Can Adults Have ADHD?: Unraveling the Complexities (with Leslie Guidotti Breting, PhD)

ADHD - Leslie Guidotti

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Like, should I go get tested? Have you ever heard that Jeremy?

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So, you know, while it is true that most people experience periods of inattention or unfocused motor activity and impulsivity, Those people that with like an ADHD experience, these symptoms, they have them to a much greater degree. And these behaviors can often interfere with their social lives, their working lives, and they're just their general mental health.

DHD. Um, and then there was a: 2007

4 percent. Um, so according to data collected by the National Health Interview Survey, the prevalence rates among children and adolescents aged 4 to 17 increased over the past 20 years. So that's something that we hear a lot, like, gosh, doesn't it seem like so many more people have it these days? And we'll delve into.

overall rate of diagnosis in: 1997

And thankfully, meaningful research exists to provide helpful data on how to diagnose and manage this condition. So let's learn more, shall we? And thankfully, we have a wonderful expert guest in the field of neuropsychology to educate us today.

Welcome to your doctor Friends, the show that teaches you to sniff out the garbage and answers all the questions that you wish you could call or text your doctor friend. My name's Julie Bruny. And I'm Jeremy Allen. And we are two physicians who work at a nationally ranked practice and take care of some of the world's greatest athletes.

We know that you have questions and we want to help. We wanna be your doctor friends.

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This is, I've said neuropsychology so many times in the last 30 seconds. I

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Oh, Dr. Gadadi Breding. Thank you so much for being with us. We are so happy to have you.

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So my journey though, let's see. I was, my first career was I was a collegiate, uh, at collegiate coach for lacrosse, a defensive coach. Um, and that doesn't pay very well. So I worked as a research assistant in neuropsychology at the university of Michigan. And while I was there doing all kinds of cool fMRI studies, they convinced me to go to grad school.

Uh, many, many years later, about seven years later, after schooling and internship and residency. Um, here we are as a neuropsychologist.

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We evaluate patients, um, most of the time, however, some neuropsychologists do 100% research or teaching. Um, so we kind of have our fingers in a lot of different roles. I'm primarily clinical these days.

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Um, additionally, I should qualify, I'm an adult neuropsychologist, so I see only patients age 18 and up. Um, whereas then there's pediatric neuropsychologists who evaluate kids and adolescents.

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Um, and then we see them again about a week or two later to go over our analysis and what we found and what it means for them in terms of next steps.

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And it sounds like Leslie, what you, what you offer to folks is really maybe helping to clarify their diagnosis. Does that sound about right?

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What, what is ADHD? Can you explain it to us as a, as a diagnosis?

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or because I'm always late to appointments. Um, on any given day, you know, sometimes I feel like I have ADHD. Um, however, ADHD as a diagnosis is really looking at someone over their lifespan having persistent inattentive or hyperactive symptoms that 12 and are continuing. Um, aside from that, one can have symptoms of this, like watching a TikTok video and say, yes, I have that.

But the symptoms have to really cause evidence of dysfunction in their day to day life, either at home, at school, with friends. It can't just be, I have these symptoms and everything's great. We won't give the diagnosis then. Um, we can get more into the nitty gritty of ADHD at some point, but, um, I guess the other thing to bring up is ADHD is the same thing as ADD.

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Um, and many people are not diagnosed until adulthood when really the demands start to pile on.

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And we say, take your best guess as to how you were during that time. Uh, we also do a full clinical interview that takes about an hour. So we ask a lot of questions from your childhood. And then it's always best if we can get a collateral report. Meaning. If I saw you, Jeremy, I might say, hey, can we send these to your mom or dad to also complete about you from when you were a childhood, because they, when you were a child, because they may have a very different recollection as to how you were.

Um, that's not always possible in adults to get that childhood report from somebody else, but we, when possible, we try. Um, on the other hand, pediatric neuropsychologists always get collateral report. So they have teacher report of that kid's. behaviors at school. They have parent report. Um, we're more limited on the adult side.

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Um, but most professionals are assuming that it's probably gone up even more since the pandemic has happened. Um, we additionally, the statistics are a little challenging to get about how many people have ADHD. Um, because we know that boys are often diagnosed about two times as often as girls, um, because of how they present with their symptoms, um, things like that.

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Mm-hmm.

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If your mom smoked while she was pregnant with you, um, exposure to things like lead or other toxins can increase your risk. your chances of getting ADHD. Um, aside from that, we know that really genetics play a pretty big role in the possibility of having ADHD. Um, so in terms of genetics for ADHD, there's some studies showing it might be the most common mental health disorder, um, that can be inherited.

Um, so I, I'm trying to recall the exact statistics, but we usually tell parents and patients about 30 to 50 percent. Um, in terms of familial and herability rates. Um, so, if you have a first degree relative who has ADHD. Um, so what that means, I guess, in easier terms is, in the population, if you have a first degree relative, so a parent, a sibling, a child who has ADHD, you're about six to ten times greater risk of getting ADHD than someone who doesn't have those

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Um, so it definitely plays a role, um, but unfortunately we don't have a blood test or genetic test to tell you who has ADHD or not, which is often the question of, do I have ADHD? Um. Which is what we're trying to answer with our questionnaires, with our tests that we do, um, really looking at attention, executive functioning, things like that.

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Um, a lot of pediatricians and primary care physicians do diagnose ADHD, so you don't necessarily have to see a neuropsychologist to get the diagnosis. Um, but it's more often than not if you're not, if they're not sure about it, the symptom reporting is inconsistent, or there's other things that might better explain kind of what you're experiencing in your day to day life is when patients get referred to see us as neuropsychologists for ADHD.

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So, I guess my question to you is, do you think that's leading to over diagnosis?

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Um, and more people are potentially concerned about it because of social media and things that happen. Um, so I do think, ugh, that's a hard one. It's controversial. Um,

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And I would think that ADHD would be a similar thing that the earlier we can find out somebody has ADHD, the better they would do in school and the better they would do with friends and the better they would do with social situations. And 10% is like a really high prevalence. So it makes me feel like why, you know, yeah.

If there aren't already screening tools for this, that there should be some sort of screening that's happening on a regular basis to get an idea if we can catch it earlier,

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Sure. Do they explain the full picture of what's going on and if they need treatment? No. Because someone could check every symptom of ADHD and then when I ask them, well, how are you doing in your day to day life? Is it prohibiting you from getting things done at work, or with your friends, or at home, and they say no, then technically I can't give them a diagnosis of ADHD. Because even though they have those symptoms, it's not interfering with their day to day life.

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Things like that. Um, different. The complexities of what they need to do are different than, for example, at age 12, when they have homework and everything else piling on. That's a

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It might be the quiet kid in the corner who's doodling or daydreaming, but is not a behavioral issue in the classroom. Versus the kid with ADHD hyperactivity, impulsivity type, who's throwing things in the classroom and blurting out words and screaming aloud and can't sit still in their desk. Those are the ones who are caught earlier.

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an adult who had concerns about it. I feel like we'd be like, whoa, whoa, whoa, whoa, whoa. I'm not going to diagnose you with that. And we would punt as quickly as possible to a neuropsychologist or a neurologist or a, you know, a mother, another, what seemed like a more qualified professional than, than we, but maybe that was.

You know, my experience, but I feel like the opposite would be true words. I feel like it's relatively difficult to find a provider who is willing to sort of take on that role as the diagnostician. So, personally, you know, as a, as a clinician and, um, I think it's, it's, it's so great to have someone like you, Leslie, to, to be the clarifier.

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Um, additionally, some providers don't like prescribing stimulant medication, right? Um, so they just avoid it. A lot of the people who are referred to me are referred in from, as you mentioned, neurologists, primary care, psychiatrists, therapists who say, Not quite sure. Let's take another look at that. Or, they get referred in for neuropsych, um, testing if they need or are looking for accommodations at school or in the workplace and need some sort of objective evidence of these difficulties and why they might need extended time on a test or things like that.

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Right? I mean, like, we're really trying to get to the bottom of you clearly have something that Brought you here with concerns. And we need to get to the bottom, as you've mentioned so many times about clarifying, right. And making sure that you have just like the food allergies, right? You don't want to get a food allergy label if you don't truly have a food allergy.

And certainly we don't want to put the ADHD label on somebody if they don't have ADHD. And I just feel I I've, I've been to primary care offices. We are primary care doctors. I've, I have many primary care friends. Like they are. Already overworked and underpaid, and they just don't have the time to do what, you know, Leslie is doing with these patients.

And so, even if a primary care provider, I think, maybe in an ideal world, what I'm thinking to myself as a primary care provider could send off the patient to someone like Leslie to do the full testing. And then it comes back to the provider to to manage it, right? Like, daily management can certainly happen with primary care, but now you have, like, close to objective testing, right?

Clearly, it's done by a person and it's not an image, but. Leslie, if you have comments on that, please add.

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Will that be sensitive and specific enough for us to come up with an accurate diagnosis? And we know that it's not, um, especially because More often than not, most of the patients who are coming in to see me, I'm not diagnosing with ADHD. Um, I'm often diagnosing with anxiety, stress, depression, um, adjustment disorder to whatever's going on in their life right now and saying, hey, let's get these mood things treated first that could be kind of intermittently interfering with your attention and kind of mimicking ADHD, and then we'll revisit ADHD.

Because I'm not really seeing enough evidence throughout your lifetime that it's been impairing.

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So again, I think it's not meant to say something is happening that's wrong or right here, but it just, I think with more specialized. My perception of this interview so far has been like if you could have more specialized testing on people who were clarifying these symptoms, I think we would get more accurate diagnosis and because everything you listed there, Leslie is treatable, right?

It's not to say that it's wrong to not get diagnosed with ADHD and then be diagnosed with something else. Those other things are also treatable.

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Right? Or it's just part of how you are and everybody knows that. Um, versus, as you mentioned, anxiety, depression, other mood conditions are treatable. Um, so oftentimes people coming in for ADHD are sad when I don't diagnose them with ADHD because they can't go get an Adderall or stimulant medication that they think will cure everything.

Um, but I said, no, this is actually good news. You know, we figured out what's interfering with your attention and some other paths to look at first before we go down the ADHD path.

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So, um, it's... It's, it's often that we're not diagnosing ADHD and saying, Hey, in a distraction free environment without your stressors, you can actually, your brain can work well for attention and executive functioning, um, which then it's hard for some patients who have connected with groups, you know, through Facebook or Tik Tok or online, and they're resonating with that.

And they're saying, I have all these symptoms. It must be that. It's hard when someone says, no, it's not that it's this. Um, so we're working on delivering that in a clear and easy way and giving people resources.

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Um, in past versions of our diagnostic manual, they couldn't be diagnosed together. Um, but we now know that they can co occur, and we're seeing that more and more often.

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Being disorganized, finding that they have a trail of unfinished tasks left behind them. Um, they're misplacing items. They're, people think they're not listening to them during meetings or conversations, um, or they find themselves, you know, uh, losing track of what they were meaning to say or to do. Those are some of the more prevalent inattention symptoms that we tend to see.

Um, there is a whole list in the D S M that we actually have to. go through and check off, um, letters A through I, and then technically for a diagnosis in adulthood, you have to meet five or more of those symptoms. Um, so we give rating forms that we check those off on with the patients. On the other hand, um, for hyperactivity impulsivity, we tend to see overactivity in adults that might present with fidgeting, bouncing their leg, having difficulty sitting still, and adjusting their position in their chair often.

Can also present with things like Um, interrupting other people's conversations. Um, you know, like old adults will come in saying, My friends hate when I'm talking to them because I just keep interrupting them. Or I guess what they're going to say next and just blurt it out and I can't help myself and I've tried to stop and I just can't.

Um, and it's, they're right. They can't stop that inability to wait. Because that frontal subcortical brain network is firing at a different pace than a typical developing brain. Um, so those are some of the most common symptoms. Um, often times in adults we see them when their child was diagnosed. And then they reflect and say, Wow, everything I'm seeing in my kid I've experienced throughout my life and was just told like, I was lazy, or I need to pay attention more, or things like that.

And then they're coming in to say, Can we look at if this is something I'm actually dealing with?

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Yeah.

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So it's also hard sometimes to tease apart what's.

Um, there's also been some genetic studies that have small effect sizes showing, you know, the dopamine pathways are more impacted by those genes. Um, but at this point, we don't, we can't do a brain scan. We can't do an fMRI scan and clinically diagnosed ADHD. Um, but we know that usually when I'm looking at, so to back it up, before we had brain imaging, neuropsychologists, test.

We use our tests to lateralize and localize brain dysfunction to say, Oh, based on this pattern, this is what area of the brain doesn't work. And when I look at my pattern of results in adults with ADHD, it's things like attention, processing speed, executive functioning, which are all on that frontal subcortical brain network, um, that are usually impaired or a significant weakness compared to their level of IQ or other functions.

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Um, no one's brain can do two things at the same time. No one can really multitask well. Um, so that's kind of a false thing that's out there. But switching between tasks. The other thing is inhibiting a response as part of that executive functioning construct. Um, so for example, many people who are probably listening to this have heard about the Stroop Task, where they have to read the color ink that's printed in blue, but it says green.

And they have to inhibit that natural response to say green and say blue instead. That's really hard for people with ADHD, um, just like they blurred out answers. And then the other part of executive functioning is planning and organizing of information. Um, and that can often be really difficult for someone's brain who has ADHD.

Um, so they tend to do better with structured information, or when someone says, Do X, Y, and Z, rather than do this huge task and I'm not going to tell you what to do underneath that. It can be kind of overwhelming for them. Um, so that's mostly what we look at with executive functioning. We also torture people through very long, sustained attention measures for 13 minutes.

You know, where they have to push the space bar every time they see a letter, but not when they see a certain letter and they have to inhibit that response. Um, so we, we put them through multiple attention tasks and executive functioning tasks throughout the day to make sure it's a consistent weakness variability.

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Appointment with a concussion is always the longest where you're educating and like, they're actively concussed.

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Um, but you're right. It's, we look at those behavioral observations too.

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Um, but it was also, I mean, as much as it was, I was exhausted by the end of it, it was, it felt So validating to have and, and I loved the thoroughness of it in the end, like, yeah, it was hard and it was, I was tired and it was a little like, ugh, like after you've done like a marathon amount of testing, like we've done for, you know, our board exams and stuff where you're just spent, you just want to go home and watch a great British baking show or something, you know, but it, uh, I, I, it was, it was Very encouraging and validating that it, that it did, it was so thorough and there were so many different avenues of, of looking at, at testing, because the way that I interpreted it through that experience was that there were so, so many different types of tests so that you could clarify a diagnosis and not even just that, but then to give me sort of this cool spit out of like, okay, well, here's where you did well, here's where you didn't do so great.

Here's what all those things mean together. So, you know, Leslie, I would love to have you talk about, Now someone, it doesn't, we don't have to talk specifically about me,

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about Julie's some more. Can

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it

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Uh, no, but, but really, and then when we met together and talked about the, the, you walked through and explained the, the results of the testing. It was wonderfully illuminating for me, um, but I can imagine for a lot of people it could be very emotional if you, if they have a, a set, um, conclusion in their mind of where, what category they fit into.

And then you give them objective data that says, maybe you don't. And that could be either relieving or frustrating for folks. Um, and, uh, I, I mean, I guess I would just like to get your insight into how, how that, how that process goes. Cause that was like another kind of hour where you and I sat down together.

I think we did it virtually cause why not? And everything's, a lot of stuff was done virtually, although to, to be clear, all of the testing and everything that we did together was in person, like the, the, the day of, of it. Um, I can't imagine if there's any way of doing that virtually. I can't, I can't imagine that could really work.

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Um, and I think that You brought up a good point that ultimately it's not about the label or the diagnosis. It's about better understanding individually where your own strengths and weaknesses are and how to apply them into your day to day life and what you can do with that knowledge. Um, because sometimes just not knowing is, is half of the problem.

Um, you know, I have seen patients who come in concerned about ADHD, referred them by their psychiatrist or primary care. At the end of the day, sometimes those feedbacks are hard when I'm saying, you know, actually, I don't think this is ADHD given the trajectory and when these symptoms started and what you're telling me about times of momentary lapses and that we saw staring spells during testing, I'm going to refer you over to see our neurologist because I think you have frontal lobe seizures.

Right? And that's a very different conversation when someone came in thinking that they were going to get ADHD and sent off to go get some Adderall. Um, but overall, I agree with you that those feedback sessions are, okay. What's most helpful, um, to go over the data to process what it means for you and what to do with it next.

Um, cause there are a lot of really great resources for all different conditions, um, but especially for, for ADHD once you know that you do have that diagnosis.

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Um, then after that are the recommendations. And I personally try to put the recommendations in terms of what needs to be done first, and then things that you can get to down the road. Um, so if someone is diagnosed with ADHD more often than not, I'm saying you need to go back either to your primary care.

Or get a referral to a psychiatrist to talk to them about a trial for ADHD medication and see if that's right for you. Aside from medication, um, we also talk to them about cognitive behavioral therapy to kind of learn strategies, um, for where they're having difficulties in their day to day life. Um, you know, there's We run an adult executive functioning group where people can kind of learn how to better structure things when their executive functioning network doesn't work.

Um, and then providing good resources. Um, you know, Julie brought up a good one earlier, chad. org, so C H A D D. org, not going to TikTok or

Facebook or all those things, um, to really give them some knowledge to empower them moving forward.

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I think that's so important to, to, I think just showing that feedback and reading that report as a, as, as. Someone who's also co managing that patient really can help to give them insight and maybe even help them learn to what things to look for and and to say, huh, I really, really thought that, you know, Steve was going to have ADHD and he really, you know, Dr.

Gadadi Breding was, you know, based on her testing and her assessment that it really does look like more, maybe he has depression and maybe I should change the way that I think. Think about sometimes how these symptoms, you know, come up. So I think that your assessments are very helpful and they're very thorough.

It's, it's several pages long and then there's, there's tons of citations and data and stuff to even explain the explanations. It's pretty cool. It's pretty rad. Yeah.

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Um, so it's, it's not an easy, quick process. Um, as I mentioned earlier, I wish we could figure out how to do it a little bit quicker. We've thought about Clinic, you know, screener models to just do a few tests and then if so come back, but most people were having we were having come back and then it's just another appointment.

So, um, take a full day for yourself. If you're concerned to get it done, uh, most good board certified neuropsychologists probably won't get an appointment for about a year. Um, but it may be worth the wait for you. So don't It's hard to tell this to someone who has ADHD, but try not to procrastinate on making that appointment because the longer you put it off the longer you're going to have to wait.

Unfortunately, there's a huge, huge access issue right now.

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Not just when you're doing this or that. Um, the hard part about stimulant medications, as you guys know, a lot of people feel benefit from a stimulant medication, whether or not they have ADHD. So that's not a good test as to whether or not you have ADHD as if it's effective for you. Um, there are some particular results that I tend to say a stimulant may not be good for you.

You might want to try a non stimulant medication or the non medication routes first because your anxiety is so high it might shoot your anxiety up. You already have sleep difficulties, it might interfere with sleep, or especially in patients with heart problems, um, because we know that hypertension can be one of the more common side effects.

s, uh, studied and written in: 2013

Um, so not even a decade old, really new up to date research on how you can work on these strategies for yourself. It was developed to be used by a clinical. Psychologist with the patient. Um, but many of the people I'm seeing are smart enough and dedicated enough to try to do it on their own. Um, if they have the time to do that.

Uh, another good book is smart, but scattered. There's a lot of great resources out there. Um. You know, there's things that say out there, Oh, if you do, if you arrange your fridge like this and it works for you, you have ADHD. That's not science. Um, I think everybody who puts things at the front of their fridge is going to eat that first before what's at the back of the fridge.

So you guys have probably seen all those memes and Tik TOK videos about putting your fruits and vegetables in the door of your fridge instead of the fruits and vegetable video drawers. I think it helps everybody. That

doesn't mean,

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Then it's just whatever copay it would be to see a specialist, right? Like forty dollars, twenty five dollars. Um, or sometimes it does then end up eating up a good chunk of someone's deductible. For Medicare, it's just the copayment.

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And if you're looking for an interest, go into neuropsychology. The job security is fantastic. It sounds like, so

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Brain works differently than other people's for some reason. Um, so do people who have ADHD and Autism Spectrum Disorder, then would they qualify as neurodivergent? Yeah, they would, because their brain does work differently than we would quote unquote typically expect. Um, I'm not using the word neurodivergence in my reports.

I don't have resources for it. Um, we're still learning a lot about it. Um, I do think that when patients come in and have found a community of people who are saying that they're neurodivergent, and if they find it to be helpful to them, I say, well, if it doesn't harm you and feel free to continue to, you know, assimilate yourself with that community.

Um, because even without this testing, if someone said, Oh, I just think about things differently, right? Um, then they could be termed neurodivergent. Um, but it

is

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Um, and it is interesting because it, my knee jerk reaction to the term divergence was like, oh good, like a way of kind of lumping some things together that seems inclusive and like wholesome and, and we could all get behind it, but. Yeah, it is interesting to hear from someone, you know, who's this, who's the expert in this field to be like, yeah, we don't really use it in the clinical world.

It doesn't really, we get what it means, but it's not something that we would use in our, um, in, in our research or in our, you know, in our, uh, paperwork that we're giving back to you or, you know, that kind of stuff. So it's interesting to hear that. And I, um, one of my friends, uh, came up with the term neuro spicy. So I'm just going to stick with that, like the Neuro Spicy and the Neuro Bland.

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mean, yeah,

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So again, but that's everybody's language is open to interpretation as well.

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Jeremy. So,

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Because it's not, there's not evidence that the symptoms are interfering with their day to day life anymore. They've learned to compensate for it. Or they've taken a job where maybe they don't need to sit down all day behind a desk. But if we were to put them in that role, it wouldn't go so well. Does that make sense?

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Cause they're 80 years old at this point. And, you know, they're, they're right in a way. Um, cause if we take it back 60 to 70 years ago, The diagnosis of ADHD did not exist,

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Um, slow cognitive temp, sluggish cognitive tempo is already another one, um, that we're looking at, um, and that's separate from ADHD. So. Uh, more to come, but if you feel like things aren't quite right and they're really impacting your day to day life, that's when you should reach out for help to your doctors and, and they'll help steer you in the right way.

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Um, so we'll be publishing on that soon. We've done poster presentations and stuff, um, but otherwise no blood tests or fun things coming out yet.

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Leslie here and get some more information.

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the amazing music is credited to Skill Cell with Bay Licensure The podcast is meant for educational and entertainment purposes only The contents of this podcast should not be taken as medical advice to treat any medical condition in either yourself or others Please consult a medical professional for any medical issues that you may be having The contents of this podcast are the opinions of the host only and do not reflect the opinions of their employers or affiliations This entire disclaimer also applies to any guess or contributors to the podcast Under no circumstances shall Dr Julie Bruny or Dr.

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