Unraveling ADHD: Inattention, Hyperactivity, and Impulsivity
In this episode of Cracking Addiction, Dr. Ferghal Armstrong and Dr. Manu Bhatnagar delve into the complexities of screening for ADHD in both children and adults. They break down the core concepts of inattention, impulsivity, and hyperkinesis, providing valuable insights into the often-misunderstood symptoms of this condition. Understanding how ADHD presents in children and adults, as well as the differential diagnosis considerations, can be crucial for parents, educators, and healthcare professionals. This episode offers valuable information for anyone navigating the challenges of identifying and understanding ADHD.
Focus Keyword: ADHD Screening
Dr. Manu Bhatnagar provides an in-depth understanding of inattention, explaining that ADHD doesn't necessarily equate to a deficiency in attention, but rather an inability to focus on a particular task for an extended period. He clarifies the distinction between concentration and attention, shedding light on the struggles individuals with ADHD face in prioritizing tasks and maintaining focus.
Learning Outcomes:
1. Understanding the Complexities of ADHD Presentation: Dr. Bhatnagar's insights highlight the multifaceted nature of ADHD symptoms, providing a clearer understanding of the challenges individuals face in managing their attention and impulsivity.
2. Differential Diagnosis Considerations: By exploring alternative diagnoses such as anxiety and autistic spectrum disorder, listeners gain an understanding of the importance of comprehensive assessments in ruling out other potential conditions before reaching an ADHD diagnosis.
3. The Impact of ADHD on Children: The episode delves into the potential repercussions of undiagnosed ADHD in children, offering valuable insights for parents and educators to recognize and address symptoms early on.
4. Utilising Screening Tools and Collateral Interviews: The discussion emphasises the significance of structured screening tools and obtaining collateral information from multiple sources to achieve a robust ADHD diagnosis.
Actionable Takeaways:
1. Encourage Collaborative Approach: Healthcare professionals, educators, and parents are encouraged to collaborate in providing comprehensive insights into a child's behaviour, ensuring all facets are considered when assessing ADHD.
2. Early Intervention: Recognising and addressing symptoms of ADHD in children early on can help prevent potential emotional and psychological impacts, emphasising the need for proactive intervention and support.
3. Comprehensive Assessments: Consider a holistic approach to diagnosis, including screening tools, collateral interviews, and comprehensive assessments, ensuring a thorough evaluation to capture the complexities of ADHD symptoms.
4. Seeking Support and Understanding: Individuals with ADHD may benefit from tailored support and understanding, emphasizing the importance of creating an environment that accommodates neurodiversity.
Quote:
Dr. Bhatnagar highlights the impact of undiagnosed ADHD, stating, "You can treat ADHD with a pill, you can't undo years of having undiagnosed ADHD and what that might do to someone's sense of self."
keywords
ADHD, prevalence, mental disorder, neurodevelopmental, screening, impulsivity, inattention, hyperkinesis, concentration, dopamine, norepinephrine, hyperfocus, success, expert, myth, functional, diagnostic criteria, sex gender, subtype, fidgeting, impulsivity, hyperactivity, angry outbursts, anxiety, sensitivity, specificity, differential diagnosis, language disorder, autism spectrum disorder, social services, psychosocial interventions
Transcript
Hello, everyone. My name is Dr. Ferghal Armstrong, and welcome to Cracking Addiction. And today we have with us Dr. Manu Bhatnagar, who's come back to talk to us about ADHD. So, Manu, we've previously discussed the concepts of prevalence and how ADHD is a neurodevelop, a mental disorder that has to be present from childhood and it may persist into adulthood. And there's roughly a kind of a 50% persistence rate, if you will. So I thought today we'd talk about how we screen for ADHD both in children and given that we are both working in the field of addiction, also how we screen for ADHD in adults.
Dr Ferghal Armstrong [:So first of all, if we talk about impulsivity and inattention and hyperkinesis, talk us through those core concepts first.
Manu Bhatnagar [:Might try with inattention first, because I feel like that's definitely going to be the more common presentation, especially for an adult population. And when we're talking about people who have other disorders and we're questioning whether it could be ADHD, it's usually because the kids who have hyperactivity as a core component get picked up on earlier. But inattention, I think there's a misconception that people think because of the name ADHD, that those who are effective have a deficiency in attention and so they just can't pay attention to anything. But in fact, you'll find a lot of people who have ADHD can do really, really good work and be hyper focused on a particular thing. And so where we can differentiate concentration and attention. So concentration. I need to do something. I'm going to spend a couple of hours and I'm going to do it and I'm going to put the whole world aside and I can do that.
Manu Bhatnagar [:That's good concentration. Inattention is. You try to do that. I'm going to sit down on my desk and I'm going to study for this exam that's coming up for 2 hours. And you try and you start, you do really well, but then all of a sudden that YouTube video that you really love to watch has come up.
Dr Ferghal Armstrong [:Like this YouTube video.
Manu Bhatnagar [:This is a prime example of a great thing that would distract someone with ADHD. So you've got, let's think of dopamine and norepinephrine, noradrenaline as the currency of the brain. That's what we think is behind ADHD. The inattention that the core component of everyone pretty much with ADHD isn't a lack of that currency. It's not that you're poor of those chemicals. It's more about the fact that your brain just wants to spend that money constantly at whatever it sees in front of it. And so it's not the lack of attention, it's that you cannot focus on a particular thing for the amount of time needed to be functional.
Dr Ferghal Armstrong [:Unless you are hyper focused. So can we draw this concept of what is hyper focus? Because for some kids studying for exams, if they like, the subject could be a manifestation of hyper focus. Yet for anything else, they hate it.
Manu Bhatnagar [:Yeah, definitely. And you'll find that some kids, and this can grow onto adults as well. They have a really favorite subject. And it's not like I like this subject a little bit more than others. It's that I will drop everything and just focus on this subject. And that could be very tailored to that person's taste. So it could be maths, it could be science, it could be creative, but it happens as a priority over everything else. Whereas for unaffected individuals, it can be something that makes them happier but doesn't come at a compromise for everything.
Manu Bhatnagar [:So hyper focus isn't something that is a part of the diagnostic criteria, but definitely you see it clinically.
Dr Ferghal Armstrong [:Yeah. And I suppose for me that was one of the biggest learning points for me was that you could have inattention and yet be hyper focused and very successful in one particular area of thinking. And so I used to think that an expert could never have ADHD. That's one of the things that I thought about. What do you say to that?
Manu Bhatnagar [:I would disagree. I feel like there are a lot of people who get very, very good rewards, either tangibly or intangibly from being successful at their tiny little niche. Addiction medicine, for example, hypothetically. And they go all the way through high school, university, and then on further studies because they have the social constructs around them that can allow them to flourish. But perhaps if you look at their entire life, they're not able to maintain those functional gains in other things. And if you were able to pick someone up and put them in another area, they might not be able to flourish and academically perform just as well. So I think it is a myth that ADHD results in people being entirely dysfunctional and you cannot succeed because of it.
Dr Ferghal Armstrong [:All right, so we've talked about. You were kind of talking about the distinction between concentration and attention. I'm still not clear. Can you just clarify that for me?
Manu Bhatnagar [:So concentration is the ability to sustain focus for a long period of time without any distractions. And attention is the ability to prioritize something as being worthy of focus.
Dr Ferghal Armstrong [:Right. So salience, really?
Manu Bhatnagar [:That's right, yeah. So that's really derived from your ability to be able to see everything in front of you and pick what's most important based on decisions that are going to have the best outcome for you. And with ADHD, inattention happens because you know that that assignment is due on Friday and you've only got 24 hours to do it. But this other thing that will give you more of a pat on the back, more of a reward intrinsically just automatically takes over. And that could be seen as procrastination from the outside. Parents may see their kids as doing absolutely nothing at all, but really they're listening to their favorite music or they're watching something, they're playing a computer game, which they derive more satisfaction from at the cost of something that's more productive.
Dr Ferghal Armstrong [:Right.
Manu Bhatnagar [:When that happens, you're not able to start tasks that are important, so you just never get around to it. So that's one of the inattentive criteria. And when you do get this burst of energy and say, I'm really going to write that essay or I'm really going to look into that topic, it doesn't fulfill that adrenaline that maybe you first get when you think about doing that task because something else takes over or it just wasn't as interesting as you initially thought. And so task completion is also an issue. So you'll find a lot of people with ADHD have ten things that they want to do and they've started all of them, but then they've given up halfway through.
Dr Ferghal Armstrong [:Yeah, the inability to complete, that's one for me as one of the diagnostic criteria there. So we've talked about the inattentive symptoms and I would make the point that I think it's actually more difficult. Or rather children fall through the diagnostic net when they have the predominant inattention subtype of ADHD because they're usually the daydreamers that no one really notices until they start not meeting their full academic potential, perhaps later on, even in high school. Whereas the other subtype, the hyperkinetic, well, they break the furniture from the age of two or three, don't they? I mean, they're very easily diagnosed. What's your comment on that? Absolutely.
Manu Bhatnagar [:I think the most common symptom of the hyperactive or hyperkinetic subtype is fidgeting. So not being able to sit still. And that could be a very obvious motor symptom of a lot of children who are fidgeting with their hands. They always need to have something in their hands, to be able to maneuver or break apart or put together, they're always tapping their legs. It's a lot more pronounced than just boredom that could. It's disruptive, and it's also distressing for them because the children affected with hyperactivity really feel that internal sense of agitation about having to get up and do something. So expecting them to sit still is actually counterproductive because it just bottles up all of that hypothesis until something catastrophic happens later on.
Dr Ferghal Armstrong [:So there's an explosion of movement.
Manu Bhatnagar [:Yeah. And that can often be paired with really strong interpersonal conflicts because one is restrained and they're not able to use their physical selves to express themselves. And anger becomes a part of that hyperactivity as well, if the right circumstances allow.
Dr Ferghal Armstrong [:So where does impulsivity fall into this dichotomous diagnostic construct?
Manu Bhatnagar [:The nature of impulsivity, I think, is in the middle of both inattention and hyperkinesis. So a lot of people will still fit that hyperactivity subset or a mixed type of ADHD, despite not fidgeting, despite not having those overt motor symptoms. At the end of the day, one example for impulsivity, that's a bit of both of hyperactivity. Impulsivity is when someone else is having a conversation and someone who has ADHD just interjects in the middle and starts conversation. Yeah, that's both a motor reflex of the hyperactivity, but it also demonstrates inattention because the thing that was happening before you spoke the conversation may not have been interesting enough to attract your attention.
Dr Ferghal Armstrong [:Yeah, sure. So we've talked about how it presents. Is there a sex gender issue in the way it presents in kids versus adults?
Manu Bhatnagar [:In kids, and I think we can probably say across the board, but definitely the studies that have been done in kids would say that it's a two to one boys to girl ratio. Now, look, this has changed. If you look at the last 20 years, some of our diagnostic criteria, the DSM, for example, has changed how we understand ADHD. For example, in previous iterations of the DSM, having an autistic spectrum disorder precluded you from having an ADHD diagnosis. It was thought that inattention and hyperactivity were subsets of ASD, autistic spectrum disorder. Now, we don't believe that. So when it comes to gender, a lot of the studies that have been done about that misattribution were because of ASD being incorporated as a potential neurodivergent illness and accounting for a lot of these boys who have an attention as well.
Dr Ferghal Armstrong [:What do you think about this idea that maybe girls are more prone to the inattentive subtype rather than boys, and therefore they get diagnosed less frequently?
Manu Bhatnagar [:Yeah, there's definitely some truth to that. And that probably evaded a lot of these studies that call boys two to one more effective. And the fact that girls have a lot more relationships with peers that can often mask the inattentive symptoms, or perhaps are in environments where in the past, succeeding academically or functionally in the work environment wasn't allowed or in certain cultures isn't expected, means that those symptoms aren't as disabling as they can be for boys, and hence the diagnosis isn't made. But definitely we're seeing a lot of young women in their 20s coming out, trying to succeed in a corporate environment or in full time work saying that they're having all of the symptoms of ADHD.
Dr Ferghal Armstrong [:Okay, so we've talked about generally the way it's thought of. It's a disorder of inattention or impulsivity or hyperactivity. How would you think about it? What tools would you use? Or how would you approach the idea of a child in front of you having ADHD? What's your kind of diagnostic pathway? Do you use screening tools? Do you use collateral interviews?
Manu Bhatnagar [:What's your approach? Yeah, look, I think screening tools are really helpful because having a structured way of approaching ADHD is really important when you're talking about a very complex set of symptoms that are very unique to each individual. So having some semblance of objectivity, even though these rating scales can be very subjective, is important to be able to not only achieve a diagnosis, but also track progress. And doing them periodically is important to see how treatments are working and how disabling they are. That being said, a lot of the recommendations suggest that screening tools alone aren't good enough to diagnose ADHD, especially with teenagers, because there may be very many reasons why a self report from a teenager cannot point to a particular diagnosis. For example, as I mentioned, anxiety is very common in the adolescent group and also for a lot of inattentive symptoms. So a young person who's presenting with these symptoms will usually present not of their own volition, but because a school has asked for a review. A parent has been saying, I've been really struggling with this behavior for a while, or someone will notice a really strong deterioration where someone's potential academically isn't being met by their performance. So having that referral source is invaluable and something that we really struggle with for adults because you have that objective, secondhand opinion about how someone is in an environment where they're meant to be functional and meant to perform.
Manu Bhatnagar [:So taking a history of history and doing an assessment of the patient is obviously the first and most important thing. But then having some collateral information from a parent and a teacher and then also screening tool, I think provides a robust amount of information to be able to reach that diagnosis.
Dr Ferghal Armstrong [:So you've introduced the idea of not meeting academic goals as kind of as a key symptom, especially in children. Let's talk about it from the point of view of a parent. What might a parent say to you that would make you think, yes, this child has got ADHD? What would be the symptoms in the home domain, as it were?
Manu Bhatnagar [:I think the hyperactivity activity, if that's a subtype that that child is presenting with, is going to be the most obvious. And you alluded to the destructive nature of a child who is hyperactive can lead to broken toys in the bedroom, frustration of not being able to complete a task, or that energy leading to anger between siblings or between parents, and also a sense of shame from the child because of multiple attempts to do something they really enjoy, be it sport, or joining a new academic pursuit and wanting to be part of a class, but not being able to fulfill all the requirements. So starting very many things that might be interesting, either by the child or the parents, getting them introduced to new areas, new concepts, but seeing them struggle to maintain effort in applying them or persisting with them is going to always be the most important sign of ADHD. And for a lot of kids, that happens much earlier if there's a hyperactive component.
Dr Ferghal Armstrong [:Yeah, I often hear the phrase that sticks in my mind, actually, is he could do so much more if only he applied himself.
Manu Bhatnagar [:I think that's important to note because that's also what these kids probably still hear. If they don't have access to mental health supports or a pediatrician, they don't know that they have ADHD. And so what they're hearing is that they're failing because they're not good enough. Sense of shame, if it's instilled in you early enough, can really ingrain itself for the rest of your life. And I think we've got pretty good evidence that the way that we're treating kids with ADHD is accounting for all of the comorbid conditions like anxiety and depression and substances that come along with it. So it's really hard to undo. You can treat ADHD with a pill, you can't undo years of having undiagnosed ADHD and what that might do to someone's sense of self.
Dr Ferghal Armstrong [:Yeah, absolutely. And so we're talking about people who are very vulnerable in a critical neuroplastic growth phase. And it's so important to get this diagnosis as accurately and as early as possible. Now, you mentioned screening tools. So what is a screening tool? And specifically, what screening tools might we use when we've got a child in front of us thinking, considering ADHD?
Manu Bhatnagar [:Yeah. This is very different for a child.
Dr Ferghal Armstrong [:As compared to an adult.
Manu Bhatnagar [:And I think the best practice for a child is to use the resources in their school and use the family's experience of what they're seeing at home versus what. So the gold standard is using something like the Connors or diva. And these are very well tested and robust studies, screening tools that have high sensitivity and specificity for ADHD. But kids, what's also often best practice is not to just administer this in 1 hour with a pediatrician or a psychiatrist. Best practice would be also to do many other measures of intellectual functioning, including an test and verbal literacy, and use a neuropsychologist to assess someone for four to 6 hours to see, okay, if it isn't ADHD, can we find something else that's accounting for your deficits at school? There could be language disorders or spectrum disorder that come as a result of.
Dr Ferghal Armstrong [:Those assessments, which goes back to our previous comments in a previous episode, where really, the art of the differential diagnosis is absolutely crucial. And you mentioned two words when you were describing the Connor screening test, which was sensitivity and specificity. So sensitivity means if it's there, we'll notice it, and specificity means if it's not there, we'll also notice it, we'll know it's not there. So a valid yes and a valid no, really. But it's absolutely crucial to consider alternative diagnoses in kids. I mean, can you give us a flavor of what else might be causing these? I mean, you've mentioned language disorder. Is there anything else?
Manu Bhatnagar [:I think from a psychiatry point of view, anxiety is always the number one differential diagnosis.
Dr Ferghal Armstrong [:And just to be clear, it's perfectly reasonable to make a diagnosis of anxiety in a child who's five or six years old.
Manu Bhatnagar [:I think when we're talking about the DSM criteria, something like a generalized anxiety disorder, it may not meet that threshold. But when you think about the environment in which a child is attempting to succeed or trying to be functional, the nature of anxiety as a symptom can be so disabling that it looks like inattention, and so perhaps not the diagnosis of general anxiety disorder, although that can happen under ten, but parent child attachment and dysfunction in that relationship can lead to symptoms such as anxiety and low mood and fear, which resemble inattention.
Dr Ferghal Armstrong [:What other diagnoses might you consider apart from anxiety symptoms or diagnoses?
Manu Bhatnagar [:And this is where people will have a debate as well, currently, but autistic spectrum disorder is a big one, where it's really important to get in early, not just from a treatment and maintenance point of view, but also, if you are under the age of six years old, having an assessment to say you have autistic spectrum disorder in Australia can derive a lot of supports through funding and resources. And if you have that all set up before the age of six, then all of schooling can be set up under the assumption that this person needs a lot of extra support. So assuming someone has adhd and getting done dusted with that, derives less attention from social services and schools to provide a structured environment. But if you look for comorbid diagnoses that could account for inattention or those symptoms, ASD is definitely a one that you should not miss.
Dr Ferghal Armstrong [:So really, there's actually a moral obligation on the part of diagnosticians, be they doctors or psychologists, to actually get the diagnosis of autism, either in or out, when we're thinking about the co occurring disorder of ADHD. Because, as you say, there is this financial benefit, which translates into psychosocial interventions, which translates into an altered, successful trajectory.
Manu Bhatnagar [:Absolutely. And that degree of self awareness and insight into someone's illness from a very early age can allow them to be a lot more functional and understand the neurodiversity from early on.
Dr Ferghal Armstrong [:Yeah, we haven't even got to adults yet, Manu, but we have run out of time. I want to thank you for your time and expertise tonight and I really hope we can speak again very soon. Thank you. All right, see you soon, Bermuda. That's all for today, folks. My name is Dr. Ferghal Armstrong and this has been cracking addiction.
