An Interview with Dr. Stephen P. Hinshaw
By Rheba Estante
Dr. Stephen P. Hinshaw is a Professor of Psychology and the Director of the Hinshaw Lab at the University of California, Berkeley. His area of expertise is clinical science, change, plasticity and development. Dr. Hinshaw earned his A.B. from Harvard University and his Ph.D. in Clinical Psychology from the University of California, Los Angeles (UCLA). He is also the author of the 2003 book; The Years of Silence are Past: My father's life with Bipolar Disorder, a memoir of Dr. Hinshaw's early life growing up with a father suffering from bipolar disorder in a household that sought to keep his father's mental illness secret.
Why does the debate remain among some members of the public about the validity of a diagnosis for children with ADD-ADHD?
The Attention Deficit Disorder diagnosis is made in a low tech fashion. It is true that there is no definitive brain scan or blood test that can indicate with 100% accuracy that a person suffers from this condition. The same can be said for other psychiatric illnesses such as clinical depression, bipolar, or schizophrenia. The brain is composed of a trillion synapses and medical science has only been able to image it with clarity in the last 20 to 25 years. There is still a long way to go in the scientific field to substantially measure, empirically, the existence of brain abnormalities that cause attention problems.
To say there is no validity in the diagnosis of the condition because of the lack of a biological set of markers is to deny what we already know of the negative impact over time of not treating the condition. Children who are not treated for attention problems run a high risk for academic failure, peer rejection and social situations, are a substantially higher risk of car accidents, and are less able to lead independent lives as adults. There is a pervasive and chronic pattern of underachievement that follows such children in many areas of life. To withhold proper diagnosis and intervention is to leave them at the mercy of the consequences of their condition. The impairments of these children can be measured psychologically over time in terms of economic impact. The impact is serious.
Does that mean that some activities or tasks or are more ADD-ADHD friendly?
Yes, but there are so many differences within the population of people with ADD-ADHD that the secret is to know what are the best activities or task for you. Some ADD-ADHD people are good athletes, artistic, excellent public speakers. No two people are the same. As with anything, the key is finding your own pattern of strengths or weaknesses, and finding support to do those things.
What are the family and peer relationship protocols that can help an ADD-ADHD patient thrive?
For children and adolescents with ADD-ADHD, behaviorally-based parent training is evidence-based and teaches families to manage behavior effectively and consistently. There are also effective peer-based interventions. This can be done one-on-one or in groups to learn about ADD-ADHD and how to measure behavior regularly, implement rewards and specific consequences and apply these consequences consistently in a non-emotional manner.
Consequences must be used in a regular and predictable fashion to deliver results.
Success in peer groups is paramount to proper development, but we must wonder how we teach social skills in a one-on-one basis to an adult. This is often done with practice and rehearsal of interactions with social peers in a group. There is a mixed history of social skills intervention but there is one group of thought that a group of ADD people can reinforce their maladaptive social skills in one another. If the group leader has a reward system and is explicit about teaching a skill that is rehearsed, modeled, and repeated and then we send these children or adults back to the playground or workplace to practice, outcomes can be measured in terms of social success.
What are the variances of externalized behavior of ADD-ADHD in different genders, temperament, IQ levels, and cultural backgrounds?
This is an area of big debate. Many ADD-ADHD girls look very much like boys. They are impulsive, disruptive and can't restrain behavior, but there is also a tendency for girls to display extreme inattention and be quiet daydreamers. Most girls like this are referred to as the combined type. A higher percentage of girls have this inattentive type and are less likely to get referred for treatment. They end up suffering in silence and may take a long time to get noticed. People differ on the diagnoses of females.
For example, Patricia Quinn at the National Resource Center for Women in ADD in Washington, DC, says that the diagnostic criteria of girls and woman need to be changed. Boys are hyperactive. Girls are hyper verbal. They show an impulse control problem in a different fashion than boys. Quinn believes that there are sex-specific ways of manifesting the problem. Girls aren't quite as active as boys but much more verbal earlier in development than boys. So it may be helpful distinguish how symptoms differ in females.
Are there particular challenges for ADD-ADHD patients from certain cultural backgrounds, such as Asian families, who put a high emphasis on academic achievement?
There may be particular stigma in cultures that emphasize restraint and achievement. However, there is such variation within a given culture and such strong impairments related to ADD-ADHD across cultures that specific instances may promote stereotypes.
So far, what are the main psychopathology profiles of females with ADD-ADHD?
There have been all too few studies, but symptoms and impairments during childhood are very similar to boys. Our own data shows that after a 10 year follow-up in early adulthood these females are at a huge risk for cutting and other forms of self-harm or suicide. Right now, we are exploring the reasons and mechanisms that characterize females with attention problems.
Why are women with ADD-ADHD more stigmatized than men who have the same disorder?
Male ADD-ADHD behaviors are more characteristic of male behavior at large and more is expected of them. Women with this same behavior are atypical of their gender and it probably leads to greater stigmatization. There are so few studies on this. Boys are expected to behave that way. For a girl, it's against the gender norm and we know that in some programs, the boys get rejected, but girls get rejected twice as much. Something about that behavior in girls makes other girls very uncomfortable. Those experiences become a burden over time and as they enter adulthood, some begin to self-harm.
Should ADD-ADHD children just be sent to special schools even though they may have higher than average intelligence?
My own view is that special schools are usually not needed for most kids with ADD-ADHD, but extensive comorbidities or other extenuating circumstances may make such separate programs optimal. It's all about individual differences. In some cases, a special class or school may be indicated. Most kids with ADD-ADHD should do well if the teacher gets support and aid. The hope is that those with ADD-ADHD who are put into special schools aren't stigmatized, which reinforces symptomatic behavior.
Is there hope for late diagnosis ADD-ADHD adults?
Yes, because evidence-based treatment (cognitive-behavioral therapies and medications) work for most adults with ADD-ADHD. In CBT, you look at the situations you are in and change thinking strategies, devise a new plan for how you want to come across, and put yourself in situations where you get support.
Rheba Estante is a San Francisco writer working in higher education and pursuing her Master's degree in Counseling Psychology at Golden Gate University. Known for her compelling articles featuring women's lifestyle and health issues, she interviews industry leaders ADDA's E-News, the Potrero View newspaper, and for the SF Women's Health Examiner for Examiner.com. Learn more about her work on LinkedIn.