617- Recognizing ADHD in Women and Older Adults: Differentiating and Diagnosing Mature Symptoms

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0:26Welcome to the Attention Deficit Disorder Expert Podcast Series. by Attitude Magazine.

0:35Hi, everyone. I'm Annie Rogers, and on behalf of the Attitude team, I am delighted to welcome you to today's ADHD Experts presentation titled Recognizing ADHD in Women and Older Adults, Differentiating and Diagnosing Mature Symptoms. Leading today's presentation is Dr. Russell Ramsey, who we are honored to welcome back to Attitude. Dr. Ramsey is a clinical psychologist and the author of a new book titled Once I Get Started, which explains his program rooted in cognitive behavioral therapy and adapted to help target the challenges of facing adults with ADHD. Dr. Ramsey's other books include the Adult ADHD Toolkit with Anthony Rothstein, MD, and Rethinking Adult ADHD.

1:32Dr. Ramsey recently retired from his role as professor of clinical psychology in the psychiatry department of the Perelman School of Medicine at the University of Pennsylvania. He had been co-founder and co-director of Penn's adult ADHD treatment and research program. He currently has a solo completely virtual psychology practice, and Dr. Ramsey is also a contributor to the new Institute for Lifespan ADHD Training, which is an educational organization that equips healthcare professionals with the skills to accurately diagnose and treat ADHD at any age, which is very apropos for today's discussion.

2:14We will link to the ILAT Global Organization and its upcoming training summit in the event resources after today's event. Today, Dr. Ramsey is going to outline professional recommendations for conducting competent adult ADHD evaluations, addressing issues unique to the assessment of ADHD in women and older adults. He'll provide guidance for differentiating ADHD from common co-occurring conditions, such as mood disorders, anxiety, and other issues that will, could increase the likelihood of diagnostic accuracy. You'll learn what a competent adult ADHD evaluation should include and why overlapping symptoms can make an accurate diagnosis challenging, especially for women and older adults.

3:11And finally, the sponsor for today's webinar is Inflow. ADHD can show up differently in women and older adults, which means it's often missed, misunderstood, or mistaken for something else. Inflow provides science-based ADHD support created by psychologists and ADHD experts to help you better understand your patterns and build practical strategies for focus, emotion, routines, and follow-through. Click the link on your screen to take their free ADHD traits quiz to get started. Attitude thanks our sponsors for supporting our free webinars. Sponsorship has no influence. on speaker selection or webinar content.

3:54Okay, with all of that out of the way, I'm so pleased to welcome Dr. Russell Ramsey. Dr. Ramsey, thank you so much for joining us and for leading this really important discussion on recognizing ADHD in older adults and women. Annie, thank you so much. So first, and this could have been three different presentations, so we got a lot to get through. My disclosures generally over the last 12 months, pretty much royalties for books, presentations I do. I have no pharmaceutical industry entanglements, for lack of a better phrase, but just want to be open just in case you see any sort of conflict or misinformation.

4:40The objectives, Annie nailed them, so we'll just slide by and really get into the content. Briefly, I want to highlight elements of the DSM inclusionary criteria. Many of this audience probably know these already, but that there's developmentally, for lack of a better phrase, inappropriate levels of inattention, impulsivity, and hyperactivity, with the latter one being also manifesting as a sense of internal restlessness in adults, which can be very distracting. One of the modifications made with the SM5 is lowering the diagnostic threshold from six out of nine symptoms of either the inattentive symptom vector or of the hyperactive impulsive vector to account for the fact that several of the symptoms may not be totally accurate for adults.

5:35Yeah, I'd make the pitch out there. There's been some research trying to tease apart adult-specific symptoms, very often coming around some sort of cognitive flexibility or inattention and some emotionality, which seems to overlap a lot with the hyperactivity and impulsivity. But more on that differentiation later. DSM-5 raised the age of onset, by which age symptoms have to emerge from 7 to 12. And so by the book, it's still 12. But there's an empirical case could be made for a 16-year-old age of onset because the 12-year-old misses that pre-adolescent, adolescent area, middle school years where there's more of a developmental, at least in Western countries, for more, not exclusively self-regulation, but greater expectation of individualized self-regulation.

6:33And the symptoms have to show up in multiple settings, generally academic, occupational, family home. And what gets lost sometimes is in the community, like doctor's visits, movie theaters, restaurants, wherever else we humans congregate. So multiple settings, even though a case could be made for adults, if you're losing your job or about to get a divorce or just from one area of life, that might be sufficient impairment. But that's part of a broader discussion. Buy the book. You want to see it in more than one situation to be sure. Now, one of the things, and there has to be impairment directly associated with ADHD symptoms.

7:15It has to be causing life problems. Does that mean you have to be losing your job or getting the divorce? No. But of note, and I think it was Greg Mattingly pointed this out one time, that for most symptoms, I'm sorry, for most diagnoses in DSM, clinically significant distress from symptoms is adequate evidence of impairment, but not for ADHD or for the other neurodevelopmental disorders. That is not included as evidence of impairment. So I just find it interesting, especially since we're going to be talking a little bit about the emotional regulation with ADHD. Some important points quickly about ADHD.

7:54ADHD and the EF in parentheses stands for executive functions. Executive functions are underrepresented, and even that's generous within DSM criteria. but many people, myself included, would view the executive dysfunction as a, if not the, core difficulty within ADHD. The how efficiently do you do what you set out to do, not to necessarily to contribute to the gross national product or get a certain degree, but the things that you view as important pursuits for you to chase and hopefully achieve. And that these executive function self-regulation capacities are features of human nature. They're part of our factory setting and part of normative development, hence ADHD is a neurodevelopmental syndrome.

8:44It's with you from early on. It can manifest differently in different settings, but it's pretty consistent across time. And even though it's clunky language, in terms of these executive functions are also the features, the classic features of ADHD. Most people, there's a spread. So there'll be a lot of people in the middle who might have a symptom or two or, you know, periodic executive functioning difficulties. There might be people at the high end of the curve who are annoyingly on time and organized. Holiday decorations go up on time. They're down the next day. They're put away, organized so you can find them the next day.

9:22Everything's taken care of the people we aspire to be or want to be our assistants. And but with ADHD, it falls regularly at the far end, the quote unquote, disordered end of a continuum. And it's not all or nothing. It's not a complete absence, but it's a consistent inconsistency where things can be OK in some settings or people say, I had three really good days last week, but I can't recapture it now. And which is also frustrating for others, and that's why there's so many, so much of the social life, personal life, interpersonal life is also affected by ADHD because of the difficulties with following through on relationship roles.

10:06And what's also important with ADHD being dimensional and executive functions being dimensional, the symptoms and thresholds may be subjective, but that doesn't mean meaningless or irrelevant, just like definitions of high blood pressure or hypertension, we draw the line somewhere. But also that tells us with ADHD, there can be people who are very impaired by maybe a few fewer symptoms than would be reflected in the thresholds. But that might still warrant attention. And there are ways to make a diagnosis where that is acknowledged. The subthreshold features of ADHD that warrant clinical attention.

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11:30And the right-hand figure is for children.

11:33Russell Ramsay: I'm just showing this wherever there's a human brain, there's the possibility of ADHD.

11:40Russell Ramsay: Now, going back to the executive function model, we're not going to go through them all. But in a study early on with the initial DSM-5 criteria, executive functioning fused with inattentive symptoms as the number one most common representation manifestation of ADHD. You can see the rest. But also number four, emotional discontrol or emotional dysregulation emerged as a distinct factor, even though it's one of the executive functions. So this also shows within the current diagnostic criteria, even though executive functions and emotional discontrol, you don't see emotions listed in any of the DSM criteria, but they're now considered part of the typical clinical presentation.

12:25Russell Ramsay: And as I said before, part of our human factory settings that help us make our way in the world and with other people.

12:36Russell Ramsay: and people will say well maybe that doesn't map on exactly to the symptoms so maybe it doesn't apply but there is a lot of overlap with what are known as the hot and cool executive functions the hot are dealing with more emotionally valent situations uh and the emotional regulation including very often down regulation of upset emotions that for lack of a better phrase the negative emotions, even though having emotions is a net positive in terms of human functioning. It's also the impulse control, the behavioral inhibition, and that ability to delay gratification. Now, even though the hyperactive, the overt hyperactive symptoms decrease over time into adulthood, one of the things after the persistence of the inattentive symptoms, which are the most persistent over time, it sort of gets lost in the shuffle.

13:30Impulsivity is in there. And that overlaps a lot with emotions because what are the impulses? They're generally the emotions and the feelings driving us to make the smaller, sooner choice now rather than delaying for the larger, later payoff. And the cool executive functions, these are more the metacognition, the time management, the organization persisting over time to reach the delayed goal, decision-making, problem-solving, the cognitive flexibility, and the up-regulation of emotions, like feeling motivated. And what is motivation in executive functioning terms? The ability to generate an emotion about a task in the absence of an immediate consequence, the ability for the college student to make herself feel enough like studying for the midterm three days before

14:20Russell Ramsay: the exam rather than waiting until the night before where there's motivation all over the place. It's panic. So starting off, before we talk about women and seniors and the differential diagnoses, what goes into a good evaluation? Maggie Sibley, I respect her for everything she does, but also one of my favorite papers that she did was this outline, which I go by. Now, this is the bare bones, straightforward, what's the minimum you need? There are some other things that are optional. But one of the important things is a structured diagnostic interview for ADHD symptoms. Yes, get self-reports of symptoms, impairments, and I would argue also executive functions.

15:12Observer ratings, somebody who knows you or knew you in childhood, a sibling, an old friend, a family member who can help with the retrospective assessment of ADHD symptoms, somebody who knows you now, a partner, a co-worker, whoever you trust with it. To triangulate symptoms, we can see if other people are seeing the same things. Now, the executive function assessment with DSM criteria, it is not necessary. You can do it without that. You could just use the DSM symptoms.

15:46Russell Ramsay: But I would add that it's, I would say it is, I would argue that it's essential. I use one, I assess for it in my, and by assess, I mean by interview, there are some executive function office-based tests, but very often they're intermingled with other cognitive issues like overall intelligence and other things that might mask a little bit some of the actual executive functioning difficulties. There was some early research saying that the self-report measures are better, and by adulthood, the self-report is more reliable than in adolescence or childhood. But also, even though you get the self-report questionnaires, the observer report questionnaires that are a good guide, but asking about each of the symptoms, both the emergence in childhood and in adulthood.

16:37So those are the informant ratings. And with all the ratings, if you're collecting multiple ones, use the OR rule. If at least one person endorses it as a symptom, count it for the time being until you can assess it by interview, rather than the and rule. You don't need consensus because people might have different vistas. The spouse might see something at home. The self-report person might see something at school or work. Somebody else might see them in their personal life. So they may not all be seeing the same things because the individual with ADHD or who's getting evaluated for ADHD might have different interactions or roles with each of these people.

17:16Also, going back to establishing impairment, ADHD has to be making a direct and causal contribution to life difficulties that warrant treatment. And there are rating scales for that if you need a number or a way to quantify it, but very often simply recording and verifying the difficulties a performance improvement plan at work, relationship difficulties, or excessive compensation, like getting by at work and doing well, but coming at the cost of sleep, overall health, or family life. Also, assessing symptom settings and timeline. When does the individual notice symptoms? Do they persist relatively over time?

18:01And this can vary over time, and I'll talk about that in a later slide. And also actively ruling out alternatives. Are there other things that could be causing these same symptoms? But as part of the ruling out alternatives, it's also looking for what could be some coexisting factors that are magnifying any ADHD or perhaps being magnified by it. And we'll talk about that later. And then finalizing the diagnosis and providing documentation. So where do you get this? And we were just talking, I was talking about this with Annie beforehand, one of the things, and probably where the Institute for Lifetime Lifespan ADHD training came from, I'll take some credit, Kate can deny it, but I think Kate read a blog of mine where I talked about how adult ADHD is the number two psychiatric diagnosis among U.S.

18:52adults, And that was the case in 2004. CDC data that I was able to dig up said it's the same for about 2023, 2024. But so few, if any, practicing clinicians, myself included, got trained in it. So how's that for self-promotion? Got trained in it at all. So I liken this to going to a family doctor and maybe for diabetes, which is numbers among the most common presenting medical issues. And not only does your doctor say, oh, I don't specialize it. They say, we didn't cover that in medical school. So I just put that out there and a little call out for ILAT. But how can you try to find out if a provider has some competency in this?

19:39We're not talking about necessarily having to be experts. but sort of knows what they're doing even if they can't provide treatment after. So there are a couple guiding questions to ask a provider. And these are reasonable things. Like, what's your experience with this? Who do you read? Like, do you have an approach you follow? Or what questionnaires do you use? They're outlined there. Then there are also things you can do to empower yourself in your evaluation, completing all the paperwork. And that was always the running gag because we ask a lot of paperwork and people come back, okay, I suspect I have ADHD and you're flooding me with these forms.

20:19But it is a way to do the job right to gather enough information. Because ADHD, it's a tricky diagnosis to make. It's asking a lot. Any old school records you might have, especially for college-age students, it's amazing how many records parents have once you ask. And also thinking of specific examples of the difficulties that you're having, or maybe things you've heard about ADHD that you said, that resonates for me. Now, it may not be a symptom of ADHD. There are some things out there that don't differentiate ADHD from non-ADHD, like having a hard time getting started on things you don't find interesting.

21:00That really doesn't differentiate somebody with ADHD from not. What does is the ability to eventually get around to facing it and doing it and completing it. So there are some subtle differences in there. And also any medical history, past treatment histories, things to help the clinician wade through everything I mentioned before. I know this is a sprint through this stuff, but we got a lot to get to. From kickoff to the final whistle, trade the biggest moments in football on Kalshi, America's number one prediction market platform. Green Bay is currently trading at 42 % to beat Dallas, meaning a$100 trade pays out$228 if they win.

21:41Download Kalshi. Use code HOOPS to get$25 when you trade$25. K-A-L-S-H-I. Kalshi. Trade what's next. 18 plus only restrictions and eligibility requirements apply. Event contract trading involves risk and may not be suitable for all investors. Kalshi products are not available in all jurisdictions. Prices, values, and available markets may differ from those mentioned. For more information, see kaoshi.com slash regulatory. So seniors with ADHD, this includes some data on women, but over the pandemic, you know, pretty much, I think adult ADHD diagnoses were the, of all the different diagnoses, the number one increase during the pandemic years.

22:19And as we can see for adult women and, you know, 45 and above the increased numbers, but also for every age group,

22:29Russell Ramsay: excuse me so with seniors and adhd um so this is 60 and older and i just turned 60 earlier this year it never bothered me before it doesn't bother me now really if this is 60 i'll take it but it was just like it's a it's a new vista um so before i don't it's sort of like a stephen right joke i always said i was uh prematurely gray and now i must just be immaturely gray maybe But anyway, kidding aside, assessing ADHD in older adults, generally about 2 % in studies of senior samples, about 2 % come out as identifying with ADHD. Now, the thing with longitudinal studies for ADHD, following children into adolescence or adulthood, adolescence into adulthood, they generally stop around the mid to later 20s.

23:18So we don't really have a lot of data on seniors. Now, and this can also include, before I was mentioning about the importance of sub-threshold symptoms, because going back to the diagnostic criteria where five out of nine of either inattention or hyperactivity is sufficient for a diagnosis. What about, so somebody could have five out of nine inattentive, zero out of nine for hyperactive impulsive. Okay, you have ADHD, predominantly inattentive type. But what about the person who has four out of nine of both, has eight symptoms of ADHD, which is more than five. I was not a math major. But it probably is closer to the combined presentation.

24:03And so somebody going by the book says, well, you didn't meet it here. You didn't meet it here. So this isn't ADHD. But that all or nothing, remember, ADHD is a dimensional syndrome. So that's why this is important. So also with seniors who might only show up in the senior years for an evaluation, looking back, they may be sub-threshold now, but part of the evaluation is verifying childhood onset and persistence into adults, which when you get in there and ask people, they may not be able to talk about, oh, on this day in September, this test, I was distracted. but overall and this is where the executive functions come in i'd got good grades but i was always late with things or i'd never handed in homework nobody said anything what whatever the case may have been so it really in addition to the structured interview for symptoms a good developmental interview asking about different levels of school is also where you'll get a sense of whether there were symptoms of adhd but often not because sometimes people come in for the attention problem, and it's something else.

25:13So there could be sub-threshold in adulthood, but that is still clinically significant. And also, one of the emerging areas of difficulty with adults with ADHD is its effects on health, overall well-being, that there are behaviors in young adulthood going into the mid to late 20s that would predict unchanged if these are changeable behaviors, but would predict reduced estimated life expectancy moving ahead if they continue on. So ADHD is not this trivial thing. It's pretty serious. So also looking at the cumulative life and health issues of the seniors and things that might have been like ADHD contributing to a sedentary lifestyle or unhealthy behaviors like substance or whatever that might not no longer be in play, but set a course or affected health before then.

26:07And some of the differentials, and there's no way we'll be doing this adequate, but menopause, and we'll talk about this more with women, mild cognitive impairment, normative cognitive decline, the reduction in working memory capacity and efficiency, pseudodementia, or any other conditions that might mimic ADHD symptoms without the degeneration of functioning, including medical issues like Lyme disease or other things that can cause difficulties or thyroid issues. Now, in terms of older adults and trying to make the diagnosis, the Barkley quick check has been found at least in one study to be helpful.

26:48But even there, they recommended reducing it from six out of nine to five out of nine. And the quick check, If you're familiar with it, this was something Russ Barkley and Kevin Murphy, their research with the Massachusetts group, I think, came up with. And it's a single list of nine symptoms that you can read here. You can get from the book. They're in the handouts. And they have more executive functions in there. Like number six is sequencing, driving a motor vehicle faster than the excessive speeding, and organizing tasking activities. This was one, and it's not the only one, where there's evidence to say a 16-year-old age of onset that symptoms were identified as emergent by that age doesn't sacrifice diagnostic accuracy.

27:35And typically, the threshold for screening would be 6 out of 9, but used as a screening for seniors adjusting to 5 out of 9, with 5 out of 9 meaning it's at least moderately symptomatic.

27:50Russell Ramsay: now going back using that so child you know some of the issues with the assessment are childhood onset verification now there is in addition to the three presentations of adhd combined predominantly inattentive and predominantly hyperactive uh impulsive there is also what two that are uh each one each one is other specified and the second is unspecified the only difference being if somebody's not meeting full diagnostic criteria, but their symptoms are best explained by ADHD and not something else, but there's something missing, say childhood onset or sub-threshold symptoms. Other specified means you specify why full diagnostic criteria was not fulfilled.

28:35And unspecified, you can guess, but it means there's no mention made of why in the documentation why full diagnosis was not met. But this comes up sometimes, like when there's a question, and like I said, this looks a lot like ADHD. I have symptoms, but they're not depressed. They're not anxious. There's not something else going on. And sometimes it could be just that the symptoms were masked for that long. Also, with adults with ADHD, seniors with ADHD, you're You're probably going to get, compared with other neurological conditions or decline, a more detailed description of persistent symptoms over time, not the last six months, even though that's the diagnostic criteria.

29:21But going back, looking at persistence, you'll see things like, oh, they were like that in college. As an adulthood, things got worse in retirement, the loss of scaffolding, but it was more of a magnification of something that was there before. With the mild cognitive impairment and what is it? Mild neurocognitive disorder, I think is the new branding of it. There's usually more of a, it'll be a decline, but it's more of a cliff where it's notable things. And with ADHD, it's more like the history of impairments at school or work or other duties, including at home, reflecting the executive dysfunction.

30:00That's why that assessment is so helpful in getting the data about executive functioning. At least I find it very helpful. And also with some of the mild cognitive impairment, these more progressive things, there's a notable worsening of functioning and memory confusion, activities of daily living, which are ADLs, not better explained by other factors. This is where what can be helpful with teasing that apart from ADHD is a good old-fashioned mental status exam. Serial sevens, start at 100, subtract seven, how far can you go? It's a working memory task. Naming the last four presidents, remembering three words throughout the exam.

30:42I'm going to give you three words, remember them whenever I ask you. Cup, pen, tree, and then every few minutes asking to repeat them. Yes, you might miss one here and there, but with more severe neurological decline, there will be a great deal of deficiency in the responses. And later on, not that we diagnose by prescription, but seniors with ADHD respond more positively to ADHD medications than do adults with mild cognitive impairment. And with the MCI-MNCD, there are neurological, neuropsychological tests that could be done over time to document that decline. Whereas with ADHD, and we're not talking about using them to diagnose ADHD, but in terms of tracking memory or other things, they should stay pretty persistent because ADHD is going to be more of a working memory.

31:41Are there age declines with working memory?

31:45Russell Ramsay: Sure, but it's a smoother decline and by still staying within the normal range for the same age group.

31:55Russell Ramsay: And, you know, other things to keep an eye out for clinically. You can see this comes from Kate Nadeau's book, Still Distracted After All These Years. some of the top struggles, you know, and pretty much a listing of executive functions and overlapping some with the ADHD symptoms. But then what can you ask about getting tasks done? And again, this is for ADHD. You know, they're doing one more thing impulse, the, you know, not being able to disengage and re-engage elsewhere for separation a bit. You know,

32:33And just a lot of the disorganization and disorganized time management and the absent-mindedness, you know, forgetting what you walked into the room for or other working memory things. We're not talking about not remembering what somebody looks like, you know, forgetting names of family members, you know, things like that.

32:53Russell Ramsay: Women with ADHD. This isn't a popular topic at all these days. But going back to the most recent CDC data and the first CDC data on adult ADHD from October 2024, in addition to giving some fresh numbers to the prevalence of adult ADHD in the U .S., the fact that half of adults with ADHD were first diagnosed in adulthood, and of those, 61 % were women. And also that meant that many fewer women were diagnosed in childhood. And what are the numbers? Several years delayed between women getting the actual diagnosis of ADHD, whether it was pursuing the diagnosis or that was suggested in the question posed to the group, having it dismissed.

33:44and reading some studies with narratives of women with ADHD, talking about, well, you were on time for your evaluation. You can't have ADHD. You've been sitting still the evaluation. You can't have ADHD. You seem to be doing well. You can't have ADHD. Or you got through college. If you fill in the blank, completed that, then you can't have ADHD. It can be right, but it can only be figured out by a thorough evaluation. And also most often, I mean, people aren't showing up for evaluations saying, hey, I'm going to do this for kicks. I'm going to see what this TikTok thing's all about.

34:27Usually people wait too long to get a diagnosis and especially with ADHD. Now, what are some of the presentations with women or where they might seek help or be encouraged to get help first, where it might be a reverse diagnosis. You're coming for an eating disorder, and it's not that that's necessarily wrong, but it might be looking backwards and saying, oh, this is also part of what might have made you prone for this was undiagnosed ADHD and the emotional dysregulation piece. So increased risk for this among women with ADHD. And also, if you're looking at a differential diagnosis, because not every woman and some men can have eating disorders, but it's relatively rare.

35:09But going back to and making the differential, is there anything else here? There's usually a pretty clear differential between the disordered eating behavior and all the ADHD-related issues, where it might be more of a depression or anxiety or trauma-based reaction, but ADHD should be assessed for. And it's like one of the ADHD medications, lisdexamphetamine, is FDA approved for binge eating disorder and the impulsivity and the emotionality that can go along with that. But a whole host of things women with ADHD are more prone to. In addition to ADHD, including some of the emotional dysregulation that can lead to self-harm, mood and anxiety as coexisting factors isn't wrong.

35:56But the problem with women is that is what most clinicians, you know, within the mental health professions, the clinician training professions, and I don't want to be glib about this, but depression and anxiety are like treating the common cold. Everybody gets trained in it, even if you're going to be a researcher or something else, but you're at least be able to diagnose and refer out. But like with ADHD, there's not that. It doesn't get introduced into medical school graduate training. Or sometimes you'll hear people say we had a one-hour lecture on it or something like that so um it's easy to see what is it like if if all you have is a hammer everything looks like a nail but also some things chronic fatigue syndrome adhd is pretty tiring because you're working twice as hard for half as much sometimes the planning the replanning the undone task what was william james's quote i have it right here nothing is as fatiguing as the eternal hanging on of an unfinished task and That's William James and not even talking about ADHD.

36:58But also with women overwhelmed, and this could be girls in school, adolescents in peer groups and academics and occupations for adult women. And, you know, even though there's, you know, there's been a lot of improvement in terms of shared task at home, mothers and women are still predominantly running households, not exclusively, but that tends to still be the case. and also a proneness for abusive relationships, be it a self-esteem issue or peer groups or whatever the case may be. It's not blaming the victim, but it's being on guard for the things where somebody might, for lack of a better phrase, settle.

37:38Now, also, it's interesting, many of the same symptoms are seen, the same behaviors are seen in boys and girls, but are less likely to be tagged as ADHD for girls. And there's actually fewer sex differences differences when stringently using the diagnostic criterion guidelines. And the impulsive symptoms can look, and hyperactive can look different in women, the emotional dysregulation piece. You know, taking pains not to turn this into, oh, the emotionality, but it's the emotional dysregulation is the same emotional reactivity anybody would have, the homework or other things people are dealing with.

38:17And initial menses for adolescent young women, perimenopause, menopause, and the various hormone fluctuations in a large part interact with dopamine systems, which we know affect ADHD. And one should be considered in terms of the treatment of ADHD for management of the mood fluctuations and other factors that could be going on. There is some research that women without a history, clearly without ADHD in entering menopause, can look like they have ADHD. And the late Tom Brown and Kay Neal Epperson, when she was at Penn, did a study of women without ADHD but scored really high on a Brown scale during menopause.

39:02And they were treated with an ADHD medication and had improvements. So that would be a symptom-based prescription. I'm not a psychiatrist. I'm just citing research. But also, you know, medication management during menopause or during the menstrual cycle, you know, premenstrual dysphoria. There's a lot of adjustments that can be made to both the psychosocial and medical treatments to help women with ADHD and also as part of the evaluation of understanding what are the effects of ADHD and treatment planning. um this is this is like one of these lines i i'll share it because it captures something but i wouldn't you know take it as all or nothing but boys adhd shows up in the classroom girls adhd shows up in the playground with social norms interpersonal reactions to situations also maybe being fidgety and restless but seated doodling mentally not being there like you know mentally active imagination or getting ensconced in some sort of reading and not hearing what's going on in the classroom and their nose in the book, even though a lesson's going on.

40:10Now, girls mature earlier than boys, so that also covers up maybe some of the academic difficulties, but there might still be difficulties with production or follow-through or handing things on time or forgetting things at home or in the book bag if anybody has book bags anymore. And also holding it together at school and then having the meltdown at home. So the teachers are rightfully saying she's a joy to have in class, but then the parents going with the transition and the evenings and, you know, other time off. So that's where the multiple informants and understanding what's going on, you know, for the child.

40:45And the same could be said for holding it together in the workplace in adulthood. And also the impulsivity and emotional dysregulation, more than the hyperactivity, because that's where it might show up. Because again, the impulsivity, procrastination, impulsivity is a core feature of procrastination. I know I should be working on homework, but I'll just send this one text or whatever else it would be. There are probably many people out there, full-fledged adults going, well, that's me too. But it's the degree, the magnitude and the level of impairment that goes along with this. And also even with the internalization of girls and women, And, you know, sometimes I just say sometimes vibrating, they're not getting up or moving around.

41:27It doesn't look overtly hyperactive, but there's just a lot going on inside and holding it

41:31Russell Ramsay: together is really tiring versus the overt externalizing. ESM-5, and I know we have to wrap up soon, had a thing, the restrictive inattentive type. It fulfilled diagnostic criteria for inattention, but no more than two symptoms of hyperactivity Because more than two, it looks more like the combined type. And this is where over the years in doing a lot of evaluations with everybody, but a lot of times I'd see women with like three or four. And it was really more consistent with the combined presentation, even though going by the book, it would be a little bit, it wouldn't be. And more likely women and teen girls more likely to be first diagnosed for and treated for an internalizing disorder, especially depression and anxiety.

42:17So look for the executive functioning difficulties and also the subthreshold presentations missing by a diagnosis or symptom or two. Underrepresented groups, you're not going to go through all of them, but just all the reasons people might delay getting help or be skeptical of help. There can be cultural differences in help-seeking or what defines a problem or a symptom, access to resources, trust in resources due to historical discrimination. There can also be the family system as a group. Parents don't believe in ADHD or extended family don't believe in ADHD or other group norms. Be mindful of masking, even though that's a really tricky term.

43:00That's why I say just be aware of concept creep. it can grow too far. And one of the studies cited below is by UK Black women, we're just not even on the map, is the title of their paper, just talking about, you know, there's a lot of narrative work by women of all sorts, their descriptions in coping, getting the diagnosis, and living a full

43:24Russell Ramsay: life. And then lastly, okay, well, so how do you tell ADHD apart from anything else? So this slide shows that ADHD can coexist with anything or any things. But what are my guidelines? So the most common coexisting diagnoses with ADHD in descending order, anxiety, depression, and substance use, and also nicotine, alcohol, and marijuana. Now, remember that the core symptoms of ADHD are nonspecific. It's like a fever in medical practice. If you go to the doctor with a fever, it could be the flu, it could be an infection, it could be malaria. You need more information. But in terms of differentiation, and this is the last content slide, I know Russ Barkley had the 30 % rule, so I'm going to market this as the Ramsey 85 % rule.

44:11But what I mean by that, these guidelines will work 85 % of the time. There'll be some really complex cases. But when did ADHD emerge, even if it wasn't fully diagnosed? Did it emerge in middle school and the first depression was in college or the first anxiety in college. Even with trauma, this is a really important differentiation because I've seen clients who've had ADHD emerge in adolescence, childhood, whatever, and then the trauma happens late adolescence in their 20s or later. Now, if it's early childhood abuse, two, three years old, it can be hard to tell apart. I would say, though, if you're looking and if it seems like there's something there, the executive functions are what to look at.

44:55There's actually data looking at trauma where the executive functions can magnify PTSD, but PTSD doesn't magnify necessarily the executive functions. Now, how they arrived at that, I'd have to go through the paper again, and I can provide the reference if anybody wants it. Also, the granular review of symptoms, like somebody with OCD, and I've had this presentation, somebody has OCD and they described being distracted. But what was really distracting was the internal obsessions, the intrusive thoughts. When they weren't activated and they were alone in their room, they could focus on their homework.

45:32It's only when they had a bad thought, like whatever that would be. I could yell out a string of expletives right now, so I have to do my mental ritual, then not do that. Whatever it was, that was the only distraction. So it was distracting, or they'd look up and the clock would say what they would view it as a bad number. So they would have to do some sort of neutralizing ritual. But outside of that, now that could exist with, okay, yes, I do that. But then I don't write down my assignments. I have a hard time getting started on things, not because of my rituals or anything like that, or my trauma reaction, but because I think this is ADHD.

46:10So that goes down to the last line. Also, if you're a clinician, ask your clients, Does this feel more like your trauma reaction or does this seem more like an ADHD issue? And you don't want to totally rely on that. Oh, how did you arrive at your diagnosis, Dr. Ramsey? Well, they said so. No, that's not sufficient. But in addition to everything else, it can help tease apart what's making the contribution and what's additive. And also with episodic mood issues like with bipolar spectrum and whatnot, did executive functioning difficulties persist in the interims? Now, be mindful of Maggie Sibley with the MTA study where she found even though there was 91 persistence of the kids with ADHD to adulthood, there was an undulating course where every other year they had thorough evaluations.

46:56And sometimes they were subthreshold, not meeting the full diagnosis, but maybe two years later they were. So ADHD isn't environmentally caused for the most part, but it is environmentally bound. So it is affected by context. So I hope you took your Dramamine before, but we are done and I'm pretty easy to find. But now we're going to take all the questions for things that I didn't cover. So I'm battening down the hatches and let me have it. Dr. Ramsey, thank you so much. You covered a great deal of ground. We do have some follow-up questions. Before we launch into Q &A, I want to quickly thank Inflow again for sponsoring today's webinar.

47:39Yeah, a common question that we got on the lines of anxiety and stress. People wanting to know to what degree, like what do we know about the role of stress in exacerbation of ADHD symptoms? And how can that be fairly evaluated in a clinical environment? um you know for the most part it's going to be a good clinical interview and even i'll also draw on the high achieving because even if somebody comes in high achieving i want to hear how they've achieved it they could be valid victorian of the school but did they sacrifice sleep to keep up with things did they cheat did a boyfriend girlfriend help them with homework how did they achieve it or was it like they were kicking up their legs oh i'm just i'm just killing time until college.

48:32You know, that would be different. But usually there's some sort of behind the scenes parents sitting with them to make sure they got their homework done. You know, cases where somebody, you know, the parents have to sleep and go to work too. So they might have finished up the assignment. Oh, let me just type that last paragraph for you. So that's behind the scenes. How did they achieve it? What were the compensatory mechanisms individually or otherwise? And ADHD, the stress and anxiety, it's sort of like flipping it around to see whether ADHD is actually causing the anxiety and stress because, you know, I, you know, ADHD, one of the things about anxiety, in addition to perception of risk, it's the intolerance of uncertainty.

49:13Am I going to pass the test, even though I studied really hard? Am I going to get the job? Am I going to whatever? And ADHD is an anxiety generator because I did well on the last test, but will I study enough and how will I do this test? Or I had a great day yesterday, but will I be able to replicated even near so today. So that's why anxiety is the number one coexisting factor. And also, I don't have data on this, but there's this kindling where it takes a little more anxiety to get started earlier. So that might be in grade school, then middle school requires more, high school requires more, then all of a sudden it's like college and you go, I missed the midterm or I missed the assignment.

49:51Now I have to drop the class. The anxiety is not enough anymore to even get started because it just ramps up. And then depression can come around because depression is associated with a sense of loss. And now it's like, maybe I'm not college material or maybe I faked it all the way through or whatever. So now these are just, these are my little narratives. It could be that somebody is highly anxious. They get really stressed by things and that causes the difficulties. But very often, like along the way for some of the roles where ADHD interferes with, like some anxiety with students, It's moderate, mild levels is motivational.

50:29So I want to do well on the SATs or whatever the case may be. And it actually helps. So there might be anxiety there, but it's more about, am I getting an A or things like that? So now some of these examples may not be perfect, but you can get the sense where a lot of times looking at ADHD, how somebody is doing it, the inefficiencies and the compensatory mechanisms behind them that is allowing them, you know, to achieve and, you know, just anxious usually isn't just anxious. It could be, but very often it's, you know, other difficulties outside of, you know, the coping difficulties, the performance difficulties, you know, I'm not keeping up with scores coming at the cost of other parts of my life.

51:12Right. Yes, it's that just anxious part. I think that it's a lot of people are running into providers who don't recognize, as you said, how anxious making living with ADHD. I should have put this on the list of things that you can do beforehand. Get a copy of the World Health Organization ASRS and complete it and hand it. I mean, a good faith completion of it and hand it to your provider to say this is a reputable screening tool. It's a screening tool. It casts a wide net, but it also, it forces, in a collaborative, nice way, it provides more data about these are the things I'm also dealing with.

51:56Yes, I'm anxious, but these are some things maybe driving the anxiety. And at least, you know, it's a way to self-advocate. mm-hmm um and we did I'll read just a few of them the comments that we received from people who um who have had dismissive conversations with health care providers someone said um their doctor said you're just a busy mother another said oh you're too high functioning whatever that means. And another heard, you seem very calm and you can finish things. So these are all, by the way, women who wrote in. So I just wanted to give voice to that.

52:46Yeah, that's like you're on time for your appointment. You can't have ADHD, but yeah. Right, right. I mean, I will jump in and say you're calm and you get things done. I have done evaluations where I'm sitting across from the person and like they came in because everybody around them said, you seem really ADHD and they were high energy. Do you talk fast? Things like that. But when we got into it and how they handled things, they had peace of mind, they balanced everything. And they were just pretty much enough. People are telling me this. I figured I'd get it checked out. And I said, I can't call you disordered because you're meeting deadlines.

53:19It's not sacrificing everything else. You're working out. You're doing everything you want to do, these things happen. Or if it's a clear case of something else, some sort of anxiety or whatnot, in the absence of the executive function, or it's tied into, well, it was after my divorce, or somebody, a student usually struggles the first semester, the first marking period of school, but always bounces back and does well and does other things where there might be this adjustment issue where it's you know something new it takes their a while to get their head around it now also if somebody with adhd describes that which they can you know it's like how do they is it that the parents are starting to sit with them and these are loving parents trying to be helpful and it's you know their body doubling um so there could be things that go away in college then all of a sudden college is you know more of a struggle because what's my line about like kids with ADHD going away to college.

54:16It's the closest thing to the witness relocation program a law-abiding citizen's ever gonna face, probably. And just losing all the supports that helped them get through to college and they deserve to be there. But now you have to perform, you have to do college. Right, self-advocate. And I wanted to take a moment just to mention because we got a lot of questions about facets of your talk. And I wanted to let everyone know Attitude has whole webinars, hour-long webinars on some of these topics. So for example, the newest research on the safety of stimulant use for adults, we have, that is podcast number 588.

55:06You can search for that and listen to a whole hour, as well as perimenopause in women with ADHD, understanding the signs and differentiating them from perimenopause without ADHD, podcast 607. Also, is it ADHD or dementia? Another hour, number 612. So these were all touched on today and there's no way that we could go in depth on all of them. So I wanted to give people those resources. But I wonder, Dr. Ramsey, if you can talk a little bit about the role of trauma. A lot of people wondering about PTSD, complex PTSD, and how to piece apart. We know that trauma, as you said, like the incidence of accidents are more common with people with ADHD.

56:09Trauma is associated with that. It's a chicken and egg. and how do you know and does it, you know, how does it play into the evaluation process? You know what, that was something when I was at Penn and I still do it now, just because we'd have not a lot, like not like, oh, 20%, but often enough people are disclosing first time their childhood trauma. And it was like, we asked about trauma several times and teased that apart. Now I would say for brevity with a limited time we have, um that's where i i would say and i'm biased but this is what i do i add like an executive function questionnaire you know self-report questionnaire in my evaluation um and observer report if we can get it and looking at because and this goes back to asking the clients this is probably like that and ocd were to what that came up a lot um like asking like you know you know outside of when you're triggered whatever that looks like and it can be quite you know it can be complex and over time but asking people you know again like be it oh i happened to see the perpetrator i met that yeah they were at a family function i wasn't expecting to see them but other times where they're safe and outside of that and again you know not dismissing complex where it can follow you, for lack of a better phrase.

57:35But the times where it might be something that somebody with ADHD struggles with, working on a report, getting started on stuff, studying other roles, self-care. And this can bundle in with some of the trauma, the psychological trauma effects, in addition to the core trauma symptoms. But engaging in a discussion like how much of that it was about like the the trigger this and this is like this 85 and maybe even lowering it for trauma but well two things one the the onset if adhd was there first and then you know later on the trauma because that happened there was somebody i saw the trauma was at 23 she clearly had adhd before but she was the only survivor of a car shooting um and things so it's pretty clear difference and a lot of times you can that can work but the early childhood trauma is tougher but asking about how much of this seems to be associated with that trauma and how, and sometimes it's all about the trauma and it's not really an executive functioning or things.

58:39And it doesn't diminish the importance of it, but you know, other times it can be, well, this happened then, but that didn't affect, you know, how I did in a class because I would get distracted or other things and they can differentiate. So that's, that's like engaging the discussion and the person might go, I don't know. It all happens at once and we do the best we can. I wish I could have a better answer than that. But it's a tough diagnosis to make in both of them. And it can be the trauma can cause attention and memory problems, but usually not as widespread. And again, I keep going back to the executive functions.

59:16And again, also the thing with ADHD, it's more the attention allocation and being able to get back on track after a distraction. Because another one of these nonspecific things is, you know, people will get distracted off a task, but individuals without ADHD are better able to shift back on task than adults with ADHD. Whereas some of the trauma inattention, for lack of a better phrase, might have just different flavor. I wish I could do a better description than that. Well, this is why it has taken the American Professional Society for ADHD and related disorders known as APSARD has been working for a few years now on the first set of formal guidelines for the diagnosis and treatment of ADHD in adults.

1:00:05I know Dr. Ramsey, you contributed on a few different facets of that. We are expecting the guidelines, I will say, within the next year, we hope sooner. But for those of you who are wondering, like, are there formal guidelines for this? This seems, given what you said, Dr. Ramsey, about ADHD being the second most prevalent diagnosis. That's what the data say. That's what the data say, yes. Right, right. So yes, the data say that. So I did want to mention that we are waiting with bated breath and it has taken so long because it is so complex. And so you have covered this very complex topic very well today.

1:00:49We appreciate this view, your expertise, and all of the nuances that you touched on today in your presentation. Thank you so much for doing this for the Attitude community. You're welcome. And thanks, everyone, who also joined us today. We had a lot of great questions. If yours wasn't answered, please know that we do read all of them, and we try as much as possible to share them with our team of experts for the magazine's advisor column and elsewhere. Also, I mentioned at the beginning our ADHD and inflammatory disorders survey. You can click or scan the QR code here to take that and know that today's event resources will be available with searching podcast 617 on the Attitude website.

1:01:44Slides and recording will be available a few hours after the live event. So we hope to see you there. And for more events in the future, thank you again, Dr. Ramsey. And then we hope everyone has a great. For more Attitude podcast and information on living well with attention deficit, visit attitudemag.com. That's A-D-D-I-T-U-D-E-M-A-G.com.

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