Research Recap with Skye: Current Methods and Issues Surrounding ADHD - Part 2

0:06Welcome 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 Skye Waterson 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. And in this episode, we're actually going to be discussing a paper called "Evaluating Attention Deficit and Hyperactivity Disorder, ADHD: A Review of Current Methods and Issues," which is a continuation of what we were talking about last week or two weeks ago, depending on how I, we release this.

0:46And, so yeah, this is gonna be our part two on this, 'cause this was such a long paper with just so much densely packed full of stuff. And, so now I will want to give you guys just a little heads-up that our original plan for this was that we were going to discuss this one week apart from each other, and, life got in the way. And, so it's been, three or four weeks, hopefully we don't go over too much of the same stuff as we discussed last time Yeah.

1:13But if you remember what we discussed last time and what we discussed now, and you are able to track the tren- the discrepancies, then well done. you're a better person than me. Yeah, I'd definitely look over what was in that transcript and what was, what we did and what hadn't been hit Yeah. But I will say, we were just talking about it before, like the reason we are diving into this paper a little bit more in depth is just because it's such a great overview of ADHD.

1:40We were both, saying that these two episodes side by side could literally be given to somebody if they had no idea what ADHD was, and by the time it was done, they'd be pretty well-versed in most of the questions you'd get asked. Yeah. And so in the first half, we were just, going over what kind of paper this is, which is a narrative review. and it covers, all the clinical presentations, the DSM history, diagnosing kids versus adults, and a lot of the evaluation tools and stuff Yeah.

2:10Yeah, exactly. And in this section, we're gonna go through clinical interviews, like how do they work, some of the, more like executive functioning tests that they do as well, including the Stroop test, which is one of my favorites. and then we're gonna talk a little bit about gender, differences and some of the limitations, of the, the DSM diagnosis and ADHD diagnosis as it exists right now. Yeah. And so clinical interviews are often what's considered kind of the gold standard of doing a diagnostic criteria for, ADHD because, self-assessment can also often be flawed in many ways with people either under-reporting or over-reporting their symptoms depending on, people can sometimes be looking for that diagnosis or, just being like, "No, I'm normal," even though they're having, they're str- they're not quite aware how much they're actually struggling Yeah.

3:03And that's one of the reasons why they said, you can have a structured and an unstructured interview, but it really is about the, the quality of, the interviewer as well, which is one of the reasons why if you had the DSM, for example, and you just went through it with a friend, that would not be considered a diagnosis at that point because we need an expert who understands how to ask these questions to go through it with you. Yeah, one of the, funny things I'll see on, social media and stuff is people will be talking about questions they answered in one of these things, and they're like, like w- there'll be th- I think this is one I've heard for, autism assessments where it's like, "Oh, would you rather go to a library or to a party?"

3:46And so people are like, the an- that answer is what's important. But what's more important to the interviewer is how you answer the question Yeah. Yeah, that's a really good point. and Library Pawty anyone. that's my answer. Yeah. yeah, 'cause when you're like, it depends," and you like list all the things, like it's getting you to explain your thought process, which is way more evaluative than act- the actual question Yeah, exactly. Exactly. And what is, what tools are commonly used?

4:15So they've got the diagnostic interview schedule for children, so the DISCV. That's a structured interview, based on the DSM, and it has approximately 3,000 questions yeah, that's, and I'm like, they don't ask necessarily all 3,000 questions, 'cause it's like a branching structure, with… But there are 358 stem questions which branch out, so it's still, even without 3,000, it's still a So if you're sitting here going, "Oh, like 20 questions, this is simple,"

4:50it's like, it does take a lot of time. There is a certain amount of research-backed systemization ways to create these kinds of structured interviews. it's funny, the 3,000 questions made me wonder if it was like, if you can answer all of these questions, you don't have ADHD. Yeah. Yeah, I can't imagine actually answering every one because it would just, it'd be so boring. It'd be the worst. Then they have, they have the, the young DIVA, so we talked about that.

5:21and they also have, an adult, the diagnostic interview for adults, for ADHD in adults, the DIVA. And the young DIVA is a structured clinical interview, designed to assess symptoms in children and adolescents age five to 17. and all of these things they get assessed. this one they said it's high diagnostic accuracy and practical use even, amongst adults as well. So all of these interviews they are doing, they're going to be testing them against previous interviews and looking at the diagnostic rates and all of that kind of stuff.

5:51So there's a whole process that goes into both what the tool is, what the questions are, and, and who does them, who is allowed to do them. in New Zealand, for example, they have made adjustments where in some cases, the person who can do some of this stuff is now your GP versus just your psychiatrist, because there was so much, desire for more knowledge about ADHD in New Zealand, and there just wasn't the capacity. Yeah. And I know in, generally in the United S- United States, it's state by state, and it's gonna be very every place you go who's allowed to do what.

6:26And it's very hard to give blanket rules on who you should be asking. Mm-hmm. Yeah, definitely. Definitely. and they did mention, that clinical interviews are considered the gold standard. but it is also, there can be some limited research on the accuracy of these. I think especially when we're doing unstructured interviews, that is something that there's a lot of, there's a lot of feelings about. there was a… I always come back to the BBC artic- did you gu- did you watch the BBC documentary that came out about, three or five years ago now, about private diagnostic practitioners and the way that they went through this process?

7:08I don't think so. I remember, I think I read articles about it, but I didn't actually watch it itself I think it's one of those things where whenever it is somewhat subjective, it's not 100% objective, there is always gonna be some kind of controversy around its use because, it is a little bit of an art and a science when you're going through this process yeah, as we mentioned earlier with the very structured one, it still, even though that's our like more objective measure, it still matters who's interviewing you.

7:39Oh And so it's even at our gold standard best way to do it, it's still not 100% objective because we don't have a way to measure things objectively like that And that's why if you go on the ADHD Facebook groups, they'll, in different countries they'll always be asking the same thing. "Who did your diagnosis? was it a good experience?" people are always looking to see who they should go to for these kinds of diagnoses if they have that ability. Yeah.

8:09And it's also one of the reasons that, self-diagnosis has become so popular is because people are like, "I don't even know if what I'm trying to do here is worthwhile if it's, not compl- if it's a subjective test, why can't I be the one doing it?" It's like, because it's better to get someone that knows what they're doing because it's… I'm not gonna dismiss someone self-diagnosing, but I do think you should go through the process if you can. I know a lot of people don't have that available, but if you can, because ADHD can hide as a lot of other things.

8:42So if you are trying to treat a condition the wrong way, you can sometimes be going the wrong way. If, for example, with if you're mistaking OCD symptoms for ADHD symptoms, they're treated very differently, and it would be a disservice to yourself to not try and find that out. Yeah, 100%. when we're working with your, with executive functioning struggles in businesses, we're very much like, "Hey, however you come to us is fine as long as you relate to those issues. We can help you with your executive functioning." But that's because we're helping you with executive functioning struggles in a business, setting.

9:19And whether you, whatever you have, those, those systems are probably likely to be the same. In fact, when I work with neurotypicals in these systems, they're always like, "Oh, this is very helpful for me, too." But if we're talking about you and your own diagnosis and whether you get medication and what kind of medication you get, and if you go to therapy and what kind of therapeutic treatment is gonna work best for you, that is a really important thing to pull apart with somebody who's an expert, in terms of, It's just like the people I know who have, been told they have anxiety half their life and then they find out they have ADHD, and they're really frustrated 'cause they went down this whole anxiety path.

9:56They did all of this particular support for this issue, and then they found out that it wasn't the symptom that they were trying to solve. if you get a… If you diagnose yourself with ADHD and you don't have it, you might find yourself down the same path in the opposite direction Yeah. So again, it's not dismissing self-diagnosis, it's just be open to the possibility that you don't know everything Yeah. Yeah, 100%. work on your executive functioning, but then when it comes to the actual diagnosis, yeah, I highly recommend getting an assessment if you can.

10:28and there's lots of different ways to do it and lots of different people to talk to about options. Okay Yeah. So moving into rating scales, which feel a lot like the, clinical interview parts, but it is, a… Once you're inside the clinical interview, this is how they assess you with things like the, child behavior checklist or the teacher report form. these are things, and it's the, one of the reasons that you want this kind of thing is that for the ADHD diagnosis, it has to be something that affects you both at home and either at school or work, in not just one arena Yeah.

11:07Yeah, and this is where you get the sort of the DSM criteria turned into questions. and there's different rating scales. And if you think about adult ADHD, for example, one of the ones that we like and reference is the Barkley Adult ADHD Rating Scale, the Conners, Adult ADHD Rating Scale, which I think is the one I did for my own assessment. and, yeah, they're all assessed and really cool Yeah, I remember doing the, Vanderbilt for my children, which is a very popular one.

11:37The… Got the parents and teachers 'cause… Which I've always been funny 'cause I'm like, "Yeah, but that one just does not ask the kids anything," Really? But I d- I understand, but also That is funny, yeah. Yeah, there's a whole bunch of things you can do. there's a teacher report form, where they look at, affective problems, anxiety problems, attention deficit problems, conduct problems. Then there's, just straight, assessments for adults. and what is used is somewhat, I don't know, I don't wanna say the word arbitrary, Will, but what do you think?

12:16it's… There are better and worse versions of them, but in general, they have been weaned down at this point to some very s- if you don't get one at all, that's a red flag. But as long as they're using one of these, rating scales that s- we're talking about, the… Yeah. I'm like, there's too many, I don't wanna go through all of them. But there we've, that we've just mentioned are like, SNAP or the strength and difficulties questionnaires. these are good to… You can be like, "Oh yeah, this, it doesn't really matter to me personally that which questionnaire that you got used for, but as long as one of them got used It's a little bit like, it's a, it's like a cultural thing, what countries and what, states decide to use will be somewhat develop- dependent on, what got used first in that area, what got ap- approved first.

13:11it's a, a bit arbitrary in that way. But the key is that they're all coming from the DSM. the DSM, which is why we talked about that last, we, last time in detail, is the sort of source of these rating scales Yeah. and yeah, I just realized that I was like, I was only looking at half my list of scales there. I was like, look, sc- scrolled. I'm like, "Okay, and then we're gonna go, oh, there's another whole list of scales. I was just looking at the kids' ones."

13:43There's a long list of scales. okay. do you wanna talk about the, the neurological and continuance, continuous performance tests? 'Cause I feel like these are the ones we talk about the most in terms of our research into ADHD it's like the more exciting stuff that's going on right now too, 'cause it's, these are like, the most like, oh, we're doing video games and brain training apps and, the, this is our-- When we're talking about the testing that happens, the go, no go or the Stroop test.

14:15and so these are a lot of the ways that we're gonna be like, oh, if you're in a clinical setting, how they're going to assess whether an intervention is working or Yeah. And I thought it was really interesting that this paper described it as, tools for assessment of executive functioning in ADHD typically fall into subjective and objective. And they put subjective into clinical psychiatric interviews, and rating scales, and questionnaires, and things like that.

14:42And that's one of the reasons why it's really important that a, a clinician is the one using them, because they are subjective. but then on the other side, we have these objective tools, which are the neuropsychological tests, the continuance performance tests, and these are the ones that you will generally see, more often in academic spaces because they are objective. although there are limitations, and that does get touched on in this paper, that we can talk about.

15:07like you said, all of these different tasks, there's a whole list of them here. digit span task, no go, no-go task. the Stroop test, which I don't know if you guys have heard of the Stroop test, but it was one of the first things I learned in psychology. It's basically when you look at the word green, but it's in purple, and you have to say green, or you look at the… so some of the w- it gets harder and harder as you go along, and it's actually very, very difficult to not say the color and say the word instead.

15:41So all of these tests are about various forms of inhibition, various forms of like that, but not that, because we're measuring executive functioning, and some of them are working memory as well Yeah. I remember, I used to play, a game called Brain Age on my Nintendo DS when I was in college, and the Stroop test was one of the tests they used to help measure your brain age to see how well your flexible thinking was That's so funny. Yeah. Yeah, so there was that one.

16:08There was the Tower of London task, which I think we've talked about before, where you're basically planning. So a key part of the Tower of London task is that you have to essentially look like you're going backwards for a little while in order to, mentally plan out the steps you're going to have to take in order to do something. Which if you're ADHD, you… I don't even need to explain to you why that's an ADHD test. and then we have, the straight- straight forward sort of digit span task, which is more of the working memory one.

16:40It's like, do you… Like, how many digits can you remember, and how many digits can you remember backwards, and those kinds of tests Yeah. Which is funny too, 'cause, one of the interesting things about tests like these is that, Which was thinking about, that Brain Age game I played, was that you can train yourself to just do well on these specific tasks, and it has… Then it completely ruins the, diagnost- not diagnostic, the, what you're actually measuring.

17:09Because you're, instead of, measuring how well I'm doing on the Stroop test, you're measuring how well I've practiced the Stroop Yeah. Yeah, exactly. Exactly. It's, it's… Yeah, it's, if you've never done it before, you're gonna find it more difficult. and this is where I think some of the controversy comes in when they're like, "These are the objective tests," And then we have the conversation about environments and versus labs and things like that.

17:33but yeah, they did say, they could lack reliability. I think it was really… This is one of the reasons I really like this paper. They straight up just mentioned they can lack reliability due to issues with software or hardware, and I think that does not get discussed enough, 'cause some of these things were, very old tech, and, clicking a button in a certain way might not register the same for different groups of people Yeah, I can imagine, testing older adults with ADHD that didn't grow up with computers doing one of these things being like, "This is really hard and non-intuitive at all." And young people that are very computer savvy but are like, "This is such a bad program.

18:16Why would you do it this way?" Yeah, it reminds me of, a paper we looked at a couple of weeks ago where they were like, were trying to test for whether you felt left out by a digital game, and the solu- answer may be yes, but also maybe a digital game with a sad face emoji on a character that looks more like a horrified scream face. in some ways, no shade to the people, I know it's hard to make that stuff. maybe it doesn't translate as I am being left out.

18:46Maybe it translates as this computer thing is broken Yeah. And yeah, again, as you said, like the… It's great that this paper mentions that these have things because it is something where oh, maybe we can work on finding better solutions to some of these problems and finding ways to actually test these things that, are a little bit more objective than what we're currently Yeah, exactly. do we wanna talk about the potential issues, with the DSM? Because that was a big piece of it.

19:15Yeah. so the DSM It was for insurance purposes, as you Yeah. Like that's what it's g- it comes down to is that it is not designed specifically with patients as best they can be treated. in… I don't want to go on a capitalist rant here, but it is one of those things where it's yeah, this is for treating, when being treated, how insurance should be paying out. And that is, that, that is a conflict of interest when trying to treat people best Yeah. Yeah, exactly.

19:53it's also they discuss some of the changes. the DSM changes a lot, somewhat in relation to that. it can be difficult to determine… There's a conversation about is ADHD over-diagnosed? Is it over-treated? Is it misdiagnosed? and in some ways it is a, a bit of a moving target because we know more about it now. I keep waiting for people to be like, the ADHD, z- like everyone finds out about ADHD and thinks they, have it," and things like this. This is like dying down now, and it's been five years I've worked in this industry, and it is in many ways ramping up.

20:25More and more people now come to me and go, "Did you know about ADHD?" And I'm like, yes, in fact I do." and, and so there's all those conversations happening as well Yeah, 'cause it's, yeah, the In general, the DSM has been considered less inclusive than it could ha- could be. So with that in mind, people are worried about it becoming more inclusive and then increasing the number of people that are diagnosed with ADHD 'cause Probably we're underrepresented in the official, what is it?

21:003 to 7% of the population is what's estimated, and it could be closer to 10%. But it's, very hard to say as we have gone through everything on how you get diagnosed and it's yeah, this is a complicated process Yeah. very hard to say. And also grouped, I think people tend to silo. We know from the research people who have ADHD tend to connect with other people who have ADHD. So if you ask me about my universe, I'm like, "Oh, it's probably 50% of people," but that's because those are the people that I know and spend time with.

21:32It's very hard for me to look at a population and say, "That's what's…" it's like social media. We're all siloed in our own spaces and so that is part of it and, and it becomes part of this overall conversation. Some people are like, "It's incredibly over-diagnosed," because I've literally never met a person with ADHD except in school. And some people are like, "I only work in businesses with creatives, so I know a lot of these people." And it depends Yeah.

21:57And then, another issue we come up with the DSM comes from the gender biases because it, the diagnostic criteria are predominantly ba- were predominantly based on male samples. So you have a lot of the historical data that the DSM is built on being like, "This is how men are diagnosed. Also, just diagnose women the same Yes. And we do not, in fact, experience it the same way. We are more likely to relate to the symptoms of inattention. we also have more, like the way that we experience it with masking, with comorbidities around mental health related to masking often, and also all of these things that tends to re- result in a later diagnosis.

22:38So women are on average being diagnosed later than boys because this system, the ADHD diagnostic, was really created with "What are we gonna do with these men?" But also what with these boys, 'cause you must remember it wasn't even for adults, in school essentially. "They're disruptive. What do we give them?" "We gotta fix this." Yeah, 'cause often what we see from the DSM is how do we treat something that is affecting other people, not how do we treat something that is affecting yourself.

23:10And inattentive con- symptoms are much more, "This is making my life more difficult," rather than, "I am making my teacher's life more difficult." Exactly. And it always amazes me how, 'cause we look at the DSM and it's part of the conversation, but when I'm actually working with clients, we are often not even touching the criteria that got them the diagnosis in the first place. We're focusing on time blindness and working memory struggles and issues with, impulsivity, yes, but not "Oh no, you leave the room sometimes when you're supposed to be sitting down."

23:44I'm like, "Get a walking pad and let's move on." that's not even gonna be part of this conversation. Yeah. And it's, funny too when you have things like, to foreshadow our next paper we're talking about, emotional regulation and stuff, where that's not even included in the criteria at all at this point. And yet I don't think I know a single person with ADHD that wouldn't say their emotions aren't affected by Yeah, exactly. And they actually do mention that in this paper, which I thought was a really nice little callback.

24:10They said, that, yeah, there is a growing discussion of emotional dysregulation and whether it's a factor and it's… Yeah, like I said, it's it's very weird to me how the things that people come to us because they struggle with and the things that people originally got diagnosed with are not always the same things. they're like the Venn diagram essentially of ADHD Yeah, there's a, so much that goes into what the diagnosis is versus what you actually need help with that it is hard to just put into a single idea, which is the great thing with this paper being like, yeah, this, there's no single tool that's enough.

24:59you need a multimodal approach to look at how you diagnosis and how you treat it Yeah, and I think that's what I liked about this paper is, in conclusion, it spoke about how diagnosing ADHD is this challenging, multifaceted process. It requires a lot of information from a lot of different sources. It includes assessments. It includes clinical observations. It also has limitations in, in, the DSM, like we talked about with, gender and also, comorbidities and the direction that those comorbidities are going in.

25:29And it kinda takes a village to figure out if you have ADHD at the end of the day Yeah. yeah, do we wanna hit on comorbidities at all? 'cause it, there's an entire section there, but it is also Yeah. I think the long and short of it is that, there are a lot of things that can be diagnosed instead of ADHD. so you might say, "I have anxiety," but then you find out you have ADHD. but at the same time, you could have both, and this is a big conversation that is happening, I think especially now with AUHD.

26:02you can have autism and ADHD, you can have anxiety and ADHD, and a lot of people have some kind of developmental struggle, like dyslexia or dyscalculia or something like that. it becomes a bit of a cloud versus a specific issue. Yeah. And I think a really important also, one that was in here is the substance use disorder, which is estimated 25 to 40% of people with ADHD, struggle with. And, talking with people that work in the prison system, the number of people that have, prison… Are in prison because of their substance use and also have ADHD, they're like, "It's just most of them."

26:43Yeah, it makes me really sad, that kind of, Yeah, that's where we get into the negative outcomes of ADHD and one of the reasons why it's so important, even though it is difficult to get this diagnosis if you can, because that is information you can then use to treat it, if you can. And, Absolutely. 'Cause often when you treat the ADHD, the comorbid symptoms reduce quite a bit as well because they're just building off of each Yeah. Yeah, exactly. Like we know from the research that, if you have ADHD, you're more likely to be criticized.

27:15You're double, more likely to receive more criticism at the rate of double than other people, and that can become self-criticism, and that can lead to mental health issues. And so if we just know it's ADHD… the way I like to describe it to people when they say, why, why would I get a diagnosis?" is that, if you don't know that you have ADHD, you will assume that you have, "I suck at this," or whatever it i- whatever phrase you're using in your head.

27:42you're not… It's not like it disappears because we didn't identify what it was Yeah. So before we wrap up too, do we wanna talk about the, differential diagnosis piece and brain scan questions that kind of come up at the end of the Yeah, go for it Yeah. 'cause, this is an interesting, thing because they're, it- brain scans, we don't actually, we're not there yet. We want to be, but we're not. I have talked to some, neuroimaging people on the podcast before, and they are, they're in the s- field of it, so they're very bullish on the science.

28:14but it's also, yeah, you still can't just be like, "Hey, we've…" B- this, it'd be q- great because then we have that objective "Hey, this scan shows you have ADHD," and people would love that. But it's just not there yet. It's, and it's something that I want to see more research go into because it would be one of those like, "Oh, this is the objective way we can tell," and we can, really fight… I don't, do we need to fight against people that are doubting ADHD?

28:44Not exactly, but it would be really helpful for getting people the help they need if we can j- if their… Problem is brain scans are a little bit expensive, Yeah. it's interesting we should talk about this because I agree with you. I love brain scans, and every time I see a brain doing different things in different… I'm always like, "Ah, look, everybody." I'm so excited to talk about it. I've also found that large language models can be helpful here as well.

29:12Like, when I read the research on just you take a bunch of conversations and you can… the AI learning model, when it's trained properly, can identify, more than you would expect who is likely to have ADHD. I wonder about that as, a screening tool. Obviously there's a lot of, futuristic cyberpunk bad reasons for this as well, but, from a diagnostic perspective, that could be really cool Yeah, it'd be, yeah, I love there's less like, "This would be great.

29:40Also, corporations will be Yes, I know. I'm almost, afraid to say it, but, given that it- the information is out there anyway, I'm like, okay, but, like, how cool to just, have a conversation with somebody and at the end of it they're like, "Oh yeah, you said five different things backwards and then you went back to a bunch of other… Yeah, we should definitely get you tested." Yeah. I think, yeah, as a first pass, thing where it's like, yeah, this is worth looking into.

30:09It's a great tool Yeah. Especially if it could be then tied like, "Okay, now we're gonna like help, help you pay for a neurological assessment," because it would make sense to do it like those two things. In my dream scenario, that's what's happening. Yeah, exactly. 'Cause there's… We, what we want the most is for people to be able to get an easy "Hey, this is even worth looking into," and then, a quick and painless way to actually be diagnosed. Because right now, for a lot of people, it is such a difficult process It takes, in some cases, years to even get to the point where you are officially diagnosed.

30:49So you can understand why people are going, "Cool, I'm really excited to learn about the DSM. That sounds super fun," but in reality, my life is self-diagnosis because it's gonna take thousand dollars and, a three-year waiting list to actually get to anybody Yeah. as we wrap up, I think the biggest takeaway we can take from this paper is that, this is like a great way to look at the understanding of what should be happening in a thorough diagnostic process.

31:17But, it's also incredibly honest about how, yeah, we're not there yet in practice, and it-- there's a lot to still learn, which is great. I love being able to be like, "Hey, this is where we're at. This is where we wanna be." And it's, I think, I was really happy to read this Yeah. If you guys want to get a sense of how you become ADHD, this paper really gives it to you, and it also, I think, takes a little bit of the power back, 'cause you're like, "Okay, cool," "This is really important, but I can also have my… I can… I have information and I now have, more agency to make my own decisions with that information."