Research Recap: ADHD Combined Diagnosis and Brain Imaging

Skye: Hi. We are the ADHD Skills Lab Podcast. My name is Skye.

Sarah: And my name is Sarah.

Skye: 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 in working through struggles in their lives.

Sarah: You might know us from Unconventional Organisation, 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.

Skye: Welcome to another research recap. Today, we actually have two papers rather than our usual three, but they are papers that we want to discuss at length. So we figured, let's jump into it, let's chat about them. So, yeah, they kind of go together in some ways because we're talking about diagnostic criteria for ADHD, and then we're talking about brain imaging in ADHD and some of the latest research around that as well. I know, Sarah, you have lots to say on this. You were doing some notes just before, so I'm excited to hear. But, yeah, the first paper that we're going to discuss is the study that found that, at least in this study, and it's really important to say this is a specific study with a specific group of 90 women. They found that girls with ASD will meet criteria for ADHD by adulthood. So they found that there was some crossover in what people were diagnosed with when they were diagnosed 20 years earlier and then diagnosed again 20 years later. And, yeah, it was really interesting. So, Sarah, do you want to provide some more context for what they found?

Sarah: Yeah, so I'm going to back all the way up to methodology, which begins around the year 2000. So, as you could imagine, sort of 23 years ago, the world of mental health was very different from how it is now. So they started out with a group of 100, they wound up with a group of 90 once they sort of did their longitudinal 20 years later follow up. So that's really good adherence. So basically, they were looking to see whether the diagnosis that was given out originally would stand the test of time. That was one main goal of this study. And then the other goal was to sort of compare the diagnostic criteria of DSM Four and DSM Five to sort of, again, see how that all stood up to the test of time. So this is really interesting. I had so much to look up around this. So the diagnostic criteria, obviously, from the DSM Four to the DSM Five, did change. I think the most important thing to note is that prior to May 2013, a dual diagnosis of ADHD and ASD were not possible. Given the DSM guidelines, you could only be diagnosed with one or the other. So the findings of this study seemed to support the decision to change that rule. Basically, they found that 89% of women with ADHD or ASD in childhood still met that criteria 20 years later.

Skye: It's pretty good considering that a lot of these people will have learned a lot of skills, a lot of ADHD diagnosis about how it affects you, it affects your experiences. And the studies were done by different diagnostic people, which does make a difference. It's not like it was done by the exact same person.

Sarah: Right. The somewhat subjective nature of diagnostics is something that we can get into in the next week.

Skye: Well we have a podcast coming. I'm not sure if it's already out or if it's coming, but we are talking about it. We're not experts, but we are going to talk about it.

Sarah: But yeah, it's always something to consider. Right? The other thing that they found in this article was that in 34% of the women, the main diagnosis shifted from ADHD to ASD, which is really interesting.

Skye: Yeah, it was very interesting. And they also found obviously co occurring was higher. So I think that's worth discussing as well. It's not like those people were only the ones who shifted. They also found for a lot of people, they were diagnosed with a dual diagnosis of ASD and ADHD, which we know now is very common at the time. Like you said, the first assessment, it wasn't an option, but now we very much have that option. I think the interesting thing is I don't know what they were really attempting to—well, not attempting, they successfully did it. But I don't know what the point of that conversation was. And this is just—I actually, I want to know your thoughts, Sarah, because I was a bit stumped. Are they saying that we need to shift a diagnosis? Are they saying that there's a lot of correlation? What do you think that the sort of thing that they were sort of coming away with in this article was?

Sarah: Yeah, so if you go down basically all the way to the bottom, some of their main points were this sort of when ADHD or ASD is suspected in a young girl or even an adult woman, the presence of a coexisting, either ADHD or ASD, should be investigated. I think it's really interesting that they started this study 20 years ago on specifically girls, because this must be like a flagship research study because they were not really studying girls back then. So that's really interesting. They also point out that, sort of, clinicians should always plan to provide support that takes into account how symptoms can shift over time. Sort of how different types of social situations can bring about different types of symptoms and things like that. But they did call for additional research to be done on this to sort of understand the adulthood applications.

Skye: I think you're totally right. And yes, now that you've said it, I read this article yesterday and you read it today because of the time zones. But yes, 100% you're right. The importance of diagnosing being like, great, you have ADHD, let's check for ASD was a big factor. And I think that's important. But I do think, as well, having further research, because on its own, this is a study that might be misconstrued, confusing. And I think it's really important to go into it a bit further because it might be that symptoms of it in adulthood look different. It also might be that maybe again, I'm not an expert, I have psychology, clinical background, but I don't diagnose people with anything. It might be that maybe the diagnosis of ASD doesn't fit with women as it currently exists in different ages and stages. I do think that there is an interesting question about whether, we've talked a lot about ADHD, but do we have enough of an understanding of what women with autism look like? Especially if they have combination of ADHD and ASD, which is, again its own thing. This is an area, because obviously we work in ADHD. Often people come to us who have had autism spectrum disorder as well. I've definitely seen and taken the autism spectrum diagnosis as it exists, but I think it is very interesting because this is my personal experience. This is not in any way related to ADHD, but I remember taking the autism spectrum diagnostic criteria and taking the ADHD one and just feeling like the autism spectrum one didn't feel like it would fit a lot of people. And I think it is an interesting question of could that one be improved? I definitely spoke a bit about it, the professional who was diagnosing me, and they sort of talked about the idea that, yes, it could definitely be improved for women. So that might be part of it as well.

Sarah: That's really interesting. Yeah. I have zero experience with that. My clinical psychologist was like, there's no way, you're not autistic. And he said the same thing about me having ADHD. I guess that does sort of support that the criteria is not always designed for women, for either.

Skye: Yeah, I think it's an interesting one, but yeah, I guess if we were to say, what is the takeaway of this study? The idea that there is this crossover, where somebody who was previously diagnosed with ADHD might find that in adulthood their diagnosis is now ASD or vice versa. What does that mean for people who are getting these diagnosis? Because these diagnosis are very expensive to get. They take a long time, they're a lot of work. You have to continue to maintain them and to suddenly switch, I mean, for one thing, if you get diagnosed with ASD instead of ADHD, then your medication options are going to shift as well. And that might be really helpful, but it also does create a difference. So I guess what is the sort of takeaway of this study, outside of the fact that we should diagnose for both initially and maybe that we should discuss the idea that both might be a more common occurrence than people realize?

Sarah: Yeah, I think it's always just really important to sort of explore for your own support needs. As you said, these diagnoses can be quite expensive to obtain and also require an enormous amount of patience with your respective medical system.

Skye: And executive functioning.

Sarah: Yeah. But just for, sort of, quality of life. Again, like I said, additional sort of support avenues or options, it can be really important to sort of explore yourself. My psychologist used to say to me, we're not treating a disorder, we're treating symptoms. And so that might be another way to sort of look at it for yourself.

Skye: Yeah. And I think as well, this is on a more practical note, if you ever do get diagnosed, whether it's ADHD or ASD, definitely try to talk to your diagnostic person and make sure you get whatever diagnosis you got in writing. Sometimes that's an additional fee. But if you don't, it can be very difficult later on if you do come back and do a follow up assessment, which I know in different countries people do have to do for different medications and things like that, just to make sure that you have that paper trail and you don't have to go back and do it again. Ending on a very practical note.

Sarah: Yeah. No, I appreciate that. I was actually just looking at the funding, and this is a Swedish study. It was sort of funded by the healthcare board, the hospital, the research council, Ministry of Education.

Skye: Wow.

Sarah: I mean, a lot of hands went into this study here, but the people who actually designed, collected, did the thing. They were all separate people.

Skye: Yeah. No potential conflicts of interest.

Sarah: Also very important to check.

Skye: Yeah, no, and it is a really interesting study and a really good study to discuss, because we don't talk enough about women and ADHD, ASD dual diagnosis. And that is a very common experience for a lot of people. And yeah, there is a thing where it's like, well, it took me nine months to get this diagnosis of ADHD. Am I really going to go back and try to do it again? Am I even going to be accepted? Is this even going to be something that is taken into account? And again, ASD is a tricky one. And I'm not an expert in it, by any means, so I'm not going to—I think it would be very interesting to have somebody on who could speak to that conversation, because I know it's—I've worked with several clients who've gone through an ASD diagnosis process. And it's been tricky to get seen essentially. Often because what a woman with ASD looks like is sometimes in contention, depending on the person, depending on the country.

Sarah: Yeah, that's a really interesting point. I also would love to talk to somebody who knows more about that world.

Skye: Yeah, we'll have to see if we can get somebody on, because that would be amazing.

Sarah: For personal interest.

Skye: Yeah. Well research, right? It's just constant personal interest. Cool. So, first big study chatted about. The second one is an interesting one because it's sort of a bookmark to the first one, because instead of talking about diagnostics, we're talking about brain imaging. And for those of you who are like neuroscience, no thank you. We will attempt as much as possible to break it down and make it as easy to understand, I promise. I did neuroscience in university up to post-grad level. Sarah, what is your experience with neuroscience? Because you love it, for lack of better words.

Sarah: Yeah, it's just sort of a personal interest to me. It takes me an enormous amount of time to sort of disseminate, and I have to look up this word and that word, and it takes me sometimes quite long to get through a sentence, but I just love it. I think that it's really changing the world of mental health as we know it. It's just really exciting to sort of think about what we know now, as the field of psychology being sort of like pseudoscience, as some people would say.

Skye: Spoken like a true psychologist.

Sarah: Something that is more concrete, way more scientific, way more observable, repeatable and all of that. That is my experience with neuroscience. It's just fascinating.

Skye: Yeah, it's very cool. And it is very cool to see it become something that we talk about a lot, because it has a lot of sway, I would say, as well. When you say to people like, we have seen different parts of the brain light up in people with ADHD, versus people who are neurotypical, there's a real sense of like, oh, that's interesting.

Sarah: That's a real thing.

Skye: Which is not my—There's lots and lots of things that are very valid about all those sciences. But yeah, it is very cool to have the neuroscience focus as well. So let's get into the study. So what they found was that a study of white matter, basically the parts of the brain, there's a lot of white matter throughout the brain. They found that they can tell whether you're struggling with fidgeting or inattention or impulsivity based on which sections of your brain were lighting up. And they talked about a whole variety of different sections. But at the end of the day, they did talk about the prefrontal cortex, which is the front of your brain. If you're thinking about where it is physically, it's at the front part, and it's often the bit associated with executive functioning. So it got a shout out, in this paper, as it does in most ADHD papers. But Sarah, do you want to talk a little bit more about what they found?

Sarah: So the sample size for this is, again, kind of small. It was 83 people, so 52 without, that's the control group, and 31 with ADHD.

Skye: And I will say, that it is a lot harder to get a huge number of people when you're doing a brain study. You actually have to test them and bring them into the lab. So there is a difference between how many people you'd expect in a survey versus how many people you'd expect in a—how many people would be a good sample size for this kind of thing. So it's an okay sample size.

Sarah: Yeah, that's fair. Have you ever had an MRI?

Skye: I have not. I have worked in places.,I've seen them done. I have also had to do, because I did a lot of neuroscience, I have had to review brain scans and use the tech. But I was a little bit of a hypochondriac about having my own brain measured. So I was like, you know what? I'm good. I believe you. But I did do a lot of work in the lab, so, like, behind the scenes looking at brains.

Sarah: Fair enough. I actually have.

Skye: Oh, wow.

Sarah: I mentioned on a previous podcast that I did a study with Yale. I'm not sure what they were really looking for. I know they said they were looking for something, but I think it might have been different. So anyway, yeah, it was quite long. It was like 2 hours in a lab. It took months to get me an appointment. So that's just sort of speaking more to like yeah, it's actually quite hard to get a larger sample size for something like this.

Skye: Did they attach electrodes to your head, do the whole white net thing?

Sarah: Yeah, they put things on my head, and then they put a cap over it just so that they didn't move. I, couldn't move for, like, I think it was 2 hours. It was crazy. But I took a nap. They were like, oh, the sounds might bother you, but it really didn't. It was actually quite meditative.

Skye: The perfect level of stimulation.

Sarah: That's what I'm saying. I wonder if it was sort of like the perfect background noise. Yeah, it was great.

Skye: That's awesome. I love that.

Sarah: I asked for a picture of my brain. They wouldn't give me that.

Skye: Oh, really? Yeah. Well, this is also just a piece of background for those of you who are learning neuroscience. This is a neuroscience learning safe space. Generally speaking, the resulting brain that you see is going to be an average of everybody's brains. And bits of people's brains are in different places. So if you were to do an actual operation, they would have to—this is going to sound intense. For those of you who are eating, I apologize. They would have to take your skull off and basically poke around in it. At least that's what they were doing when I was learning it. Might have improved now. They're always improving neuroscience, because they can't know for sure this might be your prefrontal cortex, this might be your hypothalamus, that kind of thing. But they want to make sure because it is a bit different. So where your bit of your brain that lights up for this thing and where someone else's might be different. So it is usually an average of the brains.

Sarah: That is fascinating.

Skye: Yeah, it blew my mind when I first saw it back in the lab.

Sarah: Yeah. I mean, because we know that sort of different areas of the brain are different sizes, sort of correlating to the different disorders and things like that. But I never considered that people's brains are actually, I don't know, the streets aren't in the same place?

Skye: Yes, basically it's the same city, but the map is a bit different. You might get lost. More accurately, there is no map. So you have to wander around and asking people like, are you doing this now? Are you feeling this now? To make sure that you do things when you do surgery. It's very normal, and they do it in the study as well. But it's just an interesting thing to consider our bodies that are unique and interesting in this way, as well as in others.

Sarah: So, this study, they were looking at three different areas of the brain and basically just looking at sort of how they talk to each other, how they're structured, how they're firing, which is sort of how they talk to each other. And the findings they say, well, preliminary, sort of disclaimer, suggest that these types of lab tests can be valuable information to, sort of, different diagnostics. It says sort of different neurobiological areas correlate with different ADHD phenotypes, and I would assume probably others as well. And so this study sort of calls for more. They're like do more of this to see sort of how the white matter and the networks sort of, what they can tell us, basically.

Skye: Yeah, I mean, it's very cool that you can find, or they found in this preliminary study that there was predictable relationships, the structures of the brain lighting up in different ways. And I say lighting up because if you look at the pictures, and again, you can find this article in the show notes, there's little bits that light up in orange and blue, which means that there is activity happening here.

Sarah: Do you know how they do that?

Skye: I used to, but I'd love to hear it again.

Sarah: So they actually inject this stuff into you. They sort of give you like, I think they called it an A line. Anyway, it's basically a certain type of IV that goes into your wrist and then they just sort of inject material.

Skye: Do they still need to do that all the time?

Sarah: Apparently.

Skye: Oh, that's interesting. I wasn't sure if it was still necessary, but yeah.

Sarah: At least they did for mine. I'm not sure. Maybe Yale didn't have the most up-to-date technology.

Skye: Well, it's always like, in neuroscience, if it's three years old, this is what I was taught by my professors anyway. They were like, if the paper is three years old, that means it's too old. Which is why we're bringing you the latest research. 2023.

Sarah: Yes, peer reviewed.

Skye: But yeah, no, it is literally lighting up. So they're showing this is something that you are doing and that other people with ADHD are doing, who have these struggles that people who don't have ADHD, they're not lighting up in the same way. And that is so validating for me personally, like as a person with ADHD, when I heard about this, it was such a moment to say, yes, I got the diagnosis. Yes, I ticked off those things, but also my brain lights up different. That's so cool to say, like yes. I think differently. My brain thinks differently, basically.

Sarah: Yeah. And the implications for what this could mean are huge, especially for the diagnostic space. Not just for personal validation and things like that. But I've read lots of articles by sort of psychologists and things that are like, this way that we diagnose people is kind of outdated and I sure wish we could fix that. And this technology sort of offers a new way. that's why I love this, because I just can't wait to see what happens. It's going to be something that I can't even imagine right now.

Skye: Yeah. Could you imagine if you said you couldn't imagine, but could you imagine, if this was sort of like, we talked about the last, the previous one, which is that 20 years later, your diagnosis can be different. And then we've just talked about brain imaging. Could you imagine if in the future, our diagnostics were combined? Diagnostic, I mean, I know that neurologists do get involved these days in some diagnoses, but it's not always as much or as common. It would be really interesting if in the future there was a, hopefully not more expensive. We want it to be achievable and accessible. But it would be cool if there was a combination diagnosis, and that might be very helpful for people who maybe are too nervous at the diagnostic test and they just don't present well, or maybe they lost their childhood records or there's a million ways that we can struggle with the diagnostic process as it exists currently.

Sarah: Exactly. Yeah. It would be really exciting to have sort of a dual, the interview piece, plus sort of the machine. I would imagine that eventually these things will get a little bit more affordable or they'll be in more places. But also sort of understanding what areas of your brain are being affected would also allow you to sort of be prescribed different types of medication that will target, specifically, your issue. And it might not be as much of a guessing game.

Skye: Right. So did you have anything else you wanted to add to the brain imaging research recap?

Sarah: Not quite. Unfortunately, we can't really give any practical strategies for this one.

Skye: Go get your brain imaged if you can, and if you're not anxious about it, like we learned about, sometimes your brain could be doing weird things, and it's not going to fix you long term. But I think basically, I did so much neuroscience that by the time it came to me actually getting my brain imaged, I was like, no, thank you. I know too much. but, yeah, get your brain studied if you want, or look into it, because there is a very cool and very, honestly, kind of empowering space in neuroscience where you can say, no, I'm sorry, but my brain looks different in different ways. And that's just the facts, and that can be really fun to say to people who may not agree with your diagnosis. Awesome. Great. Yeah. So two really interesting studies. Definitely a wide-ranging conversation. I'll be interested to see how much of it—we talked a lot, about a lot of different things. I'll be interested to see what we end up keeping. But, yeah, definitely if you are interested in any of these topics, if you have opinions on any of these topics, or you know somebody who you think would be a great person to have on the podcast, chat about these things in more depth, please email us. You can find our information in the Show Notes, because we love talking about this, and we'd love to talk about it more.

Sarah: Yes.

Skye: Awesome.

Skye: Thanks for listening. If you'd like to reach out or connect with us, you can leave us a message at admin@unconventionalorganisation.com.

Sarah: You can also find out more about our ADHD coaching organization, read our free articles, or sign up to our online courses at unconventionalorganisation.com. That's organization with a Z or an S, they both will get you there.

Skye: If you'd like to learn more about what we discussed here today, or you want to read the transcript, you can find that at our Show Notes page at unconventionalorganisation.com.

Sarah: If you've enjoyed this podcast and think someone else might find the strategies and stories helpful, the best thing you can do is share episodes using the Share button in the podcast player, or leave a five star review on Apple or Spotify or your podcast player of choice, letting them know why you've benefited from this podcast.

Skye: Thanks so much for listening, and we'll see you back in the ADHD Lab next week.