Research Recap with Skye: Current Methods and Issues Surrounding ADHD

0:05Welcome to Hacking Your ADHD. I'm your host, William Curb, and I have ADHD. On this podcast, I dig into the tools, tactics, and best practices to help you work with your ADHD brain. Today, I'm joined by Sky Watterson for our Research Recap series. In this series, we take a look at a single research paper and dive into what the paper says, how it was conducted, and try and find any practical takeaways. In this episode, we're going to be discussing a paper called Evaluating Attention Deficit and Hyperactivity Disorder, ADHD: A Review of Current Methods and Issues.

0:37And this paper is a narrative review that surveys the current landscape of ADHD diagnosis, where the DSM criteria came from, how they've evolved, and any known problem areas that are in there. And the paper covers a lot of ground in a relatively compact form, although it is, like, 21 pages, but it's quite a bit of fun to read. It's-- was-- I was going through and been like, "Actually, I-- this is just well-written. I'm enjoying this," which was not quite what I was expecting.

1:06But, you know, let's get into it. yeah, I was saying before we jumped on the call that I, I gave you this paper and I was just expecting you to be like, start by being like, "Skye, 21 pages? Seriously? I can't believe you made me do this." but it is, it's so good. It just had to be done. It's like this paper goes over clinical presentation of ADHD, then it goes into the DSM throughout the years before talking about the DSM-5, and then we talk about diagnosing children, diagnosing adults, and evaluation tools in general.

1:39And, you know, I would go as far as to say is if somebody said to you, "I want one paper that just really clearly explains what ADHD is. I've just been diagnosed, I know nothing about it," or maybe, "I wanna know more about it before my first assessment," or something like that, this is the paper I would probably recommend. Yeah, it's really good. And I do think we should mention to just, like, make sure there's the distinction that this is a, as we said in the beginning, it's a narrative review.

2:07Uh, typically we, on the show we do more like systematic reviews. And so a narrative review is more like the author is picking and choosing stuff on what to include in the paper rather than having a documented like reproducible protocol on how they looked up all the data. So there can be some introduction of bias, but I really feel with this paper they do such a good job of just like breaking down every point that they're going through and I'm like, they cover everything.

2:36So I understand why they did not do a systematic review for this kind of paper Okay, so let's jump into the first section. So it's into s- different sections. So the first section is the background and prevalence of ADHD. So they talked about this idea, you know, that it's one of the most common neurodevelopmental disorders, and we'll talk actually about the shift in how the DSM diagnosed, uh, or grouped, uh, ADHD in a little bit. But it affects, you know, 5.9% of children and adolescents and 3.10 among adults with inattentive as the most common type.

3:12Now, this was interesting to me 'cause this number was lower than I had seen elsewhere, although I will say that they talk about worldwide symptomatic ADHD for adults, and that is more in line with the number that I thought Yeah, when, which is an interesting thing to try and actually wrap your brain around with numbers because really what this paper is going to be looked at for a lot of people is, is ADHD over-diagnosed? And, uh, if we look at diagnosis rates around the world, we get an interesting thing because there's places that, yes, where it's could possibly be being over-diagnosed and other places where they don't even acknowledge that ADHD could be a thing I, I also think it's interesting that they say, you know, the worldwide prevalence, like you said, for persistent ADHD is 2.5, the symptomatic adult ADHD is 6.7, because it reminds me of the fact that a lot of the research that we read is actually looking at symptomatic ADHD based on, you know, assessment.

4:23They're not looking at diagnosed ADHD. And I think in adults it's almost, it's almost more common now in the research that we're starting to have those two different conversations, and it kind of comes through here a little bit. Yeah. I mean, the number of people that I've talked to, like for my podcast or just in general, that are like, "I have ADHD, I just haven't gone through the diagnostic process," is like, you know, I-- it's a lot of people.

4:49It's, Yeah ' cause… And especially for people that are not in the United States where there is some barrier to getting your diagnosis, but, you know, there are other places where they're like, "Yeah, there's just no chance I would ever get a diagnosis in a reasonable amount of time." Nine-month waiting list. Yeah, exactly. And, and it, it, it sort of, um… Yeah, I find the same thing in, in my work as well. Like, a lot of pr- business owners are like, "Oh yeah, but I'm not gonna get diagnosed. You know, I'm, I'm older, I've decided not to have that as part of it."

5:21Um, so it, it does leave room for that. But they do talk about, with the clinical presentation, they do go into, okay, well, what is ADHD? So, you know, they have the unifying theory established by Barkley in 1997. So executive dysfunction in ADHD is evident across four domains; behavioral inhibition, working memory, internalized speech, and the regulation of emotions, motivation, and arousal. That's kind of the Barkley four Yeah. And I, I really, uh, like Barkley's idea that it's a lot about self-regulation.

5:57It makes so much sense to me to be like, "Oh, this is how… If I'm looking through A- ADHD as a failure of self-regulation and it affects all these areas, that makes sense why I have trouble in these areas because self-regulat- And if I then can improve self-regulation, that will improve all, all of the d- other domains." Yeah. Yeah, I really like it as well. I will say I do feel like time blindness doesn't get as much of a showing in there as I, as I would like it to based on the research and, and the work I've done.

6:31I almost feel like when I work with clients, time blindness and working memory sit almost side by side in their, in how much they s- create a struggle. But outside of that, I think it's great Yeah. And I could see an argument for being like the self-regulation in time blindness being the, "I am not able to regulate that part of my brain to keep that in mind while I'm trying to do tasks." But Yeah semantics at best. Yeah. Yeah, exactly. Which is kind of funny, 'cause that is kinda what this paper is, is is semantics.

7:05But yeah, so then they talk about, um, you know, Mahone and I'm not gonna say his last name 'cause I will butcher it. Their debate on early neuropsychological theories of ADHD, um, you know, their considerations on disturb- disturbances in executive functioning. Um, and yeah, they go through all of the different areas of clinical presentation. let's get into the DSM then 'cause this is the bit that I was really exci- this is the reason that we pulled this paper because we wanted something that was gonna give us, like, a full history of the DSM because for those of you who may not have been diagnosed, this is how… This is the, the, the thing that people use to diagnose ADHD Yeah, and it's really important to remember when talking about the DSM that it is a, primarily a tool for insurance.

7:59Because if you want to cover something, it needs to be, like, measurable about what's being covered. And so that is how the DSM is developed, but then it is also not-- It is used way beyond that scope as well for all this diagnostic stuff. Yeah. Yeah, and that's why it can feel sometimes very different to some of the more clinical conversations. But yeah, the, the diagnostic value of ADHD first took place in 1968, but it was just called hyperkinetic reaction of childhood, um, in the DSM-II.

8:36So it wasn't really identified as ADHD m- until, like, the 1980s Yeah. And it even came in originally as ADD and then Yeah expanded into ADHD, which It's still something that I get questions about. Mm-hmm. Yeah just like, it, it like, it w- I don't think… Yeah, this paper didn't specifically talk about that, uh, hiccup, but it is something where like the idea of ADD really entered into public consciousness, and it was only in the DSM for like three or four years before it was updated to ADHD I think because it was the first one, I still get clients who are like, "I have ADD," and everyone has ADD.

9:25And I'm like, "Okay, cool." Like, that's just, it just tells me when you got diagnosed. You know, it gives me that, that kind of, um, information. But, you know, I'm very, uh, you know, the, the DSM likes to change the labeling of things a lot. So I'm sure that the next version is gonna give us a totally different name or a totally different subgrouping. I try not to let that get in the way of what we're actually discussing Yeah, because it's like, okay, yeah.

9:54Oh, is, is it very important for us to differentiate between ADHD subtypes versus ADHD presentations even though they cover the same thing? It's just, oh yeah, we wanted to update the language so that it shows that it change, can change over time. Makes sense, but I understand why people don't keep… Like, it, you should not expect everyone to keep up with it Yes, 100%. So that leads us to the latest version, which is the DSM-5, um, where they talk about ADHD type 1 and type 2.

10:31So the primarily inattentive, primarily hyperactive, and then the combined type. So this is the one that, you know, I, I know this almost off by heart now 'cause I get asked it in every single podcast I go on, you know, what it is and, and, and, like, what those differences are. It is worth mentioning that, um, you know, the DSM-5 w- is, you know, ADHD became recognized as a neurodevelopmental condition rather than a disruptive behavioral disorder, which is a really big shift Yeah.

11:03Um, which, and it's incredibly important too for people who are being diagnosed to be being diagnosed to how it is affecting them versus how it is affecting other people, because that is often how the condition is presented. Yeah. And historically that was how it was found. I mean, if you think about it, right, hyperkinetic reaction of childhood was the first version of this, and now we have it as a neurodevelopmental disorder. There is a huge shift in how we have come to think about ADHD, um, in that journey Yeah.

11:38And there's been, you know, so much, uh And how that, like, changes how people have the self-actualization of what having ADHD means for them as well Yeah. Yeah, I agree. I agree. I'm very happy to be in the mode, in the zone of, like, this version. I think it's getting better, um, in that way. But yeah, then they talk about the criteria. So, you know, for ADHD and in the previous DSM, you had to have six symptoms. Um, and then in the DSM-5, that was reduced to five for adults.

12:16So they did sort of talk about the pros and cons of that, but they, they adjusted that a little bit Yeah. Well, and the other important part there was also including adults as someone who could be diagnosed. Uh Of co… Yes, sorry. Yeah. Well, it's, it's, like, it's, it seems s- so obvious that like, of course we need to have, be able to diagnose adults, but it was something that, uh, was largely considered a childhood disorder, even though… I don't know.

12:47I've-- This is one of the things, I keep reading the literature and I don't understand at all, where I'm like, it, you know, I like, older literature I'll read and I'll be like, they talk about how it does not go away in adulthood, but they are like, "But it is primarily a condition of childhood." I'm like, I d- this is, doesn't make sense. Yeah, yeah. And it even comes up here, you know, debate over ADHD is an early age onset or late onset is still being debated.

13:15They went into, you know, some of the discussions about ADHD in adulthood, why it exists, the trauma conversation versus the we just didn't notice Yeah. So there is a lot in how the diagnostic criteria has changed, um, and I personally prefer a more inclusive approach, so I applaud them being like, "Oh yeah, we're going to be able to do this." Because people aren't seeking out ADHD diagnosis for no reason at all. It's usually because they're struggling.

13:50And the only important thing I find is, uh, which we'll get into in a minute, is, uh, how it's being assessed, because you wanna make sure that you're giving the right diagnosis Yeah, exactly. Exactly. It's a case of going, okay, it's not you don't have ADHD versus and you don't have anything, it's probably where do you fit in this space? And, you know, maybe, and this happens to people on both sides of the s- of the spectrum. Some people come in for anxiety and they go, "Oh, actually, if you get ADHD support, this is gonna be r- greatly helped, so let's not give you an anxiety diagnosis.

14:27That wouldn't be as helpful right now." And some people come in with anxie- with ADHD and they say, "Oh, this is probably depression or something in that realm, or maybe a combination, but we feel like this diagnosis is gonna be really h-". So it's really about which diagnostic profile is the one that's gonna help you with the struggles that you're having Yeah. And that's exactly where this paper goes to. It, uh, talks about every evaluation tool, every one, all of them.

14:57It's very comprehensive. Uh, but it starts off with this, uh, the Including the diva Yeah. But the, uh, gold standard here being our, uh, clinical interview, uh, which I did not realize that the… What I-- So I was reading the, so the Diagnostic Interview Scale, Schedule for Children, the DISC-5, uh, is a structured interview-based screening tool. It involves six modules and approximately 3,000 questions. Uh, just as a caveat, they do not ask you all 3,000 questions.

15:36Uh, but then again, from these, about 350 of the, them are categorized as stem questions, meaning that they are standard questions given to all respondents, meaning that the, this kind of clinical interview is very comprehensive. Yeah. Yeah, you get the feeling reading this article, um, that they have the childhood diagnostic of ADHD pretty dialed at this point Yeah. Uh, especially with, 'cause you want, you know, talking about having, you know, the teacher reports, parent reports, and then clinic reports because you want to be able to see how, uh, people are reacting in different settings because that might be a bigger indication of what's going on rather than, uh, strictly like an ADHD diagnosis.

16:21'Cause if like, oh yeah, they're only completely acting out at school or they're only completely acting out at home, that tells you a lot about what's going on. Yeah. Yeah, definitely. I feel like, I feel like it's interesting because it, it, it really raised for me a few questions about, okay, this is the gold standard, it seems very good. Like, I feel like if your child goes through this diagnostic process and comes out with an ADHD diagnosis, you can be pretty confident that's probably what they've got.

16:54But I do know that, and this is one of the controversies, is okay, how, how much is this particular process being consistently used across different areas when, you know, when it comes to actual day-to-day life? Yeah. And that's like the big thing because there are… You know, I've talked to people that have been like, "Yeah, I walked into the doctor's office and said I had ADHD," and they're like, "Yeah, I think you do." And that was the entirety of their diagnostic process.

17:27And I'm like, "That's, that's not good enough. Like, that's, that's a problem Yeah. Yeah, 100%. And so, you know, and then there's the question of like, yeah, like do, do they discount them? Do they look at the teachers? You know, do they look at the assessments? And, and that I think is where, and th- this paper breaks it down really well, and I do appreciate it, but I couldn't help but keep thinking I wish they had a section on practical implementation and use.

17:58I would like a chapter on how much people are actually using these tools and how they're using these tools for these kinds of assessments. Yeah. Um, yeah, and there's-- I mean, they did discuss, you know, there's are, you know, like, uh, systemic problems in the criteria too right now with, you know, the, uh, uh, questionnaires were historically developed using, uh, predominantly male children as their samples. And so that does provide, uh, some of the reasons that we are seeing, uh, some of the big changes in the criteria right now, because now we're finding, oh yeah, women also have ADHD Yeah.

18:42Yeah, exactly. Women also have ADHD. Adults also have ADHD. We're still not sure why. Maybe you were loved too much or not enough. It's one of the, one of the two. Um, colloquially, that's kind of what they said. And, um, and so they… Yeah, it just, it feels like, it feels like this is a great paper for the gold standard, and it didn't fully… And this is no shade to the paper. I think it's excellent. It gave me a level of expectation of the quality that I know from experience isn't happening, and I thought that was, that was, for me, one of the bigger takeaways Yeah, and it's also, like, not clear how we're going to get there either.

19:28Um, be- I mean, partially because That it's expensive to do all of that. To get to the gold standard, that's the-- going through that entire process is expensive, and, uh, not everybody's going to be able to afford that Exactly. And I think that's, that's a really, really good point. I mean, it's already, you know, very expensive anyway, especially, um, you know, I know from, from my own experience in New Zealand, they've recently made some adjustments to make it less expensive because of how difficult it was and how many people wanted to get diagnosed.

20:02Um, and it, and that also makes sense. You know, people go, "Oh my gosh, is there an ADHD pandemic?" You know, like, like it's, it's everywhere. But when you look at it, it's like it- we only realized it was really a thing in the '80s. Like, the '80s, that isn't even vintage yet. You know, that's kind of still in that space where, at least for me, I'm like, "Eh, that's just my parents' generation," you know? So it's not… It's, uh, of all of the things that you see in the DSM, you know, the depression, anxiety, like, all of those things, those are mu- have much longer histories than ADHD.

20:36So it actually makes sense that people are really starting to find that they have it because of just how early we even found out about it Yeah, that's 46 years of its existence. Like, that's… I mean, this reminds me of a little factoid I heard the other, a while ago, which was the first person to be diagnosed with autism died last year Wow. That is how recent, like I'm like, "Oh, yeah, that's, that's wild." 'Cause you'd be like, "Yeah, that, that should have happened 100 years ago."

21:16Yeah. Yeah and if we, we do, i don't know if we have data on the first person to be diagnosed with AD- ADHD, but, uh, you know, it's very likely based on normal stats that they're probably still alive Yeah. If you were not diagnosed till the '80s, you're… And it was considered a childhood disease, "disease," uh, condition, uh, then yeah, they're probably still around with us we're gonna wrap things up here because this is a 21-page paper, and there is so much more to talk about in this paper and we will come back to you with part two, uh, in a few weeks Looking forward to it Hello everyone.

21:58If you have enjoyed listening to this episode, then you might like to listen to my podcast, The ADHD Skills Lab, where we go and deep dive into more of the research, and also we focus on ADHD support for business owners, whether you're aspiring or you have your own company. Um, and if you have your own company and you wish that you had somebody who would just build these systems for you so you could stop figuring out what to do all the time, well, that's what we do.

22:24We are mentor and operator together. So if you wanna learn a little bit more about that, you can find me at Unconventional Organization. Thanks for listening.