ADHD Myths, Science and Treatment: What the Evidence Shows

Why is ADHD becoming more common?

Dr. Sultan separates two things. Better identification is real and good - whole groups were missed before, most notably girls, because ADHD classically gets noticed through hyperactivity, which disrupts a classroom, while inattention does not. A child whose mind wanders quietly generates no complaint. But he also flags something he finds suspicious: rates vary substantially between countries, and between the Western developed world and everywhere else. The diagnosis rose alongside an environment that asks children to sit still and quiet for hours, which is not inherent to being young.

Jump to this part of the interview (2:56)

How effective is ADHD medication?

More effective than any other medication in psychiatry, for any other condition - which Dr. Sultan notes has been uncomfortable to say in the mental health field. Roughly 80-90% of people see resolution of their symptoms on medication. That is not the case for depression, anxiety, schizophrenia or bipolar disorder. He is careful to add that symptom resolution is not the same as problems being fixed; other things still have to happen.

Jump to this part of the interview (15:49)

What does ADHD medication do in the brain?

On functional MRI, an untreated ADHD brain shows less dopamine activity in the prefrontal cortex than a non-ADHD brain. On medication, that activity becomes close to indistinguishable from someone without ADHD. Mechanically, Dr. Sultan describes stimulants as keeping dopamine and norepinephrine in the synapse longer, largely by blocking reuptake. He is explicit that this is a model built on basic science rather than a settled account.

Jump to this part of the interview (15:49)

What are the risks of not treating ADHD?

Concrete and well documented. Dr. Sultan lists increased car accident risk - shown in within-person studies comparing the same individual on and off medication - along with speeding tickets, divorce, job loss, teen pregnancy, accidental death, lower educational attainment and criminal justice involvement. He also raises the harm discussed least: self-esteem. ADHD shows up early, so years of unexplained struggle shape how a person comes to see themselves.

Jump to this part of the interview (26:38)

Do you have to take ADHD medication forever?

No. Dr. Sultan's framing is that medication is worth investigating rather than committing to - you can try it, dislike it, and never take it again. He describes a patient who struggled through college, was treated much later, and went on to publish a book she says she could not have written untreated - while noting she had also built substantial skills of her own, and that the years of struggle cost her something.

Jump to this part of the interview (20:54)

Can attention problems be something other than ADHD?

Yes, and Dr. Sultan treats this as the reason to get evaluated properly rather than self-diagnose. Difficulty with attention is a symptom with many possible causes, and landing on ADHD because the symptom fits skips the part where a clinician works out what is actually producing it.

Jump to this part of the interview (10:32)

Note. This is a recorded conversation, not medical advice, and the neurobiological account Dr. Sultan gives is explicitly described in the interview as a working model rather than settled fact. Nothing here substitutes for evaluation by your own clinician.

[0:00] Dr. Traci Stein:

So, hi everyone, welcome to another episode of Unpacking Possibility. I'm your host, Traci Stein, as always, so happy to be here with you. You are going to be so happy to hear from my guest today. He's got such incredibly important information to share with us. My guest is Dr. Ryan Sultan. He is uniquely skilled and qualified to talk about the topics we're going to cover today. He is an internationally recognized psychiatrist. He's double board certified. He's on the faculty at Columbia University and New York State Psychiatric Institute. And he's trained at Columbia Cornell and Emory. So, as I like to say, sometimes you're no slouch, Ryan. But he blends cognitive behavioral therapy, psychoanalytic therapy, mindfulness, and evidence-based Eastern approaches to help people with a variety of conditions, including ones we'll talk about today, like ADHD. And if we have time, we'll talk also about ketamine for depression, another really important topic. But without further ado, I'd rather you hear from him. Welcome, Ryan Sultan.

[1:10] Dr. Ryan Sultan:

Thank you for that gracious introduction. I feel like I'm back at Grand Rounds or something like that.

[1:16] Dr. Traci Stein:

It's well deserved and probably only encapsulates a fraction of what you bring to the table. And I mean that, honestly. I read some of your papers and I listened to some of your interviews. And I was really blown away with how much there is to know about ADHD specifically and how much so many of us get wrong, including a lot of professionals.

[1:42] Dr. Ryan Sultan:

Yeah, absolutely. One of the things that I remember sort of early on in my interest in ADHD was pushing back against people's concept of ADHD as little boys in elementary school, like cutting off pigtails of little girls or something like that, which is like adorable and also probably is ADHD, but that's just sort of a sliver of it. And in our modern world, which might be worsening ADHD symptoms for people that have ADHD or even giving something that looks like ADHD to the rest of us, we've had to sort of widen and reevaluate that definition. And I think that's caused a lot of confusion for people.

[2:30] Dr. Traci Stein:

So many things there. And I hope I don't lose the thread later of what I wanted to ask you that I forgot to write down. And I wrote about 100 other things down. But how our modern world has changed and changed the presentation and treatment of ADHD. Because I do think that I think it's fair to say that over the last several years, we may see a little bit of a difference. I don't know.

[2:56] Dr. Ryan Sultan:

In terms of prevalence, prevalence is going up. And there's a lot of reasons that prevalence is increasing. We're identifying people better than we were before. There are whole groups of people that were not identified well before. Females being probably the most notable group that really was sort of like, we thought of it sort of being rare in girls. But in fact, it's not. It's probably not 50-50. But we were definitely missing that group, which is problematic, because they were inattentive mostly. And ADHD is something that typically starts to present when we're younger. You know, 7, 11 years old, maybe even preschool in some cases. And classically, it's hyperactivity that gets noticed, because that's the disruptive, problematic thing that the teacher is going to be calling about. Whereas inattention is less noticeable. You're sort of, your mind is wandering. You're looking out the window. You're having trouble keeping up with what's going on. That may not be noticed because it's not causing problems. Now, the prevalence thing, certainly we're identifying more people. And that's a good thing. But the thing that sort of always strikes me as a little suspicious is that the condition of ADHD, it's the rates vary substantially from country to country. And they vary substantially, particularly between like Western developed world and everywhere else. And it's easy to sort of imagine some of this, right? Like you think about when ADHD really started to take off as a diagnosis, and we started seeing it being more problematic. It coincides with time periods where suddenly, again, I'm thinking about school, like kids are being told to sit down for hours and hours and sit quietly and not be physically active and do these things that really are not inherent to sort of the experience of being a young person. And if you go back even further to like an ancestral environment, there's even thoughts that ADHD was an adaptive thing that you might have, because it has a genetic thread to it. And the likelihood that we see it existing in the modern world among modern populations is still pretty high. So it's like weird. You'd think that if it was like a disability, which is often how we think of it in modern times, that it should have disappeared, that natural selection should have said, no, this is not helpful. But there's been a lot of hypotheses around the idea that maybe it was helpful in the past, that those individuals with ADHD were more likely to go looking for new areas to go and gather berries. That there's a guy, Randy Nese, who's a very famous evolutionary psychiatrist, and he likes to talk about how he wants to do a study and put a bunch of kids with ADHD, a bunch of kids who don't have ADHD in like a patch and see who collects berries more efficiently. And he's convinced that the ADHD kids, because they're going to get bored when there's not enough berries to collect, so they move on to the next bush. Whereas if you don't have ADHD, you try to maybe collect the point of diminishing returns, where now you're like searching for the berries there. Also that they would be interested in investigating new environments and seeing what would be available. And so imagine your tribe, your small group spreading out. So there's a lot of interesting stuff about it historically. Coming back to now, I think that we have to think about both the change in what we expect of ourselves. So white collar jobs are another example of you have to sit in a meeting all day. You have to sit and do this work all day, which is very different than what people have done historically, as well as the school situation. And then throw in devices, and you've got a whole other ingredient that really is disruptive to your attention. And there's early evidence to suggest that it really does mess up our attention. And that your attention is like a muscle, and it atrophies when not used properly, and that you build up other parts of your brain. So for instance, looking at very high intensity, lots of flashing lights, short, changing images, like imagine like TikTok, that actually builds up your visual cortex very well, because it has to process all of that. But it's not building up your ability to sustain attention.

[7:56] Dr. Traci Stein:

Absolutely. And especially in things that aren't super engaging, super stimulating. And that actually leads me to something else that you mentioned in, I'm sure, in more than one of your papers. And I realize we're jumping around a little bit, because what we didn't do is just quick, maybe we should quickly, before I get to what I want to mention, just the quick definition of ADHD for people, for the three people on Earth who maybe have not heard of it, just in case.

[8:28] Dr. Ryan Sultan:

ADHD's definition, I think, may actually be changing, because people are thinking of it much more through the lens of neurodivergence. But classically, we talk about it as a neurodevelopmental condition. We use that term because we think neuro, it has to do with the brain. And we know that because we have a lot of findings that we can talk about that support that. It's developmental because it shows up when you're young. And imagine that the brains of people with ADHD, particularly when they're younger, are like three to five years less developed in certain areas than their counterparts, which is why their impulse control might not be great. Why they may not be able to sustain their attention for as long a period of time. And thinking about the hyperactivity, that's also an impulsivity issue, potentially. Something gets them excited, and they're just going to act on that. Going back to when we were all in school, imagine people that are calling out, that are talking during class. They're having trouble managing their attention. They're having trouble not being drawn to something novelty seeking, which is a thing we see a lot in ADHD is this novelty seeking behavior. So it tends to show up in young individuals. If you develop ADHD as an adult, and you didn't have anything that resembled ADHD symptoms when you were younger, by our current definition, you don't have ADHD. You have something else, which I think is an important distinction because there's a lot of this adult ADHD talk, which originally started as people with ADHD that are now adults. And that was important because we used to think that ADHD went away when you were 18. And we know that's not true anymore. But the people that are developing those symptoms, new symptoms, without any evidence of a diagnosis when they were younger, that may actually be something else that's going on for them.

[10:28] Dr. Traci Stein:

And important to get evaluated properly.

[10:32] Dr. Ryan Sultan:

Because it could be something else. Like you can have trouble with your attention and your memory and your concentration. And that's literally in the criteria for depression. And if you're really anxious, which many of us are, you're using up 20% of your brain worrying about things all the time. It's hard to pay attention to something.

[10:54] Dr. Traci Stein:

Absolutely. And I hope this isn't too much of a tangent. And we can pull it back to the main thread if need be. But I was thinking too, also, we're still learning about how COVID changes the brain. I'm reading more about neuro-inflammation. And I'm thinking, depending on what areas are inflamed, prefrontal cortex. I'm not a neuropsychologist. I'm a health psychologist, but not a neuropsychologist. But I'm thinking like planning, attention, impulse control, emotion regulation. So we're seeing people who look different. And also have other psychological or psychiatric conditions that maybe they didn't have or they're worse. And I don't know if you're seeing that in your practice or in your research.

[11:41] Dr. Ryan Sultan:

People bring it up. It's really hard to parse what's going on. Because people don't really talk about this anymore. But COVID, early COVID for many of us was pretty traumatic. It was very, very, very scary. And we didn't really know what was going on. And that in and of itself, the trauma of that is going to have an impact on all of us and our minds and our brains. Our lives changed dramatically on a dime. I mean, it was like overnight. And then they were different for an extended period of time. And we definitely know it affected youth a lot. Definitely. I mean, that's very substantial. Because they were in this developmental time period where they're supposed to be learning things and skills and practicing stuff that maybe they weren't able to do. But for adults, think of it like you've been going to the gym. You've been running for years. You're in good shape. And now a period of time happens where you're not doing those things anymore. There's going to be some atrophy that you could see there as well. So that's not even talking about the condition of having an infection. I'm just thinking about the circumstances that are going on there. So then now layer on the inflammation associated with the infection and what we're learning that has substantial and likely long-term effects for many people.

[13:17] Dr. Traci Stein:

Absolutely. Absolutely. And I know we're going to be learning for a long time what that really means. And what the picture is going to evolve to be like. I think we're still early in understanding that.

[13:29] Dr. Ryan Sultan:

And what the trajectory will be for those people. And how much of that will they be able to recover?

[13:38] Dr. Traci Stein:

Yeah, absolutely. But I think it's so important that you're talking about even that aside. And it's really impossible to put that fully aside. But we're always in an evolving context, right? No matter what, historically, for a million reasons. I love that you spoke about ADHD as having a genetic basis. And that there's some reason why it's still present in the population. And the advantages it may confer. But also the disadvantages in certain aspects of our daily lives that require something that is kind of antithetical to the ADHD brain. And I think it's really important that you mentioned the gender differences. It does look different in girls, sunboys, disclosure. I remember being in my high school Latin class and being referred to as Spacey Tracey by my teacher, which was like so shaming. But it wasn't untrue. I had a very hard time staying fully present. And my brain compensates in other ways, thankfully. But and I think that's not an unheard of type of experience. So I think I like that you're talking about this in a non-pathologizing way. But more as like, this is the presentation. We'll talk about things too, like what people can do. I'm curious because you talk about what some of the best treatments are. And I think a lot of people will be surprised. And I'm so glad you addressed this, because I think there has been such an anti-science, anti-medicine, anti-pharmacology backlash. People are very fearful, very distrustful. And we could talk for days about the reasons why that is so much the case now and all the disinformation. You've mentioned that the best treatments we have for managing the more problematic symptoms of ADHD are, in fact, medication. Can you talk about that?

[15:49] Dr. Ryan Sultan:

Yeah, this is something that's been really not like politically correct to say in our field of mental health. People have, you're right, have really struggled with this. But in ADHD, more than any other mental health condition, the effect size, meaning how much of a difference you see from a medication is, it's better than any medication we have in psychiatry for any other condition. 80, 90% of people will have resolution of their symptoms on a medication. Now, that doesn't mean their problems are fixed, by the way. There are other things that have to happen. But that's not the case for depression or anxiety or schizophrenia or bipolar disorder. So it's a really wonderful thing, actually, that for people with ADHD, that they have this tool available to them that can really level that playing field. And we even see that on imaging. So if you take a brain, average ADHD brain and average non-ADHD brain, and you look at it under a functional MRI, which is like MRI in real time, like let's see what we can see in the brain activity-wise. And you look at activity of dopamine in the prefrontal cortex, this guy right here, the kind of newer part of your brain from an evolutionary point of view. And you look at the activity that's there in the average ADHD brain versus the sort of non-ADHD brain. The non-ADHD brain has a lot more activity going on there. And the ADHD brain, when they take the medication, their activity looks pretty much indistinguishable now from someone that doesn't have ADHD. And that's, I think, a really cool biological correlate that we've been able to identify in those individuals with ADHD. And so there's a normalization that happens, and I hate these word normalization because it's sort of abnormal being the problem, but it really makes a big difference for people. Now, you know, when we talk about medication, there's a lot of different options. There are sort of non-stimulant medications that are not that different than our antidepressants. One of them even is an antidepressant, bupropion, commonly Wellbutrin. I'm sure a lot of your listeners know someone or have been on that medication, very commonly prescribed. And then moving up, there are methylphenidate products. Those are the ones that are commonly known as Ritalin. And then there are mixed amphetamine salts, which are the ones that people think of as Adderall. And in that order, they are getting stronger. Now, that said, medication by itself is usually insufficient. There are situations that medication by itself has been okay or sufficient, but those scenarios are usually someone that has everything else has been sort of put together. They have the cleanest case that you've ever seen, and their parents have taught them all kinds of executive functioning stuff already. And then they take the medication and it's like magic. The average individual needs some skill work as well. And cognitive behavioral therapy has a nice way of adapting itself to think about those skill work. And by the way, that skill work is stuff that all of us benefit from. It's like, let's make a list of everything we have to do. How do we prioritize that list? Don't write term paper. I don't know what that means. Take right term paper and be like, okay, what's your topic? How long does the term paper have to be? What are some of the points that you want? Start doing that works or breaking it down into smaller pieces. Estimate how long it's gonna take you to work on that. Build in some breaks. Things that really all of us benefit from, but the neurodivergent folks tend to get a lot of bang for their buck out of that. And when you combine that with medication, people get really wonderful, wonderful, wonderful results.

[20:06] Dr. Traci Stein:

Absolutely. I'm also just thinking, and this probably varies in terms of its helpfulness, but even just things like setting a timer and saying, I'm gonna work for 35 minutes and take a break so that it's easier to stay focused on something that might be anxiety-provoking or tedious or both in writing that paper, right? And then go do something else.

[20:29] Dr. Ryan Sultan:

And again, why meetings are so long? Oh my God. All the science says that this is a mistake. People just can't pay attention that long. Forget someone with ADHD that no one can. Or

[20:44] Dr. Traci Stein:

The hour and 40-minute graduate school class even. And we're assuming that people, because they're now in their 20s or 30s, can still take in that information.

[20:54] Dr. Ryan Sultan:

So yeah, I mean, there's a lot of options. And I really encourage people that have ADHD or know anyone that has ADHD to investigate those options. They're not, you don't have to take them forever. You can try them and not like them and never take them again. But I have someone that I've been working with now for two years, and this person struggled to get through college. And she's very high functioning. She does a lot of things that improve her dopamine. She goes running every day. Another great thing that we should all be doing, but particularly ADHD folks are going to benefit from. Cardiovascular exercise is really going to get that dopamine up. Probably part of what runner's high actually is. And she wrote a book, which is now published. That is amazing. And that's, by her own admission, is not something that she would have been able to do had she not been pharmacologically treated. But she had lots of other skills that she had worked on. She didn't get medication until she was much older. She struggled though. And in some ways, the struggle was a little good because it forced her to sort of learn and grow. But I would also say the struggle was also not so good for self-esteem, which is the thing that I think we don't talk enough about with untreated psychiatric conditions, but particularly ADHD. ADHD shows up so early. And so it starts to create these things or foster other problems, personality disorders, meaning how do you interact with someone and do you interact with someone in a way that's socially acceptable and also functional for you and the other person? Depression, anxiety, substance use. These are comorbidities that are very, very, very high. The average ADHD person, I think in the paper that we did on this, 70% of adolescents with ADHD had another comorbid psychiatric condition. That's like almost everyone. I miss a lot of people. And that's just in adolescence. And I promise you, that's numbers going up with time. And so treating ADHD early, we really think reduces the likelihood of that happening. So again, talking to parents, you want to hold off on meds or treatment or diagnosis. I understand that. But the moment we start to see the kid have self-esteem issues and feel bad about themselves, that's when I feel like it is at that point malpractice for me to not be recommending a more aggressive treatment plan because it's a lot harder to undo that than it is to try to prevent that.

[23:51] Dr. Traci Stein:

I mean, and what you're talking about really is the risk of not treating. People are so worried about the risks of medication and side effects, which if you're properly monitoring someone, you can really reduce that risk. But if you don't treat somebody, they're continuing to develop and develop in a social context where they can't meet the demands properly or appropriately and feel terrible about themselves. And you mentioned in one of your other interviews, I think about the fear people have of being on something for forever. And I've heard people say that about antidepressants and medications just for a nonpsychiatric medical illness. And they'll sometimes spend years not treating something because of the fear of how bad treating it would be if they can't ever stop treating it, which is something we can't even determine yet.

[24:48] Dr. Ryan Sultan:

What I usually say to that is if you start this medication, we start this treatment, and it is going so well for you that you want to stay on it for an extended period of time. I said, that sounds like a great problem to have. That you are now struggling with the decision of whether you want to stop this thing that's really helping you. I want that problem.

[25:11] Dr. Traci Stein:

Absolutely. Can I tie that into something else too? Is that because I've heard people say this a number of times where it's like, I don't want to take something that's not natural. I'm afraid I'm going to become dependent on or addicted to something. I don't want to use substances to manage my brain. But I'm just thinking, a lot of times people are using nicotine to manage their brains, or they're using alcohol. And I'm not trying to demonize any of those things. Caffeine and caffeine.

[25:41] Dr. Ryan Sultan:

Caffeine, 100%. Caffeine's a drug. It's absolutely a drug.

[25:47] Dr. Traci Stein:

That we become extremely dependent on.

[25:50] Dr. Ryan Sultan:

It's everywhere. You forget it's a drug. It's definitely a drug. Oh, 100%. And it also acts in ways that are similar to stimulants.

[25:58] Dr. Traci Stein:

100%. But I'm also thinking that people who smoke weed to decrease the anxiety and distress. And again, I'm not trying to pathologize. We all use things that are tools that we feel are helpful for us. More helpful and less harmful. But oftentimes I think we go to substances that seem more socially acceptable. And I think there's too little understanding about the potential for some medications to be helpful for certain conditions. And that has to be an ongoing process with your doctor.

[26:38] Dr. Ryan Sultan:

Yeah, risk benefits. You always have to be asking yourself that. What is the risk of treating? What is the risk of not treating? And that's really something that's instilled in us as physicians early on. And that you want to be asking yourself that question. So risk of not treating ADHD, increased risk of car accidents. There's two really, really cool papers from a methodological point of view, of course, that show within the same person, the time period that they're on or off their meds, substantial decrease in the risk of a car accident. Which is, by the way, much higher if you have ADHD. It doesn't normalize. It doesn't mean, again, doesn't make it exactly the same as it is for the non-ADHD person, but it gets close. Speeding tickets, divorce, getting fired from your job, teen pregnancies, accidental death. There's a lot of things that come along with, in a modern world, having impulsivity issues, lack of educational attainment, which is the one that I always think is, I mean, I'm a research education guy, so I find that one to be criminal. Speaking of criminal, criminal activity is another thing that ends up happening. And my dad is also a child psychiatrist, and he works at Rikers, which is like this famous prison. And he works with adolescents there, and he would come home and he would say to us how sad it was that so many of these individuals weren't treated, because most of them, these adolescents feels like 75% easily have ADHD. And had they been treated, they might not have ended up in this situation, because a lot of times people end up in these situations because of bad judgment, because of impulsive decision making. They're not inherently evil individuals, but now they're in a difficult situation. And again, that may not be a demographic that your listener base is able to identify with, but there's a spectrum of things that are going on, right? There's a huge spectrum of things going on. And I even talk about myself personally. My brother and I have ADHD. My brother is a developmental pediatrician, and I'm a psychiatrist. And had we not gotten skill learning and treatment at some point in our lives, I don't know that we would have gotten on the same trajectory that we were on.

[29:12] Dr. Traci Stein:

I so appreciate your sharing that. So it's so helpful. And it makes people, I think, have an easier time relating to what you're saying. Because a lot of what we're saying today, I think people can have a hard time hearing. And I think painting a clearer picture makes it more understandable why it's worth seeing somebody, why it's worth also doing skills training and psychotherapy, why the medication is really something to consider, especially if somebody's really struggling. And you know if you're struggling, right? At school, or at work, or at home, and so forth. You mentioned before.

[29:51] Dr. Ryan Sultan:

Has that even changed during going back to your over time period thing? The treatment you get may not be the same all the time, meaning the dose of the medication, or whether you want to be on or off your treatment, may also depend on where you are in your life. For example, someone who has an ADHD diagnosis and is currently trying to do their dissertation. I mean, I don't have to tell you. It's a hard one. You guys don't know what she does very hard. This is a completely unstructured thing. You're just sort of told to go figure out a research question and design it from scratch. And you have people available to you to help you, but they're not on top of you. And if you don't do it, I mean, you're SOL. I mean, you got to be able to structure yourself. You got to be able to organize yourself. And so people that are doing new learning experiences that are learning that requires a lot of work that's very unstructured. That's a time period where people's symptoms are really going to show versus a very structured environment. Often can kind of mask those symptoms.

[31:10] Dr. Traci Stein:

I want to, like, a little quick aside related to doing advanced study. As a person who grew up in a time where people weren't getting diagnosed, you were basically told to sit still and pay attention. And there were lots of social and other costs to not being able to do that like a normal person. I'm even thinking like doing math problems and having an out-of-the-box way of coming to an answer that is different from maybe the way somebody is wanting you to think. And also having to do things under quite a bit of pressure. You mentioned in, I think, one of your interviews about the benefits of something like ADHD could be out-of-the-box thinking and creativity. And I think a lot of this journey is finding the tools inside of you and outside of you to help you optimize your own way of being in the world. I'm not taking this from what you're saying either. It's not about shoving yourself into a box to be like everybody else, because that doesn't really work. But learning skills and taking medication when indicated to help you function more optimally in a world that places certain demands on you. While still acknowledging your own particular unique skills and strengths.

[32:35] Dr. Ryan Sultan:

Absolutely. If I can expand on that a little bit. One of the things that I don't want people to take away is, well, this is just sort of how I am and whatever. It's like, well, yes, but I'm sorry. This is the world that we live in. If you want to participate in it, there are accommodations that are made. The American Disabilities Act supports that. And there was an article in The Economist not that long ago suggesting we should do more to accommodate that. But you have to work with what you got at the moment. This is a world that requires you to be organized. That requires you to be on time. That rewards these kinds of behaviors that people with ADHD can really struggle with. And we didn't get this yet. But it's not just, I'm thinking a lot about administrative work kind of stuff. It's not just that. There's a whole other area around social interactions and missing social cues that can be really problematic. One of my favorite mentors would talk about how ADHD kids are the best at making friends and the worst at keeping them because they can really struggle with navigating certain social situations. And some of that still shows up in adulthood because we know that two-thirds of people still meet criteria into adulthood. And we know that 90% of people have at least some residual symptoms. So that's basically like everyone that had ADHD as a kid except maybe 10% still have some aspect of it. That's that they're still experiencing it. So thinking about an adulthood is another aspect of it. And being a parent, that's a challenging one for someone with ADHD. When you think about the sort of organizational aspects that come along with that.

[34:41] Dr. Traci Stein:

A hundred percent. And even, I'm just thinking also, if you have children, like you said, there's a highly heritable component.

[34:50] Dr. Ryan Sultan:

70, 80%. It's first to be relative. So if you have one kid, the second kid probably has something like it too.

[35:00] Dr. Traci Stein:

And I'm just thinking if you are a parent and you have ADHD, if your child is presenting with symptoms and they are struggling, you have to use a lot of energy to organize yourself and that child. And so it's worth kind of taking some of the burden off by treating it well. I want to point out something that you said before because I think I just want to make sure we clarify it for people listening because it's great because I don't usually hear people talking to the non-healthcare public about these things. And so lower dopamine, you mentioned dopamine before. And so I want us to explain for everybody what that is and what that results in and lower norepinephrine in people who have ADHD. So if you want to just give a little quick overview.

[35:58] Dr. Ryan Sultan:

Yeah, yeah, yeah. So, disclaimer, this is a model, okay? Based on basic science we've done, it's not exactly right probably, but it seems to be pretty close. So when you have a synapse, which is the space between your two neurons, like how do the neurons talk to each other? Because they have things to say to each other. They have this space and they sort of dump these neurotransmitters, dopamine, serotonin, norepinephrine. Brain chemicals. All these brain chemicals, right? And those things go across and they bind little locks and keys to the other side of the space to that other neuron. That's the communication. And what we know is one of the things that's involved in ADHD is dopamine, another thing we know that's very involved is norepinephrine, and that the activity of those things seem to be lower at baseline. And we even see another version of that, because norepinephrine is sort of like an awake kind of brain chemical. We see when we do EEGs, which is that thing that they do for seizures, they see more slow waves with people with ADHD, which is associated with not being entirely awake, which you can imagine an ADHD person not paying attention why you might see that. The way the medications work is they allow the dopamine and the norepinephrine that are in that space between the two neurons to stay there longer. One of the main functions, one of the main ways they're doing that is that they block the reuptake. They're like these little vacuums that collect the dopamine and norepinephrine so it can be reused. And so it kind of blocks the vacuum so it stays longer, so it takes longer for it to be taken back up. And this seems to really, really, really, really, really reduce symptoms for people.

[38:01] Dr. Traci Stein:

And just the symptoms people would see is dopamine pleasure, reduced ability maybe to feel pleasure without a lot more stimulation. Would that be fair to say?

[38:14] Dr. Ryan Sultan:

Which relates to the addiction concern. It sounds like where you're going with that. People are like, oh my god, these things are addictive. It's like you're giving my child meth. It's not the same. I understand why people say it's the same. It's very different. But the data, because people have been so worried about this. There have been many, many, many, many, many studies looking at the likelihood of addiction with stimulant medications. And the overall risk of addiction is either the same on or off or reduced on medication. No study has ever been able to show. And again, people were trying to show this. They designed the study in a way that they were sort of stacking the deck to try to find that. They have not been able to show that it does anything to increase the risk of addiction. In fact, they end up showing the opposite for that exact reason, for that exact reason probably. Because the stimulus required to have that kind of pleasure seeking behavior has probably been raised by being treated.

[39:22] Dr. Traci Stein:

Yeah. And what I was thinking, I was imagining somebody listening. And I'm thinking of the things people do to stimulate the ADHD, I mean, stimulate in terms of to get pleasure. So the untreated brain, I'm just thinking of playing video games for hours or doing other things to try to generate feelings of pleasure that might be easier for a non ADHD brain to experience. So treating it, it sounds like you're saying, actually helps reduce the likelihood of addiction and addiction behaviors. So it's a good thing. And I think it was just good to clear up that misconception, because a lot of times I think people hear these terms, but they don't know exactly what they mean. And I feel like there's so much misinformation out there. So yeah, so I think this is really great. Is there anything I didn't ask you about your ADHD work that we should have talked about?

[40:27] Dr. Ryan Sultan:

There's certain things that I think are worth thinking about that I think might help some of the listeners connect. If you're the kind of person that the only way anything ever gets done is when there is a deadline and there is a last minute situation. And I wish I had a better analogy for this, but like you metaphorically feels like there's a gun to your head that you have to do it. That doesn't necessarily mean you have ADHD, but it's highly associated with ADHD. And getting back to your idea around thinking about these brain chemicals. Well, you know what a stressful situation does when you feel like it's a life or death situation for you that you have to do this? It raises these things naturally. And that's why many people with ADHD will be like, oh, no, no, no, I'm fine like right before it needs to get done. And suddenly everything comes to me and I can write this 25 page paper or whatever it is that I have to do for work. And I say that to people because I want people to sort of connect with that experience because it's a very common experience that people have. It's of course a problematic way of doing things in life because not everything has a deadline. And also what if you don't estimate correctly and you may not actually have enough time to do it. Plus you were also really stressed leading up to it, not doing it. I think that's an important thing to share. There's a tremendous amount of evidence that pharmacologic treatment of ADHD is basically only beneficial. That it might reduce many of the negative associations of ADHD we talked about, including a more recent one that people are starting to see, which might be an increased risk of dementia. And that the pharmacologists are going to reduce that risk as well. So that's another thing that I really try to hit home for people that there's a lot of things that come from the benefit of treatment.

[42:38] Dr. Traci Stein:

Do you have a sense of what the mechanism might be? And it's okay if that hasn't been elucidated yet, but do you have a sense of what it could be?

[42:46] Dr. Ryan Sultan:

I mean, I can hypothesize. My guess would be that in people with ADHD that aren't getting a lot of stimulation. So there is this version of ADHD that are very high functioning people that are not pharmacologically treated and they get a lot done. And you see that they're incredibly busy all the time. But if you're not that kind of person, you can imagine there might be some atrophy that starts to happen because you're not using your brain to its full potential and that might be a risk factor for developing dementia. Connecting to that busyness thing, there's this really cool study that's been going on now for 20 years called the MTA study, which was funded by US government NIH back in the 90s. The individuals in it are probably around my age at this point and they've been looking at them since they're like seven or eight years old. And that's a lot of the things we know about ADHD over the lifetime comes from this study. And one of the most interesting findings that they had was that ADHD actually fluctuates in its severity and symptoms over time. And that when people were busier in their life, they had more going on, their symptoms actually got better. And getting back to that, like, oh, I have too much going on. I'm stressed out. I feel like I have to work on it. It may be that's actually putting their brain into a more functional state for them. And that finding was sort of initially surprising. But when we think about that group of people that are doing really well, that are very high functioning, that are very busy with ADHD, it's consistent with that. It's so, so fascinating.

[44:33] Dr. Traci Stein:

And you're the first person I've ever heard mentioning that possible connection, that hypothesis. So that's going to stay with me, definitely, as will everything else. I so appreciate your taking your time out of your busy schedule. I think we should probably a lot more time for the ketamine discussion, because I think it's important. I don't want to give it short shrift unless you think we should do the two minute version. But I don't know. Otherwise, you have to come back at some point.

[45:10] Dr. Ryan Sultan:

I'm happy. I'm happy to come back. I think that the coming attraction is, you know, that we would like. We want to have more and better treatments for depression in particular. And that we're not quite there yet. But one of the ones that we found that is valuable is ketamine, which is kind of cool, because it's an oldie. Ketamine is not a new medication. We didn't discover it recently. It's just like stimulants, which have been around since the 50s. There have been around about that length of time. And that we find that these lower doses of ketamine seem to do a lot to alleviate depressive symptoms. They're not a panacea. They don't fix everything. And they're not just like stimulants. They're not sufficient on their own. But it's a really nice tool that we have that's been added to the toolkit for people that need treatment.

[46:06] Dr. Traci Stein:

That's huge. And I definitely want us to have another conversation when you can make time to come back. Ryan, before we go, let people know where they can find you and what sort of services you offer because you have a private practice, a group that you run as well.

[46:24] Dr. Ryan Sultan:

So yeah, we're in New York City, Florida and Montana, actually. Wow. Integrative psychiatry. I'm the medical director. And all of our clinicians are trained both in psychotherapy as well as pharmacology, which is something I'm very proud of because I want people to be able to come and get a variety of treatments because we know that combined treatment is really the best way to treat pretty much everything in mental health. So it's integrative-psych.org.

[47:02] Dr. Traci Stein:

I love it. I think that's great. And you can find out more on Dr. Sultan's website that he just mentioned. I'll put everything in the show notes. But again, thank you so much for coming. I really enjoyed our conversation.

[47:16] Dr. Ryan Sultan:

My pleasure. I look forward to coming back.

[47:19] Dr. Traci Stein:

Dr. Ryan Sultan, this has been so important and so enlightening. I really appreciate that you took the time to come on the show today.

[47:28] Dr. Ryan Sultan:

It's my pleasure. You're a wonderful person to have a conversation with.

[47:32] Dr. Traci Stein:

Thank you. This has been another episode of Unpacking Possibility. If you enjoyed the episode, and I know you did, please remember to like, share, or follow. Leave me a comment. Let me know what you think. And as always, until next time, be well. Bye.

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