't do well at all on them for sure.
William Curb: Yeah, this is often what I often see with misleading information as well, is that it's pointing people away from what is actually an effective treatment option. They see this idea of like, oh, this does have an effect, but compared to what is not really factored into why they were doing it.
Dr. Faraone: Well, that's right. And many people with ADHD adults and many parents of kids, when they're looking at the cost and benefits of treatment versus, let's say, standard medical treatment versus something else, they forget to factor in the cost to their child or themselves of not getting appropriate treatment. I'll give you a great example. A few years ago, a friend of mine called him and said, you know, I know you're an expert in ADHD when you talk to my daughter about her son.
I said, why? He said, well, I'm pretty sure he has ADHD, but for the last five years, she's been taking my grandson to every kind of quack doctor you can think of. And he named a few types. He's on New Diets. He's on homeopathy, he's feeling the blank. And I don't think he's getting much better, but she insists that this is the way to go. So, I'll talk to her.
We had a phone conversation. And to keep it short here, I'll just say what I basically said was, look, if you put your child on medication for ADHD, doesn't that be for life? It could just be for one day. If after day one you're worried, stop it. I'd recommend you at least give it a few weeks. She called me back a week after they started the medication. She said, oh my God, I wish I had talked to you five years ago. He's changed. He sits still. He can attend in school. I can talk to him better. I can obey. He does his chores.
Those things he's supposed to run the house. And this is, of course, the story that's repeated over and over again in the world of most people that ADHD do well on their medications. But this child had to spend five years of his life disrupted, not getting a good education, not making friends, being at risk for accidents because the mother and the father, to some degree too, I suppose, were afraid of these medications, mostly because it's probably misinformation on the media that they heard about.
William Curb: I often think of in terms too of, we look at side effects of medication, but what's the side effect of not taking the medication? Much harder to quantify, but it is also so important to consider.
Dr. Faraone: Well, see, for me, it's easy to quantify because the data are very clear. People who don't take their medication are more likely to have accidents and more likely to get involved in criminal activities and more likely to abuse substances. It goes on and on. There's a lot more likely to have sexually transmitted diseases as young adults and even teenagers. The list goes on and on. The medications are very effective in protecting kids and adults from adverse outcomes.
William Curb: Yeah, I'm sitting there learning a slideshow through my youth because I wasn't diagnosed to those in my 20s. And I was like, oh yeah, that tracks with everything that happened in my life.
Dr. Faraone: Yeah, no. I mean, I'm sure you could, we don't have to talk about it now, but there are many risks that people with ADHD have taken in their lives that sometimes they get through those, many of them get through that period unscathed, but not everybody does because of the problems that can occur.
William Curb: Yeah, I mean, we definitely see that reflected in studies that show ADHD in prison populations.
Dr. Faraone: They estimate that I think it's something like 25% of prisoners have ADHD.
William Curb: Yeah, and I'm like, that's just so much higher than the population average that like...
Dr. Faraone: Five times higher. Yeah, exactly. Now it's outlandish actually. And in most prisons, you actually can't get ADHD treatment because the stimulant medications are outlawed because of their potentially addictive concerns about addiction and diversion. You can't get ADHD in prisons. Two of my colleagues, Phil Asherson and Susie Young from the United Kingdom, did a study in prisons and they basically showed that if you treated prisoners with methylphenidate, they got better, they were better prisoners and they had better outcomes after they left prison. So it's a whole area that needs to be looked at in this country for sure.
William Curb: I always want to try and help underserved communities when I'm doing anything with the podcast. And I'm like, that's an area that I haven't really addressed as much as I should because that's one of the least underserved communities.
Dr. Faraone: Right. That's right.
William Curb: So one of the things that I wanted to also ask you about is just what are the biggest misconceptions about ADHD that you usually experience since you're trying to do things through evidence?
Dr. Faraone: Well, one of them is that we talked all about the misconceptions about treatment, of course. Everybody thinks medications are very dangerous. They're not. They've been used for four decades, no problems. Many people think that alternative treatments are good.
They're not. One big myth is that ADHD was invented in the United States and the extreme version of that, it was some kind of a cabal between the pharmaceutical companies and psychiatrists to medicate kids so they could all get rich. Well, first of all, ADHD was not invented in the United States. The first mention in a medical textbook of a condition that we would recognize as ADHD, even though they didn't call ADHD, was in two textbooks, one in Scotland and one in Germany.
Believe this or not, at the end of the 18th century. So we're talking about a disorder that's been recognized for hundreds of years. The first description in the medical journal was in the very beginning of the 20th century, Dr. George Still published an article about kids with ADHD.
And the stimulant medications were discovered by accident in 1937 by Dr. Charles Bradley at Rhode Island Hospital in what is now Bradley Hospital. He was doing some research on kids and for some reason I forget why he decided to give them an amphetamine to help them with headaches. I don't know why he thought it would help with their headaches. So he gave them these amphetamines for some purpose, not to treat them. And then the next day, teachers came to him and said, what did you do with these kids?
They're so much better. And he figured out it must have been, it was benzedrine, it must have been the benzedrine. And so he kept the kids on the benzedrine and studied it and realized it was effective for treating their condition. It was a hospital school for very disturbed kids. The kids used to call it the math pill because they could finally do math. They could finally sit down and do math problems. So anyway, we're talking about myths. One of the big myths is that there's some recent invention. No, ADHD and his medical treatments have been around for 100 years. Literally 100 years.
I mean, it will be 100 years pretty soon for the Bradley discovery. Another myth, always the myth that ADHD is caused by bad parenting. Oh, it's just the parents don't know how to deal with their kids and teachers are weak and so they don't have to do a good job. And that's why kids have ADHD, but it's not real. Well, that's not true. The genetics studies show unbelievably with an amazing amount of data that there are now like 37 twin studies. And twin studies is very good at documenting inheritance, which show very clearly that genetics accounts for about 80% of ADHD.
And now we have, we're in the era of what's called genome wide association where we actually have DNA samples on people. Me and my colleagues published a study of over 100,000 people with them with that ADHD. And there we document a clear, we call polygenic inheritance of ADHD. By polygenic, I mean many, many genes are involved. In fact, we estimate now that there are probably 7,000 genes that contribute to the risk for ADHD.
Each has a very tiny effect, but they kind of add up. And if you have lots of them, you would have ADHD. Lots of myths about whenever a new technology comes out, it causes ADHD. And TV came out, oh, TV causes ADHD. When tablets came out, tablets cause ADHD, screen time causes ADHD, pretty soon the new AI chat bots will be said, they'll say cause ADHD. It's not the case because the prevalence of ADHD has not changed over time.
You look at epidemiologic studies of prevalence, they go back a few decades. You don't see any change at all. That's due to time. All of these changes in technology have not really made a difference in the prevalence of the condition. We've seen changes in the diagnosed prevalence because when doctors become aware of a disorder, they diagnose it. So, well, another myth about ADHD is that it disappears in adulthood. And some doctors still believe this. I know this because I do AMA sessions on Reddit and some of the questions I get tell me what doctors tell their patients. One doctor told his patient that when he became an adult, well, he couldn't have ADHD anymore because ADHD disappeared in adulthood and it transformed into depression.
So, he started treating him for depression, not for ADHD. Totally stupid. I mean, moronic actually. It's just unbelievable.
We know now that ADHD does persist into adulthood, but in the 1990s, it was very hard for an adult to find treatment for ADHD. We used to get adults coming to our child psychiatry clinic asking for treatment because they knew that their kids were getting treated there and they figured that we could give them treatment. And so, we launched a research program in adult ADHD headed by Dr. Biederman and Dr. Spencer. And that work basically proved to the world that ADHD persisted into adulthood. And now it's recognized so the diagnostic rates for adults have gone up dramatically in the last two decades.
William Curb: Do we think we're going to see a continuation of that increase as it becomes more culturally acceptable?
Dr. Faraone: I think it will level off. Right now, the latest CDC data suggests that we're reaching a level of diagnosis, which is pretty consistent with what it should be. The other thing is important, the CDC data, that the diagnostic rates for women are catching up to the diagnostic rates for men. In fact, they have caught, I shouldn't say they're catching, have caught up. By the early 20s or 30s, the diagnostic rates are equivalent for men and women. Whereas for children and adolescents, the boys are diagnosed with much higher rates than girls. They're still underdiagnosed as females at younger ages.
William Curb: And is that just because we're seeing more boys tested? Probably.
Dr. Faraone: Well, it's because girls tend to be less disruptive than boys. And when you're a child, you get sent for mental health services if you're causing someone else a problem. When you're an adult, you go to mental health services if you're having a problem. So women with ADHD really have a problem. They seek help. We're seeing equivalent rates really in adulthood.
William Curb: Yeah, I was also thinking that we might see fewer rates of ADHD in adults simply because or this idea that you outgrow your ADHD simply because you have the tools now to more manage your symptoms and it kind of goes to more of a subclinical.
Dr. Faraone: Well, I should add that some people with ADHD do outgrow their ADHD. We do know that from the long-term studies, including some I was involved in that by essentially we call it the age-dependent decline that throughout aging, rates of ADHD will tend to get lower. And we know that, for example, by age 60, 70, the prevalence in the population is really about one or 2%. Whereas in childhood, it's maybe about 7%. So there's this consistent decline that occurs. We think because of, it's probably because of brain maturation. That's a combination of brain maturation and developing skills, of course, to help with ADHD that leads some children to essentially remit the disorder.
William Curb: From my understanding, we can kind of view ADHD primarily as a developmental disorder. So yeah, it makes sense that as you develop, then you see less of an effect.
Dr. Faraone: It used to be thought that ADHD was due to developmental lag, that the brain was simply lagging behind normal development. And once you caught up, everybody would be okay. That was the belief back before, say 1995. And now we know that's not true. Now we know that some kids, as their brain develops, their ADHD does remit, but not everybody. So it's not simply some kids, the brain still is in a state. And when I say it's still in a state, we know this from neuroimaging studies, that there are still subtle brain differences that probably account for why some kids continue to have ADHD as adults.
William Curb: Yeah, I think neuroimaging actually would be also a great place for us to veer into because from...
Dr. Faraone: Sure
William Curb: When I started this podcast five years ago versus where neuroimaging stuff is now, I'm like, oh, it is. Like when I started, there was almost no evidence for neuroimaging being relevant. But now it seems like it's kind of catching up there.
Dr. Faraone: It is catching up. So the first thing people need to know is that when we say there are, that neuroimaging detects differences between people with and without ADHD, we're talking about very small differences. We're not talking about, for example, they're so small that the person with ADHD would have to do a brain scan and give it to a radiologist.
The radiologist would not see anything in that brain scan that would be, they would say, this is a problem at all, because these differences are very tiny. They're only detected when you have hundreds, if not thousands of brain scans from people with or without ADHD, and you can make comparisons. And then you start to see these small subtle differences that we think may account for to some degree ADHD. And what's interesting is that those differences get smaller as you move from childhood to adulthood, because as the brain develops, we see that, in fact, in adulthood, the differences are very hard to detect.
You need very, very large samples and complex methods. And I guess I would say the way to summarize the literature that you have, what are called structural differences, we can talk about, we're going to have functional differences. A structural difference typically means, is the ADHD brain, or parts of the ADHD brain larger or smaller than the typical brain? And it turns out that some parts are a little bit smaller. There's kind of less neural tissue, if you will, in these areas than in this typical. And some of the areas of the brain that are implicated are areas of the brain that involved regulating attention and behavior. And so that's kind of consistent with the symptoms of ADHD. The functional studies are intriguing.
They're harder to do, so it doesn't have as many of them. For example, for the structural studies, we now have a big consortium called Enigma that has several thousand brain scans that we can look at and make really definitive statements. But one way to think about the functional literature, to use the analogy of, you can think of all of us, not just people with ADHD, we can think of our brains as, when we're doing a task, like right now, we're doing a podcast, right? So our brains are online.
They're online and they're activated to do this podcast. You're thinking of questions, I'm thinking of answers, we're focused on that. When we're relaxing by the pool or wherever we relax, our brains become offline. If we're not reading a book or stuff, we're just kind of lying there, kind of looking at stuff. Our brains are offline. We're kind of daydreaming. Newer images have actually documented that there's a brain network called the default mode network, which is really the daydreaming network. It differs from the executive control network, which is the one you and I are using right now. And what images have found is that it seems that ADHD people have a more difficult time moving between the default mode and the executive mode network.
So when they're doing something active like this, they're more likely to start daydreaming, if you will, or get off task, something you'll kind of impede, like if I start to look over here, because, oh, that's an interesting picture. All of a sudden, I'm outside of my executive control network. So you can think ADHD people, the brain is not always online when it should be online. It's also not always offline when it should be offline, which is one reason they have people with ADHD have a hard time sleeping because the brain goes online and they're thinking of all these things they shouldn't be thinking about and it's hard to fall asleep.
William Curb: Both aspects of that are really interesting. How it's just like, oh, yeah, if one of the kind of things I've been playing with is like doing slightly more stimulating things for both times, you know, like playing with fidgets while focusing can help or while doing the executive tasks can help, you know. It's like, okay, I'm doing just enough more that my brain is staying focused. And then I was like, oh, I wonder if that would play the same kind of role when I'm trying to fall asleep. If I have a little bit more stimulation than having just trying to do nothing and go to sleep, you know, and I'm like, oh, yeah, you're listening to sleep podcasts or a weighted blanket or something can give just a little bit more stimulation to help go into that sleep mode.
Dr. Faraone: You know, it's interesting that about sleeping ADHD that even though, you know, stimulant medication can cause insomnia and that can be handled. But ignoring that for the moment, it's also been shown that if patients given medication, sometimes that can help them go to sleep. Not if they take it at night, they have just a little bit of enough in their system at night, it can help calm their ADHD down enough so that they can sleep better. Talking about the imaging data reminds me to tell your listeners that neuroimaging and any kind of neuro testing, be it psychological testing or be it imaging testing should not be used to diagnose ADHD, should not be used either rule in or rule out ADHD.
I know again from my AMA sessions on Reddit that, you know, some people have been told by the doctor, you don't have ADHD because you did well on neuropsychological testing. That's just wrong. Get yourself another doctor. They don't know what they're doing. The only way diagnosis is made is doctor talks to the patient about the symptoms of ADHD in the diagnostic manual. Testing is useful for lots of other things, but not for saying whether or not a person has ADHD.
William Curb: Yeah, I think that's a great point because it's, it's hard because the idea that ADHD is overdiagnosed often feels silly to me because I'm like, the actual diagnostic process is not simple to go through.
Dr. Faraone: That's right. That's right. And the other thing we were talking about myths and misinformation, one of the big bits of misinformation is that the diagnosis isn't valid because it's not objective. It's not a blood test. It's not a computerized test. It's a doctor talking to a patient. And really that's just wrong. And again, I could spend an hour talking about why it's wrong, but it's wrong because the diagnosis itself has been shown to be what we say reliable and valid, reliable, meaning that two doctors can agree that the same person has ADHD and valid, meaning we know that the diagnosis predicts important things, such as response to treatment, outcome, family history and so forth. And so don't worry that we don't have a objective test for diagnosis. What we have is very, very good at doing the job it needs to do.
William Curb: I was wondering if there was anything you wanted to leave the listeners with?
Dr. Faraone: One thing I think it's important for people with ADHD and parents of ADHD kids to know is that we talked about impairments associated with ADHD, the symptoms of disorder, the name disorder connotes it's a problem. And that's all true. But you have to remember that ADHD is only a small part of you as a person. There are many other aspects of you as an individual that you've got to know about.
And everyone, we have to deal with and discover our strengths and weaknesses. Believe me, you might have ADHD, I say deal with that, deal with it appropriately, deal with it according to treatment guidelines. But also remember you have other strengths in your life to capitalize on it. The ADHD does not define you as a person. You're much bigger and broader than the diagnosis. Any medical diagnosis be it ADHD or anything else.
William Curb: Awesome. Thank you. And if people wanted to find out more about your work, where should they go?
Dr. Faraone: I'll go to adhdevidance.org and you'll find out everything I'm doing there is free to access.
William Curb: Thank you so much for your time. This was really an enlightening conversation.
Dr. Faraone: Yeah, I enjoyed it. Thanks for inviting me. Appreciate it.
This Episode's Top Tips
Stick to treatments that have been proven effective through rigorous studies. Large studies and meta-analyses are more reliable than small studies when determining ADHD treatments.
Not all ADHD treatments you find online are helpful—be cautious of sources that aren't peer-reviewed. Beware of misinformation as well as misleading information that can lead you down the wrong treatment path.
While some alternative treatments may help, their effects are often significantly smaller compared to standard stimulant medication. When thinking about approaching what we do to help manage our ADHD, we want to think about the magnitude of the effect and do the things that will help the most first.