ADHD Research Recap: Emotional challenges, late diagnosis, and internet addiction

Hi, we are the ADHD Skills Lab podcast. My name is Skye. And my name is Sarah. And we will be your hosts chatting to you about practical ADHD strategies you can use, the research behind some of these strategies, as well as interviewing other professionals with ADHD about how they've developed skills and working through struggles in their lives. You might know us from Unconventional Organization, where we talk about this kind of stuff all day long. So we're super excited to have you along and we're going to chat through it together.

Today for our research recap, we're talking about three papers, two of which touch on things we've actually discussed before but have a slightly different angle to them. So we're going to focus on emotional dysregulation, the experience of being a woman with ADHD, and then internet addiction.

Evidence of emotion dysregulation as a core symptom of adult ADHD: A systematic review

The first paper we have is evidence of emotional dysregulation as a core symptom of adult ADHD, which is interesting because it sort of just indicates that there is a growing acceptance of the idea that emotional dysregulation is a core symptom of adult ADHD. I wouldn't be surprised honestly, Sarah, based on the amount of research we're finding, if it became part of the DSM the next time there is a DSM rewrite, given the amount we've seen it come up the last couple of months in the research. Yeah, I mean, I would love to be a fly on the wall to listen to these discussions because you know that they're talking about it. Somewhere out there, there's meetings being held about the next edition of the DSM, whatever that may look like. Yeah, I've had a lot of people. So it definitely does seem like there's a lot more research around this. Definitely. It's only been 10 years. The three aims of this study were to understand emotional dysregulation in adults with ADHD, to examine the connection between ADHD symptoms and emotional dysregulation. And then the last one, and the one we found personally most interesting, was to identify ADHD neurofunctional abnormalities related to emotional dysregulation. So what's going on in the brain? And they did a systematic review. So do you want to take us through a little bit of what that looked like, Sarah? Sure, so they did a systematic review of literature. They came away with 22 articles. Your study could be included if it was empirical, using the scientific method, if your participants were adults, so 18 or plus, if your sample was diagnosed with the DSM-4 later, and then it had to also have some measure of emotional dysregulation or emotional self-regulation is what it's sometimes called. it had to be clinical diagnosis of ADHD. So if this study defined ADHD as like a presence of symptoms or even a self-report, it was excluded, which I love. Yeah, it was nice to see that. So we know for sure, not necessarily that the other research isn't useful, but if there is division there, that we have a sense of how people know they have ADHD, which is very, very helpful. It changes the way that we're able to talk about this study. Yeah. In this case, it's sort of like a compilation, greatest hits, diagnosis style. And also if the study was qualitative or a meta analysis itself, it was also excluded. So they just wanted quantitative papers. Yeah. So in terms of the results, they showed some things that we've already talked about. So adults with ADHD had lower emotional regulation than adults without ADHD. I'm sure that comes as a surprise to really no one, given what we've been talking about. They also found that women with ADHD had greater emotionality and poor emotional regulation than men with ADHD. They found a higher emotional dysregulation score was associated with sluggish cognitive tempo, which we've talked about before, and also substance abuse. What else did they find, Sarah? One interesting thing that they found was that the emotion regulation scores of people with ADHD did not differ significantly from the other psych disorders that were sort of in these studies. Things like borderline personality disorder, autism spectrum. So the emotional profile of all of the mental health group were sort of similar or at least did not differ significantly. Yeah. I mean, more stuff that we already know. ADHD people tend to use maladaptive regulation strategies. Do you want to just take us through, for those who didn't listen to that episode, what a maladaptive regulation strategy would be? Yes, of course. Maladaptive sort of just means that it's not helpful. When you try to use self-regulation strategies, such as suppression, you know, like pushing them away, avoidance, not wanting to deal with it, that doesn't tend to help you. Instead, they suggest that you use something like cognitive reappraisal, which is just like reframing a problem and other sorts of things, you know, mindfulness, etc. The grounding conversation is so large. They mentioned in here that people with ADHD also tend to report the strategies that they use don't work as well compared to other people. And so the fact that it doesn't work like it works for other people leads to that negative self talk, that self blaming sort of lack of control, rumination, etc. Yeah. And they also found something interesting, which might explain why those emotional regulation strategies don't work as effectively when you have ADHD, which was the neural reactivity. So what they found was that ADHD, was associated with very distinct activity in their brain in relation to emotional stimuli. And what this suggested was that it takes greater cognitive effort to manage emotional stress when you have ADHD compared to when you are neurotypical. And I don't know if you've ever been in an emotionally stressful situation, but that definitely rang through. Yeah, absolutely. Especially sort of when you see that other people aren't having these kinds of reactions, it can almost amplify it. And yeah, it just reinforces that point of like, why is everything harder for me? There's definitely something about being in a situation where you have what is considered to be an outsized reaction compared to the people around you. It can be very connected to self-blame, self-criticism, all of those things that we've talked about. So the fact that this research is very well done, I will say, systematic literature review found that there appears to be greater cognitive efforts to managing emotional strength in the brain if you have ADHD indicates that it is more stressful for you. You could describe it as if everyone else just had to count backwards from 10 and you had to count backwards from 10 and do Sudoku at the same time. You might be a little bit more frustrated. Yeah, and in that scenario, like the only observable difference between you and them is you. Because we can't see into people's brains to see how hard they're working just to function. Exactly. If we could have little like sign above you, you know, like how much bandwidth you have. Yeah, what is your battery looking like right now? Yeah. Yeah, they also connected this to the idea of top-down regulation, which the literature also says is really difficult for people with ADHD. Basically, top-down regulation is like using the prefrontal cortex, sort of the logical responding to an emotional stimuli instead of reacting. And so they connected this whole idea of the abnormal activation patterns that they saw in the different areas of the brain to suggest that experience the stimulus of the emotional response might be different from the very beginning for people. It's sort of like that whole idea of, I think that I feel things differently from other people. I don't know if that resonates, but yeah. Yeah, I think it does. Can you give me an example? Oh, sure. I mean, I could probably give you 100 examples. No, but just sort of like experiencing joy in a way that like it doesn't look like anybody else is having that great of a time or a lot of us are really vibrant people. And sometimes that can come with some self-doubt as well because it's like, why am I the only one having this like, having this great time? That is an interesting idea. They don't talk about it in the research here. They only talk about emotional stress, but they don't talk about the positive side of it, which we sort of see as well, at least anecdotally with ADHD, this idea that we have outsized emotions, negative and positive. I wonder what the brain is doing at that point. It's being chaotic. They do say sort of at the end here that this cognitive effort thing supports the hypothesis of emotional hyperreactivity in ADHD. So that's sort of the tie in there. Yeah. There were some limitations here. The studies all seem to be like the same, like the sample population wasn't very diverse, or they didn't look at the diversity specifically, you know, gender differences, med status or anything like that. So they were kind of lacking some information that could have been more helpful and make it more generalizable. They specifically said, because there's no unifying criteria for ADHD and emotional regulation, it makes it difficult to compare those studies because like, emotional dysregulation doesn't have an agreed upon definition yet. Yeah, definitely, definitely. And that is very true. That is very true. And we sort of see that come through in a lot of the papers. So in terms of a practical takeaway, I think this is a reinforcement of what we already, I wouldn't say we know it, but we've already got a lot of indications from the research, which is that emotional regulation is a struggle with ADHD specifically, but with a little added twist of this greater cognitive load concept, which I think helps to just explain it a little bit more, what might be going on. Well, yeah, it's a little bit of the why with the what. We're understanding what the emotional dysregulation experience is like. And now we're starting to see why it might happen functionally in the brain. Exactly. Which is great.

Exploring Female Students’ Experiences of ADHD and its Impact on Social, Academic, and Psychological Functioning

So if we move on to our second paper, it reminds me a lot of the paper we did previously, a qualitative analysis of woman's experiences with ADHD. This was very, very similar. In fact, they also did a thematic analysis. So their paper was exploring female students' experiences of ADHD and its impact on social, academic, and psychological function. And it was from the Journal of Attention Disorders looking at the female ADHD experience. So do you want to take us through a little bit about who these women were and what they did to sort of find out about them? This paper was based on qualitative, structured interviews. So they were looking specifically at concepts. They were interviewing these people in depth, in person. The sample size was eight. They recruited adult women with ADHD living in the UK. They had to be students at any university in the UK. They asked specifically whether these women had a clinical diagnosis of ADHD, but didn't do any confirmation or anything like that. Interesting, yeah. They recruited these people on ads, like Facebook and Instagram ads. They started with 25, wound up with eight. The only exclusion was comorbidities, which like the only exclusion. I mean, how many people were excluded from that? Yeah, that's very, very true. And interesting that they ended up with eight. 25 is a more standard for thematic analysis. Eight is pretty low, even for qualitative thematic analysis. I would be really interested to hear what happened to over half of their sample, like a significant portion dropped out. there's almost more data to be gathered from the people who dropped out than the people who stayed. So just kind of putting that in context, although qualitative analysis is not. Well, I could tell you it was probably ADHD aversion to admin tasks. So 25 people said that they were interested and registered, but then only eight of them followed up by completing the consent forms and all the questionnaires and attended their allocated interview time. Too many questionnaires. Yeah, I mean, 13 of those people just said like, I'm interested and then never heard like ghosted. That's half of them right there. We're just like, Nope, you're asking too much of me. They only got paid five pounds. Yeah, no, that's interesting. I mean, we could probably do a podcast episode on what it must be like to make an ADHD friendly research study because I imagine that there's a lot of non-ADHD friendly sort of ways to do it that we probably think about a lot. That could be enormously helpful. Mm hmm. Yeah, that'll be our first paper, how to write a paper, how to do research to get the most ADHD. Alright, listen up guys. Because it is an interesting concept, you know, I mean, we want to know as much as possible about ADHD, but how many studies have you participated in? I mean, I think we've both participated in a very small handful between us, Sarah, and it's worth mentioning. Okay, let's move on to the results. So what did they find? Since this is a thematic analysis, they were looking at like the overlap in experience, right? So they identified three core themes, and then each theme had sort of two sub themes. So we can talk through that a little bit. So the first one is stigmatization surrounding ADHD females included in that conversation are things like misconceptions, you know, social discrimination, and then because of those issues, the concept of selective disclosure. So like choosing, being very careful about who you disclose your ADHD to, which sounds quite lonely to me. Yeah. And also a lot of people's experiences, a lot of people in the academy and also clients will say, I told one person, I told no people. We are very unusual for putting our ADHD on the internet. Yeah. Yeah, I mean, and the misconception part isn't just around like outsiders misperceptions of ADHD. It's actually more like ADHD being entirely male slanted and sort of really struggling to overcome those male stereotypes. Yeah, I think it also says that misdiagnosis with a mood disorder was common. Yes. And I think that's, that's what we hear as well. anxiety, depression, diagnosis route to get to the ADHD. You know what, or even something even more harmful like bipolar, where they put you on like really hardcore medications. Yeah, definitely. The other thing they talked about was the journey to receive a diagnosis. And I thought it was really interesting. Seven out of eight people referred themselves. They did not get referred by anybody else. I referred myself. I referred myself as well. Yeah, I referred myself to dyslexia. Yeah, it was interesting, you know, that concept and I think it speaks to a lot of people's experiences and it also speaks a little bit to the journey to receive a diagnosis. If the journey starts with you figuring out you have ADHD and then you going to find the resources and you getting diagnosed sometimes in the face of people saying that you shouldn't be, you know, that you shouldn't try or various things like that. That's a very, very different experience from your doctor picks it up. The amount of self advocacy and like confidence and like persistence that it can take sometimes it's astounding. It's very sad. And that is why we talk so much about the subjectivity of diagnosis and like we like pray to the gods for like more concrete diagnostic tests because like yeah yeah these experiences are tough. It is very tough and it was interesting to see to that point doing the diagnosis for ADHD and then doing it for dyslexia. It was very interesting to see how much harder it is to understand whether you have ADHD. It's not for both of them but. It takes a village basically to diagnose you with ADHD. So that flows really nicely into the third theme, which is the difficulty of being diagnosed later in life with ADHD. Because that comes with a whole mixed bag. There's like a whole bunch of emotions involved, some positive, some negative. There's validation going on, but also like grief over that loss. Yeah. What could have been. Yeah, no, 100 percent. Going back through your life, basically and having to re-visualize everything based on this new concept. Yeah, like a total identity crisis. Yeah, 100%. Yeah, we laugh because we experienced it. Yeah. So participants felt that undiagnosed ADHD had gotten in the way of their functioning. They could now take better control of their symptoms, but there's also that feeling that they had lost time to do that even as they were able to do it now. And it's also worth just pointing out that they found that low self-esteem and high self-criticism was related to ADHD across everything. And that speaks to both the previous paper, the first paper that we discussed, and also just what we've discussed in general, which is that people with ADHD really can struggle with self-criticism. I would love to see a study that contradicts that statement. I mean, I just don't think that any exists. So I'm sort of like challenging someone. Yeah, I just don't believe it. Like, I'm pretty certain that if we studied ADHD and its relationship to low self-esteem, high self-criticism, negative self-talk, I mean, like all of that stuff, we would just over and over and over find how related they are. Yeah. Hopefully that will change in the future when people understand their ADHD and manage it. But at the moment, yeah, definitely feels like very high self criticism for everyone. Sure. I mean, we also have to put this in a historical context, right? It was only 10 years ago that adults could be diagnosed with ADHD, even like less time. It feels like we've been paying attention to like mental health. It was very much not taught when I was a child. Yeah. Yeah, it was definitely more stigmatized. And so now that there are more people out there sharing their experience, more people getting recognized and like reevaluating who they are, who they could be, like, there could be a huge shift. Absolutely. Yeah, I hope for it. Are you retracting your statement? Oh, yeah. I mean, it was kind of more like, come at me, bro. I think it would be great if you can find one. I'd love to talk about it. Yeah.

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Internet addiction and its relationship with attention deficit hyperactivity disorder (ADHD) symptoms, anxiety and stress among university students in Malaysia

The third paper we talked about actually comes from Malaysia. It is internet addiction and its relationship with ADHD symptoms as well as anxiety and stress among university students. This is an interesting one, internet addiction, because it's something that we talked about a lot when I was in university because Facebook was becoming a thing at the time. I haven't seen a paper on internet addiction for a little while, so I was interested to find it popping up here talking about ADHD. The research question is, is there a relationship between psychological symptoms, so that includes ADHD hyperactivity as well as stress, depression, anxiety, and loneliness, and the development of an incident addiction within university students? So how did they do this methodology, Sarah? So this was a good old-fashioned study. They had a sample size of 480 randomly selected Malaysian public university students. pretty narrow age range, 18 to 24, 73% female, some sort of mix ethnically, but participants sort of completed a series of self-report questionnaires, things on the internet addiction tasks, symptom scales, and things like that. It was an ADHD self-report symptom checklist that they used. Yes, yes. That is important to point out. And in fact, everything was a checklist. So that was how they did the whole study was they were given various self-administered tests. Yeah, everything was self-report questionnaires. The good thing though, is that there's sort of random sampling and it was broad amongst all the universities. This sort of sample can be more broadly generalized, at least within this age group, right? You know, the young adult sort of phase. The data comes from 2016. So before COVID. Yes. Oh, gosh. Yeah, before COVID. I wonder if they're re-studying these kids now. So they did some statistical analyses, and they were looking at the relationships between the variables. So that's things like the mental health scores that they got, as well as that internet addiction test. They were basically just trying to see if they could predict who was more likely to be addicted to the internet. And what they found was that people who were more likely to be addicted to the internet were males, were people with ADHD, and those who reported stress and loneliness. So there was two groups that didn't have that significance, and that was anxiety and depression. It was not related to higher addiction to the internet, but everything else was. And they found, I think, largely what they expected to find. Yeah, they mentioned in here that the literature is shifting a little bit, that the study is a little bit different from that that they've seen in the past. But yeah, they definitely seem to just want to help these kids. They also found that among the entire sample, a third of them did have internet addiction, as defined by this questionnaire, which is quite a large amount for a random sample. Yeah, in fact, that is a very, very good point. And I'm actually going to take a minute to see what was the test. So this is the Indonesian Internet Addiction Test. So this is not the Malaysian one. But just to give you a sense of what these tests look like, because I think it's worth mentioning, they have questions like how often do you choose internet enjoyment over intimacy with your friends? How often do you find yourself planning when you will play on the internet again? How often do you feel that life without the internet would be boring, empty, and joyless? How often do you get angry or act annoyed when someone disturbs you? I think the reason that this is worth mentioning is because of the dopamine conversation. When we talk about internet addiction and ADHD, it's not just an addiction, it's a source of dopamine. When you mentioned how many people had internet addiction in general, it did make me wonder if this is just something that... This is a very strong source of dopamine for a lot of people, and it could definitely become problematic. And this is what they're getting out here. Does your school performance suffer? Do you not get sleep enough because of the internet? But it does change a little bit when you think about it from the perspective of ADHD and the idea that we don't get as much dopamine as neurotypicals. So we would therefore struggle with accessing dopamine. And for a lot of people, that dopamine comes through their phones. I'm just taking a moment to tally up how many of their totally random sample scored highly on ADHD symptoms. Their totally random sample gave them ADHD to cystic scores of 81.5%. That's a hugely high number of people with ADHD, but it is a self-reporting. Yeah, they add up. Holy cow. Sorry guys, we're just doing research literally in real time. Yeah, just making sure that these stats match up. Well, yeah, because that's almost 400 people out of a sample of 480. So we were talking about the idea that they associated ADHD with internet addiction, but what you're saying is they associated ADHD with doing this test significantly. Kind of, yeah. So I was just looking at the full table of results here and they used a basic self-report scale for ADHD, which gives you likely or unlikely to have ADHD. So people who scored likely with ADHD in attention or hyperactivity were 400, 392 to be exact, which is like almost 82% of their sample self-reported some type of ADHD. Yeah, which is interesting because it does bring us back to that self-reported thing, which is to say, did everybody who had ADHD and everybody who thought they had ADHD and everybody who thought that ADHD was something they didn't quite, you know, like all of those different ways that you can self-report yourself as having ADHD. The potential flaw in my math here is that without the raw data, there's no way to know whether or not somebody was classified ADHD in attentive and not hyperactive or they could be in both categories. So I could be over counting people, but the percentages match up with what I got. So I don't know. I guess if we were to kind of think about what we could take away from this paper then, there is a bit of a question mark here around this idea of ADHD and internet addiction, because not only is it based on a self-report, which is very, very high self-report, but also some of these questions: how often do you find yourself saying just a minute when playing on the internet? They speak to, yes, maybe an internet addiction, but maybe an internet addiction as a result of not giving enough dopamine from other sources. And so the solution might be something that looks very different from what people would expect. Yeah, or even just like executive functioning challenges, like time blindness. Yeah, or that. You know, just in a minute and then like use it. Yeah. For the next 15 years. And the other question was, how often do you neglect, like this is the Indonesian Internet Addiction Test, this is not the Malaysian one, I just want to make that very clear. How often do you neglect household chores to spend your time buying all the internet? And the answer is often. That's hacked. Yeah. I guess again, to kind of come back to what appears to be the theme of this episode, as it were. There is a question of whether considering that they're focusing on people with ADHD, are they asking the right questions for people with ADHD to get useful information? That is a brilliant takeaway. And I am so grateful that you were able to take us outside of all of this because, yes, absolutely. That is so big, yeah, because when you look at everything lined up, particularly in this last one. I mean, you don't do a random sample and then come away with 82% ADHD people. Like that doesn't happen. We've done lots of these research reviews. Yeah. But maybe it does if you're focusing on a very specific age bracket. And then again, if you're talking about internet addiction and you're focusing on, do you get lost in your phone? Do you ignore chores? You could, for example, ask that question as, how often do you neglect household chores to spend more time staring at your fridge? That's probably very significant for people that age. Yeah, I mean, they also might have really self-selected themselves because these students were basically approached after class, sort of en masse, and then asked, do you want to participate in this study? Yeah, it depends on how much they knew about the study as well. It does say that they were explained the procedures, purposes, participation, benefits, and risks. It says that they were fully informed right from the get-go. Yeah, which makes sense, but also it depends, I guess, did they say, hey, you want to do a paper about ADHD and then all the ADHD people stuck their hand up or whether it was explained later on. Yeah. So it's interesting. It just, I guess it kind of speaks to the concept of What does neurodiverse research look like? And that is something that we haven't really talked about, and I don't think a lot of people have talked about, really. So definitely worth considering. Amazing. Yeah, this is great. Yeah, this is cool. Makes me want to write research. Got to find the type of that. Was there anything else that you wanted to add about the papers overall that we've looked at, Sarah? Another thing I think that ties the three of these papers together is that each of them in their own way highlight the need for looking at methodology, particularly the one with the sample size of eight. People don't always look for that information. And so you could never say that the results from that study would be as significant as a much larger sample size. And that's just one example. As we just discussed, kind of ad nauseum in the Internet addiction segment. How you're measuring things is super important in analyzing your claims of the data. Yeah, exactly. It is interesting. I mean, the paper on female students is not meant to be, they're not looking for significance. It's a qualitative paper. But it is interesting that from their eight, their eight people were diagnosed according to the DSM. And then the next one on internet addiction, that was people who did a self-report. And again, that creates a huge disparity potentially. And we sort of see that as well. So yeah, very, very interesting. Just makes me interested to see what the next one is. So yeah, if you want to hear it as well, we will see you next week or in the next two weeks for some more research recaps. See you later.

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