Managing ADHD in Perimenopause with David W. Goodman, M.D. #242
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You're not imagining it.
Your ADHD symptoms can change as you age.
ADHD in older adults can be very different than when you were younger and it's definitely not researched enough yet!
You don't need to qualify as a senior citizen before your age affects your ADHD, so youngin’s and elders alike, let's listen in.
For ADHD Awareness Month, we’re talking to a new ADHD guest expert every week.
Today’s guest is David W. Goodman, M.D., an expert in ADHD in older adults.
David W. Goodman, M.D. is Assistant Professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. and Clinical Associate Professor of Psychiatry and Behavioral Sciences at the Norton School of Medicine, State University of New York-Upstate. An internationally recognized expert, he has presented over 750 lectures to medical specialists, authored peer-reviewed scientific papers, conducted clinical research on several of the ADHD medications now on the market, serves as a consultant to the NFL, widely quoted in national media, teaches 4th-year psychiatric residents at the Johns Hopkins School of Medicine, and serves on the executive committee of APSARD (American Professional Society for ADHD and Related Disorders).
In this episode, Dr. Goodman shares a great refresher on the basics of ADHD and how to determine if you've met with a qualified diagnostician to get your ADHD assessment. He dives into the nuances of how ADHD can be confused with other disorders, conditions, and comorbidities. Then we uncover how ADHD can change through your lifespan and how hormonal shifts in perimenopause and menopause affect your ADHD symptoms.
I'm also over the moon that Dr. Goodman is currently working with his fellow experts to redefine the symptoms checklist for ADHD diagnoses in adults.
Let’s dive into a much needed conversation about how you change over your lifetime, as we look at ADHD in older adults and perimenopause.
Find David W. Goodman here: https://addadult.com/
You’re invited!
It can feel super intimidating to show up to a party where you don’t know anyone. Well, I don’t want that fear to keep you from finding your people.
I want to make this super low risk for you to come, try it out, and get a sneak peak before you join our ADHD mom community.
You’re invited to the next Successful Mama Meetups Open House!
Join us on Zoom on November 6th to body double for the first 30 minutes, then hangout and meet the other moms in the community for the second half. (Hint hint, we’re pretty amazing IMHO.)
No charge, no pressure. Just come hang out!
Let me know you wanna come right here and I’ll send you the zoom link.
And since it's on Zoom, everyone can come no matter where you live. Self-diagnosis and ADHD-curious moms welcome.
It’s time to hang out with other moms who get you and make you feel like you’re at home. So come in your comfy clothes and let’s hang out! See you soon!
David W. Goodman [00:00:00]:
ADHD, 75 to 80% of the cause is genetic. You don't wake up at 6 years old or 12 years old or 15 years old and say, I think I'll have ADHD for the rest of my life. It doesn't work that way.
Patricia Sung [00:00:12]:
Are you overwhelmed by motherhood and barely keeping your head above water? Are you confused and frustrated by how all the other moms make it look so easy? You can't figure out how to manage the chaos in your mind, your home, or your family. I get you, mama. Parenting with ADHD is hard. Here is your permission slip to let go of the Pinterest worthy visions of organization and structure fit for everyone else. Let's do life like our brains do life, creatively, lovingly, and with all our might. When we embrace who we are and how our brains work, we can figure out how to live our lives successfully, and in turn, lead our families well. At the end of the day, we just want to be good moms. But, spoiler alert, you are already a great mom.
Patricia Sung [00:01:03]:
ADHD does not mean you're doomed to be a hot mess, mama. You can rewrite your story, from shame spiral to success story, and I'll be right here beside you to cheer you on. Welcome to Motherhood in ADHD.
Patricia Sung [00:01:19]:
Hey there, successful mama. It's your friend, Patricia Sung. It's ADHD Awareness Month and look at me. It only took me 5 years on the podcast to pull together a series for ADHD Awareness Month. Just so you know, it is never too late. Every episode this month will be a new guest expert on the field of ADHD. I am so honored that these powerhouses are here to share with you. So let's dive in with today's guest.
Patricia Sung [00:01:44]:
What a treat we have today to have Dr. David Goodman here on the show. Dr. Goodman is an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine, as well as a clinical associate professor of psychiatry and behavioral sciences at the Norton School of Medicine at SUNY. He is an internationally recognized expert. He's presented nearly 1000 lectures to medical specialists, authored peer reviewed scientific papers. He has conducted clinical research. I mean, this gentleman has taken care of the ADHD community for decades, and his experience shows. He's also serving on the executive community for APSARD, which is the American Professional Society for ADHD and Related Disorders.
Patricia Sung [00:02:36]:
I am honored that he is here to spend an hour with us today talking about ADHD as we move into later adulthood. Not only is he working to change things at a systemic level in our country, in the work that he's doing, he has a wealth of knowledge about ADHD in older adults in perimenopause, and we are going to dive into your questions from the community as well as understanding how perimenopause affects our ADHD, our hormones, what kind of support we can look at from our doctors as well as from the people in our lives, and understanding also how this affects our relationships. You are in for a treat, for an episode full of science packed information, but also real life what can we do about this. So let's dig into, is it anxiety? Is it depression? Is it ADHD? Is it all of the above? And how our lives are affected by our hormones as we move through the years. I am so honored to invite Dr. David Goodman to the show. So let's welcome Dr. David Goodman to the show. How are you doing this morning?
David W. Goodman [00:03:47]:
I'm good. Thank you for having me, Patricia. This is, this is a wonderful venue, and I'm glad we can exchange a lot of information for your listeners.
Patricia Sung [00:03:54]:
Well, thank you. I cannot wait to dive in, but I'm gonna take a pause and reverse back. When you think about your childhood, is this what little you thought you would be doing as a grown up?
David W. Goodman [00:04:08]:
I did not. As a youngster and a teenager, my dad was a physician. I thought I'd always go into medicine, but I was gonna go into real medicine, as he would say, not psychiatry. And so as I went to medical school and I got interested in psychiatry and I went to Johns Hopkins School of Medicine for my psychiatric residency, I endured the family members in my, community who were saying, you know, why don't you be a real doctor? Psychiatry is not really medicine. Well, now many decades later, I won't mention. And now psychiatry is at the forefront of medicine. Given the mental health issues and the crisis that have evolved out of the pandemic, given the advancement, the international research on brain chemistry and psychiatric disorders and international research. Psychiatry is at the forefront of medicine.
David W. Goodman [00:05:02]:
It is one of the most critical aspects contributing to the quality of life. And I'm glad that you're doing this program for your viewers because we are gonna discuss a lot of information about women, ADHD, and hormonal issues that are very specific to women that often don't get covered in the typical media articles about this.
Patricia Sung [00:05:24]:
And when you think back to when you first started in medicine, what's something that you wish you had known that, obviously, well experienced you does coming right out of med school? What would you wish you had known going into this field?
David W. Goodman [00:05:37]:
So what I wish for, I will reserve. What I'm glad no one told me was that going through medical school and residency is extraordinarily taxing and demanding. The volume of information that one needs to be doubles, In 1900, it took a 100 years to double the amount of information available to us. 100 years in 1990. In 2,024, information doubles at the rate of every 18 months. So if people are feeling overwhelmed by the amount of information coming at them, it's not you. It's the reality of what's going on. So I guess going back to your question, what would I have liked to learn then that would have helped me now? I don't know.
David W. Goodman [00:06:42]:
I mean, I've always been given to trying to help people achieve a better quality of life, and medicine seemed to be the best way to do that. You know, it's it's one thing to have circumstances in life that are a challenge and that you have to figure out. It's another thing to have a medical illness. And I consider psychiatric illness as a medical illness that evolved out of the brain. Yes. There is a mind, and I won't discount that. But we really need to understand brain chemistry and how it influences how we function during the day. We very much believe in free will.
David W. Goodman [00:07:12]:
I can make a decision based on the psychology of my mind at the moment. That's free will. But let me tell you, free will doesn't operate autonomously unless your brain is operating normally. And if it's not operating normally, either because of genetics or traumatic injury or a stroke or chronic use of substances, you're not actually in full control of your decision-making process. And you only understand that then when we go to ADHD. If you've had ADHD for 3 or 4 decades and somebody diagnoses you and prescribes medication and gives you treatment and you wake up and realize, wow, this is how the rest of the world functions, then you come to understand that brain chemistry plays a huge role in your experience of yourself and how you can function.
Patricia Sung [00:08:02]:
And how would you say that your brain chemistry is different when you have ADHD?
David W. Goodman [00:08:07]:
Well, we know certain aspects of brain chemistry. We don't understand the entirety. So often, it's said that ADHD is a function of dopamine deficiency. The dopamine is not working quite as well. It's a chemical in the brain that controls mood, motivation, and your thinking ability. And so this dysregulation of dopamine is very largely genetically determined. So ADHD, 75 to 80% of the cause is genetic. You don't wake up at 6 years old or 12 years old or 15 years old and say, I I think I'll have ADHD for the rest of my life.
David W. Goodman [00:08:43]:
It doesn't work that way. Nor do you develop ADHD by sitting in front of a computer screen or a TV screen or any other environmental events like that. So it's very important to understand that this is brain chemistry, not by your choice. And the critical element in psychotherapy for me in dealing with patients is having patients come to the understanding of what they have, ADHD, versus who they are as a person. Now as a child, it's easier to teach a child to early adolescence the difference between their ADHD and who they are because they have not yet evolved into who they are, which is largely influenced by environmental remarks. But if you're a 35 or 40 years old and you've lived your life listening to people criticize you, you're lazy, you're crazy, you're stupid, you don't care about details, you're passive aggressive because you show up late, you come to incorporate that criticism and assume the environment is accurate, and I'm just a bad person. And then you get diagnosed and treated, and the symptoms reduce and your functioning improves. And you realize, no.
David W. Goodman [00:09:51]:
The environment was responding to my ADHD, not who I was. So I'll tell you an interesting story then to drive this home. I had a Hispanic woman, 35 years old, who came to see me, and she said she just couldn't function anymore in life. And she was terribly demoralized, complaining of anxiety and depression. Went through the evaluation, clearly has ADHD symptoms since childhood and early adolescence, told her she had ADHD, put her on medication, gave her some treatment, followed her up. And in 3 months, she came in, within 5 minutes started crying in my office. I said, did I say something that hurt your feelings? She said, no. I'm actually crying because I now realized I'm not as my family told me, mentally retarded and stupid.
David W. Goodman [00:10:36]:
I'm crying because I'm so grateful to have a diagnosis and a treatment that has reduced my symptoms, improved my function, and now allows me to realize what I actually can do as a person. That is both heartbreaking to live with that. But it's heartwarming to understand that if you get accurately diagnosed and effectively treated, it's the difference between wandering through life with blurred vision and somebody says, you know, put these glasses on for a month and see how it works out. Yeah.
Patricia Sung [00:11:07]:
So you mentioned, like, a lot of women will get diagnosed with anxiety and depression way before the ADHD is noticed. For the mom that's listening, it's like, I already got those ones. I I have those on my dance card already. How can we start to pull apart? When is it anxiety? When is it depression? And when is it time to go look to see if there's something else lurking under the surface that's not been noticed yet?
David W. Goodman [00:11:33]:
Yes. Well, your question is complex because there's multiple layers. So let me try to tease this out. The first issue I want to address is clinician and provider training. If you look at professional training programs, whether it's psychiatric residency, medical residency, psychology programs, nurse practitioners, social workers, very few of these professional training programs have had any focus on ADHD. And to this day, unless there's a faculty member involved in the educational coursework, you're not gonna hear much about it except for 1, maybe 2 lectures. That means that all these providers and clinicians in the field don't really have the training to identify. And if you don't know, you don't see.
David W. Goodman [00:12:19]:
So that's the first order. If you're going to see someone to have this evaluated, you need to see a clinician who knows what ADHD is and how to go looking for it. If they don't, what they focus on is your initial complaints. I'm anxious because I can't get things done. I'm anxious because I forget my kids at school. I'm anxious because I'm not showing up to work on time. Oh, you must have an anxiety disorder. Let me put you on an antidepressant.
David W. Goodman [00:12:47]:
Or I'm depressed. My spouse and partner is gonna leave me. My friends don't invite me out anymore. Nobody wants me to drive because I'm too distracted and run through a stop sign. So, oh, you're depressed. Let me put you on an antidepressant. It's like all things lead to an antidepressant unless there's a comprehensive psychiatric evaluation that includes queries about ADHD. So for your listeners, if you're going to see someone for an evaluation, find out whether this person is familiar with ADHD or not.
David W. Goodman [00:13:19]:
If they're not, then clearly find somebody who is. Now going back to the presentation, certainly, you can be anxious and depressed because of the impairments ADHD causes. If you can't show up to work on time and people are critical in rolling their eyes, you're gonna get anxious. If your spouse is threatening to leave because you don't close the doors and you leave the keys in the car and you forget that the water is running, you're gonna be depressed. But those are psychological reactions to the impairments that are occurring in your environment. Now one has to distinguish whether your cognitive difficulties are a function of your anxiety, and anxiety can compromise thinking ability, or whether the anxiety is secondary to the ADHD. That's called a differential diagnosis. What are the symptoms, and what diagnostic bucket does it get dropped into? Now I've clearly stated this concept, but I will tell you this is very complex when you're sitting in an interview with a patient who is telling you all of these symptoms and all these experiences.
David W. Goodman [00:14:24]:
That's the differential diagnosis. What is it and what is it not? The other concept here is concurrent psychiatric conditions. That means you can have 2 processes going on at the same time. So it's not you have ADHD or you're anxious. It's that you have ADHD and you can have a primary anxiety disorder. You can have both. A well trained clinician is able to sort this out. Now if you have both, then the question is, how do you diagnostically prioritize? That is, what gets treated 1st, 2nd, and 3rd? And the object here is to treat one condition without making the other conditions worse.
David W. Goodman [00:15:07]:
And so there is an algorithm to figure out how to do that. And let me stop there because it was a bit of a long answer. But the question is actually far more complex, and I just wanted to sort out some of the individual aspects to that question. So to summarize, look, see a clinician who knows ADHD, find out what their experience is with it. If they don't really know ADHD, then I recommend that you find somebody who does. Now how do you find that? You yourself have to be educated. The patients now have to take some responsibility to learning something about their condition or their symptoms. And you can go to doctor Google and type in please don't accept doctor Google's answer as being an authority.
David W. Goodman [00:15:51]:
By the way, doctor Google trained TikTok. So TikTok just finished their psychiatric residency, and they're available 4 year queries. And I say that in light, but there is so much misinformation on the on the Internet. Some of it is well intended. That is, it's people who have ADHD who want to share their stories, but they don't really have the training and the medical background or the accuracy of what they're saying. And then there are people whose agenda is just to distribute disinformation. That is, we want to discourage you from thinking that this is real. We want to discourage you from taking medication for it.
David W. Goodman [00:16:27]:
We want to encourage you to empower yourself to take control of your life. Well, with all due respect, you can't wish yourself out of blurred vision, and glasses are really helpful.
Patricia Sung [00:16:37]:
Yeah. I just wanna get you a microphone for all that.
David W. Goodman [00:16:41]:
Patricia, this is why I teach. Now I'm old enough to have retired essentially from patient care, and I spend my time doing research and writing and teaching and advocating. And I know we're gonna get to the issue of women and older women and perimenopause and ADHD and and aging. But, again, my job at my age now is to remain an advocate for putting this information and really putting the science first. If you have opinion, that's great. But let's talk about the science because that tends to be the disinfectant to crazy ideas and theories.
Patricia Sung [00:17:14]:
I like that analogy. Okay. So in in looking at you're working right now on updating the diagnostic list for adults with many colleagues, I'm sure. Can you tell us about what are the changes that you are seeing and how this is going to go into effect in the years to come?
David W. Goodman [00:17:36]:
So the American Professional Society for ADHD and Related Disorders is a professional organization whose focus is on ADHD across the life span, so from young children up to elderly patients. And we are in the process now of developing and to be published the first set of US guidelines for the diagnosis and treatment of ADHD. The impact of that is multiple from the patient level. The purpose of this exercise and publication is to standardize a level of care across the country. We don't have that now. As I said earlier, the education for clinicians is poor at best. And hopefully, this will elevate a standard of care amongst clinicians across this country. The other is obviously for patients and families to get a concise read on the state of the art, where we are with the research.
David W. Goodman [00:18:35]:
And, again, it neutralizes misinformation and extreme opinions. It also has impact in validating ADHD in adults. And the reason we want to do that, despite the fact that 30 years of research would validate this, but if we have these published clinical practice guidelines, then we can go to education training programs and say, you know what? You really need to add this as part of your certified curriculum. And that would produce another round of clinicians who are more adequately trained and prepared to deal with patients. As we move up from the micro level to the macro level, we now move into insurance companies. We wanna have a standard of care that insurance companies will say, okay. We're gonna follow this. And if you're not gonna follow this, offer up a reason as to why you're not gonna follow the science of ADHD.
David W. Goodman [00:19:30]:
To move to the next level, we wanna have an impact on policymakers and legislatures. We want people to understand ADHD as a neurologic and psychiatric disorder that affects, by the way, about 4% of adults in the United States, of which only about 25 to 30% have been treated in the past year. So huge number of people who have this disorder don't even know they walk around bumping into things because the walls aren't moving. It's your ADHD. You got distracted. So coming back to why we're gonna publish these, there are multiple stakeholders here. We wanna have an effect on everyone. We also have government agencies, the DEA and the FDA.
David W. Goodman [00:20:14]:
The DEA is the law enforcement aspect for medications and especially controlled drugs. They're concerned about the increase in prescriptions since the pandemic, and the FDA also is concerned about the prescriptions from a diagnostic perspective. They wanna make sure that the diagnosis of ADHD is being made accurately and that we're not putting controlled drugs in the hands of people who really don't have ADHD. Long answer, but you'll understand it's complicated, and hopefully your listeners begin to get a sense that there's a lot more thought and layers to the onion than they might have otherwise thought.
Patricia Sung [00:20:52]:
No. And I think where a lot of people are feeling the heat right now is around the medicine shortages and understanding that it's not just that there's not medicine. It's like there are so many layers beyond of things being approved and manufacturing is not just it. It's all of the policy and everything that comes with it that allows them to make medicine and who's deciding these things based on what information. It's so much more complicated than just why doesn't my pharmacy have my medicine this month. It is 14 layers deep by the time the medicine's arriving at your pharmacy. So to know that these groups are going to be informed by quality information, like, everyone's like, yeah. Like, we're here.
Patricia Sung [00:21:36]:
Yes. There are a lot more people getting diagnosed in recent years, but I think that's because everybody, you know, like you said, if only 25% of adults are getting treatment, if we still have 75% wandering around, I know it's unlikely that we'll get everybody treated. But I mean, that's a large amount of people who are going to need support and medicine and strategies and clinicians to be able to treat quadruple the amount of people who are being treated right now.
David W. Goodman [00:22:01]:
Yes. And we saw during the pandemic, if you look at the CDC's data on prescriptions, during 2019 to 2022, there was a clear increase. The slope of that line changes dramatically for, for adults and everyone across the board, which means that there was an increased need for filling an increased number of prescriptions. What's interesting, though, is it's often said now that women are underdiagnosed. They're not recognized. Actually, the latest CDC data published just last year or the year before shows that boys are written more stimulant prescriptions than girls up to about age 20. At age 20, females and males are being prescribed an equal number of stimulant medications. And at 35 and older, women are prescribed more stimulant medications than men.
David W. Goodman [00:22:59]:
So we actually have caught up in regards to this prejudice about girls and women not having ADHD, that they're more likely to get antidepressants for their anxiety and depression and not be assessed for ADHD. So we are making progress, and that's that's good news. Again, just because stimulants are being prescribed, we have to make sure they're prescribed to the people who have ADHD and not prescribed to people who either don't have ADHD or just are gaming the system to get stimulants to use for performance enhancement.
Patricia Sung [00:23:35]:
Have you ever been invited to a party and you realize, like, you weren't gonna know many people there?
Patricia Sung [00:23:41]:
And so then you, like, dread it all the way going up to the event or you talk yourself out of it so you don't go. Because it's scary to put yourself out there in a situation that, like,
Patricia Sung [00:23:51]:
what if I don't like them? What if they don't like me? And it feels stressful. Well, I don't want you to feel that way about hanging out in this community, mama. So I am hosting an open house, and I want you to come and meet all the mamas so that you know what kind of people we are. PS, we're great. And that you feel comfortable joining in this community. Because if you are thinking about joining successful Mama Meetups or thinking about joining the retreat, I want you to know that these are your people, and what better way to do that than to actually meet the people. So come join us at our Open House. We are hosting an open house in Successful Mama Meetups on November 6th, and come meet the moms.
Patricia Sung [00:24:34]:
Hang out. See what it's like. You'll get the feel for, like, who are these people? What's the vibe? Do I wanna hang out with them? Yes, you do. It's gonna be so fun. So come hang out with us. So it's totally no charge, free 99. Come hang out at Successful Mama Meetups on November 6th. Our meetings are on Wednesdays.
Patricia Sung [00:24:53]:
They're at 12:30 EST. Go over to my website at patriciasung.com/openhouse, It's all one word,
Patricia Sung [00:25:01]:
o p e n h o u s e, and sign up for the link so that you get the Zoom link. And this is all virtual, so anybody can come anywhere in the world. See what time it is on your time zone, and come join us for the first 30 minutes. We hang out and get stuff done. So I have help there for, like, how to plan your week, or if
Patricia Sung [00:25:21]:
you're just like, I just need to get some stuff done and the body doubling helps, do that. Like, there's no wrong way to show up and do stuff at successful mama meetups. Did you get something done? Great. That's what we're here for. Okay? So that's the first 30 minutes, and then the second 30 minutes is social time where we hang out and we make it fun. You actually want to show up to the body doubling because you get to hang out
Patricia Sung [00:25:42]:
with your friends, and meet people who understand how your brain works,
Patricia Sung [00:25:46]:
and you feel at home. So come join us November 6. Sign up at patriciasung.com/openhouse, and I can't wait to see your face. And if you are listening to this after November 6, still go over to that link and see when the next one is. I think I'm gonna do this again. I'll see you then. Okay. Onto the episode.
Patricia Sung [00:26:06]:
So I don't know how much you can speak to what has not been published yet. But is there more information in there about the emotional regulation and energy regulation that we often see as women with ADHD compared to what's available now in the diagnostic criteria?
David W. Goodman [00:26:23]:
Right. So that's an interesting question. One would say over the last 15 years, emotion dysregulation has been recognized as a symptom of ADHD. But you have to keep in mind that emotional dysregulation is what we call transdiagnostic. That is you can see emotional dysregulation in high levels of anxiety, in depression, in bipolar disorder, in PTSD. So you can't look at a single psychological symptom and say that's diagnostic. It's transdiagnosis. It's over the course.
David W. Goodman [00:26:59]:
So it's an overlapping symptom. However, ADHD does have emotional dysregulation as a part of its constellation of symptoms. The research, though, has only evolved over the last 15 or 20 years. So the DSM 5, the Diagnostic and Statistical Manual 5, which is the American Psychiatric Association's diagnostic manual, was published in 2013. There's a lot of research that's come out since the DSM 6, which will probably be published in 2 to 3 years from now, hopefully, will reconsider whether emotional dysregulation is part of the diagnostic criteria. What we do know is that emotional dysregulation tracks with ADHD symptoms, if you have ADHD. And that if you're prescribed ADHD medication, a stimulant or a non stimulant, emotional dysregulation improves along with the cognitive symptoms. So this idea that you shouldn't prescribe a stimulant medication to an ADHD person that's very anxious or very emotionally reactive is just mythology, and it's not borne out by the research.
Patricia Sung [00:28:05]:
That's good to know because I think that's something that a lot of people hear and knowing that what you need may not be what you're being told and finding that clinician who truly understands and is listening thoroughly to figure out what you really need and not a blanket statement. And having that really good conversation, which is, I mean, hard to do when you don't have a lot of time, but finding someone who really is gonna ask you the tough questions and dig in to figure out what's really going on underneath it and that that there's not a blanket rule of like, oh, you're too anxious. No. You can't. That's not good for you. That everybody's different and everyone needs different things. So, like, y'all, get a second opinion. I always tell people, just just if you feel if you leave the doctor's office and you don't feel good about that conversation, get a second opinion.
Patricia Sung [00:28:50]:
Like, you don't have to just accept whatever the first thing is that you came across. Now do you need 14 opinions? No. You don't. But you should feel good when you left that office that that person really asked you good questions and cared to know what was going on with you when you leave. So
David W. Goodman [00:29:05]:
So I wanna qualify that. I I think what you said is very important. I wanna add a layer of insight to that.
Patricia Sung [00:29:12]:
Okay.
David W. Goodman [00:29:13]:
If you're a patient and you go to see a clinician, if the clinician has good bedside manner, you're gonna feel emotionally good about the conversation. But I would tell you, separate out the feeling you have towards the person from the objective interview. Did the person ask you a lot of questions in order to explore your psychological experience? Because that becomes the measure of whether the person has accessed enough and appropriate information in order to come to a diagnostic conclusion. That's really important. And the other aspect here is you say, well, get a second opinion. You know, it's not like the McDonald's drive thru where you can easily pick up your burger, Coke, and fries. Getting second opinions from knowledgeable people is not always so easy because these professionals are not in your community. One of the advantages of telehealth is that you can do a telehealth evaluation with someone who has the credentials to do what it is you need them to do for you.
David W. Goodman [00:30:20]:
So I would say that your clinician, your practitioner, your provider doesn't necessarily need to be in your geographic area if you're trying to access an expert.
Patricia Sung [00:30:30]:
Yeah. That's gonna encourage that. For me so I live in Houston, which is, you know, quite the medical center, capital of the the US, and I am lucky to be in a city that has many options. But to know that if you don't, that's the beauty of the Internet now. You can find somebody who is a good fit for you, and they don't have to be within an hour drive.
David W. Goodman [00:30:52]:
Yeah. We need to be mindful of those people who don't live in major metropolitan centers. I live in Baltimore. I'm on faculty at Johns Hopkins. I have access to some of the best people in the nation or the world. But keep in mind, there are suburban communities and and a lot of rural communities that say, well, you know, that information is great, but I can't do anything with it because I have to drive 3 hours to see someone, and that's not possible. So I'm just mindful of that. That's where telehealth comes.
David W. Goodman [00:31:21]:
And if you look up some experts and then call their office and say, chi, will you do a telehealth consultation and send me a report? And you'd be surprised. A lot of people would say they're happy to do it.
Patricia Sung [00:31:31]:
Yeah. No. Anytime we can get more resources out there, I want people to know that they have options there. I was like, well, I'm asking so many questions. I'm like, I didn't even get to perimenopause, and this is why we're here. Okay. So when we think about perimenopause, if you can give me, like, the teeny tiny version of, like, what is perimenopause? Just in case the mom listening is like, I don't even know what that is. Like, the mini version of, like, what it is and what to look for, but then how is that change in your body going to affect your ADHD as you move through life?
David W. Goodman [00:32:03]:
So the global concept here is to what degree the fluctuations of hormones affect cognitive and emotional symptoms directly associated with ADHD. And so that global issue then extends to menses, pregnancy, perimenopause. Those are probably the three most important hormonal events in a woman's life. Let me talk about perimenopause. Perimenopause is as women get older, your hormones change. The most critical here is that estrogen declines. As estrogen declines, some women, not all, experience physiologic symptoms, hot flashes, changes in sleep pattern. They experience emotional changes, sensitivity, reactivity, annoyance, depression.
David W. Goodman [00:32:51]:
They experience mental symptoms, cognitive inattention, forgetfulness, misplacing things. It happens variable across women. But if you're going through this, perimenopause is the 3 to 5 years before the end of a regular period. And as that relates to ADHD, I would like to tell you there's a lot of research. There's not a single randomized controlled trial of any pharmaceutical agent on ADHD and perimenopause. Now think about that for a moment. If you wanted a statement for diversity and research, there's almost no research on ADHD and perimenopause. There's a fair amount of research on ADHD medication in pregnancy, although not adequate.
David W. Goodman [00:33:38]:
And there's no research on ADHD and perimenopause. So when I offer my expert opinions, it's very much based on having taken care of patients for 40 years and thousands of patients and trying to seam together all of those experiences. The interesting thing about hormones, and women in particular, is you understand that there's a reason women have hormones. It controls a variety of aspects. Well, you have hormone receptors in your brain, estrogen and progesterone, in your brain. So you have a fundamental area of your brain, deep in your brain, and that's where a lot of those receptors are. But there are actually estrogen and progesterone receptors in the prefrontal cortex. So right in front of your the front part of your brain, which is responsible for attention, emotional control, impulse control, executive function, being able to remember and manipulate information.
David W. Goodman [00:34:31]:
As your estrogen declines, that prefrontal area gets affected. And so we can extrapolate that, yes, this is why women are experiencing these symptoms. And, hopefully, your listeners are coming to the understanding that this is happening to my body. This is not who I am. You know, you're not being b I t c h y because that's who you are. This is happening because the hormone changes in your brain are leaving you unable to regulate your mood in a more consistent fashion. Now that doesn't mean you abdicate responsibility for managing yourself appropriately. But at least, again, it goes back to the point I made earlier, being able to distinguish, who you are from what you have and then seek treatment and counseling, in order to do that.
David W. Goodman [00:35:22]:
If the listeners are saying, well, that's all very well and good, but, you know, tell me what I should do about it. From a medical perspective, there are 2 things. 1 is you can go on hormone replacement therapy for 3 months and see whether that changes and then decide with your GYN whether that's appropriate. There are breast cancer risks and a variety of other risks associated with that. But if you were to do that for 3 months and it significantly improved, you at least have the answer. Mhmm. For ADHD individuals, let's say I have a woman, I've been treating for 10 years, she's on ADHD medication, and now she's in perimenopause and complaining that her ADHD is worse. At that point, the question is, do we try hormone replacement therapy, or do we increase the ADHD medication? I would like to point to a piece of published peer reviewed scientific evidence that tells me what to do, and there's not a single paper on this.
David W. Goodman [00:36:13]:
And so I have to make the clinical decision. Do we try hormone replacement first, or do we try increasing the ADHD medication? I know there wasn't a thumbnail, but it was comprehensive. Let me medication? I know that wasn't a thumbnail, but it was comprehensive.
Patricia Sung [00:36:23]:
Well, the problem is I would ask you 53 more questions, and we would talk about it for an hour and 20 minutes. And I know I don't get you for that long, so I'm like, I gotta rein myself in too. One of the moms in my community asked, Katie wanted to know, like, is there any I mean, obviously, we know there's no evidence because there's no reports. But in your experience, can estrogen support help during perimenopause? And, like, how is that different from hormone replacement therapy?
David W. Goodman [00:36:50]:
So hormone replacement therapy is the generic for estrogen replacement.
Patricia Sung [00:36:54]:
Oh, okay.
David W. Goodman [00:36:54]:
And there's a variety of combination of medications. This is beyond my bailiwick, so your GYN would be able to walk you through what options were available, especially given any risk factors you might have for using in combination estrogen progesterone or whether you use just estrogen. So this is an issue with GYN. Now if your GYN rolls their eyes and dismisses you, that may be time to reconsider who you see. I won't make gender disparaging remarks, but I will say, in general, it is my opinion there is a clinical bias in approaching women with symptoms versus men. There is a body of medical literature that would support that. And so it really is important to have your clinician, your provider understand the medical aspects of your psychological experience and not simply discount this as a psychological state and conflicts and stress environmental stresses and go see a therapist. While seeing a therapist can be useful, let's try to keep in mind, again, the difference between what's happening medical
Patricia Sung [00:38:00]:
Right.
David W. Goodman [00:38:00]:
What's happening psychologically.
Patricia Sung [00:38:02]:
And I think that's part of the confusion is, like, for those of us who don't have a medical background, how do we know which person we ask for what things? And knowing, do I talk about this with my psychiatrist? Do I talk about this with my gynecologist? Do I talk about this with my therapist? Where do we start when we're having these conversations? So to know that when it comes to hormones, start with your gynecologist. That's but also having that conversation with your psychiatrist at the same time is, like, how do we pull those together and make sure that we're all working on the same page?
David W. Goodman [00:38:31]:
I would give you two factors to consider. 1 is the knowledge base and training that the person has, which you can assess by asking them a series of questions. What's your experience? Are you comfortable with? So that's the medical content and training. And the other aspect is, do you feel as though they're listening and understand, or are they being dismissive? Now they may be being dismissive because there really isn't anything substantial there. And this is a person who's overinvested, exaggerating, distressed, which doesn't have a medical basis for it. But you wanna get a feel as to whether or not your provider is listening and understanding, complemented by the wealth and depth of their training and experience. Going back to your question, who should I tell, the GYN, the primary care, the psychiatrist? I would tell everybody and see what their response is. As a psychiatrist, I'd like to say the psychiatrist is probably gonna be the most responsive, but, that's not always the case.
David W. Goodman [00:39:31]:
So, talk to as many people as you can.
Patricia Sung [00:39:34]:
Alright. And then I mean, it's such a huge topic, And you've mentioned some of the things we can start doing. What else can we do to support ourselves during this transition of moving into perimenopause and seeing how your ADHD is changing? What else can we do to support that?
David W. Goodman [00:39:49]:
I think the first step here is to understand a lot of the information that I convey today, to understand what the future may hold, to anticipate that, and to put in scaffolding and supports and compensatory mechanisms and psychological insight in order to plan that potential for the future. That's the first order of business. Education, education, education. Trying to learn what this is and what it's not. Being able to be able to distinguish accurate information from misinformation, being able to judge sources of accurate information from inaccurate information. You know, if you want, if you want accurate information in the area of ADHD, you go to the American Professional Society For ADHD and Related Disorders, which is a professional association, or you go to children and adults with ADHD association with a which is a patient oriented national association. And all the information that they provide is vetted and accurate. From there, there are resources they will give you, and that keeps you in the lane of accurate information.
David W. Goodman [00:40:54]:
What can you do specifically? If you live with someone, there ought to be a conversation about where you are and what's affecting your ability to function. Hopefully, your partner, your family member, whoever you live with is receptive and will be helpful and supportive by saying, what can I do that would be helpful? And then coming up with very specific mechanisms and compensatory skills at home. One of the dynamic in partnerships is that the non ADHD spouse or partner will start offering reminders and information. The ADHD individual hears it as criticism and reacts defensively. There needs to be a conversation about partnership. I understand these are where your deficits are. Here's how I can try to help. How would you like me to be helpful? In return, you need to sign on to the fact that I'm here to be helpful, and I'm not criticizing you because you left the refrigerator open or you left the keys outside on the lawn.
Patricia Sung [00:41:56]:
So in the way that things start changing, is it could we categorize it as all the things just seem like more, like symptoms are just magnified, or are there changes in the way that your ADHD shows up that would make it feel different than how it was before?
David W. Goodman [00:42:12]:
The symptoms are magnified. It's not that the symptoms change or the experience of the symptoms change. The symptoms are magnified. Now the symptoms of ADHD will be experienced as worse in part because if estrogen is declining, the symptoms are worse. What is most important, though, beyond the symptoms is the impairment that it causes. So if the environmental demands are still strenuous, your impairment, your ability to execute is gonna be compromised, and you're gonna feel badly about that. If you can reduce the environmental demands so that the impairments are not so evident, then that's what would be best. You can do that within the confines of the demands of your life.
Patricia Sung [00:42:55]:
Okay. I have 75 more questions, but I'm gonna do one more and then we'll we'll wrap up. So the last one I have for you, doctor Goodman, is, again, from my community, Heather asked about how do we adjust to these changing cycles? Because a lot of women with ADHD have learned to cycle sync and adjust their life to match along with how their hormones are already going. But then once your cycle starts to change, all of a sudden your plan goes out the window. Do you have any advice to offer in those times where things are shifting where we can then still support ourselves?
David W. Goodman [00:43:26]:
It's a tough question because every woman is different, circumstances of their lives are different, and the environmental demands are a bit different. In this regard, I think working with an ADHD therapist is really helpful, that they can provide additional resources, tools, compensatory skills, auditory cues to reorient you, visual cues to remind you of where you are. The smartphone now is smarter than me. My smartphone knows more than I do, and I use my smartphone as the executive manager. So I use Siri to dictate. This idea of punching in data with your thumbs, very, very slow and inefficient. If you can use Siri or whatever your voice recognition software is to dictate into the phone any thought that crosses your mind for which you're gonna have to remember it at some point later, I just use my phone now and dictate it into my phone and say, Siri, remind me at 8 o'clock. Pick up the dry cleaning or etcetera, etcetera, etcetera.
David W. Goodman [00:44:30]:
Once you discharge the thought into a memory bank, then you don't have to worry that you're gonna forget it. There's so much of the distress occurs from the worrying that I've forgotten something. You know, so many people with ADHD walk around their day saying, you know, I I know I forgot something. Well, you're right. You probably did forget something. The problem here is you can't remember whether it was important or whether it was not really important.
Patricia Sung [00:44:56]:
Yes. That is, I say I laugh like, yes. How much of our day is going to worry about what what I might have forgotten possibly is humorous? Okay. So before we do our lightning round questions, is there a way for people to keep up with you and your work and support what you're doing?
David W. Goodman [00:45:15]:
Well, I appreciate that question, and I wish I could tell you I'm so socially media savvy that you could find me all over. But the reality is that I'm not. And so ways to stay in touch with me, I have a nonprofit foundation called My ADHD Foundation that leads an effort to research and collaboration, efforts in the in the practice guideline development. You can do Google searches on me. There are YouTube videos from a number of conferences. There may be one that goes through in detail everything that we've discussed much more at a clinical and scientific basis. I haven't written any books that are out that I could prompt you to buy, but I appreciate this. Look.
David W. Goodman [00:46:04]:
Patricia, hopefully, you've had the same experience I have. It's been a lot of fun. And, look, you have so many more questions that, you know, maybe in 6 months, we do this again. If your if your listeners give you feedback and say, hey. You know? Bring this guy back because we're not done with him.
Patricia Sung [00:46:20]:
I would absolutely love that. Thank you. Yeah. Whenever I can find someone who can convey all of this scientific data, but in a digestible yet interesting way is like, because our we love learning about all this stuff, but also our brains can only hold so much information. And also, I I've talked to some people who are not very exciting. And then the people that are gonna tear it out after a while. So I I so appreciate it. Okay.
Patricia Sung [00:46:45]:
I just have my lightning round questions. So you don't think too hard. Just spit out an answer Okay. And we'll wrap up. So number 1, we're just fill in the blank. The best thing I've read or listened to recently is?
David W. Goodman [00:46:57]:
A book on Taoism by Lao Tzu Mhmm. If you wanna change your perspective from a western theologic perspective, read something about Buddhism or read something about Taoism. It's a vastly different perspective, and you realize the world doesn't revolve around western civilization.
Patricia Sung [00:47:21]:
Number 2. My most boring about me fact is
David W. Goodman [00:47:25]:
There's nothing boring about me. I'm sorry to say. My friends invite me to parties solely for the entertainment. My colleagues invite me to give talks not because I'm particularly smart, but because my jokes are funnier than everyone else's.
Patricia Sung [00:47:41]:
So What's your favorite joke?
David W. Goodman [00:47:42]:
None of which I probably can say on a public podcast. My favorite joke. Okay. You're gonna edit this out, but I'm gonna give it to you anyway. You might actually include it. So my patient goes to the pharmacy, and, the pharmacist says, look. We don't have your we don't have your Adderall today. Come back in 3 days.
David W. Goodman [00:47:59]:
So she frustrated. She walks away, and she comes back in 3 days. And the pharmacist, says, I am really sorry. We still don't have it. And she's furious. I mean, you don't understand. I'm gonna lose my job. He says, I can't do anything about it.
David W. Goodman [00:48:10]:
You should come back in a week. So she comes back in a week, and he doesn't even say anything. And she just sees by his face that he doesn't have it. And she launches into him, and he says, calm down. Calm down. Let's do a spelling test. Can you spell Concert in Concerta? C o n c e r t. Great.
David W. Goodman [00:48:26]:
Can you spell Rita in Ritalin, r I t a? Can you spell f as in Adderall? And she says, there's no f in Adderall. He says exactly my point. I have to be careful to articulate that joke, but you you can edit that out.
Patricia Sung [00:48:47]:
Well, I mean, I probably won't edit it out if you don't want me to. But
David W. Goodman [00:48:49]:
You don't have to edit it out. I enunciated it in such a way that the point is made with and I can claim plausible deniability.
Patricia Sung [00:48:57]:
And then okay. Where did I oh, wait. Okay. On track. 3, when I'm having a rough day, my go to quote, song, poem, book, podcast, activity, whatever is
David W. Goodman [00:49:08]:
I'm a big believer in Mark Twain. So he said, if you're in a bad mood, go for a walk. And if you come back and you're in a bad mood, go for a walk.
Patricia Sung [00:49:17]:
Number 4. Don't tell anyone I So
David W. Goodman [00:49:21]:
the answer to that question is gonna be available to the public. And if you if the question is don't tell anybody I, I've just told everybody that that I don't tell anybody don't tell anybody that I really enjoy doing what I do and and the decades in which I've been privileged enough to help not only thousands of patients, tens of thousands of families, hundreds of thousands of families that are treated by clinicians that I've educated over the last 30 years.
Patricia Sung [00:49:53]:
Number 5. If I had a magic fairy wand for one spell, I would
David W. Goodman [00:49:58]:
I would hit the planet Earth in a way that everyone would have psychological self awareness.
Patricia Sung [00:50:07]:
And final one, my best piece of advice for mamas with ADHD is?
David W. Goodman [00:50:12]:
Identify the supportive people in your life and to keep them close to you while expressing your appreciation for their belief in
Patricia Sung [00:50:23]:
you. Dr. Goodman, thank you so much for being here. Immediately, when you said that, I just pictured all the families that you have affected and the ripple out effect of the clinicians that you have trained and how you have shared this information with so many people and how that has just expanded and expanded and expanded to create huge change in so many families. So I thank you, not just for the time that you spent with us today, but just all the work that you're doing to support me and the people that I work with and anyone listening that, it really does make a difference, and we appreciate you. Thank you so much.
David W. Goodman [00:50:58]:
Thanks, Patricia. I appreciate being invited, and hopefully those listening will come to this conclusion they've learned something and that there are good clinicians out there who can provide satisfactory care to you and your family.
Patricia Sung [00:51:10]:
Thank you so much.
Patricia Sung [00:51:12]:
For more resources, classes, and community, head over to my website, motherhoodinadhd.com.