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.

Welcome to this week's research recap. This week we're gonna be going over a review of ADHD and hyperactivity. We're gonna be talking about some of the risks associated with undiagnosed ADHD and autism. And we're also gonna be talking a little bit about a different type of brain scan, looking at blood changes and what that means for people who have ADHD, medicated and non-medicated. So lots of interesting topics today and we'll dive right in.

Adult Attention-Deficit/Hyperactivity Disorder: a Narrative Review of Biological Mechanisms, Treatments, and Outcomes.

So the first topic, this is from current neurology and neuroscience. Somebody did a narrative review of the biological mechanisms, the treatments, the outcomes, all of those kinds of things when it comes to adult attention deficit or hyperactivity disorders. So this was kind of a non-systematic narrative review of 102 studies. That kind of provides a very broad overview. And a few interesting things came out of it. So Sarah, do you want to jump in and tell us a little bit about what they found in general? So broadly speaking, adults with ADHD experience disruptions across almost every and or possibly any area of life. Whereas you might not be impacted on every single level, it is possible to have issues socially with your job, with your body, things like that. They get into sort of some more specifics around those things, but it kind of just stayed as a fact. This paper does that kind of over and over. It just sort of states facts. It cites those sources. And if you want to sort of do a little bit more digging into those, you have to go directly to those sources. It does a pretty poor job of explaining like where they got this stuff from, but that's fine. I think probably one of the most shocking. stats that they say here is that ADHD is associated with an average reduction of 11.1 years in your life expectancy. Yeah, I was really surprised by this as well. I would say this paper is really good if you want to read one paper and get a really good sense of what the general current understanding of ADHD is. Yeah, so if that is something that's for you, I would say, go with this paper. the average reduction of 11 years, that was confronting. And it's kind of interesting because both me and Sarah were sort of like, wait, tell us more. Tell us why. Like what's going on? And they sort of didn't in too much detail. And part of that's obviously going to be because they don't have ADHD. Chances are the people who wrote this. Yeah. And they're sort of just providing the information. Yeah, they did a really good job at least. During their citation, they also wrote that the study that they're citing is a cumulative risk assessment based on data from 14 different variables of ADHD. The findings were that accidental injury and death by suicide were significant factors leading to that figure. Yeah, which is very confronting, and I think, and also very sad, as a member of the ADHD community, we do know these things. They are... information that we have, but sort of seeing it in black and white in an article was tough. It was very, very tough to read. They also talked about the heritability. So they said ADHD has a maximum heritability estimate of 74%, which was very, very cool. Sarah, do you want to just tell us a little bit more about that as well? Heritability is basically just an estimate of how much our genes are responsible for the presence and expression of whatever. So in this case, they were looking at... ADHD and ADHD symptoms put into context that basically means that the general consensus right now is that about 74% of your ADHD is caused by genetic variations. Polymorphism, if you will. Yeah. Which we learned last week. Yeah. It is really interesting. And again, it kind of brings back that concept of if you have ADHD. Or if somebody comes and their kid has ADHD, it's always good to look at the parents as well and look at that heritability so you can see it across the whole family and be able to provide that support for sure. They also went into a little bit of what ADHD means in terms of the disruptions in dopamine, in the receptor genes, in the brain. They talked about neuropronephrine playing a role which is another part of the brain They've seen some things with regards to effectiveness in treating ADHD symptoms. So Sarah, do you want to chat about that as well? Yeah. So I did a pretty deep dive into this when I first read it. I know. That's why I'm asking you. Well, I was really excited because for all that we know about dopamine and ADHD, it sort of feels like not the complete picture, right? So norepinephrine is part hormone, part neurotransmitter, just like dopamine. It's synthesized from dopamine, which means that your brain takes the dopamine and turns it into norepinephrine, which for someone who just doesn't make enough dopamine kind of might be a problem. So norepinephrine is the hormone that triggers the fight or flight response. Basically, it increases alertness, arousal, attention. It can also affect your sleep-wake cycle, your mood, and your memory. So a lot of things. So that's a lot. Yeah. And the implications for this and understanding this better in the ADHD context are huge, especially as it relates to the emotional dysregulation conversation. Yeah, that's such a good point. This paper came out this year, so hopefully we'll see more norepinephrine studies as well that we can dive into because, yeah, you're right. Like, dopamine is one factor, but one of the things we're really learning, I think... doing this, going through the research is just how many different factors can affect the brain. You know, how many different ways that the prefrontal cortex and other parts of the brain are affecting ADHD. It's a growing area for sure. The other thing was that they found which was ADHD symptoms. Unsurprisingly, if you've been following along with this research, with this podcast, ADHD symptoms can persist from childhood into adulthood with approximately half. of the children with ADHD meeting criteria for the disorder in adulthood. So we talked about this in some previous studies, talked about how not only can children with ADHD then meet the criteria for adult ADHD, but also you might have a period where you don't meet the criteria for ADHD, but that doesn't mean that you'll never meet the criteria for ADHD. So I thought that was really interesting. They didn't discuss that. But we have discussed that previously. So we're kind of adding that ourselves into what this research is bringing to this conversation. I mean, I think that is completely unsurprising. It also tracks with the conversation around the need for updated diagnostic process, what is diagnosis compared to what isn't and how does the concept of resurgence actually make sense? 100%. And they actually talk about this as well. They talk about the importance of. the idea, I'm just going to skip to that for this conversation, they talk about the idea that the current adult diagnostic process of ADHD is insufficient. And I thought that was really, really nice, especially given that they'd done a full literature review to be able to come away and say, we think this is insufficient and just adding to the pile of research at this point, that feels the same way. They even add that co-occurring conditions make the current Yeah, definitely. And I think they, including some of the neurological stuff in here was really interesting as well. They said neurobiological theories suggest that maybe sections of ADHD brains mature a bit later. There's executive dysfunctioning, there's metabolic disturbances. There's a whole raft of things going on in the brain that could be affecting why we're experiencing ADHD and what that looks like. And once again, it does really bring up the possibility that maybe there should be some kind of neurological assessment done as part of ADHD diagnosis rather than it just being a more clinical one. I know it depends where you go. Sometimes that is included, but the potential of that being an option would be really good. And I think sort of, I think hinted that here as well. Awesome. So what is the overall impact of this study? Yeah. I mean, it sort of functions as like a one-stop shop. for the current research on adult ADHD. They also did a really good job of shining a light on those unanswered questions. The debate is on about the current diagnostic process and things like that and what to do about it. So the impact is really that it continues that conversation. Yeah, I will say the more we do these episodes, the more excited I am for the new DSM to come out. I'm just like, I'm gonna be reading it, just be like, do you have it? Like, what's going on? But yeah, in terms of practical takeaways, I would say if you can access this, I mean, if you can't, then we kind of go through it. But if you can, having something like this, having an understanding of the latest research will hopefully allow you to better advocate for yourselves and your loved ones when you are discussing ADHD and how it works and maybe discussing the need for you to be tested as well if, you know, your child or someone else in your life has been tested that is related to you. and other things like that. It's always important to have that information and just make sure that you're on the same page if you can, and this is a good paper. So yeah, I would flag this paper as one to read for sure.

Risks Associated with Undiagnosed ADHD and/or Autism: A Mixed-Method Systematic Review.

So the next thing that we're looking at is the risks associated with undiagnosed ADHD and or autism. And they did a mixed method systematic review, which means it's a combination of. looking at data and then looking at survey results as well. So a combination of different things. I will flag this paper before we go into it. It is quite heavy. So we're going to sort of dip our toes into it. And then if you wanna read more, you can. But if you want a paper that goes into this with more of a positive ADHD focused light, I would highly recommend the qualitative research that we talked about a few weeks ago, the misdiagnosis research. this sort of covers some similar areas, but without much of a focus on the positives, which we know are there as well of being diagnosed and learning about yourself. So I just wanted to flag that first of all. So Sarah, yeah, tell us what they were looking for and what the methodology was. Yeah, so they specifically were looking for the impact associated with late or undiagnosed ASD and or ADHD. They are specifically defining impact as any consequence from having these conditions pretty much across all sectors of life. So this was a systematic search. They eventually came away with 17 studies. They pre-registered with Prospero, which Skye knows way more about than I do. It's the place where you go to say, like, I'm doing a systematic review. This is the process that I'm using. This is what I'm doing. Sort of there as well because you know, you don't want two people doing a systematic review of the same thing because it's a long process. So it's a bit of a like, hey, this is what I'm doing. Maybe pick another topic that can kind of be part of it as well. That's really cool. So their inclusion criteria, like they were looking at only published and peer reviewed studies. They searched specifically topics like impacts, effects, risks associated with. They. used both qualitative and quantitative studies. And their search criteria was basically from like the inception of the publication up until the 5th of December, 2022, which is probably when they concluded. Exclusion criteria, if there was no diagnosis status, threw it out. If it talked about more than just ASD and ADHD, they threw it out. Gray literature, studies not in English, you know, pretty standard things. And I will say if we jump back, let me just jump back to the actual paper here to show what this means, because sometimes they take out a lot, so it's always good to mention. So they basically, initial screening, they found 3,000 papers, then they screened, they took away like duplicates, things like that. They ended up with 1,600. They excluded 1,094. And then... The final assessment of actually the studies included in review that met all the criteria was 17. So I just wanted to say that to flag, and this is pretty common with doing a systematic review of the literature. I've done one before, they are long. Shout out to anyone who's done a systematic review of the literature. It's a long process, but they basically ended up finding only 17 papers that met their criteria from a very broad total of about a thousand if you take away some of the... Wow. Yeah. Yeah, it's a big endeavor. There's a reason why people do systematic reviews and you think, yeah, you're just reading literature like that's not much. It's like, well, it can be. So let's go into some of their findings. So Sarah, do you want to take us through sort of the three main themes of what they found? Among everything that they found, they grouped them into three sort of themes, physical and mental health, offending behavior, and day to day impact. So in the physical and mental health category, you know, it's things like looking at doctor's visits, co-occurring disorders, mental health and sleep, general things like that. The offending behavior is a little bit. interesting to define. It basically just talks about rates of what I'm used to calling maladaptive behaviors, like substance abuse, run-ins with the law, and that sort of thing. And then the day-to-day impact stuff is really just like, what is your life like? And then something called higher rates of functional impairment, which Sarah, I know you delved a little bit deeper into. Just functional impairments, things like struggling with self care, struggling to manage your finances, social interactions and that sort of thing. Yeah, definitely. And in terms of what they found, they found that basically, you know, as we mentioned, there was just more negative outcomes for people who had ADHD across all of these areas and what that meant in terms of impact. was from their argument that undiagnosed adult ADHD makes life more difficult and getting a diagnosis is really important part of getting support for these things and hopefully getting to a place where there are better outcomes. And they don't really go into what those better outcomes could be, but we know from having done other studies like the misdiagnosis study, that there are a lot of emotional and cognitive benefits. to understanding you have ADHD, to getting that diagnosis and to getting that support. What do you think, Sarah? Do you have anything to add to the sort of impact results? I think the only thing is just that these authors also highlighted the importance of recalling the diagnostic process, again, pretty much hitting the exact same points as the study previous. Yeah, very true. One thing that they do say that was sort of different is that with the exception of cost, there are no observed downsides to treating someone how to manage ADHD symptoms if they do not have it. Obviously, they're not talking about meds here because that can have a negative impact on someone who is not ADHD. But yeah, just teaching people like general executive functioning strategies could be beneficial for everyone. Yeah, yeah, I think this was really interesting that they said this, they were talking about therapy and coaching, basically saying that everyone could benefit from therapy and coaching. I definitely think that is very true outside of the cost, obviously. I think in terms of the coaching side of it, it really comes down to whether you have an executive functioning struggle. You know, one of the things we talk about a lot with coaching is sometimes people come to us for coaching and we say, hey, I think therapy might be a benefit. And I'm sure the other option as well, sometimes people come to us because their therapist is like, I need you to get some executive functioning support. So there is still a level at which you want to treat the person for the thing that they're struggling with the most and maybe you do a bit of both, but if you are struggling with executive functioning and they don't specifically say that, then yeah, I think coaching would be very helpful. Regardless of diagnosis, in fact, that's very much what we do. We don't require a diagnosis in order to. work on executive functioning struggles. We just require you to have executive functioning struggles. So let's talk a little bit about the limitations because we did find a few limitations with the population of this study in particular. Some of the self stated limitations of this paper were that there was some variation around diagnostic yes no for ADHD. So like Some of the studies that they included relied only on self-report screenings. Others required a clinician's diagnostic stamp of approval. So that was one of them. Which is very common. That comes up so much in the research that we do is like, who's doing it? How are they doing it? They also didn't have a lot of people who had ASD. So they really wanted. You could tell the study was a bit disappointed that they had found that research. It was a big part of their. reason for existing is that no one had looked at undiagnosed ASD and ADHD especially combined. But they only found three studies on undiagnosed ASD. And they didn't find anything on comorbid ADHD and ASD. Yeah, so you'll probably notice that we didn't really talk results of the ASD stuff. And that's because they didn't either. Yeah, so that was interesting. So definitely more I think. Anything that can be done on comorbid ADHD and ASD. I know this is such a new area to begin with that there's not a lot of that, but we know it's definitely a factor and it's a highly comorbid thing. So any more research on that would be really helpful. Another thing that the 2013 DSM did was allow for the co-diagnosis of ADHD and ASD. Prior to that, it was one or the other. Yes. Sorry. It's so confusing to me that I forget. It's so silly. I mean, I guess you have to put people in a bucket. Again, this is such a new area. Like I said before, very interested to see what the next iteration of ADHD diagnosis in the DSM is going to be. Because since their last DSM came out, the amount of conversation that has been had about ADHD specifically has been huge. So it is really interesting. they have to be sitting behind closed doors somewhere, having a really solid conversation about ADHD in adults because that's the reason so many people are coming to psychiatrists at this point. Oh, to be a fly on the wall. Yeah, I digress. I'd probably be very frustrated. Yeah. Okay, so before we move on, we also had to talk about what sort of people they went looking for, what sort of studies they found, and who are those people? What is that population? Yes, because to speak to the population, this population was not just a cross cut of the US or something like that. It was very much like different countries and then very different kinds of populations. It was definitely not a homogenous sample. Yes. Yeah, I think that's a perfect way of putting it. Yeah, it's a really tricky subject. But when you actually look at the types of studies that were included in this, You'll see a lot of similarities around like how poor the outcome was and like really obvious reasons for why that would be the case. Just for one example, it was like prison populations specifically. They had almost like 50% of the studies that they found and remember they had a thousand and they got it down to 17. So they had very specific requirements. But about 50% of their population came either from psychiatric units or hospital or people who were in addiction centers or people who were imprisoned. And that makes sense if you think about the fact that they were looking for people who were undiagnosed with ADHD but were on the path to being diagnosed with ADHD. Often when we get diagnosed with ADHD in the current population, it's hard to get that diagnosis. So it would be hard to find those people. And so... I mean, I think we've seen enough studies to know that there is definitely those negative outcomes, but it is worth mentioning that the population was very fragmented. There were studies that just looked at women of a certain age group or children of a certain age group, but there was a lot of different groups to then make that kind of holistic discussion of what was the overall outcome for people with ADHD. It was more overall outcome given 17. papers that looked at very different groups in very different countries, some of whom were in prison, some of whom were children, some of whom were in hospital. So that did have an effect potentially on the results. It would be hard to say this was a generalized sample basically. Yeah, I would definitely expect to see some difference, possibly something more positive if we were talking about a population who had more built-in supports. Yeah, I think the fact that they didn't mention that as a limitation is quite interesting because yeah, I think it was definitely a limitation that we found. Not to say that the paper wasn't really interesting, but I think in terms of what it was, it would have been good to say like, I almost feel like they could have done two separate papers looking at the outcomes for this group and then the outcomes for that group and seeing whether there are any differences because it's so important to support both groups. It's just really good to put it all into context. Yeah, definitely, definitely. And there was a few conflicts of interest. Some people were receiving grants, personal fees, and non-financial support from different groups. There was some pharmaceutical funding that was coming through this paper, which was really interesting because their outcome results was like, we should really get therapy and coaching for all of these people even if they're unmedicated. But yeah, they did have a bit of conflict of interest, a bit of funding from different pharmaceutical groups for this study. Definitely a heavy study, but one we thought was worth mentioning as well because it is good to have this kind of information, but then also to consider it in context and all of those kinds of things.

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Functional Near-Infrared Spectroscopy of English-Speaking Adults With Attention-Deficit/Hyperactivity Disorder During a Verbal Fluency Task.

So our last study for today is looking at a different kind of brain scan. So you know we love a brain scan. We're both self-confessed, you know, neuroscience nerds. So this one was interesting. They used something called functional near infrared spectroscopy, which was essentially if you know what an fMRI is, it's something that they used to do a whole brain scan. This was a more specific scan. They were looking at deoxygenated and oxygenated hemoglobin. They were looking at blood in your brain, what it was doing, comparing it to. people who didn't have ADHD and seeing if there were any differences. Once again, moving closer to what we talk about with regards to the idea of could we diagnose ADHD in a different way. This was from the Journal of Attentional Disorders. Sarah, do you want to go into a little bit of what the methodology actually was? They had a sample of 195. There were 75 healthy controls. We both didn't like that. controls guys, just people without ADHD. Yeah. And then there was also a 75 medication naive, outpatient adults, which means people who do not have a tolerance to medication. So either they don't take it or whatever the case may be. And then 45 medicated adults as well. Yep. Who weren't allowed to use medication for the actual experiment, which was quite interesting. It was, it was also really interesting that if you reported being drowsy at the time of arrival, they would send you home. Yeah. We both agreed. We'd be asked to leave. Yeah, immediately. How tired are you? We both have small children, so we're just like, okay, I'm going to go take a nap. Apparently this study isn't for me. ADHD was diagnosed by a psychiatrist, which was cool. Always nice to see that. ADHD symptoms and psychosocial functioning was measured by a self-report survey. They also measured your cognitive function, depression and anxiety. And then they did the actual test. So do you want to take us through, Sarah, what does it look like to do this functional near-infrared spectroscopy? I still think I might be saying that wrong. Spectroscopy. Yep. And what was that process like? So imagine if you're a patient. take us through what they would have done. So I'm gonna try to make this as simple as possible because they use the word optodes and I was just like, what? Basically, they put the little receivers on your forehead and your scalp and they were looking specifically at the changes to your blood while you participated in a particular task called a verbal fluency task. More on that in a second. They were looking at changes specifically in like your bilateral prefrontal cortex, frontopolar cortex, and the interior regions of the superior and middle temporal cortex. So basically the front of your brain and then also sections of the sides of your brain were there as well. So if you think about you're kind of wearing a little helmet or maybe even a visor on the front of your head. That's kind of the areas of the brain that they were looking at specifically. So the verbal fluency task, basically you were given some letters and then you had to come up with as many words that started with that letter as possible. And at the same time, they were monitoring those blood changes in your brain again. Really interesting. Yeah, and that was really interesting. Yeah, and we spent a bit of time looking into. why the verbal fluency task and what we can see from why they did it was because it was it was a good task to measure blood flow shifts. This is something that they'd already discussed and had found worked really well so they wanted to do that task. So it wasn't necessarily looking for whether you were good at the task, which my academic brain is just immediately like, did they win? Did they do well at the task? I don't know. And the truth was that everyone did about the same. And that wasn't the point. The point was that even though they did do about the same, the actual differences in their brain were still different if they had ADHD versus not, which was so, so interesting, personally. I just found that really interesting that even if we do the same things and get about the same results as neurotypicals, how we do it in our brain might look different. Yeah, that concept is just so crazy. But it really just lends itself to like, this is why we call it a neurodevelopmental disorder. It's just a different sort of class. Yeah, even if we get to the same outward result, we might be doing it in a different way. And this study really, really highlights that. So anyway, do you want to get into the results, Sarah? Cause I'm skipping ahead. The blood response that they found during the verbal fluency task was lower in patients with ADHD compared to the control group. which supported previous research. And also there was no significant difference between the medication naive and the medicated patients. They're not sure if it's because of the wide variety of medication that an ADHD person could take, but also you weren't allowed to take your Ritalin on the day of participation. Yeah. So which one is that? Yeah, I feel like. You know, if you don't take medication, you tend to have a bit of a rough day. I almost wonder if they were wondering if this was going to have like, if ADHD medication has a long-term effect, like maybe overall that kind of supports your ADHD, even when you're not medicated. I assume, and again, we don't know because they didn't do it, but I'm guessing if they had allowed people to take their medication on the day of participation, they would have done differently because that was the point of the medication. So to not take the medication feels a little bit interesting. But anyway, that's what they did. That was an interesting result, but perhaps unsurprising. Sarah, what do you think? You're frowning at the screen. So I was looking at if they provided justification for telling people not to take their meds. I'm not seeing anything yet. Yeah, I feel like maybe there's something that we didn't. Maybe there's a reason that we don't know about. But yeah. I was really interested in the idea that they thought there might be after effects of ADHD medication because I'd literally never thought about that before, whether they would be, because most of the time we sort of assume that there isn't. But maybe they thought there would be and that's why they did it. But yeah, overall, they found that the FNIRS, so that's what the study was called, that way of doing a brain scan was promising as a potential biomarker for adult ADHD. Yeah, really just any way to objectify diagnostics. They should keep looking for biomarkers. Yeah, yeah, definitely a very, very cool biomarker, particularly because there was no results that you could see outside of the biomarker and yeah, in terms of the impact, you know, it adds to the research. It was one of the first studies look using this particular kind of infrared light, looking at hemoglobin in the cerebral cortex. as opposed to doing a more general brain scan, which was very cool. So again, using a different brain scanning system to do it. Overall, very cool study. They did have some limitations. All medicated patients, they actually stopped their medication on the day they participated, and they thought this might come with a substantial performance deficit. Again, why did you do it then? I don't know. We'll have to ask the people who did it. So that was one of the limitations. It is a pre-print study. It's been peer reviewed, it's been accepted for publication, but it hasn't been yet published in the actual journal volume. And that happens all the time. It takes a while for these things to come out. So yeah, Sarah, what do you think a practical takeaway of that study would be? I think the practical takeaway of this is really just that we should be looking at more of those biomarkers for ADHD because just borrowing from the previous two studies that we were looking at. Just the subjective clinical interview is not necessarily always sufficient, reliable, whatever the case may be. So biomarkers in addition to that clinical interview are really going to be the new goal standard. That's my prediction anyway. Yeah, I would agree. I think it will be interesting to see if the DSM does that. I mean, because essentially the thing we've been using to diagnose ADHD has been the DSM. And the DSM really clinical interview process, they don't really talk about bringing in additional markers. So for them to do that, they would really be going outside of what they do, what they've currently done. I agree with you. I think it would be really cool to see that happen and to see more accessibility for that as maybe even a pre-screening tool to do the next thing, if that's an option. But it would require quite a big shift. in how things are currently being done? You know, I've been really excited about the new DSM for many years. And when I was talking to my clinical psychologist about this, he kind of said that I would be waiting for a really long time because there was a really big debate going on about how neuroscience is going to change how we diagnose people and that we might need to reimagine the entire DSM as a structure. And that's going to take a really long time. He was like, keep waiting. So how long is it going to take for multiple academics from different systems to agree on a process of diagnosis? Um, they can't even agree on words definitions. Yeah, we're still trying to figure that out. So, so yeah, definitely it could be a while. Oh, well, until they do, we will be here continuing to bring the research and continuing to ask for more academic research, particularly neuroscience and other spaces as well. So yeah, three interesting studies, a couple of heavy topics, but good to discuss and obviously, you know, if you have anything you want to add, if you want to say anything, just send me an email. You can find me sky at unconventional organization, and I'm more than happy to chat about the stuff always. Great, well wonderful to see you again, Sarah, and I'll see you next week for the next episode. See you next week. 

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