Sasha Raskin (ADHD Coach) and Dr. Peter Robbins (Psychiatrist) Talk ADHD Coaching, Diagnosis and Meds
Sasha Raskin (ADHD Coach / Career Coach): Hi, Dr. Robbins.
Dr.Robbins (Psychiatrist): Hello there.
Sasha Raskin (ADHD Coach / Career Coach): Hi. I'm very excited to have this conversation with you. I'm an ADHD coach and a counselor and yoga psychiatrist, and you're managing a multidisciplinary center which I think is incredibly important since there are different ways of working with ADHD. And I think different professions need to definitely be in a more closer dialogue with each other and working as a team (a), and (b) learning from each other, what really is working, what is working less. And I think just for the benefit of the clients and also the professions as a whole.
So we met since we have a shared client and we connected over that, and we thought it would be a good idea to have a conversation about ADHD. So take it away, maybe say a few words about who you are and what do you do.
Dr.Robbins (Psychiatrist): Sure. So I'm Peter Robbins, I'm a child and adolescent psychiatrist. My practice is in Fairfax, Virginia, just outside of Washington DC. Historically I've worked in inpatient, day treatment and outpatient settings, but for the last 20-something years exclusively doing outpatient child and adolescent psychiatry. And as Sasha mentioned, I'm the medical director of a multidisciplinary team, the child and family counseling group. We have ... there are five child psychiatrists, seven PhD psychologists and four masters level clinicians, MSW's and LCSW's. And we try to work as much as we can as an integrated team.
My approach to child psychiatry has very much been informed by Engel's bio psychosocial model, trying to integrate the biological factors, the internal psychological factors that affect a person's development and the environment in which the person lives, their cultural, social, even physical environment. And trying to pay attention to all of those factors when looking at treatment.
ADHD was something that I kind of almost inadvertently got involved with. It really was something that I think in my original training programs probably got maybe an hour of time cumulatively in three years of adult psychiatry.
Sasha Raskin (ADHD Coach / Career Coach): Interesting.
Dr.Robbins (Psychiatrist): As a total. And in child psychiatry, yeah, probably got two lectures about it in two years. And as it turns out, of course, almost everything that I do nowadays from a medical standpoint is completely different from what we did back in the 1980s. So then maybe a little bit of Ritalin, most of the medicines we use nowadays are different formulations or very different dose delivery systems. And the idea of integrating medical treatment with coaching, with IEP's and specialized educational plans, with family support services, it is something that has sort of evolved over the last 20, 30 years.
Sasha Raskin (ADHD Coach / Career Coach): Yes. And as the idea of ADHD in general I think in the first edition of the DSM, the diagnostic statistic manual, it was called if I'm not mistaking the injured baby brain syndrome.
Dr.Robbins (Psychiatrist): Yes, indeed. And then after that minimal brain dysfunction was one. So MBD, it went on to ADD, either with or without hyperactivity, and then when you got to DSM 3 they sort of ... the lump is one up over the splitters, and so everything became ADHD and then with little subheadings, whether hyperactivity or distractibility was prominent.
Sasha Raskin (ADHD Coach / Career Coach): So the view on ADHD keeps on changing. The way to treat it starts changing ... well, it changes a lot. And also what I noticed that it's moving more towards at least in the coaching and counseling professions, towards the strengths-based view. And well, let's talk not just about the pathology but also about the incredible gifts that sometimes come with it, like the ability to hyper-focus and the open-mindedness, creative thinking. And I think one of the biggest challenges with ADHD is growing up and feeling that you're so different, and things that seem to be so easy for others seem to be extremely difficult if not impossible for you.
Dr.Robbins (Psychiatrist): Uh-hmm.
Sasha Raskin (ADHD Coach / Career Coach): Right? So isn't it wonderful to realize usually as an adult, "Oh, I actually am gifted in many ways," right? If it's something that really interests me, with someone with ADHD, I can hyper-focus for five, six hours and the world seems to disappear, and I can just zero in on what I need to do.
So I'm curious to hear your specific view of ADHD, maybe expanded outside of the ... the last definition was 2013 I think. They've changed since then. So how do you view ADHD?
Dr.Robbins (Psychiatrist): I see it as in its origins a delay in neuro development. We know from some of the very good neuroimaging studies done at the National Institute of Mental Health, which is right near my practice in nearby suburban Maryland, they've looked at where the brain centers are that are under active in children with ADHD and how that compares to age and gender match controls, and what the impact of medications are. When you look at neuroanatomy though, that doesn't necessarily tell you very much about functioning.
A little story - a number of years ago I had a family came to see me and I helped to treat their little girl for ADHD that was primarily inattentive type. And in the course of the treatment at one point I remember the mother turned to the dad and kind of gave him an elbow and the ribbon said, "You know they're talking about you." And he says, "I know, I know." And of course, he had not told me that he had been diagnosed as hyperactive when he was a kid, put on medicine which he didn't like the effect of and so on. And he asked ultimately to come to see me himself for a consultation, and that was how I got interested in working with adults with ADHD was being involved in treating the parents of the child patients. So I knew that I was confident about the diagnosis of the child, diagnosing the adult not so much.
And the image of riding a tiger comes to mind, the idea that if you know how to ride a tiger it's exhilarating, it's like being part of the wind, you're riding something that's very powerful that can go through almost anything, nothing will stop it. On the other hand sometimes the tiger turns around and bites you. So you have to look at both sides of that.
So this gentleman had a practice, a business of selling a franchise, and he keep having trouble because he was great at closing the deal but he didn't get the paperwork signed, so he made very little money. So he and I talked and we decided we try a little bit of medicine, the same one his daughter took actually. And after about a month he came back, I said, "So what did you think?" He said, "Well, you know, I really appreciate the opportunity but I'm not going to take the medicine." And I said, "Why not?" He said, "Because I was great at doing the paperwork but I couldn't close a deal. I wasn't ready to turn on a dime with the client and find what they needed and what I had to offer."
So what he gained in crossing T's and dotting I's on paperwork he lost in terms of his ability to pivot, ability to hear all that was going on in the environment to not miss any clues. That was one of the first educations that I got from one of my patients about how you have to be careful what you wish for, you may get more than what you need or more than what you expected.
I have many friends who are physicians who I know are certainly ADHD. And in fact, for them it's a real source of strength. Imagine being able to go from examining room to examining room, six to ten minutes, walk in the door, see somebody, listen to a problem, do an examination, order some tests. Boom. Jump out, walk down to the next examining room, the nurse catches you. Here's something else to do. "Oh, your pager goes off." Here's something else to do.
The end result of all of that is you have to be ... rather than being overwhelmed by all of this information, you have to be excited. What a lovely challenge? What an exciting opportunity to do many different things? Never be bored.
So I know that that is something that I've seen in a lot of physician colleagues. But again, sometimes they have a nurse or they have a secretary or they have someone who comes and make sure the paperwork gets signed up.
So anyway, so the end of the other story is the gentleman decided not to use the medication and instead he hired someone as an administrative assistant who was the paperwork person. So he did what he did best, got someone else to take care of the things that were not as easy for him, and it was a stunning success. And I thought that the medication was a very useful learning experience for him, because he realized, "I could be more focused but I may lose more than I get."
Sasha Raskin (ADHD Coach / Career Coach): Yeah.
Dr.Robbins (Psychiatrist): There are certainly people who have had different experiences, but that's a good example of how you need to be careful of assuming that the only thing that you want is to treat the symptoms till they are eliminated.
Sasha Raskin (ADHD Coach / Career Coach): I see the balance between medication and maybe the skills that can be learned and practiced and implemented. If someone has a really big difficulty of focusing or getting started in the morning, medication can be helpful and you can say more about that. And if I put gas in my car I still need to learn how to drive and I still need to know where the destination is, right? Many times not knowing what the destination is, basically having a huge to-do list, that just overwhelm someone that makes things more difficult. And not knowing how to drive, well, how can you actually ... I love how one of my mentors, Greg Cosby, puts it - how do you manage your attention in action, right? How do you actually start, sustain, shift and stop your attention in action, right?
And when you have the skills and you master those, together with being medicated or nutrition, sleep exercise, the big three, once those are there you're actually able to create what you want in your life.
Dr.Robbins (Psychiatrist): A little example to highlight exactly your point there. We are currently recording this in the middle of the Covid-19 epidemic and one of the things that I've found fascinating over the course of the last several weeks as I've been doing these video interviews and consultations with patients is how very different different kids with ADHD, different teenagers with ADHD are responding to this time at home. There are some who are quite overwhelmed, they've got cabin fever, they can't wait to get out, they miss their friends and so on.
But there is a significant subset, I would say maybe thirty to forty percent of the patients that I see, who are doing so much better now and the reasons are very clear - they don't have any scheduled start for school, at least not until this week, so they're sleeping more like eight or nine hours a night every night.
Sasha Raskin (ADHD Coach / Career Coach): Exactly.
Dr.Robbins (Psychiatrist): They're eating three meals a day prepared for them at home, so they're not eating junk food, they're actually eating somewhat more balanced nutrition.
Sasha Raskin (ADHD Coach / Career Coach): Such a good point.
Dr.Robbins (Psychiatrist): And for many of these kids their family said, "Well, we're working from home, we're going to go out and get exercise." And every day they're getting out for at least 40, 50 minutes for a bike ride, a jog, even a brisk walk. And so they're sleeping better, they're eating regular nutritious meals; they're getting vigorous exercise and physical activity every day. And several of them are said, "You know what? I'm doing so much better; I really don't feel like I need my meds right now." I'm like, "Great, that's terrific." And let's learn from this, when we take better care of ourselves and are attuned to what our body needs we can do marvelous things.
Sasha Raskin (ADHD Coach / Career Coach): Yeah, so you're saying, "Well, for me when someone ... when a patient doesn't need medication," and I feel, yeah, there is truth for that, "in their life, that's great for you." Could you say more about that? I think the stigma out there at least from some clients that I hold that psychiatrist and medication are synonyms and that's your only purpose as a professional. And it sounds like that's not the case.
Dr.Robbins (Psychiatrist): It is one of the most frustrating things about my ... I was trained in an era when the expectation was that as a psychiatrist I would not only prescribe medication, I would do the evaluation, I would do the psychotherapy, I would do the medication management - sort of one-stop shopping. That's obviously rarely the case anymore for a variety of reasons - economic, societal, insurance-based as well.
But I think one of the things that it has taught me is to be very alert to the intersection between ... this is where that bio psychosocial model comes in, the intersection between the biology and the psychology. I can give the perfect medicine to a child with ADHD and have their attention just excellent, but that doesn't make them want to open a book.
Sasha Raskin (ADHD Coach / Career Coach): Good point.
Dr.Robbins (Psychiatrist): Right. So where does freewill come in? Where does the individual's autonomy come in? Particularly for an adolescent struggling with issues about individuation and identity and trying to figure out who am I in this crazy world and where am I going to take my life. All of a sudden I have to take a pill to do that. Forget about it.
So you have to be careful that even if the medicine is useful or has a useful role, you need to make sure that the individual's understanding of it, its pros and cons, is very clear and they have to be clear. Whatever annoying things come from this medicine the value must outweigh the deficits so much that it's clearly worth trying. And I think that's often something that's not done nearly enough.
Education about the medicine, I tell my patients all the time, "I have medicine, not magic." There's no such thing as a medicine without side effects, anybody that tells you that - run for the door, they're trying to sell you snake oil.
The key isn't to be without a problem. The question is how do you manage it so that it's insignificantly small. And that also ... It is hard in America, because in America bigger is better, if ten milligrams is good then twenty must be wonderful. But great can be the enemy of good in this, right? Trying to get the best attention so my kid gets straight A's and gets 800's on their SAT's. Well, that's all well and good but if the child feels like they've been flattened like a pancake and their personality is gone, then they're not going to take it.
And I can't tell you how many kids I've seen whose families have pushed them to be on their medicine against their wishes. The minute they get away out of the house, either they graduate from high school and start a job or go off to university ... stop their medication, crash and burn. Why? Because there's no context, there's no inclusive sense of how this child functions in the world, what do they need and how do they ... what's the phrase these days? Self-advocacy. Can they advocate for their own needs in an effective way and know the resources they need to be able to do better?
Sasha Raskin (ADHD Coach / Career Coach): Yes. If someone is watching this or listening or reading it and they think, "Well, I might have ADHD or my kid might have ADHD," what's the next step for them to do? If they're just in that discovery stage, not even sure what is the next step and don't even know what's the difference between psychiatrist, psychotherapist, coach, maybe just read a book and that would be that.
Dr.Robbins (Psychiatrist): Well, books are very good way to start by getting educated and informed. So there are several things that would influence me to think that someone really did have ADHD, one is that it's a persistent pattern of difficulty that has lasted through their whole life. Now there are some exceptions we can talk about later, but for the most part, for the typical average person it would be fairly unusual barring a traumatic brain injury to suddenly develop ADHD at age 27 or something like that.
Sasha Raskin (ADHD Coach / Career Coach): Yep.
Dr.Robbins (Psychiatrist): The second is that the difficulties of either sustaining attention or dealing with distractibility or impulsivity and hyperactivity or some combination of the two is creating some combination of distress and dysfunction. If you look at the DSM that we've been chatting about earlier, always in there, there must be multiple areas, at least two, of the child's life that have to be affected in order to qualify for the diagnosis. So no matter how much ADHD type symptoms you see in a classroom, if they have no difficulty getting along with their friends, if there's no problems at all at home then they don't qualify for the diagnosis.
There was a time, probably the early 1990s or mid-1990s, there was one giving of the SAT or ACT where more than 50% of the students taking the exam had an ADHD exemption for extended time.
Sasha Raskin (ADHD Coach / Career Coach): How many?
Dr.Robbins (Psychiatrist): More than half.
Sasha Raskin (ADHD Coach / Career Coach): Oh, wow.
Dr.Robbins (Psychiatrist): So the Educational Testing Service said we must be doing something wrong, because the percent ... in the population ADHD occurs between four and six percent of the school-age population. So how did more than half of the kids taking an SAT need extended time for ADHD? And the answer was a very loosey-goosey kind of diagnosis. You go and your pediatrician says, "Oh, he has trouble paying attention, oh, has ADHD, here give this to the Educational Testing Service." So ETS said, "No, we're not doing that anymore." And they came up with a very stringent rule that you not only had to have a letter from a doctor or a professional saying you had the diagnosis, but you had to have testing of some kind of document that it was so severe that it warranted modifications to the testing paradigm.
Sasha Raskin (ADHD Coach / Career Coach): So how do you know? Where is the line? When someone thinks, well, I'm just constantly procrastinating, every time I need to do the dishes I go and watch Netflix instead, whatever it is, my taxes I've been putting it off till the last moment. Where is the line between this is just a part of human experience, delaying difficult tasks for the sake of instant gratification and ADHD?
Dr.Robbins (Psychiatrist): The patients that end up in my office if they're adults it's because their spouse, their partner, their family member has said, "Dude, you got to do something about this." I would say in my experience most of the male patients that I see are less likely to come in saying, "I think I have a problem," unless their significant other has said, "You do this or we can't keep going."
I had one gentleman who came in and he said he was there and he knew he had ADHD all his life, and I said, "So why now have you come in?" "Well, because my third wife said I had to." I said, "Your third wife." I said, "What did the first two do?" He said, "Oh, they said the same thing." "So why did this one matter?" And he said that, "This one I want to keep," he says.
Sasha Raskin (ADHD Coach / Career Coach): That's so true. I see that as a couples therapist and I specialize in working with couples when one or both have ADHD. I see that what's happening gradually or really fast is that when one partner has ADHD, the power dynamics shifts or just the general dynamics from being romantic partners it switches to this parent and a child dynamic, when one person feels they need to nag and constantly monitor and constantly remind the person with ADHD and kind of take this micromanager parent and the person with ADHD is in the position of a child that is viewed and starts viewing themselves as a person that cannot function without the other person's basically micromanagement, right? And no one is happy about that.
So I think what is lacking in the DSM view is the systemic view of understanding that it is never the individual's problem, it is the problem of the family and all the systems that are around them. And the effect are now affected by other people in their lives, but also that's where the solution lies many times, and places to get support and start changing things around. If logistics are not the strong suit of the partner with ADHD, why do they have to take it on them all the time? I see clients do that all the time just because they feel, "I should be able to do this, so I'll just keep trying more and more." They keep on failing and expectations are not met and then it's just this vicious cycle.
Dr.Robbins (Psychiatrist): I think trying to get clarity is important because there's more than one ... all that's inattentive is not only ADD, and so being able to separate out what is more of a neurodevelopmental issue such as the people who've had it in all their lives versus someone who has it because of say following up multiple concussions or a very significant traumatic brain injury, versus there are some folks who end up realizing they have ADHD and it only becomes clear as they get older because they happen to be extremely intelligent and with raw brain power alone they can often bowl their way through a lot of things, but they get to the higher levels where more meta analysis, compare and contrast essay questions that you might get in a high school or college setting not the same as just what's the name of the main character in this story.
Memorize and regurgitate pretty easy to do if you're just smart enough to hear it and remember it. Compare and contrast, describe what are useful and not useful attributes of this character in this portrayal, all of a sudden you have to have read it and thought about it and that requires more sustained effort. So sometimes you'll see kids that start to have more difficulty as they get older, and you look back and realize, "Well, they were kind of fidgety back in elementary school but they always got good grades and so everybody was happy with them or they were so well behaved people overlooked difficulties they had because it was a sweet kid, they got good grades in their school so they let them go."
And very often these are families where they had a particularly good attunement of the type of parenting that they got and what they needed, and when that's all dialed in well it holds things together very nicely. You get to higher levels of education or you get done with your education and out into the workforce, all of a sudden people aren't attuning to you, they're expecting you to attune to what the boss says or what the company has as their status and all of a sudden you have to make yourself fit into a setting that's being not designed for you.
And that's one of the risks of extensive IEP's and educational plans that are so attuned to help the child that they're rarely asked to stretch to grow in some way. And some of the coaches that I've worked with I think have done the best job is by encouraging the families, "Let's let him try or let her try and see. If she fails, well, better than she should fail in 8th grade or 9th grade or 10 grade than when you're paying college tuition or when her job is on the line. Better to figure out how can she advocate for what she needs in real time at a time when you're there to catch her when she falls as opposed to supporting the child until all the sudden it's like, okay, you're 19, that's it you're on your own and then we're disappointed that you're not able to do everything on your own when we've done so much for you all along."
Sasha Raskin (ADHD Coach / Career Coach): Yes. So you're saying the more the need for independence and higher, more complex of functioning in the world, the more it grows the more difficult it is to cope with ADHD and that's where many adults start thinking, "Well, maybe this is a challenge that needs to be addressed."
And you're completely right, I have clients who are extremely intelligent and some of them are extremely successful as well, CEOs and owners of companies. So it does not prevent people from achieving pretty incredible levels of success, it's just that the price that they are paying for the strategies that they are used to use is to high.
And there's this beautiful book, Your Life Can Be Better by Douglas Puryear, a medical doctor. And I think the name of the book is a great example of that, your life can be better. It's not that your life is horrible, it's just, well, you can use strategies that are just much more effective. Because the fact is that it works, yes. People can use anxiety to motivate action, to put themselves in a corner. There is one hour before not now becomes now and I need to finish this paper, right? And they get that paper finished, but they live in a constant state of anxiety, which is for me is a price that's too high to pay.
And also exactly what you said about the person hiring someone to help and do the work, outsourcing what's not your biggest strength. It reminds me of the Jet Blue founder and if I remember the story correctly his mom was called to the high school principal and was told, "This is a brilliant kid, he'll do great if he has a secretary," right? So that's the thing. And he often tells in his interviews, "I have piles of clothes everywhere in my space, and he's the person who invented the electronic ticket. So a lot of great possibilities await, it just take care of what's really difficult for you.
So if you had your top recommendations or maybe insights in terms of what are the most helpful things with ADHD, both adult and child ADHD that you notice that seemed to be helping across the board, what would those be?
Dr.Robbins (Psychiatrist): So several things come to mind, first a really accurate diagnosis - we know that from the MTA study, the multicenter treatment of ADHD study that was done back about 20 years ago, that only about 20 or 21% of patients with ADHD have only ADHD as a thing that's giving them difficulty. There are Venn diagrams, overlapping circles that you can draw, all the kids who have ADHD about 25 or 30% of that if I'm remembering correctly are likely to have a co-occurring anxiety disorder. About 15% of that group of kids with ADHD are likely to have some kind of significant learning challenge, either visual processing, auditory processing or other. About 15% of kids with ADHD will have a tic disorder of some kind, sometimes Tourette's, vocal and motor tics, sometimes just simple motor tics. Mood regulatory problems and other things occur in a a frequency in this population than in the population as a whole.
That doesn't mean that everyone has everyone, but when you look at the overlapping ... there's a lot of overlapping circles that happen frequently. And we know that ADHD and the co-occurrence of ADHD, anxiety disorders and tic disorders is so frequent that there's been some speculation that there are actually genetic tags that we may be able to find that will identify them as well.
So as Sherlock Holmes once said, "If you eliminate the impossible what remains however improbable must be the truth." If you notice someone doesn't have these other problems and inattention distractibility, hyperactivity, impulsivity are significantly interfering with their functional capacity or their happiness, then that's where the treatments start to come in.
We know from the MTA study that in children and adolescents if you take every non-medical treatment possible - individual counseling, family counseling, behavioral plans, social skills training groups, and you add all of that up together it accounts for about 10% of the variability of the data. As soon as you add the medication in 85% of the variability of the data is accounted for. So we know that ... I'm not trying to say that medicine is the answer to everything, but you can't ignore it as a possible tool.
So getting someone to work with you and your family on whether medicine is appropriate. And if it is, how to dial that in in a way which is judicious? I'm a big fan of the Goldilocks approach - not too hot, not too cold, but just right.
Sometimes having a child take a little bit of medication and have them say, "Huh, I really noticed that I'm doing better." I would rather have the child asked me to increase the medicine dose than the parent, because the child is saying, "I see something that is good for me. I see something that's making my life easier."
Another factor with kids especially and even to some extent with teenagers is it's very hard to pay attention to how you pay attention. A child is much more likely to notice, "Boy, I have a lot of free time since I started on that medicine." Oh, yes, that's right, you're getting your homework done in 30 minutes not in 4 ho