December 9, 2024 • 54 mins
Unlock the secrets of ADHD with guest Dr. Michael Manos and gain a comprehensive understanding of this genetic condition that affects so many lives. In this enlightening episode, Dr. Manos shares his expertise on how ADHD manifests differently in brain function and about the gender disparities in ADHD diagnosis and treatment.
Managing ADHD behaviors effectively is crucial for improving quality of life, and Dr. Manos provides valuable strategies and tips. Tune in for a wealth of knowledge and actionable advice that can help individuals with ADHD thrive.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Welcome to the Speaking of Women's Health
podcast.
I'm your host, dr Holly Thacker, and I'm back in the Sunflower
House for a new episode with aguest, dr Michael Manos.
He is a PhD and he is an expertin ADHD attention deficit
(00:31):
hyperactivity disorder.
Dr Manos is the former head ofthe Center for Pediatric
Behavioral Health in theChildren's Hospital at Cleveland
Clinic and he is the foundingclinical and program director of
Pediatric and Adult ADHD Centerfor Evaluation and Treatment.
(00:53):
And Dr Manos is adjunct facultyat Case Western Reserve
University College of MedicineDepartment of Psychiatry
University College of MedicineDepartment of Psychiatry and
he's an associate professor atthe Cleveland Clinic Lerner
College of Medicine and he's gotspecial interest and expertise
(01:14):
in both children and adults withADHD, behavioral pediatrics,
clinical behavioral pediatrics,family management, as well as
pharmacotherapy research, and hehas written and presented
several hundred scientificallybased papers on ADHD.
(01:34):
Welcome, dr Manos.
Speaker 2 (01:38):
Hi, Dr Thacker.
Thank you for the invitation tobe here.
Speaker 1 (01:41):
Well, it is wonderful to have you to be here.
Well, it is wonderful to haveyou.
As our Sunflower Houselisteners know, my major area of
expertise is in midlife women'shealth and menopause and
hormones, and I have a lot ofwomen come to me for inattention
and brain fog, and sometimesthat is menopause.
(02:02):
Sometimes they have newdiagnoses of ADHD themselves or
they think they may have itafter their children or
teenagers are diagnosed with it.
So can you tell our listenerswhat is ADHD and what causes it?
Speaker 2 (02:16):
So ADHD is a genetic condition and so it's handed
from parent to child and ittends to occur certainly in
families.
So ADHD is a distinctdifference in two kinds of
(02:42):
attention in the brain.
So I do want to emphasize thatfor many people ADHD is not a
disorder.
It's not like a, a viralinfection where there is
something wrong with anindividual.
It's actually a difference inhow the brain functions.
And because it is a geneticcondition, it certainly doesn't
(03:09):
have necessarily a cause, otherthan if you consider some
individuals, such asevolutionary, who consider that
ADHD has been selected forthrough natural selection and
(03:30):
evolution.
Speaker 1 (03:32):
Fascinating.
Why is that?
Speaker 2 (03:35):
Yeah, that's actually the question, and what's
interesting is that, because thebrain is adapted to the
environment through naturalselection, when all of us lived
in a very dangerous world, aworld where hunter-gatherer
(03:56):
tribes were necessary in orderto enhance survival, hunters
were the ones who could bediagnosed with ADHD, because
their brains were highly attunedto the external world and they
were highly reactive to theexternal world, and so just by
their ability to recognizedanger and adapt to danger, they
(04:20):
kept people alive, so evolutionselected for it.
They kept people alive, soevolution selected for it.
What's also interesting is thatfollowing the ice age, people
lived on farms and now a brainthat could wait a long time for
something to happen, likeseasons changing or plants
growing.
Now a different brain wasselected for in evolution.
(04:44):
Now a different brain wasselected for in evolution, so
farmer brains became moreprevalent.
And if you consider many of theadult tasks in our world today,
where things are relativelysafe, that the farmer brain
largely is the brain that reactsbetter to, say, school tasks or
(05:08):
work tasks, as opposed to theADHD brain, which largely reacts
to incurring stimuli.
Speaker 1 (05:21):
You know it's interesting that you talk about
the school brain.
You know it's interesting thatyou talk about the school brain.
I'm the mother of three sonsand I noticed early on,
especially when I wouldvolunteer in schools, that it
seemed like schools were betterset up for girls.
And of course I'm a femalemyself.
But even I felt like I had moreof that male brain and wanting
to move from task to task or behands-on or be more physically
(05:44):
active instead of sit quietlyand write neatly.
Are there gender differenceswith ADHD, and is the school
environment not as good forsomeone who's more wired to be
sensitive to all the stimuli?
Speaker 2 (06:00):
Well, if you ask most kids, do they like doing school
tasks?
They're going to tell you no,they don't.
So school tasks themselvescertainly may have something
inherent in them that make thema little less invigorating.
So girls with ADHD arediagnosed less than boys with
(06:21):
ADHD, by a factor of about threeto one three boys to one girl
than boys with ADHD by a factorof about three to one three boys
to one girl.
And ADHD in girls is a littlemore difficult to recognize
because there are expectations,societal expectations that apply
to child behavior, that areallowed more grace in girls, for
(06:49):
example, so what things areallowed more grace in girls.
Well, boys are highly recognizedbecause of their overactive
behavior.
A girl with ADHD who hasoveractive behavior may be
considered just more social, orthey may be considered just more
talkative, as opposed to a boy,who may be more aggressive and
(07:15):
more intrusive in schoolactivities.
So the ratio of boys to girlstends to be three to one, and
girls also tend to have societalexpectations that preclude a
(07:40):
diagnosis of ADHD, and so thereis a very interesting statistic
that, by a factor of about threeto one, girls and women are
provided with antidepressants oranxiolytics before they're
provided treatment for ADHD,whereas boys it's the opposite.
Speaker 1 (08:03):
Now, is that because girls are being underdiagnosed,
or are boys being overdiagnosed,or are there sex hormonal
differences in the brain thataffect the expression of the
symptoms of ADHD?
Speaker 2 (08:16):
No, it's not a question of being over or
underdiagnosed, or over andunder or undertreated or
mistreated, and or over andunder or under treated or
mistreated.
The paper that we publish inthe Cleveland Clinic Journal of
Medicine has been very wellreceived, actually worldwide,
and it's very interestingbecause we address that very
(08:38):
question overdiagnose and overtreated or misdiagnose and
mistreated.
Boys tend to be more easilyrecognized, especially in
childhood, because of theirhyperactive and impulsive
behavior, whereas girls'behavior is generally excused or
allowed to be there.
(08:59):
It's not necessarily recognizedas being problematic, and girls
tend also to internalize.
When they accrue negativeattention for, say, being
distracted in school, they tendto make themselves wrong or they
tend to be critical of theirown behavior and of themselves,
(09:22):
as opposed to boys, who may bemore accustomed to acting out or
being more aggressive.
Speaker 1 (09:35):
And maybe we should back up a little bit and you can
tell us the common symptoms ofADHD, as opposed to some people
are just telling me they onlyhave ADD, they're not really
hyperactive, and how wouldsomeone know if they have this
condition or how?
Speaker 2 (09:59):
would a parent know if his or her child or
grandchild has ADHD?
Or four diagnoses for ADHD ADHDinattentive type, adhd
hyperactive, impulsive type,adhd combined type, which is
both of those.
Then there is a third kind ofADHD called unspecified type,
(10:20):
and I've used it only veryrarely with people who do show
intruding symptoms in theirlives and their lives are
actually impacted by thesesymptoms, but they don't
necessarily meet full symptomcriteria.
In a child, we're looking forat least six of nine behaviors
(10:40):
that are associated withinattention and or six of nine
behaviors associated withhyperactivity impulsivity.
It's either one of thosecategories that there needs to
be a clustering of at least sixsymptoms.
In an adult, we're looking fora clustering in either one or
(11:01):
both categories, of at leastfive symptoms.
Speaker 1 (11:05):
And what are those classic symptoms?
Speaker 2 (11:09):
Inattention, distractibility, disorganization
, starting tasks and notfinishing them, leaving tasks
incomplete.
The biggest problem that peoplewith ADHD have is this notion
of incompletion.
Somebody says they're going todo something and they do not do
(11:30):
it.
They leave the task incomplete.
This is, of course, veryobvious in childhood, where
children are expected tocomplete schoolwork and finish
it and turn it in the next day,complete an entire test.
So children have tasks thatthey are assigned by adults and
(11:51):
typically there is what occursin childhood.
Social scaffolding is veryprominent, so you have parents
and teachers who are keepingtrack of the child's ongoing
performance in school andsubsequently, that ongoing
performance is monitoredcontinually.
When you are an adult, thingschange and adults are expected
(12:16):
to be self-responsible and theyare expected to identify the
task and complete the task.
They're not expected to bereliant on social scaffolding,
on parents or others to tellthem what to do.
However, that certainly isbuilt into certain occupations.
(12:39):
If you're at the executive of acompany, then certainly you
have people around you who willallow you or assist you to
structure the day and to do thetasks that need to get done, but
in childhood that's not alwaysavailable, unless you have a
very loving parent.
Speaker 1 (12:58):
Wow.
And so how would a parent knowif their child has it?
If they're just concerned aboutthe symptoms, would a general
pediatrician be the one to makethe diagnosis?
You know one thing I just feellike I just see at least
children like of my grandparents, my grandchildren's age.
(13:19):
It just seems like they're moremedicalized than like maybe my
kids were, and they seem to bemore medicalized than like maybe
my kids were, and they seem tobe more medicalized than like I
was as a child.
So I don't know if it's justwe're better at diagnoses or are
we just less tolerant ofcertain behaviors, being a
scatterbrained or a silly heador, you know, just being a child
(13:39):
?
Speaker 2 (13:40):
Well, I think that we have given a name to a body of
behaviors that, when theycluster, they interfere with a
child's life.
They interfere with the child'sresponsibilities at home and in
school and they certainlyinterfere with an adult's
responsibilities unless there isa very notable scaffolding.
(14:04):
But adults also learn all kindsof new behaviors in order to
manage the behaviors that areproblematic in ADHD.
Speaker 1 (14:14):
So I'm not quite sure if I'm answering your question
properly, but nevertheless so doyou think we're just better at
diagnosing it, or do you thinkthat maybe older parents and
overworked teachers are lessable to support the child?
I mean, do you think there issome over diagnosis of of this,
(14:34):
or do you think there's actuallyunder diagnosis and not enough,
not enough treatment or enoughpeople that specialize in this,
or is it regionally?
Speaker 2 (14:43):
dependent, right understood, and I don't think we
are over diagnosing by anymeans, and I think actually that
we are under diagnosing andbecause of that, many kids, and
girls especially, areexperiencing failure where they
don't need to experience failure.
(15:04):
They are more interested inwatching the squirrel climbing
the tree than they are in doingthe math homework or finishing
their test in school, and sothey are considered to be
scatterbrained or they'reconsidered to be frivolous and
they, they really don't care.
Sometimes we even call kidslazy, and that is one of the
(15:29):
most absurd descriptions of achild.
I have never, ever, met a lazychild ever, and there is a lot
of avoidance.
There are certain tasks thatchildren will avoid and adults
will avoid.
However, that doesn't mean thatthey're lazy.
(15:50):
So I think that the realconcern here with ADHD is what
is it that is the cause of, orthe instigating factor that
leaves a task incomplete?
Speaker 1 (16:12):
We are listening to Dr Michael Manos, a PhD and
expert in child and adult ADHD,in the Speaking of Women's
Health podcast, and I'm yourhost, dr Holly Thacker, and
we're talking about behaviorsthat can indicate a condition
(16:32):
which is treatable, and thesuffering and the problems and
the misunderstandings that cango along with it.
Speaker 3 (16:40):
Hello, you just listened to part one of this
podcast episode on ADHD with ourguest Dr Michael Manos of the
Cleveland Clinic.
In the original recording ofthis podcast interview, dr
Thacker interviewed Dr Manosentirely.
However, we had a bit of atechnical glitch in the second
half where it did not record thesecond part of the interview.
(17:04):
So I will be hosting thisre-recording of the second part
of the podcast episode with DrManos.
My name is Leigh Klecker and Iam the producer of the Speaking
of Women's Health podcast.
I am the producer of theSpeaking of Women's Health
podcast.
So first thank you, dr Manos,for taking time in your busy
schedule to re-record this partof the podcast episode, and we
(17:24):
did hear a lot of importantinformation in the first part
with Dr Thacker.
But I'd like to start thisportion of the interview
discussing academics and theconnection to performance in
school and ADHD.
So, generally speaking, do mostchildren with ADHD not perform
(17:45):
as well in school?
Speaker 2 (17:47):
So that's a very good question.
To perform well in schoolrequires certain fundamental
behaviors that often are notavailable to a child with ADHD.
So, for example, staying inseat, sitting still and paying
attention to one source ofinformation, like the teacher,
(18:08):
is a fundamental part of beingsuccessful in school.
So many children with ADHD,whether they are of the
inattentive type or hyperactiveimpulsive type, tend to have
difficulty staying seated andbeing able to attend to one
(18:31):
voice source, for example, likethe teacher, and so children
often miss things in school.
And on top of that, let's say,there is silent work being done,
like a worksheet a child is tocomplete at the desk.
Worksheets are often veryunstimulating and not very
(18:53):
activating to attention not veryactivating to attention so
children tend to get distractedor drawn away from tasks much
more easily than when you haveADHD, than a child who does not
have ADHD.
Speaker 3 (19:08):
Okay.
Speaker 2 (19:09):
So ADHD can clearly interfere with functioning in
school.
Speaker 3 (19:14):
Mm-hmm.
And if someone is doing well inschool and getting good grades,
does that usually eliminate thefact that they have ADHD?
Speaker 2 (19:25):
No, in fact, that's very insightful of you to ask,
because people with ADHD, whohave higher IQs or manage
information much moreeffectively, can pay attention
for perhaps a quarter of thetime that another student must
pay attention to for the wholetime.
So many kids who are brighttend to perform quite well in
(19:48):
school and in fact do quite welleven through high school.
So they breeze through schooland get good grade point
averages.
Then they go on to college andrealize that the workload in
college is far more demandingthan the workload in school, so
(20:08):
subsequently they begin torequire more assistance in
completing the schoolwork thatbefore came so easily to them.
So just performing poorly inschool is not an indicator of
ADHD at all.
Speaker 3 (20:25):
Okay, okay, so well then, how do clinicians test for
ADHD?
Speaker 2 (20:33):
There is really only one way of knowing whether ADHD
is present, and that is doing aconcerted, semi-structured
interview related to thedescription of behavior.
What does the child do?
So?
For example, in our office,this conversation takes anywhere
(20:54):
from 40 minutes to an hour anda half, depending on what's
occurring for the child.
So one asks how does the childbehave at home and how does the
teacher report the child behavesat school?
It's important to address thiskind of functioning across
settings home, social network.
(21:16):
Has there been trauma in thechild's history?
Is there difficulty in school?
And so asking about behavioracross settings is very
important to do.
Speaker 3 (21:33):
And while you're doing that testing, is it
usually with the parent inperson, the child in person and
maybe someone like you mentioned, either a teacher or another
person in their relationship orsocial world, or is it just with
the child?
Speaker 2 (21:52):
No, it should never just be with the child and in
fact it's best to begin theinterview with a parent, and we
always do testing here and inthat testing.
The examiner is the one whodoes the interview with the
child.
But a detailed, systematicinquiry as to the child's
(22:15):
behavior in multiple settings iscritical.
And who knows the child bestbut parents and teacher?
Right Now we typically do notdirectly interview teachers, but
we get teacher input by askingthem to complete several
different rating scales scales.
Speaker 3 (22:43):
Okay, okay, so what is the prevalence?
Speaker 2 (22:44):
of ADHD here in these states compared to the rest of
the world.
So there are a variety ofdifferent estimates of
prevalence, and in the UnitedStates the childhood prevalence
is considered to be about 11%.
Worldwide prevalence of ADHD israted from 4.7 to 7.2%, so
(23:06):
there are very, very many peoplewith ADHD children and adults.
Speaker 3 (23:12):
So why do you think that here in the US the
percentage is higher compared tothe rest of the world?
Speaker 2 (23:21):
That's a very good question, and I know some people
have cracked jokes about itthat what attracted people to an
unknown territory like theUnited States from the very
beginning was that they had thatrestlessness associated with
ADHD.
So they came to the US.
Now some people think that it'skind of funny to also joke that
(23:48):
Australia has a very highprevalence of people with ADHD
because Great Britain sent allof their criminals to Australia.
Now I don't know if that'ssomething you want to say in
there, but nevertheless it's aninteresting anecdote that people
bring up.
Yeah, why the prevalence ofADHD in the United States is so
(24:12):
high?
I don't know of anybody who'sgiven a satisfactory explanation
other than that somehow it's inour gene pool.
Speaker 3 (24:24):
Interesting.
So can the condition, the ADHD.
Can it be correctable,manageable, Is it lifelong?
Does the brain sort of developand help people maybe outgrow it
later in their life?
Speaker 2 (24:39):
ADHD does not go away and people do not outgrow it.
So when I was in graduateschool, we were always told that
adults don't get ADHD and thatit's a childhood condition.
But that's absolutely not thecase.
What happens is that over time,hyperactive and impulsive
(25:00):
behavior tend to tone themselvesdown or to be less observable.
But inattention does not goaway and many times people
experience comorbidity likedepression or anxiety
comorbidity like depression oranxiety.
So ADHD is a lifelong conditionand doesn't go away.
Speaker 3 (25:23):
Huh, well, I know just from working with Dr
Thacker for such a long time.
You know we have.
She has noticed and I've heardfrom you know, in our meetings,
that more and more women arecoming in and getting a ADHD
diagnosis, even, you know, up tomidlife.
So maybe back when you know,when they were younger or you
(25:45):
know, as you mentioned, you know, during their younger school
age they didn't really notice it.
They did well in school andthen as they've gotten older,
you know it's sort of now becomemore of an issue for them in
their adult life.
Speaker 2 (25:57):
So my wife is very fond of telling me that women
are smarter than men anyway.
So that's why?
So women being smarter tend tofind it easier I shouldn't say
easier they tend to be moresuccessful in getting through
school and subsequently, thedetriment of ADHD.
The problem that it poses inliving everyday life doesn't
(26:19):
show up oftentimes until womenhave children and are the
primary caretakers of children,because when you have children
in the household, suddenly thedemand of life gets
exponentially bigger.
Speaker 3 (26:32):
Oh yes, very overwhelming.
I have three at home and twoboys who are very well, I'd have
to say, one more restless thanthe other and for a long time.
I would ask, you know, hispediatrician teachers.
I've had him tested but youknow what's kind of come back is
just, this is his personality.
(26:53):
He's not diagnosed with ADHD,he's just has a.
You know he's an energetic,rambunctious young man.
He's 14 now and I'm hoping, ashe gets older, this, that
frontal lobe part of his brain,will keep developing and he'll
be able to sort of.
You know, relax a little bit.
Speaker 2 (27:12):
Well, so you're bringing up something very
interesting when you talk aboutfrontal lobe bit.
Well, so you're bringing upsomething very interesting when
you talk about frontal lobedominance, and that is that
there are two distinct kinds ofattention.
One kind of attention is calledautomatic attention, and in the
ADHD brain, automatic attentionis exceptionally strong.
People with ADHD tend to noticethings far more than most other
(27:35):
people with ADHD tend to noticethings far more than most other
people, so automatic attentionis very strong in the person
with ADHD.
Directed attention, however, isthe kind of attention you use
when you have to do somethingthat is of low interest, like
doing taxes or completing boringschoolwork.
(27:56):
Directed attention is the kindof attention that is quite
effortful.
You have to force yourself touse it.
Automatic attention is a kindof attention that is just there.
It's applied to things that areinteresting, and automatic
attention is attracted to anychange in the environment around
(28:18):
us.
So many times, some people haveextrapolated that the historical
significance of ADHD is thatwhen we all lived in
hunter-gatherer tribes, hunterswere the ones who had ADHD,
because their brains were thekind of brains that noticed
things that other people didn'tnotice, and subsequently they
(28:42):
were successful at hunting andproviding sustenance to people
in hunter-gatherer tribes.
The ice age, when peoplesettled down and lived on farms,
a different brain that couldsustain attention for a longer
period to watch plants grow orwait for seasons to change
(29:04):
became predominant.
So evolution selected for thatbrain, which would explain why
in some cultures there is alower incidence of ADHD and in
some there's a higher incidenceof ADHD.
Speaker 3 (29:21):
That's really interesting.
So let's talk a little bitabout medication and if there's
any side effects to those.
So can some ADHD medicationscause other symptoms or side
effects, like we've talked aboutdepression briefly, you know,
(29:42):
especially if children have beenon these medications for, you
know, most of theirdevelopmental years.
Speaker 2 (29:49):
So again I want to be clear that I do not practice
medicine and I don't givemedical advice, but I have
conducted clinical trials ofmedicine for about the past 30
years, so I'm fairly familiarwith how these medicines work.
And what medicine simply doesis provide greater access to
(30:11):
directed attention, and directedattention is moderated by
language.
For example, if you have to goto the store and get milk, eggs
and butter, you say to yourselfI'm going to get milk, eggs and
butter, and so you do that.
When you walk into the store,you are speaking to yourself or
(30:31):
using language to orientyourself to what it is that
you're there for.
So milk, eggs and butter, soyou can go down the aisles and
get milk, eggs and butter.
But let's say you happen towalk down the cookie aisle and
you see Oreos.
Oreos may attract yourattention, and so you get Oreos
too, which is not milk, eggs andbutter.
(30:53):
But language is what sets humanbeings apart in terms of their
managing themselves and theirdirecting their own behavior.
We use language to direct ourown behavior, and language is a
directed attention task.
Consider the tasks that areassigned in school.
(31:13):
The teacher says children, sitdown and do this worksheet.
Here's how you do the worksheetand then she reviews the
directions for the worksheet.
Those are language-directedbehaviors, and language-directed
behaviors are what aredifficult for a child or an
(31:35):
adult with ADHD to use.
So what occurs in the immediateenvironment, the attraction of
what's occurring around theperson, is often far more
powerful than the language thatwe're using to regulate or
self-regulate our own behavior.
Speaker 3 (31:52):
Mm-hmm.
Okay, so it seems that moreyoung people and I know this
just because I do have threeschool-age children are being
diagnosed with either an anxietydisorder or ADHD.
So is there a connectionbetween the two, adhd and
(32:12):
anxiety?
Speaker 2 (32:14):
So again, that's a very astute question.
That is, that people getanxious when they leave things
incomplete.
It's more obvious in adulthoodthat when an adult leaves
something incomplete, therealways is a reaction to it, and
incompletion is actually abroken agreement.
(32:35):
You said you were going to dosomething and you didn't do it.
That is the biggest problemthat adults with ADHD have.
Leaving something incomplete, abroken agreement, will always
result in anxiety or depressionof some kind.
Very few people can ignorebroken agreements and there may
(32:56):
be a variety of reactions tothat, but nevertheless, you
cannot ignore a broken agreement, and so people who leave things
incomplete consistently andsystematically often are anxious
and can get depressed as welldepressed as well.
Speaker 3 (33:20):
That's really interesting because my son last
year transferred schools in themiddle of high school and it was
a big you know change for him.
He went from being a you know astudent who had no problems and
you know, to trying to keep upwith all the school work and I
think it led to a little bit ofanxiety because he was he was
having you know, doing half aworksheet, trying to turn it in
and and you know new gradingscale and everything in the
(33:42):
school, yeah.
So, while it's reallyinteresting that you say that
and it kind of makes sense towhat he was, what was happening
in his life last year.
Speaker 2 (33:50):
Well, again, remember that school tasks are largely
farmer brain tasks and I'm notdiagnosing your son, of course.
Yeah yeah, people who have verysensitive attention that reacts
to things that occur aroundthem are going to do just that.
They're going to react to thethings that occur around them
(34:12):
rather than to the thing that'ssitting in front of them, that
they are directed via languageto do.
Speaker 3 (34:21):
Sounds like him.
Yeah, okay, so we talked againa little bit about the
medication.
But does the ADHD medication itallows the person to focus
better on the task at handcorrect usually?
Speaker 2 (34:36):
Yes.
So the American Academy ofPediatrics has as its gold
standard the use of thestimulants for treating ADHD.
All the stimulants do isimprove directed attention, so a
person can use languageeffectively to complete the
tasks that are extant in theirworld.
(34:57):
So pharmacotherapy is a veryeffective strategy for treating
ADHD because it improvesdirected attention.
Many kids, for example, whoseattention is automatically drawn
to things that are external tothem rather than to the
instructions that may be givento them, that they need to
(35:22):
repeat to themselves to puttheir behavior under the control
of those instructions.
Many times that cannot beavailable to a child, and what
medicine does in strengtheningdirected attention is allow the
child to use language orinstruction more effectively to
(35:43):
self-regulate.
That's, in essence, what itdoes.
Speaker 3 (35:50):
That's, in essence, what it does.
Okay, so, other than medication, are there any other say, like
at-home tips or steps that aperson or a child can do instead
of taking medication?
To kind of get that focus.
Speaker 2 (36:03):
Well, for example, we have at the Cleveland Clinic a
summer treatment program.
At the Cleveland Clinic, asummer treatment program the
summer treatment program isconsidered to be the best
behavioral program for kids withADHD that there is.
There is nothing better thanthe STP, and what the STP does
(36:25):
is to provide contingentacknowledgement of appropriate
behavior, and contingent thetechnical word is punishment,
but the contingent withdrawal ofreinforcement or withdrawal of
points for negative behavior.
(36:46):
And so by reinforcingappropriate behavior, you
strengthen the presence or theactivation of appropriate
behavior for children.
So many times we live in I mean,most of us live in this culture
, so this culture tends to be apunitive culture.
The cop doesn't stop you andgive you a $20 bill when you're
(37:12):
going the speed limit.
The cop stops you when you'renot going the speed limit or
going over the speed limit, andso you are punished for that.
So, as a result, we live in apunitive culture and we're so
subsequently accustomed topunishing the things that kids
(37:32):
do.
So a child will lose his iPadfor two or three days if he
doesn't do what his parents tellhim to do right now, and so
that kind of thing is notparticularly effective.
But when you also showappropriate behavior and that
appropriate behavior can resultin a positive consequence, then
(37:59):
appropriate behavior tends toconsistently improve over time,
which is what we find in thesummer treatment program,
treatment program.
So there absolutely arebehavioral programs and there
are a number of different parenttrainings and parent behavioral
programs that can be veryeffective.
Speaker 3 (38:18):
Okay, can people find any of this?
Maybe in a book, you know?
If they don't have maybe thetime or the resources to do, you
know, a professional treatment,is there anything at home that
parents can do?
Speaker 2 (38:31):
Well.
So we often recommend thatparents use the book One, two,
three Magic.
One, two, three Magic, we feelis probably the best way of
managing behavior in thehousehold that there is, and it
also indicates how to increasepositive behavior and increase
(38:53):
compliance at home, butessentially for teenagers also,
there's a 123 Magic for Teensthat incorporates and includes
the teenager in the managementof behavior in the household,
which is very important for ateenager's autonomy.
Speaker 3 (39:14):
Yeah, absolutely.
That's great.
I'm going to look into thatbook myself, because my second
follow-up question was you know,is it too late after maybe they
hit a certain age?
Speaker 2 (39:24):
But you know.
So if there's a teenage version, that's great.
I think that'd be reallyhelpful the kinds of things that
(39:46):
they may do and revise how theydo things in the household to
avoid having to rely on directedattention.
So putting things in thephysical environment, like a
shared to-do list, for example,can be a helpful thing.
Now, to-do lists don't getsomething done.
(40:09):
To-do lists only indicate whatneeds to get done.
It's the action towards thetask that gets the task done.
So adults themselves can usebehavioral strategies to improve
the concerns that they have forthemselves.
Speaker 3 (40:38):
Right, I love that shared to-do list and I think
that'd be really helpful for alot of households, even if you
are empty nester and your kidsare grown or you don't have
children.
But I mean, I feel like,speaking as a woman, we take on
we tend to take on a little bitmore around the house and work
and maybe are raising childrenor helping with grandchildren
and it can get overwhelming andI know probably a lot of
(41:00):
arguments are why am I the onealways cleaning the bathroom or
vacuuming or going to thegrocery store?
So I think that's a reallyhelpful tip.
Speaker 2 (41:08):
I'm going to start that.
The bad question to ask is whyam I always the one?
Speaker 3 (41:13):
Yeah, I mean, yeah, it's very common, it is.
Speaker 2 (41:16):
It's useful to come to agreements and to agree that
you are going to completeagreements, that you're going to
adhere to them and bringintegrity to the agreements,
because an agreement not keptcan be a true source of problems
itself, right.
(41:37):
So if you are going to agree tomake agreements and to keep
your agreements, then keepingagreements becomes the sole
source of planning between twopeople.
Speaker 3 (41:50):
Yeah, that's great.
So we talked about thenon-stimulant treatments and so
that's really helpful.
I wanted to follow up a littlebit on the medicine, really
quick on does, and I'm thinkingthis more specifically well, not
just for children, because somany adults have issues, you
know, falling asleep.
But do you need to take themedicine while you're sleeping,
(42:13):
or is it better for that drug tomaybe be taken early in the
morning, so then it's out ofyour system by the time you're
trying to fall asleep at night?
Speaker 2 (42:20):
It should always be taken early in the morning,
according to physicians, becausethe stimulants are in the
system for between six and 13hours and then they're out of
the system, so when a personsleeps and they can interfere
with sleep even if they're outof the system.
So it's important to usemedicine in an appropriate way
(42:44):
and follow the doctor's orderswhen they're taken.
The immediate releasestimulants last between three
and four hours.
The extended release stimulantscan last between six and 13
hours.
Speaker 3 (42:59):
Wow.
Do you think the screen timeuse in young people and adults
is bad for the brain or thatbrains need more directed
attention because our screen useis disrupting that in some way?
Speaker 2 (43:18):
So saying something is bad for the brain is going a
little bit too far for me tocomment on, but I do not think
screen time is helpful to aperson with ADHD.
But I do not think screen timeis helpful to a person with ADHD
, and the simple reason is thatscreen time activates automatic
(43:44):
attention.
It's interesting sorts of otheractivities that are in the
corner of the screen or not.
You know they attract yourattention.
Screen time activates automaticattention, and you know as well
as I do that all of ourattention cannot be activated
(44:10):
solely by something that'sinteresting, and in fact, much
of what we do in fact most ofwhat we do during the day is
simply not interesting, and sothe brain has to get, or the
brain can get accustomed todoing directed attention tasks.
(44:30):
If the brain gets accustomed toonly being activated by
interesting things, which iswhat screen time does, then that
is a very difficult thing toovercome, and in fact, many of
the screens that kids areaccessing these days have built
into them something that showsup as interesting every 30
(44:51):
seconds, and when the brain isactivated by something every 30
seconds, a person begins toexpect that that's the way it's
supposed to be.
And so if the mom says, go scrubthe toilet right now, and
there's nothing interestingabout scrubbing a toilet
whatsoever, and there's nothinginteresting about scrubbing a
(45:11):
toilet whatsoever.
So having to go do that taskbecomes it's like being in a
desert and there's nothing therethat can be activating and even
the threat of a punishment ifyou don't do it is not
activating enough to make aperson do it.
(45:31):
So screen time gets childrenused to having automatic
attention constantly activated,as if that's what's supposed to
be.
And yes, it would be ideal ifeverything was interesting all
the time, but it's never goingto be interesting all the time,
at least not in the world thatwe live in right now.
Yeah, so I discourage unmanagedscreen time as strongly as I
(46:01):
can discourage it in that theAmerican Academy of Pediatrics
says by age six, an hour ofscreen time a day is the maximum
.
And then, as you go up intoadolescence, screen time becomes
much more difficult to manage.
But there still should belimits to screen time.
Speaker 3 (46:26):
Absolutely.
I mean it's difficult, but Iwholeheartedly agree with you.
I mean we've tried to kind of,you know, not give those phones.
We've never even actually hadan iPad in our house, so but as
long as we could get away withit, you know so because and now
I just they're just I'm talkingto them and they're on their
phones and I'm like, put it downand look me in the eyes because
(46:47):
you're not focusing on me.
Number one, don't tell me youare, because I don't believe you
.
Speaker 2 (46:56):
Well, and even when you look at being an adult
situation, like if you go out todinner at a restaurant, if you
look at tables of individualstwo individuals sitting with
each other, both- of them ontheir phones two individuals
sitting with each other, both ofthem on their phones.
Screen time is becoming trulyintrusive into our modern world,
(47:21):
and I, for one, just find itreally difficult to accept.
Speaker 3 (47:22):
I agree, I mean you're so right.
I mean I don't get to go out toeat too often, but when I do, I
can't believe how many peopleare just sitting there on their
phones together rather thantalking.
You know, it's it.
Culture's really changed in thelast you know decade.
Speaker 2 (47:36):
My dear, my own dear wife gets mad at me because I
don't answer her when she callson my cell phone, and she's used
to it by now though, so so it'snot that much of a problem, and
she knows how to reach me ifshe needs to.
So, at any rate, screen time isa major problem today.
Speaker 3 (47:56):
Yeah, I agree.
Well, I don't want to keep youtoo much longer.
We're wrapping up here.
I guess my last question wouldbe, if there's I know this is
going to be a big one but anyconnection to the COVID-19
pandemic and that impact on thechildren's brains who were, and
(48:17):
adults who were, forced to workfrom home or stay home, maybe
spending a lot of time onscreens or, you know, working
virtually, children virtuallyduring school.
Do you think that's anyconnection to increases in ADHD
and, you know, these otherlearning disorders?
Speaker 2 (48:39):
So I've not read any active research that took the
COVID infection as beingindicative or intrusive in
people with ADHD, other thanthat, when kids were at home,
they have more access to screensand their brains are more
(49:02):
accustomed to doing what'sentertaining to them as opposed
to doing what is required ofthem.
That certainly is a possibility, but as far as COVID is
concerned, regarding impactingADHD directly, I don't know of
evidence that indicates that.
Speaker 3 (49:21):
I mean I just know I can say I definitely in my older
children.
Just, you know, doing schoolonline for a year did not help
them with their grades oranything like that.
So I know we've seen it.
I mean, that's just my personalopinion, so I'm sure other
parents you know as well.
Yeah, but are there any otherfinal thoughts before we wrap up
(49:44):
our interview that you'd liketo share with our audience?
Speaker 2 (49:49):
Well, I think the final thing that I would really
like to say is that a person mayhave ADHD, that does not mean
that their life is limited inany way, and, in fact, many very
successful people have ADHD andwould be diagnosable ADHD.
I mean, if you consider peoplewho are on television or screen,
(50:12):
there are many people who arevery high energy and who would,
some who have admitted and beendiagnosed that they have had
ADHD or are diagnosed with ADHD,and there are many, many people
with ADHD who are highlysuccessful.
There are many, many peoplewith ADHD who are highly
successful.
And so I'll just give you aperfect example.
(50:34):
When I married my dear wife, shehad a little three-year-old boy
named Michael.
Michael was the mosthyperactive child you have ever
seen in your life, and at thetime I was working at the
University of Hawaii and Melissaand I lived in Hawaii and
Michael would do anything if wetook him to the airport on a
(50:55):
Saturday so he could lay in thegrass by one of the biggest
runways and feel those planesland.
So I set up a marble system forhim where he earned marbles for
appropriate behavior, and whenhe cashed those marbles in, the
thing that he invariably wantedto do was to go to the airport
on a Saturday, and if you'reliving in Hawaii, why do you
(51:17):
want to go to the airport?
Speaker 1 (51:18):
on Saturday.
Speaker 2 (51:20):
But we took him to the airport on Saturday and he
lay in the grass and could feelthose huge 747s landing.
And Michael is 39 years old now.
What do you think he does?
Speaker 3 (51:30):
for a living.
I see a pilot.
Speaker 2 (51:32):
Oh my gosh, he's a pilot.
He flew for Pacific Northwest.
It was a freight company andthey transferred freight from
Guam to the United States and toHawaii.
And one time he was flying oneof those big planes and he was
(51:53):
landing in Guam and the frontlanding gear did not descend,
and so he had to fly around fora while and get rid of some of
the fuel, and then he landedthat plane.
It stayed exactly in the middleof the runway.
Nobody was hurt, nothing wasdamaged.
He told me that when he landedthat plane, he was so
(52:14):
hyper-focused on the instrumentpanel that nothing else got in,
and so people with ADHD canperform exceptionally well in
circumstances that many of uswould consider pretty concerning
.
Speaker 3 (52:31):
Yeah overwhelming for sure.
That's a great story.
I actually also did the marblejar with my three children a
rewarding system.
Speaker 2 (52:39):
I did.
Speaker 3 (52:40):
I think I probably found it online and they could
earn something, and a lot oftimes it would be like can we go
to the zoo on the weekend orsomething fun, rather than maybe
a toy.
So I agree with that.
Well, thank you, dr Manos, forjoining us on the Speaking of
Women's Health podcast again,and thank you to our listeners
for tuning in to another episode.
(53:01):
We're so grateful for yoursupport and hope you will
consider supporting the podcastand sharing it with others.
And to catch all the latestfrom the Speaking of Women's
Health podcast, you cansubscribe for free on Apple
Podcasts, spotify TuneIn orwherever you listen to podcasts.
So thank you again and we willsee you next time in the
(53:22):
Sunflower House.
Be strong, be healthy, be incharge.
Welcome to the Speaking of Women's Health
podcast.
I'm your host, dr Holly Thacker, and I'm back in the Sunflower
House for a new episode with aguest, dr Michael Manos.
He is a PhD and he is an expertin ADHD attention deficit
(00:31):
hyperactivity disorder.
Dr Manos is the former head ofthe Center for Pediatric
Behavioral Health in theChildren's Hospital at Cleveland
Clinic and he is the foundingclinical and program director of
Pediatric and Adult ADHD Centerfor Evaluation and Treatment.
(00:53):
And Dr Manos is adjunct facultyat Case Western Reserve
University College of MedicineDepartment of Psychiatry
University College of MedicineDepartment of Psychiatry and
he's an associate professor atthe Cleveland Clinic Lerner
College of Medicine and he's gotspecial interest and expertise
(01:14):
in both children and adults withADHD, behavioral pediatrics,
clinical behavioral pediatrics,family management, as well as
pharmacotherapy research, and hehas written and presented
several hundred scientificallybased papers on ADHD.
(01:34):
Welcome, dr Manos.
Speaker 2 (01:38):
Hi, Dr Thacker.
Thank you for the invitation tobe here.
Speaker 1 (01:41):
Well, it is wonderful to have you to be here.
Well, it is wonderful to haveyou.
As our Sunflower Houselisteners know, my major area of
expertise is in midlife women'shealth and menopause and
hormones, and I have a lot ofwomen come to me for inattention
and brain fog, and sometimesthat is menopause.
(02:02):
Sometimes they have newdiagnoses of ADHD themselves or
they think they may have itafter their children or
teenagers are diagnosed with it.
So can you tell our listenerswhat is ADHD and what causes it?
Speaker 2 (02:16):
So ADHD is a genetic condition and so it's handed
from parent to child and ittends to occur certainly in
families.
So ADHD is a distinctdifference in two kinds of
(02:42):
attention in the brain.
So I do want to emphasize thatfor many people ADHD is not a
disorder.
It's not like a, a viralinfection where there is
something wrong with anindividual.
It's actually a difference inhow the brain functions.
And because it is a geneticcondition, it certainly doesn't
(03:09):
have necessarily a cause, otherthan if you consider some
individuals, such asevolutionary, who consider that
ADHD has been selected forthrough natural selection and
(03:30):
evolution.
Speaker 1 (03:32):
Fascinating.
Why is that?
Speaker 2 (03:35):
Yeah, that's actually the question, and what's
interesting is that, because thebrain is adapted to the
environment through naturalselection, when all of us lived
in a very dangerous world, aworld where hunter-gatherer
(03:56):
tribes were necessary in orderto enhance survival, hunters
were the ones who could bediagnosed with ADHD, because
their brains were highly attunedto the external world and they
were highly reactive to theexternal world, and so just by
their ability to recognizedanger and adapt to danger, they
(04:20):
kept people alive, so evolutionselected for it.
They kept people alive, soevolution selected for it.
What's also interesting is thatfollowing the ice age, people
lived on farms and now a brainthat could wait a long time for
something to happen, likeseasons changing or plants
growing.
Now a different brain wasselected for in evolution.
(04:44):
Now a different brain wasselected for in evolution, so
farmer brains became moreprevalent.
And if you consider many of theadult tasks in our world today,
where things are relativelysafe, that the farmer brain
largely is the brain that reactsbetter to, say, school tasks or
(05:08):
work tasks, as opposed to theADHD brain, which largely reacts
to incurring stimuli.
Speaker 1 (05:21):
You know it's interesting that you talk about
the school brain.
You know it's interesting thatyou talk about the school brain.
I'm the mother of three sonsand I noticed early on,
especially when I wouldvolunteer in schools, that it
seemed like schools were betterset up for girls.
And of course I'm a femalemyself.
But even I felt like I had moreof that male brain and wanting
to move from task to task or behands-on or be more physically
(05:44):
active instead of sit quietlyand write neatly.
Are there gender differenceswith ADHD, and is the school
environment not as good forsomeone who's more wired to be
sensitive to all the stimuli?
Speaker 2 (06:00):
Well, if you ask most kids, do they like doing school
tasks?
They're going to tell you no,they don't.
So school tasks themselvescertainly may have something
inherent in them that make thema little less invigorating.
So girls with ADHD arediagnosed less than boys with
(06:21):
ADHD, by a factor of about threeto one three boys to one girl
than boys with ADHD by a factorof about three to one three boys
to one girl.
And ADHD in girls is a littlemore difficult to recognize
because there are expectations,societal expectations that apply
to child behavior, that areallowed more grace in girls, for
(06:49):
example, so what things areallowed more grace in girls.
Well, boys are highly recognizedbecause of their overactive
behavior.
A girl with ADHD who hasoveractive behavior may be
considered just more social, orthey may be considered just more
talkative, as opposed to a boy,who may be more aggressive and
(07:15):
more intrusive in schoolactivities.
So the ratio of boys to girlstends to be three to one, and
girls also tend to have societalexpectations that preclude a
(07:40):
diagnosis of ADHD, and so thereis a very interesting statistic
that, by a factor of about threeto one, girls and women are
provided with antidepressants oranxiolytics before they're
provided treatment for ADHD,whereas boys it's the opposite.
Speaker 1 (08:03):
Now, is that because girls are being underdiagnosed,
or are boys being overdiagnosed,or are there sex hormonal
differences in the brain thataffect the expression of the
symptoms of ADHD?
Speaker 2 (08:16):
No, it's not a question of being over or
underdiagnosed, or over andunder or undertreated or
mistreated, and or over andunder or under treated or
mistreated.
The paper that we publish inthe Cleveland Clinic Journal of
Medicine has been very wellreceived, actually worldwide,
and it's very interestingbecause we address that very
(08:38):
question overdiagnose and overtreated or misdiagnose and
mistreated.
Boys tend to be more easilyrecognized, especially in
childhood, because of theirhyperactive and impulsive
behavior, whereas girls'behavior is generally excused or
allowed to be there.
(08:59):
It's not necessarily recognizedas being problematic, and girls
tend also to internalize.
When they accrue negativeattention for, say, being
distracted in school, they tendto make themselves wrong or they
tend to be critical of theirown behavior and of themselves,
(09:22):
as opposed to boys, who may bemore accustomed to acting out or
being more aggressive.
Speaker 1 (09:35):
And maybe we should back up a little bit and you can
tell us the common symptoms ofADHD, as opposed to some people
are just telling me they onlyhave ADD, they're not really
hyperactive, and how wouldsomeone know if they have this
condition or how?
Speaker 2 (09:59):
would a parent know if his or her child or
grandchild has ADHD?
Or four diagnoses for ADHD ADHDinattentive type, adhd
hyperactive, impulsive type,adhd combined type, which is
both of those.
Then there is a third kind ofADHD called unspecified type,
(10:20):
and I've used it only veryrarely with people who do show
intruding symptoms in theirlives and their lives are
actually impacted by thesesymptoms, but they don't
necessarily meet full symptomcriteria.
In a child, we're looking forat least six of nine behaviors
(10:40):
that are associated withinattention and or six of nine
behaviors associated withhyperactivity impulsivity.
It's either one of thosecategories that there needs to
be a clustering of at least sixsymptoms.
In an adult, we're looking fora clustering in either one or
(11:01):
both categories, of at leastfive symptoms.
Speaker 1 (11:05):
And what are those classic symptoms?
Speaker 2 (11:09):
Inattention, distractibility, disorganization
, starting tasks and notfinishing them, leaving tasks
incomplete.
The biggest problem that peoplewith ADHD have is this notion
of incompletion.
Somebody says they're going todo something and they do not do
(11:30):
it.
They leave the task incomplete.
This is, of course, veryobvious in childhood, where
children are expected tocomplete schoolwork and finish
it and turn it in the next day,complete an entire test.
So children have tasks thatthey are assigned by adults and
(11:51):
typically there is what occursin childhood.
Social scaffolding is veryprominent, so you have parents
and teachers who are keepingtrack of the child's ongoing
performance in school andsubsequently, that ongoing
performance is monitoredcontinually.
When you are an adult, thingschange and adults are expected
(12:16):
to be self-responsible and theyare expected to identify the
task and complete the task.
They're not expected to bereliant on social scaffolding,
on parents or others to tellthem what to do.
However, that certainly isbuilt into certain occupations.
(12:39):
If you're at the executive of acompany, then certainly you
have people around you who willallow you or assist you to
structure the day and to do thetasks that need to get done, but
in childhood that's not alwaysavailable, unless you have a
very loving parent.
Speaker 1 (12:58):
Wow.
And so how would a parent knowif their child has it?
If they're just concerned aboutthe symptoms, would a general
pediatrician be the one to makethe diagnosis?
You know one thing I just feellike I just see at least
children like of my grandparents, my grandchildren's age.
(13:19):
It just seems like they're moremedicalized than like maybe my
kids were, and they seem to bemore medicalized than like maybe
my kids were, and they seem tobe more medicalized than like I
was as a child.
So I don't know if it's justwe're better at diagnoses or are
we just less tolerant ofcertain behaviors, being a
scatterbrained or a silly heador, you know, just being a child
(13:39):
?
Speaker 2 (13:40):
Well, I think that we have given a name to a body of
behaviors that, when theycluster, they interfere with a
child's life.
They interfere with the child'sresponsibilities at home and in
school and they certainlyinterfere with an adult's
responsibilities unless there isa very notable scaffolding.
(14:04):
But adults also learn all kindsof new behaviors in order to
manage the behaviors that areproblematic in ADHD.
Speaker 1 (14:14):
So I'm not quite sure if I'm answering your question
properly, but nevertheless so doyou think we're just better at
diagnosing it, or do you thinkthat maybe older parents and
overworked teachers are lessable to support the child?
I mean, do you think there issome over diagnosis of of this,
(14:34):
or do you think there's actuallyunder diagnosis and not enough,
not enough treatment or enoughpeople that specialize in this,
or is it regionally?
Speaker 2 (14:43):
dependent, right understood, and I don't think we
are over diagnosing by anymeans, and I think actually that
we are under diagnosing andbecause of that, many kids, and
girls especially, areexperiencing failure where they
don't need to experience failure.
(15:04):
They are more interested inwatching the squirrel climbing
the tree than they are in doingthe math homework or finishing
their test in school, and sothey are considered to be
scatterbrained or they'reconsidered to be frivolous and
they, they really don't care.
Sometimes we even call kidslazy, and that is one of the
(15:29):
most absurd descriptions of achild.
I have never, ever, met a lazychild ever, and there is a lot
of avoidance.
There are certain tasks thatchildren will avoid and adults
will avoid.
However, that doesn't mean thatthey're lazy.
(15:50):
So I think that the realconcern here with ADHD is what
is it that is the cause of, orthe instigating factor that
leaves a task incomplete?
Speaker 1 (16:12):
We are listening to Dr Michael Manos, a PhD and
expert in child and adult ADHD,in the Speaking of Women's
Health podcast, and I'm yourhost, dr Holly Thacker, and
we're talking about behaviorsthat can indicate a condition
(16:32):
which is treatable, and thesuffering and the problems and
the misunderstandings that cango along with it.
Speaker 3 (16:40):
Hello, you just listened to part one of this
podcast episode on ADHD with ourguest Dr Michael Manos of the
Cleveland Clinic.
In the original recording ofthis podcast interview, dr
Thacker interviewed Dr Manosentirely.
However, we had a bit of atechnical glitch in the second
half where it did not record thesecond part of the interview.
(17:04):
So I will be hosting thisre-recording of the second part
of the podcast episode with DrManos.
My name is Leigh Klecker and Iam the producer of the Speaking
of Women's Health podcast.
I am the producer of theSpeaking of Women's Health
podcast.
So first thank you, dr Manos,for taking time in your busy
schedule to re-record this partof the podcast episode, and we
(17:24):
did hear a lot of importantinformation in the first part
with Dr Thacker.
But I'd like to start thisportion of the interview
discussing academics and theconnection to performance in
school and ADHD.
So, generally speaking, do mostchildren with ADHD not perform
(17:45):
as well in school?
Speaker 2 (17:47):
So that's a very good question.
To perform well in schoolrequires certain fundamental
behaviors that often are notavailable to a child with ADHD.
So, for example, staying inseat, sitting still and paying
attention to one source ofinformation, like the teacher,
(18:08):
is a fundamental part of beingsuccessful in school.
So many children with ADHD,whether they are of the
inattentive type or hyperactiveimpulsive type, tend to have
difficulty staying seated andbeing able to attend to one
(18:31):
voice source, for example, likethe teacher, and so children
often miss things in school.
And on top of that, let's say,there is silent work being done,
like a worksheet a child is tocomplete at the desk.
Worksheets are often veryunstimulating and not very
(18:53):
activating to attention not veryactivating to attention so
children tend to get distractedor drawn away from tasks much
more easily than when you haveADHD, than a child who does not
have ADHD.
Speaker 3 (19:08):
Okay.
Speaker 2 (19:09):
So ADHD can clearly interfere with functioning in
school.
Speaker 3 (19:14):
Mm-hmm.
And if someone is doing well inschool and getting good grades,
does that usually eliminate thefact that they have ADHD?
Speaker 2 (19:25):
No, in fact, that's very insightful of you to ask,
because people with ADHD, whohave higher IQs or manage
information much moreeffectively, can pay attention
for perhaps a quarter of thetime that another student must
pay attention to for the wholetime.
So many kids who are brighttend to perform quite well in
(19:48):
school and in fact do quite welleven through high school.
So they breeze through schooland get good grade point
averages.
Then they go on to college andrealize that the workload in
college is far more demandingthan the workload in school, so
(20:08):
subsequently they begin torequire more assistance in
completing the schoolwork thatbefore came so easily to them.
So just performing poorly inschool is not an indicator of
ADHD at all.
Speaker 3 (20:25):
Okay, okay, so well then, how do clinicians test for
ADHD?
Speaker 2 (20:33):
There is really only one way of knowing whether ADHD
is present, and that is doing aconcerted, semi-structured
interview related to thedescription of behavior.
What does the child do?
So?
For example, in our office,this conversation takes anywhere
(20:54):
from 40 minutes to an hour anda half, depending on what's
occurring for the child.
So one asks how does the childbehave at home and how does the
teacher report the child behavesat school?
It's important to address thiskind of functioning across
settings home, social network.
(21:16):
Has there been trauma in thechild's history?
Is there difficulty in school?
And so asking about behavioracross settings is very
important to do.
Speaker 3 (21:33):
And while you're doing that testing, is it
usually with the parent inperson, the child in person and
maybe someone like you mentioned, either a teacher or another
person in their relationship orsocial world, or is it just with
the child?
Speaker 2 (21:52):
No, it should never just be with the child and in
fact it's best to begin theinterview with a parent, and we
always do testing here and inthat testing.
The examiner is the one whodoes the interview with the
child.
But a detailed, systematicinquiry as to the child's
(22:15):
behavior in multiple settings iscritical.
And who knows the child bestbut parents and teacher?
Right Now we typically do notdirectly interview teachers, but
we get teacher input by askingthem to complete several
different rating scales scales.
Speaker 3 (22:43):
Okay, okay, so what is the prevalence?
Speaker 2 (22:44):
of ADHD here in these states compared to the rest of
the world.
So there are a variety ofdifferent estimates of
prevalence, and in the UnitedStates the childhood prevalence
is considered to be about 11%.
Worldwide prevalence of ADHD israted from 4.7 to 7.2%, so
(23:06):
there are very, very many peoplewith ADHD children and adults.
Speaker 3 (23:12):
So why do you think that here in the US the
percentage is higher compared tothe rest of the world?
Speaker 2 (23:21):
That's a very good question, and I know some people
have cracked jokes about itthat what attracted people to an
unknown territory like theUnited States from the very
beginning was that they had thatrestlessness associated with
ADHD.
So they came to the US.
Now some people think that it'skind of funny to also joke that
(23:48):
Australia has a very highprevalence of people with ADHD
because Great Britain sent allof their criminals to Australia.
Now I don't know if that'ssomething you want to say in
there, but nevertheless it's aninteresting anecdote that people
bring up.
Yeah, why the prevalence ofADHD in the United States is so
(24:12):
high?
I don't know of anybody who'sgiven a satisfactory explanation
other than that somehow it's inour gene pool.
Speaker 3 (24:24):
Interesting.
So can the condition, the ADHD.
Can it be correctable,manageable, Is it lifelong?
Does the brain sort of developand help people maybe outgrow it
later in their life?
Speaker 2 (24:39):
ADHD does not go away and people do not outgrow it.
So when I was in graduateschool, we were always told that
adults don't get ADHD and thatit's a childhood condition.
But that's absolutely not thecase.
What happens is that over time,hyperactive and impulsive
(25:00):
behavior tend to tone themselvesdown or to be less observable.
But inattention does not goaway and many times people
experience comorbidity likedepression or anxiety
comorbidity like depression oranxiety.
So ADHD is a lifelong conditionand doesn't go away.
Speaker 3 (25:23):
Huh, well, I know just from working with Dr
Thacker for such a long time.
You know we have.
She has noticed and I've heardfrom you know, in our meetings,
that more and more women arecoming in and getting a ADHD
diagnosis, even, you know, up tomidlife.
So maybe back when you know,when they were younger or you
(25:45):
know, as you mentioned, you know, during their younger school
age they didn't really notice it.
They did well in school andthen as they've gotten older,
you know it's sort of now becomemore of an issue for them in
their adult life.
Speaker 2 (25:57):
So my wife is very fond of telling me that women
are smarter than men anyway.
So that's why?
So women being smarter tend tofind it easier I shouldn't say
easier they tend to be moresuccessful in getting through
school and subsequently, thedetriment of ADHD.
The problem that it poses inliving everyday life doesn't
(26:19):
show up oftentimes until womenhave children and are the
primary caretakers of children,because when you have children
in the household, suddenly thedemand of life gets
exponentially bigger.
Speaker 3 (26:32):
Oh yes, very overwhelming.
I have three at home and twoboys who are very well, I'd have
to say, one more restless thanthe other and for a long time.
I would ask, you know, hispediatrician teachers.
I've had him tested but youknow what's kind of come back is
just, this is his personality.
(26:53):
He's not diagnosed with ADHD,he's just has a.
You know he's an energetic,rambunctious young man.
He's 14 now and I'm hoping, ashe gets older, this, that
frontal lobe part of his brain,will keep developing and he'll
be able to sort of.
You know, relax a little bit.
Speaker 2 (27:12):
Well, so you're bringing up something very
interesting when you talk aboutfrontal lobe bit.
Well, so you're bringing upsomething very interesting when
you talk about frontal lobedominance, and that is that
there are two distinct kinds ofattention.
One kind of attention is calledautomatic attention, and in the
ADHD brain, automatic attentionis exceptionally strong.
People with ADHD tend to noticethings far more than most other
(27:35):
people with ADHD tend to noticethings far more than most other
people, so automatic attentionis very strong in the person
with ADHD.
Directed attention, however, isthe kind of attention you use
when you have to do somethingthat is of low interest, like
doing taxes or completing boringschoolwork.
(27:56):
Directed attention is the kindof attention that is quite
effortful.
You have to force yourself touse it.
Automatic attention is a kindof attention that is just there.
It's applied to things that areinteresting, and automatic
attention is attracted to anychange in the environment around
(28:18):
us.
So many times, some people haveextrapolated that the historical
significance of ADHD is thatwhen we all lived in
hunter-gatherer tribes, hunterswere the ones who had ADHD,
because their brains were thekind of brains that noticed
things that other people didn'tnotice, and subsequently they
(28:42):
were successful at hunting andproviding sustenance to people
in hunter-gatherer tribes.
The ice age, when peoplesettled down and lived on farms,
a different brain that couldsustain attention for a longer
period to watch plants grow orwait for seasons to change
(29:04):
became predominant.
So evolution selected for thatbrain, which would explain why
in some cultures there is alower incidence of ADHD and in
some there's a higher incidenceof ADHD.
Speaker 3 (29:21):
That's really interesting.
So let's talk a little bitabout medication and if there's
any side effects to those.
So can some ADHD medicationscause other symptoms or side
effects, like we've talked aboutdepression briefly, you know,
(29:42):
especially if children have beenon these medications for, you
know, most of theirdevelopmental years.
Speaker 2 (29:49):
So again I want to be clear that I do not practice
medicine and I don't givemedical advice, but I have
conducted clinical trials ofmedicine for about the past 30
years, so I'm fairly familiarwith how these medicines work.
And what medicine simply doesis provide greater access to
(30:11):
directed attention, and directedattention is moderated by
language.
For example, if you have to goto the store and get milk, eggs
and butter, you say to yourselfI'm going to get milk, eggs and
butter, and so you do that.
When you walk into the store,you are speaking to yourself or
(30:31):
using language to orientyourself to what it is that
you're there for.
So milk, eggs and butter, soyou can go down the aisles and
get milk, eggs and butter.
But let's say you happen towalk down the cookie aisle and
you see Oreos.
Oreos may attract yourattention, and so you get Oreos
too, which is not milk, eggs andbutter.
(30:53):
But language is what sets humanbeings apart in terms of their
managing themselves and theirdirecting their own behavior.
We use language to direct ourown behavior, and language is a
directed attention task.
Consider the tasks that areassigned in school.
(31:13):
The teacher says children, sitdown and do this worksheet.
Here's how you do the worksheetand then she reviews the
directions for the worksheet.
Those are language-directedbehaviors, and language-directed
behaviors are what aredifficult for a child or an
(31:35):
adult with ADHD to use.
So what occurs in the immediateenvironment, the attraction of
what's occurring around theperson, is often far more
powerful than the language thatwe're using to regulate or
self-regulate our own behavior.
Speaker 3 (31:52):
Mm-hmm.
Okay, so it seems that moreyoung people and I know this
just because I do have threeschool-age children are being
diagnosed with either an anxietydisorder or ADHD.
So is there a connectionbetween the two, adhd and
(32:12):
anxiety?
Speaker 2 (32:14):
So again, that's a very astute question.
That is, that people getanxious when they leave things
incomplete.
It's more obvious in adulthoodthat when an adult leaves
something incomplete, therealways is a reaction to it, and
incompletion is actually abroken agreement.
(32:35):
You said you were going to dosomething and you didn't do it.
That is the biggest problemthat adults with ADHD have.
Leaving something incomplete, abroken agreement, will always
result in anxiety or depressionof some kind.
Very few people can ignorebroken agreements and there may
(32:56):
be a variety of reactions tothat, but nevertheless, you
cannot ignore a broken agreement, and so people who leave things
incomplete consistently andsystematically often are anxious
and can get depressed as welldepressed as well.
Speaker 3 (33:20):
That's really interesting because my son last
year transferred schools in themiddle of high school and it was
a big you know change for him.
He went from being a you know astudent who had no problems and
you know, to trying to keep upwith all the school work and I
think it led to a little bit ofanxiety because he was he was
having you know, doing half aworksheet, trying to turn it in
and and you know new gradingscale and everything in the
(33:42):
school, yeah.
So, while it's reallyinteresting that you say that
and it kind of makes sense towhat he was, what was happening
in his life last year.
Speaker 2 (33:50):
Well, again, remember that school tasks are largely
farmer brain tasks and I'm notdiagnosing your son, of course.
Yeah yeah, people who have verysensitive attention that reacts
to things that occur aroundthem are going to do just that.
They're going to react to thethings that occur around them
(34:12):
rather than to the thing that'ssitting in front of them, that
they are directed via languageto do.
Speaker 3 (34:21):
Sounds like him.
Yeah, okay, so we talked againa little bit about the
medication.
But does the ADHD medication itallows the person to focus
better on the task at handcorrect usually?
Speaker 2 (34:36):
Yes.
So the American Academy ofPediatrics has as its gold
standard the use of thestimulants for treating ADHD.
All the stimulants do isimprove directed attention, so a
person can use languageeffectively to complete the
tasks that are extant in theirworld.
(34:57):
So pharmacotherapy is a veryeffective strategy for treating
ADHD because it improvesdirected attention.
Many kids, for example, whoseattention is automatically drawn
to things that are external tothem rather than to the
instructions that may be givento them, that they need to
(35:22):
repeat to themselves to puttheir behavior under the control
of those instructions.
Many times that cannot beavailable to a child, and what
medicine does in strengtheningdirected attention is allow the
child to use language orinstruction more effectively to
(35:43):
self-regulate.
That's, in essence, what itdoes.
Speaker 3 (35:50):
That's, in essence, what it does.
Okay, so, other than medication, are there any other say, like
at-home tips or steps that aperson or a child can do instead
of taking medication?
To kind of get that focus.
Speaker 2 (36:03):
Well, for example, we have at the Cleveland Clinic a
summer treatment program.
At the Cleveland Clinic, asummer treatment program the
summer treatment program isconsidered to be the best
behavioral program for kids withADHD that there is.
There is nothing better thanthe STP, and what the STP does
(36:25):
is to provide contingentacknowledgement of appropriate
behavior, and contingent thetechnical word is punishment,
but the contingent withdrawal ofreinforcement or withdrawal of
points for negative behavior.
(36:46):
And so by reinforcingappropriate behavior, you
strengthen the presence or theactivation of appropriate
behavior for children.
So many times we live in I mean,most of us live in this culture
, so this culture tends to be apunitive culture.
The cop doesn't stop you andgive you a $20 bill when you're
(37:12):
going the speed limit.
The cop stops you when you'renot going the speed limit or
going over the speed limit, andso you are punished for that.
So, as a result, we live in apunitive culture and we're so
subsequently accustomed topunishing the things that kids
(37:32):
do.
So a child will lose his iPadfor two or three days if he
doesn't do what his parents tellhim to do right now, and so
that kind of thing is notparticularly effective.
But when you also showappropriate behavior and that
appropriate behavior can resultin a positive consequence, then
(37:59):
appropriate behavior tends toconsistently improve over time,
which is what we find in thesummer treatment program,
treatment program.
So there absolutely arebehavioral programs and there
are a number of different parenttrainings and parent behavioral
programs that can be veryeffective.
Speaker 3 (38:18):
Okay, can people find any of this?
Maybe in a book, you know?
If they don't have maybe thetime or the resources to do, you
know, a professional treatment,is there anything at home that
parents can do?
Speaker 2 (38:31):
Well.
So we often recommend thatparents use the book One, two,
three Magic.
One, two, three Magic, we feelis probably the best way of
managing behavior in thehousehold that there is, and it
also indicates how to increasepositive behavior and increase
(38:53):
compliance at home, butessentially for teenagers also,
there's a 123 Magic for Teensthat incorporates and includes
the teenager in the managementof behavior in the household,
which is very important for ateenager's autonomy.
Speaker 3 (39:14):
Yeah, absolutely.
That's great.
I'm going to look into thatbook myself, because my second
follow-up question was you know,is it too late after maybe they
hit a certain age?
Speaker 2 (39:24):
But you know.
So if there's a teenage version, that's great.
I think that'd be reallyhelpful the kinds of things that
(39:46):
they may do and revise how theydo things in the household to
avoid having to rely on directedattention.
So putting things in thephysical environment, like a
shared to-do list, for example,can be a helpful thing.
Now, to-do lists don't getsomething done.
(40:09):
To-do lists only indicate whatneeds to get done.
It's the action towards thetask that gets the task done.
So adults themselves can usebehavioral strategies to improve
the concerns that they have forthemselves.
Speaker 3 (40:38):
Right, I love that shared to-do list and I think
that'd be really helpful for alot of households, even if you
are empty nester and your kidsare grown or you don't have
children.
But I mean, I feel like,speaking as a woman, we take on
we tend to take on a little bitmore around the house and work
and maybe are raising childrenor helping with grandchildren
and it can get overwhelming andI know probably a lot of
(41:00):
arguments are why am I the onealways cleaning the bathroom or
vacuuming or going to thegrocery store?
So I think that's a reallyhelpful tip.
Speaker 2 (41:08):
I'm going to start that.
The bad question to ask is whyam I always the one?
Speaker 3 (41:13):
Yeah, I mean, yeah, it's very common, it is.
Speaker 2 (41:16):
It's useful to come to agreements and to agree that
you are going to completeagreements, that you're going to
adhere to them and bringintegrity to the agreements,
because an agreement not keptcan be a true source of problems
itself, right.
(41:37):
So if you are going to agree tomake agreements and to keep
your agreements, then keepingagreements becomes the sole
source of planning between twopeople.
Speaker 3 (41:50):
Yeah, that's great.
So we talked about thenon-stimulant treatments and so
that's really helpful.
I wanted to follow up a littlebit on the medicine, really
quick on does, and I'm thinkingthis more specifically well, not
just for children, because somany adults have issues, you
know, falling asleep.
But do you need to take themedicine while you're sleeping,
(42:13):
or is it better for that drug tomaybe be taken early in the
morning, so then it's out ofyour system by the time you're
trying to fall asleep at night?
Speaker 2 (42:20):
It should always be taken early in the morning,
according to physicians, becausethe stimulants are in the
system for between six and 13hours and then they're out of
the system, so when a personsleeps and they can interfere
with sleep even if they're outof the system.
So it's important to usemedicine in an appropriate way
(42:44):
and follow the doctor's orderswhen they're taken.
The immediate releasestimulants last between three
and four hours.
The extended release stimulantscan last between six and 13
hours.
Speaker 3 (42:59):
Wow.
Do you think the screen timeuse in young people and adults
is bad for the brain or thatbrains need more directed
attention because our screen useis disrupting that in some way?
Speaker 2 (43:18):
So saying something is bad for the brain is going a
little bit too far for me tocomment on, but I do not think
screen time is helpful to aperson with ADHD.
But I do not think screen timeis helpful to a person with ADHD
, and the simple reason is thatscreen time activates automatic
(43:44):
attention.
It's interesting sorts of otheractivities that are in the
corner of the screen or not.
You know they attract yourattention.
Screen time activates automaticattention, and you know as well
as I do that all of ourattention cannot be activated
(44:10):
solely by something that'sinteresting, and in fact, much
of what we do in fact most ofwhat we do during the day is
simply not interesting, and sothe brain has to get, or the
brain can get accustomed todoing directed attention tasks.
(44:30):
If the brain gets accustomed toonly being activated by
interesting things, which iswhat screen time does, then that
is a very difficult thing toovercome, and in fact, many of
the screens that kids areaccessing these days have built
into them something that showsup as interesting every 30
(44:51):
seconds, and when the brain isactivated by something every 30
seconds, a person begins toexpect that that's the way it's
supposed to be.
And so if the mom says, go scrubthe toilet right now, and
there's nothing interestingabout scrubbing a toilet
whatsoever, and there's nothinginteresting about scrubbing a
(45:11):
toilet whatsoever.
So having to go do that taskbecomes it's like being in a
desert and there's nothing therethat can be activating and even
the threat of a punishment ifyou don't do it is not
activating enough to make aperson do it.
(45:31):
So screen time gets childrenused to having automatic
attention constantly activated,as if that's what's supposed to
be.
And yes, it would be ideal ifeverything was interesting all
the time, but it's never goingto be interesting all the time,
at least not in the world thatwe live in right now.
Yeah, so I discourage unmanagedscreen time as strongly as I
(46:01):
can discourage it in that theAmerican Academy of Pediatrics
says by age six, an hour ofscreen time a day is the maximum
.
And then, as you go up intoadolescence, screen time becomes
much more difficult to manage.
But there still should belimits to screen time.
Speaker 3 (46:26):
Absolutely.
I mean it's difficult, but Iwholeheartedly agree with you.
I mean we've tried to kind of,you know, not give those phones.
We've never even actually hadan iPad in our house, so but as
long as we could get away withit, you know so because and now
I just they're just I'm talkingto them and they're on their
phones and I'm like, put it downand look me in the eyes because
(46:47):
you're not focusing on me.
Number one, don't tell me youare, because I don't believe you
.
Speaker 2 (46:56):
Well, and even when you look at being an adult
situation, like if you go out todinner at a restaurant, if you
look at tables of individualstwo individuals sitting with
each other, both- of them ontheir phones two individuals
sitting with each other, both ofthem on their phones.
Screen time is becoming trulyintrusive into our modern world,
(47:21):
and I, for one, just find itreally difficult to accept.
Speaker 3 (47:22):
I agree, I mean you're so right.
I mean I don't get to go out toeat too often, but when I do, I
can't believe how many peopleare just sitting there on their
phones together rather thantalking.
You know, it's it.
Culture's really changed in thelast you know decade.
Speaker 2 (47:36):
My dear, my own dear wife gets mad at me because I
don't answer her when she callson my cell phone, and she's used
to it by now though, so so it'snot that much of a problem, and
she knows how to reach me ifshe needs to.
So, at any rate, screen time isa major problem today.
Speaker 3 (47:56):
Yeah, I agree.
Well, I don't want to keep youtoo much longer.
We're wrapping up here.
I guess my last question wouldbe, if there's I know this is
going to be a big one but anyconnection to the COVID-19
pandemic and that impact on thechildren's brains who were, and
(48:17):
adults who were, forced to workfrom home or stay home, maybe
spending a lot of time onscreens or, you know, working
virtually, children virtuallyduring school.
Do you think that's anyconnection to increases in ADHD
and, you know, these otherlearning disorders?
Speaker 2 (48:39):
So I've not read any active research that took the
COVID infection as beingindicative or intrusive in
people with ADHD, other thanthat, when kids were at home,
they have more access to screensand their brains are more
(49:02):
accustomed to doing what'sentertaining to them as opposed
to doing what is required ofthem.
That certainly is a possibility, but as far as COVID is
concerned, regarding impactingADHD directly, I don't know of
evidence that indicates that.
Speaker 3 (49:21):
I mean I just know I can say I definitely in my older
children.
Just, you know, doing schoolonline for a year did not help
them with their grades oranything like that.
So I know we've seen it.
I mean, that's just my personalopinion, so I'm sure other
parents you know as well.
Yeah, but are there any otherfinal thoughts before we wrap up
(49:44):
our interview that you'd liketo share with our audience?
Speaker 2 (49:49):
Well, I think the final thing that I would really
like to say is that a person mayhave ADHD, that does not mean
that their life is limited inany way, and, in fact, many very
successful people have ADHD andwould be diagnosable ADHD.
I mean, if you consider peoplewho are on television or screen,
(50:12):
there are many people who arevery high energy and who would,
some who have admitted and beendiagnosed that they have had
ADHD or are diagnosed with ADHD,and there are many, many people
with ADHD who are highlysuccessful.
There are many, many peoplewith ADHD who are highly
successful.
And so I'll just give you aperfect example.
(50:34):
When I married my dear wife, shehad a little three-year-old boy
named Michael.
Michael was the mosthyperactive child you have ever
seen in your life, and at thetime I was working at the
University of Hawaii and Melissaand I lived in Hawaii and
Michael would do anything if wetook him to the airport on a
(50:55):
Saturday so he could lay in thegrass by one of the biggest
runways and feel those planesland.
So I set up a marble system forhim where he earned marbles for
appropriate behavior, and whenhe cashed those marbles in, the
thing that he invariably wantedto do was to go to the airport
on a Saturday, and if you'reliving in Hawaii, why do you
(51:17):
want to go to the airport?
Speaker 1 (51:18):
on Saturday.
Speaker 2 (51:20):
But we took him to the airport on Saturday and he
lay in the grass and could feelthose huge 747s landing.
And Michael is 39 years old now.
What do you think he does?
Speaker 3 (51:30):
for a living.
I see a pilot.
Speaker 2 (51:32):
Oh my gosh, he's a pilot.
He flew for Pacific Northwest.
It was a freight company andthey transferred freight from
Guam to the United States and toHawaii.
And one time he was flying oneof those big planes and he was
(51:53):
landing in Guam and the frontlanding gear did not descend,
and so he had to fly around fora while and get rid of some of
the fuel, and then he landedthat plane.
It stayed exactly in the middleof the runway.
Nobody was hurt, nothing wasdamaged.
He told me that when he landedthat plane, he was so
(52:14):
hyper-focused on the instrumentpanel that nothing else got in,
and so people with ADHD canperform exceptionally well in
circumstances that many of uswould consider pretty concerning
.
Speaker 3 (52:31):
Yeah overwhelming for sure.
That's a great story.
I actually also did the marblejar with my three children a
rewarding system.
Speaker 2 (52:39):
I did.
Speaker 3 (52:40):
I think I probably found it online and they could
earn something, and a lot oftimes it would be like can we go
to the zoo on the weekend orsomething fun, rather than maybe
a toy.
So I agree with that.
Well, thank you, dr Manos, forjoining us on the Speaking of
Women's Health podcast again,and thank you to our listeners
for tuning in to another episode.
(53:01):
We're so grateful for yoursupport and hope you will
consider supporting the podcastand sharing it with others.
And to catch all the latestfrom the Speaking of Women's
Health podcast, you cansubscribe for free on Apple
Podcasts, spotify TuneIn orwherever you listen to podcasts.
So thank you again and we willsee you next time in the
(53:22):
Sunflower House.
Be strong, be healthy, be incharge.
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