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 and dive into what the paper says, how it was conducted, and try and find any practical takeaways.
In this episode, we're going to be discussing a paper called "ADHD Symptom Manifestation in Adulthood: Moving Beyond Conceptualization of Inattention and Hyperactivity-Impulsivity." And in this paper, we're looking at whether the DSM-5's triad of inattention, hyperactivity, and impulsivity actually covers how ADHD feels and functions in adult life, or if we should be looking at a more comprehensive list of traits that come hand in hand with ADHD. All right. Let's get into it.
If you'd life to follow along on the show notes page you can find that at HackingYourADHD.com/324
https://tinyurl.com/56rvt9fr - Unconventional Organisation Affiliate link
https://tinyurl.com/y835cnrk - YouTube
William Curb: All right. Let's get into it.
Skye Waterson: Yeah, I'm excited to get into this one. They used a thematic analysis, which is always a great way to build a new codebook and a new category process. And like you said, they were specifically looking at what is the breadth of different symptoms that we can discuss when it comes to ADHD.
William Curb: Yeah. And they did find—I was doing three. No, we started off with three. We're branching out to nine primary themes of: attention, hyperactivity, impulsivity, disorganization, forgetfulness, activation, emotional lability, sleep, and time perception.
Skye Waterson: Yeah, 100%. And do you mind if I talk a little bit about how they got there, like what the—
William Curb: Yeah, go.
Skye Waterson: —analysis was? Okay, because this is really important, 'cause often people are like, "What? How do you figure this out? Did they just read it? Like, how did this work?" So basically, what they do is they create a codebook. So an initial codebook was created based on the DSM using a system called NVivo, which is very expensive if you ever try and buy it for yourself. And they wanted to look at the top-level codes that represented broad themes such as attention, and then had narrower specific codes within that. So like "makes careless mistakes" versus "difficulty sustaining attention." Then that created an initial template of codes. And then, new codes were created when new information emerged that was not sufficiently represented by the existing codes based on the DSM. And then what they were able to do was, they kept a reflective journal throughout the whole process, which is very qualitative research of them to have a reflective journal of their thoughts and ideas of what was coming up for them. And then they had collaborating psychiatrists review the codebook, and then three researchers applied the codebook to a single transcript each to familiarize them with the codes. And all of the—so the three coders, one had ADHD, and two had lived experience, so they're coming from that perspective of it. And then they held several meetings, which are always fun meetings, where they then used the same transcript to check the codebook's reliability, and they got an 80%. So when they had the transcript, they used the codebook independently. They were coding the exact same, and that's how they came up with the themes that they have now. And the reason I'm saying that—Will's looking at me like, "Well, what?"—is because when we talk about statistical analysis, people are often very much more familiar with "this was significant, this wasn't significant." When we talk about qualitative, people can sometimes feel like that just means they made it up. But it's a very rigorous process.
William Curb: Yeah. And they also had psychologists bring in people to interview so that they could have—
Skye Waterson: Yeah.
William Curb: —these things in. So everyone that was interviewed was diagnosed through the CAARS diagnosis process. And everyone that came in definitely had ADHD. They also excluded people that were on the autism spectrum and bipolar because they were like, "Hey, we want to have this be very strictly ADHD things that we're looking at here." Although they have some in their discussion, being like, "Yeah, we probably saw some overlap with some of these other symptoms."
Skye Waterson: Yeah, 100%. And all that's to say is that from a qualitative perspective, this is a high-level research study. This was a well-executed thematic analysis, which I really appreciated.
William Curb: Yeah, when I first came across this, I was like, "Ugh, nine themes of ADHD? Is this another thing where we're trying to redo how we diagnose?" And I was like, "Oh, actually this is really good."
Skye Waterson: Yeah, 100%. Exactly. Exactly. Okay, so we've kept you guys in suspense long enough. Shall we talk about the nine themes of ADHD?
William Curb: Yeah. So I guess we can start off with our first one, attention, which is not a surprising theme.
Skye Waterson: Yep. It's still the case.
William Curb: Yeah, all the participants described having attention difficulties—not surprising. And do we want to talk about where it overlaps with some of the other themes?
Skye Waterson: Well, let's just talk about what it was first. So yeah, it was the most frequently endorsed primary theme, and the secondary theme of difficulty sustaining attention. One of the things that was interesting about attention overall is that they described it occurring unknowingly, which I hear a lot from my clients when they say, you know, "People ask me to pay attention, but I don't know when I'm not paying attention, so how am I supposed to figure that out?"
William Curb: Yeah.
Skye Waterson: Which is really great. And they also talked about hyperfixation, which I found very interesting because this business is a testament to hyperfixation.
William Curb: Yeah. And so I guess an important thing here too is to differentiate hyperfocus from hyperfixation, 'cause I see people mix that up online. Where hyperfocus is a very, "Now this is what I'm focused on, this is what I'm doing. I'm ignoring everything around me. I'm not paying attention to my own bodily functions and stuff, and I'm just doing this one thing." Whereas hyperfixation is a longer-term thing where I'm like, "Oh, I'm just working on this single project. If I'm not working on it, I'm thinking about it." And that can last weeks, months. And it's something where that was one of the places that they definitely discussed the overlap with autism.
Skye Waterson: Yeah. Yeah. It was interesting actually, 'cause I guess the best way to describe it would be hyperfocus is where you know you need to eat, but you don't want to get up from your chair because you're busy doing the thing that you're doing. And hyperfixation is the one where you know you need to ask this person about their day and become interested in their own life, and you want to do that, but you're data-dumping all of the information that you know about your hyperfixation.
William Curb: Yeah, you're like, "So this is what I spent all day doing, and also, we're gonna keep doing it."
Skye Waterson: Yeah. Versus, "How are you? How was your day? Tell me about your issues at work," or whatever it is. You're trying to stay focused on the thing you're interested in. So yeah, definitely interesting the overlap there. They said that required additional research. But yeah, it was this idea of what to pay attention to, when to withdraw attention, and they described it as like a not very finely tuned instrument, which I thought was—it's like very, "Oh, it's too much. Oh, now it's not enough," and there's that conversation as well.
William Curb: Yeah, I often think that the inattention piece is really one of those things where people hear "attention deficit hyperactivity," and they're like, "Attention deficit." And it's often more just this modulation of where your attention is and being able to pay attention to the things that you want to pay attention to rather than what your body's just, "Oh, I want—what's that?"
Skye Waterson: Yeah, yeah, and it's one of those things—the way that a person with ADHD experiences it is different from when it annoys somebody in a classroom environment, for example. So that's often why, and that's part of the reason why they even made this study, was that shift between the classroom and adult experiences.
William Curb: Yeah. All right, moving on to our next one, we have hyperactivity, which from our DSM baseline, we get "often fidgets, often leaves seat, running, climbing"—very much the hyperactive little boy definition of what you would think of hyperactivity.
Skye Waterson: Exactly. Exactly. And they said the ASRS and the CAARS do well in capturing adult-specific experiences of hyperactivity, and the items pertain to physical, external hyperactivity, et cetera. So yeah, they did mention that there was a discussion about internal hyperactivity—that was racing thoughts specifically—which I thought was interesting that it wasn't as covered because I hear that all the time from people.
William Curb: Yeah, I feel like that is definitely a shift from childhood ADHD to adult ADHD, where you might have fewer of the physical symptoms. You might still have fidgeting and maybe tapping your foot and that kind of thing, but you have less of, "Oh, I can't stay in my chair. I have to..." I do know people that are like that, so I'm not saying that disappears entirely for everyone. But I know a lot more adults where they're like, "Oh yeah, I'm just mentally like I can't stop," and—
Skye Waterson: Yeah. And also, you know, there's a lot of adults, myself included, who have built lives that we don't have to stay in our chairs. I have a walking desk, and if I'm in my chair, it's because I'm doing something like this, which is taking a lot more energy and a lot more interest than a classic meeting.
William Curb: Yeah. And then even then, I'm still doing fidgets and stuff and—
Skye Waterson: Yeah.
William Curb: —playing with my hands. And I think the hyperactivity rolls really well right into impulsivity, which is our next one. Which again, DSM-5: blurting answers, difficulty waiting our turn, interrupting, intruding on others. That is such a weird definition to me of what impulsivity is, 'cause I'm like, "Oh yeah, that is definitely impulsive behavior," but it covers so much more in my—
Skye Waterson: Yeah. They talked about financial difficulty, so impulsive spending came up. Also, you know, doing things that are considered risky in general. I think impulsivity, the way I take it, because I always think of it through more of an entrepreneurial lens, and in the entrepreneurial world it's interesting 'cause impulsivity is not a negative all the time. Moving fast in a fast-changing market is considered to be a strength of ADHD. We talk about being a pivot chaser. Are you just chasing the pivot, or are you doing some verification before you make the adjustment? But at the end of the day, keeping up in a—you know, AI exists now—do you have a business that looks super different from how it did six months ago? Well, you might have ADHD, but you also have a thriving business, so that sort of thing. I always bring that lens to the impulsive conversation.
William Curb: Yeah, it's like a great thing in sports and stuff where you can be like, "Oh, because of my impulsivity, I am able to react to things very quickly."
Skye Waterson: Yeah. So often it's tested by that stop-go test, and so not being able to stop as quickly and having a tendency towards "go" can be a positive. Like we did a study that I spoke about on my podcast about foraging, and we found that people with ADHD, at least according to this one study, were closer to optimal foraging levels. Like, we tended to move on at a higher rate, like a better rate for what you need.
William Curb: Oh, I love that study too. And also just to give people a sense of some other impulsivity things that are not physical or long-term, like constantly checking your phone, opening new tabs, being like, "Oh, I need to check my email"—you having a thought and then having to act it out. That's kind of impulsivity. And so a lot of it gets played upon in digital worlds fairly hard.
Skye Waterson: Yeah, 100%. Okay, and then we talked about disorganization. There's just a little bit on it here, but it occurs in several life domains, so that could be finances, daily routines, work. It's not just messy belongings. I always say to people, "Okay, we've looked at your physical space, but let's look at your digital space," because that is a—
William Curb: —how many tabs do you have?
Skye Waterson: Yeah, how many tabs do you have open right now? How many new files do you create on a whim when you're trying to save something? Does everything go in your downloads folder? Things like that. I do think that is a good point with the disorganization, that almost all of these things we often think of—many of our ADHD traits hitting one area of our life: "This is where I'm impulsive. This is where I'm disorganized." But in general, ADHD affects everything, so—
William Curb: Yeah, yeah, yeah. And you might have more supports in certain areas. I had a former CEO of Kellogg on on Monday, and he talked about—because he also worked in the political sphere for a while—and the political sphere apparently gives you way more executive functioning supports, which was interesting, compared to being a CEO.
Skye Waterson: All right, moving on to—okay, yeah, be—
William Curb: —before we forget.
Skye Waterson: Before we forget, yeah. So the DSM included a symptom about forgetfulness in daily activities, difficulty keeping track of appointments, struggling to recall events. This is where I would put your classic working memory struggles. And that was pretty much it. Forgetfulness was covered.
William Curb: Yeah, it's very straightforward. This is one I think people would be just like, "Oh yeah, of course. Yeah, that's definitely one of the pillars."
Skye Waterson: 100%. Then we talked about activation. So I would colloquially consider this to be procrastination. If you're like, "What is activation?" It's like, this is where that lives—people struggling to activate, so difficulties with starting, completing tasks, even important tasks, and lots of conversations here around the connection between the other things here.
William Curb: Yeah. And this is one of the places where the study diverged quite a bit from the DSM, which really just kind of looked at, "This is just task avoidance for things that you didn't want to do," which is inaccurate at best.
Skye Waterson: Yeah. I struggle to activate sometimes for things I really want to do.
William Curb: Yeah. It's one of the worst things where you're like, "Oh, I want to do this thing, and I just can't get myself to do it." And either because of a transition or just capacity or any number of things where you're just like—
Skye Waterson: Or the working memory struggle of the amount of things you'll have to plan to... I have three small children, so this is very—we're like, "We're gonna leave the house," but are we gonna leave the house?
William Curb: Yeah. I hate the things where I'm like, "Oh, I have to go pick up the kids in 20 minutes. Okay, I could go and do this other thing that I want to do before I have to do that." And then 20 minutes are gone and I haven't done anything.
Skye Waterson: Yeah. Yeah, exactly. So this was activation, and they said it presented differently in participants. Some reported feeling stuck, unable to start tasks. Even if participants managed to start a task, they struggled with completion, which I think is really important, like actually finishing the task. And they would jump from one to another rapidly without completing any of them, which is very common to my experience and the experience that I know for people with ADHD. Then they had emotional lability. So many participants reported, unsurprisingly to a lot of people here I'm sure, that ADHD affected their emotional experiences. And this was covered—
William Curb: Yeah. It's not in the DSM at all, but CAARS and the ASRS didn't have it at all, either. So it's just CAARS had the emotional lability and emotional dysregulation piece.
Skye Waterson: Which I still—yeah, I think that I would be surprised if the next version of the DSM doesn't contain some conversation about emotional lability.
William Curb: Yeah, 'cause you see a lot of the participants were like, "Yeah, I had intense fluctuations of my emotions," often regarding anger.
Skye Waterson: Mm-hmm.
William Curb: Where—'cause I know so many people that talk about their anger going from zero to 100, and I do wonder what plays in there if that's something that is specific to ADHD where there's these different thresholds that people are hitting, or if it's more of an interoception piece where, "Oh, I don't realize that I'm getting angry until I am furious."
Skye Waterson: Yeah. Yeah, it's interesting. And also there's the conversation about impulsivity as well. You know, like is the bit that says, "Hey, maybe think about it from a different person's perspective." And you're like, "Absolutely not. We're going straight to the red button." Like that conversation as well. Yeah. Okay. And then we—
William Curb: Yeah, sleep, the big one. This is what I consider the big one because I woke up way too early today, so—
Skye Waterson: I have a baby, so—
William Curb: —you beat me.
Skye Waterson: I got some sleep, and I am feeling amazing about it. That's kind of where we're at. Yeah, but several participants endorsed sleep difficulties, struggling to fall asleep even when feeling exhausted. I think it's one of the reasons why so many people with ADHD are using things to sleep, like music and podcasts and things like that, because it can be a struggle to quiet the brain. And then also just generally not sleeping well even if they do sleep.
William Curb: Yeah. And the interesting thing for this one is, of the four things that they were looking at, only one of them had sleep on it at all, which was the CAARS-2. And even then, the study was arguing that CAARS-2 didn't even go far enough 'cause it mostly focused on difficulty getting to sleep.
Skye Waterson: Yeah. But I will say shout out to CAARS-2, because it is winning right now in terms of covering things. Yeah, the sleep one is interesting. When I have clients who struggle to sleep, and to be fair, it's most of them, it's a very holistic conversation because one of the big things that comes in is the next thing that we're gonna talk about, which is time perception.
William Curb: Yeah, it's not a distinct symptom in the DSM, which is shocking to me. I'm like, "I've read this before. How did I not clock this as not being something that I should be on the watch out for?" But it is such a big piece of everything I know, from very few people I know with ADHD are like, "Oh yeah, time is not something I have a problem with."
Skye Waterson: Yeah, I even read a paper, and it was a good paper where they found that even with medication people still struggled with time perception. Whatever the medication was doing was not affecting time blindness. And so I would say, for the people who struggle with it, it's like a big struggle. It's one of the core pieces.
William Curb: Yeah, and so it was something I have treated myself, often through anxiety. And then when I started treating my anxiety, then I was like, "Oh, I have more trouble with time perception again because I'm not anxious all the time."
Skye Waterson: Mm-hmm.
William Curb: So good to not be anxious all the time and being like, "Okay, I run a podcast on ADHD, I kinda know some of these strategies to deal with this. This is great."
Skye Waterson: We're learning. Yeah. But they did mention that. They said one of the things that they could be missing in this time perception, which, you know, contains difficulty in time estimation, overestimating the amount of time for undesirable tasks, underestimating the amount of time for tasks you want to do. One of the things that may be happening is that people are overcompensating for time blindness, and struggles with time will not get picked up. This actually happened to me. I really appreciated them saying this. I was in Psych 101, and we did a test and a personality assessment, and the personality assessment included these little flags for lying, and one of the flags was, "Have you ever been late for anything?" And I said no because I, at the time, was a very anxious, perfectionistic, hyperfocused, masking child who overcompensated by making sure I was early to everything. And I was called out by my professor in class for lying on this test. I was like one of the kids that were like, "You lied," and that's like a thing, and I got really mad. So really it just covered the spectrum of today's diagnostic paper. But yeah.
William Curb: Yeah, and it is funny too—I can imagine that too, just being like when you are so hypervigilant about things like being late, being called out on it is just like the worst.
Skye Waterson: Yeah, that was when I got told, like everybody else said that they were late at least once because everybody else isn't apparently being hypervigilant about this. And to be fair, I was probably late at some point and I forgot—please see previous conversation about forgetfulness. But it was such a focus. Yeah, I can't be late. I have to be on time, and this is really difficult for me.
William Curb: Yeah. So I did love that this study did a great job of really expanding the conversation of what is included in, or at least should be included in, an ADHD diagnosis.
Skye Waterson: Mm-hmm. Yeah. No, I really loved it. I mean, from my perspective, put it all in the DSM right now. Like I said, do more studies on this, but this was such a solid starting point for this conversation.
William Curb: Yeah, absolutely.