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Rio Bravo qWeekAuthor: Rio Bravo Family Medicine Residency Program
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Episode 191: Diagnosis of ADHD
Friday, 16 May, 2025
Episode 191: Diagnosis of ADHDFuture Dr. Granat explains how to diagnose Attention Deficit Hyperactivity Disorder. She explained the influence of social media in increasing awareness of ADHD. Dr. Arreaza added input about the validated tools for ADHD diagnosis and highlighted the importance of expert evaluation for the diagnosis of this disorder. Written by Yen Stephanie Granat, MSIV. Ross University School of Medicine. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Steph: I love podcasts—many of us do—and if you, like me, spend any amount of your leisure time listening to podcasts, perusing the news, or scrolling social media; you’ve likely noticed an alarming trend in the number of discussions we seem to be having about ADHD. It has grown into a very hot topic over the past couple of years, and for some of us, it seems to have even begun sneaking into our “recommended videos” and across our news feeds! Naturally, for the average person this can spur questions like:“Do I have ADHD? Do we all have it? How can I be certain either way, and what do I do if I find myself relating to most of the symptoms that I’m seeing discussed?”Granted that there is a whirlpool of information circulating around this hot topic, I was hoping to spend a bit of time clearly outlining the disorder for anyone finding themselves curious. I believe that can best be achieved through outlining a clear, concise, and easy-to-understand definition of what ADHD is; outlining what it is not; and helping people sift through the fact and the fiction. As with many important things we see discussed on the internet, we’re seeing is that there is much more fiction than fact. Arreaza: I’m so glad you chose this topic! I think it is challenging to find reliable information about complex topics like ADHD. Tik Tok, Instagram and Facebook are great social media platforms, but we have to admit that fake news have spread like a fire in recent years. So, if you, listener, are looking for reliable information about ADHD, you are in the right place. With ADHD, there aren’t any obvious indicators, or rapid tests someone can take at home to give themselves a reliable “yes” or “no” test result. People’s concerns with ADHD are valid, and important to address, so we will discuss the steps to identify some of signs and symptoms they are seeing on TikTok or their favorite podcaster. Steph: Healthcare anxiety is a vital factor to consider when it comes to large cultural conversations around our minds and bodies; so, I hope to sweep away some of the misconceptions and misinformation floating around about ADHD. In doing so, I want to help alleviate any stress or confusion for anyone finding themselves wondering if ADHD is impacting their lives! We might even be able to more accurately navigate these kinds of “viral topics” (for lack of a better term) next time we see them popping up on our news feeds.Arreaza: The first thing I want to say about ADHD is “the crumpled paper sign.”Steph: What is that?Arreaza: It is an undescribed sign of ADHD, I have noticed it, and it is anecdotal, not evidence based. When I walk into a room to see a pediatric patient, I have noticed that when the paper that covers the examination table is crumpled, most of the times it is because the pediatric patient is very active. Then I proceed to ask questions about ADHD and I have been right many times about the diagnosis. So, just an anecdote, remember the crumpled paper sign. Steph: When you have patients coming to you asking for stimulants because they think they have ADHD, hopefully, after today, you can be better prepared to help those patients. So, for the average person—anyone wanting to be sure if this diagnosis applies to them—how can we really know?”Arreaza: So, let’s talk about diagnosis.Steph: Yes, the clearest information we have is the DSM-5, which defines these disorders, as well as outlines the specific criteria (or “checkpoints”) one needs to meet to be able to have a formal diagnosis. However, this manual is best utilized by a trained professional—in this case, a physician—who can properly assess your signs and symptoms and give you a clear answer. Steph: ADHD stands for Attention Deficit Hyperactivity Disorder. It is among the most common neurodevelopmental disorders of childhood. That is not to say it does not affect adult—it does—and because it can be easy to miss, it’s very possible for someone to have ADHD without knowing. Arreaza: I recently learned that ADD is an outdated term. Some people with ADHD do not have hyperactivity but the term still applies to them. Steph: Yes, there are multiple types that I will explain in just a bit. But overall the disorder is most simply characterized by a significant degree of difficulty in paying attention, controlling impulsive behaviors, or in being overly active in a way that the individual finds very difficult to control. (CDC)Arreaza: How common is ADHD?Steph: The most recently published data from The CDC estimates that 7 million (11.4%) of U.S. children between the ages of 3 and 17 have been diagnosed with ADHD. For adults, it is estimated that there are 15.5 million (6%) individuals in the U.S. who currently have ADHD. Arreaza: I suspected it would be more than that. [Anecdote about Boy Scout camp]. Steph: I totally agree. With short videos on TikTok, or paying high subscription fees to skip ads, it feels like as a society we all have a shorter attention span. Arreaza: Even churches are adapting to the new generation of believers: Shorter sermons and shorter lessons.Steph: When it comes to better understanding these numbers, it's also important to know that there are three distinct presentations of ADHD recognized by The CDC and The World Health Organization. Arreaza: The DSM-5 TR no longer uses the word “subtypes” for ADHD. Instead, it uses the word "presentation" to describe the different ways that ADHD may manifest in a person. That reminded me to update my old DSM-5 manual and I ordered it while reading today about ADHD. This means people with ADHD are no longer diagnosed as having a “subtype”. Instead, they are diagnosed with ADHD and a certain “presentation” of symptoms.Steph: These presentations are:Inattentive TypePeople often have difficulty planning or completing tasksThey find themselves easily distracted (especially when it comes to longer, focus-oriented tasks)They can often forget details and specifics, even with things that are part of their daily routineThis used to be referred to as “ADD” (you’ll notice the absence of an “H”, segue).Hyperactive-Impulsive TypePeople often have a sense of intense “restlessness”, noticeable even in calm environments.They tend to be noticeably more talkative, and might often be seen interrupting others, or finishing their sentences.They find significant difficulty in being still for extended periods. Because of this, they are often unable to sit through a movie or class time, without fidgeting or getting up and moving around.With this category of ADHD, we often see an impulsiveness that unwittingly leads to risky behavior. Because of this, accidents and bodily injury are more common in individuals with this type of ADHD.Combined TypeThese are individuals who exhibit symptoms from both “Inattentive” and “Hyperactive-Impulsive” ADHD equally.Some listeners might have noticed that the categories are quite different, meaning that ADHD presents in different ways depending on the person! Two people who have ADHD can be in the same room and have vastly different presentations, whilst still having many of the same types of challenges. You also might have noticed what makes the discussion so interesting to the general public, which is also the thing that makes speaking to a professional to get formally tested so important:The diagnostic criteria rely heavily on patterns of behavior, or external variables; rather than on how a person might feel, or certain measurements taken from lab tests.Arreaza: Diagnosing ADHD requires evaluation by a professional who is properly trained for this. Fortunately, we have tools to assist with the diagnosis. The attention deficit must be noted in more than one major setting (e.g., social, academic, or occupational), that’s why the information should be gathered from multiple sources, including parents, teachers, and other caregivers, using validated tools, such as:The Neuropsychiatric EEG-Based ADHD Assessment Aid (NEBA), recommended by the American Academy of NeurologyThe Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) and the Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS), recommended by the Society for Developmental and Behavioral Pediatrics.For adults: The validated rating scales include the Adult ADHD Self-Report Scale (ASRS) and the Conners Adult ADHD Rating Scales (CAARS).Steph: This is important because nearly everyone alive has experienced several, if not most, of these behavioral patterns at least once. Whether or not an individual has ADHD, I’m certain we could all think of moments we’ve had great difficulty focusing or sitting still. Perhaps some of us are incredibly forgetful, or act more impulsively than the average person might find typical. Getting a professional diagnosis is important because it is in skillfully assessing “the bigger picture” of a person’s life, or their patterns of behavior, that a skilled physician, who understands the nuances and complexities in these disorders, can properly tell each of us whether we have ADHD, or not.Essentially, most of us could stand to use a bit more focus these days, but far fewer of us would meaningfully benefit from the kinds of treatments and therapies needed by individuals with ADHD to live healthier, more happy and regulated lives.Arreaza: I had a mother who came to discuss the results of the Vanderbilt Questionnaire. I think she left a little disappointed when she heard that, based on the responses from her and the teacher, her son did not have ADHD. Some kids may have behaviors such as being distracted during a meeting, forgetting about homework or having a lot of energy, but that does NOT mean necessarily that they have ADHD, right?Steph: Absolutely! The important thing to remember here is that these patterns of behavior outlined in the DSM-5 are merely an external gauge for a neurological reality. What the science is showing us is that the brains of people with ADHD are wired differently than that of the more “neurotypical” brain. Much like a check engine light would serve as a signal to a driver that something under the hood needs attention; these patterns of behavior, when they begin impeding our day to day lives, might tell us that it’s time to see a professional (whether it be an auto mechanic or a trained physician). I think we all know someone who drives with their check engine light and not a care in the world. Arreaza: How serious/urgent is ADHD? Why should we care to make the diagnosis?Steph: Although we’ve yet to see anyone incur harm solely from having ADHD, it does lead to quite a range of more serious issues, some of which might prove more urgent. In the cases of ADHD, specifically, what we know is that there is a notable degree of dysregulation in some key neurotransmitters, like dopamine and norepinephrine. More plainly, what we are seeing in the brains of people with ADHD is a disruption, or alteration, of some of the brain’s key chemicals.These neurotransmitters are largely responsible for much-needed processes like Motivation, Satisfaction, Focus, Impulse control, even things like energy and feelings of happiness. Many of these things serve as “fuel” for our day-to-day lives; things we’d call our “executive function”. These are also what prove dysfunctional in those struggling with ADHD. It is in this sense that we might be able to bridge a meaningful gap between ADHD as being seen through patterns of behaviorthat signal a real, neurological reality.Steph: We often hear of the brain referenced as a kind of supercomputer. A more accurate assessment might be that the brain is more of a network of interconnected computers that run different processes and require continual communication with one another for our brain to function properly and seamlessly. What we’re seeing in members of the population with this diagnosis, is a significant disruption in these lines of communication. Although this is a very broad oversimplification, for the purposes of our metaphor is to think of it like our brain chemicals getting caught in a traffic jam, or parts of our brain attempting to communicate to one another with poor cell signal. Arreaza: Making the diagnosis is critical to start treatment because having that level of dysfunction sounds like having a very difficult life.Steph: Yeah! I think that’s why this conversation matters so much. There’s a sense of urgency there, because much of life is, in fact, boring. Things like paying bills, exercising and eating well, work and school—these are all things that are vital to health and wellbeing in day-to-day life; and for the more neurotypical brain, these things might prove occasionally challenging. Yet, they are still doable. For those with ADHD however, this goes far beyond mere boredom or “laziness” (which proves to be a trigger term for many—more on that in just a bit).For folks listening, I wanted to offer some statistics that show why this is such a big concern for the public, whether one has a formal ADHD diagnosis or not. The facts are figures are:Children with ADHD are more than five times as likely as the child without ADHD to have major depression.A significant increase in the prevalence of anxiety is seen in ADHD patients, ranging from 15% to 35%, when accounting for overlap in symptoms.There are significant correlations in youth diagnosed with ADHD, and those diagnosed with what are known as “externalizing disorders”. These are things like Conduct Disorder, Disruptive Mood Dysregulation Disorder, and Oppositional Defiant Disorder.We are seeing a much higher rate of academic problems in kids who have ADHD, like reading disorder, impaired verbal skills, and visual motor integration.We’re finding that many, if not most, of these connections are being made after diagnosis. In the case of the “internalized disorders”, like depression and anxiety, we’re often seeing years between ADHD diagnoses and the diagnoses of major depressive disorder or anxiety disorders. Given this framework, much of the data is theorized to point towards what we call “negative environmental circumstances”, otherwise known as “ADHD-related demoralization”.For children, this often looks like struggling with sitting still during class, failing to get homework done (because they forgot, or couldn’t focus on the tasks at hand), and struggling to focus their attention on what their teacher is saying during lecture. These things often lead to bad grades, discipline or forced time sitting still in detention. This can be seen in more problems at home, with children being disciplined often for behavior that they struggle immensely to control.For adults, this can mean forgetting to pay your bills, missing work meetings, having trouble making appointments, or having difficulty with day-to-day tasks, really anything that requires sustained attention. We often see adults with ADHD who are chasing normalcy with caffeine addictions or even struggling with substance use. Arreaza: Substance use disorder actually can be a way for some people living with ADHD to self-treat their symptoms. Steph: These differences between the individual’s experience and the world around them can lead to really powerful feelings of failure or inadequacy. They can affect your social life, your sense of community, and even further limit your capacity to seek help.Literacy in these things is so important—not just for the individual who feels that they may have ADHD, but also for those who are likely to encounter people with ADHD in their own lives. Understanding why some of these patterns pop up, even those who might not have a formal diagnosis, can go a long way to properly approaching these behaviors with success and with empathy.Arreaza: Learning about ADHD is fundamental for primary care doctors. We talked about the high prevalence and the influence of the media in increasing awareness and sometimes increasing public panic. So, we have to be prepared to diagnose or undiagnosed ADHD. Steph: Whether we’re the physicians in the room, or the patient in the chair, I think it’s important to have a clear understanding of what ADHD is and how it can affect lives. Thanks for listening, I hope we were able to teach you a little more about ADHD. ______________Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _______________References:NICHQ-Vanderbilt-Assessment-Scales PDF: https://nichq.org/wp-content/uploads/2024/09/NICHQ-Vanderbilt-Assessment-Scales.pdfADHD: The facts. ADDA - Attention Deficit Disorder Association. (2023, January 11). https://add.org/adhd-facts/American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, Inc. https://doi.org/10.1176/appi.books.9780890425596.Gnanavel S, Sharma P, Kaushal P, Hussain S. Attention deficit hyperactivity disorder and comorbidity: A review of literature. World J Clin Cases. 2019 Sep 6;7(17):2420-2426. doi: 10.12998/wjcc.v7.i17.2420. PMID: 31559278; PMCID: PMC6745333.Staley BS, Robinson LR, Claussen AH, et al. Attention-Deficit/Hyperactivity Disorder Diagnosis, Treatment and Telehealth Use in Adults — National Center for Health Statistics Rapid Surveys System, United States, October – November 2023. CDC.Gov, MMWR Morb Mortal Wkly Rep 2024;73:890-895.Danielson ML, Claussen AH, Arifkhanova A, Gonzalez MG, Surman C. Who Provides Outpatient Clinical Care for Adults With ADHD? Analysis of Healthcare Claims by Types of Providers Among Private Insurance and Medicaid Enrollees, 2021. J Atten Disord. 2024 Jun;28(8):1225-1235. doi: 10.1177/10870547241238899. Epub 2024 Mar 18. PMID: 38500256; PMCID: PMC11108736. https://pubmed.ncbi.nlm.nih.gov/38500256/Mattingly G, Childress A. Clinical implications of attention-deficit/hyperactivity disorder in adults: what new data on diagnostic trends, treatment barriers, and telehealth utilization tell us. J Clin Psychiatry. 2024;85(4):24com15592. https://www.psychiatrist.com/jcp/implications-adult-adhd-diagnostic-trends-treatment-barriers-telehealth/Didier J. My four kids and I all have ADHD. We need telehealth options. STAT News. Published October 10, 2024. Accessed October 10, 2024. https://www.statnews.com/2024/10/10/adhd-medication-shortage-telehealth-dea-congress/.Hong J, Mattingly GW, Carbray JA, Cooper TV, Findling RL, Gignac M, Glaser PE, Lopez FA, Maletic V, McIntyre RS, Robb AS, Singh MK, Stein MA, Stahl SM. Expert consensus statement for telepsychiatry and attention-deficit hyperactivity disorder. CNS Spectr. 2024 May 20:1-12. doi: 10.1017/S1092852924000208. Epub ahead of print. PMID: 38764385. https://pubmed.ncbi.nlm.nih.gov/38764385/Gabor Maté: The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture. (2022). Youtube. Retrieved April 27, 2025, from https://www.youtube.com/watch?v=ttu21ViNiC0. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.
