Eating disorders and teens; explaining ADHD; bedtime for babies: Upstate Medical University's 'HealthLink on Air' for Sunday, Nov. 26, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," we'll take an in-depth look at why eating disorders are affecting so many young people.

Nurse practitioner Davia Moss: ... Eating disorders thrive on isolation. Often it starts as a matter of control. And these teenagers lost a lot of control in their life. They were home and had more time to pour their energy that typically would've gone into school or socializing, maybe into exercise. Then you add the social media piece to things. ...

Host Amber Smith: And we'll meet the Upstate researcher who is known worldwide for his investigations of attention-deficit/hyperactivity disorder.

Stephen Faraone, PhD: ... My first major was in comparative literature, and as I was taking some other courses to round out my liberal arts degree, I became interested in psychology. ...

Host Amber Smith: All that, advice about helping a toddler sleep through the night, plus a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, a pediatrician gives some quick tips for helping a toddler sleep through the night.

Then, attracted Dr. Stephen Faraone to the field of medical research?

But first, a nurse practitioner specializing in adolescent medicine discusses how eating disorders are diagnosed and treated.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Eating disorders have one of the highest mortality rates in all of psychiatry, with 12 times higher death rates in 15- to 24-year-olds than any other cause. It's a crisis that's part of the nation's mental health crisis. Here to talk about care of patients with eating disorders is Davia Moss, who is a family nurse practitioner specializing in adolescent medicine at Upstate. Welcome to "HealthLink on Air."

Nurse practitioner Davia Moss: Hi, Amber. Thank you so much.

Host Amber Smith: Let's start by defining what qualifies as an eating disorder. What are the main types of eating disorders?

Nurse practitioner Davia Moss: So the diagnoses that people have probably heard of are anorexia nervosa, bulimia nervosa and binge eating disorder. There is also a newer diagnosis that the letters we use are ARFID, (Avoidant/Restrictive Food Intake Disorder.) Sometimes we see this in younger patients. We see it with patients who have maybe sensory difficulties with different foods and they can have a very restrictive eating, without the body image concerns. So those would be the most common diagnoses that you would hear.

Host Amber Smith: You mentioned anorexia, bulimia, and binge eating. Do those all have body image tied up in them, or how do they differ from one another?

Nurse practitioner Davia Moss: Anorexia nervosa is probably what everyone pictures when we think of eating disorders, when we see an emaciated body, that's sort of our stereotypical eating disorder, which actually does not apply to majority of people with an eating disorder, that sort of visual that we have.

Anorexia nervosa has restrictive patterns of eating. Also very significant body image concerns. Bulimia nervosa has a binge and then intentional vomiting, which some people call purging after eating. So that would be the difference there.

And then a binge eating disorder is where people actually feel out of control with food and often are not able to control how much intake they have.

Host Amber Smith: How prevalent are these eating disorders?

Nurse practitioner Davia Moss: The numbers are changing rapidly. You can look at a hundred different sources, anywhere from 5 to 10% in the general population. However, we know there that there are certain populations that are underdiagnosed significantly, in particular males. Populations of color are often underdiagnosed. And certainly as you spoke to during this crisis, we will see those numbers change rapidly as more data comes out in the next few years.

Host Amber Smith: Is it mostly adolescents? Are you seeing a lot of this in your patients?

Nurse practitioner Davia Moss: We are seeing an enormous increase in our patients, both in our outpatient clinic and in the hospital. The number of patients that we have had to hospitalize has gone up by about four- to fivefold throughout this crisis.

Host Amber Smith: Do we know what this is all about or what is causing it?

Nurse practitioner Davia Moss: Eating disorders thrive on isolation. Often it starts as a matter of control. And as we all know, these teenagers lost a lot of control in their life, and they were home and had more time to pour their energy that typically would've gone into school or socializing, maybe into exercise. Then you add the social media piece to things. It often started as, I will quote, because I hear this from a lot of my patients, they will say they were "just trying to get healthier and then somewhere along the line things became out of control."

Host Amber Smith: Are student athletes more at risk for eating disorders because they focus on the performance of their bodies?

Nurse practitioner Davia Moss: There are certain sports that we know for sure are at higher risk. There are certain sports that actually require a weigh-in. So wrestling, rowing, those things are certainly a higher risk. And sometimes you'll see more eating disorder behaviors during the season. And then there are other sports that actually, focus on body image -- cross country running, dance, ballet. Those are definitely higher-risk activities that we see in our population.

Host Amber Smith: And the ones that got started trying to eat healthy, were they trying to lose weight or trying to bulk up and be more muscular? Because I hear a lot about protein powders, and "health food" stores are popular with adolescents now.

Nurse practitioner Davia Moss: Yeah, our diet culture is really, really incredible. And to be honest, there's no reason for any adolescent to be on a, quote, diet. Their brains are not capable of balance, so it often can get very quickly out of control. The other tricky part is they often get a lot of positive feedback when their body starts to change. And for an adolescent, they really thrive off that, and that's when things can get very out of control pretty quickly.

Host Amber Smith: Are close friends at risk? If you have someone that you're close to who's dealing with an eating disorder, are you vulnerable to developing this disorder as well?

Nurse practitioner Davia Moss: That's a great question. I don't know any particular data on that. I would say I don't see it anecdotally. There is a huge genetic component. We do know that if a parent had an eating disorder or a grandparent had an eating disorder that that does put you at risk for an eating disorder.

Host Amber Smith: Eating disorders are the third most common chronic health condition for children and adolescents, behind asthma and obesity. It was not always that way. Is the pandemic to blame for this?

Nurse practitioner Davia Moss: The pandemic, combined with social media, combined with our diet culture has sort of been a perfect storm to create this crisis of eating disorders. Absolutely.

Host Amber Smith: How is it that eating disorders have such a high mortality rate, though? You said a lot of your patients end up hospitalized. How do you go from binging and purging or whatever to needing to be hospitalized?

Nurse practitioner Davia Moss: So the patients that are hospitalized are often the ones that are restricting to very, very significant, under 500 calories a day, over exercising. They can have long-term cardiac, when I say sequelae, those are sort of symptoms that you could deal with for a very long period of time. So cardiac (and) things having to do with the gut, with the GI (gastrointestinal) system. We have patients that abuse laxatives, which can actually impact the ability of your GI tract to even function correctly for the rest of your life.

Patients will have frequent, the term is syncopal episode, where they pass out. Unfortunately sometimes it's seen as normal for a teenage girl to pass out. If that's happening more than once, that should be followed by a medical provider. It can go downhill very quickly, and they're at a time of rapid growth in their life.

Host Amber Smith: How would a person know they have an eating disorder?

Nurse practitioner Davia Moss: I'm going to focus in on the adolescent population for right this second because that's what I work with. And I think we really depend on the caregivers, parents, teachers, guidance counselors to be able to hone in on if something is changing in a child, if we notice that their body is changing dramatically, that's a red flag. If we notice that their attention concentration is changing, their fatigue levels, if they're starting to isolate themselves more, suddenly wanting to exercise more often. All of those are red flags that should be followed up on.

Host Amber Smith: Is it normal though for teens to have concerns about their appearance or weight? I thought that was sort of part of growing up?

Nurse practitioner Davia Moss: It's very normal to have concerns of our body. Unfortunately, actually, the concerns about weight are really this diet culture that we currently live in. You know, the other crisis is obesity. And unfortunately sometimes when our medical providers really hone in on obesity being a weight issue, depending on how we discuss those things with our teenagers, that can actually send the wrong message.

So you know, medicine is constantly evolving, and changing how we communicate with our kids about their bodies is very important.

Host Amber Smith: So are eating disorders usually diagnosed by the primary care provider, someone like yourself?

Nurse practitioner Davia Moss: I'm not a primary care provider. We're the specialty, so usually we receive the consult from the primary care providers. But certainly in a well-child check, if an adolescent has lost weight since their last visit, there needs to be a conversation.

Often parents notice these things before the pediatricians because teens don't go to the general provider often. It can be once a year. During COVID, it was even less than that. So it can depend. Sometimes it's a teacher, sometimes it's a guidance counselor, sometimes it's a coach. But certainly, yes, we definitely depend on our primary care providers to make that call.

Host Amber Smith: Is this something that can be handled without medical intervention? Can a family solve this on their own?

Nurse practitioner Davia Moss: Family-based therapy is actually the strongest evidence for healing an eating disorder, but also you need a mental health provider to help guide you through that.

There are certainly books out there, and I'm sure there are families that have made this happen on their own and helped their child turn it around. But support for the family and the patient is really important to help those relationships stay intact through a really difficult time.

Host Amber Smith: How would you recommend someone prepare for a medical appointment if they're coming to talk about eating disorders? What should they bring with them or be prepared to answer?

Nurse practitioner Davia Moss: We hopefully will have records from their primary care provider or whoever referred them, which shows weights, which is not all the information we need, but that is a huge indicator and often the first sort of red flag that will bring them into our office.

We do, it's called a blind weight, so our patients step onto the scale backward, and we do not show them what their weight is in our office. And if, honestly, if there's any question, even if someone was sent to us for a different diagnosis, if there's any question that this might be a difficult topic for the patient, we do a blind weight.

This is followed by orthostatic vital signs, which is a heart rate and a blood pressure in different positions. Often when we have malnutrition, when we go from laying to sitting to standing, our body doesn't do what it's supposed to do, so we can have dizziness, our blood pressure can drop, our heart rate can change significantly, and those are really big indicators that we're not getting enough nutrition.

Host Amber Smith: Is there any other medical testing that has to be done, or imaging or blood work?

Nurse practitioner Davia Moss: There's no imaging. We do have some blood work done on our patients. Our bodies are very, very good at keeping us stable. So often, blood work can look normal, and that's a good thing.

For patients that are hospitalized, when we start refeeding them -- meaning start giving them nutrition again -- there is a syndrome called refeeding syndrome that can be fatal. It's rare, but because it can be fatal, we're very careful to watch what happens to their electrolytes. That's things like magnesium, phosphorus, sodium that's in our bodies, and we keep an eye on those things to make sure they stay within normal limits.

Host Amber Smith: Can eating disorders be successfully treated, or can they be cured?

Nurse practitioner Davia Moss: They can. It's actually only about a third of our patients are truly cured. Some providers say it's similar to addiction, where you say you're continually in recovery. Some patients that I'm still in touch with that are in adulthood say that they truly are cured, and they don't -- what we refer to as the "eating disorder voice." It really can be a pretty cruel voice in their head -- and they find that that voice truly goes away. But it is a small, small amount of people that have true recovery. Some deal with this chronically through the rest of their lives, and some do succumb to their illness.

Host Amber Smith: So what's involved generally in the treatment?

Nurse practitioner Davia Moss: The most important thing is nutrition. We always say food is their medicine. Sometimes it involves SSRIs (selective serotonin reuptake inhibitors) or other antidepressants, anti-anxieties. These medicines actually don't work if you are malnourished. You need a chemical called serotonin, and when we're malnourished, we actually don't produce enough serotonin.

So that can be really, really discouraging, especially for parents that, it's just terrible to watch their child getting sicker and sicker. And unfortunately, food is their main medicine, and the food is the most difficult part for their child.

Host Amber Smith: So is nutrition education... are there classes or guides that the patient learns?

Nurse practitioner Davia Moss: We have a couple of dietitians that we work with that have experience with eating disorders. You really want to make sure that your dietitian has experience with eating disorders because unfortunately, there are dietitians out there that do focus on weight loss and are more focused on the diet culture. So you want to make sure that your dietician has that knowledge, so they're able to help with nutrition counseling as you're going through that process.

Host Amber Smith: What about psychotherapy? Is that always a component of this?

Nurse practitioner Davia Moss: Always, both for the patient and the family. The more that the family can be involved and help understand the underlying symptoms that have led to this eating disorder, the better the patient can do.

Host Amber Smith: Are there therapists that specialize in eating disorders?

Nurse practitioner Davia Moss: Yes. We work with a number of therapists in our region that are specialized in eating disorders. And it's so crucial that as a team we collaborate. We often are emailing after every appointment, so we are all on the same page. Eating disorders are very, very, very powerful, and they can almost convince the patient that one part of the team, one provider and the team, is bad versus another member of the team. So it's really important the team is on the same page to make sure we can provide the best care for the patient.

Host Amber Smith: Upstate's "HealthLink on Air" will take a short break, but please stay tuned for more about eating disorders with nurse practitioner Davia Moss.

Welcome back to Upstate's "HealthLink on Air" with your host, Amber Smith.

My guest is Davia Moss. She's a family nurse practitioner who specializes in adolescent medicine at Upstate, and we've been talking about the crisis of eating disorders.

What happens to someone who has an eating disorder that goes untreated?

Nurse practitioner Davia Moss: The longer a patient stays in an active eating disorder, the likelihood that they will recover from their eating disorder actually quickly declines. So the faster that we can find the eating disorder and treat the eating disorder, the better they do. The younger that we can address it, the better that they do.

We do have some patients that if they are not doing well with outpatient, which is what I do, they may need something called either partial hospitalization, which is like a full-time day program or residential treatment, which was when they live there for anywhere from six to 12 weeks while they're recovering.

Host Amber Smith: When you have someone that you're treating, do you ask them to limit their social media usage or television, or are there things in the home environment that you try to shape for them?

Nurse practitioner Davia Moss: We try to find the balance of quality of life for teenagers. Social media is a huge piece of quality of life for them. So I think that piece is for the therapist to discuss what might be, we use the word "triggering" for a patient, and what is helpful. I think it's the same as, are these friendships toxic to your life, or are these friendships helpful? So those conversations are definitely important.

Exercise can be the same thing. Finding the balance of pulling a patient from their activities that they love so much, but recognizing what's actually helpful to their body at that time.

Host Amber Smith: Well, I want to ask you also about some of the medical side effects that come along, often, with eating disorders. Electrolyte imbalances, is that something that can be managed in the outpatient setting?

Nurse practitioner Davia Moss: Yes. So depending on how sick a patient is guides us on how often we might be doing blood work, or if we have patients waiting for a bed and residential treatment, especially through this crisis right now, we will do blood work more often. Sometimes we have them replacing electrolytes with things like Gatorade, eating foods with more salt, such as pretzels, what we know they can tolerate. That's sort of more like crisis management while we're waiting to get them to a higher level of care. EKGs, meaning we actually put stickers on the chest so we can get a picture of the electrical activity in the heart, is also something very important that we keep an eye on, in the outpatient setting.

Host Amber Smith: How common are digestive problems like constipation or diarrhea?

Nurse practitioner Davia Moss: Very, very common. Constipation is much more common. Obviously the less you eat, the slower your gut is working. And then our patients that have abused laxatives or maybe diet pills can impact our gut for long-term use.

Host Amber Smith: For the female patients, do they typically have menstrual problems as well?

Nurse practitioner Davia Moss: They can. They can lose their menses for numerous months, which can impact their bone density. After losing their menses for about six months, we will do a bone density scan. Although truly bone density scans, we can't read them very well for adolescents because their bones are different. We only gain our bone density until about 22 years old. So if we don't treat that eating disorder and get them back on track and get their hormones such as estrogen back to the healthy levels, they can impact their bone density for the rest of their life.

Host Amber Smith: What about tooth erosion, cavities? Does this impact dental care as well?

Nurse practitioner Davia Moss: Absolutely. That's something we look at in our physical exam. That typically happens in our patients that are self-induced vomiting. And there are also patients that, if they're trying to decrease the amount of laxatives they're using, they actually can have unintentional vomiting. So dental care is very important.

Host Amber Smith: Well, knowing that this is such a risk for adolescents, is there anything that parents can do to try to prevent an eating disorder from developing in the first place?

Nurse practitioner Davia Moss: I think, 1. the culture we create in our house, how we talk about food, how we talk about good foods, bad foods, how we talk about dieting. If our parents are dieting frequently, throughout their lives, that's a huge risk factor for these kids. And then it makes you wonder, does the parent themselves just have an eating disorder that was never addressed? So absolutely creating the culture, being careful of how we talk about bodies in general.

I have a number of patients that were told when they were young, that they were so skinny, and the minute they hit adolescence, which is very normal, all of a sudden they stopped hearing that, and that was the trigger. That was all they needed to go down the path of an eating disorder.

Host Amber Smith: Are there triggers like that -- for someone who's treated as an adolescent and 10 years later, 20 years later -- are there triggers that may make the eating disorder return?

Nurse practitioner Davia Moss: Yes. Especially in the female population, think pregnancy, body changes, even just stressors, going off to college, being in another environment that's full of diet culture, being surrounded by other people that may have an eating disorder that was never addressed. Absolutely those are things that we try to prepare them for as they move into the recovery phase of their eating disorder. We then try to move into having conversations about the triggers that will happen throughout their life.

Host Amber Smith: So someone who's in recovery from an eating disorder, does that set them up for other medical problems later in life? Not the ones that you would treat actively, but later on. If you have a history of eating disorders, would your primary care doctor need to be thinking about other things that might come up?

Nurse practitioner Davia Moss: It would be very important for a primary care provider to know if an adult did have an eating disorder as an adolescent.

We can certainly see from a mental health perspective, you can see OCD (obsessive compulsive disorder) symptoms, significant anxiety. We can see fertility difficulties, again, bone density difficulties. And of course those need to be addressed, maybe in a 30-year-old, where typically an internal medicine provider would not think to address that until much older.

Host Amber Smith: Do you see support groups for people with eating disorders?

Nurse practitioner Davia Moss: There are support groups. There's not enough. as we know in this mental health crisis in general, there's just not enough.

I think the biggest thing to look out for, for support groups, especially if you're a parent looking for a support group for your kid, is to know what stage of recovery the other members of the group are in. Because, of course, this could be very triggering if one patient is not in a state of recovery and maybe not healthy, doesn't have that support at home. That's definitely something to be aware of.

Host Amber Smith: It's got to be tricky to learn, if you've dealt with an eating disorder, to then learn how to eat healthy because you're focusing on food again to do that, right?

Nurse practitioner Davia Moss: Yes. So I think there's a balance. People use the term "intuitive eating," and that is sort of, I would say, the end of the road in recovery, to truly learn how to intuitively eat.

I know there's a lot in the diet culture world about what's not healthy on our shelves, what is healthy on our shelves, and so knowing that there's a balance. And if your body is craving something, typically that means that it wants it. And often if we withhold it, eventually you end up eating more than maybe you would have if you had just given your body what it was asking for.

Host Amber Smith: Davia Moss, thank you so much for making time for this interview.

Nurse practitioner Davia Moss: Thank you, Amber.

Host Amber Smith: My guest has been family nurse practitioner Davia Moss. She specializes in adolescent medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

He's world famous for ADHD research, and we'll talk with him next -- on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

A world-renowned ADHD researcher from Upstate is ranked as one of the top 80 scientists in the world, largely because of the volume of his research into attention-deficit/hyperactivity disorder. Dr. Stephen Faraone is a distinguished professor and vice chair of research in psychiatry and behavioral sciences at Upstate, and he serves as the president of the World Federation of ADHD and the editor of the journal Neuropsychiatric Genetics.

Dr. Faraone, welcome back to "HealthLink on Air."

Stephen Faraone, PhD: Thank you, Amber. Nice to be here.

Host Amber Smith: Your bachelor's degree in psychology came from SUNY Stony Brook. Did you go into college thinking that you wanted to become a research scientist?

Stephen Faraone, PhD: I did not. Not at all. No, when I went into college, my first major was in comparative literature, and as I was taking some other courses to round out my liberal arts degree, I became interested in psychology, and I, more and more that as that interest developed and also became interested in the, I would say, scientific side of psychology, I was drawn to that and then decided to seek a graduate degree in clinical psychology after my undergraduate years.

Host Amber Smith: So the classes you took just interested you, and you followed where your interests were.

Stephen Faraone, PhD: That's really what happened, yeah.

Host Amber Smith: So then how did you choose the University of Iowa for your master's and your doctorate in clinical psychology?

Stephen Faraone, PhD: The truth behind that is, I was a poor student at the time, and they offered me the best financial package, (laughs) including one year where essentially they would pay me, but I didn't have to work at all for the pay.

Frankly, that's really what it was.

My first choice was actually to go to Purdue because there was a psychologist there I wanted to work with, and I did get accepted to Purdue, but they didn't make me as good a financial offer. So I went to University of Iowa. But after I finished my graduate work there four years later, that person I had wanted to work with had moved to Brown University, and I ended up doing my internship at Brown. So we ended up working together after all ...

Host Amber Smith: Oh, very good.

Stephen Faraone, PhD: ... and actually became lifelong friends as well. So it's a nice kind of story.

Host Amber Smith: At what point did you start getting involved in research? Was that in Iowa or at Brown?

Stephen Faraone, PhD: No, that was in Iowa. What I liked about the University of Iowa was a psychology program that was essentially oriented to producing what they would back then would call the Boulder Model psychologist, which was a classic kind of clinician that was also a good researcher but also had good clinical training. So that's where it started. And it only intensified at Brown because Brown had an internship, which, unlike most internships, allowed for us to do some research as well and continue that work.

Host Amber Smith: So what is it about science in general, and research in particular, that you like?

Stephen Faraone, PhD: The first thing is that you have a method whereby you can ask an interesting question and actually get an answer to that question. And if you're working in a field like mental health, you can get an answer that actually helps people.

And that's very rewarding. It's also rewarding to actually help people. And I used to practice as a clinical psychologist, and I don't mean to, by any means, put that down. That's a great profession to go into. Any kind of mental health profession where you're working one-to-one with people is a wonderful thing to do.

But literally, by doing research, instead of helping maybe under a thousand people in your lifetime, you can help millions -- millions -- of people by the dissemination of the work that you do. That's really one of the reasons why I ended up becoming a full-time researcher as opposed to a part-time researcher, part-time clinician.

Host Amber Smith: You've published more than 1,500 journal articles, and you're one of the scientists who are most frequently cited by other scientists. Did you ever dream that you would have so much influence as a researcher when you got started?

Stephen Faraone, PhD: (laughs) No. When I got out of graduate school, the big worry was, would I have enough data to publish papers on?

I never thought we'd have so much productivity. Now, of course, people have to understand that productivity is not just me, it's me and teams of people, teams of researchers. In some cases, some of my articles have 10, 15, 20 or more co-authors. So I would say that my influence in the field has been being able to surround myself with people that are also good and that we can produce work that is good enough that other colleagues will cite it and use it in their own work.

And that also was rewarding, and it's a very nice kind of benefit -- not benefit, but accolade -- if you hear from your colleagues that they cite your work and say, I think, it's important enough to actually influence their own work. That's a great thing.

Host Amber Smith: Which do you enjoy more: doing the actual research or sitting back and writing about it for a journal?

Stephen Faraone, PhD: I like the planning part and the disseminating part. The actual doing part, I don't like as much. It's OK, but the actual implementation part is ... in fact, in my career I've, when possible, (laughs) I've found other people that could do that, who like to do that more. I like the planning and the dissemination part mostly.

Host Amber Smith: Like you said, it's a team effort.

Stephen Faraone, PhD: It's a very big team effort, especially these days. Any kind of big science. Our Genome Wide Association Studies of ADHD, which now comprise upwards of 50,000 research participants, there's probably at least a hundred authors on that paper.

And that was an international consortium from around the world that put that together. I had the privilege to lead that consortium for about two decades. But it would never have gotten anywhere if we didn't have all these people participating. And with all sorts of expertises, like statistical genetics or clinical assessment and many more.

Host Amber Smith: You've become known all over the world for your expertise in ADHD. What sparked your interest to begin ADHD research?

Stephen Faraone, PhD: It's hard to believe that, and this is a lesson for some of the young people out there, that a lot of the directions you take in your life sometimes occur by happenstance, not by out-and-out planning.

We tend to think, oh, we can guide our lives, and we can plan everything out, and you can. But sometimes happenstance pushes you in different directions. And I was a young faculty member at Harvard Medical School back in the early '80s, and I was working mostly in a group that was doing work in schizophrenia and bipolar disorder and largely in family studies and genetics.

And during that time another young faculty member at Harvard, who was at the Mass General (Massachusetts General Hospital), came to our group and actually went to my mentor at the time, Ming Tsuang, and said, "Hey, I need your technical advice about this grant proposal I'm putting in." And he was studying kids, he was studying ADHD.

His name was a superstar.

I would vet people for him, say, is this person worth talking to or not? And if I thought they were worth talking to, he'd interview them. And this was my colleague Joe Biederman, and I said, yeah, this guy is definitely worth interviewing. You should do that.

And he came down and we met with him, and he just was very influential in getting me to turn my sights away from adult psychiatry into child psychiatry, for a few reasons. One of which was that child psychiatry back then was relatively undeveloped as far as research, compared to adult psychiatry.

They were, I would say, they were way behind in terms of solid, empirical knowledge about the disorders they were studying. So I saw a real need there. And then in my friend Joe, I just saw a colleague that I know I could work with and probably do some really good things together. And that turned out to be true because we ended up working together for almost 40 years before his, actually, his death, just a few weeks ago, ended that.

But it was a good example of how happenstance can change your career for the better.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Upstate's distinguished professor Stephen Faraone. He turned up in a ranking of top scientists by the website research.com. He's No. 80 worldwide and No. 57 nationally, and that's based largely on the number of publications and citations and some other factors.

Now, what, if anything, has surprised you the most about ADHD?

Stephen Faraone, PhD: Probably what surprises me the most is that even after four or five decades of accelerating research, there's still a lot of misunderstanding and stigma about the disorder out in the community, out on the internet, out on TikTok, where you'll get people just saying things that are just untrue about ADHD.

It's been a lightning rod for some of the anti-psychiatry forces, and that sounds Darth Vader-ish, I say anti- psychiatry forces, but I guarantee, you just Google "anti-psychiatry": You'll find many websites that are devoted to saying why psychiatry is bad, and they frequently choose childhood disorders because kids are vulnerable, and so they see that as a better way for them to recruit more people to their cause.

It's really amazing. The child psychiatric disorders, like ADHD, are as well validated as any psychiatric disorder, are as well validated as most medical disorders. And yet they continue to be stigmatized. And any listener out there who has any thought that ADHD, or any childhood disorder, somehow not real or some kind of crazy invention of psychiatry, it's just not true.

I'll send them to my website, adhdevidence.org, where I curate evidence-based information about ADHD, including an international consensus statement by leaders around the world.

That's continually the biggest surprise in my career about ADHD.

Host Amber Smith: You've contributed to the understanding of genetics in ADHD. What were your most important findings?

Stephen Faraone, PhD: I would say the most important finding was this very big group finding that required so many scientists from around the world that we could finally document with information from collecting DNA samples from people with and without ADHD that there were clear genes, that it was very clear to us, without any uncertainty. In the past there's been lot of uncertainty about which genes might be involved, but now we have certainty that at least we know 27 of the genes that are involved in ADHD.

And when I say certain, meaning the likelihood that would be overturned by future research is almost zero. In addition, this probably is maybe in terms of the most interesting scientific fact that ADHD that I've learned, is that ADHD is highly polygenic.

And what we mean by that is, back in the '80s, we thought maybe there'd be one, two, three, four genes that can account for ADHD. And if so, that would help us find treatments. Maybe even prevent the disorder by knowing who's at high risk and not at high risk. Turns out from this last paper, which just came out in Nature Genetics, that we now estimate there are probably 7,000 genomic loci that regulate ADHD.

Now I say genomic loci, not genes, because some parts of our genome aren't actually genes. They're parts of DNA that regulate other genes. I'll say genes as a shorthand, but the main point is that it's not one, two or three or 10 or a hundred. It's maybe it's as many as 7,000 is our current estimate. And that creates difficulties because it means that it's not going to be simple to track out a pathophysiological pathway or to take it into drug development, but it does have some implications for how we think about the nature of ADHD as a disorder.

Host Amber Smith: You received a Book of the Year Award in 2003 from the American Journal of Nursing for your book "Straight Talk About Your Child's Mental Health: What to Do When Something Seems Wrong." Are there lessons on those pages that would still apply to parents today, 20 years later?

Stephen Faraone, PhD: Oh, absolutely. I think the main thing I would say to parents is that if they suspect that their child has a mental health problem, they need to, as soon as possible, bring it up to their pediatrician. If their pediatrician won't deal with it, or it seems to not be able to deal with it effectively, then you need to find specialist care, which would mean a child psychiatrist. That can be difficult or impossible in some areas of the country, I realize.

But it is really essential that the treatment be sought and that it be sought soon, that if you wait -- a lot of parents will say, "We can wait and see how this goes." And again, that's part of the stigma about mental illness. You'd never say that about cancer, right? If your child was diagnosed with cancer, you wouldn't tell a doctor, "Let's wait and see how it goes before we give them medication."

But yet we say that a lot. Not me, but many people, say that about psychiatric disorders. So seek treatment and seek it soon, because otherwise, every year your child's not treated, there's one more year that they're living with disability, that they're not achieving in school, that they're not making friends, that they're perhaps associating with the wrong kinds of friends and so forth, exposing themselves to substance use risk, to many potential problems.

Host Amber Smith: We hear about ADHD in relation to kids a lot, but you're part of a steering committee to develop guidelines for diagnosing and treating ADHD in adults. Can you tell us more about that process?

Stephen Faraone, PhD: Absolutely. A few years ago, a group of us got together, and we started the first stage of this, where we got some experts together, and we came up with indices of quality care for ADHD in adults, and we needed to do that because they just didn't exist at all in the United States.

We subsequently ran a big study of something like over 70,000 medical records of adults with ADHD in a collaboration with the American Academy of Family Practitioners, and we found out that although quality care had improved over the past decade, from 2010 to 2020, there were still large gaps in quality care. And for that reason, we thought we really need to get a group together and come up with systematic guidelines that could help particularly people in primary care, where we think the biggest problems occur, but even to some degree in adult psychiatry.

Because again, part of the stigma of ADHD -- it is just literally hardly ever taught about in medical schools, in residencies (physicians' training), in adult psychiatry. When we've asked, if you ask at a meeting to people who are adult psychiatrists, "How many of you got more than two hours of lectures about ADHD?" almost nobody raises their hand.

They learn a lot about depression, a lot of about schizophrenia, a lot about other disorders, but they hardly learn about ADHD. And when doctors don't learn about something, they're uncomfortable treating it. And patients suffer.

Host Amber Smith: When you're asked what causes ADHD, how do you respond to that?

Stephen Faraone, PhD: I say that there are many causes. I say that it's unusual that only one thing causes ADHD in a given person. That can happen, but it's very rare. There are some very rare genetic variants that do that. There's some rare environmental circumstances, like extremely adverse environments, but for the most part, most of what we call common ADHD, like 99% of the cases, are caused by the accumulation of many risk genes, but also many environmental risk factors as well.

You mentioned your website, adhdevidence.org, where you post responses to some popular questions about ADHD, so I'd like to ask you a few of those questions now and get your response.

Host Amber Smith: The first is, what are the most effective changes people with ADHD can make to improve their lives and management of ADHD?

Stephen Faraone, PhD: First one is to adhere to whatever treatment is prescribed by your prescriber, be that a psychologist, a psychiatrist, a primary care doctor. One of the biggest problems in ADHD is people forget to take their medication, or they don't adhere to their therapist's guidelines for how to approach their cognitive behavior therapy.

If you don't take your medicine, or if you don't follow your therapist's guidelines, you're not going to be able to improve. I would say that's really the most important thing that a person could do that has ADHD.

The second most important thing would be to keep in mind that ADHD does not define your life, does not define you as a person. You are not an ADHD person. You're a person that has been diagnosed with ADHD. But that means there's many other things about you that, including some strengths that you have as a person, that you need to discover if you haven't discovered them.

And therapy can help you with that if you don't know them already, and find those strengths and use them to make your life a better life because although your ADHD would make that more difficult than (for) the average person, it by no means makes it impossible. And there are many people with ADHD who live productive and happy lives, especially when they have effective treatment.

Host Amber Smith: What suggestions do you have to help an adult heal from the stigma from being judged and bullied since childhood for the ADHD symptoms?

Stephen Faraone, PhD: This is where the medications don't help.

The medications are good for the symptoms of ADHD, but for these other kinds of problems, that's where a good therapist can help a person. I always suggest cognitive behavior therapy because there are cognitive behavior therapies that have been devised and tested specifically for adult ADHD.

And with a good, competent therapist, they can help you work through not just your ADHD problem, but other problems of the sort, Amber, that you're talking about.

Host Amber Smith: How helpful is caffeine in helping a person focus? And are there any particular foods that are helpful or harmful for someone with ADHD?

Stephen Faraone, PhD: Caffeine is not helpful for ADHD.

It will help you stay awake, like most people, have that kind of an effect, but it's not going to, and studies have looked at this, it's not going to help ADHD symptoms dramatically, if at all. There are really no foods, there's no diets that are good for ADHD.

The only nutraceutical that's shown some hope as a treatment for ADHD are the omega-3 fatty acids, and there, clinical trials, very good clinical trials, have shown that omega-3 fatty acids, particularly those that have a higher dose of EPA versus DHA, in them, because there are different kinds of fatty acids, they're not all the same, have a small effect on symptoms. By small, I mean on a scale of one to 10, there, they might their effect might be a two, whereas an ADHD drug is more like a nine. So it's a very small thing.

That doesn't mean that for some people they might have a big effect because that's the average effect, but I'll say to anybody that's trying omega-3's before medication, it's OK to try them. But if they're not working with, for you in a few weeks, then you should, you need to find appropriate treatment, for sure. The probability of them helping you is not very high.

Host Amber Smith: What advice would you give to a young person who's interested in science today?

Stephen Faraone, PhD: I would say that to be effective in science, you have to be somebody who likes the idea that they can ask a question, and they can get an answer to it.

They're curious about the world. I would advise young people, let's start with kids, right? Young kids are very curious by their nature. We know that from just observing how they interact with the world. Unfortunately, as we get older, boy, that native curiosity sometimes gets beaten back by society, which kind of wants to funnel us in this direction or that direction. Instead of making us curious about the world, it really just makes us want to focus on, "I want to get this goal." And not that that's wrong, some people are very goal driven, and that's OK, and they don't see the rest of the world.

But if you want to be a scientist, you really have to be curious about the world around you and to kind of be willing to live with the uncertainty that goes with that.

Now, the other thing I will say is that, this is really plus anything you'd want to do, that you have to do something. You have to work in an area that you feel some passion for, that something about it just lights a fire, and it could be a fire that's lit for all sorts of reasons.

It could be that you just find it fascinating, almost from a puzzle point of view. It could be that you feel a real need, that you want to help a certain kind of patient, maybe because you have a brother who has autism and you really want to work on autism, or a parent with Alzheimer's disease.

There's lots of ways that one becomes passionate about a field in science, and I would say all the people I know that are successful have some kind of passion that has driven them to do what they do. And it's not a 9-to-5 job. It's the kind of thing where it's work that you do it because you really love it and enjoy it. Not that you can't have a life outside of science. Of course you should and can, but it's not a 9-to-5 job.

Host Amber Smith: Dr. Faraone, thank you for making time to talk with us.

Stephen Faraone, PhD: Always happy to do it. Look forward to it next time. Thank you.

Host Amber Smith: My guest has been Dr. Stephen Faraone. He's a distinguished professor and vice chair of research in psychiatry and behavioral sciences at Upstate, and he serves as the president of the World Federation of ADHD and the editor of the journal Neuropsychiatric Genetics.

I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Travis Hobart from Upstate Medical University. What can parents do to get a toddler to sleep through the night?

Travis Hobart, MD: That's a challenging question that I get often from parents, and it's a challenging problem to fix over time. I think the key things the parents can do are: Try to be really consistent with bedtime. Try to make it the same time every night, the same pattern of getting into PJ's brushing their teeth, yada yada, taking a bath, whatever the bedtime routine is, reading a story, hopefully. But doing that at the same time and in the same order every night, and that that is a quiet routine, too, is important. So it's not watching TV before bed. It's not playing video games before bed. It's not looking at an iPad or a phone before bed, not looking at screens. It's better to get the half an hour, or hour before bed screen-free, quiet activities, bath time, reading a story and making that as consistent as possible.

Then you want to respond to your toddler's needs, if they want a glass of water by bed or they want the nightlight on, that's fine. That's great. Or if they want a toy or something or blanket that they snuggle with, that's also fine. That can be a comfort for them at nighttime to help them fall back asleep if they wake up.

And then I think really trying to be strict, as strict as you can about keeping the kid in their own bed, not letting them come into your bed, but trying to redirect them back to their bed and help them fall asleep in their bed. But then you have your own bed so that they get used to falling asleep on their own, in their own bed.

And if they are waking up in the middle of the night, over time as you deal with it on a night by night basis, if you have to go in and calm them down in the room, try to gradually make that process -- wait a little bit longer before you go in, give them a little bit more time to fall asleep on their own, and then gradually make that process a little bit less intensive. So you might go into the room the first night and hold them in the bed. Then the next night, maybe you stand next to the bed, and do that for a few nights. And then the next week you maybe don't go in the room, you stand outside the room and try to calm them down from the doorway, that kind of thing, so that you're gradually allowing them more of their own ability to fall asleep on their own, if that makes sense.

The main other thing is just be patient. Because it is going to take some time. And I know that it's frustrating, and I know everybody gets tired. It is a challenging problem, but it will take time, and they will learn eventually.

Host Amber Smith: You've been listening to Dr. Travis Hobart from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Health care professionals often wonder if patients see them, see how hard they are working to gain trust, provide comfort, speed healing. Pam Freeman, a poet and actor in Upstate Medical's standardized patient program, wrote us a gorgeous poem that pays tribute to nurses' heroic work. Here is "Request Line":

The acute floors were full so instead of going upstairs

I lay on a gurney at the far end of the ER

A whole room all to myself

Unused because the heat didn't reach there

They apologized and offered blankets

But I bathed gratefully in the chill

While a fever roasted me

No thank you I said and drew the sheet up

Letting my feet float in cool air

Was it sepsis I still don't know

That was before they told you things

Not wanting to scare you

All I knew at the time was

My sed rate was high and everything hurt

So when the nurse peeked in from the door

Spoke my name like a secret password

And finding me awake padded in

How did that nurse know the one thing he could do

Without causing more pain was give my toe a small squeeze

While saying how are you dear

Just give my toe the merest wiggle

And I would relax

He smiled under his walrus mustache

Told me his first name which I've long forgotten

Then with simple instructions

Made a quick neat task of the dreaded bedpan

Which I thought would never work

But it did and he whisked it away

Saying thank you dear

I learned that he was also a firefighter

And played bagpipes

What was his name I wish I could remember

Why bagpipes I asked

He said well you know dear

Someone has to

There must have been other nurses

I was there for days

But he's the only one I recall

The firefighter bagpiper hello-dear nurse

With the cartoon mustache

Who saw my toe sticking out from a thin sheet

In a cold room

And used it like a telegraph key

Pressing messages onto it such as

It's all right

You are safe

You will heal

You are worth a careful touch

You are worth your questions

You are worth knowing that I dress in other outfits

And hoot like a band of owls

Or run uncoiling a fire hose

All within this wild romp of a world

To whose possibilities we will soon return you

And so

This goes out to the nurse

In his scrubs

In his kilt and sporran

In his helmet and asbestos

A uniformed doorman to the world

Waving right this way dear

This way to the music and fires

The songs and battles

Who gives my toe a last confident handshake

Yes please this goes out to him

A tendril of melody

A thin distant chant

Over the daily drone of living

His greeting is still on my playlist

In case I need to hear it again

Once in a while

When all I can seem to get is

The all-night insomniac

Radio station of my mind

Host Amber Smith: Expert advice for helping your toddler sleep -- next, on Upstate's "HealthLink on Air."

This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel. This is your host, Amber Smith, thanking you for listening.