PODCAST. Why is ADHD Diagnosis Difficult? Education, Medication, and Societal Ignorance with Psychiatric Nurse Practitioner, Tom Roseland.

Feb 14

Written By Dave

Today, we speak with Tom Roseland, Psychiatric Nurse Practitioner, BS, BSN, MS, MSN, FNP-C, who runs Compassion Family Health, LLC. Tom has worked around ADHD since 1983 as a Special Education Department teacher, Public Health Nurse, School Registered Nurse, and with the Individualized Education Program & School Attendance Review Board. He is a parent of an ADHD child with a passion for foster care, assessment, and Treatment of ADHD children and adults in Family Practice, Pediatrics, & Child and Adult Psychiatry.

Understanding ADHD.

Roseland emphasized the need to recognize ADHD not as a disorder but as a unique brain type with its own set of strengths and challenges. He highlighted the importance of proper diagnosis and medical treatment to help individuals function optimally within society.

Challenges and Frustrations in ADHD Diagnosis

The conversation shed light on the underdiagnosis and inadequate screening for ADHD globally. Roseland discussed biases against attention deficit, recounting personal experiences where healthcare providers dismissed ADHD as non-existent. He stressed the significance of comprehensive assessments, including evaluations for anxiety, depression, and trauma, which can often coexist with ADHD.

ADHD and the Impact on Education

Roseland shared insights into the evolving landscape of education and the struggles faced by students with ADHD. He discussed the shift from Individual Education Plans (IEPs) to less comprehensive alternatives, highlighting the need for accountability and proactive intervention in schools.

Entrepreneurship and ADHD

A notable aspect of the discussion was the correlation between ADHD and entrepreneurship. Roseland pointed out that many individuals with ADHD thrive in entrepreneurial settings due to their unconventional thinking and aversion to traditional work environments. Famous entrepreneurs with ADHD and why they create great companies are included in The Root Down.

Societal Perspectives about ADHD

The conversation explored the concept of envisioning a society where ADHD is the norm rather than the exception. Roseland contemplated how such a shift would redefine cultural norms and educational practices, citing examples like specialized schools tailored to the needs of ADHD individuals.

Advocacy and Empowerment for ADHDers

Throughout our interview, Roseland's passion for helping individuals with ADHD achieve their full potential was evident. He emphasized the importance of self-advocacy and encouraged individuals to seek healthcare providers who listen and validate their experiences.

This ADHD Wise Squirrels interview with Tom Roseland provided valuable insights into the multifaceted nature of ADHD and the urgent need for societal change to better support individuals with ADHD. His advocacy for comprehensive assessments, destigmatization of ADHD, and empowerment of individuals underscored the importance of addressing this issue with compassion and understanding.

0:00
So yeah, I've been I've been really looking forward to first of all having you on the podcast. I know. Unlike a lot of people that I've spoken with, you've been working in ADHD in this sort of this space. Since before it was cool.
0:18
Yes. So back in 1983, is that right? Actually, I started to interface with people with attention deficit during my time at USC, and a master's program in special education.
0:34
Interesting, so what in what way? Like how were you in the 70s? In special education we're dealing with, with kids with learning disabilities, etc. And at that time, attention deficit was being seen as a behavior disorder,
0:50
oppositional, defiant, etc. And these kids were constantly in trouble or being put into opportunity classes or into special education resource situations. And the question was, how can we help them learn? And how can we help them fit into an education environment. So it was one of the groups of kids that I was learning to work with.
1:16
After that, I actually had quite a few kids that I interfaced with when I was working as a coach that had difficulty paying attention or focusing or being involved with the group. And so I became more and more fascinated with,
1:32
with how the brain worked so that people could attend or not be so distracted. That was sort of the beginning.
1:41
After that, so when I moved when I moved into nursing,
1:47
in the 83.
1:50
In my county, we actually had quite a few kids with attention deficit, and the residency program in our area was having an ADHD clinic. And when I graduated from Cal State, Fresno, and started working in public health, we started to interface with quite a few of those kids who were trying to to survive the school system. And their parents, by the way, because their parents
2:20
also demonstrated attention issues. And the question was, how do you work with a family now that is
2:29
full of distractibility, and attention impulsivity and hyperactivity? So
2:35
it became a challenge
2:38
to me, did you find that parents were receptive to both the idea that they're their child has ADHD or that they, too have ADHD, which is something I've learned a lot in, in my own sort of early days of this, but my own conversations and reading and things, how many parents are late diagnosed adults 10, like me, tend to find out well, not in this case, but like, likely in the age tend to realize they have ADHD because their kids are diagnosed, and they see it in themselves. But
3:16
yeah, there's a distinct bias in our culture against thinking about the brain as actually being a, a biologic mechanism.
3:27
Most people are seeing things as either character faults or those kinds of things. So it usually was when the parents were getting into a desperate situation that they wanted to think about that for their child.
3:43
A lot of times, it affects a fair number of families, I was on what's called the school attendance Review Board, or sarb. And they showed up at our meeting, because they were being told get your kid to school, get your kids to behave at school, or we're going to have consequences for you as a families. So at that point, they were getting a little more receptive to the idea that there could be a medical intervention. Unfortunately, I've seen an awful lot of kids who were noticed in second, third, fourth grade, and the parents wanted to do things behaviorally, counseling wise, and the child was being
4:28
educationally damaged and, and person personality damaged during this whole period of time as they're being put into corners in the back of the classroom, being sent to detention all the time being sent to the office. All of those kinds of things that were happening with children and a lot of school failure was resulting at that point. So it was usually out of desperation that they would think about medication. A lot of times I would spend
5:00
for some period of time saying, Well, what would be the risk if we were to do two weeks of something and see what happens. I mean, you have your child's life, we could change in the matter of a few days if it works. But would you be willing please to, to at least take three to four or five days or a week because when you treat with the dopamine agonists that we use like Adderall or Concerta, methylphenidate. Dextroamphetamine, we see results in
5:32
in days. And, and the risk to the child is very minimal. And I was I started this when we used to think that risk, there was risk to cardiovascular issues, heart issues,
5:47
addiction issues, or issues of dependency, all of which have been studied and discounted. There are no cardiac issues and children, I used to do an EKG and, and a chest X ray and all the kids. And it turned out that was just extraneous.
6:06
It turns out, in fact, I just read a paper this morning, from the JAMA, the Journal of American Medical Association, there is no indication that kids go on to become
6:17
dependent or addicts because of using Adderall or or or Ritalin. In fact, there's lots of data that indicates if you appropriately treat a child, that their risk of going into Substance Abuse drops to very, very, very tiny. If you don't treat them their risk of finding methamphetamine on the street goes up. And a lot of times, it's one of my standard questions did you use meth because they they, they found out if they use meth, that they could pay attention and focus instead of getting wired, although they were killing dopamine cells. Straight meth is very dangerous and damaging to the brain because of the concentrations and doses. So the parents would eventually say yes. And there was a remarkable change that happened. I've seen kids who were on the risk of being expelled. And I obeyed the systems at the school system and the parents, please let me treat your child and one child who was a freshman I think in high school went on to be valedictorian.
7:24
To succeed in the school system, as a child with attention deficit, to teen with attention deficit, you have to be very bright.
7:35
It's it's to compensate for the distractibility and the inattention. And these very bright kids are being told they're stupid, not able to succeed at all. But they are keeping up. One of my phrases to the kids is, and the parents is, you know, you're keeping up with kids with C's and B's. And that means you're very smart.
8:04
If I take the weight belt off of the attention deficit, just think about how much better you can interact and compete with all the rest of the kids take that 60 pound weight belt off
8:17
and run fast.
8:20
And that's what we're discovering with adults as well.
8:24
One of the main differences that you're seeing in like a child with ADHD versus an adult with ADHD,
8:33
the difference between a child and an adult
8:39
Oh,
8:41
the differences?
8:44
Well, that the adults has spent a long period of time attempting to create coping mechanisms so they can survive
8:54
at work in their families in the environment. And so I see a tremendous number of people with some very interesting ways of coping.
9:07
A majority of those coping skills work, but sometimes there are a little dysfunctional
9:15
111 adult I know, very bright, knew he was very bright, but to get an A, he had to spend an inordinate amount of hours working
9:26
versus after he was treated, it would be 1/10 of that time.
9:32
So the difference is the child has not yet had a time to develop the strategies the adults have developed many strategies. The other differences that the adult has modified their personality
9:49
to fit whatever
9:51
environment they are able to move into that many of the adults
9:58
with some really
10:00
had tremendous innate ability to take less than appropriate jobs or, or move into jobs or careers that they would have been able to
10:13
where they would have had more options in the future. So instead of, I have some adult patients who are very, very creative, that's one of the side pieces of the ADHD brain is a huge amount of creativity. And they've become tattoo artists. But I treat them and we start talking, we're talking nuclear physics, we're talking about all these various educated subjects, and they're extremely bright, intelligent, competent people, you know,
10:46
PhDs and physics and chemistry etc. But they're working as tattoo artists. There's nothing wrong with the tattoo artists, but these people have tremendous potential. We are, we are basically throwing away some of our most creative minds, because we won't recognize that we can assist them
11:07
in becoming everything they they have the potential to be.
11:13
It's very sorry, I didn't mean to cut you off. Go ahead. No, I was just going to add that it's just fascinating to me to reflect on my own life, my own childhood, and, and, and consider this for myself, like a lot of the music, that I grew up listening to a lot of those artists, you know, and I've since being diagnosed, and that's realized, I started reading up on this and realize that, like, so many of the musicians that I love, all have come out and said they have ADHD. Right? And, and then
11:51
when I shared on Facebook, my diagnosis because I want to, I want to remove the stigma. That's the whole purpose of this and to and to share. You know what, what I'm going through with folks, I had a lot of people comment privately to me, who are our old friends. I grew up listening to like a lot of skateboard punk rock stuff, and, and a lot of friends who hung out with me back then messaged me and said, You know, I am too and you'd be surprised, like, how many people from back in the day were like that, and many have become tattoo artists? Not to downplay Yeah, no.
12:31
There's nothing wrong with that. It's just, yeah, it's a secondary choice for a lot of them.
12:38
A lot of them made an attempt to be successful students, a lot of them wanted to move into an academic or
12:46
profession, like medicine or, or whatever, and they just could not. They could not make the grades. Right. very frightened. And, and some of these are brilliant. I mean, just think of how creative hyperactivity is.
13:05
Well, let me just change the direction, I don't see that this is a disorder actually, I see that it is a type of brain that has tremendous potential, if we learn how to put it into our environment, or let it be the kind of brain it can be for, for creativity, for working with multitasking, for doing multiple things at the same time.
13:35
Paying attention. I mean, in the old days, I'm pretty convinced that if you had out in the wilderness or in in places where your life was at stake, you'd won an attention deficit, brain
13:47
change, observing, seeing everything that's going on responding to it coming up with creative ideas to survive all of that. And this is what we're throwing away.
14:01
I was just thinking, maybe, maybe you can insert this. But the difference with adults is that women
14:10
who are typically not hyperactive have
14:16
really suffered for a long time as adults because these bright, bright students are trying so hard to succeed in school and in their groups at school.
14:30
And all they can do is get a D or a C. And you can imagine what that does to their self esteem, what it does to their options, what it does to their peer group pressure responses, and we see these women move into careers of various various various types and they just are not attaining their potential.
14:57
What I see when we treat them is that all
15:00
as potential rises to the surface, and they are suddenly moving into positions of supervising people in their industry
15:11
coming up with incredible new options, being very productive in their families more productive in their careers. And it's like we've thrown away half of the the population.
15:27
It's it just amazes me to see the women's start to, to Excel that thought that they were failures their whole life.
15:36
It's just fascinating to see.
15:40
We don't, we don't see women girls being diagnosed with attention deficit because they usually don't have as much hyperactivity or even impulsivity. They're highly
15:54
distractible people are very distractible, or they have tremendous problems with focus and attention and maintaining interest in something.
16:05
And they are very frustrated that they can't do it. And they know they should be able to do it, it just damages their self esteem. So we don't see women or girls that are attention deficit, because we're always thinking hyperactivity, we're always looking for the kid who's getting into trouble or who can't sit still. And a lot of these gals sat in the classroom quiet, getting D's, C's and B's when they're really a plus students. And moving on into life, I've also seen them move from high school into college. And some of the high school work was easy, because they were so bright, but when they got to college, they could not organize themselves, for the kind of, of schedules and intense pressures that college requires. I mean, you have to set up your own
16:57
your own schedule, you have to adhere to the schedule, you have to study, you have to turn papers in on time, and there's no teacher standing there telling you to do it.
17:06
And so they literally start to fail and fall out of college or out of some technical training program. Same thing happens with guys too. And it's it's,
17:20
it's, it's, it's so simple.
17:23
To do a, a diagnostic screen the WHO World Health Organization has the adult self report scale,
17:32
I use the 1.0 version. And it has 90% sensitivity to attention deficit and 90% specificity to attention deficit, it means it's only wrong 10% of the time, because it's based on observational long term qualities and symptoms and characteristics. And if a person scores,
17:56
if it's a person scores high on this scale, because it's measuring functionality and productivity is, then we know that this person is is really struggling. You know, do you ever complete work? No. Are you able to start something but go and go back to it? No. Are you able to pay attention in a conversation without interrupting constantly? No. Are you able to
18:28
do things that are interesting to you? In spite of having to do it? No. We think what that does to a person's functionality is society. And not only does it affect functionality, but it affects safety. I mean, do you want an attention deficit person on a large crane working overhead?
18:52
This this distract him or him pull? You don't but the person gets those kinds of jobs in the in the world.
19:01
We have in the United States, not the world, we have about 9 million adults identified with attention deficit. I think that's a tremendous under
19:12
estimate of the number because we just are really bad at finding attention deficit, especially in women. And that that results in a cost that I have here a paper of $14,000 per individual in the United States of lost productivity or injury or damage to property. And according to to this statement, one of $125 billion a year is lost because of inappropriate or not finding Attention Deficit Disorder. Half of that is is due to unemployment. Quarter of that is due to loss of productivity. A 10th of that is due to the cost of health care issues related to ADHD. Now that's a lot of money and a lot of people
20:00
I think it's more like 20 million myself.
20:03
I really think the estimate has been underestimated because of the really horrible job we do at diagnosis. So everybody's basing the numbers
20:14
on the actual number of treatment. Well, we're not finding these kids. Were not finding these adults. I would typically, when I was working in the Junior High in high school setting, I would find kids that were obviously attention deficit
20:30
in second, third and fourth grade. And they have gone through all the schools, and now they're a high school student. And it's obvious that they're failing because of attention deficit, we do a scale. I said, How come nobody noticed it? Well, they noticed that they never made the appropriate referral. What Why didn't they? Why didn't the teacher stood? Well, my experience is about half of the teachers in the education system don't believe that attention deficit exists.
21:00
And so you would talk to them? Well, no, no, this kid's just a behavior problem. We're calling him oppositional defiant. Yeah, but he doesn't have the characteristics of oppositional defiant See, that's really equal to antisocial personality disorder. But this kid is very empathetic, he's very compassionate, he wants to succeed, he just can't, then we label him as a behavior problem. Guess what happens? A large number of these kids move into the juvenile justice system. Because they're impulsive. They've gotten involved with a group, they've done something impulsive, they get
21:39
into the courts, they don't really know what's going on the next thing they know they're in juvenile hall. If you've ever been to juvenile hall, you know that if you don't do what the guard tells you that you will receive additional time in juvenile hall. And these kids are constantly being
21:57
time is constantly being added to their time in juvenile hall. I have seen kids go in at 15 and 16, and come out of the adult justice system at 45.
22:09
It's a real, it's a real crime. If you look at the adult system of justice in the United States. And you ask the question, how many of them have clinically defined psychiatric disorders, including attention deficit? It's about 85%.
22:26
Folsom apparently did a, a very good job of identifying
22:32
psychiatric disorders during a period of time and treated them appropriately and their recidivism rate dropped from 85% to 15%. Wow, wow. You know, these are statistics that we have, that are clearly known throughout the world. And yet we have a bias against people becoming successful by identifying their attention deficits, and treating them appropriately so they can do what they're capable of doing. I'm frustrated, I don't understand why society wants people with attention deficit, it almost looks like a
23:13
conspiracy. We don't want to compete with these people. It's almost in my mind a subconscious thing. We just want to label them as
23:23
lazy, not not very bright, etc, etc.
23:30
Maybe you can tell me, Dave, why? Why is this? It does that. It's hard to say. I mean, it's interesting.
23:39
You know, right away my, my, you know, in some of what you have mentioned here, well, first of all,
23:46
knowing my wife, especially, you know, I think as a couple of guys chatting here, I could probably safely say that, that women tend to be smarter than us. Let's just say it.
23:59
A different kind of brain. No, but I mentioned that, and here's what why I started thinking of this. So you were talking about how girls, you know, ADHD is always been known or traditionally been known as this, you know, naughty boy thing, right? Where the hyperactive boy. And as you're mentioning, girls don't really show that hyperactivity the same way. And then I think about, you know, all the reading and things that I've learned and just self reflection about being an adult. And when I have conversations with other adults about this, they say, you know, I used to think I had ADHD, but I'm not hyperactive. And I'd say haha, but this is what I've been reading up on is that as an adult, I like chew my lips I stim, like, I chew the inside of my mouth all the time.
24:49
I feel the fabric of my shirt under the table all the time. I do these other things that I've realized in my own room.
25:00
research and learning about this, these are all symptoms of hyperactivity, it's only that I as a as an adult, without realizing I have learned to cope and to, you know, use the use this hyperactivity in different ways, and maybe matured with it some. So it's only a lot, a lot of it's in my head, but I was gonna say the little girls in the classroom, who are not showing signs of hyperactivity are probably smarter than the boys because they're processing the hyperactivity at this advanced level in their minds more than the boys who are just losing their minds. Well, does that make sense at all?
25:39
Tremendous sense, because the diagnostic dilemmas have to do with the comorbidities that present
25:46
the Johns Hopkins and George Washington University recently, we're talking about, what are the comorbidities that you see, most of the time with attention deficit? The comorbidities are depression and anxiety and panic. And what an awful lot of people do with their inattention
26:08
or with their their distractibility is that it turns into an anxiety disorder have many they've actually recommended that all adults presenting with with anxiety or depression that the second question you ask is,
26:28
are they attention deficit, we should be screening for everybody who has
26:34
presents to an office or has an anxiety for attention deficit, we should be screening everybody, for the presents for depression for attention deficit, because 50% of those people will will meet the criteria for attention deficit disorder.
26:55
The first thing you ask for is do they have a mood disorder? You want to know do they have a bipolar one bipolar two recurrent unipolar depression or some sort of
27:07
beginning psychosis because that has to be ruled out. What typically has happened now is that people present for anxiety or depression and the first thing they are given is an SSRI, like,
27:21
like sertraline, which is good. And we used to use sertraline actually for treating attention deficit. So, some people get better.
27:29
But it's not treating the underlying cause of attention issues. And then the next thing will happen is they'll get another SSRI, which is chemically almost the same thing with slightly different characteristics. And they'll go through three or four SSRIs. They might move into something like Effexor, XR venlafaxine, an SSRI, and the person gets a little bit better, but they're not treating the underlying reason for the anxiety or the depression, which is inattention, distractibility, impulsivity or hyperactivity or some combination. These these four characteristics of Attention Deficit happen independently in some people or happen in various combinations. So you can have a person that is not hyperactive, not impulsive, not distractible, but has the very great difficulty in focusing and paying attention to something. You can have somebody who can do all the other three, but they are so distractible that when they walk into any environment, that's noise or whatever, they just cannot pay attention, or they're spending so much time processing all of the environment that it's driving them to panic or to driving them to anxiety. I had one gal come in who was being treated with a benzodiazepine clonazepam for tremendous panic disorder, and social anxiety. And she had not been very successful in that. It turned out as we asked the question and did a little more history, that anytime she moved into an environment with people, it just was so intense, so much data, her brain wanted to process it all so much, that she would become panic, she would become, have social anxiety when we treated her attention deficit at all went away.
29:30
We have to ask the question, what's happening to the brain? What's happening inside the brain? Or is the brain able to filter out extraneous data? Is it able to correlate that data? Is it able to process it? Is it able to ignore data? Is it able to initiate interest and focus? Many times I call this an interest Deficit Disorder.
29:54
You notice that people with ADHD love to do video games
30:00
or they love to watch TV. The reason is their interest is being rekindled every 15 seconds or five seconds, and they congest it sustains their interest, or they have an interest in something. And once they have an interest, they are going to do that, they are going to focus on that and they are able to do it because of high interest. A lot of what we're doing in treatment with ADHD is working on the receptors in the brain that help you generate interest. That's why we call them dopamine agonist, dopamine helpers, others will say that these are stimulants. Well, they're stimulants when you use concentrations that are above what actually helps the dopamine receptors move into a normal range. So the person can actually focus and filter, pay attention and manage their hyperactivity.
30:53
It just occurs to me to mention that hyperactivity is a receptor in the brain that controls Restless Leg Syndrome. In other words, when that dopamine receptor is out of whack, you have to move it's not a matter of
31:09
wanting to move or needing to move. It's like an itch. It pushes you to movement. So hyperactivity is actually a Can you imagine having Restless Leg Syndrome all day long. That's body legs and you know, body restless body syndrome. That's really, that's really what's happening. These people can't sit still.
31:33
It will drive them nuts to sit still.
31:37
These people have impulsive thoughts. The thought comes into their brain, and it and they impulsively act on it. I had one kid in the junior high. I said, What are you doing on the roof? I don't know. Because came into my mind. Of course, now he's in trouble. You know, he's a troubled kid.
31:54
So we talked about and attention, we talked about distractibility. These things are overwhelming, a lot of attention deficit people, adults cannot be around lot loud sounds, lots of sound drives them nuts. They're sensitive to sound. That's one of the one of the criteria that we should use. How sensitive are you to the environmental sound, I have one little gal that we had identified as attention deficit, she's working in a job at Goodwill. And the noise of the customers, the noise of the office is making it very difficult for her to function.
32:34
We've treated her attention deficit, it got better, but we've actually had to get noise counseling, noise cancelling earphones so that she is able to not be completely distracted all the time at work. Does that Does that all make sense? Yeah, it does. Yeah. No, it makes a lot of sense. I'm, I'm curious. From a maybe from a societal point of view, where these changes need to come in order to help I guess, professional like help medical professionals and so forth, be screening for this more often more frequently. But then also for for people like me to realize because I'm learning a lot about I'm use my a lot about ADHD. Now that I know that I have ADHD, but you know, so what needs to happen in the medical community?
33:31
You know, the medical community is full of bias. People believe this or believed that.
33:39
You've got to primary care providers who don't believe in ADHD and so they don't look for it.
33:47
You have providers who don't believe in depression, they think they see it as a character flaw or some grief reaction. They don't believe that it's actually a a function of of
34:01
brain neural physiology. They just,
34:05
but is this not part of the education of becoming a physician or a doctor? Is this not? I mean, they, you know, you have to update your certification or whatever, each year with the latest, like, what I noticed in residency programs, and it may have changed, you know, we have many, many more women going into medicine, and so there's a different sensitivity.
34:27
But what I noticed that with during their residency during their rotation, many of them would actually they could actually drop one rotation and the rotation they love to drop with psychiatry.
34:42
Does that make sense?
34:44
And, or when they got into the psychiatric rotation, they really didn't have a psychiatric facility or good psychiatrists to work with. So it was not it was it wasn't a marginal thing. Or they were mostly focused on the the
35:00
A very sick, you know, somebody with schizophrenia or bipolar disorder with psychotic features or things like that, or those depressions that were suicidal, those kinds of things. And so the, the, the other components of psychiatry were put on the back burner.
35:22
So, and then we have a huge
35:26
difference between medicine and Behavioral Sciences, the behavioral sciences, don't have the option of using medications. So the sciences have grown that science has grown up around behavioral
35:40
issues like counseling, cognitive behavioral therapy, directive, therapy, mindfulness, those kinds of things. And so when they get somebody like somebody with attention deficit, they want to use behavioral modification or cognitive skills to modify something that is actually a physiologic issue in the brain. And so people are not are holding on to patients for a long time. We're seeing the side effects of ADHD like depression or anxiety, and they're just not asking the question, is this an attempt at attention issue? Is this a distractibility issue? That's why Johns Hopkins is trying to say to the medical community screen for ADHD? Second,
36:33
not last, yeah. Green for mood disorders first, not last.
36:40
These are, it's like a heart attack walking into your emergency room, right?
36:46
Heart attack comes into the emergency room, what is the first thing you do? Well, it, it may be heart attack, or it may be gastritis. Or it may be asthma, it may be costochondritis. It may be muscular. But the first thing you do is you rule out the most serious thing that can be happening. So you rule out a heart attack. When a person walks into our offices, the last thing we think about is attention deficit. The last thing that we think about is a mood disorder. But these are just like heart attacks in the person's life.
37:21
Most people they're being trained to think of simple depression.
37:26
Most people are being taught to think about simple anxiety, they don't go any further, they've got a five minute visit, they've got to chart for 20 minutes on the visit. This is simple, straightforward. The person's not suicidal, I will just treat with an SSRI. And then the person gets into the system, they come back in three or four weeks, and it's Oh, it's a little better. And they they go on for years that way, without somebody doing an intense assessment. They just, you know, primary care is not thinking about the brain very much. I'm sorry to say. And that's what I see happening all the time, people are not doing a good assessment. They're not doing a complete assessment, what has happened, and because of that, we now have requirements to do the brief scale, the PST, and some of the others for anxiety, those have been mandated, you have to do them, you won't get paid if you don't do them. In one sense, what we should do is we should mandate that a an ADHD scale, like the ASRS must be part of the initial workup. And it has to be documented in the chart. You have to document that you've ruled out attention issues, you have to document that you've ruled out anxiety, you have to document you've ruled out depression, you have to document that you've ruled out adverse effects,
38:54
you know, an eighth of the ACE, the Adverse Childhood episodes, and you have to document that you've ruled out a mood disorder, you have to do that. That is a complete assessment, that would be a screen. It's interesting, because on the flip side, from a consumers or, you know, a patient's point of view, like I think and this is uh, you know, I'll observational, of course, I don't have any data to back it up or anything, but I mean, I think of, well, first of all, as I'm Canadian, right, so it's it most of my life, maybe still is, it was it was against the law, it was illegal to advertise drugs on television versus, you know, anything prescription wise, so, you know, Tylenol, sure, but you couldn't, you couldn't advertise, you know, all these different drugs. And that was partly, you know, because to kind of stop problems from happening with with abuse and, you know, kind of what's happened with opioids in this country, but like you look at the US and
40:00
A time television. And there's like, it's constantly ads for things that have like half the ad. It's like side effects rolling up the screen. But I bring this up because I also think that it else it also.
40:14
I've always thought about it in a negative way where like the consumer or the patient is watching television, they see an ad for Viagra. And so they go to their doctor, and they ask about it. And then whatever the doctor might prescribe it, who knows? And again, for somebody who doesn't watch daytime television, I almost feel like if there was a lot of ads for stimulants on, on daytime television, more people would be asking their doctors, hey, I think I might have ADHD. Does this make sense at all? It's a weird, kind of roundabout way of raising awareness for consumers. But what how does the How does a medical person respond to that? Oh, this guy's drug seeking. Right, but don't they? Yeah, yeah, I suppose so. But it works in the opioid case, as well, to negative a grand negative import that that is a whole nother issue, because the so called opioid epidemic was not due to providers, or patients with legitimate pain.
41:16
And what happened is we harmed 1000s and 1000s of people, because we didn't have an alternative. And we started ripping them off of their opioids, even though they had dependencies without doing it correctly, not realizing the that opioids themselves are mood stabilizers, and we were uncovering a tremendous number of people with mood disorders. And we just left them naked in terms of their mental health.
41:43
Where do you go then we'll use a lot of them went to heroin. And we weren't. We warned the system that they were going to do that. And they have done that there's been a tremendous increase in heroin use. And people's pain is so intense. I mean, I do disability exams and people's pain is so intense, they cannot work. They can't not do household stuff. Oh, well, that's just a drug seeker. There. They could do it if they want to have you. Have you ever had a bullet crash into your spine. I had a patient who was a sniper in Vietnam and he was hit in the spine and he's had extreme
42:26
pain from this, this bullet that's still there and his spine his whole life and a little tiny bit of Norco was able to make him functional.
42:35
boss walks up to me and says you have to take him off of Norco. We haven't no opioid policy in our I mean, it's, it was insane. And it was political. It was not based on science. The CDC put out a very good art protocol on pain. It was totally misunderstood and misrepresented by most of the clinical staff. It didn't say that you weren't to treat pain with opioids. It said that if a person comes in with opioids, and they have developed dependency, that they need to be connected to a substance use disorder counselor, and that you need to work in concert with that person with the counselor to modify their pain through counseling and medication. And to find an appropriate level that works. That is being monitored carefully. But instead, we use that I have a trained substance use counselor who went in because she had tremendous pain and was trying to had learned how to manage her pain mostly through mindfulness, etc. But she'd have exacerbations and she'd walk into the emergency room and say, My pain is now a 10 over 10. It's intense, I could hardly function. And in the note, the person wrote the substance abuser here seeking opioids.
44:02
She actually had to go to the administration and have them removed that because she's a substance use counselor and her license was at risk because somebody's first assumption was that she's a substance abuser. And this also goes to attention deficit right now, I spend an awful lot of time with pharmacists trying to convince them that this this medication this prescription for Concerta, or, you know Adderall or Vyvanse is a legitimate diagnosis. I've had pharmacists insist that I have to send them my patients notes to prove number one, that they're a patient and number two, that they actually have attention deficit which they don't believe in anyway.
44:44
My patients, some of which are doctors, lawyers, Indian chiefs, or whatever walk in and are treated with disdain by the pharmacy staff because they have, quote, a controlled substance. I was in a DEA conference and people liked
45:00
Mi are being blamed for the stimulant
45:04
epidemic. In other words, nurse practitioners who were designed to be out in rural areas working with rural patients with real needs, you know, injuries, etc. But also with it's almost the environment selects for attention deficit people, because where do they go when they can't get jobs done in the professional world, they end up in the rural community. And we're being blamed in piece by the DEA at this conference, we are being blamed for the increase in the number of prescriptions for Adderall and
45:38
and Concerta that we are being told that we are inappropriately using these medications. And we really don't know what we're doing. But what they haven't asked is, are we actually doing a better job of diagnosis? They are not asking the question, how many of us are in the rural environment, finding all of these kids and adults who have been suffering, and are out there in that environment because of untreated undiagnosed attention deficit disorder? The assumption is, it's a controlled substance. It's bad news, it should be never used for anything.
46:14
And it's, again, a stimulant epidemic. It's not what's happening. I mean, we've got some charlatan groups out there that are using it as an opportunity to make money. In Oregon, I have to prove that they're a patient of mine, and that I'm not connected to one of these organizations. That is they're seeing as ADHD mills. You know, if I'm sorry, I'm getting frustrated. Oh, no, it's great. And I appreciate your frankness and what you're sharing here? And yeah, I mean, I My question was poorly worded, because I shouldn't have said opioids, specifically, but what I was, I guess what I was getting at was, you know, how can consumers or patients become more aware of this in order to communicate their their concerns with their physician, their GP or whomever? So that,
47:17
you know, obviously, we're not going to solve all the world's problems on this podcast, but I'm trying to think of like, ways to I mean, you've talked very eloquently about helping, you know, helping the medical professionals and helping that industry improve, you know, and be looking for this first and foremost.
47:37
And maybe that's just it, maybe that's all we should be doing. I don't know, I wish we would not do medicine by politics. Right? I, you know, you have World Health Organization talking about attention deficit as an international crisis, the number of people injured, the number of people who
47:58
end up not being productive in countries where we need them to be productive. The number of the last,
48:06
the, the amount of crime that's probably related to hyperactivity or impulsivity.
48:12
They see it as an international crisis, their estimate is 10 to 20%. More like 15% of humans have some attention issue that is causing profound damage within their lives, or within society. Injury,
48:31
damage to property, extreme damage to property, the cost of of welfare, the cost of health care, all of which is related to
48:44
lack of attention and inadequate treatment. 15% of the world's population 15% of 8 billion people have attention deficit issues. 15%. Let's put numbers on that. What is 15% of a billion? I don't do math. Don't do math.
49:08
Okay. 15 people out of every. Okay, yeah, have a classroom. If you have a classroom, you're a teacher and you have 30 kids in the classroom? How many of those kids are struggling with an attention deficit? All right, number five of them. Okay, yeah, four to five kids in your classroom.
49:29
Four to five kids. in your classroom, you should expect to find at least four to five kids in a classroom. When I was functioning as a school nurse, and I knew that 10 to 15% of kids have asthma. And I knew that we only knew of five kids in this in this in my population of 4000. I had a suspicion that maybe we were under diagnosing and so I went out and found them. If we know that 15% of the kids in in a junior high school
50:00
Our attention deficit than we should be looking for 15% of them in the schools. But is it the is it that? Is it the fact that teachers are already underpaid and overworked? And listen, David David, I'm a special educator, right? And I'm married to a teacher. So Okay, listen, and my dad was a teacher, which you do if you want to be an effective teacher, and you don't want to spend your time doing fire, you know, putting out fires as you do pre emptive assessments, you've got 30 kids in a class, okay. 30 Kids is an elementary school teacher, they are with you day in day in and out for 18 times to 36 weeks. Okay. Take two weeks and assess every kid that's in special ed, you know, what their their skills are, you know, what they're learning. I mean, I could take a child and in about 35 minutes, do an assessment, assessment on learning disability, attention, deficit, anxiety, etc. It takes me 30 minutes. What does the teacher do with that information, though, like when they do identifies several kids in a class that that are likely you claim your creative teaching plan for the kid?
51:23
That's what we do with IEPs Individual Education Plans. Every child, we know their strengths, we know their weaknesses, we know what to think about. And we create appropriate activities for them in the class with appropriate structure of the class to make them successful. 30 Kids 36 weeks? Come on. It's such an I mean, it is simple.
51:50
Right? And it's been, it's been your time putting out fires, I don't have time to do it. Because I got this problem, that problem, this problem and that problem. You do pre emptive work. And you don't have this problem. That problem. I saw teachers in the junior high school and elementary and high school who did good assessments of their whole classroom. I mean, in high school, you've got what, six, six classes or five classes a day of 30? How long does it take to do a quick assessment of those kids? I mean, you got cume files, it doesn't take long to pull 30 cubes, and look at the ones that have some identified issues. It doesn't take that long. But instead they spend, you know, instead of spending the three hours to do that, they spend close to 30. I'm just pulling numbers out of the air per student trying to put out fires. What a stupid word I'm sorry, shouldn't use the word stupid, what an error. Well, it doesn't make sense to me to do that. And I've watched I've watched teachers do this and their class and their students excel, their classic cells.
52:58
And it can happen I had one teacher who actually did this with all their students, the students were English was a second language. They had Hmong, men, Hispanic, of Punjab, etc, in the same room. And these you walk into this room and this room is buzzing, it's it's humming, with learning, humming with learning, then you walk into an English only class and the classes, you know, when kids over in the corners doing this and sitting at their desk doing that. It's it's just doesn't work.
53:33
Yeah. Does that make sense? I don't have time. I don't have time I'm overwhelmed.
53:40
I'm burned out on teacher to being a teacher. I understand that you come into teaching with a high amount of desire to help students, then do it. Be a teacher? I'm sorry, I love teachers. Yeah. I loved working with teachers. But I found out that the culture of teaching develops almost an anti student mentality. You go to teacher's room, say Have you ever been on a teaching
54:13
with teachers on breaks in their room? Oh, they talk about this kid and that kid and this kid and that teacher and this teacher instead of being positive and figuring out ways this probably never get on there. And it's just a very negative environment. I'll tell you, so in Tennessee, we're going back to school and my wife school yesterday. Her her and her colleagues, all the teachers got into their cars together and they brought
54:46
popsicles, ribbons signs and they did a parade through multiple neighborhoods who are mainly low income neighborhoods in the area around their school. And they basically had a back to school parade.
55:00
They got out of the car, they they were hugging the kids handing out. And this is on their own time, which I thought was amazing. So I want to make sure we're not throwing teachers under the bus here. No, no, I love teachers. My dad was a teacher I am. I'm a tenured teacher. Okay. Yeah, I left a tenured position to move into healthcare. I love education, I've sat on 1000s of IEPs. The problem is, even the IEP has become a burden when I was in special ed, in my master's IEPs didn't exist Individual Education Plans, a federal instrument, designed to go with the student, to any state in the United States. I don't know if it goes to Canada, to any physician, that they work as a job, it goes into juvenile justice, it goes to work with them, it goes to college with them.
55:51
And we were excited. You can have a doctor, a nurse, a an educator, a psychiatrist, a psychologist, a counselor all sitting in the same room together, focused on this kid for an hour, and come up with a plan to make them successful for the rest of their life. What has it become? Oh, no, I've got to go to another IEP, oh, well, gee, maybe we can get rid of this IEP and call it a 504. Because we can do it quicker with fewer responsibilities? Well, we don't in an IEP, you're supposed to be doing a full developmental screen, it can only be done by two categories of people, a nurse or a physician, I would see many, many of the developmental histories and the medical histories done by the school secretary. Completely wrong up in Southern Oregon right now, they won't hire a school psychologist, a psychologist to do the assessment. So basically, you've got somebody I don't know who had administrator coming up with an assessment, they don't have anybody doing a developmental screen, they completely seem to ignore the fact because of money, that they don't have time. And then they wonder why they don't have time to deal with students in a proactive way. They just don't do the upfront. And I think one of the, you're going to get 1000s of letters. I love patient, I love teachers. But the teaching community schools have no accountability. And there needs to be accountability, they need to be held accountable for assessing every student that comes in the school, Developing A Success Plan for every student that comes in the school. And you're going to talk about money. And we don't have time. But let me tell you, if you do it upfront, you don't have to waste all the time that you're spending putting out fires. I have seen it work. I know it works. It just takes a certain degree of commitment to do the upfront work. I know it is.
58:01
Sorry. I'm sorry. No, your students get to know your students do an assessment, et cetera. I'm curious, getting back to, you know, for adults who are listening who are late diagnosed. I'm curious,
58:20
you know, of the of the adults that you see what, like, what would the percentage be of entrepreneurs or solopreneurs? Because I find in the writers I've done, yeah. are noticing. Yeah, I've been noticing that as why don't they don't fit, right. They called in, in Silicon Valley. We call them misfits. And actually the culture had to change to work with misfits. But the number of entrepreneurs like Etsy and eBay, etc, is huge. Because they don't fit in the work a day environment. hyperactivity. I want you to sit down in front of a desk for eight hours. Is that gonna work? I want you to go into a busy office where there's 15 people, and I want you to to pay attention and answer the phone and do all this stuff. Does that kind of work? It doesn't. I want you to manage. I want you to manage
59:22
and supervise staff.
59:26
You can't even organize your own life
59:29
because of your attention issues. It's it's a huge number of people in entrepreneur. It's also a huge number of people who don't progress. We didn't talk about dyslexia and dysgraphia. But they are hand in hand with attention deficit. So I've seen people who should have been a supervisor managers and they can't, they can't move on because they can't do the paperwork. They can't read.
59:58
They've been moved on through school.
1:00:00
without being able to read, there's a there's a large number of them that are dyslexic and the school system has decided that dyslexia doesn't exist. My son is dyslexic, he was given in special ed, he was given sight words to memorize.
1:00:16
Now, he can't decipher words, he can't pull words apart, he has huge vocabulary speaking vocabulary. And they put him and they tell him to memorize a whole bunch of words, when he has attention deficit, he can't pay attention to something that's not interesting. And he sees the words either backwards upside down, or he can't see the middle of the word we had on our own, we had to spend, what three years to get him a dyslexic specialist and teach him how to do word attack skills and sentence attack skills.
1:00:48
And that that was with so called special education services. It's it's really interesting how the society works.
1:00:59
And for those people, that those entrepreneurs who are, you know, we look at Steve Jobs, and his fame is, you know, think different, different. You know, here's some of the crazy ones, the misfits, that speech that he did.
1:01:15
Are there strategies that you recommend for people like myself, who, you know, for the most part, I work for myself by myself and and,
1:01:26
and I run my own business? So what are your
1:01:30
Yes, strategies? Yeah, things? Yeah, there's, there's Chad Cha DD, there's a DD I too, you know, attitude. There are a fair number of books on strategies for ADHD. But personally, I think the first thing to do is to get appropriate diagnosis and, and use the medical treatment so that the brain is at least functioning the way it's supposed to function in this society, so that you can have the skills
1:02:04
that you need to work within this, this culture.
1:02:08
Personally, I, I have difficulty calling ADHD a disorder, I see it as a certain type of brain with tremendous power and skills, that has to be utilized in the appropriate environment. And what I'm doing half the time is pushing the brain into a slightly different brain type, so that they can function within our society. You know, you've got to be able to pay attention, you've got to be able to not be distractible, you have to not be moving, you have to not be impulsive. And so we're we're bringing that brain into a more organized a, it's more organized around a certain cultural type and a certain type of thought process. Are there are there societies or cultures or countries or places that you think are doing a better job this way? I almost put your like, I believe it's maybe in the Netherlands or somewhere that created like a basically like a small town for for people with dementia and Alzheimer's to function. But in a safe way. And, you know, as someone who whose father passed away from that, you know, that hits home and, and when I saw, saw that, like, I saw some videos about it. I thought, Wow, what a great, great idea. I wonder art? Well, first of all, are there countries or cities that do a better job? And and could you envision like a society or a city or an area created specifically for people with ADHD, I want to write a book. I'm a science fiction net. And I want to write a book where the ADHD brain is the normal brain.
1:03:53
And to determine how society would look if ADHD were the typical brain type.
1:04:00
I love that idea. The court, it would be fascinating because you think it would be a disaster. But the societal norm would not be sitting in a room, listening to a lecture by being quiet, and the societal norm would not be sitting still at a desk. It would be putting something together or doing something active, you understand what I'm saying? Yeah, 100% It'd be a totally different type of culture. I mean, I know I'm going a little bit off but there was a school in San Francisco for ADHD where they taught all of the academics subjects by building a car from scratch
1:04:37
from and actually doing the metal work and the design work, etc.
1:04:43
And learning about how engines work learning chemistry, learning, physics, learning English, learning to read learning to write all based on building that car.
1:04:53
You know, it's a whole different society. Are there countries that are doing a good job? The World Health Organization
1:05:00
It's got tons and tons of people working on this one paper, they put out the World Federation consensus statement. It Right now they're spending time just trying to convince countries they have a problem that I saw papers just recently where they go through 208 evidence based on criteria about ADHD and its effects. And they studied, they only took in studies that have over 2000 participants. And they they did a meta analysis on this. There was 80 authors from 27 countries and six continents. And their conclusions was it's under diagnosed, it's inadequate screening. There's a biased against attention deficit in every country of the world. And every country of the world has 10 to 15% of their population with attention issues. No, people are not doing a good job. Countries are not doing a good job. It's costing billions and billions of dollars. It's costing lives and injury. It's costing productivity, we're doing a crummy job with it. It's a worldwide problem. It needs to be attended to. But there's a distinct bias. I had a boss once that said, I don't want you to treating attention deficit because it doesn't exist. Yeah. And I hear of that of others who go to other diners, and their doctor says yeah, at the same sort of thing. So he pulled up a paper, one paper from France. Now, in France, the culture doesn't want to believe in attention deficit.
1:06:31
For some reason, I don't know why. And, and they estimated their attention deficit population at two to 3%. Well, two to three people out of 100 is still a lot of people. Sorry. Yeah. But he said, Well, look, if there is attention deficit, it's only two or 3% of the people and you're treating this number of people that can't be, I want you to stop doing it.
1:06:55
He, I brought to him a list of 1000 researchers around the world who are attention deficits, specialist, PhDs, MDS, etc. And he said, they just don't know what they're talking about.
1:07:11
The world has a bias against mental illness that psychiatric based, the world does not want to believe that the brain is more than one or three organs. It is literally if you looked at it from an organizational standpoint, it is literally over 300 separate entities within this little skull of ours. And these entities aren't just doing their job. They're highly interactive and highly interrelated. If one system goes out of whack, all the rest have to compensate. Does that make sense?
1:07:50
It's like having a car where the carburetor doesn't where it was you nobody knows what that is. It's like
1:07:57
a car where the radiator goes out of whack does that affect the rest of the system, it's like a car where the the oil is no longer in that is that this is a highly integrated system. The brain is a is a biologic neurologic physiologic electrical
1:08:16
phenomenon that is malleable it is it is able to change and it can change in various directions. And if it doesn't interface with each other, if it doesn't have good mechanisms for
1:08:32
control, it will go in the wrong direction and you'll have problems with mood, you'll have problems with tension, you'll have problems with rage you'll have all of this happens with learning, etc. And we just cannot get the world to believe that the brain is complicated. Well, that's our that's our goal here on why squirrel. So Tom, this has been amazing.
1:08:59
No, this has been fantastic. I really have appreciated this conversation. So thank you. So how can Yeah, how can people get a hold of you and learn more about what you did? Oh, I have a little concierge practice in Oregon.
1:09:16
And
1:09:18
I can
1:09:21
chi what is the best way to do that?
1:09:26
I don't want to get overwhelmed with with texts on my number.
1:09:31
Is there like I like website or email or something like that? Yeah, it's called compassion family practice LLC, compassion family practice, LLC.
1:09:44
And you can actually email me at that. It's it's all one word compassion family practice@gmail.com rained on the practice. And I will include links to that and everything we talked about here and then I couldn't get
1:10:00
See, I can give you the website where they can actually request an appointment. But again, I am limited right now the way telehealth works to to Oregon but I have been willing to do consultations for people to give them my opinion and they can take that to their primary care provider. I think if if PE patients want to get their providers to pay attention that that I have, I'll just tell you real quick, I use the scared SCA our IDI assessment for anxiety it's supposed to be for children or works well for adults. I use what's called the Columbia Depression Scale, which is much more sensitive than the ones they're using the Columbia depression scale the mood disorder questionnaire, the MD Q is important than the A s r s. W H O World Health Organization ADHD scale. 1.0 is more sensitive in my mind because it differentiate between inattention and distractibility in one poll and impulsivity and hyperactivity on the other.
1:11:05
And so that's looking at depression, anxiety, attention deficit, and mood disorder. And then I always want to include the AC E, because, unfortunately, trauma has a lot to do with how the brain functions. And and then that's, that's the assessment they can use with their primary and walk in with those assessments done. Right. Say, pay attention to this, please pay attention to this. If you don't believe in this. Tell me what's happening. And or if you don't believe in it, refer me to somebody who does, please
1:11:43
don't disregard me.
1:11:46
You walk into your dock and you say, Well, I don't think you have ADHD and your score and ADHD skill is 48. You know, 30 is significant. Well, what do you what do you think's happening here, Doc? Tell me what's happening. I want you to listen to me.
1:12:03
It's a great if you find that there's a provider who's not listening to you. That's a mismatch. Yeah.
1:12:10
Your provider should listen to you. You're the consumer. You're the boss in the room. He's supposed to pay attention if they don't move on. And that is a great point to leave there. Thanks, Tom. This has been awesome. Seriously, thank
1:12:27
all I want is people to get better. I want them to function and fly. I just love watching. My patients suddenly Fly, Fly to the highest extent of their ability. It's just fascinating to know we can do that simply. Thanks a lot, Dave.