Click here to listen to this episode, part 1 of a discussion with Dr. William Dodson.
Welcome to the podcast today. I'm so excited to have Dr. Bill Dodson. He's a board-certified adult psychiatrist who was one of the first clinicians specializing in adults with ADHD over 25 years ago. He has been on the faculties of Georgetown University and the University of Colorado Health Sciences.
He was named a life fellow of the American Psychiatric Association in recognition of his clinical contributions to the field. He was a recipient of the National Maxwell Sewer Award for his distinguished service to persons with disability. He has written more than 120 articles in book chapters designed to help a lay audience better understand ADHD and its treatment.
Dr. Dodson is now semi-retired and devotes most of his professional time to working with homeless adolescents on the streets of Denver. He also is writing a book about the optimal treatment of ADHD in both children and adults. So without any further ado, welcome to the show, Dr. Bill.
I keep busy. I'm working harder in retirement than I did when I was still seeing patients.
That's, that's so awesome and, and I know that. It's one thing you mentioned about working with homeless adolescents on the street. I like metaphors, and sometimes people with fibromyalgia feel like they're homeless from a metaphorical standpoint, not getting the right care, not getting the help, and often being tossed from doctor to doctor and often in a lot of despair and hopelessness.
But for many, a place where they fit and they're accepted. Exactly, and that's rare, and for both fibro and ADHD. Hopefully, for those struggling with fibromyalgia, their family, and loved ones, and for physicians trying to learn more, I hope to continue to help grow their understanding.
Many people suffering with fibromyalgia also have ADHD, and the numbers may vary. There may be reasons for this, from how they measured it and research, et cetera. Many want to know if they could perhaps have ADHD. Those who listened to Teresa's story in a previous podcast may wonder, do I have ADHD? And can you help at least, especially for the adult who has not yet been diagnosed but may have it? What kind of things might help them understand if they may have ADHD?
Dr. Dodson shared the following thoughts.
One of the biggest obstacles is going to be the fact that they've always had ADHD. And ADHD is their normal. That's all they've ever known. They don't know what it's like to be neurotypical.
About 10% of the population, wherever you go in the world, will have an ADHD-style nervous system. We're getting away from the notion of ADHD as a disorder because it is a second nervous system. The ADHD nervous system works perfectly well, but by its own set of rules, techniques, methods, whatever you want to call it.
The problem is we keep those a secret from people with ADHD. We demand that they change and be neurotypical. So let me tell you why the difference between those two. In the last couple of years, we've learned to ask the right questions. For the last 60 years, we've been asking questions that led the whole field of ADHD astray.
And one of the questions I ask is suppose you look back over your entire life to see if you've been able to get engaged and stay engaged with literally any task of your life. Have you ever found anything that you could not do? Most people with ADHD, and we're talking like 99% of people with ADHD, well think for a moment and go, now if I can get engaged,
I can do anything. I can literally do anything. The term emerging in the lay literature is that people with ADHD are omnipotential. They can do anything. And so that puts to question a whole bunch of stuff. How could you call something a disorder where people can sometimes be "superhuman?"
It really puts to question the leading theory at the moment called executive function deficit theory. People with ADHD do not have a deficit of abilities. ADHD is not a problem of knowing what to do. It's a problem of doing what, you know. On top of that, ADHD brings with it a lot of positives.
People with ADHD are much brighter than the general population. The average IQ of an adult with ADHD is 123, at the 93rd percentile. All the IQ necessary to do anything they want, and half are higher than that. They're very creative people and world-class problem solvers. When they do get engaged with something, they pursue it with what's called relentless determination.
They're also funny and quick-witted, which are often overlooked. They are the world's best friends, absolutely loyal people. Because they know they've been rejected their entire life, they value their friends. They would literally die for their friends. They're a great group of people.
The problem is that medicine doesn't serve them very well. For instance, there's no book on how to treat ADHD, which blows my mind. Even if a physician wants to learn how to treat ADHD, there's no place for him to learn. 93% of adult psychiatry residencies do not mention ADHD in four years of training.
Most psychiatrists out there are functionally illiterate when it comes to ADHD. Half of the pediatricians are never exposed to ADHD. They're the ones we think should be the repository of knowledge about how to treat ADHD, and have to admit they don't know what they're doing. And so this is really just a failure of medical education worldwide.
So let's go through what ADHD is. How do you know if you got it? So we have a set of diagnostic criteria. They're 18 of them, but they're based solely on children ages six to 12. They work very well for elementary school-aged children, but they've never been validated in a group of people over the age of 16. Now we've spent 20-30 years trying to show that what we diagnose as childhood ADHD persists into adulthood.
The problem is the diagnostic criteria are for children. If adults met those diagnostic criteria, they would function on the level of an elementary school-aged child with untreated ADHD. They would be so impaired that they wouldn't be functioning. And so, unfortunately, the researchers of the world have kept any new diagnostic criteria for adults from coming forward.
It was recognized in 1980, 40 years ago, that ADHD persisted into adulthood, but we still don't have diagnostic criteria. The other thing is that when you look at our diagnostic criteria, they can appear nebulous.
All 18 are things everybody has done at some point in their life. We've all been scattered. We've all misplaced things. We've all blurted out something in a conversation we wished we hadn't wanted back. We've all been restless—every single one of those 18 criteria, everybody's had. So they said, why? Why are you calling this a disorder? I've done every single thing on that list. Well, it is because that's just the first step of five you must do to get the diagnosis. Those 18 criteria must be consistent, persistent, pervasive, and impairing.
They have to be there all the time, consistent. Persistent. They must have started in childhood and come without a break to this day. They're pervasive. It doesn't happen just at home. It occurs in every area of life, at school, at work, on the golf course, and everything else.
But the big one is the last. It must be impairing. It's more than just some lovable little trait or quirk. It has to cause significant impairment everywhere you go, every day, as far back as you can. Then it becomes a diagnosis. So diagnosis after you get to be 16, they suck badly.
So many people are trying to get rid of those diagnostic criteria and find something else. We've been looking at what are the things that everybody with ADHD has and nobody else has. The term is pathognomonic, which names the disorder you can rely on.
And so people with ADHD have two such pathognomonic features. The big one is the cognitive side of ADHD. It's what causes that swinging from being omnipotential and being able to do so much to swinging to being in la la land and not able to get engaged with anything. This causes a huge misunderstanding with parents in that when a kid can get engaged, he's wonderful at what he does, but no good deed goes unpunished.
From then on, the child is expected to be able to do that everyday. Kids with ADHD can't guarantee that. And so when they don't do it, the next time, parents put the worst face on it and say, this is willful. You're a bad kid. You're being oppositional and defiant. It's the kid's fault rather than, that's the nature of ADHD.
People with ADHD can show how bright and capable they are and be productive in one of four ways.
They can do it when they're interested in what they're doing. If you get a kid with ADHD interested, you can't pry away. Kids love video games because video games present a new exciting challenge every two seconds.
Second, they can do it when they're challenged or competitive, which I think is one of the reasons why ADHD is so heavily overrepresented in professional athletes.
You can do it so long as it's new, novel, and creative, but by definition, that one is time-limited. Everything becomes old hat after a while, and you get bored with it.
The one that's big for adolescents and college students, they can get engaged when it's urgent, right at the do or die deadline, they can get engaged and turn out a huge amount of high-quality work in a very short period of time. So when people with ADHD can get in the zone is the slang, when it's interesting, challenging, novel, urgent.
In contrast, those sorts of things are entirely optional for the other 90% of the neurotypical people in the world. They could take them or leave them. They're nice, they're helpful, but they don't need them. Neurotypical people can
Get engaged,
Access their abilities reliably every time, and
Stick with it all the way to the payoff for two reasons.
It's important, and they have a luxury that ADHD people don't have. It doesn't have to be important to them. It can be important to their teacher, to their boss, to their spouse, to their career.
It doesn't have to be important right now. I need to do this to advance my career over the next ten years.
However, the person with ADHD must be interested, challenged, and find it novel or urgent right now, or nothing happens. The other one is that there's a reward for doing the task or a consequence if you don't. I mean, if you talk to parents with ADHD, they're just pulling my hair out because they don't know what to do.
We've tried everything. We've tried bribing him, punishing him, and taking away his Nintendo, and nothing affects him, nothing motivates him.
So what we see is that people with ADHD have what's called an interest-based nervous system. When they're interested, they can literally do anything. And it's one of those few times in life when you can draw a bright and shining line and say, always and never.
A person with ADHD can say I have always been able to do anything I want if I can get engaged through interest, challenge, novelty, and urgency. I have never even once been able to use the things that organize and motivate the rest of the world; importance, rewards, and consequences. It is that clear always and never.
And so that is really what ADHD is. It's a different nervous system that works just fine, but not by a single rule taught in a standard school.
That's a great high-level view of things. Understanding how those criteria in kids don't apply well to adults and the awareness of the higher IQ in most with ADHD are helpful. There's often this negative stigma where people may fight the diagnosis because they have been equated to the kids who did get diagnosed at younger ages. The younger you get diagnosed, the more likely you will have a lower IQ and probably more acting out on things. So they equated that as being stupid. I'm not stupid. I know I'm smart. I'm not dumb. I can connect the dots. But I think there are criteria like the WHO ADHD v1.1 and the DIVA 2.0 that adapt the pediatric criteria are helpful along with a careful history. Talking carefully with patients and understanding everybody's intelligence and circumstance is essential.
I've heard ADHD drops functional IQ by probably 10 to 15 points. So yes, that may drop you down to more average.
And that's where you can have people who are doctors, anesthesiologists, orthopedic surgeons, and, like you said, athletes. Some of the coaches' favorite but also, at the same time, least favorite players are the ADHD athletes because they want to work out all the time and not do homework.
They'd instead prefer working out. Yet they may not have run the play correctly. And the farther you get along in your school with more significant challenges, struggles for those with ADHD start to show up more. I saw a patient who liked being creative. He got a two-year degree as an Architect technician, and he thought that was great. He loved the training.
When he realized as he got into his job, he had to sit at a desk, and he didn't get to create anything. He just had to do the fine touches on what the architect did, and the architect did the creative work. And I often like to use the acronym TCB, taking care of business. It's the daily methodical tedious grind.
Dr. Dodson shared more of his insights.
That's why they pay you to do it. And it's so much harder for those with ADHD. And that's every day. You know, every day it's due. Now they don't have that, okay, here's the term paper every six weeks, and now I can cram the weekend. Every day they have that grind. And that can cause a tremendous amount of internal anxiety.
If you look at the people in business who have been remarkably successful despite their
ADHD, you see one pattern. That's what we call having an implementer finisher partner. People with ADHD can wade into a problem that has stumped everybody else, think creatively or with out-of-the-box thinking, and get right to the answer. They just intuitively know it. But once the problem is solved, it has no more interest or challenge, And so they have all of these great ideas that are never implemented.
So if you look at people who've done well, they've had somebody very capable with the implementation that's not their strength. The implementers would've never figured out the solution to the problem in a million years. But they are world-class implementers, so they take the idea and actually implement it. So Bill Gates had Paul Allen, and Steve Ball.
Steve Jobs had Steve Wosniak. These implementer finishers are so important. We know who they are. They wouldn't have been able to implement any of these wonderful ideas without some neurotypical person to implement them.
To summarize,
ADHD is in about 10% of the population and persists into adulthood. T
he diagnosis of ADHD Classically works best for six to 12-year-olds, but if you use the same criteria for six to 12-year-olds, this would be an adult who's barely functioning. Fortunately,
we have criteria that apply to adult situations, adapting to adult situations.
One of those is the World Health Organization Adult ADHD questionnaire along with the DIVA 2.0. and this is used along with the clinical history looking for problems and started earlier in childhood.
Delays in diagnosis often occur in those with higher IQs who are less physically active and less likely to act out. This is often the inattentive type, which is often more in women and girls than in men and boys.
We often think of a stigma not just with fibromyalgia but also with ADHD.
Dr. Dobson shared with us that the average IQ of someone who has ADHD is 123, with normal IQ being 100.
Many people working in the business world are successful with A partly because their highly creative minds are paired with an implementer.