ADHD Research Recap: Practical support strategies and stressed out study life

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.

Hi, so today on the ADHD Skills Lab, we're going to be doing a research recap of two very interesting papers. There were a couple of extra papers about genetics, but we're going to leave them to the side because we are hopefully going to have a really awesome guest coming on to chat to us about genetics and ADHD. So today what we're looking at is two really interesting papers. The first one is a paradigm for ADHD. It's a commentary written by... manos and short from the Cleveland clinic about ADHD, why we don't do some of the things we do, why we do some of the things we do, and a bit of a strategy, a bit of a very practical strategy for ways that we can support it. We're excited to go through that and we're also going to be talking about higher perceived stress in medical students and how that could increase the subjective reporting of ADHD. So... another paper on ADHD diagnosis, but this time looking at a very interesting group of people and really surprising results. I was very surprised by how many, how many stressed out. Well, I shouldn't be surprised by how many medical students are stressed out, but definitely the effect that has on their self-reporting. Yeah. Should we get into it, Sarah? Yeah, let's do it. Awesome.

A new paradigm for adult ADHD: A focused strategy to monitor treatment

So the first paper, the one that I referenced, the Cleveland Clinic, it is a commentary paper. So it is peer reviewed. but it is not necessarily looking at a research that they actually did. It's more of a review of the literature. But we decided to include it because it was very, very interesting. I went into a lot of detail about some of the strategies that these people talked about in terms of being a coaching position and how you can support ADHD. So what did they look at, Sarah? Essentially, they were looking at the literature in sort of describing symptoms of ADHD. and sort of the current best treatments for adult ADHD. As you mentioned, this is a non-systematic lit review. They have a total of 26 references. And I mean, these authors go really into excruciating detail of the effects of impaired task completion in adults with ADHD, specifically looking at like what they refer to as broken agreements with the self, which are sort of just things like, Oh, you know, I'm going to do this and then don't do it. Who among us has not done that? I mean, I totally just sort of blast over that because it's, I mean, it's just such a core part of life sometimes. Yeah. So they'd start by talking about ADHD in general and, and medical treatment. So what are they talking about there, Sarah? This is a really great paper because it is so comprehensive. So they start by things like. These are how we diagnose ADHD. These are some unique considerations when diagnosing ADHD. And this is gonna be one of those sort of like first bold statements coming up that this paper made. So they sort of bring up the concept of subthreshold ADHD, which is when you don't meet the exact criteria, but you're sort of like still experiencing impairment in life. And then also the concept that childhood ADHD is not required. to have adult ADHD. The fact that they just so boldly stated that, I think really gave me pause. And I had to go back and say like, oh my goodness, that is cited as well. And then sort of do a little investigation into that because I feel like while other research that we've sort of gotten into discusses that, I don't think anybody has really come out so boldly as to just say like childhood ADHD diagnosis is not required in bold. Yeah, period. Yeah, it was really interesting. I think you have to have all the experience of what these people have, which is, you know, they have a clinic of ADHD support to be able to write this paper with so much confidence. Yeah. And they talked a little bit about what we've talked about in so many papers, that enduring presentation of symptoms is necessary, but it's hard to know this masking in childhood, that kind of stuff. and then they talk a little bit about the medicines as well. Also, when talking about the childhood ADHD diagnosis part, they mentioned that this concept of a social scaffolding and structured daily activity as part of the support for childhood ADHD symptoms. And the idea that can mask ADHD symptom presentation if you have a highly academic. child or maybe a highly regulated parent who is kind of masking a lot of the struggles that students would be having when they go to uni, for example, which is interesting because the next paper we're talking about will be about people who got a struggle. So, you know, yeah, it was interesting. They talked about the idea of the gold standard of ADHD support for adults in this case, because they're talking about adults, which we love, being that combination of pharmacotherapy, which is that stimulants, that kind of thing, but also engaging with the focused behavioral strategy. So they talk about the importance of doing both. They don't really go into who's doing both. They do have some resources at the bottom, which is quite interesting as well. But they talk about the importance of basically what we intend to colloquially refer as pills and skills. The concept that you need to have both or you don't have to have both, but it's considered to be the gold standard when it comes to medical support for ADHD. They even have a list of stimulants that they use to treat the tension deficit disorder, which is again, something I haven't seen in a lot of different places, different information about that. Because I know people always ask us and we say, we don't know. I love the way that this table is broken up into two columns. This is a really helpful one. They also have another one above the DSM criteria. Yeah. So they have a lot. So yeah, this is really good paper. Yeah. It's written. I don't know if it was written for people, they need to see, but it was written for people who don't have a lot of time and just want a table of stuff. And you can see that here, they divide the medication into immediate release versus extended release and yeah, I think definitely very interesting. But then what they go into is, you know, they sort of say, for a thorough review of the medications approved, you can find it in other reviews, they refer to the table and they kind of leave it there. What they really go into detail about is the idea of different kinds of attention, how those different kinds of attention look different when you're a child versus when you're an adult, and then this idea of broken promises and what we can do. So they... they really go into the behavioral side of ADHD, which is again, unusual and very, very cool for us. So they talk about automatic attention versus directed attention. Sarah, do you want to take us through those two? Yeah, so automatic attention is also sometimes called bottom-up attention. So it focuses really just on like motivation, reward, it's self-activating. It sort of happens automatically, like obviously, you know, when something is really interesting to you. and there's no consequences, you're gonna choose that thing. So it's like the automatic attention. And then sort of the directed attention is more of that top-down regulating. So it's like you have to actively choose that thing. They give examples, doing taxes, cleaning your bathroom. Dull homework, yeah, they say concerted effort. Force completion. Yeah, I mean, the language and the descriptions are just very different. Yeah, very elegant. You quite quickly get a picture of what they're talking about. Oh, yeah. I mean, this is visceral for me. Yeah. And then they go on to talk about sort of task management, as you said, and, you know, in adulthood, that looks very differently from completing tasks in childhood. I might ask my child to go like empty the recycle bin into the larger bin outside. an adult task for me though is sort of like comb every single room in the house looking for recyclables and then task gating and then they go into what we can do when it's difficult to sort of keep up with that. Yeah, but before we go into this, I want to make a note of something that you said, which I think is a really good example. When they talk about task management in childhood versus adulthood, they talk about the concept of, again, that scaffolding. that we're going to talk about. And you can sort of see that here. It's like you are telling your child, I need you to put the recycling out. You are giving them the task. You might even be breaking that task down for them. You're kind of watching whether they did the task, following up on whether they did the task. There's also, I mean, there might be some kind of punishments, but there's no, you know, it's not like they're going to lose their job or have this huge outside, you know, negative response to not doing the task. Whereas for you as an adult, you have to see that you need to do the recycling. You have to motivate yourself to do the recycling. You have to figure out how, where to, you just mentioned it yourself and go around all the different rooms, picking different things up. Then you have to remember that you were doing it. And then you might have additional adults who come in and support you or less supportively support you and just remind you. But it's not necessarily the same way of your appearance. So that's your job. It's more a case of, is this your job? It can get a bit stickier. So that's a great example of what we're talking about here with the struggles with directed attention in adulthood versus in childhood. Wow, that was so nicely put. Thanks, yeah. Well, you said it. I was just like, we have to use that as an example because I think that's a great example. And... The adverse consequences, I guess, of not redoing or recycling are a bit less when it comes to adulthood. But a lot of tasks, incompletion, it does have big consequences. I mean, people come to us generally speaking because they're worried about some of those consequences impacting their life and that's why they come for coaching. Yeah, that is essentially the differences that they discuss. They also go on to discuss anxiety and depression, the nature of incompletions, broken promises. I don't want to go into that in too much detail because they go into it in a lot of detail. If you want to read it, you definitely can. But they basically developed this concept of if tasks aren't done, it's like a broken promise. It's a broken agreement that's hanging over your head. Most of us with ADHD will have experienced that for sure. Undoubtedly. Yeah, it just feels like such a common experience. sometimes it's difficult to know how to support that. Yeah, no, 100%. Yeah, you don't want coaching to feel like another iteration of broken agreements. I think you spoke about that with Russ. Yeah, definitely. It's tricky with coaching. You wanna provide that external support that is missing with adulthood, and you wanna be that support and accountability, but you also wanna be empathetic. And a lot of what we do is just, there's just lots of strategies. It's about kind of helping. about helping you become somebody who can regulate your own strategies and your own self as much as possible rather than staying around forever to be that external support, at least in different areas. And they do touch on the emotional aspect of this. And I think it's really important to say that that's a big deal. If you're constantly going around, they talk about the fact that this can make you seem lazy to your peers. It can... It can become a sort of emotional judgment on you. It can contribute to anxiety and depression. They have a metaphor, the idea that a broken agreement is like a rock that you put in your backpack and you keep walking, but you're adding the weight of those. That was not referenced that they just put that in there, which I love. And everyone is- Those bold statements. Yeah, they said the weight of incompletions defeats the person's energy and joy in living. and that person can become self-critical, which we do know from research is the case with ADHD. Definitely, you know, if that's you, just remember this is a common experience of ADHD. A lot of us feel like this. And yeah, we'll talk about the strategies in a minute. We're not gonna leave you in that space, but I do just wanna acknowledge that space as well. Yeah, it's definitely not a comfortable place to be. Yeah, yeah. What this paper does is sort of talk to us at this point about how to clean up broken agreements. They name it four simple strategies and they really break it down. So the first one is just to name the broken agreements, acknowledge the thing. The second strategy is to complete the named agreement. So at this time, you can choose to do the thing. The third strategy is to make new adjusted agreements. So sometimes we realize, oh man, that was unrealistic. Let me revise this. And that way you can do the thing. And then I think the fourth strategy is really important and I wanna talk more about it, but it's cancel the agreement. And like that means also let yourself off the hook for that. If you decide like, oh, this is unrealistic, I'm not gonna do this, that's okay. But like Sky said, don't put it in your pocket. Don't carry it around like a rock. Cancel it physically, mentally, emotionally. Step back. Yeah. And for those of you who are listening to this and thinking to yourself, oh, complete the named agreement. Gosh. Didn't think of that. Thanks, guys. Yeah. Exactly. It's OK. We are going to go into strategies. Obviously, we have a lot. This is what we do for a living. This is one of the reasons that we wanted to talk about this. they have a few as well and we'll sort of talk about it and sort of build on theirs as well. But yeah, those are kind of the four main strategies. So the first one was naming the agreement, which I think, you know, they talked about the importance of writing it down. They sort of talked about the idea that if you don't write it down, it just ends up in your head as something that you want to do. And that's something that we have all experienced. But I think what they don't mention here is obviously with working memory. you're going to forget it as well. And that's one of the reasons as well. You want to write it down. You want to write it down somewhere you're actually going to see. Yeah, they also talk about agreement keeping may rely on environmental support. You might need to reach out to somebody and have them hold you accountable and things like that. And in this paper, they sort of suggest first degree connections, your partner, maybe your parents or your siblings. But. Yeah, I mean, sometimes that can get like emotionally complicated. Also, which they do reference as well. It's just that they mentioned here that for a lot of people with ADHD, the idea of relying on your spouse, for example, can feel a bit infantilizing and it can be something that people resist. They don't necessarily go into what you can do about that. Yeah, they talk more about the idea that. it is important to be part of a team and that is part of, you know, you can't do everything by yourself. And then they do have Table 4 outlining some coaching resources for individuals with ADHD. So because of that, I will say that one of the things that we do as part of coaching is we do develop your agreements, basically, your first session is coming up with those long term goals based on the struggles that you're having. And that could be considered like naming those agreements that you want to complete. essentially. And then dealing with the emotional stress of having written them all down because it's not, it's not an uncomfortable process. And also a lot of work. Yeah, and also a lot of work to figure out, okay, yes, sure, but like, what is the sub task of the task that I have to do here? So that's the first one, you know, name those broken agreements, what are the things that you're going to do? The second one, as I mentioned, super easy, we'll just skip past it, complete the agreement. I identify the buy-win of completion and then act on it. I'm obviously being sarcastic. But I thought it was really interesting they mentioned the buy-win, because again, a lot of people just said, this is something that I will do when I get around to it, which is really frustrating for you and also for the people around you. One of the things that's interesting here is, first of all, if you're completing a buy-win, It's really important to know that with ADHD, we struggle with time blindness. So understanding that you might not be the best person to tell yourself when you're going to do something by, because tomorrow seems like a really good idea. But in fact, maybe next month is more realistic, given the time that you have. So there's a lot to this concept of coming up when you're going to do it. And then also if you have a buy, when it's sort of like breaking it down a little bit, understanding what that means and yeah, just trying to get a sense of. what buy when so it depends how big the task is basically. The buy when is also sort of a good thing too if you need to be able to visualize how this is going to fit. You know like if it can't be completed right now thing then you need to at least be able to visualize when it can be completed. So specifying a due date is the first like the first constriction of many and figuring out where in your calendar this goes. Yeah, I mean, a lot of people with ADHD do have success with just doing it now. It's not always feasible. You know, obviously I'm not going to advocate for like going outside and like cleaning out your garage, you know, midnight unless that's something that you've already chosen to do. I'm just like remembering all the times I decided to clean my house and it ended up being a midnight. So I'm sorry. Pre diagnosis. They just have a bunch of scenarios in here of just like how you can complete tasks. But like honestly, we know how to complete tasks. Sometimes that's not the issue. Sometimes it's I don't have enough time. Sometimes it's I didn't think about the order in which I needed to complete this task. Or I'm not motivated. Like you can tell me to do it. You can tell me it's due and you can tell me when. And like the other thing I really wanted to point out is that with clients. I talk all the time about what is the real deadline for this task, because you can make a fake deadline. But the thing about ADHD is that we know if it's a fake deadline. And this is something that can be a real struggle is if you're told by somebody else, oh, don't worry, just complete it whenever you get time, maybe they're trying to be really supportive. That's actually incredibly demotivating. So it can be helpful. They use the example of putting up the paneling in the basement. to say, okay, the paneling in the basement needs to be done by this date, because that's when we're going into winter and it's going to have a negative effect on the long-term value of the house if we don't do it by this date, something like that. We don't have basements in New Zealand, so I'm sort of making that one up. It sounds legit. Thank you. But then you've got a deadline. Now you're actually working towards something because... One of the things that can happen is if your life is just littered with fake deadlines for agreements or fake buy wins for agreements, because you felt like you should do it in a week, but none of these deadlines are real, that can create a lot of complicated feelings that you have to deal with and demotivating feelings as well. If everything is actually due when it's due, it's a lot easier, but it's hard to do. Not everything has a due date. It can always really help to get somebody else's perspective on due dates as well. just because they might see things differently than you. Yeah, I've worked with a lot of clients where I've said, well, let's say it's due in a month. What if you came back and you told your supervisor that you would do it in a month? They go, oh no, my supervisor would not be happy. I'm like, okay, so it's due earlier than a month. Is it due in a week? So we do kind of like a mental model of like, how would you feel if this took a month to get a sense of like what the actual due date is? Because yeah, different cultures, different. spaces, different jobs, people are not always very good at giving you the actual time and it's a big part of it. So that's the second part, complete agreements. If you need help with that, break it down, figure it out. That's all we do in coaching and that's all the articles, the whole thing. So we have so many strategies for how to do that. The next one is make a new agreement. The idea that sometimes the original plan is no longer feasible, the original agreement can be changed to a more which I thought was a really good point. Maybe the first scenario was a bit vague. So they have an example of a husband relying on their own effort to panel the basement and then instead going with a contractor to panel the basement. Definitely always great to get support if you can. So agreements don't have to be stuck to just because you made them. That's something to consider as well. Yeah, I mean, and plus the original agreement, if this was a truly an ADHD person, the husband would have purchased the paneling for the basement and then said that to his wife that he was going to get it done in a weekend. And then 18 months later, I think that paints a better picture of the kind of task, the broken agreements. Yeah. And the reason you might not at that point want your spouse to be the person who's keeping that on you, because you probably already. Well, yeah, right. And then so the new agreement becomes like, okay, well, they're still sitting here three weeks later. So I guess maybe now it's time to sort of reach out for support. Yeah, exactly. And then we talked about canceling the agreement and Sarah, you said you wanted to focus on this. So I'm going to let you take this one. So in this case, canceling the agreement might be sort of forced. Let's say, for example, these people now have to move out of their home because their basement. collapsed or something. I don't know. That doesn't really happen. I have no idea. Again, no, no basements in New Zealand. No, I'm just poking fun, but no, I mean, you know, they might have to move. In which case, like, I guess now you're never going to repanel the basement. But also if you agree not to repanel the basement, you know, you can't. take that with you for the next sort of like five, 10 years. Like, oh man, I never got to redo that basement. Canceling the agreement and deciding not to do something means that you have made the decision not to do it. You don't need to take it with you any further than that. Yeah. And that's where sometimes therapeutic processes like acceptance of commitment, things like that can come in to kind of, you know, it's not the easiest thing to let go of things that you regret, let go of self-criticism. There's always those memes, you know, you're about to go to bed and it's like, would you like me to replay this for you? And like, this is something, you know, with ADHD, particularly we can get, we can get a good solid like book of things that we should have done that we didn't do, particularly as we're learning the things, your experience as an undiagnosed person with ADHD or a person with ADHD who's still developing those strategies, it's going to be a struggle over time as you're learning. I suspect that, you know, non ADHD people. also don't complete all of their agreements. Like nobody is out there existing who completes 100% of the things that they say they're going to do. Like there is no mystical neurotypical who does that. But I think the difference here is that emotional lability piece. It's the fact that they don't take it with them. They don't add that stone to their back pocket. So you don't have to either. Yeah, you don't have to either. And also I think there's also the piece of like views as being an appropriate amount of things that you haven't done versus an inappropriate amount of things that you haven't done or these tasks are fine to have put off or forgotten about but these tasks are not. So sometimes it's also just the fact that you're doing something that other people would have put in quotes considered easy and that's the thing that you're struggling with. Maybe you did a bunch of really hard things that you know just are not socially considered to be important for whatever reason. But yeah, it is funny because they have a quote here in 1890. William James talks about nothing is so fatiguing as the eternal hanging on of an uncompleted task. I said to Sarah before we went on, I was like, who has done all of their tasks? Who are these people who's like, oh, that one uncompleted task is just hanging around. I am not convinced that was a neurotypical. Like, I feel like maybe that guy just. has all of these all of this weight on him. I'm not sure but I do know that um yeah maybe they just had less tasks back then or something maybe we put too much on ourselves now I don't know but that was a funny quote and also just another great example of this paper being such a different style from so many other papers that we've read. The fact that they quoted somebody from 1890 was really unsuspected. but also really appropriate for this paper too, because that's like pretty early on in the conceptualization of ADHD. And this guy specifically, they say he talked about incomplete tasking. He didn't know about ADHD at the time, obviously. So, I mean, it's just really interesting that like how thorough this paper got and like in what ways it's just, yeah, this was really nice. Yeah, definitely, definitely. So those were the four strategies that they had. I want to make a note that they also say some other things here. They say, we know here that a brain with ADHD tends to be highly attuned to the physical world. This accentuates the practice for people with ADHD to take action in the physical world. So cues, notes, lists, reminders are quite helpful for individuals with ADHD. Just knowing what to do does not ensure task execution. So they're sort of coming here to a place where I would expect to see a conversation about time blindness and working memory and transitioning. I definitely agree. Physical things are great, but again, you can lose them the same way you lose other things. So yes, but this is the reason why. Yeah, it's sort of just like one piece of the strategy, really. Yeah, it's not just that we just love environments that are full of post-it notes. You would think so, looking at our notes. And then they talk about, yeah. Understanding task completion, the idea of why, you know, weak activation of executive functioning could be the reason that people are not completing tasks, the emotional consequences associated. So the distress, the emotional regulation can result in task avoidance, the complexity of the task demands, their mounting tasks, and all these different things can be effective. So it's really nice to see them talk about that as well. This paper. really went into it. I mean, it was, it was a fun read, which is not always the case, particularly when you're talking about ways to support ADHD. So really good paper overall. We've gone into so much detail. If you want to check it out, I highly recommend it, but just a really nice paper to go through and talk about something that is different from what we've had been talking about in the past. Very practical, very strategy-based and relatively supportive of ADHD they talk about. the brain of an ADHD person, they're sort of trying to understand where people with ADHD are coming from. This paper was really nice. Like you said, it offered those pastoral strategies and it sort of points to ADHD as a lifelong condition. But that doesn't mean that people should just suffer, you know, like maybe we should come up with new treatment methods. And so this is sort of one person's call out for something other than therapy and meds and it sounds a lot like what they're suggesting is sort of coaching. So it would be really interesting if more studies talking about alternative treatments were to pop up. Yeah, no, definitely. I think we talk so much about the importance of therapy and obviously for many people who choose to take medication, it's such an important factor as well. But the behavioral side is often missing in the research and the more we have researched behavioral side. the more we can say, but actually this bit didn't work when they did a double blind study of a thousand people. Like we want to know that information. At least I want to know that information. It's such a helpful thing in the same way as it is in the other two areas of ADHD support to have that kind of peer reviewed research backed focus, which is so much of what we try and do. Yeah. So very, very cool study and definitely look it up if you're interested.

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Higher Perceived Stress Increases the Subjective Reporting of ADHD: A Sample of Medical Students

So the next study we're gonna talk about is a sample of medical students and the subjective reporting of ADHD. So this is very different. So this paper came from Turkey, actually. It's been translated into English, but it is... from their university's faculty of medicine that is basically going through the experiences of medical students, not all of which I think are from Turkey, but we'll get into more detail about what they were doing and what they found in a minute. So Sarah, do you wanna tell us a little bit about what the study was looking at? Yeah, absolutely. So I think the first thing I wanna say is that this study was focused on like, helping medical students better manage their stress and develop better support networks while going through medical school. The purpose of this paper was not to further the research into helping ADHD people. But that being said, they had sort of a two-fold research question. So one, they wanted to evaluate the subjective symptoms of ADHD. So what do people self-report and what does their cognitive profile look like? And then also, sort of examining the psychological factors associated with ADHD in the med school population. So like stress and sort of symptoms of that nature. So to do that, they had looked at a total of 56 undergraduate students between the ages of 18 and 23 recruited from their medical school. So yeah, Turkey's medical school, 39 females and 17 males. So very high number of females compared to males. And one of the things they were excluding for was treatment with ADHD medication, along with other things. Yeah, any psychiatric medication. Yeah, yeah, any psychiatric medication. And I think that's important to note because what they were essentially doing there is if you were somebody who had ADHD and you were medicated for it, you were excluded from the study. So that speaks to what Sarah was saying about this. Focus wasn't on supporting ADHD people specifically, more about supporting this community that they were looking at. and they had subjective reporting of ADHD. This is a great example. We always talk about subjective reporting. It was, do you think you have ADHD? And that was the question. Yeah, so from that point on in the study, it refers to those people as reporting having ADHD, when really they ask them, like, do you think you have ADHD? And like answering yes meant you have ADHD. I hope nobody reads this paper and uses it to make assumptions about ADHD people. That would be such a misuse. Yeah, the title is, Higher perceived stress increases the subjective reporting of ADHD. So hopefully that's enough. But yeah, we just want to say this population, this whole group, is just people who said, yeah, I can have ADHD. That's it. That's the whole group when asked, which is worth mentioning. And then they also looked at the Stroop test and the Trail Making test. We've talked about the Stroop test before, and then they also had people fill out self-report scales of ADHD. So two different self-report scales. One of them was developed by the World Health Organization. And then one of them was a Turkish version of another paper that was assessing ADHD. But obviously, if you listen to our previous podcasts, you'll know. People have talked about self-reporting questionnaires not actually being a good indicator of whether you have ADHD. It's a good indicator whether you don't have ADHD, but not necessarily able to tell. So there's just a lot of things going on here. A lot of very subjective things going on here. So what did they do specifically, Sarah? What was like the analysis? I know that we want to go into the, the struve test and the trial making tests and kind of what they found. They had people fill out. those self-report scales, the ADHD symptoms scales, the anxiety scale, perceived stress scale, just to see where people were at in terms of what the scales would say about that. Then they also had them perform the strip task and the trail-making test, and those were being used to measure their executive functioning abilities, which is kind of interesting. It's not really what I would think of. if I were wanting to measure my own executive function. They were sort of talking about this. So do you want to tell us, first of all, do you want to give us just a brief overview of those two tests? Yeah, I think that's a great idea. So the Strobe task is basically five sets of different tasks. Either the objective is something like naming different words or naming the color of the word or something like that. and then the trail-making task, they did it two different ways. Basically, you connect the circles by a certain order. In one iteration, the circles were going to be connected by ascending numerical order, so numbers counting up. The other group had letters and numbers, so the alteration would be something like alternate between letters and numbers in ascending order. The authors argued that you had to focus as part of that. You had to be very detailed oriented. It required you to stop and then continue, remember where you were, etc. That was their justification for using that one. They talked a little bit about set switching or what we sometimes call transitioning and the idea that if you were struggling to transition because you weren't doing as well at these tasks that indicated ADHD. But once again, this is just another very subjective. reporting of what may or may not be ADHD. So we're sort of talking about subjective, do you have it, subjective survey that you have it, subjective stoop test. It's all super subjective, which is good to know. But what did they find Sarah? What they found was that reporting having ADHD was associated with higher levels of stress and anxiety resulted in higher levels of like ADHD symptoms scoring on the reports. Yeah, so there was a significant correlation between perceived stress, which means like your perception of your stress and reporting having ADHD or reporting that you might have ADHD. Yeah, which was high. 43% of people surveyed here. Yeah, that was mind blowing. I thought that they'd gone out and found people who had ADHD when I first read that. I did not realize that it was that high. Well, I think it's a really interesting point about how stress impacts ADHD symptomology. And I think that actually might be the practical takeaway from this study for ADHD people. It's just that like, yeah, if you're stressed, then also your symptoms are going to be worse because symptoms can present just from stress in people who technically don't have ADHD. That's sort of what this study is suggesting. Or sleep deprivation. Oh man. Yeah. It's sort of similar to sleep deprivation in that way where we work with clients. And if you're struggling with sleep deprivation, we sort of talk about the idea that you're experiencing the effects of ADHD and the additional executive functioning struggles that aren't necessarily related to your ADHD, but are just there as well. So it's a tough day. That's basically what we're saying. It's a tough day. It's a tough week. Definitely sounds like. At the very least, these students were struggling whether or not they had ADHD. A really interesting finding of this study is that there's no correlation between the executive functioning measure and reporting having ADHD. So basically, the performance on the STRIP test and the trail-making test were the same for people who reported versus not having reported ADHD. There was no difference in exam anxiety. However, the group who reported having ADHD obviously had higher stress levels and anxiety scores. Yeah, and that's a tricky one because obviously it could just be, again, this is all self-reporting on top of self-reporting, so it could just be that the 43% of people, like 50% of them didn't have ADHD, they were just particularly stressed. And if you say, could it be related to ADHD? They're like, maybe, I don't know, I'm just really busy and tired. I'm going to say yes to this. Or it could be the fact that maybe the strip test and that trail making tasks are not as indicative of ADHD executive functioning struggles as they thought when they did this test. It's sort of hard for us to know at this point. That's a really good point. I mean, even just based on how our reaction to those tests measuring executive functioning, like it just doesn't make sense. Well, it's one of those things that if you're really into it, I mean, we talked about this. In fact, we talked about this just before with the different kinds of attention. If you're in a test environment and you're really focusing on what you're doing, you might not have as much struggle with it as if it was like taxes that you had to pay next week. Um, it's hard to know in an experiment. I'd like to see the other papers where they've done these tests and see what happens with people who've got diagnosed ADHD. See what the difference is there. That's true. The authors did say that maybe because of their sample being relatively high IQ that might have compensated for any of the executive functioning deficits. Maybe. They're also very young though in terms of having like strategies, you know. Yeah. I know a lot of very smart people in ADHD who struggle in these environments. So yeah, maybe possibly. But again, very, very much we don't know. So what do we know from this study, Sarah? I think you've mentioned it a little bit before, but that's kind of... focusing on what are the actual takeaways we can take? So I think the takeaway here is that even med students who do not fit the criteria for ADHD, when exposed to significant stress, will present as though they may struggle with ADHD symptoms. So, you know, particularly med students who are like cramming for their exams, maybe they're about to come up on their licensure, maybe they're applying for residency programs and things like that. The stress of those situations is tremendous, even for people who don't have ADHD. So if you're out there and you're a med student, who's applying for residency programs, who's like doing these exams, taking these courses, and has ADHD, good for you. Keep up the good work, rely on your strategies, and- Yeah, good luck. Everybody is stressed. You're not the only one out there who's stressed by this. I would say take that information. I would include a lot of people who are struggling with anything that involves high stress and sleep deprivation. So I'm thinking like anybody who's studying law or clinical psychology, trying to get into clinical psychology or parents who are going through the period of having very small children where there's a lot of sleep deprivation. going on as well, you know, there's so many different spaces where you might want to take a step back and say, okay, I'm really, really struggling. In this case, we're talking to people who know they have ADHD, but maybe they're really struggling with their executive functioning right now. Is it potentially the sleep deprivation and the higher stress that is affecting this as well that I might want to consider? That might be. Yeah, I think that's a really good tie into the variability of symptoms conversation. Yeah, that's so true. That's so true, that idea. Yeah, just because you're struggling right now doesn't mean that there's anything wrong with you or that you didn't have it all figured out, you know? Revise the agreement. Yeah, definitely, definitely. Well, two very interesting papers and really cool to talk about some practical strategies. Definitely hope to see more of that coming across our desks sometime soon. But until next time... We will see you later. So I'll see you in two weeks. Bye, everyone. 

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