Understanding the Nuances of ADHD with Dr. Michael Manos

Podcast Transcript

Nada Youssef:   Hi. Thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio, and we're here with Dr. Michael Manos. Dr. Manos is a psychologist at Cleveland Clinic's Children's Hospital, and we'll be talking about ADHD. Thank you so much for being here today.

Michael Manos:  My pleasure, Nada. Thanks for having me.

Nada Youssef:   And please remember, this is for informational purposes only, and it's not intended to replace your own physician's advice. Let's talk about ADHD. Let's just talk about definition. What is ADHD?

Michael Manos:  There's a formal definition, and the formal definition that it is a biological disorder, and it's associated with particular symptoms, and a particular network in the brain. And the core symptoms are inattention, distractibility, and hyperactive impulsive behavior.

Nada Youssef:   Okay.

Michael Manos:  That is a typically useless definition for most people. And the way it has been defined is that ADHD's like having a Ferrari engine for a brain but with bicycle brakes.

Nada Youssef:   Wow.

Michael Manos:  It's actually somewhat of a misnomer to call it an attention deficit. Because what it actually is, attention to too much. The thing is that the brain is always active. It's always putting its attention on something. And the difficulty comes in when the person can't select the object to put attention on, and keep it there. Because the attention wants to go where it wants to go.

Nada Youssef:   Sure, sure. So you're saying it's not trouble paying attention, it's paying attention to too many things at once.

Michael Manos:  Yes. Exactly. That's well said.

Nada Youssef:   Okay. So how common is it nowadays, in the USA?

Michael Manos:  That is a question that keeps changing, but the current prevalence data in the United States from the Centers for Disease Control is 11%.

Nada Youssef:   Wow.

Michael Manos:  Worldwide prevalence is 7.2%, which is huge. When you consider that evolutionary biologists say that natural selection selects for a particular condition if it's 1% of the population, this is very, very high.

Nada Youssef:   This is ... Yeah. That is very high. So, is it considered a learning disability?

Michael Manos:  No.

Michael Manos:  Learning disabilities are associated with difficulty in manipulating or managing the symbols of language. So there are reading disabilities, there are math disabilities we call dyslexia or dyscalculia. ADHD is a matter of placing attention to sustain attention for task completion. Associated with doing that, the way you do that is to use executive functions. Now, most of us, especially those of us who have work that requires it, and it's especially needed in school, we have to self-regulate. So, an adult example for example, if it's 2014, and you have your taxes due, and it's April 14, and taxes are due the next day, and it's a beautiful day outside, and you haven't done your taxes, you have to regulate yourself to sit down and get your taxes done, rather than go outside and enjoy the day.

Nada Youssef:   Right.

Michael Manos:  We use executive functions to do that.

Nada Youssef:   Okay.

Michael Manos:  The self-regulation that is available to most neurotypical individuals, not available to an individual with ADHD. The individual with ADHD tends to live a different sort of life. They're attracted to the world around them. Using language which is how most of us get things done ... It's how I got here to talk with you. It's how you got here originally.

Nada Youssef:   Sure.

Michael Manos:  It's how our administrative assistants manage people. We use language. Language to manage personal behavior in a person with ADHD is not very powerful.

Nada Youssef:   Right.

Michael Manos:  So we might go to the store and we might have in mind, I have to get milk, eggs, and cheese. And you get to the store, you buy what you buy, and you walk out and you have bread, and you have Havarti cheese, and you have one of the broiled chickens that are ... And you walk out with five things and not one of them is one of the things that you said you were gonna get.

Michael Manos:  So you see language is not as particularly potent. That's why you don't treat ADHD by counseling. Counseling's useless. I know how to say brilliant things. I can have golden words come out of my mouth, when I'm talking to a child. And by the time the child ends the session and walks out the door of the hospital at the rehab hospital, walks through the green awning, whatever I say is gone. It's why parents in managing children with ADHD, they do all this talking. And a child does something, like spills the milk. A child gives a five minute lecture on how you're supposed to hold the glass with two hands and you're supposed to ... Whatever it happens to be. And the next the day the child's sitting down and spills the milk again.

Nada Youssef:   Yeah.

Michael Manos:  Do you get the idea?

Nada Youssef:   Right.

Michael Manos:  Okay.

Nada Youssef:   So language is not the appropriate way to communicate with a child with ADHD.

Michael Manos:  Well, appropriates not ... I'll use a different word. It's not the effective way of making a difference for ADHD.

Nada Youssef:   Okay, fair enough.

Michael Manos:  I'm gonna tell you something. Every lecture ... I give lectures at a lot of places, and I went out to Stanford, and gave a presentation there. And I told them at the very beginning, "Look, I'm an expert in ADHD. By the time this conversation is over, in the hour later after we're all finished, I will know exactly who in this room is ADHD."

Michael Manos:  So, for example, you can often tell people who have ADHD, not because of overt symptoms, but because they seem just to notice everything. There are some adult jobs for example that are perfect for the ADHD brain. But when you have ADHD, your attention is on the world around you. Your attention is drawn to any change in the world around you. And if the world around you is not particularly fascinating or interesting or attention-getting, guess what? The brain generates thoughts, and conditions. It can ruminate on things that happened years ago. The brain will always be attending to something.

Nada Youssef:   Right.

Michael Manos:  That's the difficulty of ADHD. It's the nature of it. Now when you consider adult positions, adult jobs, consider a policeman. What does a policeman have to do? What's good ... Policeman goes to a crime scene? What does he have to do, or she have to do? To notice everything.

Nada Youssef:   Mm-hmm (affirmative). Analyze.

Michael Manos:  There are certain professions ... David Neeleman, for example, was the former CEO of JetBlue. Now those people who follow airlines and stocks, JetBlue was the most successful airlines for a long time. I think now it's second to Alaskan Air. But you know what he said? He said, "I wanted to make the airlines suitable for me. I want things fast, simple, and efficient." He created it that way and created a very successful airlines. In fact, you might be too young to remember when we used to use paper tickets for flying the airplane. So David Neeleman used to use paper tickets. What do you think happened to his paper ticket, given that he's ADHD?

Nada Youssef:   Lost it?

Michael Manos:  He lost it. Of course. So, he was the one who invented the electronic ticket.

Nada Youssef:   I see. Very interesting. So what is the difference between ADHD and ADD? Because I heard that a lot, too. ADD, is that similar to ADHD, or is it being used anymore?

Michael Manos:  In the professional field, it's all called ADHD.

Nada Youssef:   Okay.

Michael Manos:  There are three types of ADHD. There's what's called ADHD predominantly inattentive presentation. And to diagnose ADHD, there are nine symptoms associated with inattention, and nine symptoms associated with hyperactive impulsive behavior. An adult has to have at least five in either one or both of those categories. A child needs to have at least six.

Nada Youssef:   Okay.

Michael Manos:  So, it's not enough however just to show those symptoms. Because everybody shows those symptoms from time to time.

Nada Youssef:   Right.

Michael Manos:  People who don't get enough sleep are often forgetful. People who are depressed or anxious and have actual anxiety depressive disorders often forget things or often overlook something, or often seem scattered.

Michael Manos:  There are certain conditions. So let's say you have a child who is inattentive, shows eight of nine symptoms for inattention. There have to be certain conditions there. First of all, they have to have been there for a long time. They have to happen a lot, so much so that it's intrusive. Usually, the measure that we use for intrusiveness is that the child's behavior is compromised at home and in school.

Michael Manos:  In an adult, you might consider home and work. You can consider relationships. I had a truly remarkable guy, married, and inattentive type, ADHD. He told his wife, "Honey, I'm gonna accept your request and I'm gonna put up paneling in the basement just like you've asked me for the past two years." He went out and he bought the paneling on a Saturday, put it in the basement, and another year went by. Finally, after all of his excuses and all of the disruption that his wife had, and all of her upset, when are you gonna do it, all of his promises that he ultimately broke, he called up a friend of his, and he said, "Can you come on over? I know you know how to put up paneling. Will you come over and do it? I'm going to get a keg of beer. You and I are gonna go put up the paneling in the basement. I'll pay you for it." He had it done in four days, after virtually three years of not keeping his promise to his wife.

Nada Youssef:   So what changed? Besides the beer.

Michael Manos:  Well, what do you think what changed?

Nada Youssef:   The experience, maybe? The alcohol? The friend?

Michael Manos:  No. Actually got nothing to do with the alcohol. No.

Nada Youssef:   You brought that up.

Michael Manos:  It had nothing to do with the alcohol. It had to do with the context within which he did it. To do it himself, is a characteristic of ADHD that is difficult. People with ADHD tend to have significant difficulty self-directing, saying, "I am going to write that paper," or, "I am going to clean that room."

Nada Youssef:   Right.

Michael Manos:  They say it to themselves. What's the consequence? They could forever say, "Oh, I'll do it tomorrow."

Nada Youssef:   Right.

Michael Manos:  And there's no serious consequence.

Nada Youssef:   Okay.

Michael Manos:  But, if you change the context of the situation, and make the person obligated to another person, who's going to come over, and who's there to complete the task, then things change completely.

Nada Youssef:   Makes it easier.

Michael Manos:  That's where the real mistake is. Or I shouldn't call it a mistake, actually. That's where the real ineffectiveness is, in what most people think they're supposed to do with ADHD.

Nada Youssef:   Right.

Michael Manos:  If you have ADHD, I'll sit and talk with you, and help you through it. It's utter nonsense. If you have ADHD, what I'm going to do is actually have you alter your circumstances. If you have difficulty studying, then go join a study group. If you have difficulty remembering written material, then have somebody read to you-

Michael Manos:  ... or use books on tape, or alike. It's to do things differently, is the way you treat ADHD.

Michael Manos:  Now you asked me a question a long time ago about what's the difference between ADD and ADHD?

Nada Youssef:   Mm-hmm (affirmative).

Michael Manos:  Nobody professionally uses the term ADD.

Nada Youssef:   Okay.

Michael Manos:  It's all ADHD. The three types are inattentive type, hyperactive impulsive type, and combined type, which is both of those things.

Nada Youssef:   Okay. All of the above. So what you were saying earlier, right before you answered this. Is it the outside factors or environment that we're changing, to help the person with ADHD?

Michael Manos:  Again, that's well said. You don't treat ADHD in the therapist's office. It's an illusion, that I don't know how it got propagated, but-

Nada Youssef:   Yeah.

Michael Manos:  You treat it at the point of contact.

Nada Youssef:   Okay.

Michael Manos:  So for example our summer treatment program at Cleveland Clinic. It is the most advanced, sophisticated behavioral program for ADHD in the world.

Nada Youssef:   Oh. Please explain.

Michael Manos:  There is one in Japan, there's five in this country, of the research type that we use. Now, by the way, I'm not self-aggrandizing. I didn't invent this program. This belongs to a person named William Pelham. Dr. Pelham is at Florida International University. I've known him for years, and in fact, he used to be at the University of Buffalo, and that's how we started our program here.

Nada Youssef:   Yeah. That's excellent.

Michael Manos:  The STP came to Cleveland Clinic in 1999.

Nada Youssef:   And you were saying the program itself is very effective. What is going on with the summer program? Tell me more.

Michael Manos:  You are an excellent listener.

Nada Youssef:   Thank you.

Michael Manos:  The ... You treat ADHD at the point of contact, and the most sophisticated program there is behaviorally for ADHD is the summer treatment program. We target for example 13 negative behaviors. We reduce their frequency during the day. And then, we target nine positive behaviors, like prosocial intervention, or cooperating with another person, or responding to a directive. These nine positive behaviors, we increase. And then we also train parents to do exactly the same.

Michael Manos:  So, what's very interesting in our world today, especially for parents, is that you probably remember Hillary Clinton's venture into "It Takes a Village," way back in the '90s. Our world has advanced to a place where the village, like most of us grew up in, where you'd run down the street and do something you weren't supposed to do, and the mom down the street called your mom and you got in trouble when you got home.

Nada Youssef:   Yeah.

Michael Manos:  It's not there anymore.

Nada Youssef:   All right.

Michael Manos:  There are no norms to behavior. And the village has actually ... It's shrunk to a household. So behavior management has to occur in the household, but there's no consistency of it across households.

Nada Youssef:   Right.

Michael Manos:  And parents are left with not knowing what to do.

Nada Youssef:   Right.

Michael Manos:  What is appropriate behavior? So, a tendency is to fall back on how my own parents raised me. I turned out okay. Now, sometimes that's a question, but not to the person themselves.

Nada Youssef:   Right.

Michael Manos:  So, you start using the things that worked at a different time, in a different context, with different people.

Nada Youssef:   Right.

Michael Manos:  And it doesn't work now.

Nada Youssef:   Yeah. Gotta customize it to our new lifestyle.

Michael Manos:  Yes. Well, I'm gonna say it in a little more harsh way.

Nada Youssef:   Mm-hmm (affirmative).

Michael Manos:  We're going through life looking at history, rather than facing the future. We're looking at what's already been, as opposed to what we're building.

Nada Youssef:   Right.

Michael Manos:  It's a problem that occurs in almost every facet of life. It's a problem that occurs in relationships, for example. My mom used to treat me like this. My wife should treat me like that, too.

Nada Youssef:   Yeah.

Michael Manos:  Or some version of this.

Nada Youssef:   Yeah. So it's like high expectation based on what we went through, based on memories, versus how our lives has changed.

Michael Manos:  I wouldn't even call it high expectation. I would call it an expectation from our history, whatever that happens to be.

Nada Youssef:   Right.

Michael Manos:  And you can see ramifications of that in all different kinds of family dysfunction.

Nada Youssef:   Sure. Now, I want to ask you about adult ADHD versus children. When an adult is diagnosed with ADHD, were they diagnosed as a child, or were they just ... Did they miss out on that part of their life and weren't diagnosed, and something, new lifestyle changed them later on? Or how does adult ADHD usually get diagnosed?

Michael Manos:  Adults with ADHD are generally referred to our lifespan clinic, the ADHD Center for Evaluation and Treatment, because somebody mentioned it to them. You might have ADHD. Or, they've had their child diagnosed with ADHD, or they just have always known that something is off.

Nada Youssef:   Okay.

Michael Manos:  I just had a young woman today, 21 years old, absolutely, clearly meets symptom criteria for ADHD combined presentation. She has about a 2.2 grade point average in college, and she described to me the things that she does. She described for example that she ditches her friends. She'll make an agreement to meet her friend at 4:00 but then 4:00 in the afternoon comes, and what she really wants to do is to go for a hike in the woods, by herself. So she doesn't show up. Now of course, she has to go clean it up with her friend, but it happens again and again, and now her friends just say, "Oh, that's just Julia." Not her real name, by the way.

Nada Youssef:   Right.

Michael Manos:  She has consistent difficulty with procrastination. The conversation that she has with herself is, "I have two weeks to do this thing. I don't have to work on it today. I can ... I got plenty of time to get it done later." That conversation rolls right up into the day before the assignment is due.

Nada Youssef:   Yeah.

Michael Manos:  And when she decides to do something, she described for example several different art projects that she really enjoys. And she'll start the thing, there'll be a lot of enthusiasm at the beginning, but then when the project gets to be more of a task-

Nada Youssef:   Mm-hmm (affirmative). She loses interest.

Michael Manos:  She loses interest, and doesn't initiate or put enough effort and energy to complete the thing. So, with adults, I will tell you the primary difficulty. Adults lead lives of incompletions. Now William James was, is probably considered the father of Western psychology. He wrote in 1890, "There is nothing so fatiguing as the eternal hanging on of an uncompleted task." Now, that is exactly one of the first things that I personally address with a person, an adult who comes in to see me.

Nada Youssef:   Sure.

Michael Manos:  And if you look at an uncompleted task as an agreement that's been broken, you can consider that the brain never forgets a broken agreement.

Nada Youssef:   Right.

Michael Manos:  If I sat down with you and I said, "What things have you gotten incomplete?" You would tell me a few things.

Nada Youssef:   Mm-hmm (affirmative).

Michael Manos:  And they're incomplete because you said you were gonna do them, and you didn't do them. At least, perhaps not to completion.

Nada Youssef:   Right.

Michael Manos:  Now what does it feel like when you have incompletions, when you have broken agreements? It's like wearing a backpack, and you're constantly putting rocks in the backpack and weighing yourself down. Everybody has had the experience of saying they're gonna do something, students in college for example. By agreement, they're in college to complete all of the work that they have to do. So, a paper is due on a particular day, on a Monday, and they haven't written it, and it's Sunday night. That feeling of incompletion, of breaking the implicit agreement that if you're in college, you're gonna do the work, weighs on them. Now, and everybody has had the experience of, "I said I was gonna do this and I didn't do this."

Nada Youssef:   Right.

Michael Manos:  The brain will never forget a broken agreement. I had a person come in, mid-40s, and we were talking about incompletions and he said, "You know, it strikes me that I promised my high school friends, three of them, that I was gonna contact them after we graduated and went to college, and I never contacted them." He said, "My brain reminds me of it all the time, and I keep saying I'm gonna do it, and then I never do it."

Nada Youssef:   Never get to it.

Michael Manos:  And if any individual looks to see what broken agreements there are, what things they haven't done, they've left incomplete, it's a burden. And what does it feel like when you finally do something that you've been putting off forever?

Nada Youssef:   Right.

Michael Manos:  Feels great, doesn't it?

Nada Youssef:   Right, of course. I hope you don't get a lot of calls from college kids thinking they have ADHD because, I feel like a lot of kids are pushing the assignment until the very last day, or forgetting stuff. I'm just trying to see ... The line is thin, between when is it actually a problem versus just forgetfulness, or pushing something back, or ... Because we all experience that on a daily basis.

Michael Manos: A very useful observation. It's not that a person procrastinates and that makes ADHD. You have to have the symptoms, six of nine or five of nine, of inattention, five of nine or six of nine for hyperactive impulsive behavior, and you have to have the conditions. The conditions have to have been around a long time, they need to be intrusive in more than one setting-

Nada Youssef:   Consistent. Now you mentioned earlier, parents could worry if their kids have it that they may have it. So is this a genetic disorder?

Michael Manos:  Professional thinking at present is that it is definitely a genetic condition.

Nada Youssef:   Okay.

Michael Manos:  Way back in 2000, 2001, -2, there were maybe four genes that were associated with ADHD. Now I think there's over 29. I haven't done a recent talk. So, the difficulty of genomically identifying ADHD is pretty significant. So-

Nada Youssef:   Now, the symptoms of ADHD can make school, family, just like you said, relationships, everything, very difficult. So how to cope? Because it sounds like something like an ADHD student, that goes to a school where it's all about talking and learning and raising your hand, and going into that box, and some people learn differently. How ... What is the approach that you see fit for these students?

Michael Manos:  So there was a major study that was conducted, called the Multi Treatment Assessment Study, or the Multimodal Treatment Group for ADHD. It was started in '94, went to '96, and then ... Several hundred children participated in this study, and they've been collecting data on it ever since. So, what's fascinating is that from that study, we've gotten very clear notion that a combined approach of using pharmacotherapy and behavioral intervention is the best approach.

Nada Youssef:   Okay.

Michael Manos:  Now, for very young children, the American Academy of Pediatrics recommends using behavioral intervention first.

Nada Youssef:   Okay.

Michael Manos:  In our own summer treatment program, and in the other summer treatment programs in the United States and in Japan, investigations have indicated that you can use lower doses of medicine, and you can use, when you use very intensive behavioral intervention.

Nada Youssef:   Yeah.

Michael Manos:  And when you use very intensive behavioral intervention first, you can use, you can start with lower doses of medicine, to have things be effective.

Nada Youssef:   Okay.

Michael Manos:  Now the real ... I think the real issue is, many people consider that ADHD is overdiagnosed. I thought that's where you were going in your question before, about college students coming in, and because they procrastinate, they think they got ADHD, and they should have Adderall. Well, so the truth of the matter is, Adderall's not hard to get on a college campus.

Nada Youssef:   Sure.

Michael Manos:  It is the most diverted drug that there is. You can typically buy a capsule of Adderall for $5. During midterms and finals, costs $20.

Nada Youssef:   Wow.

Michael Manos:  Or, something to that effect.

Nada Youssef:   Yeah.

Michael Manos:  So, when you consider what makes ADHD, you have to do a thorough assessment. You may have seen the study that just came out, that described younger children in kindergarten, whose birthdays occurred just before-

Nada Youssef:   The school year?

Michael Manos:  ... August 30.

Nada Youssef:   August?

Michael Manos:  Yeah.

Nada Youssef:   Mm-hmm (affirmative).

Michael Manos:  31st.

Nada Youssef:   Mm-hmm (affirmative).

Michael Manos:  ... compared to kids born after that date, tend to be diagnosed more with ADHD than their peers.

Nada Youssef:   The ones before school year. So-

Michael Manos:  The ones before school year got diagnosed more than the ones after.

Nada Youssef:   Okay.

Michael Manos:  Because if school is supposed to start on December 1, and you're born on ... Excuse me. If school starts on September 1, and you're born on September 2, then by the time you get around to school, you're gonna be a whole year older than the one who's born on August 31.

Nada Youssef:   Right, right.

Michael Manos:  And the kids who were born in August, or before August 31, just before the school year starts, more of them, 30% more of them, were diagnosed with ADHD.

Nada Youssef:   Wow.

Michael Manos:  Now, automatically people are gonna conclude, "Oh, we're overdiagnosing ADHD." The issue is not overdiagnosing. The issue is misdiagnosing. Anybody who knows child development is going to be crystal clear about whether or not a child is actually exhibiting symptoms of ADHD, or whether this is a developmental issue.

Nada Youssef:   Sure.

Michael Manos:  It's a ... This is a question that is consistent with exactly what you were bringing up before. College students who want an edge will go in and tell the therapist, "I have this symptom and that symptom and that symptom."

Nada Youssef:   Yeah.

Michael Manos:  It's up to the therapist to be able to tell, the diagnostician, to be able to tell, is this ADHD? Is this someone who wants to look like they're ADHD? Is this somebody who's just anxious, because they're studying a very difficult subject and they can't quite get it, and so they think they have ADHD?

Nada Youssef:   Sure. And that's actually my next question was, how is it diagnosed? How ... So when someone comes in, asking for Adderall or Ritalin or whatever the treatment is, what kind of steps are taken to make sure that it is true ADHD versus just like you said, just trying to get the pills?

Michael Manos:  Again, that ... Well, so I'm gonna simplify it and turn it into a three-step process.

Nada Youssef:   Okay.

Michael Manos:  And then I'm gonna comment on the three-step process and how it's used. So, the first step in diagnosing ADHD is to determine if the symptoms are there. So again, we're talking about nine symptoms of inattention. How many of them are there? Nine symptoms of hyperactive impulsive behavior, how many are there? So you have to determine if the symptoms are there. So, what most people do is to use a rating scale like the Vanderbilt Scale, or the ADHD Rating Scale. And I would ask a parent, and I would ask a teacher. So I have two rating scales now.

Michael Manos:  And then, many times people stop there. So are the symptoms there? Yes, this one says yes, and this one says yes. High level of agreement between the two. But that's not enough. There's a second step, and the second step is, what can I rule out as the cause of these symptoms being there? Could it be the child is not getting enough sleep? Could it be the parents are really aberrant in how they're managing behavior in the household? Could it be that the child is depressed, or anxious? What actually can I rule out as causes of these symptoms being present? That's the second step.

Nada Youssef:   Okay.

Michael Manos:  Now, like I said, many times when professionals do diagnostics for ADHD, they stop at the first step. And even that step ... There are school districts in our country who would, some of them, count and make sure they have a lot of the symptoms of ADHD because it means they get more federal aid. Some school districts, because they have such an excellent record, don't want their kids to have, be diagnosed ADHD, so they underplay the symptoms. So, the ... If ADHD is diagnosed, then a school has to provide accommodations for that child. And sometimes, the school is so strapped for money that they do not have the capacity to provide it, so there's a subtle pressure not to diagnose ADHD.

Michael Manos:  So you see rating scales themselves may not ... There may be other things that factor them. I can't tell you the number of times that children who are in families whose parents are divorced, and the mom thinks ADHD is complete nonsense but the dad is very clear that it's ADHD, so the mom fills out the rating scale and underplays, underrepresents the symptoms.

Nada Youssef:   Right.

Michael Manos:  The dad may overrepresent, and the parents are at odds about it. So the first step is not enough. The second step, to rule out other causes, of which that might be a cause.

Nada Youssef:   Sure.

Michael Manos:  And then there's a third step. The third step is to determine comorbidity. Is there something else occurring, co-occurring, which is what comorbidity is, co-occurring with these symptoms and with ADHD?

Nada Youssef:   Okay.

Michael Manos:  It's especially so in adults. This ... It broke my heart the other day, that this young, 38-year-old man, had a family, good job, very, very active. He felt all his life that he was stupid. He was very close to his family, very responsible for his family, but never felt like he could do anything else. He would look at his classmates when he was in school. He would see that they finished their tests sooner than he did. They got better grades than he did. They could recall the answers to things that just escaped him.

Michael Manos:  Now, when that happens, he's not concluding to himself, "Oh, I know. It's that my network in my brain doesn't use directed attention very well and I'm constantly in the phase of automatic attention which is the default mode of the brain. That must be why this is all happening." That person doesn't say that.

Nada Youssef:   No.

Michael Manos:  What do they conclude?

Nada Youssef:   Well, people are harsh on them, so just like you said, you would think, "I'm stupid. I can't learn as much as others do."

Michael Manos:  Exactly the point. Fundamentally, a person says, "There's something wrong with me."

Nada Youssef:   Right.

Michael Manos:  And this young woman that I just saw today before I came to talk with you, cried when she says, "I always thought I couldn't do things." And when she realized that it had nothing to do with how bright she was or how bright she wasn't, how committed to her education she was or how committed she wasn't, she constantly referred to herself, throughout our conversation, as lazy. I finally corrected her, or intruded on that conversation. And I said to her, "Perhaps you're no lazy at all." But she thinks she's lazy, when what she's really doing ... She thinks she's lazy primarily because she procrastinates constantly and it's drawing her grade down.

Nada Youssef:   Right.

Michael Manos:  She's not doing her best work.

Nada Youssef:   Right.

Michael Manos:  She thinks she's lazy because she avoids things. Laziness is a state. You can look at somebody and say, "Oh, you're just lazy." Laziness is a state, a characterization of a person like personality or something. People with ADHD are almost never lazy. Almost never. I have ... First of all I have never, ever met a lazy child. Never. You've met them?

Nada Youssef:   Maybe a few, but-

Michael Manos:  No. You've not met them either. You probably have met-

Nada Youssef:   They're the most energetic balls of fire.

Michael Manos:  Well you probably have met children who avoid things.

Nada Youssef:   Yes. Absolutely.

Michael Manos:  What do they avoid? Schoolwork. Why?

Nada Youssef:   Yes.

Michael Manos:  Schoolwork is boring.

Nada Youssef:   Yes. Right.

Michael Manos:  I had a little kid, for example. One of the most fascinating little kids I've ever met. On one Saturday he organized five other kids in the neighborhood, because on his street they were building new houses. He organized five other kids in the neighborhood. They all went around and they took wood, and they went back in the woods and they built a tree fort. And they had it done by Sunday afternoon and they played in it until dinnertime and ... And then he came in, on Monday morning, to school and the teacher said, "Children, here's a worksheet. Start doing it right now." Everybody else did all 30 problems. He had two. Is that a lazy child? It's not a lazy child at all. It's a child who avoids the kinds of tasks that-

Nada Youssef:   Are uninteresting to them, right?

Michael Manos:  ... are characteristic of ADHD. And I think this is a good point to really give the nature of ADHD. We think that we have one kind of attention.

Nada Youssef:   Right.

Michael Manos:  There's not one kind of attention. There may be three, but there's two definitely. So, the kind of attention we use when we're really interested in something, or watching a good movie, or having a wonderful conversation with somebody, or reading a good book, that's the default mode of the brain. The default mode of the brain, if we're very lucky, is where we end up having our careers. The default mode hijacks attention for a person with ADHD.

Michael Manos:  But there's a second kind of attention, that we use to self-regulate. It's the kind of attention that we use our frontal cortex, with language, to self-regulate. So if you know you have to have a meeting in the A building at 4:00, you'll be there at the A building at 4:00, whether you're hungry or whether you are having a great conversation, or whatever you happen to be doing, you'll separate yourself from that, and place yourself in the A building.

Nada Youssef:   Right.

Michael Manos:  A person with ADHD has difficulty with that kind of attention, which is called directed attention. And it has its own network of the brain, which is called the task mode. Primary neurotransmitters associated with the task mode are dopamine and norepinephrine, and that's what pharmacotherapy addresses.

Nada Youssef:   Sure.

Michael Manos:  Some people say there's even a third kind of attention, and the third kind of attention is an emotional regulator. Because there are some kids with ADHD who have real difficulty managing their feelings. But at any rate, there's at least two kinds of attention, the default mode and the task mode, and the task mode is what's difficult for people with ADHD. That's why an adult who is in work that they love, primarily engaged with default mode.

Nada Youssef:   Right. So, let's talk about the causes, or what the causes may be, for ADHD.

Michael Manos:  Genetic.

Nada Youssef:   Genetic. It's all genetic?

Michael Manos:  It's genetic. So I know ... Were you about to go to media?

Nada Youssef:   I'm just-

Michael Manos:  And screens?

Nada Youssef:   I'm just wondering ... I'm just wondering if there's anything else. Screens is, just like you said ... That's a completely different lifestyle that we have nowadays. We have our iPhones, our iPads, our TV, our GPS in the car. We have everything everywhere. Does that ... Technology, is it making it worse for our children? Is there anything else that could be causing ADHD? Because it's the worst that it's ever been, correct?

Michael Manos:  I don't know that it's the worst that it's ever been. It's the worst that we've ever recognized it.

Nada Youssef:   Okay.

Michael Manos:  So ADHD's been in the population since forever. There was a study by UC Irvine. It followed the genetic patterns of hunter gatherer tribes, going back 30,000 years. Followed migration patterns too into South America. It was a fascinating study. I couldn't comprehend it myself, how they did things. I understood the conclusions, but ... The ADHD symptoms have been around for a long time, 30,000 years ago. Some people make the case that it's ... These are hunter genes. When we lived in hunter gatherer tribes, the hunters were the ones who noticed everything, which is what the ADHD brain does. A brain, ADHD brain notices everything.

Nada Youssef:   Observant. Yeah.

Michael Manos:  And when you're over ... If you're living in a dangerous world, you want to be around the guy who knows, danger's that way, we gotta head that way.

Michael Manos:  So, some people make the case that we're living in a world dominated by screens, and that screens are making the attention span shorter. Now there's no question that the expectations for some kind of reinforcement, some kind of change in the environment, is somewhat exacerbated by screens. But screens do not cause ADHD. ADHD is largely genetic.

Nada Youssef:   Okay.

Michael Manos:  Now, screens certainly are impacting how children react to directed attention tasks. Because if you have a worksheet in front of you, with 30 math problems on it, that worksheet isn't doing anything. It's not changing. You have to bring your attention to that worksheet, in order to interact with it.

Nada Youssef:   Right.

Michael Manos:  You're the change agent for the worksheet.

Nada Youssef:   Right.

Michael Manos:  If you're looking at a screen, and the screen is having all kinds of action occurring in a war zone, the screen is changing, and it's actually capturing our attention.

Nada Youssef:   Right.

Michael Manos:  So the real issue is not that it's changing attention, at least as far as we know now. There are no clear studies that confirm screens cause ADHD. That's a myth.

Nada Youssef:   Okay.

Michael Manos:  At least at present.

Nada Youssef:   Okay.

Michael Manos:  It's that the brain and the person expect things to change. Now, children with ADHD tend to have, tend to require a bigger difference in their world to respond to it. So, screens are perfect for that. And when the screen is not there and we're looking around the world to find something to do, kids are not looking to say, "Hey, let's go to the new houses, get some wood, and go build a fort back in the woods." What they're doing is looking for the next game to play, or the next very exciting situation, which requires, which actually attracts and draws and lights up their default mode and attention.

Nada Youssef:   Sure. Okay.

Michael Manos:  That answer your question?

Nada Youssef:   Yes, it did.

Michael Manos:  Okay.

Nada Youssef:   Thank you. Okay, so now, naturally, let's just go on to treatments. I know we talked about Adderall. Ritalin, is that another one? Are there-

Michael Manos:  So the two compounds are methylphenidate and amphetamine.

Nada Youssef:   Okay.

Michael Manos:  Methylphenidate has a variety of different ... There's about 29, maybe even over 30 different compounds, or different delivery systems for methylphenidate and amphetamine.

Nada Youssef:   Mm-hmm (affirmative). Okay.

Michael Manos:  Methylphenidate works in one way in the synapses, amphetamine works in three to four ways in the synapses. And now I want you to be clear, I do not practice medicine. I don't give medical advice.

Nada Youssef:   Okay.

Michael Manos:  So nobody can listen to this and say that I'm saying one thing or another about medicine. If you want medicine, you talk to your physician.

Nada Youssef:   Sure.

Michael Manos:  The stimulants are highly effective in managing the symptoms of ADHD. Why? Because they target dopamine and norepinephrine in the default ... In, excuse me, in the task mode, the mode of directed attention. And remember, if you are going to self-regulate, you have to suppress the default mode. So, the sunny day versus getting the taxes done. You have to suppress the sunny day, suppress wanting to engage with the sunny day, and do the boring task of doing your taxes.

Nada Youssef:   Right.

Michael Manos:  You do that through executive functions, and the stimulants enhance directed attention, so you can self-regulate. The stimulants do nothing more than allow a person to do what they ordinarily would want to do.

Nada Youssef:   Okay.

Michael Manos:  You can be as inattentive on stimulants as you are off stimulants.

Nada Youssef:   Right. So another thing that I've heard a lot from my own friends are parents of kids maybe with ADHD or maybe need something like Adderall, the side effects with maybe sleep or appetite, something like that. Do you think the benefits outweigh the side effects?

Michael Manos:  You have just stated exactly what the question is when there are side effects. So the three primary side effects of the stimulants. Appetite suppression, sleep delay, and irritability. There is what's called a rebound effect of the medicine that when the medicine's wearing off at the end of the day, people can become irritable, more easily angered or upset. More cry periods. More easily agitated.

Nada Youssef:   Right.

Michael Manos:  So the key question is, does the benefit of the medicine outweigh the side effect? So let's say a child has appetite suppression. So, doesn't eat lunch. So, the parents give a good breakfast in the morning, then give medicine.

Nada Youssef:   Okay.

Michael Manos:  And the child doesn't eat lunch, or doesn't eat much lunch. Comes home at 3:30, doesn't get hungry until 6:00. Well, have dinner at 6:00, and then give really good snacks. Then, it's also useful to consider what are called structured treatment interruptions, or colloquially called drug holidays.

Nada Youssef:   Okay.

Michael Manos:  The American Academy of Pediatrics does not recommend weekend drug holidays, but it does endorse longer times, like Christmas break, or ... Excuse me. Winter break, spring break, summer times, if there are side effects. So, if the benefit of the medicine outweighs the side effect, then you manage the side effect.

Nada Youssef:   Okay.

Michael Manos:  If it doesn't, then you either lower the dose, or change the medicine.

Nada Youssef:   Yeah. How about sleep? Is there something that then they can take for sleep if they're not sleeping well on the medication?

Michael Manos:  So again, many physicians will recommend using melatonin.

Nada Youssef:   Okay.

Michael Manos:  Melatonin can be very, very effective for assisting with sleep.

Nada Youssef:   Great. How about any natural remedies? And when I say natural remedies, I'm talking about more mindfulness or meditation. Does any of that help with ADHD?

Michael Manos:  Let me say this. There are a lot of products out on the market.

Nada Youssef:   Yeah.

Michael Manos:  And these products, most of them, have not been demonstrated to be effective. There are three alternative or integrated medicine treatments ... Or, I shouldn't even call them treatments. They're actually protocols, or methods. Three of them that have been demonstrated to be effective for ADHD. The first one is omega-3. So omega-3 is good for any of us, actually.

Nada Youssef:   Yes.

Michael Manos:  And it has been demonstrated to have a very, very small effect on attention. So whereas stimulants may have this much effect, omega-3 has about this much effect.

Nada Youssef:   Okay.

Michael Manos:  You probably wouldn't even notice it, actually.

Nada Youssef:   Okay.

Michael Manos:  The second thing is mindfulness. So mindfulness is exploding. It's exploding in medicine, in education, in business, in psychology. Mindfulness practice, which we use in our own summer treatment program, has been demonstrated actually to be effective for ADHD. Because it allows the person the moment of separation between responding to a default mode stimulus event, and redirecting attention to a task, like the boring math sheet.

Nada Youssef:   Right.

Michael Manos:  The third thing is, is a computer program called Cogmed. Cogmed has been demonstrated to be effective with working memory.

Nada Youssef:   Okay.

Michael Manos:  We have Cogmed available here in Cleveland.

Nada Youssef:   Excellent. How about nutrition, since we're talking about omega-3? Does poor nutrition or eating habits cause any ADHD or at least contribute to it?

Michael Manos:  When I first started working in this area in the 1970s, there was a diet called the Feingold Diet. The Feingold Diet ... I was at the University of Hawaii at the time, and the Feingold Diet was this magical thing. It removed salicylates from food. So, oranges have salicylates, processed food has salicylates. And the object was to remove those salicylates and supposedly hyperactivity disappeared. There have been any number of studies with the Feingold diet, and none of them when done in a rigorous, scientific design, demonstrated effectiveness of the Feingold Diet. That has been so, to date, with all of the other diets that have been investigated. So, removing gluten for example for some people may be effective.

Nada Youssef:   Okay.

Michael Manos:  Removing food dyes, for some people, may be effective. Because some people have allergic reactions to these things.

Nada Youssef:   Sure.

Michael Manos:  Green, red, and yellow food dye can actually generate hyperactivity in some people. Not everybody. And you would know it, because the child's behavior is gonna become quite active after they ingest something. So, there has been no other clearly studied diet that has impacted ADHD.

Nada Youssef:   Okay.

Michael Manos:  Now, for example, the person that I saw today. She would get this feeling of being agitated, and her ... She said, "My thoughts just would be going all over the place." Much more so than it is when she would wake up in the morning for example. That's typically a result of having directed attention getting depleted. Oh and by the way, directed attention in a person with ADHD gets depleted far sooner than in a neurotypical individual.

Nada Youssef:   Okay.

Michael Manos:  But she would describe that when this occurred for her, and she knew she couldn't study, she would go for a hike in the woods, and she would want to do it all alone. Because being in the woods somehow brought back her equanimity. And there are even some books that describe that, being in nature, and doing something that doesn't elicit a lot of response in the brain. And when I even think back to, when you think to screens, some of us older folks probably remember Mr. Rogers. Remember Mr. Rogers?

Nada Youssef:   Yes.

Michael Manos:  He'd walk, gradually, to another place, and he would say what he said.

Nada Youssef:   Yeah. Very present in the moment.

Michael Manos:  Very present, and also slow-moving.

Nada Youssef:   Yes.

Michael Manos:  And kids were captivated by him.

Nada Youssef:   Yes.

Michael Manos:  "Hello little neighbor," and life would light up.

Nada Youssef:   Absolutely.

Michael Manos:  It's that slowing down of the response to the world around, that has an effect on the brain.

Nada Youssef:   Sure.

Michael Manos:  And that's what mindfulness practice does. Now the biggest problem of mindfulness practice with people with ADHD is getting bored. That's the whole purpose of mindfulness is to manage-

Nada Youssef:   Yeah, to be bored. Right, yeah.

Michael Manos:  Well actually it's to manage boredom.

Nada Youssef:   Sure.

Michael Manos:  Boredom is nothing more than the same thing occurring in the brain as when thoughts are flowing through it.

Nada Youssef:   Yeah.

Michael Manos:  So, the tolerance for boredom for a person with ADHD is a little more intense-

Nada Youssef:   Okay.

Michael Manos:  ... than for a neurotypical individual. However, mindfulness practice is a clearly very useful strategy that any of us could practice.

Nada Youssef:   Sure.

Michael Manos:  We use it in our own summer treatment program.

Nada Youssef:   That's excellent. So, can you outgrow ADHD?

Michael Manos:  Brilliant question, Nada. Truly brilliant. That's one of the things, the findings from the Multi Treatment Assessment Study. This may astound you, but a child who's been diagnosed with ADHD with intrusive symptoms ... 49.9% of them will show intrusive symptoms as an adult. That means 50% of them don't.

Nada Youssef:   Wow.

Michael Manos:  So do you outgrow ADHD? I don't know that that's a clinically relevant term, outgrowing it. Typically what people do is to grasp how their brain is actually working.

Nada Youssef:   Okay.

Michael Manos:  And they put in place strategies that work for them. Like, it's rather odd, but many adults with ADHD end up marrying someone who's very organized. Or they end up working for an organization that's highly structured.

Nada Youssef:   Sure.

Michael Manos:  Or they end up doing something that's absolutely fascinating to them.

Michael Manos:  So I have diagnosed physicians at some of the best institutions in our country with ADHD, and yet they're some of the best doctors in the world.

Nada Youssef:   Yeah.

Michael Manos:  Even surgeons. One of the capacities of these people is they can over-focus on something. And their ability to notice everything makes them some of the best people around. But when they have to stop and do a directed attention task, as opposed to the default mode task of surgery-

Nada Youssef:   Sure.

Michael Manos:  ... and they have to enter an electronic medical record, they have to have ... They figure out, they have to have somebody accompanying them-

Nada Youssef:   Right.

Michael Manos:  ... to get the thing done, so they can get it done on time.

Nada Youssef:   Great. Now, how do medications actually work in the brain, for ADHD patients?

Michael Manos:  Many people have misconceptions about what these medicines do. Some people think they calm a child down. Some people think they dope the child up. It's got nothing to do with that. If you consider that the network of the brain that is not as effective, it's not working as powerfully, called directed attention, or the task mode of the brain, neurotransmitters dopamine and norepinephrine, that that network, if it's strengthened, allows the person to put their attention where they want it to go, as opposed to the attention going where it wants to go.

Nada Youssef:   Controlling their attention.

Michael Manos:  It ... Yes. It actually allows them to adapt their attention to the task. So, that's all it does.

Nada Youssef:   Sure.

Michael Manos:  It doesn't do anything else. It strengthens the directed attention needed to self-regulate. So a child actually can do what they want to do.

Nada Youssef:   Sure. Okay, so we are running out of time. But before I let you go ... Now I know you talked quite a bit about the nine symptoms for people to notice when their children are going through maybe ADHD symptoms. Is there something so our listeners or viewers, that you want to tell them? Are these symptoms ... Is it something that they can just Google, and find out what these symptoms are if they want to check out?

Michael Manos:  Yes, they are.

Nada Youssef:   Okay. So just look them up, and just to find out in case it sounds like it could be someone they know or a-

Michael Manos:  Yes.

Nada Youssef:   ... child that they know.

Michael Manos:  You can go to the American Academy of Pediatrics. You can go to the CHADD website, C-H-A-D-D, Children and Adults with ADHD, ADD.

Nada Youssef:   Okay.

Michael Manos:  And you can find the symptoms, you can find discussions of the treatment. The thing to watch out for there, there is so much disinformation out there.

Nada Youssef:   Right.

Michael Manos:  And we for example here at Cleveland Clinic offer shared appointments. And in the shared appointments we describe what ADHD actually is, from the science of it.

Nada Youssef:   Great.

Michael Manos:  And you have to be very careful as to what you are going to believe.

Nada Youssef:   Sure. Well, thank you so much for being here today. It's been a pleasure.

Michael Manos:  Well my pleasure, Nada. Thank you for inviting me.

Nada Youssef:   Sure thing.

Michael Manos:  I appreciate the conversation.

Nada Youssef:   Thank you.

Michael Manos:  You're a gracious hostess.

Nada Youssef:   Thank you so much. I appreciate it. And for more information, or to make an appointment, call 216-444-5437, or visit clevelandclinicchildrens.org/adhd. And thanks again for listening. We hope you enjoyed this podcast, and if you want to hear more of our Health Essentials Podcast from our Cleveland Clinic experts, make sure you go to clevelandclinic.org/hepodcast, or you can subscribe on iTunes. Thank you again. We'll see you again next time.