Melanie Cole (Host): Do you have trouble paying attention? Do you have trouble staying still? There are particular challenges as a college-aged individual with ADHD. Welcome to Conversations with MIT Health. I'm Melanie Cole. My guest today is Dr. (Showlu She). She's a clinical psychologist at MIT Health. Welcome to the show, Dr. Hsi. Please just tell us a little bit about ADHD and what it is.

Dr. Xiaolu Hsi (Guest):  Thank you very much for having me. Well, for starters, I want to say, and you'll see why I say this:  it is a psychiatric disorder. It's recognized by the DSM 5, which is our diagnostic manual. So, it is a recognized psychiatric disorder, although it came a long way, and you can see why. It is a very complicated syndrome. It’s very different from what people think. "Oh, you're hyperactive, you have ADD." You're not; you don't. That's the common misconception. Like any other syndrome, it has all sorts of individual variations and garden varieties. The core symptoms are what you described already. People having trouble paying attention; people having trouble staying focused. What people don't always recognize, although they almost always report when they come with a question about ADHD, is what we call the “Executive Function Impairment”. This is the troubles in getting starting with the work--getting started and buckling down. They commonly misunderstand this as, "Oh, I have motivation issues". I always say, "No, you have initiation issues. You have trouble getting started. You have trouble regulating your behavior." Co-directed behavior, in other words. They also have trouble with organization and planning. These are the messy folks and they often do things in such a haphazard way. At the core of this is what we call, in our jargon, “difficulty exhibiting an appropriate response”. Now, inappropriate response here does not mean the urge to curse or the urge to rob a bank, as I explain to my patients. The inappropriate response is, instead of the action to stay on task, for instance, they chase around things that are more interesting and do other things. So, they procrastinate, they get off track or, when writing--this is a very common report--that they have too much to put in the paper in a coherent way. Why? Because they cannot differentiate between what is only relevant and what is critically importance. They have trouble saying "no" in other words. So, you can see the trouble that can come with that. The other common report of problems is problems with memory. Actually, it's working memory, meaning that they don't have trouble remembering what they learned in let's say, 6th grade in Social Studies or in math class in high school. What they have trouble with is they forgot where they put their keys, or they forgot what they asked you to do as soon as they got off the phone, or that they forget what they have just said in the conversation with somebody else participating in the conversation. I've met scientists who have published brilliantly but often would not participate in discussion because they're afraid that somebody else has said an opinion or given a position already or given a statistic and they're going to make themselves look foolish because they can't remember. So memory difficulty is what they often report and they forgot also the things in life, as well. So, ADHD is what we call a “neurodevelopmental disorder”. What it means is, unlike depression or anxiety, you don't have an onset of, let's say, at age 20 or 24 or 16 when you enter college. There has to be a trail, even if it's not a paper trail,  that goes all the way back to childhood. Now, what’s very interesting with MITs population is a lot of these kids would not have failed, not only because they're smart--they'd easily go through high school, middle school and do quite well--but often, when they are tardy with the homework or they're disorganized. Usually, most teachers would not think much about it because they perform well. They are obviously smart.

Melanie:  So then, how is it diagnosed?

Dr. Hsi:  It is not diagnosed by testing. That's another common perception. Often, when you need accommodations for testing, for instance--if you take SAT, or you take GRE--you need extended time. Agencies like ETS were required to have testing. That's for the purpose to document that deficit. That's not for the purpose of diagnosis. It is diagnosed, really, by a very, very careful diagnostic interview that really goes all the way back to the time when you're in your mother's womb. We go all the way through the developmental history about the birth, about the milestones and about when people started to notice difficulties with sitting still. Often, children have trouble with following directions not because behaviorally they were oppositional but simply they were having a hard time paying attention and following simple directions particularly if the directions that go beyond one. You know, you turn to page three, look at the figures and please copy this down. The poor kid is already lost. Turn to page three, they can do that. You copy these figures, they can do this. You copy these figures, they can do this. Then, you do this. Often this is the kind of report you hear. Of course, you also have the classic hyperactive kid who is in trouble all the time and gets sent to the principal's office every other day.

Melanie:  Now, tell us a little bit about some of the treatments and if somebody is diagnosed as a child, does it carry through into adulthood?

Dr. Hsi:  Yes, except it carries into adulthood in different ways. For instance, the hyperactive type, really, the kids who are very impulsive, who are bouncing off the wall types, they tend to--not always--but a fair amount of them will tend to "grow out of it” or calm down. So, behaviorally, they won’t be disruptive. However, the physical restlessness often continues. They will either sit in your office, drumming the fingers, tapping the feet, and really having a hard time sitting still or they feel such internal restlessness that it really makes it very hard for them to stay seated for a long time. So, you can imagine how hard it is for them to be in a classroom. The inattentive type--the dreamy, the spacey, the absent-minded, the scattered type--that's the inattentive type. People mostly have trouble with attention or procrastinating or are very disorganized, very messy, very forgetful. Those symptoms don't tend to budge much in adulthood. So, you can also imagine how hard that would be for them to go through college, to come to college, or, you know, sometimes go into a job after this, completely on their own without the supervision or support of adults or other people.

Melanie:  What are some of the treatments that can help people with this attentional deficit to focus and have more attention for things?

Dr. Hsi:  Okay. The two tiers of symptoms that I often explain to people—now, I want to make very clear that I'm a psychologist. I'm not a psychiatrist. Therefore, I'm not one of those prescribers, as we term them. I don’t do medication. Of course, and you know, that giving them medication can help them, so let me put this out first. There are two tiers of symptoms that are embedded in ADHD. Inattentive type or hyperactive type or, more often than not, a combined type because, typically, you have those. I've never met anybody who's only hyperactive and who doesn't have attention problems. Medication can be very, very helpful to help people sort of become less hyperactive, less impulsive, less reactive, and also, they can get started, to pay attention and stay focused longer. That is true and often, about 70% of the population would respond well to one type of stimulant medication and about 30% who don't, but tend to be the 70% that respond to another of the two main types. There are several other types as well. I'm not going to go into details about that. What it does not help, however--and this is really important for both the patients and, frankly, the prescribers to know--is medication does not do much at all, if anything, to what I described earlier. The so-called "Executive Function". So, that is how you approach your problem, how you solve your problem, how you plan, how you organize, how you inhibit those responses through impulse control. Those are the skills. Those are higher-level classic skills that you have to learn. It's like, put simply, good habits.

Melanie:  So, you learn those with what? Behavioral cognitive therapy?

Dr. Hsi:  You can do that in the cognitive behavior therapy but, more likely, what would really be helpful is to work with somebody, regardless of the discipline, who is familiar with ADHD. One of the big hurdles to really overcome is the lack of understanding  of what ADD is or isn't--or ADHD, I mean. I used the common term  ADD. People often feel this is something that you can control when it is not something they control. However, they can be trained to pay attention to how they're doing things in an impulsive way without going through the hassle and learn to become mindful, learn to become attentive, and learn to have strategies to help to manage those things.

Melanie:  Well, then, speak about some of the particular challenges that a student with ADHD face in managing their studies and campus life.

Dr. Hsi:  Okay. First of all, like everybody else, when they come to college, Mom and Dad did not come with them. So, laundry and food, don't just show up on the table anymore. At MIT, this is a particular issue as well. We don't have dining halls in every single dorm. So, all of a sudden, they have to manage their lives as much as their studies. Also, nobody is getting them up in the morning to catch a school bus and, if they miss classes, you know, people don't know. A lot of classes are not particularly attendance-based. So, in that case, the saying applies:  "All hell can break loose" without people catching up for a long time. So, they have this adjustment for college as well as everybody else and, on top of that, they're going to struggle that much more because they're constantly distracted, they're disorganized, they're missing things without even knowing about it. So, they're having this additional burden. The two additional things I see it in at MIT that are really important to mention is that there is a stigma against the ADHD. Now, we don't hold it against the people if they're treated for Type I Diabetes. We don't necessarily hold it against people if they're treated for depression or anxiety. But often, there is a stigma about how, "Oh, you know, this is just the easy way out. This is just to get them on medication or performance enhancers. It benefits everybody." Incidentally, it does not. Empirically, we know that. Some people don't. So, there's a stigma about that as well. I see it in students all the time who, as much as they feel validated by having been diagnosed and are treated and see the treatment, they feel like it might be, you know, getting an unfair advantage. That's number one. Number two, in college, and, in particular, in a place like MIT, I think one of the challenges is how much they can do. These are bright students--very curious, very motivated. They're excited and they're at the right place. They're among other peers who are just like them. For the first time, they're having fun. They're doing great things together and the sky's the limit. No, unfortunately, the sky's not the limit. I tell everybody, "God did not give you 48 hours just because you come to MIT." So, often there's this struggle between, "Do I push the limits and do as much as I can and crash and burn at some point or do I wrestle with the limit", meaning, I respect it, I accept the limit and I try to work with it. This is something I see in students without ADHD, as well. I think it’s equally difficult and challenging. 

Melanie:  Sure. That ability to pace yourself.

Dr. Hsi:  That’s right.

Melanie:  And make it so that you do take things as they come. In just the last few minutes, Dr. Hsi, what treatments options are available to MIT students with ADHD?

Dr. Hsi:  Well, we have a lot. I've often been told that the schools of our tier and our size--this includes some of the Ivies—probably all of the Ivies, I think--they tend to refer all the students with ADHD off campus for assessment or for medication or for behavior treatment. That accompanies this, of course. We actually treat them, at least so far to this point, on campus. We're able to diagnose them there. I have neuropsych councils specifically made available to my colleagues and all of our providers, certainly, are equipped and trained to make the diagnosis. We have a large number of colleagues who are prescribers. They can prescribe. I would also provide both the consultation as well as therapy really geared toward this particular group, anywhere from helping them understand the emotional implications as well as really, the cognitive deficits--that they are quite real. So, we go and discuss really, the neural cognitive underpinning of the struggles. This is not something because they're smart or because they're lazy and they're smart, but rather that there are, indeed, cognitive deficits and a cross between some of this cognitive behavior work, some of the DPT work, to really help them manage it. Managing the negative feelings, emotions that further impacts your learning is something they struggle with, as well. I run a group for graduate students--it's a skill and information skill group for graduate students with ADHD. I'm about to run a group for undergraduate students next term. So, students can meet together with other people who have similar experiences and, basically, they share the experience and support each other. They gather information. They also, frankly, trade tips in terms of how to manage them. So, there's this community here that they can support each other. So, we have the assessment, we have the medication and we also have the counseling in the way that includes coaching, therapy, and the support. We also have this standard disability office services that can provide accommodations and support and advocacy and also skill training as well. So, we really have a fair amount of support for a student with ADHD at MIT.

Melanie: Wow. It's great information. Thank you so much for being with us, Dr. Hsi. Listeners can visit Health.mit.edu for more information and to get connected to one of our providers. That concludes this episode of Conversations with MIT Health. Please remember to subscribe, rate and review this podcast and all the other MIT Health podcasts. I'm Melanie Cole. Thanks so much for joining us today.