The future of ADHD

这里是斯坦福工程学院的《万物未来》，我是主持人阿尔特曼。

This is Stanford Engineering's The Future of Everything, and I'm your host, Altman.

我觉得有必要重新聊聊这档节目的初衷。

I thought it would be good to revisit the original intent of this show.

2017年我们刚启动时，就想打造一个平台，深入探讨斯坦福校园里同事们在科学、技术、工程、医学等领域的研究动因和成果。

In 2017, when we started, we wanted to create a forum to dive into and discuss the motivations and the research that my colleagues do across the campus in science, technology, engineering, medicine, and other topics.

斯坦福大学，以及绝大多数高校，长期以来都在从事影响世界的重要工作。

Stanford University and all universities for the most part have a long history of doing important work that impacts the world.

能和大家分享这些研究背后，那些为创造更美好未来而不懈努力的人们，真的让我感到欣慰。

And it's a joy to share with you how this work is motivated by humans who are working hard to create a better future for everybody.

抱着这样的初衷，我希望每期节目结束后，你都能更深入地理解这里正在进行的研究，并愿意把它们分享给你的朋友、家人、邻居和同事。

In that spirit, I hope you will walk away from every episode with a deeper understanding of the work that's in progress here, and that you'll share it with your friends, family, neighbors, coworkers as well.

注意力缺陷多动障碍确实是一种严重的疾病，可能让人极度困扰，给患者带来巨大压力。

ADHD really is a serious condition and it can be debilitating and it can create a lot of strain on an individual who has it.

多年来，多项大规模前瞻性研究都表明，ADHD与更差的健康结局相关，甚至包括更高的死亡风险。

And there are very significant studies over the years that are large prospective studies that showed that ADHD is associated with higher bad outcomes, including mortality.

他们更容易发生车祸，更容易受伤，更容易出现药物或酒精滥用、心理健康问题、入狱，工作不稳定，就业困难，教育方面也一样——我没提的是，很多人无法完成学业。

So they are more likely to get into car accidents, they're more likely to be injured in general, they're more likely to have drug abuse, alcohol abuse problems, mental health issues, incarceration, holding a job, employment issues, educational, of course I didn't mention problems and not completing school or education.

所以这确实是一种非常严重且伴随终身的疾病。

So it is a very serious condition and it's a lifelong condition.

这里是斯坦福工程学院的《万物未来》，我是您的主持人罗斯·阿尔特曼。

This is Stanford Engineering's The Future of Everything and I'm your host Russ Altman.

如果你喜欢这个节目，愿意收听，我们非常希望你能给它打分和写评论。

You know, if you're enjoying the show, if you like to listen to it, we really would love it if you would rate and review it.

如果我们配得上，我们特别希望你能给五星好评。

Rating and reviewing, we like to get a five point o if we deserve it.

评论能告诉别人你为什么喜欢，或者为什么不喜欢。

Reviews tell people why you like it or why you don't like it.

这真的很有帮助，也能帮助节目发展壮大。

It's really useful and it helps grow the show.

同时，也能让我们听到你的反馈。

It also helps us get feedback from you.

非常感谢你这么做。

So thanks very much for doing it.

记得给个评分和评论。

Rate and review.

今天，来自斯坦福大学的叶尔·班内特将告诉我们，注意力缺陷多动障碍可以在幼儿时期确诊，及早干预至关重要，这样才能帮助孩子避免伴随这种疾病而来的终身风险。

Today, Yair Bannett from Stanford University will tell us that attention deficit hyperactivity disorder can be diagnosed in young children and it's super important to do so so you can implement treatments to help them avoid the lifetime risks that come with that disease.

这就是ADHD的未来。

It's the future of ADHD.

今天，我们继续推出新栏目——一分钟展望未来。

Today, we are continuing our new feature, the future in a minute.

在与叶尔的访谈结束时，我会问他几个快速问题，他会给出简短回答，就这样。

At the end of my interview with Yair, I'll ask him a few rapid questions, he'll give a few rapid answers, and that'll be it.

在开始之前，再提醒一下，我们非常期待你们的评分和评论。

Before we get started, another reminder, we love it when you rate and review.

这对我们有帮助，对节目有帮助，也能推动算法推荐。

It helps us, it helps the show, it feeds the algorithm.

谢谢您做这件事。

Thanks for doing it.

注意力缺陷多动障碍，也就是ADHD，是近几十年来诊断率显著上升的一种疾病。

ADHD or attention deficit hyperactivity disorder is a disease that we've seen diagnosed much more in the last couple of decades.

儿童行为发育专科医生是研究这种疾病的专业人士，他们了解如何诊断、治疗，以及为什么及时干预如此重要。

Developmental behavior pediatricians are the specialists who study this disease and who understand how to diagnose it, how to treat it, and why it's so important to treat.

诊断起来确实有难度，尤其是对年幼的孩子，但并非不可能。早期发现能让医生及时介入，包括药物治疗和非药物干预，这些都能显著改善ADHD患者的生活质量和未来前景。

It's difficult to diagnose, especially in small children, but it is possible and recognizing the disease early allows physicians to start treatments, both medical treatments, drugs, as well as non pharmacological treatments that can really improve the life and the future of the patient who suffers from ADHD.

Yair Bannett是斯坦福大学的儿童行为发育专科医生，也是ADHD领域的专家。

Well, Yair Bannett is a developmental behavioral pediatrician at Stanford University and an expert at ADHD.

他最初在门诊当儿科医生时就开始接触这类病例，后来就把研究ADHD变成了自己的核心方向。

He saw it as a primary pediatrician in the clinics, and then he made it his research passion.

他会跟我们聊聊ADHD的症状、治疗方法，以及未来的发展方向。

He'll tell us about ADHD, its symptoms, its treatments, and what the future is like.

Yair，您为什么选择研究这么小的孩子的ADHD呢？

Yair, why did you decide to study ADHD, especially in children who are pretty young?

谢谢你邀请我，拉uss。

Well, thank you for having me, Russ.

能上这个播客真的很开心。

It's great to be on the podcast.

我想说的是，我最初是以全科儿科医生的身份开始关注多动症的。

And I'd like to say that initially I started being interested in ADHD as a primary care pediatrician.

刚当住院医的时候，我对发育和行为问题的接触并不多。

When I first trained as a resident, I didn't have a lot of exposure to developmental and behavioral problems.

但后来在社区当儿科医生时，我发现很多家长都会来找我，担心孩子有多动症或者其他发育方面的问题。

But then as a pediatrician, as a PCP in the community, I noticed that parents often came to me with these concerns for ADHD and other developmental concerns.

于是我开始不断学习发育行为儿科学，决定专攻这一领域，好更好地帮助有这些困扰的孩子。

And so I started learning more and more about developmental behavioral pediatrics, and I decided I want to specialize and know how to support children who have these challenges.

好的，很好。

Okay, great.

那我们先来梳理一下关于这种疾病的一些基本事实吧。

So I think what we should do to start is establish some of the baseline, basic facts about the disease.

我们通常叫它ADHD，但全称是注意力缺陷多动障碍。

So first of all, we called it ADHD, but it is attention deficit hyperactivity disorder.

我说得对吗？

Tell me if I'm wrong.

你能简单说说，主要有哪些表现吗？

And could you give a little picture about like, what are the symptoms?

关于它的成因，目前有哪些了解？

What's known about the causes?

现在我们对这个病的了解到了什么程度？

Where are we with this disease right now?

当然可以。

Absolutely.

ADHD是一种非常常见的疾病，发病率因地区而异。

So ADHD is a very common condition and the prevalence varies.

我会主要讲美国的情况，但即使在美国，不同地方的发病率也不一样。

Also, I'll talk about The United States, but it even varies within The United States.

大约有百分之八到十的儿童被诊断出患有多动症。

Somewhere between eight to ten percent of children get diagnosed with ADHD.

这个发病率已经相当高了。

That is pretty high prevalence.

我们说的核心症状包括多动、冲动，还有注意力不集中。

The symptoms we're talking about, the core symptoms are hyperactivity and impulsivity, as well as inattention.

这些就是核心症状。

Those are the core symptoms.

就像《精神障碍诊断与统计手册》里规定的那样，必须存在功能上的损害。

As anything in the DSM, the manual that defines this condition, there has to be a functional impairment.

光有这些症状是不够的，对吧？

So it's not enough to only have these symptoms, right?

我们每个人偶尔都会分心或者精力过剩，但这些情况必须已经影响到生活了。

All of us sometimes are inattentive or have a lot of energy, but it has to be impairing.

它必须妨碍孩子或成年人完成他们该做的事。

It has to prevent you as a child or as an adult from doing what you need to do.

还有一个要求是，这些症状必须出现在至少两个不同的场合。

And another stipulation is that it has to occur in at least two settings.

不能只是在家里才有这些表现，至少得在两个地方都出现。

So it can't just be at home that you're presenting with these symptoms, it has to be at least in two settings.

对于孩子来说，通常这两个场合就是家里和学校。

And again, for children, typically the two settings would be home and school.

这确实挺有意思的。

So that's really interesting.

在我这一辈子的经历里，我觉得确诊的比例明显升高了。

And in my lifetime, my impression is that the frequency of diagnosis has gone way up.

我们后面肯定会聊到这个，不过先让我深入了解一下这些症状。

I'm sure we'll talk about that, but let me dive a little bit into those.

你提到多动是其中一个症状，注意力缺陷也写在名字里了。

You said hyperactivity is one of the, and attention deficit, it's in the title.

我们怎么界定正常范围？家长怎么判断孩子的情况是正常的还是异常的？

Where do we get our baselines from and how does a parent know if what they're seeing is at a normal level?

因为你知道，这些孩子嘛，小孩本来就很活泼，那怎么判断他们的活跃程度是不是已经超出正常范围了呢？临床医生又是怎么分辨的？

Because you know, these can be kids and like kids are crazy, but, and how can they figure out and how does the clinician figure out if this level of activity is dysfunctional?

能不能再具体说说，家长或老师通常会观察到哪些表现？有没有一些典型的情境？

Are the, can you give a little bit more about the signs that they see, maybe typical situations that a parent or a teacher might find themselves in?

是的。

Yeah.

这是个很好的问题。

That's a great question.

我觉得这其实也回应了你之前的问题，为什么我特别关注幼儿，因为在这个年龄段，真的最难区分正常和异常。

Would say and it also ties to the to your first question around why I chose to focus on young children because I think that's where it becomes the hardest to distinguish.

对吧？

Right?

毕竟小孩子本来就是到处跑来跑去的。

Because they're always bouncing around.

所以，简短的回答是：确实很难分辨。

And so, yes, I think that the answer, the short answer is it's very hard to distinguish.

我觉得这也是多动症争议的一部分，有些人会说，这根本不存在。

And I think that's part of the controversy around ADHD that exists where people some people will say, oh, it doesn't even exist.

根本就没有这回事。

There's no such thing.

只是孩子天性活泼罢了。

It's just kids being kids.

但作为这个领域的专家，我们都认同这种说法是不对的。

And I think as, you know, as experts in the field, we all agree that's not true.

它像很多其他情况一样，是一个连续谱。

And it's a spectrum like many other things.

尤其是对于第一次当父母的人来说，根本很难分辨和判断。

And so for parents, for especially first time parents, it is pretty much impossible to distinguish and know.

所以他们才会带孩子去看儿科医生，说：我不确定。

And that's where they they go to the pediatrician and say, hey, I'm not sure.

这正常吗？

Is this normal or not?

这其实经常发生。

And and that's exactly what happens often.

我当全科医生的时候就遇到过这种情况，我说：好吧，我得去多学点东西，弄清楚什么时候孩子只是正常调皮，该观察等待、给点支持，什么时候才需要更深入的干预。

That's what happened in my office as a PCP where I said, okay, I want to get more training and understand how to distinguish when it is within the realm of normal, let's just watch and wait, or gives minimal supports versus more.

所以，这属于一种依赖行为观察和主观报告的状况，通常得靠家长和老师提供信息，而这些信息往往差别很大，对吧？

And so again, there is it's a type of a condition that where the diagnosis relies on behavioral observations on reporting, subjective reporting from the parents, from teachers often, and all of these vary, right?

有时候，一个家长或老师会这么描述，另一个家长或老师却完全不一样。

So sometimes you might have one type of parent or one type of teacher that will report things and then another parent or another teacher will report very differently.

没错。

Right.

你能想象这有多容易出错吧。

So you can imagine how inaccurate it might be.

所以我们作为专业人士，很多时候得靠临床经验，结合我们在诊室里自己的观察，才能做出判断。

And so we have to again, as experts, we have to use our clinical judgment many times, use our own observations as well in the clinic to make a decision.

那我们现在对这种疾病的成因了解多少？

Now, what do we understand about the causes of disease?

你知道，总是有先天和后天的争论。

You know, there's always nature versus nurture.

当然还有其他无数因素，但我们是否认为这本质上是患者、是孩子与生俱来的特质，还是对环境的一种反应呢？

There's a million other things, of course, but do we think this is fundamentally an inborn feature of the patient, of the child, or is this something that is a response to environmental conditions?

我完全理解这问题有多敏感，因为你不想跟家长说，是你们的养育环境造成了这种问题，对吧？

And I understand completely how this is a very sensitive issue because you don't wanna tell a parent you created an environment that created this disease, right?

这评估肯定特别棘手，我能想象。

I mean, this is a very difficult, I'm guessing assessment.

没错，确实如此。

That's right, that's right.

过去几十年，随着数据不断积累，我们已经能明确地说，多动症儿童确实存在先天性的差异。

So we do know for sure over the past few decades, data is gathering, you know, to clearly say there are inborn differences in children with ADHD.

我们知道这跟遗传因素有关。

We know there are genetic components to it.

我们也知道，多动症患者的脑结构确实和常人不同。

We know that there are differences in the brain structure of individuals with ADHD.

所以，答案是，这确实是一种与生俱来的特质。

And so yes, the answer is it is something that is inborn.

但与此同时，就像所有这些状况一样，比如自闭症——这也是我们专业领域中经常遇到的一种情况。

At the same time, as with all of these conditions, including autism, for example, which is another condition that we see frequently in our specialty.

答案是肯定的，环境同样会产生影响。

The answer is yes, the environment can also have an influence.

至于影响有多大，目前我们还说不准。

We don't know yet to what extent, I would say.

但在ADHD这个问题上，大家特别关心的一个话题，比如屏幕时间，到底在多大程度上起了作用。

But in ADHD specifically, you know, there's this whole question around, for example, screen time and how much of that's influencing.

所以，目前这些答案都还没有定论。

And so again, the answers are not there yet.

不过我可以肯定地告诉家长，通常来说，这绝对不是你们做错了什么，除非是极其特殊的情况。

But I would say for certainly we can we always assure parents that, you know, it's nothing that you did wrong, typically, unless it's a very extreme case.

孩子出生时的特质才是主要原因，我们能做的，就是调整家庭环境，也许这个家需要一些不一样的安排。

Most likely it is the way the child is born, and we can just try to adapt the household and maybe this household needs to be a little bit different.

所以环境不只是问题的一部分，很多时候反而是解决的关键。

And so the environment is not only a part of the problem potentially, it actually a lot of times is a part of the solution.

太好了。

Great.

我再问几个问题，因为这些信息真的非常有帮助。

So a few more questions because this is really, really very helpful.

你提到一个很有意思的观点，说多动症的发病率不仅在世界各地不同，在美国国内不同地区也不一样。

You made a very intriguing side comment that the prevalence may be different in different, not only in different parts of the world, but in different parts of The United States.

能详细说说这方面的研究吗？听起来特别有意思。

Talk to me about what's known about that because that sounds really interesting.

是的。

Yeah.

美国疾控中心会定期发布发病率数据。

So the CDC, the Center for Disease Control, has a prevalence rates that it publishes.

我上次查看的时候发现，尤其是西海岸，比如我们现在所在的加利福尼亚州，发病率比东海岸要低一些。

And the last time I looked, it looks like the West Coast specifically, and we are in California now, has lower prevalence compared to the East Coast.

这两个地方可以说是发病率的两个极端：西海岸最低，而美国东北部则最高。

Those are kind of, I would say, the two extremes in terms of the prevalence, where it's the lowest, around the West Coast, and it's the highest, I would say, in the North East Of The United States.

这种情况已经持续很久了。

And that has been true for a while.

我再说一遍，我不是流行病学家。

And I don't know to say again, I'm not an epidemiologist.

要我说出背后的原因，还真不太好讲。

It's hard for me to say, you know, the reasons behind it.

恐怕也没人能说得清楚。

I'm not sure anyone does know.

但总有人在争论，这到底是真实的发病率差异，还是某些地区诊断更积极造成的。

But, you know, there's this argument always about how much of it is true prevalence versus just, you know, higher detection in certain areas.

这其中也涉及文化因素。

There are cultural aspects to it as well.

我们都知道，比如西班牙裔人群的发病率就相对较低。

One of the things we know is that in Hispanic patients, the prevalence is lower, for example.

有一种观点是，在某些文化里，人们对行为和发育上的多样性可能更宽容一些。

And one of the thoughts would be that, you know, in certain cultures, maybe there's just more tolerability for a wider, you know, presentation of behavior and development.

那在国际上呢？

So what about on the global scene?

我记得你提到过，你曾经在以色列当了很多年全科医生。

So I think you mentioned that you practiced in Israel for many years as a primary care physician.

你在那儿也见过类似的情况吗？对其他文化或大洲的情况，你了解多少？

Did you see a similar syndrome there and what do you know about other cultures and other continents?

是的，关于以色列，我的看法是，那里的发病率和美国以及许多其他西方国家很接近，差不多都是这个水平。

Yeah, I would say that, yes, to your question about Israel, it is very similar prevalence to The United States and many other, I would say, westernized countries, we find pretty similar prevalence.

在一些国家，可能对这类情况的监测不够准确或不够完善，要掌握真实的发病率就更困难了。

I think it becomes harder in other countries where maybe the monitoring also of these conditions is not as accurate or as robust, and it's just harder to know the real prevalence.

所以，到底有多少是监测手段带来的差异，有多少是文化认知的不同，真的很难分得清。

So again, it's really hard to tease out how much is just about the monitoring and being able to give a good number versus maybe like we said earlier, differences in cultural perceptions.

对，没错。

Yes, yes.

我还想了解一下这种状况的自然发展过程。

And then I also wanted to get a sense for the natural history.

你面对的是孩子，我们当然会谈到治疗，我相信大家对此都非常关心。

You're dealing with children and we're going talk about treatments of course, that's I'm sure people are very interested in that.

我也非常关心这个部分。

I am very interested in that.

但在谈治疗之前，如果没接受治疗或没被发现，你能说说它的自然发展是怎样的吗？

But before we get to treatments, if untreated or if it's not recognized, can you give us a sense for what is the natural history?

患者长期来看会过上什么样的生活，面临哪些挑战？

What is the type of life and the type of challenges that a patient might have over time?

这是个非常好的问题。

Yeah, so this is a great question.

我觉得这也是人们对注意力缺陷多动障碍存在很大误解的一个方面。

I think this is, again, one of the areas where there are large misconceptions about ADHD.

很高兴能有机会来解答这个问题。

So I'm glad to have the opportunity to answer that.

首先，我们知道多动症是一种终身性疾病。

I would say first, one of the things we know is that ADHD is a lifelong condition.

就在不久以前，人们还认为它只是儿童期的问题。

It was originally thought to be not too long ago, it was thought to just be a childhood disorder.

有些孩子长大后，确实不再到处乱动了。

And what happens is children some age eventually stop bouncing around.

所以一般你看不到成年人东蹦西跳的。

So you don't see adults bouncing around typically.

对吧？

Right?

但很多小时候有多动症、曾经坐不住的成年人，其实依然有这个病，只是表现形式不一样了。

But many of these adults who had ADHD and were bouncing around still have ADHD, even though they're not bouncing around.

这一点非常重要。

So that's one important thing to know.

其次，多动症确实是一种严重的疾病，可能让人非常困扰，给患者带来很大的压力。

And the second part is that ADHD really is a serious condition and it can be quite debilitating and it can create a lot of strain on an individual who has it.

多年来，有多项大规模前瞻性研究显示，注意力缺陷多动障碍与更差的结局相关，包括死亡率升高。

And there are very significant studies over the years that are large prospective studies that showed that ADHD is associated with higher bad outcomes, including mortality.

他们更容易发生车祸，更容易受伤，更可能出现药物或酒精滥用，也更容易遭遇心理健康问题、入狱、就业困难，以及学业问题，比如无法完成学业。

And so they are more likely to get into car accidents, they're more likely to be injured in general, they're more likely to have drug abuse, alcohol abuse problems, mental health issues, incarceration, holding a job, right employment issues of educational, of course, I didn't mention problems and not completing school or education.

所以这确实是一种非常严重的终身疾病。

So it is a very serious condition and it's a lifelong condition.

因此，在谈治疗之前，我想先说说它的自然病程——就像你提到的，这个病程其实相当严峻。

And so that I would say the natural history before we'll talk about treatment, like you said, but I'd say the natural history can be quite grim.

而且，它的表现范围非常广。

And again, it is a wide spectrum.

当然，有很多人患有ADHD但依然过得很好，但对不少人来说，它确实会严重妨碍生活。

So obviously there are many people who have ADHD and certainly thrive, but it can be quite debilitating.

那我们的应对能力如何呢？

And what is our ability?

我现在非常感兴趣。

So now I'm very interested.

成人医生在识别ADHD并做出诊断方面有多大的能力？

What is our ability for adult physicians to recognize ADHD and make that diagnosis later in life?

我觉得这应该更难一些。

I'm imagining that it's more difficult.

你对这个比较敏感。

You're kind of attuned to it.

有些家长会担心。

There are parents who are worried.

可能还会收到老师的反馈。

There may be teacher reports.

你是儿科医生。

You're a pediatrician.

我知道你一般不会接诊18岁、30岁或者50岁的患者。

And I know you might not see 18 year olds or 30 year olds or 50 year olds.

那我们在基层医疗中，对成人ADHD的识别能力到底怎么样？

So how good are we in our primary care, for adults in recognizing this disorder?

是的，我觉得要识别出来确实不容易，尤其是现在的成年人，我们临床上常见的状况是，他们都是带着孩子来的

Yeah, so I would say it's hard to recognize, especially now adults these days, typically what we hear in clinic, because they bring their children

谁

who

孩子有ADHD，对吧？

have ADHD, right?

就像我之前说的，这病有遗传因素。

So as I mentioned, there's a genetic component.

所以我见到的都是作为父母的他们，而不是以成年患者的身份来看病。

So I do get to see them in the office as parents, not as the adult pediatrician or the adult physician.

但回答你的问题，我们最常见的就是成年人说：‘我觉得我小时候可能有ADHD，但从来没被诊断过。’

But to answer your question, what we mostly see is is adults saying, oh, you know, I think I had ADHD, you know, but I've never been diagnosed.

DSM诊断ADHD的一个标准是，症状必须在12岁之前就出现了。

One of the, one of the criteria actually in the DSM for diagnosing ADHD is that the symptoms have to appear before age 12.

所以关键在于，我们谈ADHD，指的是儿童时期就显现的问题；如果成年后才突然出现，那很可能是别的原因。

So the idea again is that, to talk about ADHD, we're talking about something that emerges in childhood, because if it's something else that emerges only in adulthood, likely it's something else.

原来如此。

I see.

这一点很重要。

That's an important distinction then.

所以他们得回头想想自己12岁之前的生活是什么样子。

So they'll have to be going back and thinking about what life was like before they were 12.

作为成年人，他们得去问父母或者了解他们小时候的人，有点像考古一样，去回溯当年到底发生了什么。

So as an adult, they would have to talk to their parents, people who remember them and there would be a little bit of archeology going on there to figure out if in retrospect, that could have been what was happening.

没错。

That's right.

现在人们对成人多动症的识别也更准确了。

And there is also better recognition of adults with ADHD today.

我通过阅读文献和跟人交流也了解到，现在越来越多的成年人回头说：‘我小时候没人发现，但现在回头看，很明显我那时候就有ADHD，现在还是有。’

I do know that from also just from reading the literature and speaking with people, certainly more adults now going back and saying, yes, wasn't recognized when I was a kid, but it is clear that I had ADHD and I still do.

我还了解到，原来吃药能帮助我更好地应对工作。

And I learned that I can take medications that can help me function better at work, for example.

很好，行，不错。

Great, okay, good.

那我们现在来谈谈治疗吧，因为大家一想到ADHD，第一反应就是吃药，但我知道你研究过药物治疗，也研究过非药物疗法。

So now let's get into treatments because of course people always think about pills, but I know that you've looked into both medications, but also non medication treatments.

那目前治疗方面的情况怎么样？

So where are we with treatments?

确实，ADHD的治疗主要有两种方式。

So, yeah, there are two types of treatment for ADHD.

一种是大家熟悉的药物治疗，另一种是非药物干预，主要针对年幼的孩子，相关研究也大多集中在低龄儿童身上。

There are the medications that most people know about, and there are also non pharmacological interventions that are mostly for younger children, that most of the research is done on younger children for that.

所以我们跟家长，尤其是有年幼孩子的家庭沟通时，会同时介绍这两种治疗方式。

And so when we speak with families, especially of young children, we talk about these two arms of treatment.

对大多数孩子来说，我们最终希望他们能接受两种治疗。

And ultimately for most children, want them to receive both.

所以目前的金标准是，理想情况下，孩子能同时接受药物治疗和行为干预。

So that is the gold standard is to eventually, hopefully you'll be getting both medication treatment and also behavioral interventions.

所以，这大致就是治疗方式的概况了。

So that's, I would say, an overview of kind of the types of treatment.

我们可以再深入聊聊细节。

We can go dive deeper into it.

接下来是Russ Altman带来的《未来已来》。

This is the future of everything with Russ Altman.

接下来，我们继续与Yair Bannett的对话。

We'll have more with Yair Bannett next.

欢迎回到《未来已来》，我是Russ Altman。

Welcome back to the Future of Everything with Russ Altman.

我现在正在与来自斯坦福大学的Yair Bannett交谈。

I'm speaking with Yair Bannett from Stanford University.

在上一部分，我们详细了解了注意力缺陷多动障碍（ADHD），包括它的症状、一些成因，接下来我们要探讨的是：这些治疗方法有效吗？为什么它们如此重要？

In the first segment, we got a great tutorial on ADHD, attention deficit hyperactivity disorder, its symptoms, a little bit about its causes, and we're about to start understanding what are the treatments, do they work, and why are they important?

别忘了，对话最后我们会进入‘未来一刻’，我会向Yair提几个快速问题，听听他即兴的回答。

Don't forget, at the end of the conversation, we're gonna have the future in a minute, where I'll ask Yair some quick questions and get his off the cuff answers.

Yair，你提到过有两种治疗方式，一种是药物治疗，一种是非药物治疗。

Yair, you mentioned that there were both pharmacological and non pharmacological treatments.

我们先从药物治疗说起吧。

Let's start out with the pharmacology.

目前常用的药物有哪些？它们是怎么起作用的？

What are the drugs that we use and how do they work?

关于这些药，我们该了解些什么？

What should we know about them?

好的，一般来说，我们主要用两类药物。

Great, so we use generally two types of medications.

其中历史最久的一种，已经用了将近一百年了，属于兴奋剂类药物。

The most longstanding medication that's been around for almost a hundred years now is in the category of stimulant medication.

这类药统称为兴奋剂。

So the name of the family are stimulants.

你可能听说过一些常见的名字，比如利他林、专注达和阿得拉。

The common names you may have heard of are Ritalin and Concerta and Adderall.

这些药物对儿童来说非常安全。

And so those medications are very safe to use in children.

我们很清楚，它们在短期内效果显著。

We know that they have a really significant benefit short term for sure.

一旦开始用药，大多数孩子的多动、冲动行为就会明显减少，注意力也会提升。

Immediately once you start using the medicine, see reductions in hyperactivity impulsivity and increases in attention for most I think there's

很多人对此感到困惑，因为它们叫兴奋剂。

a lot of confusion because they're called stimulants.

你能不能解释一下这个点？

So maybe you can address that.

人们会想，为什么给一个多动的孩子用兴奋剂？

People thinking, why would you give some kid who is hyperactive a stimulant?

是的，确实如此，效果因人而异。

Yeah, so it is true and the effect varies depending on the person.

对没有多动症的人来说，可能会更兴奋，但有趣的是，这个发现其实是偶然发生的。

So a person without ADHD might become more stimulated, but what's interesting is, and again, this was a discovery that would just happen.

并不是说人们随便试了试，就发现它效果惊人。

It's not, you know, people just tried it out and saw it had an amazing effect.

我们看到的是，兴奋剂实际上能帮助提升专注力。

And so what we see is that the stimulants actually create more focus.

作用机制目前还不完全清楚，但确实观察到，使用兴奋剂的孩子在ADHD的核心症状上普遍有明显改善。

There isn't, I think the mechanism of action is not entirely understood, would say, but we do see that children who use stimulants typically have a large positive effect on the core symptoms of ADHD.

我觉得大概有百分之八十的孩子都会有正面效果。

I would say probably close to eighty percent of children have a positive effect.

这太好了。

That's great.

所以第一类就是兴奋剂。

And that's, so that's the first class is the stimulants.

没错。

That's right.

兴奋剂对症状的改善效果非常显著。

So the stimulants, again, have a very strong positive effect on the symptoms.

最近的研究还表明，这一点很多人可能还不知道，但确实存在长期的好处。

We also know from recent research, and this is very interesting, I think not many people know about this, but we do know that it also carries benefits, long term benefits.

这方面的研究才刚刚起步，因为要做这种长期追踪研究实在太难了。

And this is just emerging now because it's so hard to do these long longitudinal studies.

但已经有很强的数据证明，长期服用这些药物的人，之前提到的那些负面结果——比如入狱、药物滥用、酗酒、车祸等等——发生率会明显降低。

But there are really strong studies showing that people who are taking these medications long term are less likely to have those bad outcomes I mentioned earlier, including incarceration, including drug abuse, alcohol abuse, and those kinds of bad outcomes, getting into car accidents.

我觉得这一点特别重要，因为大家在权衡是否要用药时，都认同短期有效，但未必知道它还有长期的好处。

So I think that's a really important thing to know about it, because when people think about weighing the pros and cons of trying these medications, I think everyone agrees there are short term benefits, but not everyone knows that they're actually long term benefits as well.

这么说来，你可能得一辈子吃，或者至少吃很长时间。

And that implies just to make a point of it, that some of these drugs you might be on either for life or for very long time.

对吧？

Is right?

没错。

That's right.

而且这些药有个好处，就是想停就停，想开就开，非常灵活。

And these medications are very easy in the sense that you can stop and start whenever you want.

实际上，这类药不像其他精神类药物那样需要逐步加量。

There actually isn't even a ramp up period like many other medications that are psychopharmacological medications.

是的，确实如此。

So, yeah, it's true.

而且随着孩子长大，最终做决定的也会是他们自己，对吧？

A lot of and once the child grows older, he or she become the person to decide also, right?

比如上了大学或者成年后，他们自己决定要不要吃，什么时候吃？

For example, in college or later in life, do they want to take it and when do they want to take it?

他们还可以选择在某些日子吃，或者只在考试这类特定场合前吃。

And they can choose to take it on certain days or just before specific events like tests and things like that.

这真是太好了。

Oh, that's great.

明白了。

Okay.

我觉得你之前还提到过另一类药。

And I think you said there were another class.

没错。

That's right.

第二类药物叫做非兴奋剂。

The second class of medications are called non stimulants.

最常见的包括α受体激动剂和托莫西汀。

The most common ones for that are alpha agonists, as well as atomoxetine.

非兴奋剂类药物对大脑的作用机制略有不同，但效果通常比兴奋剂弱一些。

And the non stimulant medications work a little bit differently on the brain, but they have also a smaller effect compared to the stimulants.

它们能减轻多动和冲动，但在提升注意力方面作用没那么明显。

And so they reduce the hyperactivity and the impulsivity, but they don't as much increase the attention.

明白了。

Okay.

你们通常会把它们合用，还是只选其一？

And do you tend to use these together or is it one or the other?

有些孩子会联合使用，但大多数情况下只选一种。

So in some children may use them together, for most it's one or the other.

我觉得我们越来越倾向于为年幼的孩子使用非兴奋剂，因为它们的副作用谱更温和。

I would say that we're looking into using non stimulants for younger children more often because they have less of a different side effect profile.

兴奋剂的一个主要问题是常常会降低食欲，还可能带来其他问题，比如睡眠障碍或情绪易怒，尤其在小孩子身上更明显。

So one of the issues with stimulants is that a lot of times the main side effect is a reduction of appetite, but it can also have other problems like maybe sleep problems or irritability, especially in young children.

所以很多时候，针对年幼的孩子，我们会优先选择非兴奋剂。

So that is why a lot of times for younger children, we use non stimulants.

明白了。

Gotcha.

好的，那我们来聊聊非药物干预吧。

Okay, so let's move to the non pharmacological.

我知道你在这方面的研究挺多的。

I know that you've done some work in these.

除了药物之外，还有哪些方法可以帮助改善多动症呢？

And so what are the things other than the medications that can help in ADHD?

确实有很强的证据表明，当父母或看护者参与父母培训和行为管理，学会调整环境，掌握应对具体行为的策略时，不仅孩子的症状会改善，家庭环境的整体混乱程度也会明显降低。

Yeah, so there is really strong evidence to show that when parents or caregivers participate in what's called parent training and behavior management, and they apply some strategies to modify the environment, as I mentioned, and also learn how to manage specific behaviors, there is improvement both in the symptoms, but more in the environment of the home or the chaos in the home.

家里有患多动症的孩子时，通常都会比较乱。

Homes are typically chaotic when there's a child or children with ADHD.

一旦实施了这些行为干预，情况就会好转。

And so that becomes better once those behavioral interventions are applied.

我想再深入问问，因为我对这个很感兴趣——您是医生，那对于一个乱糟糟的家，您会开什么‘处方’呢？

So just to dive in a little bit, because I'm intrigued by this, you're a physician, what is the prescription for a chaotic home?

比如，您会建议家长具体考虑哪些做法？

Like give me some examples of what you might ask a parent to consider.

这是个很好的问题。

Yeah, so that's a great question.

而且我们希望，不只是发育行为儿科医生，普通儿科医生也能给家长提供这方面的指导。

And this is something that, again, we're hoping that pediatricians can also consult parents on, not only developmental pediatricians.

我们常提到的一些简单做法，首先是确保和孩子建立牢固的情感联结。

And the simple things we talk about are, first of all, making sure that you have a strong connection, building a strong connection with the child.

这其实是所有工作的基础。

That's the foundation really.

你还要和孩子建立积极而牢固的联系。

And you want to have a positive, strong connection with the child.

在此基础上，再逐步加入一些规则和奖励机制。

And then on top of that, then you layer some structure, some reward system.

其中一个原则叫正向管教。

One of the principles is called positive discipline.

我们不希望一出错就惩罚孩子，说‘你真调皮，该罚’，而是要抓住他们表现好的时候。

We don't want to punish them and say, oh, you know, you were bad and you get punished, but rather catch them when they're good.

你要留意他们什么时候表现得好，比如没老从桌边跑开、没大喊大叫、没插话。

You want to identify when they're behaving well, when they're not, you know, getting up from the table every second or not yelling or not interrupting.

这时候就夸他们做得好，然后建立一套奖励机制。

Oh, that you did a great job there and and build a system of rewards.

这些只是其中几个要点。

Those are just a few of the principles.

另外，日常作息的安排也很重要。

There are also things related to structuring the routines also.

所以事情都有所预判，还会用一些视觉提示来辅助。

So things are anticipated and and there's some visual aids also.

比如早上这段时间通常比较难搞，要整理好东西、做好准备。

For example, morning time is usually difficult, getting organized in the morning.

像这样的方法还有很多，都能帮上忙。

So there are different techniques like that that can help.

这些方法有经过研究吗？

And have they been studied?

真的有效吗？

Are they working?

是的，有研究证实。

Yes.

研究显示，采用这类干预方式后，孩子的行为会有改善，家庭环境和整体生活质量也会提升。

So there are studies that show again, when you take that type of intervention, you can see improvements in the behavior as well as in the environment of the home, the quality of life of the family.

太好了。

Great.

最后几分钟，我想问一下，我知道你们在用多种方法评估护理质量，毕竟那些专攻这种疾病的儿科医生，正如你所说，他们开药，也可能建议家长改善家庭环境，减少混乱。

So the last few minutes, I wanted to ask, because I know that you're using a variety of methods to, assess the quality of care, because of course the pediatricians who are specializing in this disease are, as you said, they're using medications, they might be making prescriptions about a less chaotic home.

你怎么知道这些方法真的有效呢？

How do you know if it's all working?

是的，我专注于这个领域，其实我是在当了几年全科儿科医生之后，才转到发育行为儿科的。

Yeah, so what I've focused on, and again, I came to this area of developmental pediatrics after several years of being a PCP, of being a primary care pediatrician.

当我意识到我们并不总能提供合适的治疗，甚至不清楚什么才是合适的治疗时，我的热情就来了。

And my passion grew when I realized that we're not doing a great job in offering the right treatments always, or even knowing what the right treatments are.

我之前没提到的是，大多数患多动症的孩子都是由他们的全科儿科医生来管理的。

And one thing I didn't mention is that most children with ADHD are managed by their primary care pediatrician.

所以我到斯坦福后，专门研究发育行为儿科，就决定把我的研究和职业重心放在帮助全科医生上，让他们能更好地为孩子提供护理。

And so that's why once I came to Stanford and specialize in developmental behavioral pediatrics, I decided to focus my research and my career on helping to support PCPs to know how to give, you know, provide better care for children.

因为他们身处一线，而像你这样的专家数量有限，不可能覆盖所有患病儿童。

Because they're on the front lines, there are probably not enough specialists like you to go around for all the amount of kids with the disorder.

对。

Yeah.

所以我选择专注多动症，因为这种病太普遍了，大家都清楚全科儿科医生应该负责管理，事实上他们也确实在做。

So that's why I chose ADHD because it's so prevalent and it's clear to everyone that PCPs should be managing it, and indeed they are.

大多数孩子都是由他们来管理的。

They're managing most kids.

我的做法是，我的团队一直在分析电子健康记录。我从2017年开始接触自然语言处理，当时我的导师提出来，我觉得挺有意思的。

And so the way I've done it is, my team has been looking at electronic health records, and we've been using I started looking at natural language processing back in 2017 when my mentor offered it and I said, oh, that sounds interesting.

后来人工智能突然火了起来。

And then this big AI boom came about.

现在我们用上了大型语言模型，在识别治疗方式方面取得了很好的成效。

And so now we're using large language models and having really a great success in identifying what treatments are being offered.

比如，我们可以查看，对于那些学龄前的多动症儿童，儿科医生有没有推荐非药物干预？

And so we're able to look, for example, and see for young kids, for those preschool aged kids with ADHD, are the pediatricians recommending non pharmacological interventions?

还是直接开药了？也许他们根本不知道有哪些非药物干预手段。

Or maybe they're jumping to medications, maybe they're not aware of the interventions.

他们有没有给家长提供我们之前提到的那些正确指导？即使他们不知道该把家长转介到哪里。

Are they giving the right counseling that we talked about to the parents, even if they don't know where to refer to?

这些信息我们都能从电子健康记录里提取出来。

So all of those things we can glean from the electronic health record.

这真的很令人兴奋，因为以前我们根本没法分析这类数据。

I think that's very exciting because beforehand we were not able to analyze that data.

这对儿童发育医学或任何精神健康相关领域尤其重要。

This is especially for developmental pediatrics or any mental health related field.

大部分数据都藏在自由文本里。

Most of the data lie in the free text.

所有内容都是在这里面描述的，

That's where everything is described, that's

就是医生写病历的地方。

where Where the physician writes their notes.

没错，完全正确。

Exactly, exactly.

所以我想，有了这种能力，你就能给每位医生提供个性化的反馈，比如：你做得不错，但我们注意到你还没用过这种干预方式，或许可以考虑一下。

So, and then I'm imagining that with an ability to do this, you could do like sensitive feedback to the individual physician that, you know, you're doing a good job, but we have seen that you haven't made use of this modality, you might wanna consider it.

当然了，如果反馈方式得当，我觉得他们收到后会非常高兴。

And of course, if it's delivered appropriately, they would probably be very glad to get this feedback is my guess.

说得太对了。

That's exactly right.

我觉得正因为我自己当过全科医生，才更能理解这一点。

I think that's where it helps that I was a PCP myself.

所以每次和他们交流时，我都会说，我知道这有多难。

So whenever I interact with them, I say, I know where I know how hard it is.

我知道你们时间根本不够用。

I know you don't have time.

但在这里，我们来帮你们一把。

But here, yeah, let's help you.

这完全不是为了惩罚谁。

It's really not punitive in any way.

也不是在评判，说你没做好该做的事，而是想说：我们能做个工具来帮你们，再配合反馈，让你们看看自己和别人相比做得怎么样。

It's not judgmental, like, oh, you're not doing what you should be doing, but rather, listen, we can build a tool and we can help you, you know, with also with the help of, again, providing you feedback, this is how you're doing compared to others.

这对临床医生来说是个非常明确的激励，能促使他们做得更好，也知道该为孩子提供哪些帮助。

That's a really well known motivator for clinicians to do a better job and to know what to offer to children.

所以现在我们可以预见一个未来：像您这样的专家所发现的基础性成果，能够传递给全科医生，从而整体提升这种疾病的诊疗水平。

So then now we can see a future where as the basic findings in the field come from specialists like you, you have a way to then spread that to the primary care physicians to improve, basically float all the boats a little bit better for the treatment and recognition of this disease.

最后一个问题，我本该早点问的——在很多情况下，早期确诊总是更有利的。

The last thing I wanted to ask, and I should have asked it before is in many situations that I'm aware of, it always helps to get the diagnosis early.

我想知道，这一点在这里是否也成立。

And I'm wondering if that's the case here.

我推测，如果能在非常小的孩子身上做出可靠的诊断，就能更早介入，获得更好的治疗效果。

I'm kind of assuming that if you can make a reliable diagnosis in a very young child, it gives you more ways to intervene and get better outcomes.

这对多动症也适用吗？还是说这仍然是个疑问？我知道在自闭症上这是明确的，但在多动症上，早期诊断是否真的更有优势，还不太确定。

Is that true for ADHD or is it still a question about whether, I know it's true for autism, there a question about ADHD that you do better when you get an earlier diagnosis?

是的，虽然证据可能不像自闭症那样充分，但就多动症而言，我相信早期识别非常重要。

Yeah, I would say the evidence is not as strong perhaps as we know it is for autism, but for ADHD, my belief is that yes, it is very important to identify it early.

原因在于，我们清楚，学龄前儿童如果患有ADHD，将来在学业上更可能遇到困难，包括进入小学后也会出现各种问题。

The reason is because we know that in preschool age, if you have ADHD, you're more likely to not succeed in school, including elementary school, you'll have problems.

所以，提前做好准备，了解情况，一进学校、一进幼儿园就能上手，这带来的好处真的很大。

And so that's where really preparing and knowing in advance and coming into the school and coming into kindergarten prepared is a huge benefit.

太好了。

Great.

这简直太棒了。

Well, that's fantastic.

如果可以的话，我想换个话题，聊聊我们新推出的‘未来’环节。我会问你几个简单的问题，你给些简短的回答就行。

And if it's okay, I'd like to switch tracks now and go to our new feature called the future in a minute, where I ask you some, I think simple questions and you give me some simple answers.

这样安排可以吗？

Does that sound okay?

听起来不错。

Sounds great.

你觉得未来最让你充满希望的一件事是什么？

What is one thing that gives you the most hope about the future?

要说最让我充满希望的，也是我最期待的，就是把人工智能和大语言模型应用到电子健康记录里，从中挖掘出更丰富的信息，从而更清楚地了解我们对孩子治疗的效果如何。

Well, think the most hope, the thing I'm most excited about also is really in applying the AI technologies, the large language models to identify rich information in the electronic health record and get a better sense of how well are we treating children.