Research Recap with Skye: Current Methods and Issues Surrounding ADHD - Part 2
Welcome to Hacking Your ADHD. I'm your host, William Curb, and I have ADHD. On this podcast, I dig into the tools, tactics, and best practices to help you work with your ADHD brain. Today, I'm joined by Skye Waterson for our Research Recap series. In this series, we take a look at a single research paper, dive into what it says and how it was conducted, and try to find practical takeaways.
In this episode, we're discussing a paper called "Evaluating Attention-Deficit/Hyperactivity Disorder (ADHD): A Review of Current Methods and Issues." This is a continuation of what we were talking about two weeks ago. This is Part 2 because the paper was so long and densely packed with information.
If you'd life to follow along on the show notes page you can find that at HackingYourADHD.com/316
https://tinyurl.com/56rvt9fr - Unconventional Organisation Affiliate link
https://tinyurl.com/y835cnrk - YouTube
William Curb: Welcome to Hacking Your ADHD. I'm your host, William Curb, and I have ADHD. On this podcast, I dig into the tools, tactics, and best practices to help you work with your ADHD brain.
Today, I'm joined by Skye Waterson for our Research Recap series. In this series, we take a look at a single research paper, dive into what it says and how it was conducted, and try to find practical takeaways.
In this episode, we're discussing a paper called "Evaluating Attention-Deficit/Hyperactivity Disorder (ADHD): A Review of Current Methods and Issues." This is a continuation of what we were talking about two weeks ago. This is Part 2 because the paper was so long and densely packed with information.
I want to give you a heads-up that our original plan was to discuss this one week apart, but life got in the way. It’s been three or four weeks, so hopefully, we don't repeat too much of what we covered last time.
Skye Waterson: Yeah! But if you remember what we discussed last time and can track the discrepancies, then well done—you're a better person than me!
William Curb: I definitely looked over what was in that transcript to see what we hit and what we missed.
Skye Waterson: Yeah. But as we were saying before, the reason we are diving into this paper in such depth is that it's a great overview of ADHD. These two episodes side by side could literally be given to someone who has no idea what ADHD is, and by the end, they'd be pretty well-versed in most of the questions people ask.
William Curb: In the first half, we went over what kind of paper this is—a narrative review—and covered clinical presentations, the DSM history, diagnosing kids versus adults, and evaluation tools.
Skye Waterson: Exactly. In this section, we’re going to go through clinical interviews—how they work, some of the executive functioning tests like the Stroop test (which is one of my favorites)—and then talk about gender differences and the limitations of the DSM diagnosis as it exists right now.
William Curb: Clinical interviews are often considered the gold standard for diagnostic criteria in ADHD. Self-assessments can be flawed, with people either under-reporting or over-reporting their symptoms. Some people might be seeking a specific diagnosis, while others might say, "No, I'm normal," because they aren't fully aware of how much they're actually struggling.
Skye Waterson: That's one of the reasons why the paper notes that while you can have structured or unstructured interviews, it really comes down to the quality of the interviewer. If you took the DSM criteria and just went through it with a friend, that wouldn't be considered a diagnosis—you need an expert who understands how to ask those questions going through it with you.
William Curb: One funny thing I see on social media is people talking about assessment questions. I think this comes up for autism assessments too, where a question asks: "Would you rather go to a library or a party?" People focus on the choice itself, but what's more important to the interviewer is how you answer the question and your thought process.
Skye Waterson: That's a really good point! "Library Party," anyone? That's my answer.
William Curb: Right! When you say, "It depends," and list out all the factors, you're explaining your thought process, which is far more evaluative than the question itself.
Skye Waterson: Exactly. So, what tools are commonly used? They mention the Diagnostic Interview Schedule for Children (DISC-IV). That's a structured interview based on the DSM, and it has approximately 3,000 potential questions.
William Curb: They don't necessarily ask all 3,000 questions because it uses a branching structure. But there are 358 core stem questions that branch out, so it's still a massive tool.
Skye Waterson: If you're sitting there thinking, "Oh, 20 questions, this is simple," it actually takes a lot of time! There is a lot of research-backed systemization that goes into creating these structured interviews. Looking at that 3,000-question figure made me wonder: if you have the focus to answer every single question, maybe you don't have ADHD!
William Curb: I can't imagine actually answering every single one. It would be so boring—the absolute worst.
Skye Waterson: Then there is the DIVA—the Diagnostic Interview for ADHD in Adults—and the Young DIVA. The Young DIVA is a structured clinical interview designed to assess symptoms in children and adolescents aged 5 to 17. It has high diagnostic accuracy and practical utility.
When researchers evaluate these interviews, they test them against previous standards and look at diagnostic rates. A whole process goes into determining the tool, the questions, and who is qualified to administer them. In New Zealand, for example, they adjusted regulations so General Practitioners (GPs) can administer some of these tests alongside psychiatrists, simply because the demand for ADHD evaluations exceeded capacity.
William Curb: In the United States, it varies state by state regarding who is licensed to administer what. It's hard to give blanket rules on who you should see.
Skye Waterson: Definitely. While clinical interviews are the gold standard, there can be limited research on the accuracy of certain unstructured formats, which causes some debate. I always think back to that BBC documentary from a few years ago about private diagnostic practitioners and their evaluation methods.
William Curb: I remember reading articles about it, though I didn't watch it myself.
Skye Waterson: Whenever a process is somewhat subjective rather than 100% objective, there's bound to be controversy. Going through an assessment is a bit of both an art and a science.
William Curb: As we mentioned earlier with structured tests, even with objective frameworks, the skill of the interviewer still matters. Even with our gold standard, it isn't completely objective because we don't have a purely physiological way to measure ADHD.
Skye Waterson: That's why on ADHD Facebook groups in different countries, people always ask, "Who did your diagnosis, and was it a good experience?" People actively seek recommendations for clinicians who understand the condition.
William Curb: That's also why self-diagnosis has become so prevalent. People wonder, "If it's a subjective test, why can't I evaluate myself?"
While I don't dismiss self-diagnosis—especially given how inaccessible care can be—it is always better to get evaluated by a professional if you can. ADHD symptoms overlap with many other conditions. For example, mistaking OCD symptoms for ADHD leads to completely different treatments, and treating the wrong thing does you a disservice.
Skye Waterson: 100%. When we work with people on executive functioning struggles in business settings, we tell them, "However you came to us is fine—if you relate to these issues, we can help you build better systems." Those strategies often help neurotypicals, too!
However, when it comes to formal diagnosis, medication choices, and finding the right therapeutic treatment, it's crucial to unpick those nuances with an expert. It's like people who are treated for anxiety for half their lives only to discover their anxiety stemmed from untreated ADHD—they spent years treating the symptom rather than the root cause.
William Curb: Exactly. Don't dismiss self-diagnosis, but stay open to the possibility that you might not have the whole picture.
Skye Waterson: Work on your executive functioning, but seek a formal assessment for an actual diagnosis if it's available to you.
Moving into rating scales—these are often used within the clinical interview process, such as the Child Behavior Checklist (CBCL) or the Teacher Report Form (TRF). One reason these scales are necessary is that an ADHD diagnosis requires symptoms to cause impairment in at least two settings, such as both at home and at school or work.
Skye Waterson: That's where the DSM criteria get converted into practical questionnaires. For adult ADHD, common ones include the Barkley Adult ADHD Rating Scale (BAARS) and the Conners' Adult ADHD Rating Scale (CAARS)—which I believe was used during my own assessment.
William Curb: I remember filling out the Vanderbilt Assessment Scale for my kids. It gathers input from parents and teachers, which always amused me because it doesn't ask the child directly! But I understand why.
Skye Waterson: There are teacher report forms assessing affective problems, anxiety, attention deficits, and conduct issues, alongside standardized self-reports for adults.
William Curb: While there are better and worse versions, if a provider doesn't use a standardized rating scale at all, that's a red flag. Options like the SNAP-IV or the Strengths and Difficulties Questionnaire (SDQ) are well-validated. As long as a recognized scale is used, the specific brand matters less.
Skye Waterson: Which scale gets used often comes down to regional precedent—what was approved or adopted first in a given country or state. But ultimately, they all stem from the core DSM criteria.
Now, should we talk about neuropsychological and Continuous Performance Tests (CPTs)? These come up frequently in research discussions.
William Curb: This is the exciting stuff happening right now—it involves software, gamified tasks, and objective measurements. In clinical settings, these tests help evaluate executive functioning and measure whether an intervention is working.
Skye Waterson: I liked how this paper categorized executive functioning tools into subjective (clinical interviews, rating scales, questionnaires) and objective (neuropsychological and continuous performance tests). Objective tools are more common in academic research because they provide quantifiable data.
However, they do have limitations. Tasks like the Digit Span task, the Go/No-Go task, and the Stroop test all target specific executive functions. The Stroop test—where the word "GREEN" is printed in purple ink and you have to name the ink color rather than read the word—measures cognitive flexibility and response inhibition.
William Curb: I used to play Brain Age on the Nintendo DS in college, and the Stroop test was one of the exercises used to measure cognitive flexibility!
Skye Waterson: That's funny! There's also the Tower of London task, which tests spatial planning and problem-solving. A key element is that you sometimes have to move a piece backward to set up the sequence to win—which requires mentally planning several steps ahead.
Then there's the Digit Span task, which measures working memory by seeing how many numbers you can remember forward and backward.
William Curb: One issue with these objective tasks is practice effects: you can train yourself to get better at a specific game or test, which ruins its validity. Instead of measuring baseline executive function, you're just measuring how much someone has practiced that specific task.
Skye Waterson: Exactly! If you've never done it, it's much harder. That's where the debate arises about laboratory testing versus real-world performance.
The paper explicitly notes that CPTs can lack reliability due to software or hardware issues, which isn't discussed enough. Some of these tests use outdated tech, and input lag or button responsiveness can distort results across different groups.
William Curb: I can imagine an older adult who isn't used to computers struggling with the interface itself, or a tech-savvy younger person performing poorly simply because the software interface is unintuitive or clunky.
Skye Waterson: It reminds me of a study testing social rejection using a digital game. If a participant feels left out, is it because of the game dynamic, or because the graphics are so bad that the character looks glitchy? Tech limitations can distort what you're trying to measure.
William Curb: It’s great that the paper addresses these flaws so researchers can develop more accurate, objective tools in the future.
Shall we discuss the potential issues with the DSM itself? That was a significant part of the review.
Skye Waterson: Yes. As mentioned, the DSM was originally developed in large part for standardized classification and insurance coding rather than purely patient-centered care.
William Curb: Without getting into a full critique of health economics, it’s true: the criteria are heavily influenced by diagnostic coding and insurance reimbursement requirements, which can create a conflict of interest when trying to deliver optimal individual care.
Skye Waterson: The paper also discusses how diagnostic criteria evolve across DSM editions. There's an ongoing debate about whether ADHD is over-diagnosed, under-diagnosed, or misdiagnosed, which remains a moving target as awareness grows.
People keep saying, "Everyone thinks they have ADHD now, it's just a trend." But after five years of working in this field, I see awareness continuing to grow. More people are learning about it and recognizing the traits in themselves.
William Curb: Historically, the DSM criteria were fairly restrictive. As definitions become more inclusive, diagnostic rates naturally rise. While official estimates suggest 3% to 7% of the population has ADHD, the actual prevalence could be closer to 10%. It's hard to pin down because the evaluation process is complex.
Skye Waterson: It's also influenced by social dynamics. People with ADHD tend to connect with other neurodivergent people. In my immediate circle, it feels like 50% of people have ADHD, but that's a biased sample!
It creates contrasting perspectives: someone who has never knowingly met an adult with ADHD thinks it's over-diagnosed, while someone working in creative industries sees it everywhere.
William Curb: Another critical flaw in the DSM is gender bias. Historical diagnostic criteria were built predominantly on male sample groups. The data reflects how ADHD manifests in young boys, and clinicians applied those same expectations to girls and women.
Skye Waterson: And women rarely present the exact same way. Women and girls are more likely to exhibit internalizing, inattentive symptoms, high levels of masking, and secondary mental health issues resulting from that masking.
Because the diagnostic system was originally designed to manage disruptive behavior in young boys in a classroom, women are, on average, diagnosed much later in life.
William Curb: The DSM historically focused on how a person's symptoms affect others rather than how the symptoms affect the individual. Inattentive symptoms make internal life difficult, whereas hyperactive symptoms are more likely to disrupt a classroom teacher.
Skye Waterson: Exactly. When working with clients, we rarely focus on the literal DSM checklist that got them diagnosed. We focus on time blindness, working memory limitations, and impulsivity. We don't spend time worrying about whether someone struggles to sit still in a chair—we get them a walking desk pad and move on!
William Curb: To foreshadow our next episode, emotional dysregulation isn't even included as a core diagnostic criterion in the current DSM, yet almost everyone with ADHD experiences significant emotional intensity and regulation challenges.
Skye Waterson: The paper actually included a great callback to that, noting the growing clinical discussion around emotional dysregulation and whether it should be formally recognized as a core feature. The things that bring people into a clinic for help aren't always the exact items listed on the diagnostic checklist.
William Curb: There's a wide gap between formal diagnostic criteria and real-world daily challenges. As the paper concludes, no single assessment tool is sufficient on its own—diagnosing ADHD requires a thorough, multimodal approach.
Skye Waterson: Diagnosing ADHD is a complex, multifaceted process that relies on gathering information from multiple sources, including self-reports, observer scales, clinical observations, and developmental history, while keeping in mind the limitations around gender biases and comorbidities.
William Curb: Speaking of comorbidities, should we touch on that section briefly?
Skye Waterson: The key takeaway is that many conditions share overlapping symptoms with ADHD. A person might initially be diagnosed with anxiety, only to realize the anxiety was driven by untreated ADHD. Alternatively, conditions frequently co-occur.
We see high rates of AuDHD (co-occurring Autism and ADHD), co-occurring anxiety, depression, and learning differences like dyslexia or dyscalculia. It often presents as a cluster of overlapping challenges rather than an isolated issue.
William Curb: A critical comorbidity mentioned in the paper is Substance Use Disorder (SUD), which is estimated to affect 25% to 40% of adults with ADHD. Practitioners working in correctional facilities often note that a significant proportion of incarcerated individuals struggling with addiction also have undiagnosed or untreated ADHD.
It highlights the serious risks of untreated ADHD and why accessible diagnostic pathways are so vital. Proper identification allows for targeted treatment.
Skye Waterson: When you treat the underlying ADHD, comorbid symptoms often decrease significantly because they were being exacerbated by executive dysfunction and chronic stress.
Research shows that children with ADHD receive significantly more negative feedback and criticism growing up than neurotypical peers. Over time, that external criticism turns into internal self-criticism and mental health struggles. Getting a diagnosis helps frame those struggles correctly. Instead of thinking, "I'm lazy or broken," you realize, "My brain operates differently, and I need different tools."
William Curb: Before we wrap up, what did you think of the paper's discussion on differential diagnosis and brain imaging?
Skye Waterson: Go ahead!
William Curb: It’s an interesting topic because while neuroimaging holds promise, brain scans are not yet a viable diagnostic tool for ADHD in clinical practice. I've interviewed neuroimaging researchers who are optimistic about the future of the technology, but we aren't at a point where you can scan a brain and definitively diagnose ADHD.
While an objective biological test would be incredible for validation and reducing skepticism, functional scans remain costly and clinically inconclusive for individual diagnosis right now.
Skye Waterson: I love neuroimaging studies, but I've also been following research on Large Language Models (LLMs) used as screening tools. Studies show that natural language processing models, when trained on conversational speech patterns, can identify linguistic markers associated with ADHD with surprising accuracy.
While there are obvious privacy and ethical concerns around how that technology could be misused, as an initial, low-cost screening tool, it could be very interesting.
William Curb: As a preliminary screening tool to highlight whether someone should seek a full evaluation, it could be very useful.
Skye Waterson: Exactly. Imagine a scenario where a screening tool identifies potential traits and helps direct you toward affordable, formal diagnostic options.
William Curb: What we need most is an accessible way for people to screen themselves early, followed by a streamlined evaluation process. Right now, navigating the diagnostic pathway is overwhelmingly difficult for many.
Skye Waterson: In some regions, people wait years and spend thousands of dollars just to see a specialist. It’s completely understandable why so many people rely on self-diagnosis while stuck on multi-year waiting lists.
William Curb: As we wrap up, the biggest takeaway from this paper is that it provides a comprehensive framework for what a thorough diagnostic process should look like, while remaining honest about the current limitations in clinical practice and the research still required.
Skye Waterson: If you want to understand how ADHD is formally evaluated and where the field is heading, this paper provides a great foundation. It helps empower patients with information so they can advocate for themselves during the diagnostic journey.