PODCAST. ADHD Diagnosis Red Flags, Gender Differences, and the Hormonal Link with Dr. Maggie Sibley, PhD.

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Have you ever wondered why some people thrive in high-stress environments while others feel completely overwhelmed? Or why an ADHD diagnosis can feel like solving a lifelong puzzle, especially for women?

In our latest episode, Dave sits down with Dr. Maggie Sibley, a Professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital. She has authored over 130 scholarly publications on ADHD with research funded by the National Institute of Mental Health and the Institute of Education Sciences.

Sibley is a Professional Advisory Board Member for Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD) and Chair for the forthcoming APSARD Adult ADHD Diagnostic Guidelines coming out later this year. She is the author of Parent-Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation.

Whether you are navigating your own diagnosis, supporting a loved one, or working as a healthcare provider, this conversation offers a masterclass in modern neurodivergence.

1. The Shifting Mask of ADHD Across Lifespan and Gender

Statistically, boys are diagnosed with combined-type ADHD far more often than girls—but Dr. Sibley questions whether this data reflects reality or just a gap in the diagnostic checklists. While hyperactivity in boys might look like running around a classroom, in women and girls, it often manifests internally as:

• Mental restlessness and an urge to constantly switch jobs.

• Impulsive behaviors like compulsive shopping.

Furthermore, while scientific data suggests that the literal severity of core symptoms may decline as we age, the real-world impairment often goes up. As adult life demands more accountability—marriage, parenting, career management—the cognitive resources required to keep up become a major bottleneck.

2. The Hormonal Wildcard: The Estrogen-Dopamine Link

One of the most fascinating revelations in this episode is how aging affects men and women with ADHD differently. While cognitive decline in aging men correlates directly with chronological age, in women, it correlates heavily with hormone levels.

Estrogen acts as a key neuromodulator in the brain, directly influencing dopamine availability. When estrogen levels drop during the menstrual cycle, perimenopause, or menopause, women with ADHD experience a "double whammy"—their already strained dopamine receptors face an even steeper decline in available neurochemicals, leading to severe brain fog and sudden executive dysfunction.

3. The Environmental "Sweet Spot" (The U-Shaped Curve)

Dr. Sibley introduces a brilliant framing for environmental design: The Environmental U-Shaped Curve.

• Too much demand/chaos: The ADHD brain becomes cognitively overburdened and completely dysregulated.

• Too little demand/complete freedom: The brain slips into a total slump of a-motivation, leaving you stuck on the couch and unable to activate.

The secret to thriving with ADHD is designing an environment that hits the absolute sweet spot: just enough structure to keep you accountable, paired with enough novelty and genuine interest to keep you moving.

4. Writing the New Rules: The APSARD Task Force

Right now, Dr. Sibley is leading a vital national task force for the American Professional Society of ADHD and Related Disorders (APSARD) to write the first official U-S adult ADHD diagnostic and treatment guidelines.

While the DSM provides the what of symptoms, clinicians desperately need a standardized how. The market boom of post-2020 telehealth and online startups has led to dangerous diagnostic shortcuts. Dr. Sibley outlines how the upcoming guidelines will help protect patients from misdiagnosis and empower local primary care physicians to provide thorough, affordable, and accurate care.

🚩 Diagnostic Red Flags to Watch Out For

If you are seeking a professional evaluation, keep an eye out for these clinical warning signs mentioned in the interview:

• The 30-Minute Window: If a practitioner evaluates you in under 30 minutes and hands you a prescription, walk away. Real adult diagnosis requires careful, longitudinal due diligence to rule out mimics like clinical depression or thyroid disorders.

• The Interrogation Dynamic: A good clinician should be open, curious, and collaborative. If you feel like you are being interrogated or dismissed because you are "too successful" in your career, seek a second opinion.

• Siloed Reporting: Accurate diagnosis shouldn't rely solely on your own memory. Trusted evaluations bring in outside perspectives—like report cards, partners, or parents—to paint a full picture of your cognitive history.

Why You Need to Listen to This Episode

If you’ve ever felt like your productivity systems work beautifully for two weeks and then suddenly "expire," or if you're trying to figure out why your focus seems to vanish during certain times of the month, you cannot afford to miss this conversation. Dr. Sibley injects rigorous science into topics that are all too often oversimplified in 30-second social media videos, providing actionable clarity on how to truly set yourself up for success.

Connect with the Expert

Want to learn more or get involved in cutting-edge neurodivergent research? Dr. Sibley’s team runs an active research participant pool where adults with ADHD can share their lived experiences and test experimental treatments. Visit MargaretSibley.com to sign up or get in touch.

• Transcript

  00:00:00 Maggie: My name is Maggie Sibley. I am a clinical psychologist in Seattle, Washington. I'm a faculty member at the University of Washington School of Medicine. I do some clinical work at Seattle Children's Hospital, and I do a lot of advocacy work in the ADHD space as well. I'm involved in, um, helping advise different organizations on their policies and their, um, activities related to ADHD. So kind of pop around the ADHD space. I've been doing this line of work for about twenty years. So ever since I got out of grad school, this has kind of been the space that I've been really at home in and I've been enjoying it.

  00:00:39 Dave: What made ADHD a topic of interest for you?

  00:00:44 Maggie: I went to grad school with this interest in mental health that came from having several family members with mental health issues, that I felt the impact of their experiences, but I didn't have a sense of like, if there would be any specialty area for me. But when I got to grad school, the first placement I was put in was helping out in an after school program with a bunch of middle school boys who had ADHD, and I had the most fun with them. I think of any clinical experience I ever had, and I realized that this is such an under-recognized group of folks where all you ever heard was how people with ADHD bother others, and yet there was so much joy and like promise and potential in these kids. And I just saw this like path that like, there's so much work to be done to sort of like clarify what ADHD is and help people with ADHD walk through the world, that it just felt like a calling to me that, you know, I always say ADHD kind of found me and I, and I've just really enjoyed the work ever since.

  00:01:50 Dave: That's great. Yeah, I love that. And, you know, I was one of those boys, my understanding too. And you can correct me where I'm wrong, but, like, uh, boys tend to be more of the predominantly hyperactive, impulsive presentation, and girls tend to be more the inattentive presentation, typically. Is that correct?

  00:02:13 Maggie: Statistically that's correct. I question whether it's actually correct, because I think manifestations of hyperactivity and impulsivity are happening in girls and women, but they look different. And so they don't always get checked off on a checklist. But if you get to know women with ADHD, a lot of them will talk about prominent mental restlessness and feeling like they want to switch jobs a lot, or things like impulsive shopping. And so it may be that we just don't notice the manifestations of those symptoms. But if you looked at like epidemiological data, yes, more boys get diagnosed with the mostly the combined type than girls and women would. Yeah.

  00:02:56 Dave: Yeah. Do you and do you find that like, as we age, we get we all tend or not everyone but people. Of course, ADHD is different in different people. And I always like making sure people understand that. Um, but of course it is an acronym too. do you find that as adults with ADHD mature or as children mature into adults? they become more combined. Is that correct in their maturity as they learn, like, obviously you don't have a man or a woman for that matter, running around the office like a like a little hyperactive kid might in class, in school. So you learn these coping mechanisms and ways to slow yourself down, assuming you're not diagnosed, of course, with no information. what are your thoughts on that?

  00:03:46 Maggie: Have you so if you again, like there's one story that's told by all of the scientific data that we have, and then there might be like another story told by the people living with ADHD. So the scientific data suggests that, um, the severity of ADHD symptoms seems to go down as people age. Um, and the idea that we like kind of have lived under the umbrella of, for what decades is that people grow out of their ADHD. But, um, at the same time, there's also scientific data that suggests that the impairments or the functional difficulties people have in their life related to ADHD goes up as people grow older because life gets more demanding. You get married, you have kids you have to suddenly be accountable to more than just yourself. And so we see that kind of like differentiation there. Um, we see that as people, I think as cognition develops and matures in general, like as people move through their twenties, there may be a greater being able to self manage and being on top of yourself because your brain is just sort of like, you know, at its peak, probably in its thirties, whether you have ADHD or not. Right. So you may have more cognitive resources during that time to sort of like help yourself. But then as people get older, obviously, no matter if you have ADHD or not, your cognition is going to be impacted by getting older. And so you kind of see on IQ tests to like people peak and then they sort of decline a little bit. So interestingly, like with men, you see that decline correlate with age more, but with women, you actually see it correlate more with hormone levels than age itself. And so there is sort of like possibly sex differences in the way that people's ADHD symptoms may change in ebb and flow as they, you know, get older. And then, um, you hit this peak where their cognition should be at its best and then start to lose slowly, like some of those cognitive, uh, like resources, I suppose.

  00:05:48 Dave: And is it right that the prefrontal cortex has roughly a three year delay in development for ADHD ers. Is there truth to that?

  00:05:56 Maggie: Yeah. There's some evidence to suggest that it's really based on some studies that were done as people moved from childhood to adolescence. So whether you can like extrapolate that to a permanent three year delay, you know, in terms of entire life that I think that's a little unknown. But but I don't think that's a harmful concept to sort of endorse that. Like, it may be the case that if you have sort of like a slower pace of brain development, then it's not that you won't get there eventually. It's that, you know, you're sort of getting there more slowly. And since I work a lot with this sort of like high school to, uh, young adult crowd, and I work a lot with their, um, nervous parents, you know, I think that's a really helpful sort of framing to tell folks is like, just because somebody is really struggling now, it doesn't mean that in a few years when they just sort of have matured a little bit more cognitively, that they can't kind of like be in a much better place. So not to fret over somebody's current, um, like functioning because we do know that ADHD waxes and wanes and there's all kinds of factors that really impact that.

  00:07:00 Dave: What are some of the factors that, affect ADHD that you found?

  00:07:05 Maggie: We've been doing research on this more recently because it's, I think, kind of an interesting topic. It's also really hard to study this, um, like in a, in a really like solid research design way. Um, but I've been fortunate to be an investigator on some of these big longitudinal studies where they like, identify kids when they're in childhood with ADHD and follow them at least into sort of like their through their twenties. And then some of that work we're finding that, um, there may be this kind of interesting U-shaped curve between the environment and, um, a person's ADHD severity. We've heard about U-shaped curves before, often in the context of anxiety, right? So like, um, it's good to be a little bit scared because that keeps you safe, right? But if you're way too scared, you're going to have some problems, like, you know, trusting yourself and going forward and doing things in life. Well, there might be something similar going on with ADHD, um, and the environment. So a lot of times we talk about the demands of the environment or the structure of the environment and needing to hit like a sweet spot for people with ADHD. Um, and we've been doing a lot of interviews with folks where we learn that, like if there's way too much going on, you can get cognitively overburdened, overwhelmed and just feel like you can't function and just feel dysregulated all the time. And that's not good. But if you find yourself in a state where you don't have a lot, um, that you're accountable to, or you don't have a lot of demands on you, that may be not good either because you may find yourself sort of like slipping into like a slump of a motivation and sort of sitting on the couch and not being able to get yourself up and activating and doing things. So I think one of the pieces here for people with ADHD is sort of designing their optimal environment where they can feel like, you know, it's not too demanding, but there's stuff that kind of like interests me, excites me, and gets me moving and engaging, um, every day. So we've been looking a lot about environmental features. Um, in women. There's a lot of work going on right now understanding the impact of hormones on the waxing and waning of ADHD, which I think is really interesting as well. Um, and then other things in people's lives, for example, um, substances, even just talking about things like caffeine and nicotine, we don't even need to be talking about like illicit drugs. Um, you know, how people find ways to optimize and cope and self-regulate with exercise? Um, just like the little things that you figure out how to put in your day to kind of keep yourself at this, like equilibrium.

  00:09:45 Dave: I've joked before that, like, I want to become hyper focused on exercise. How do I do that? You know what I mean? I have learned that, you know, and I do it most days where I go for like a three mile walk in the mornings just to plan my day, clear my head, listen to a podcast, talk to myself, whatever it is. and I know there's evidence that exercise, you know, is especially helpful for ADHD or obviously it's helpful for everybody. so that's a given, but I think it does help kind of clear the cobwebs in the morning. And also this feeling of success kicking off the day that you've already succeeded in doing that walk that maybe you didn't feel like doing, but you got your shoes on and you went out and you did it. It is a good way, like from a positive mindset way of, of starting the day with a success. what are some tips in helping folks, you know, adjust or update or, fix their environments in a sense, whether it's a home office like I have, whether it's, an office office, like so many people do have or dorm rooms for college kids.

  00:10:50 Maggie: Yeah. I think if you zoom out, the most important thing is to have a trial and error mindset. So you could read all of the tips and tricks out there, but only some of them are going to work for you and everyone's different. So it's really just like about, um, coming into it like a detective on yourself and sort of not getting demoralized. If something you thought was going to work is hard to stick with. And it's a journey of sort of like figuring out what features or what, um, structural aspects of your environment, like help you do your best. And for some people it's novelty. And so they need to learn to mix things up, you know? And for some people, it's routine. They just like to have everything the same way and less to think about, you know, just wear the same red shirt every day. If that's what makes you feel like, you know, you can just sort of like be automatic with things and getting to know yourself because people aren't just ADHD, people are ADHD plus all their personality traits. And so really kind of understanding the interaction between your ADHD and who you are. I think you that self knowledge, that self-awareness, um, you know, I think can put people at ease and just sort of help them just sort of neutrally as they move through the years of their life, learn more and more about themselves and what works. Um, and just because, you know, something that someone says should work for you doesn't, doesn't mean that there's anything wrong with you also.

  00:12:06 Dave: Great point. Yeah. And there is this curse. I find one of the biggest or not, I mean, not compared to, anxiety and depression and addiction and these really negative comorbidities that can come along for the ride. but also a challenge at least for me and I hear this from others is, this curse of novelty where you find the system, you find the way to do something that works. and then for some reason your brain's like, yeah, I don't like that anymore. And suddenly it's like, damn it, it was working so well. Mhm. It's this curse. It's like, ah, man. So now you got to find the analog way to do it, or the digital way to do it or some other method. Yeah. Yeah. Um, you're working currently on, the American Professional Society of ADHD and Related Disorders observed as the kids say.

  00:13:00 Maggie: Good work.

  00:13:01 Dave: Hashtag apps. Ah. tell me like, because obviously there's the DSM, you know, the, the Bible for, for mental health professionals. How does. Is this related to the DSM? Tell me how this all connects or does it.

  00:13:19 Maggie: Yeah. So I am one of the sort of leaders of a task force that is writing adult ADHD diagnostic and treatment guidelines for the US. Um, so basically every developed major country or region, at least in the world, has guidelines of how practitioners should diagnose and treat ADHD. Um, and it's important for us to have guidelines because the, the care of ADHD is really under the purview of many types of practitioners. And, um, because we've had such a huge demand for ADHD care in the US since basically twenty twenty, a lot of new professionals that didn't necessarily specialize in ADHD when they got their training and in the first part of their career are kind of being forced into the fold to make sure there's enough people to take on this demand for services. And so we're at this point where the, um, there's a lot of diversity in terms of what practitioners are doing to diagnose and treat ADHD. And some of them may be using well-established trustworthy practices and some may not be. And so even though there is a DSM that anyone can go read, for example, how do you diagnose ADHD? The DSM is really the what. But there you really also need guidance on the how. And in ADHD, um, there is a lot of complexity to how you gather trustworthy, good information about a person's symptom level, about their history, about how those symptoms have changed over time, about the way those symptoms interfere with their life. Also about, um, pitting the possibility of ADHD against alternatives that could also explain somebody's symptoms, because there's a lot of overlap between ADHD symptoms and other things. And if we accidentally assume ADHD, we may give someone the wrong treatment, for example. Yeah. So we we know there's a high demand among practitioners for just like more detailed information on exactly how you make good inferences, collect good information, and feel more confident in the diagnoses that you're making. So. Yeah. That it's, you know, we can't rewrite the DSM. Unfortunately, we don't have the authority to. But we're going to do our best to say if this is the the book, the document we have right now, what's the best way to basically use it and interpret it for practitioners?

  00:15:51 Dave: And when is this document being released or or published?

  00:15:55 Maggie: It doesn't have a release date yet. Um, a lot of it is contingent upon external folks. So we've had like three rounds of review where we send it to either organizations or people for review. And so, um, once we get that back from everyone and integrate their feedback, like we're in kind of the final stage of release for it. So I think the hope is that we'll see it by the end of twenty twenty six, but I think the exact month and date is not yet, um, confirmed.

  00:16:23 Dave: So yeah. That's great.

  00:16:25 Maggie: Yeah. It's good. Um, you know, I'm not allowed to disclose its contents per se, but I can say a few things about it. I mean, we're really, um, going through and trying to look at a couple perspectives, like scientifically. Um, we do have studies that show us, um, which methods of diagnosing ADHD seem to pick up on the right people versus false positives versus missing people. And so we can kind of collect all that science information and put it together, collate it. It's a lot of stuff. And not everyone always looks at all of it all together. So that's one helpful piece of Of information. We also have like basically a panel of clinicians from different professions who can fill in the gaps with their own like experiences for decades, treating and working with people with ADHD and sharing also from their perspective, what works. And then we also have sort of like this third piece where we're going to, um, advocacy organizations, like people may have heard of Chadd or Adda, um, and asking them to share it with their kind of like community to give feedback as well on whether or not what we're coming up with feels comfortable to like, from like a patient's perspective or a person with ADHD perspective.

  00:17:40 Dave: And is the guidelines mainly for the diagnosis and treatment or just the diagnosis?

  00:17:48 Maggie: Well, I'm chairing the diagnosis section. There are two other sections. There's one on pharmacological treatment, and then there's one on non-pharmacological supports or treatments as well. And so.

  00:18:01 Dave: And.

  00:18:02 Maggie: Yeah, exactly. So the three groups kind of like are working sort of separate from each other, but there's like an overall steering committee that looks at all of their work and makes sure it integrates well, etc..

  00:18:13 Dave: So I know you can't, you can't speak too much about what's in there right now. My understanding at least, is that, well, first of all, I mean, there's so many things I've learned that like, that women typically have about a five year delay in being diagnosed versus men. what are your thoughts on all that?

  00:18:30 Maggie: Yeah. So I think, um, it's what you said is one hundred percent true, but I think it's not, um, um, like a monolithic explanation for what has happened with women. I think the other important thing to remember is that girls may have ADHD symptoms that are partially undetected because they aren't causing them any impairment until they're older. And we do diagnose based on impairment. Even if we have a girl that we have a watch on because she seems a little inattentive. If she's got friends, if she's getting along well at home, if she's getting her responsibilities done, and if her grades are decent, like, um, we wouldn't I at least I wouldn't advocate for diagnosing that person with ADHD because that would lead, I think, to over pathologizing a person who is doing okay in their life. It doesn't mean we're not going to put a watch on that kid. Yeah. So I think a lot of times the part of the reason girls get diagnosed later is because they actually there, there have been genetic studies that even find that there are protective effects of the female sex on the expression of ADHD, genetic risk. So they just may not express it a little bit until later. But there are also girls who are not noticed, and that's very valid. The other piece is that I think is probably even more important here. Um, there is a generation of adult psychiatrists that were trained to think that ADHD is something that you grow out of when you're eighteen, and that that diagnosis is not under their purview. And that generation, you know, I would say as recently as ten years ago and even still today, that is being perpetuated in training programs for people studying adult psychiatry, adult clinical psychology, kind of our front line mental health diagnosticians. And so they aren't even looking for ADHD in anyone over eighteen. They're not screening for it. They, they don't think about those symptoms as being ADHD. And so that is for, from my perspective, a huge issue of just understanding how we can integrate education on adult ADHD into these adult training programs. Um, because the only people who really specialize in adult ADHD these days are, I'd say ninety percent of them had child adolescent training. That's how they got into ADHD. And then they realized, oh, this is also going on in adults and I'm inspired to help there, but you don't see a lot of the other way around. And so, um, that's where all these anxiety and depression diagnoses come in is that if you're nineteen, twenty year old woman experiencing maladjustment in college as everything is chaos, you know, for a lot of young adults with ADHD and you go to an adult psychologist that's a couple blocks down from your college dorm, and you endorse general kind of a little bit of anxiety, a little bit of depression, you know, some ADHD symptoms, you'll probably get put on an SSRI, put out the door. And unless you stumble upon an ADHD specialist, that may be what happens to you for ten years or so.

  00:21:35 Dave: I know with women with ADHD, my understanding is it's more certainly from the listeners of this show to there's more, many more women being diagnosed now over men. And I think my understanding at least is because ADHD is and correct me, where I'm wrong is highly heritable, like extremely heritable, chances are. they learn as their child is is diagnosed. And as they start to learn about ADHD, they realize like, oh wait, I have ADHD too. I or my husband does or partner. is that accurate? Yeah.

  00:22:10 Maggie: You've heard I've been seeing that the entire time I've been practicing. So for about like twenty years or so, I've been seeing that. Um, and I think the other one that we're seeing more of more recently is that people are seeing things on social media that's relatable. And they're saying, whoa, that sounds a lot like me or that sounds a lot like my partner. Yeah. Um, and, you know, I've, I've met with many people who say that their partner showed them a TikTok video and they were kind of like, whoa. Okay. So I think that right now, I think those are the two that like kind of big aha moments that we're seeing people have where they self recognize in themselves. And that may be people who've never had any contact with the mental health system. Um, because they've always just kind of been just a little, they've had it together enough that it hasn't, you know, brought them in the door to get any help.

  00:23:00 Dave: A topic that comes up from time to time. And I really know nothing or very little about menopause for obvious reasons, being male and not a doctor. What do you know as far as ADHD symptoms and its connection to perimenopause and menopause?

  00:23:15 Maggie: So this relates to the idea earlier of like the cognitive resources of people, um, waning as they age or in the case of women, um, you know, as your hormone levels deplete, um, as you go through that hormonal transition. Um, estrogen in particular is a neuromodulator. And so it does have an impact on dopamine levels in the brain. And so there is sort of like a direct link between levels of estrogen or, um, you know, I'm not an endocrinologist, but as I understand it, the ratio between estrogen and progesterone also is part of this. Um, and the level of dopamine available in the neurochemical environment of the brain. So, And that you also see that in the menstrual cycle too. So you can see it earlier too. And so with that relationship, um, obviously, I think the, the severity of people's cognitive symptoms can be exacerbated by having that double whammy. Um, you also see that women without ADHD experience cognitive impacts of going through that hormonal transition as well. And some of the same areas of the brain that ADHD impacts. And so that's often a very tricky differential diagnosis for clinicians is if you have like a forty five year old woman coming in saying, like, things have gotten worse for me, I'm feeling this way. And you have to figure out like, is there a developmental history? There have some has at least some of that system symptom cluster been present kind of all along the way? And it takes that detective work. But yeah, it's like a double whammy, essentially.

  00:24:54 Dave: and just so I'm clear or what you're saying is that and I really don't, I my understanding, at least, is that for a year. Because for a long time I thought we lacked dopamine. But my understanding is we don't. It's the dopamine receptors who are not receiving adequate dopamine. so from what you're saying, like if with, uh, estrogen reducing the amount of dopamine, now you've got dopamine receptors who are more challenged, that doesn't mean total amateur neurologist here Now you don't have enough dopamine either. Like making it worse. Does that make any sense?

  00:25:32 Maggie: That is that is a fair thing to say. It's it's super complex. I'm not a I'm not a neurology person either. Like I understand enough of it to be a good clinician. But like, yeah, the, the, there's often, I think a tendency to oversimplify the, like the neuro cognitive, um, expressions of ADHD. And I think it's like, it's okay because like, we have to talk in simple terms in order to be able to exchange ideas without being neuroscientists. But yeah, the main thing is it's super complex. And as a result of this complexity, there are various, um, there are various things going on in the body that can impact cognition that aren't just your traditional mental health, um, diagnoses. Um, endocrine going into thyroid disorders is another big one. Um, people who have cardiovascular disease also have cognitive impacts of that. So there's all kinds of things that if you're not at, you know, ideal health that that can be impacting your cognition. And increasingly it's becoming a bigger, bigger part of sort of important differential diagnosis in adulthood, because you do want to make sure that you're understanding the source of somebody's difficulties with cognition so that you can get the right treatment.

  00:26:44 Dave: Yeah, yeah, yeah, that makes complete sense. And I think that's part of the reason my understanding at least is part of the, the diagnostics is looking back at their childhood and life. And yes, you know, challenges ebb and flow, certainly for everybody. But, you know, if the red flags were there, like, thank God my mom kept all my old report cards, which are hilarious to read the comments. And I have a lot of apology letters to send. Probably, um, my teachers are still around. so I often tell people that if you are going to go see your doctor because you feel like you might have ADHD, a really great first question is if before even stating this is to ask what their views are or thoughts about ADHD. Um, so that way if they say, oh, you grow out of it or it's not real or blah blah, or it's overdiagnosed or whatever, those are all red flags to say like, okay, it's time to find a new doctor because they also may not believe in cancer, um, or whatever. So I think that advice stands. And from what I've heard from other guests as well, I'm curious, unless I'm wrong on that one, feel free to chime in. But I'm curious what are what are some good or bad? What are some red flags that a person can look for? to protect people from a misdiagnosis or a misdiagnosis. Uh, what are some red flags that you could, uh, talk about that a person going to see their doctor about this could ask

  00:28:19 Maggie: Yeah, I love your question. I think that that's a great one. People should do that. Um, another question you can ask is what, you know, if they are comfortable, um, evaluating someone for ADHD in adulthood that's never been diagnosed before. What is their process of evaluation look like? If anyone is going to evaluate you in less than thirty minutes and give you a diagnosis. That's a red flag because at least for adults, nine times out of ten, you need to do more due diligence and learn more about a person before you can draw any conclusions. I'm not going to say one out of ten times. There's not this person who comes in and they're so textbook that like, that's fine, we got this figured out, but people are complex. And if you made it that long without being diagnosed, you're probably not that clear cut. So, you know, I think that's important that they take their time with you. Um, a good diagnosis also involves asking your loved ones to share about you as well. It doesn't mean that we don't trust you, that we don't think you're able to tell about yourself. But it doesn't matter if you have ADHD or not. There's a view you have of yourself and there's a view other people have of you and you put the two together. You get the best sense of a person. And so it really does help to see the things that people notice about you that maybe you don't notice about yourself, that can put together the picture. So I think that, you know, that they're being thorough is important. I think that, um, in general, I like to ask people how they came to think that they have ADHD, you know, because I think that's really important from a clinician's perspective. So I would say like, if you don't feel like the clinician is, you know, engaging in a meaningful conversation with you that's curious and interested in, you know, where you came to like get that conclusion from. And instead they seem to be interrogating you about it. That is a huge red flag as well. Like, yeah, I, I've definitely worked with clinicians that are sort of like, well, that person's like a really successful, um, like investment banker. Like, why would they have ADHD? Like you don't want to work with someone like that, right? So just like, look for those kinds of just like implicit red flags as well.

  00:30:36 Dave: So just repeating what you said, like really in that initial consultation with a care provider, first of all, like I said, like asking what their views are about ADHD even before saying, like, I think I have ADHD, but hey, hey, I read an article about ADHD. What are your thoughts about that? Just to see what they say. I also always add that they may refer to it as add, and that just means they're more old school.

  00:31:01 Maggie: that doesn't turn me off. It is, you know, some specialists in ADHD still call it that, but they know what they're doing.

  00:31:06 Dave: Yeah, yeah, yeah. It's just the name change, which is really annoying. And to keep people confused because I hear, I hear from people like just saying like, oh, I think I, I think I might have ADHD, I don't have ADHD because I'm not hyperactive and I'm like, oh, that's so like science people. Come on.

  00:31:23 Maggie: It's so nice.

  00:31:23 Dave: We can communicate better here. Um, but yeah, so asking those questions and then, as you said, like, if they're rushing you through a thirty minute process, you know that's a red flag. And then also, if they're not, finding more about you and your past. I don't even know the answer to this. So I'm curious, like, who can, who can diagnose you? Is it your, it's your, your GP, maybe you're like your family doctor, right? Um, psychologist, psychiatrist, nurse practitioner, am I.

  00:31:55 Maggie: I mean, there isn't like a hard, it has to be a licensed healthcare practitioner at the very least. Okay. So that that could involve a wide range of people. Um, there isn't like this there. I don't, there aren't really turf wars about who's allowed to diagnose and who's not like, basically, you should use your own judgment. Like, ah, do you have enough competence, you know, to diagnose people? You will see, uh, that sort of like the traditional people diagnosing for many, many decades has been psychologists and psychiatrists. But as there haven't been enough of those to go around, we saw a movement into primary care, maybe the last ten, fifteen years, because often they're providing prescriptions anyways. Um, now we're seeing an even broader, broader movement into nurse practitioners, um, from MDS. Um, on the psychosocial side, we're seeing social workers, mental health counselors who've gotten enough training that they're feeling confident making those diagnoses. Um, so even people like occupational therapists may be making diagnoses. I think part of the thing is that we have to, we have to affix that diagnosis to bill for services. And so if you haven't received one previous, but you're receiving services for something that is basically ADHD, symptoms like that person's in a position where they either have to make the diagnosis to bill, or they have to ask you to get it from somewhere else. And I think increasingly, people are just feeling more comfortable making that diagnosis because there is starting to be better education on what adult ADHD looks like.

  00:33:31 Dave: You mentioned earlier about self-diagnosis or, or about people seeing stuff on TikTok. What's the stuff that you've seen that's most incorrect?

  00:33:41 Maggie: Well, first of all, as a caveat, I don't have TikTok. I don't go on TikTok, but I do like kind of see things and people.

  00:33:47 Dave: Wait, wait, you're a mental health professional and you don't have TikTok.

  00:33:49 Maggie: Yeah, I like love the idea of staying under a rock and staying off social media. But no.

  00:33:55 Dave: Like a cancer doctor, like smoking cigarettes, you know, it's like, oh my God, what is wrong? Yeah, something is wrong here. Sorry.

  00:34:01 Maggie: Totally fair. Yeah. But I think, um, well, I think the issue at hand here is that the average American on several studies has two or three symptoms of ADHD. So it's not that people are, um, producing content that's wildly inaccurate about ADHD. But for me, the biggest issue is that like, just because one symptom of ADHD is relatable does not mean you have ADHD. You have to have a robust cluster of those symptoms for most of your life that you know is debilitating. To really qualify for the diagnosis. So I think the issue with TikTok has been, um, there is a piece of ADHD that is relatable to probably everyone out there and that people are making this like inference that because this really engaging, funny, interesting content, it like hits home that like, oh no, I have ADHD. Um, I think there are some, um, mythologized symptoms of ADHD that may be true, but that just don't have scientific backing yet. And so people like me who are, you know, trusted to stay within the science, like can't go out on such a limb to say like, yes, this is definitely a symptom of ADHD or no, it's not. But it doesn't mean that a person with ADHD isn't genuinely experiencing that symptom. I just can't say for sure whether that is a core part of their ADHD or a part of their personality or a part of a comorbidity they have. And so, you know, and some examples like with that would be like rejection sensitivity. Like I think that's something that people experience. Like it also comes a lot from the social anxiety world. They, they've had that concept for a long time. And so I think like, for me, it's like, I don't know whether that is a comorbidity related to social anxiety that happens to be a version of social anxiety that a lot of people with ADHD experience, or whether that is actually a core psychological impairment of ADHD that's unrelated to having comorbid anxiety. And the reason for that is because no one's done a research study on that and that that nuance is important. Like I have a colleague who's starting to do work on that, and she's doing EEG research in the brain, right, where they're measuring electrical signals in the brain to see if the actual, um, like neural transmission that is associated with ADHD is firing differently in social paradigms that might elicit rejection sensitivity. And if the answer is yes, then it probably is part of the cause of ADHD. But if the answer is no, it's really only present in people with anxiety. Then it's just like a flavor of a co-occurring condition. Um, and so I think that's the kind of thing that TikTok can't put into like a thirty second video.

  00:36:48 Dave: Well, and also if you're getting, if you're spending time on TikTok or social media, I mean, like Jonathan Hyatt's book, you know, which is, uh, you know, the anxious generation, I think, and having, you know, a nineteen year old and a twenty year old myself, um, and also being sort of an early adopter and a lot of social before I went evil. Um, I, uh, yeah, I find that like r d I, and I know my understanding is rejection sensitivity disorder is not even part of the DSM or not in there at this point anyway, but because to your point, like it hasn't been researched enough, perhaps, but um but that is. Yeah. It's yeah. I mean, I think everybody feels our, I mean, if you're swiping for dates like R.s.d. Is going to be like the, the symptoms of rejection are, are going to be there or somebody doesn't show up for a date or you don't get the job you hope for or you're not hearing back from any jobs you're applying to now because, the HR department is using AI and the applicants are using AI. And really, we're all just hoping AI chooses us until it destroys everything. Um, but, uh, although there are, there are probably are you guys doing anything with as because I could see the, I could see that obviously there's a lot of good with AI putting away, you know, the, the ending of humanity. But putting that aside for a second and the data centers, um, it could make the case for AI where if, when you release these findings of, of helping, you know, clinicians, uh, detect or diagnose ADHD, there could be sort of a choose your own adventure for the clinician to go through each of the steps that you've created with a patient in order to then help them diagnose. Right. Does that make sense?

  00:38:39 Maggie: Like having an AI tool that helped with clinical decision making. Yeah. Yeah.

  00:38:44 Dave: I mean, I know they already exist, but yeah.

  00:38:46 Maggie: If the AI was good enough, um, in the future, that could be something to look at. I think, um, the consequences of the AI getting it wrong are very high. Yeah. And so I would see it being more of a aid than an actual decision making tool. You know, we have issues with AI hallucinating things, and we've played with AI and some of our work with ADHD. And it does. And so the issue there is, you know, I mean, think about the missed misdiagnosed woman with ADHD. Write the consequences of somebody not being able to dig deeper and understand algorithms. Somebody is probably exactly what's going to put those people at risk. So yeah, I think it could be in the future, but I would personally, um, I would be hesitant to take the human connection out of the diagnostic.

  00:39:39 Dave: Yeah.

  00:39:40 Maggie: That's for me. Like, I think when you really get to know somebody, you can see things that are unsaid sometimes and maybe AI will get that smart, but I don't think it's that smart yet.

  00:39:51 Dave: Yeah. And actually, yeah. Yeah. And just to be clear, I'm not, I'm not suggesting just using that like, like a clinician using something like that to process the information. But I suppose like I have a, uh, an ADHD assessment at y equals dot dot com on the website with full disclosure, very clearly it states that like, if you, if and it's really, it's a link to the American, uh, mental health Association's online assessment. So it's that one. I don't see the results, of course, but I always say very clearly that you can use that online assessment as a starting point. But even if it comes back and says you do not, you probably don't have ADHD and you still, I mean, you're doing the assessment for a reason. You should still speak with your healthcare provider regardless. Like, don't just take that verbatim. Right.

  00:40:40 Maggie: I agree, yeah, I.

  00:40:41 Dave: Agree, you could almost take that. But what you're cutting out the AI thing you like, you could create a tool that just is like a survey based that a clinician could use. Look at me like explaining.

  00:40:53 Maggie: Yeah, no, they, I mean, there are, they exist. Yeah.

  00:40:55 Dave: They exist.

  00:40:56 Maggie: Yeah. Yeah. And, um, you know, the big thing about diagnosing ADHD and looking for new symptoms of ADHD and how do we do a better job finding people who are usually missed is like, you have to find these symptoms that both, uh, what we call sensitivity and specificity. So what that means is that they have to both be able to ring true to people with ADHD and have most people with ADHD say yes to them. But then also you have to make sure that the rest of the world isn't also saying yes to them. So like a perfect example of this is I have trouble getting myself to do things when I really hate this task. That sounds really true for people with ADHD, right? Like that's a very core experience for them. But also seventy percent of the population says yes to that. So although it's a core experience of a person with ADHD, it's not a good diagnostic symptom because it doesn't help us tell the difference. And so we're looking for these symptoms, and we have to do a lot of mathematical analyses on different options for symptoms that are both the core experience of people with ADHD and not the core experience of the everyday person who doesn't have ADHD. And some of those can be tricky to find. And so that's why the work of like, just integrating any symptom that somebody brings up on TikTok and saying like, okay, the ADHD community feels really strongly about this. It can't just stop there because then we have to test it with different groups of people. And it's not just testing it with the general population, you've got to test it with the people who often mimic ADHD. So like, for example, there are studies where they test these candidate symptoms against people who have other prominent impulsivity, like people with gambling disorder or borderline personality disorder, or they test it with people who have high depression. And if they can differentiate, those are the real clinical dilemmas that we are faced with, like, oh, is this person just depressed or do they have ADHD? Like if it can differentiate those people, those are strong symptoms. So there is like, as much as I like am psyched about the new ideas coming off of social media, like there is a part two where we have to do the science to figure out which ones functionally help medical or health care providers make sound decisions as well.

  00:43:07 Dave: Yeah, because I think, you know, and my understanding too, from Russell Barkley is with, you know, undiagnosed and untreated ADHD. Your life expectancy can be can be up to thirteen years less. And that is because of things like addiction, like excess or impulsivity, driving too quickly and crashing or, or getting diabetes from eating too too much or junk food or the impulsivity associated with stuff like that. Um, and so, so helping to, to solve. Yeah. It's got to be challenging because yeah. And with those comorbidities, because my, like, for some of the stuff I followed from what he's talked about in the past about like, if you're not like, if you're not treating the root cause and my understanding is ADHD. I mean, if you have clinical depression, it doesn't mean you have ADHD. Like we're talking about, but if you have ADHD, there's a high likeliness. You probably have comorbidity like depression or anxiety, certainly. And so if you're only treating the depression, you're not treating the root. I use air quotes on cause, but like sort of that thing in the background that's helping to drive that depression. And thus you're not going to effectively treat that depression because you're not recognizing and treating the ADHD. Is that right?

  00:44:25 Maggie: Yeah. And this goes back to like, I mean, any clinician that isn't saying this is not being honest with you, it is so hard sometimes to do the differential diagnosis because you have to. There's three possibilities. It could just be ADHD. It could be that it's depression that just looks like ADHD, or it could be a person with ADHD who also has depression. And you have to just like figure out like, does that ADHD have a life outside this depressive episode? Was it there before this depressive episode? Is it worse during this depressive episode? Um, another tough one is folks who smoke a lot of marijuana. They come in, they've been doing it their whole adult life and you're like, did this ADHD predate this heavy use of marijuana? Because, you know, there's cognitive impacts. If you are a heavy smoker of weed. So yeah, those are the types of tricky things that are very hard for us. We do our best with them. Even the people with the most knowledge often walk out not one hundred percent confident. So yeah, if people aren't, if the practitioner is not taking enough time with you, especially if you are a complex presentation like that to figure out like what, what's going on with you? That is exactly the red flag we talked about earlier. Like it can be, it can take hours of getting to know people to really try to, you know, make a good conclusion.

  00:45:42 Dave: And is it, do you think part of the process then once this report or this study comes out or these findings are released that you're working on? Um, that's probably a good question to, for your medical provider, right? Is like, have you, are you familiar with Assad or the findings from Assad? Do you say Assad? Is that right?

  00:46:03 Maggie: Yeah. You got it. Yeah. So this is like the the big professional organization for any health care provider from any discipline that's interested in specializing in ADHD so that it's multidisciplinary group. And yeah, I mean, those guidelines are going to be public. It's something that a person who has ADHD and is not a medical professional can get and look at and read and, you know, they can ask themselves, is the person that's treating me or diagnosing me like following these steps that it should create transparency? I think from the patient side as well, you know, that's great.

  00:46:35 Dave: I'm keeping an eye on the time here because I know, I know we got a hard stop, but, um, are there questions I haven't asked you about this or do you have questions for me that about ADHD or about the journey or what have you or.

  00:46:50 Maggie: Yeah, I think it'd be cool to hear you talk about like from your experience, what would you want us to know? You know, as people who are trying to like improve the diagnostic system, um, in this country for people with ADHD, like what do you think practitioners might be missing?

  00:47:08 Dave: Yeah, and it's a great question. are there tips for maybe people that are whether not necessarily low income, but certainly people that don't have the resources financially or, you know, are there tips or ideas you have for, for folks or who don't have the adequate insurance or insurance at all? obviously, I mean, you're going to need to be diagnosed in order to receive the psychological treatment or medication and so on. Uh, it's a big question, but yeah, are there, I don't know, what are your thoughts on that?

  00:47:40 Maggie: Yeah. Like, I think something that's important to my task force and me is like, um, making sure that we're keeping ADHD evaluations as affordable as possible while being as thorough as possible. Because, um, obviously, like there are fancy schmancy ADHD evaluations that people can get that cost six thousand dollars that give you like a thirty page report on your brain. And you really don't need that to know if someone has ADHD or not. Um, yeah. And so like, for us, like keeping the standard is like what is sufficient and needed, but you know, no more is important. Um, and primary care settings are probably the most affordable way to get an ADHD diagnosis. Like for a person who maybe has limited health coverage, um, primary care offices can spend just as much time with you, but they have to do it over multiple short visits and there's nothing wrong with that. So you probably want to look for if you're getting new insurance or, you know, if you, um, are even if you're uninsured and you're just trying to figure out who's like, what clinic can I go to for as needed care? Like try to find someone where they have experience with ADHD or they say in their profile that they're, that they also have interest in, um, behavioral health as a part of their expertise, because that's the kind of provider that hopefully can do more in-house for you than having to send you off to specialty care, which is where you get more expensive. So I'd say like, take time with choosing who you're going to primary care with. Yeah. Don't and then don't be, um, be careful with the online startups that have mostly been shut down now. But you know, we had a model during the pandemic that people may know the federal government really cracked down on and made some indictments on where you basically filled out an online survey. It was super cheap. You know, you were you met with a, a, a practitioner for five minutes. They, they gave you a prescription. And, um, that, you know, there's, there's a cheapness in that that's tempting, but there's a danger in that. And that they came, they may misdiagnose you, um, they may not give you the correct medication for you. And then you may be in a worse off situation, situation psychiatrically than before you went. So it's risky. Yeah.

  00:49:54 Dave: Yeah, yeah. I think that was dose that was shut down and, and charged. I believe that was the name. Um, as far as, uh, collaborating with other organizations, being Canadian or American. Now, uh, does Apsaa share findings and information with other health bodies of the NHS in the UK and others to, to help you get a consensus because obviously this is this is ADHD isn't an American thing. The A is not for American. Uh, you know, all, all humans, hunter gatherers. Come on hunter gatherers. If it wasn't for us. Um, so, and I'm curious about whether you're working with other bodies to, to help kind of study this. And then also, um, any thoughts on, I know like some Asian countries, uh, have, have banned stimulants and things. So like a person with ADHD traveling to, I think Japan, you can't bring stimulants, they're outlawed there any, any thoughts? I just gave you a whole bunch of stuff with like a couple minutes.

  00:50:56 Maggie: Yeah. So there's a world federation on ADHD, which is like, um, all of it has, um, it's an umbrella organization for all the regional organizations like, and there's Caddra in Canada and we have, um, the Australian ADHD organization is the one that we've been working most closely with because they put out their guidelines in twenty twenty three. So they're the most recent group to do the whole literature review and the process. So we've been working really closely with them because they're in time closest to us in doing this. Um, and the UK group under the Nice guidelines, they have a pretty comprehensive guideline. So we've have on our task force we have um Europeans, folks from Canada, folks from Australia who've sort of been involved in the other regional efforts who are kind of like helping us. And we've also had review by, um, people who were on the original DSM five committee that wrote the, the criteria for ADHD. So we do have sort of like these connections with people who've been through this and done this before to keep sort of everyone talking with each other. Um, yeah, I'm not super familiar with the, like the politics behind the countries that are outlawing or banning stimulant medications. Um, but, but it does highlight the fact that there is just like really cultural differences in the way ADHD is viewed and its treatment is viewed. I think, you know, something like the World Federation of ADHD has value because it brings people every two years together from all over the world to kind of have these discussions and make sure we're not siloed when we're, you know, dealing with the policy implications of ADHD in our individual countries.

  00:52:38 Dave: Yeah, no. That's great. Maggie. Man, this has been so great. How can people get Ahold of you and learn more about what you do?

  00:52:44 Maggie: I have a website. It's Margaret Sibley dot com. I think for my engagement with folks, the best thing is that we have a big research participant pool that you can find on my website by hitting, um, that you want to participate in research. And we do interviews with folks with ADHD who want to tell us about their lived experience. We show you experimental treatments and get your feedback on it. So we have like a real kind of cool back and forth with the ADHD community. So if anyone thinks that speaks to them, feel free to sign up to be in our participant pool. Um, but other than that, I kind of hide off of social media. So the best way to get in touch with me is send me a message through my website, Margaret sibley dot com. Thanks for having me.