ADHD + Addiction
This week we’re looking at the ways ADHD and addiction are linked. Nzinga answers listener questions about ADHD medication, parenting a kid with ADHD, multigenerational trauma and ADHD, and why folks with ADHD can be more prone to addiction. It’s not as simple as you think.
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[00:02] Dr. Nzinga Harrison: Hello. So I know a lot is going on, but I cannot let Pride Month pass without shouting out my LGBTQI+ people. I consider myself a staunch ally. And so I need you guys to help me out. Help me be better. Helped me raise my voice on your behalf. I was so excited to see the Supreme Court do the right thing. Work discrimination against people for LGBTQI+ status has been struck down. So that is amazing. And my friends, that is just the beginning. We have so much work to do. I am on the team with you. Let me know how I can support you. I am educating myself on how I can support you. But for today I just want to celebrate you. Rainbow Pride. Love is love. Love wins. All of that. And now we’ve got this week’s show.
[01:08] Dr. Nzinga Harrison: Hey, everybody. You’re listening to In Recovery. And I’m Dr. Nzinga Harrison, your host. If you’re a first-time listener, this show’s about all things addiction. Not just drugs, but also sex, exercise, chaos, relationships. And I’m your host because I’m a physician, psychiatrist, addiction expert. And I believe in this so much, I’m even co-founder of my own company, Eleanor Health, where I serve as chief medical officer. As important as all of those things are for my credibility, I’m also a wife, a mom, a human. And so I’ll be answering your questions from all of those perspectives. Today’s show is about ADHD and addiction. But before I jump in to physician, psychiatrist, addiction expert, chief medical officer of Eleanor Health role, let me just talk to you about my life this past week. I actually ventured out. So I’ve been working from home, which is sitting 12 to 13 hours a day in front of my computer screens. And my neck has been screaming. I’ve been having so much pain. So you know, I got back to doing my yoga, it wasn’t making a difference. I decided I was gonna have to venture out. So I actually went to get a massage so that I could actually turn my head side to side. I checked to make sure they were gonna have all the Covid precautions in place, and they did. So they had you know, you can check in from outside. They staggered the appointments so only one person would be in the lobby at a time. They had touchless pay. They disinfected everything. Everybody was wearing masks. But it was interesting to me, I realized, I’ve developed just a little tiny agoraphobia. Like I literally, like, had anxiety, like, oh, my gosh, I’m about to go be like in a place with other strangers, which I hadn’t done. And that’s not so much a concern for my own health, because thankfully I’m healthy and I’ll go ahead and call myself young. So thankfully, I’m in a low-risk Covid category, but my moms are not. And so I have been like hard core about social distancing so that I can get back to being in the same space with my moms.
[03:28] Dr. Nzinga Harrison: But anyway, it went well, OK. But then I had to stop at the gas station and nobody had on masks and that broke my heart. So my public service announcement is, please wear a mask. If you have to venture out, go ahead and do it. Please wear a mask. I saw a lot of people that I could tell were in high-risk groups with no mask on. And I wanted to be that person that just, like, started handing out masks to strangers. But then I decided that was kind of random. But please just wear a mask.
[04:03] Dr. Nzinga Harrison: So this week, we’re talking about ADHD and addiction because we’ve received, I think, a lot of questions early on about how ADHD impacts and influences addiction, right Claire?
[04:15] Claire Jones: Yeah, definitely. We have gotten a bunch of questions sent to our email, a couple of voicemails. And we also did a social media call-out and got a bunch of great questions from Twitter. So I think that we should hop right in. But I’m curious, what is the stigma around ADHD?
[04:33] Dr. Nzinga Harrison: Yeah, hopping right in. Stigma is one of my favorite topics to talk about, because the way we reduce stigma is by talking about it. So there’s actually been pretty good movement on reducing the stigma of ADHD in professionals. So folks that are in kind of higher “echelon,” if you’ll allow me to use that word, professional status. So, like doctors, lawyers, business people. It’s not as difficult to say, “I have ADHD,” and not get judged about that than it has been for others. But for other groups, ADHD still carries a lot of stigma, and I’m particularly talking about school-age kids. So in college, it’s a bit more acceptable. But I’m definitely talking about school-age kids of lower socio-economic status, who are in poor communities. And then definitely compound stigma for black kids and other kids of color in school-age and high school who are getting diagnoses of ADHD. And so really the stigma of ADHD started out by being like, these are the kids that everybody thought were just bad kids. Like kids that don’t listen, kids they can’t control their behavior. Kids that don’t do what you say, kids that can’t sit still in the classroom and kids that challenge you. Kids that say things with a “smart mouth,” we call it. They got a smart mouth. Those are the kids with ADHD. And so adults really had this concept that, like, these kids are just bad. And quite honestly, if I were not a psychiatrist, so my oldest son, Zahir, is 14. He got diagnosed with ADHD when he was six.
[06:22] Dr. Nzinga Harrison: And once we got the diagnosis of ADHD, we realized as parents, we had been getting him in trouble for things that were symptoms. And so it really helped us as parents to be able to conceptualize like, oh, he’s not just not listening because he’s being disrespectful. Like, oh, he didn’t just not do what I told him to do. And, you know, black momma, I’m like, I tell you once and I expect that to get done. And then we got the diagnosis of ADHD and the psychologist that did his psych testing, who was amazing — first of all, I highly recommend psychological testing. I wish he was more widely available to people. But when she gave us the feedback and she was like, “and one of the things we recommend for kids with ADHD is that you have to say everything no less than three times. And after you say it three times, then you have to have them say it back to you.” And we were like, oh, man. Oh, three times and a repeat back? We’ve been falling a little short of that threshold.
[07:32] Dr. Nzinga Harrison: And then getting this kid, Zahir, who is just like an amazingly smart, compassionate, well-behaved — I mean, like everything about this kid is super shiny and beautiful. And we’re like getting him in trouble for symptoms of ADHD, right? So that’s the first stigma is like these are bad kids. But then you put on top of that stigma — so, the kids who are at most risk, I’m going to talk about disparities. So the first disparity I’m going to talk about is gender disparity. We kind of expect boys to be boisterous and all over the place and climbing on things, that is our gender stereotype for what we expect from little boys in America. And so when you have a girl with ADHD, then her stigma is even more compound, because not only are you a bad kid that listens, you’re also not following into that gender construct that we expect from nice little girls. And then take the next disparity, which is race. So you have a kid of color, Hispanic kid or black kid, and they’re hyperactive. And that in this country is really experienced as disrespectful and criminal. So they get sent to the principal’s office for things other kids wouldn’t get sent to the principal’s office. So the same way we were getting Zahir in trouble for symptoms, there’s like a whole punitive construct for those kids getting in trouble. So that’s gender disparity, right? Like, that’s gender stigma. That’s bad-kid stigma. That’s bad black kid stigma, which wraps into kind of like criminality stigma that we have about kids of color anyway. And then definitely socioeconomic stigma.
[09:30] Dr. Nzinga Harrison: And this compounds from a whole bunch of things that kids that are otherwise not able to get their basic needs met — so like housing insecurity, food insecurity, maybe come to school not in the cleanest clothes. Can’t seem like they can pay attention. They need so much. When kids with those circumstances get diagnosed with ADHD, that is like further compounding their risk. And that comes from the system not being appropriately structured to meet the needs of a kid that doesn’t have lots of resources. And so the same thing there, when Zahir got diagnosed with ADHD — this is my same approach to all things health. Like, I think depending on the severity of illness, if you have mild or moderate symptoms, we should see what lifestyle interventions we can do. We should see what psychological, what social interventions we can make. We try those that we have access to. That doesn’t work? Then we think about a medication. So the same thing when you first catch a cold. You’re like, oh, I think I might be sick. You try to drink some hot tea. You try to use a cough drop. Those things don’t work. And you say, oh, OK, well, let me try this Alka Seltzer. You try Alka Seltzer, that doesn’t work. And you say, oh, OK, I need to go see a doctor to help me figure out what medication, what I can do. So I believe in that same process for all illnesses. So that was the process we took with Zahir’s ADHD because his symptoms were moderate when he got diagnosed. But do you know how much money we had to spend on those psychological and social interventions? The fact that we could even get full psychological testing. we had to pay for that out-of-pocket. And we had insurance. So think about the person that didn’t have insurance. And then I was able, just because I’m a psychiatrist and I know the system, to find a child and adolescent psychologist who was willing to come to his class to do an in-class observation.
[11:25] Dr. Nzinga Harrison: When you think about public school, when you think about people who are not psychiatrists, when you think about people who don’t have all of those resources, it just strips the ability to really try to do a robust psychological social intervention. And the stigma lays on top of that because part of the reason those resources are not available to lower socio-economic groups is because they’re just “bad kids” of color that need to pay attention or that need punitive interventions. So the stigma for ADHD really is hurtful.
[12:06] Claire Jones: And it has to be a negative feedback loop in some way. Like these kids who are hyperactive, where their parents don’t necessarily know that it’s because of ADHD, teachers don’t necessarily know because it’s ADHD. They’re in lower income neighborhoods, which means the schools are most likely overcrowded, the teachers are overworked and underpaid. And the disciplinary process for those kids just compounds this idea of like “You’re a bad kid. You’re a bad kid. You’re a bad kid.” That gets in their brain. I know this only because my best friend is in a grad master’s program where she’s trying to sort of think about discipline, especially in low income and schools where there is a majority of kids of color. Think about discipline and think about mindfulness and think about access to resources that these kids aren’t having. How do we improve those to allow these kids to actually learn information and make space for kids who have different learning styles and ADHD, things like that. And, you know, the biggest thing that she’s realized from this is it’s a negative feedback loop for these kids as they start to grow up, because they have this narrative of, like, “I am bad. And I don’t learn the same way, so I am dumb.” And it has to have a lasting impact.
[13:18] Dr. Nzinga Harrison: Yeah, that’s exactly right. And it definitely has a lasting impact. We can follow ADHD undiagnosed and diagnosed forward to pathways to anxiety, depression, you know, further difficulties later on in life. So it 100 percent has an impact. So, Claire, I got to give you some kudos, because your language just gave me rainbows and unicorns the whole time you were talking there, because at no point did you say because public schools are bad. Like the same way we talk about kids. You said public schools under-resourced, overcrowded. You pointed at the systemic ills instead of pointing out — a lot of times people say, like, you know, these public teachers don’t care and blah, blah, blah. And so I love that it was just so natural for you to point your finger at the systemic ills that it was at the people who are struggling in the system. Just like they also pointed at the public school kids, it’s like, no, no, those kids are struggling because of the ills of the system, just like those teachers are struggling because of the ills of the system. So go ahead, Claire! I loved it.
[20:28] Claire Jones: I think this is also a good segue to actually hop into our first question. This was one that we got from Twitter and this person asked, what do you think about Dr. Gabor Maté’s theory on ADHD being a response to trauma? And if you agree with him, what does this mean for ADHD-related substance use disorder treatment?
[20:47] Dr. Nzinga Harrison: OK. Thank you for this question. And so I do want to point out just a little bit, because I’m a psychiatrist and I’m a physician, so when we use the word trauma, we use it very specifically. So what Dr. Gabor Maté actually said is that ADHD is a response to multi-generational family stress and disturbed social conditions in a stressed society. And the reason why I want to separate that — now, trauma can absolutely be a part of that. And kind of like in general language, we would say the multi-generational family stress of poverty is traumatic, or the multi-generational family stress of racism is traumatic, or the multi-generational family stress of homelessness is traumatic. But to use the word “trauma” just has a specific meaning in psychiatry. And so I want to make sure that people understand that what I’m responding to is Dr. Maté’s theory that ADHD is a response to multi-generational family stress and disturbed social conditions, which I agree with. And so I don’t agree with that just for ADHD, I agree with that for all illnesses, physical and mental. So when you hear Nzinga — I always crack myself up when I refer to myself in the third person — when you hear in Nzinga talking about biological, psychological, social, cultural, political, the psychological, social, cultural, political is a synonym for multi-generational family stress and disturbed social conditions in a stressed society.
[22:35] Dr. Nzinga Harrison: Literally, we’re saying the exact same thing there. And so to get to the part of the question, then, so what does that mean for ADHD-related substance use disorder treatment? It means the same thing it means for the treatment of any other illness. And what that means is we cannot think for one second that we can take a child that has ADHD, give that child Ritalin, and the illness is treated. Because if the root cause of any illness includes multi-generational family stress and disturbed social conditions in a stressed society, then the treatment for that illness has to address multi-generational family stress. And that treatment has to address disturbed social conditions in a stressed society that are driving that illness. The last very fine point that I want to put on how much I agree with Dr. Gabor Maté’s conceptualization is that biology — so we’re all born — and you’ve heard me say this in previous episodes — we’re all born with our DNA, but our experiences change our DNA, and we pass those changes onto the next generation.
[23:48] Dr. Nzinga Harrison: It’s called epigenetics. And so when I say all illnesses are biological, and you take the rest of that psycho social, cultural, political, when you understand epigenetics, then you understand that this person may have had coded in their DNA 10 percent risk for developing ADHD. But then during childhood they experienced homelessness and food insecurity and a punitive school system that didn’t realize they had ADHD, which led them to a criminal justice system in the face of racism, in the face of poverty. And now they’re epigenetics has laid on top of that 10 percent. And when they pass their DNA to their first generation offspring, then maybe that risk is 20 percent. And then the chances that that child was born into the same conditions are high. So then epigenetics lays on top of epigenetics lays on top of original biological risk, and then maybe the third generation has 30 percent risk. And so when we look back at the multi–generational family stress, that’s looking at the past. And when we look at the stressed society, that’s looking at right now. All of those are interfering with our kids and those that go on to continue to have ADHD as adults, it is interfering with their ability to do well despite their illness. And that is on us. That is not on the people with the illness. That is on the people taking care of the illness. And that is on all of us that are trying to fight for a better, less stressed society that doesn’t heap so much multigenerational stress on families.
[26:00] Claire Jones: Yeah, and that actually leads to our next question from Elise. Let’s hear a little bit of her voicemail.
[26:08] Elise: Hi, my name is Elise. I want to know how sexual trauma is related to sexual addiction. Because a lot of people with ADHD have gone through something like that, for various reasons. And how is ADHD connected to addiction? I think that’s probably it.
[26:27] Dr. Nzinga Harrison: Thank you, Elise, for sending in this question, because she’s absolutely right. Children with any mental health diagnosis are at increased risk for being victimized. And so people don’t necessarily think about that for kids who have been diagnosed with ADHD. But remember, at the very top of this episode when we talked about the stigma that goes along with being a “bad kid,” it is awful, but I’m just gonna come right out and say it, systemically, we don’t protect kids that we’ve labeled as “bad.” And so a lot of times, going back to Dr. Gabor Maté’s position, the multi-generational family stress and the disturbed social conditions, a lot of time kids that are getting diagnosed with ADHD have so much else that they’re having to deal with in their lives that are already putting them at risk for being vulnerable. So our kids who are living in poverty or at risk of being exploited. Our kids who have housing insecurity are at risk of being exploited. Our kids who have parents who have their own illnesses and mental illnesses, substance use disorder, chronic physical illnesses that interfere with their ability to provide kind of stable parenting, that is putting these kids at increased risk of being victimized. And so she’s exactly right. We look at kids with ADHD, there is a lot more risk of them being victimized because we’re not taking the extra precautions to protect especially those kids that have been labeled “bad.” And so when you think about the connection of ADHD to addiction, maybe you can guess my answer. There are shared biology and there are shared psychosocial, cultural, political components that are linking these two illnesses together. So just to drop some statistics before we kind of get into the theoretical part of it. The studies have shown us that kids with ADHD have been found to be at increased risk for developing a substance use disorder. The risk of substance use disorders is as much as twice as high among people with ADHD, all the way up to as high as four times as high for people with ADHD that also are diagnosed with other psychiatric disorders. The most common one in children being this conduct disorder. And conduct disorder is this whole other long episode, so I don’t even want to go down that rabbit hole right now because I will get on a little bit of a soapbox. We’ll do a future episode on conduct disorder. But so the short of it is that kids with ADHD have twice to four times the risk of developing a substance use disorder. I want to be very loud on this next point. What the literature also seems to show is that kids with untreated ADHD are the kids with the highest risk.
[29:50] Dr. Nzinga Harrison: So treating ADHD as early as possible seems to reduce the risk of those kids going on to start smoking, develop substance use disorders, and a whole host of other disorders down the road. So that is my plug for early identification. I know there’s this movement that’s like, “why are all these kids getting diagnosed with ADHD? Some of this is just normal behavior. Some of this doesn’t have anything to do with ADHD.” And part of that is muscle box on conduct disorder also. And that is absolutely true. But I think what those people are responding to is this idea that the treatment of ADHD is medication alone. So it’s like black boys are disproportionately getting diagnosed with ADHD, which is true, disproportionately getting put on medication for ADHD, which is true. This is just another systemic ploy to just medicate our kids, and they can’t see that these are just kids being kids because of all the racial constructs that go around the way people see kids of color. All of that is true. What is also true is that multi-generational family stress and current stressed social conditions are disproportionately falling on kids of color, which is also disproportionately increasing the risk, one, that they’ll be victimized, to get back to Elise’s point. Two, that they’ll develop ADHD. Three, that that ADHD will be seen through a punitive lens instead of through a health lens, thereby, four, increasing their risk of developing substance use disorder and other difficulties down the road. And so what I would like is for us to be looking, especially in these schools where there are a lot of kids with a lot of need, like we need to be practicing an ounce of prevention. Isn’t that our responsibility as adults to be protecting these kids and to be looking early to say — I mean, that same thing happened with Zahir. Zahir was six years old.
[31:55] Dr. Nzinga Harrison: We got a little signal like, oh, something might be going on here. And the initial impulse as a mother is my child is fine. That’s the initial impulse. You’ve got to get past that initial impulse and say if there’s something going on here that I could do something about, I want to know about it as soon as humanly possible, so that I can start doing something about it. And we have to hold our schools and all of our other institutions to that same level. Early identification, because we know biologically there is a link between ADHD and substance use disorders. So, Claire, I’m about to talk about my favorite subject: Neurobiology.
[36:19] Dr. Nzinga Harrison: So our brain is responsible for the way we feel, the way we think, the way we behave, the decisions we make. And so I’ve split the brain into two pieces in previous episodes, we’re gonna split it into the same two pieces. Because ADHD is an illness that starts in the brain. So just like high blood pressure is an illness that starts in the cardiovascular system, the cardiovascular system is made up of your heart and your blood vessels. So there are a lot of different cardiovascular illnesses, they all share biology because it’s the heart and it’s the blood vessels. It’s different things about it. So the same is true for ADHD and substance use disorders because it’s the brain. So it’s going to be the deep brain, which is the automatic part of the brain where our emotions and our impulses and our reflexes and our fight or flight, all of that is in the deep brain. It can run without us. Or it’s going to be in the cortex, which is where our thinking and our decision making is. And so because it’s the brain, substance use disorders are sharing those two parts of the brain. ADHD is sharing those two parts of the brain. So we mostly think about ADHD, even though you can’t separate out the parts of the brain no more than you can separate out and say the heart can work without the lungs. Like, not true. So you can’t separate out the two parts of the brain, but it looks like ADHD is overwhelmingly a function of the cortex.
[37:58] Dr. Nzinga Harrison: The cortex is right underneath your forehead. That’s where you’re thinking, that’s where your impulse control, that’s where we call it executive functions. So taking all of the information that’s coming from the outside world and the inside world, your prefrontal cortex is your CEO. Like, if your body is your company, your prefrontal cortex is your CEO. Your CEO is taking all of the information, assigning a value to it, assigning a priority to it, assigning a meaning to it, and then telling you what to do, what decisions to make around that, what behaviors to have. In ADHD, that pathway is affected. So the space between getting information and thinking about that information before acting on that information. That thinking spaces impulse control. This is disordered in ADHD. And so that was part of the work that our psychologists really helped us with when Zahir first got diagnosed. She was like mantras help, because the more you have a pattern, the more the brain can be impulsive and not be dangerous. And so we developed a mantra for Zahir that was “think first.” And we said to him just hundreds of times a day. “Think first.” Every single time we saw him about to be impulsive. think first. And we trained his prefrontal cortex into impulsively developing that thought, think first, so that then he could respond to think first instead of, you know, whatever piece of furniture he was about to jump off of and break his arm. But so the point is that there is a shared biology between substance use disorders, because guess what is also impaired in substance use disorder? That space that is thinking before reacting. And so the deep brain is bringing forward to the prefrontal cortex for whatever reason, triggered by whatever, whatever set of, you know, life circumstances. You need to drink that alcohol. And it’s the space between that thought coming to the prefrontal cortex and the prefrontal cortex being able to think about that before acting on it. That is the space that is shared between ADHD and substance use disorders. So a friend says to an adolescent with ADHD, “you should snort this line of cocaine.” A kid without ADHD may have more space to say, “well, let me think about the pros and cons of snorting this cocaine.” And then make a decision not to. Whereas a kid with definitely untreated ADHD doesn’t have that space. The friend says do this line of cocaine. The kid with ADHD does that line of cocaine. And then afterwards says, oh, man, should I have done that? So, all linked.
[40:52] Claire Jones: So if I am a parent with a kid who has ADHD, what are some ways that I can talk to them about this process? And more specifically, a question that we got from Twitter, what are some parenting strategies to help them build on the strengths that ADHD can have. And to help them avoid these addiction pitfalls that they might be vulnerable to?
[41:19] Dr. Nzinga Harrison: Yes. OK. Check is in the mail for whoever tweeted us that question. I love it. The perfect setup. So the first thing I always say to everybody who can ever hear my voice they will tell you: anybody who’s interacting with kids, at the first sign you get that inkling, like, could there be something? Act on that, like immediately. Immediately get your child in, and my preference is to a PhD-level psychologist, or a CAD-level psychologist, that specializes in kids that can do structured testing to tell you what’s going on with the kid. Because structure testing is less vulnerable to the bias of the interviewer. So even when you come to me as a psychiatrist, I have my own set of biases that I’m interviewing that child and interviewing that family through. And my subjective evaluation, which an interview-based evaluation is going to have a significant amount of subjectivity, is prey to those biases. Psychological testing is going to be less vulnerable to those biases. So the very first ping you get — and that ping is like, could there be something going on with my kid? But we talked earlier in this episode about “bad kids.” If you think to yourself, is my kid bad? If you find yourself asking that question, then I want you to reframe that question in your mind.
[42:52] Is there something here that I should be getting my kid help with? And the next level of that is there’s something here I should be getting myself help with? Because our kids’ experiences are extensions of our own experiences. Our kids’ emotional functioning are extensions of our own emotional functioning. Our kids’ thinking, decision making and impulse control are extensions of our own thinking, decision making and impulse control. That is true biologically, psychologically, social, culturally, politically. And so if you think to yourself, my kid might be bad, reframe that and say my kid might need help with something. If you think to yourself, is there something here my kid might need help with? Please just err on the side of getting a structured, testing-based psychological assessment for your child. That is going to come with a list of recommendations. Even if they get to the end and they say, you know what? Nothing your child is doing is outside of what kids do. That psychologist is going to give you a list of recommendations that says, but let’s talk about how to reduce the stress around what’s happening with your kid. Number one, say everything three times and then have him reflect it back to you. Even if Zahir didn’t get a diagnosis of ADHD, that would have been helpful information. So err on the side of getting evaluated. There are tons of resources. I have been an avid consumer — and I don’t stay on a lot of mailing lists because, you know, I can’t be having all these emails coming to me all day, all night. But I have stayed on the mailing list for this organization. It is called ADDA — Attention Deficit Disorder Association. And their website is www.ADD.org. Man, the resources are amazing. Being able to find a certified ADHD professional is amazing. Being able to find doctors that can prescribe ADHD medication safely is amazing. Like this is my go to resource for ADHD. And as a mom of a kid with ADHD, like I’m saying that not just as a doctor. As a doctor, I’m telling you, the information here is reliable and evidence based. As a mom with a kid with ADHD, I’m telling you, this website has helped me. So look for your resources.
[45:21] Dr. Nzinga Harrison: And then the last thing I’m gonna say to answer this question is practice an ounce of prevention. So be looking for it. Don’t be afraid to get a diagnosis. If you get a diagnosis, that’s fine. Also, make sure you have that entire treatment plan. So if you’re with somebody and they give you a diagnosis and they’re like, “oh, you just need this prescription,” I want you to find somebody else, because you don’t just need this prescription. You might need this prescription. And I want you to take it if so, especially if the symptoms are severe. Prescription is the first step and everything else is going to layer in. If the symptoms are mild to moderate and you have a lot of resources, you may be able to do the other steps first and then decide, depending on how the illness responds, if you need to do a medication there. But I don’t want anybody to think I’m talking you out of medication because this is what one of my friends said to me, who is a psychiatrist, a child and adolescent psychiatrist, Dr. Osvaldo Gaytan. He was a resident in front of me when I was in training. So he was one of my senior residents when I was a junior resident. Crazy, smart guy, amazing all-around, great human being. So I was posting a lot when Zahir just got diagnosed with ADHD. I was posting a lot on Facebook because, you know, I believe in being transparent with my experiences and I was reaching out for help. And he said this beautiful thing to me that I have said a million times and I always give him his credit, so make sure you leave his name in the podcast, Dr. Osvaldo Gaytan said, “Zahir is exceedingly smart,” which is true. He legitimately has the highest IQ in the house. We all tested ourselves. His is the highest. So it’s true. “He has great parents.” Thank you. We do our best. “You guys have a lot of resources.” This is true. We have financial resources. We have support system because I’m a psychiatrist. I know how to navigate the mental health system. All of those are incredible. He said, “could Zahir get up this mountain with all of these rocks in his backpack? Yes, he could. But as a parent, wouldn’t you love to take the rocks out of his backpack? So it would be easier for him to climb the mountain?”
[47:35] Dr. Nzinga Harrison: You just heard me get teary. It was beautiful. Literally, when he said that to me, I felt like that freed me as a mother to do whatever I need to do to take the rocks out of my kid’s backpack. And so that’s what I’ll say to the parents who are listening, the caregivers who are listening, the teachers who are listening. Anybody who can make a difference in a child’s life. One, it is our responsibility to look for what those rocks are. And then two, it’s our responsibility to do absolutely everything we can do to take those rocks out of our kids’ backpacks. And that is 100 percent of the time more than medication.
[48:23] Claire Jones: The question that comes up as a follow up to that is for teachers. School is sort of the place where ADHD comes out the most, maybe. And so as a parent, is it your responsibility to talk to your teacher and be like, “hey, my kid has ADHD. Here’s what works for us at home. If you see these behaviors in your classroom, here’s what you can do.” Or is it more of a systemic thing where teachers should just know about this as part of their education or teaching certificate. But how do we address that with teachers?
[48:58] Dr. Nzinga Harrison: Yeah. So it’s bi-directional. I think about it exactly the same way as I think about the patient that walks in my office. That patient walks in my office, they’re expecting me to be an expert in medicine. They’re expecting me to be an expert in psychiatry. They’re expecting me to be an expert in addictions. And so it is my responsibility to proactively bring that expertise to that person that walks in my door to be helping them. But what I also need, because I don’t know you as an individual, so what I also need when you come in is for you to be the expert in you. And as much as I’m educating you on what the medical evidence says or what the evidence base is or what the addiction literature says, and this has been my professional experience and this is my expertise from that vantage point, I need you to be telling me this is what our experiences have been with our child. This is what has been helpful. This is not what has been helpful. I need you to bring that expertise of your child proactively to me, the same way I’m bringing my expertise as a medical professional proactively to you.
[50:06] Dr. Nzinga Harrison: And so I would say the same thing for teachers, which is that all teachers should be getting trained in ADHD as part of teacher training. All teachers should also be getting trained in mindfulness and meditation because the evidence is unequivocal there. Kids that have mindfulness, a meditation starting as early as pre-K have better all the outcomes — academic outcomes, emotional outcomes, substance use disorder outcomes. All of the outcomes are better. Right. And so there is no reason why mindfulness, meditation, managing ADHD and depending on the age group, especially when you get to adolescence, but even being able to recognize depression and anxiety in younger kids. So it’s not that you have to be able to diagnose it. It’s not even that you have to be able to develop the 360-degree plan. You should be able to recognize this child may need to be evaluated. And you should know how to have that conversation with parents in a way that increases the chance that kid will get evaluated. And the system should provide a pathway for you to easily get that child connected, whether that’s through the school counselor or whatever other pathway to get that child connected and make sure they don’t fall through the cracks. Now, I’m saying “should” there because we got a lot of work to do on that systemically. Parents should also. So, yes, Zahir got diagnosed. The Montessori school he goes to has three-year blocks. He got diagnosed in his first year of this level, primary, six, seven, eight years old. When he was nine years old, he moved to a new teacher. I took that psychological testing to that teacher. That’s the other thing. What our psychologist did said these are interventions that parents can do at home. These are interventions that teachers can do at school. She laid that out for us. So I on the first day of school, met that teacher and was like, OK, so let me let you know, Zahir is exceedingly smart. He also has significant ADHD. These are all the things we’re doing. This is what the psychologists recommended for the classroom. Which of these can we do? Like which of these do you have the capacity to do? And so that set it off on the very first good foot because that teacher doesn’t have the chance to start developing Zahir is the bad kid narrative in her head. From the very beginning, oh, Zahir is a kid with ADHD. And this is how I manage this if it comes up.
[52:54] Claire Jones: Yeah. OK. Let’s talk about teenagers for a second. So we got an email from Cheryl, a mom to a 15-year-old son with ADHD. And she says that he often leaves the house and seems to be self-medicating with pot. Isn’t really opening up to his parents, like a lot of 15-year-olds, and has high emotions that kind of swing back and forth. She also says that he is super bright and funny and has a lot of potential, but she doesn’t necessarily know as a parent how to talk to him about this. She’s also afraid that his use of pot right now will lead to addiction in other ways in his life. So what is your advice for Cheryl?
[53:33] Dr. Nzinga Harrison: Yeah. So first of all, Cheryl is right to be concerned. Second of all, I just want to lift up, in case Cheryl’s son ever listens to this podcast. And Cheryl, maybe you play this podcast for your son. I really want to lift up that you said “our son is very bright and funny and has tremendous potential.” Because I know that is the case and I love that that’s the way that you see your son. And I hope your son knows that that’s the way that you see him. And so what’s really special about the way you ask this question is I’m worried about my son. And I think that’s what our kids need to know. A lot of the ways we parent — and to adolescents, it will just sound like I’m telling you what to do because I’m the adult and I’m telling you what to do. So I’m telling you, marijuana is not healthy, and you don’t have your healthy coping skills, and you’re at increased risk is how it can come off sounding to our kids. So the first thing is open up this line of conversation easy, breezy, right? “Oh, I feel like I noticed you smoking a lot more weed lately,” or whatever you guys call in your house pot. And he’s gonna be like, I am not talking about this. That is also normal for a 15-year-old. Like, I swear, we’re social distancing. We are all up in this house. I am like I feel like I haven’t seen my teenage kids in two days, even though none of us has left. So that is also normal. But you open it up. “I feel like I noticed you smoking a lot more marijuana. And I’m worried about you. Because this isn’t how I’ve usually seen you coping. Like you usually cracking jokes. You’re usually so bright. You’re usually like super positive. And I’m worried that you seem a little different to me.”
[55:27] Dr. Nzinga Harrison: Approach it from that way instead of like you got to stop smoking so much marijuana. Because mom is right. The fact that he has a diagnosis of ADHD, we just said at the top of this episode, increases his risk of developing a substance use disorder, marijuana included, two to four times. The other thing is at 15, it’s very much an age where depression and anxiety show up. And so I would want to be especially putting my eye on the ball to see if her son has any other signs of depression and anxiety, especially in this social distancing time where he’s maybe lost his other outlets. So if he was playing sports, if he was going out with his friends, the other things he was doing that are not virtual, that were probably taking away time that could have been spent smoking marijuana. Our adolescents have experienced a huge loss because of coronavirus social distancing. You figure how important socializing is to us. Socializing is actually the number one developmental need for adolescents. School is where that happens. Both of my boys have said to me, I would pay money to go back to school right now, Mom. And I never thought I would say that. And they were like, let me be clear. I’m not talking about the classes.
[56:55] Dr. Nzinga Harrison: And so us being able to be very sensitive that our kids are going through it right now. They have lost a lot and they are grieving. And there’s probably some depression and some anxiety there. And not all peer groups — because of the stigma that we heap on having a therapist, especially on boys, that stigma is even higher — don’t necessarily know if they can have that as an outlet, are comfortable having that as an outlet. So as parents, we just have to let them know that I am trying to understand. I feel like I see you hurting. And as your mom, that makes me worry about you. And what I’m noticing, that makes me feel like I see you hurting is that you seem like you’re smoking more marijuana. I know you don’t have your sports. I know you can’t go hang out with your friends. I know all of those things you used to do to kind of like keep yourself feeling good, have disappeared. So I’m checking in to see if you need help. That’s the way that I would approach it. And if he can’t let you in, our job as parents is to be persistent. So you don’t have to hammer it home right there. But then you just say, you know, the next time, I know we just had this conversation a couple weeks ago, but I feel like my worry is even higher. And I know you don’t want to talk to me, but I need you to talk to me. I need you to let me know. Do I need to be worried? And if you say I don’t need to be worried, then I need you to give me some evidence. Try to approach it horizontally, try to remove the power dynamic out of it and let it just be like starting with I love you so much, and I think so highly of you. And none of this can change that. It is my job to be here for you if you’re going through something. And it’s my job to see if you’re going through something, even when you don’t tell me you’re going through something. And I feel like I see it.
[58:56] Claire Jones: Yeah, that’s a great response. OK, one last final question. Sort of a pivot from what we’ve been talking about, but how does nutrition figure into ADHD? Does clean eating help?
[59:15] Dr. Nzinga Harrison: Yes. OK, so you can take ADHD out and fill in any illness right there. How does nutrition figure into fill in the blank with any diagnosis we have? Does clean eating help? And the answer is yes. So let me make sure I define what I’m talking about for clean eating. There are some people who are going to say, oh, that means no sugar, no carbs, no processed foods. OK, when I say clean eating, I’m really talking about well-balanced eating. So is it possible to cut everything processed out for most people? No. For people without a lot of money? Definitely no. For people with not a lot of time, like everybody is working all day everyday? Definitely no. But yes, try to eat as many whole foods that are not processed as possible. So minimize processed foods. What we know is that preservatives and simple sugars definitely affect the way our brains work, and they make our brain functioning not optimal. So when you have ADHD, you’re already climbing up the mountain. So healthy eating is one of the rocks we can take out of the book bag. The other thing is also sleep. Please, please, sleep hygiene is so incredibly important. I’m going to broaden into just like the health routine. So an ADHD, just like all other illnesses, well-balanced, eating, minimizing simple sugars, minimizing processed foods.
[01:00:44] Dr. Nzinga Harrison: All of this is excruciatingly important. Eating regularly. So at the same time each day and making sure those are enough calories. And this is actually huge for our adolescents with ADHD. Adolescent eating habits are all over the place. Literally one day Zahir will not eat. And then the next day Zahir will make the entire box of pancake mix and eat all the pancakes in the house, or the entire box of cereal all at once. And so it’s like as much as we can support our kids, but also our adults that have ADHD and eating at the same time each day. The more routine you set up for your brain, the more your brain functions at its top optimal ability. Same with sleep. Try to go to bed at the same time each night. Try to make sure you’re getting in the number of hours you need, that varies for people between five and a half and nine. You know what it is for you, because you wake up kind of naturally and you don’t feel tired. Put your sleep hygiene and bedtime routines in place. Exercise. I cannot emphasize enough. There is a beautiful literature that shows regular aerobics exercise reduces impact of ADHD. You have to eat. You have to sleep. You have to exercise. And stress. So stress decreases our prefrontal cortex functioning. And so you have to be reducing the amount of stress in your life if you want to optimize your brain’s functioning around ADHD.
[01:02:17] Dr. Nzinga Harrison: Now, I do want to give adults with ADHD a segment here, because I spent pretty much the whole show talking about kids with ADHD. But what we know is that people our age, who’ve had — like I probably have ADHD right now, as we speak. I really believe that the DNA that Zahir got on that is from me. And that’s actually what I told him a lot. I’m like, look, I never got diagnosed because when I was a kid, people didn’t even know about ADHD. And then as I became an adult, like, I just put kind of organically all of these coping skills in place for myself to manage my scatterbrain. But anybody who knows me will tell you — I don’t want to offend people who are blonde. But my best friend says, like, my blondest friend is in Nzinga. But I’m like, I’m super scatterbrained. Anybody who knows me knows this. And what I tell my son is, “and still, I’m very successful.” I feel like I’m a great person that still has great potential. It’s just I have to use all of these other strategies to keep myself on task so that I can be successful. And so what I want to say for my adults with ADHD: a third of kids who get diagnosed with ADHD carry that diagnosis into adulthood. So two-thirds of kids actually, as the prefrontal cortex matures, it matures and falls below threshold of having a diagnosis of ADHD. You might be a little scatterbrained, but it doesn’t rise to the level of ADHD. You don’t have to take medication for it. You just use your executive function to overcome it. Two-thirds of adults will ”grow out of” the diagnosis of ADHD.
[01:04:07] Dr. Nzinga Harrison: Similarly, a lot of kids with asthma grow out of the diagnosis of asthma as your airways mature and get bigger. So same phenomenon going on there. For the one third of my adults, whether you were diagnosed as a child or not, that did not grow out of ADHD, Claire, the resource that you can drop is MDCalc. And when people go to www.MDCalc.com, that’s short for M.D. calculator. They have like all these scales that we use. The scale that I use for my adults that come in with complaints of ADHD is called the Adult Self Report Scale. ASRS for ADHD. Go on M.D. Calc, scale yourself. See what score you get. The interpretation is there. If ADHD symptoms really are interfering with your life, seek somebody out. Go to www.ADD.org and seek somebody out. Now, I am warning you, there is a stigma. And when you first go to your doctor as an adult who has never been diagnosed with ADHD and you say, I think I have ADHD, automatically, that doctor is going to think you’re just shopping for stimulants. That is the stigma, and unfortunately, that’s rooted in some real experiences. And so I just want you to know that you’re going to encounter that unless — that’s why I sent you to www.ADD.org, because those are physicians that have become ADHD specialists. So when you come to them, they’ll have a more open mind. Because we do have to try to distinguish between folks that are just coming to get stimulants. So what I would say to that is it’s probably a substance use disorder. Please send them my way. We would love to take care of you at Eleanor Health. And folks that have ADHD that have had it their whole lives, but just because of the age we are didn’t have the benefit of getting diagnosed. We also want to take the rocks out of your backpack. Like, we’re all climbing mountains. We also want to take the rocks out of your backpack.
[01:06:09] Dr. Nzinga Harrison: But I also have to say, when adults come to me and they’ve never been diagnosed with ADHD and they think they have ADHD, that I’m doing this ASRS, but I am also doing a full evaluation for what else it could be. Because overwhelmingly in an adult, the chance that anxiety is interfering with your focus and concentration is way higher than ADHD. The chance that depression is way higher. The chance that stress is way higher. And so I’m looking for anxiety, depression and stress and other physical illnesses so that I can optimize those. Because the medications for ADHD do carry — except for Strattera — do carry a risk for addiction. And so I’m very sensitive to increasing that risk for people. And so I want to make sure kind of the same thing, I think I said it on the on food addiction episode. I said if you get an evaluation for food addiction and it didn’t include an evaluation for depression, anxiety and other physical illnesses, then you have not had a good enough evaluation. I’m saying the same thing for my adults with ADHD symptoms. The evaluation has to include all of that. And so what I’ll usually do is try to look for an anxiety, depression, see if there’s anything there. If so, I’m trying to manage that, because a lot of times that will actually make any ADHD symptoms fall below threshold. If I can get those managed. And then if the ADHD symptoms don’t fall below threshold, or the symptoms are so significant — remember I said, you got severe symptoms on the first day. I’m definitely moving in and recommending a medication while we get all of the rest of this in order. So it just depends on how your symptoms are affecting you and what else might be going on. But don’t suffer, is my point. The same thing I said about the kiddos, if you have the question, might there be something here? If you have that question for yourself, don’t suffer.
Get in front of somebody and see what you guys can do together.
[01:08:11] Claire Jones: Do you want to wrap up with any words of wisdom or my words of wisdom?
[01:08:21] Dr. Nzinga Harrison: My words of wisdom are: we continue to be in uncertain times. We’re just starting to recover from the coronavirus pandemic, and we’re not sure if and when things will get back to normal, and if they do, when it might come back. We are just starting to get on the other side of the protest about George Floyd’s murder and police brutality and systemic racism, and we know that that hasn’t gone anywhere. So that’s not a question about that coming back. We know that is with us that we have a lot of work to do for the long haul. So my words of wisdom are, number one, do something. Anything you do, putting on a mask is activism. Protesting is activism. Talking to a friend is activism. So just do something. But always make sure part of what you’re doing is filling your own cup. Sometimes it can feel wrong to laugh or to do something fun or to look for a piece of joy when there’s so much pain. But we actually have to do that. We need it. So find a piece of joy, find a piece of laughter, find a piece of sunshine and make sure you are grabbing onto a piece of that every single day, so that you can be filling your own cup so that we can have you in this fight against everything that we have to fight against. Those are my words of wisdom today.
[01:09:45] Dr. Nzinga Harrison: In Recovery is a Lemonada Media original. The show is produced by Claire Jones and edited by Ivan Kuraev. Music is by Dan Molad. Jessica Cordova Kramer and Stephanie Wittels Wachs are our executive producers. Rate and review us and say nice things. And follow us @LemonadaMedia across all social platforms, or find me on Twitter @naharrisonmd. If you’ve learned from us, share the show with your others. Let’s help destigmatize addiction together.