Today, I am so fortunate to be talking with Dr. Maggie Sibley. Maggie just recently took a new appointment at the University of Washington as an Associate Professor of Psychiatry and Behavioral Sciences. Just prior to that though, she was a clinical psychologist and researcher at Florida International University at the Herbert Wertheim College of Medicine and Center for Children and Families.
She studies executive functioning, motivation, and attention problems in adolescents and young adults. She has received tons of recognition from the Scientific community, and a lot of grant funding from the NIMH and the U.S. Department of Education.
She has written a book called Parent-Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation. It’s a comprehensive guide for professionals and gives information about how to work with families using the therapy that she developed called Supporting Teens’ Autonomy Daily. We’ll talk about that in our interview today.
Maggie knows her stuff. We have a great conversation. We get into some of the ins and outs of ADHD, differential diagnosis, and intervention which is a passion of hers. So, stick around. I think you’ll really enjoy this one.
Like I mentioned last time, we’re so excited to have the podcast certified for CE Credits. Those will be available ASAP. I will make that announcement as soon as I have confirmed it, but just to build some excitement, that will be happening soon.
In the meantime, if you are interested in any sort of consulting to build or grow your testing practice, reach out at thetestingpsychologist.com/consulting, send me an email and we’ll figure out if consulting could be a good fit for you.
All right, that’s it for the intro. Without further delay, here is Dr. Maggie Sibley.
Hey, y’all welcome back to another episode of the Testing Psychologist Podcast. I’m Dr. Jeremy Sharp. I hope you all are doing well this morning or this afternoon, or this evening, whenever you might be listening. We have a fantastic guest with us today. One of the cool things about doing this podcast is like I’ve talked about before, connecting with folks in our community and in this world, and then getting introduced to other pretty amazing folks. And this is one of those cases.
Maggie Sibley, we got an introduction through Dr. Joel Nigg who was on the podcast a few months ago. I feel really fortunate to have her on the podcast today to talk about all kinds of things that I think are going to be super interesting for us.
Maggie, welcome to the podcast.
Dr. Sibley: Thanks for having me, Jeremy.
Dr. Sharp: I’ve been looking forward to this one. Ever since Joe mentioned your name and we started to connect, I’ve really been looking forward to talking with you. So, I’m very grateful for the time and energy that you’ve got for us today.
So like usual, I’ll start off. I would love to hear a little bit about what you are doing day-to-day. I know in the intro, people heard that you do a lot of academic work and you’re an Associate Professor and you got a lot going on. So, can you tell us what you’re up to these days and how you got there?
Dr. Sibley: Sure. I am a person who specializes in treating and diagnosing ADHD in adolescents in young adulthood. My primary work is probably about 75% research in applied settings and maybe about 25% treating and supervising and participating in the assessment of actual people who are coming in to find out if they have ADHD or not, usually for the first time as a person who’s either a teenager or an adult.
I work with schools. I work with community mental health agencies, private practices, and hospitals to help them often refine the way that they are working with teenagers and adults with ADHD. So, I do a lot of different things. I’m involved with working with a lot of different people in the common thread of this area of expertise that I have.
Dr. Sharp: Sure. Yeah, it sounds like you have your hands in a few different arenas, which is really cool. It keeps it interesting I would imagine. So, are you doing some consulting as well? Is that part of the picture with the schools and other agencies?
Dr. Sibley: A lot of what I do is working on grant-funded projects where folks bring me in to train their camp. Some of the projects that I have are actually federal grants that are designed to evaluate better ways of working with kids in those types of systems. So, we’re actually doing some research on how to implement effective programs and effective procedures for working with people with ADHD.
Dr. Sharp: That’s fantastic. I would love to get into that here as we go along. Could you maybe just talk a little bit about how you got here? That could be education, training, all that stuff but I’m also just curious about why ADHD, why this arena for you.
Dr. Sibley: I love teenagers and young adults in that transition. I was always first and foremost interested in studying mental health in that age group and understanding how mental health changes as people are aging.
I think I stumbled upon ADHD because some of my early mentors in graduate school were doing work in that area. And it turned out that a lot of the kids that I was interested in working with clinically, kids who were having trouble figuring out what they wanted to do in life, being motivated, people who were trying really hard in school and had a lot of potentials but weren’t quite living up to that potential, it turns out a lot of them met the criteria for ADHD.
So although I’ve never been super attached to the specific category, I found myself doing the kind of work I wanted to do with the population who is having the kind of difficulties I wanted to help by staying close to that diagnosis. So, I do work with kids who sometimes don’t meet the criteria for ADHD and who are still struggling and still need the same help as well.
I’m really interested in taking family-based approaches. I think there’s so much value in supporting a child who’s struggling with families who do some of the right things. And on the other side of that coin, kids can really get held back and hurt by families that don’t know how to do some of the right things. So, that’s something that’s been really important to me.
Also, a lot of my work takes an autonomy support approach where the idea is to help people be able to stand on their own two feet and know what they need to do in their lives to make themselves successful rather than relying on professional day-to-day that kind of coach them through it. From a theoretical perspective, that’s been important to me as well. Some of those professional values have led me in the direction that I’m in right now.
Dr. Sharp: I got you. That’s interesting. I’ve never heard that term. What did you say, autonomy support? I would love to get into that as well. So we’re good. Our agenda is filling up quickly here. That’s good.
So, tell me just a little bit before we totally dive in, what has your research looked like over the years in terms of major topics or focuses?
Dr. Sibley: Great question. I think the two areas that I’ve done a lot of work in are: what should the criteria for ADHD be in people who are over age 12? That’s one area. And then what steps the practitioners need to take to figure out who really has ADHD and who doesn’t in that age range. That’s one set of work I’ve done.
And then another set of work is related to, what are the ways that we can help this age group that doesn’t necessarily have an interest in coming to therapy or getting help for their own difficulties, but we still know they need a lot of help. What’s a way that we can find things that are engaging for them that they actually want to participate in that could be effective and help them? And how do we wrap those opportunities for help into the communities and the systems that these kids are already interacting in? So, those are some of the major topics that I’ve been doing work in.
Dr. Sharp: Okay. Both are super crucial. So, what should ADHD look like in kids over 12? And how is that different from what we currently conceptualize it as?
Dr. Sibley: It’s a great question. A lot of people who are listening are going to be already familiar with what the DSM-V says are the main symptoms of ADHD. And there’s a list with two sections. Each section has nine symptoms on it. The first set is the inattentive symptoms. And the second set is the hyperactive-impulsive symptoms.
The history of those symptoms really dates back pretty far to observations that were made in the 1950s and 1960s with children who were being treated clinically for what we now call ADHD. And these were children who were in elementary school. So, those symptoms were derived by seeing what were the most common troubling behaviors that these elementary school children were displaying. And then the thought back then was if we could put them on a list, people who displayed a lot of those behaviors must have ADHD.
What has happened over the years since that list was first formulated is a growing recognition that ADHD exists in people who are not elementary school children. And there’s been a lot of excellent research that started to paint the picture of what people in adolescence and adulthood look like when they have ADHD. At the same time, it’s really challenging for the people in charge of that list on the DSM committee to make revisions wholeheartedly when the science is still coming out and it’s not that we have a perfect list to replace our childhood list with yet. So then you’ll see this evolution is slowly carving out more and more of what we’re sure of.
If you look at the DSM-V list of symptoms that came out in 2013, there actually are new texts that have been added. The symptoms are the same, but now you’ll see parentheses after them that say what the disorder should look like in older individuals. And that’s a good step in the right direction.
And so if folks haven’t checked out that list, a lot of people didn’t realize that the symptoms had actually morphed a little bit. That’s a good place to start. But one of the things that we’re still struggling with as a field is that even though we’ve figured out the adult version of those childhood symptoms, there may actually be adult symptoms that children don’t even experience. And so, those symptoms aren’t even captured on the list yet. And we’re still trying to figure out how to grapple with that problem.
So you’ll see that there are still core features of inattention and hyperactivity-impulsivity in people who have ADHD that are over 12, but you’ll also see that the manifestation of those same difficulties has changed.
One of the key things you’ll see is that motor overactivity, that hyperactivity, that running around is dissipating pretty steadily from around the teenage years through adulthood. So, you won’t be likely to see people seeming physically hyperactive who have ADHD when they’re older.
That group of symptoms really morphs into something that looks a little bit more like difficulties with self-control generally. So, this could be decision-making, this could be verbal impulsivity, it could be difficulties with trying to get yourself motivated to do things because you have a hard time regulating your own behavior. And those are some of the things that people who are older with ADHD might struggle with on the impulsivity side.
On the inattention side, you’re still going to see those classic difficulties with executive functioning that you see, difficulties with organization and time management, with memory, with being able to do complex tasks and keep yourself focused. But of course, the demands of life are going to be asking us to do different tasks when we’re older. So you might see the symptoms come out in different ways. So, whether it be trouble with your driving record because you’re having trouble focusing or difficulty remembering to pay bills or being able to meet deadlines at work, or developing reciprocal interpersonal relationships that are both friendships and romantic relationships. Those are some of the problem areas for individuals with ADHD when they get older.
Dr. Sharp: I got you. And I think that these are all things that anecdotally we have seen and really struggled to reconcile with the diagnostic criteria when you’re trying to follow up a manual, which is challenging. So, how do you take all of that and integrate it with an assessment when you’re trying to diagnose ADHD, let’s say, and the presentation is different than what shows up in the DSM?
Dr. Sibley: That’s a good question. Some of the work that my colleagues and I have done shows that even though we know that the DSM list isn’t perfect right now, it’s still the best thing we’ve got unfortunately because a lot of times people have come up with these lists of alternative symptoms, things you seem to see over and over again in adults with ADHD, things like I have a really hard time getting myself to work on something if I’m not enjoying it.
And the trouble with those symptoms is even though a lot of older people, adolescents, and adults with ADHD will say yes to those symptoms, a lot of people who don’t have ADHD will also say yes to those symptoms. So even though it might make you describe people with ADHD better than we were with just the DSM symptoms, then you get yourself into this really difficult gray area of having more mistaken diagnoses because you might accidentally start diagnosing people who don’t have ADHD.
So the criteria for ADHD have five parts. The A criteria, which is this list we’re talking about, is just the first part. So the recommendations now are to follow those criteria for now because that’s what the field is recommending and that’s our manual but to be open-minded about the manifestations of those symptoms. Also, there’s a lot we can get into here about the B through E criteria, which we also have to follow, which are going to help us make good diagnoses.
The B criteria is making sure that people are impaired and that they’re not just mildly showing those symptoms. Those symptoms are actually causing problems in their life. We’re looking at criteria where we have to make sure that the symptoms are in more than one setting. We have to make sure that this is a chronic pattern in the person’s life and not just something that jumped up in their life during a really stressful time. We have to make sure that we can’t explain the symptoms from some other source. So we really have to be detectives in making sure that if people are meeting criteria on the list, that they also have this profile that would essentially help them meet criteria for a mental health disorder generally- that they’re severe enough.
Dr. Sharp: Yeah. That’s such a good point. I’m glad that you touched on that. I think with a lot of diagnoses, we do get wrapped up in the “A” criteria and just look at symptoms and then forget to scroll down the list and make sure that those other pieces are in place.
Dr. Sibley: Yeah. And there’s been a number of studies now. It’s not just one study or my work that has shown that the majority of people who have enough symptoms do not meet the criteria for ADHD because of the other B-E criteria. So that’s an important thing for people to know that you can’t just stop at the A criteria. You have to keep going.
Dr. Sharp: Yeah. I’m going to ask you to say that again just to emphasize it a little bit.
Dr. Sibley: Sure. The majority of people who have enough symptoms on the A criteria checklist to meet the criteria for ADHD do not actually meet the criteria for the full disorder once you take into account the other criteria, the impairment criteria, the fact that you need to have the symptoms in more than one setting, the fact that you need to show a stable pattern of the symptoms over time.
Also one of the biggest things is ruling out other reasons why someone might be having potentially cognitive difficulties at a certain point in their life. And there’s a lot of other reasons that somebody could have trouble focusing with their memory, trouble staying organized, or getting motivated than just ADHD.
Dr. Sharp: Absolutely. This might be getting too nuanced, but is there any one in particular of that B-E criteria that tends to “disqualify people”? Is it the chronic nature or the multiple settings, or is that too specific?
Dr. Sibley: I think the biggest chunk of them are eliminated from consideration once you consider the impairment criterion.
Dr. Sharp: Okay. I’m glad that you said that. That’s a nice coincidence because I took some notes when you were going through this. I said, how do we define impairment in adults or even maybe adolescents? So can we start maybe with adults? How would you tell if they are impaired?
Dr. Sibley: This is a really good question and one that I think doesn’t have a very clear answer. However, there are some things that I think we can all agree on. First of all, ADHD is supposed to be affecting about 5% of the population. So, that means that the person in front of you should be more impaired than 95% of the people that are part of that person’s peer group, right?
Dr. Sharp: Yeah.
Dr. Sibley: So think about that. That’s one thing.
A big thing that plays into impairment is what kind of environment you’re in. You could put the same 11th grader in really basic classes and give them no extracurricular activities, and they would probably get pretty good grades and not have a lot of problems. But if you took that same child and put them in very advanced classes and gave them a sport to play after school and put them as a president of a club and gave them a bunch of chores to do at home, that same child might not be meeting the expectations that are placed upon them. And therefore, people might be saying they’re having trouble with impairment in their daily life. So we really have to consider the environment the person is in as part of the picture as well.
And then the third piece of this is clear examples of impairment are not being able to get the best grades that you can considering your intelligence level. It might be not being able to keep relationships with people because of behaviors that you’re doing that are making it hard for people to interact with you. It might be not being able to keep steady jobs. So, we’re talking about things that are really impacting somebody’s ability to live a healthy productive life.
One thing that isn’t impairment is distress. Distress is something different. Sometimes people are distressed because they are living in a world where there’s a lot of expectations placed upon them for them to be excellent at a lot of things. And we’re not all excellent at all things. So sometimes when people feel like their cognitive resources aren’t allowing them to do something they want to do, a person can become distressed and they could seek answers for that or seek help for that. And it becomes the clinician’s job to decide whether a person who’s looking for an ADHD diagnosis and complaining about their ability to perform in their life is really a truly impaired person or just a person who’s dissatisfied with their own performance.
Dr. Sharp: That’s such a good point. And it makes me think about almost the philosophical question of, is our culture, for lack of a better word, generating more ADHD-like cases where people feel overwhelmed, in demand, not enough time, more homework, you could throw any number of things in there. And I don’t know if there’s a question wrapped in there necessarily or not, but just an observation may be that you may have run across in your research as to how our culture, in general, is contributing to all of this.
Dr. Sibley: Yeah. You’re not the first person to raise that question. There’s an important cultural piece of ADHD that always has to be looked at when you’re making a diagnosis. What are the norms that the person is following? What kind of environment are they in? What are the expectations placed upon them? And some of that has to do with the community that they live in. It could have to do with their parent’s socioeconomic status. It has to do with the country they live in and what’s considered to be acceptable behavior in the country or in society more broadly.
So all of this is part of a diagnosis. It is really trying to understand the context in which a person is operating and trying to stick to some of our agreed-upon principles within that and about how severe they have to be, what would that person look like if they weren’t in this setting? Those all should be things that should be considered.
Dr. Sharp: Sure. I want to ask you some more about how all of this might translate to the actual assessment process, but before I go in that direction, can you comment at all? I feel like there’s a lot, and admittedly I’m not an expert in this area by any means, but a lot out there in terms of lack of ADHD in other countries outside of the US and other cultures. Can you speak to that at all?
Dr. Sibley: If you look at studies that are population-based that are simply trying to understand if there are people in various countries that show the symptoms of ADHD or meet the criteria for ADHD, and these aren’t people who are in a clinic seeking a diagnosis, just people in the general population, you tend to see the same percentage of people who are showing those difficulties across nations.
So, the actual incidents are assumed to be equivalent across people of various different cultures. However, that doesn’t mean that the same number of people are being diagnosed in every country. So, a separate question is in which countries are more people coming to clinical attention? And it could be a good or a bad thing because you want the people who need help to be identified and linked to care, and on the other hand, you also have some countries where people might be concerned that too many people are coming to attention just because of the way the symptoms are being interpreted by people or the diagnostic standards which might be different in different countries as well.
Dr. Sharp: Yeah, that totally makes sense. So that’s an interesting piece of information just for me that the symptoms are there, it’s maybe just the diagnostic part and who’s presenting that changes. Just curious.
So, maybe jumping back a little bit, you started to open that door of the cultural component. And I use that word so broadly and probably inappropriately, but just everything in the world or in someone’s universe could contribute to these symptoms. How do you start to translate that to the assessment and figuring out what is “environmentally driven” versus true ADHD?
Dr. Sibley: Well, my approach I think to a good ADHD assessment, especially in somebody who might be an adult is, first of all, you need to get information from multiple sources. So you have to step out of the person you’re assessing personal lenses and you need to get more information from people who knew them as a child. Usually, the parents are the gold standard second person to ask if they’re available. People who know the person currently and observe them in hopefully multiple settings, and anything objective that you can obtain to be able to verify especially looking back in childhood and people recalling, yeah, maybe the teachers said there were concerns back then.
Sometimes parents keep their kids’ report cards and there are actually notes on there from the teacher about how the kid is doing and there can be clues in there. So you’re really trying to create a timeline of this person’s functioning with respect to what we consider almost like a trait of ADHD over time because that’s how we view it as a chronic difficulty.
You’re asking multiple people, you’re trying to get objective information, and then you’re really trying to be a detective and try to understand, are there things that happened that correlate with when symptoms seem to get worse or when symptoms seem to get better or when they weren’t there at all or when they first became recognizable.
There’s a lot of people out there who struggle with ADHD symptoms but they have other things that have made those symptoms not cause problems for them. So they could be really smart. And they’re able to use their wit to get themselves out of situations or finish their homework real quickly before they get in trouble for it. There are also people who’ve been in really excellent settings that have given them what they needed to be successful in spite of their symptoms.
So when you look back and you can say, this is why this person didn’t come to attention until they were 17, 18, 19 years old, and you feel good about that narrative, that’s going to be a time where you feel more comfortable giving a diagnosis. If you’re just scratching your head about where this is coming from, then you’re going to need to ask more questions. There’s a number of alternative explanations you could also consider why the person is coming to you now with these concerns.
Dr. Sharp: Yeah. Are there any right off the top of your head that you’ve found tend to masquerade as ADHD that we should really be considering?
Dr. Sibley: Just two categories. For one, there are certain societal benefits to having an ADHD diagnosis. People listening I’m sure are very familiar with these, especially at this age group that I’m talking about. So for one, you could get stimulant medication. Some people who want to enhance their cognitive performance, who want to go from being a person of normal cognition into a person of supernormal cognition might be interested in that medication.
Alternatively, some people who are living a lifestyle where they’re not sleeping much and they’re using a lot of substances and their goals are not rooted in academic or professional ambitions but rather may be more recreational or social goals have been known to use stimulant medication to make up for or regulate the downsides of that type of lifestyle as well. So there are people who are out there potentially seeking a diagnosis to obtain the medications.
You could get extra time on your standardized testing if you have an ADHD diagnosis or other support in school. And psychologically, some people just want the diagnosis as a way to make themselves feel like there’s a reason that they’re not doing as well in life as they want to be.
So those rewards may lead some people to it. It doesn’t mean that they’re necessarily intentionally being misleading. They may actually see their situation as one in which they may feel like they have ADHD, but those could be some underlying motivators for people to tell their story in a certain way to clinicians. So that’s one thing you have to be on the lookout for.
Another is there’s a number of disorders that share features with ADHD. And so differential diagnosis is really critical, especially because it’s different when they’re children. When they’re children and you’re hyperactive or impulsive or inattentive, there are only so many things at that point that could potentially be causing it. So it’s a lot easier to narrow it down to ADHD.
When you get older, you’ve had the opportunity to develop comorbidities that may not be common until you become an adolescent like substance use disorders, depressive episodes, anxiety. In addition, you have a lot of people who could have had negative things happen to them in their life either physically like head trauma or it could be something that’s like a psychological trauma that psychological trauma has been shown to have cognitive aftereffects. So there are all these other things that could now explain why somebody is potentially meeting the criteria for these symptoms.
So without a full assessment of all these other possible hypotheses about where these symptoms would come from, you wouldn’t probably have enough information to make a good diagnosis.
[00:34:15] Dr. Sharp: I got you. So is it a leap to say that you’re a fan of the more comprehensive assessment model? Like if someone walks in with a question of ADHD, is it almost like the standard of care to look at these other possibilities?
Dr. Sibley: Yeah, I think at this point, at least with this age group, it’s necessary to do a full diagnostic assessment. And I like to use instruments that are somewhat structured because it just makes sure you ask all the right questions. And so I think that’s important. But then also being able to really deal with ADHD, more than ever, develop your own hypothesis and act like a detective and start crossing things off the list to really try to figure out because a lot of ADHD is subjective and gray areas. So you do have to just try to uncode the puzzle.
Dr. Sharp: Right. What structured instruments do you like?
Dr. Sibley: Well, I think […] is pretty good for people who are under 18. And there’s now evidence that I think that that instrument could be extended upward to young adults. And I think in adulthood something like the SCID is certainly good in terms of just making sure you remember to go through this full breadth of all of the DSM disorders. But also health history is really important for people with ADHD. Getting a timeline of any negative life events that people have experienced, family, trauma, all of that really can play into the reason a person is sitting in front of you today.
Dr. Sharp: Sure. I know that we had talked before we got the interview scheduled just about topics and such. And something that we talked about was the comorbidity with trauma, or differential diagnosis with trauma, and some other things that can look like ADHD.
Dr. Sibley: That’s an area that I think we’re still trying to figure out how to do our best. However, I think one key thing is a timeline. So if you can understand what was the difference between the times when the person seemed to be functioning okay in their life and the times when the person was having troubles and you can find differences.
A lot of times you may end up understanding that the drug use preceded the symptoms. Or you may understand that these symptoms have never truly been documented in the absence of a depressive episode. Or you may see that these symptoms really started after this person experienced this traumatic experience. And so I think the assessment question is, and I really think a timeline of mapping out everything really helps, is can you see patterns between the onset of symptoms or the escalation of symptoms and these other factors?
Dr. Sharp: Yeah, it’s a complicated picture sometimes. I think about, and this may be a little young for who you typically work with or do the research on, but I see a lot of maybe 6,7,8-year-olds who have had traumatic experiences of varying degrees. But there’s also a question of ADHD in there. And it’s challenging for parents to separate those out and challenging for me to separate out even with a timeline because the kids are young enough where the symptoms were co-occurring as they developed if that makes any sense.
Dr. Sibley: Yeah. And that’s true. And sometimes I think you may never be able to know to what extent these symptoms are environmental versus genetic. And I guess that’s ultimately what we’re asking with that type of question. And at some point, the most important thing is that the person gets the best treatment that they can get. So I think at some point, either diagnosis or both diagnoses are okay as long as qualitatively in the report you explain that confusion in that inability to fully understand exactly the chicken and egg question so that whoever’s reading can also share that information and make their own conclusions so to speak.
Dr. Sharp: Yeah. I see what you’re saying with that. It is hard.
Dr. Sibley: Yeah. It’s not like there’s a version of inattention that looks different if it was PTSD versus ADHD. It doesn’t look different. It’s more of a matter of figuring out the patterns of things coming on and going away.
Dr. Sharp: Yeah. I like how you said that. That’s the question that I was trying to ask without actually asking it. That’s what we run into a lot. It seems like there are some habit tale but it really seems like it’s not. You just got to have maybe a good history and a wait-and-see approach to see once the trauma is hopefully resolved, then you see what’s left.
Dr. Sibley: Yeah, the wait-and-see approach is good. I’m glad you brought that up because I think people should feel comfortable giving provisional diagnoses, especially with some of these questions we’re bringing up because if you come across somebody who’s experiencing some internalizing and externalizing difficulties at the same time, and you’re wondering whether it’s really ADHD or just a part of the psychological difficulties they’re having and you want to recommend or treat the depression or the anxiety first and see if the ADHD persists or not, sometimes you have to not just look at the snapshot but actually become involved in following the person a little bit longer to see what happens. And that might give you diagnostic clarity in the long run.
Dr. Sharp: I’m so glad to hear you say that. I’m a big fan of provisional diagnoses and I feel like professionally when I got to a place that I made peace with saying, I don’t know for sure right now, that made my evaluations so much easier and maybe helpful even too. I wasn’t trying to zero in and say, yes, this is definitively what’s going on, and here’s what you do about it.
Dr. Sibley: Yeah, people are complicated. It’s okay to not know yet. And I think the best thing we can do is write reports where we’re just really good at explaining all of that and letting people know what’s going on and why they don’t fit into a box right now. And also saying, here’s the information we need to start figuring out in order to get to a place where we can make a diagnosis so that everyone can be working together to gain clarity.
Dr. Sharp: That’s so true. So I know that when we were talking again, as we were trying to schedule, we were talking about mood disorders as well. And that’s how your name got brought up when I was talking to Joel a few months ago. I was asking him about these kids with what we think might be bipolar or a disruptive mood, or even just ODD, and some of the kids that seem to go maybe beyond typical ADHD. How do you separate those from just the impulsivity and trouble with self-regulation that comes with ADHD? I wonder if that’s something that you’d be willing to talk about?
Dr. Sibley: Yeah, I think that’s a bigger question for the field too. I don’t think the field has figured out how to slice that pizza because they think there’s a lot of overlap in the systems involved in those different sets of difficulties. And so it becomes really hard for all of us who are struggling with figuring out how to provide a diagnosis to an individual like that. How to do that person the best justice.
I mean, yes, there is an emotion regulation component of ADHD that comes from the poor executive control and self-regulation that these kids have that’s going to the extent of regulating all aspects of themselves, including their behavior, their thoughts, and cognition, their motivation, their emotion. Then there are other kids who are having those emotional problems because a different part of their brain is acting up, but it may look the same to us, right? So they may have trouble with actually the level of emotion that they’re experiencing because of the way the neurotransmitters in their brain work.
So sometimes kids look the same clinically, but if we only had the magic ability to go inside with an MRI and figure out what was going on, we would see that there are different explanations for this.
Because the science isn’t there yet, the best thing we can do is I think stick to the DSM and just make sure that we can defend the diagnosis we make because we feel like the kids actually meet the criteria for the symptoms. And sometimes you may end up giving multiple diagnoses just because ADHD alone doesn’t explain the full spectrum, but if you took away the ADHD diagnosis and only left them with a bipolar or mood disorder that wouldn’t explain it either. But those complex kids are different from people who only have one of the issues but you’re just trying to tell which one it is if that makes sense.
So those are different difficulties for diagnosis. I think people who are complex versus people who just have to figure out what’s the reason that they’re having attention problems.
Dr. Sharp: For sure. What do you think of ODD as a standalone diagnosis?
Dr. Sibley: I think it’s a valid standalone diagnosis, but you don’t see a lot of people with ODD who don’t also have ADHD. So, you should just always be on the lookout if they have ODD. Part of the feature of ODD that is related to ADHD is this verbal impulsivity- this talking back without thinking about the consequences of what you’re about to say. And there are so many family processes involved in the onset of ODD as well, and parenting is such a big part of that, that a lot of times ODD is conceptualized as ADHD with dysfunctional parenting. Not always though.
There are some people who maybe their personality, the traits that they have, the temperament that they have just make them a difficult person regardless of the environment they’re in. And those people are I think fewer and far between the ADHD variant of ODD but I do think they exist.
Dr. Sharp: Sure. I’ve got ODD on the brain. I’m interviewing Ross Green later today. So that’s where I’m trying to think through these kids a little bit and see how we conceptualize them.
I feel like I run into a lot of kids who do not quite reach the criteria for a disruptive mood because they behave pretty well at school and outside the home, but then home, they’re blown up and losing it. There’s an anxiety component it seems like or a rigidity, maybe that executive functioning component, and then there’s often some ADHD kind stuff mixed in there. And I feel like I get those types of kids very often. They don’t fit neatly into anything. I’m always struggling with how to conceptualize that.
Dr. Sibley: That group of kids I agree with is the most difficult one because they are not necessarily conduct-disordered, but they seem to have difficulty with their anger. They’re very anger disordered, but we don’t seem to have this anger disorder diagnosis because ODD isn’t purely that anger. I think everyone in the field knows that our diagnostic system just has to keep evolving with science. And I think a lot of times the science is behind all of our day-to-day observations. We’re seeing things and we’re like, this is clearly off from the criteria, but the people who write the criteria need to see the science that confirms these assumptions we’re all making before anything will change. So, it’s frustrating for us to feel like the system is behind our ideas for how we can classify people better sometimes.
Dr. Sharp: Sure. Well, if nothing else, this is validating that I’m not the only one that’s wrestling with this. We’re just trying to catch up and figure out what’s going on for these kids. I know marijuana is part of the picture too. We had touched on that. And that’s something you brought up as certainly something to consider when you’re looking at ADHD. Could we dive into that for a bit?
Dr. Sibley: Yeah. One thing that makes this complicated is that people with ADHD tend to use marijuana at higher rates than people without ADHD. So, if someone’s a heavy marijuana user, to begin with, it’s not a crazy hypothesis to think maybe they could have ADHD. And that could be one of the reasons that they happen to be using marijuana. A lot of people who have ADHD report that they’re using marijuana because it’s helping them in some way. We’re not sure whether it’s just making them feel better or they’re actually experiencing some true benefit from it on their symptoms of ADHD.
Dr. Sharp: Can I stop you for a second? How would you separate those two things?
Dr. Sibley: Well, if you smoke marijuana and it creates a reduction in your ADHD severity, that would be therapeutic. But if you smoke marijuana and you like the way it makes you feel, but it doesn’t actually reduce the severity of your ADHD symptoms, it would probably be recreational.
Dr. Sharp: Okay, I see.
Dr. Sibley: For example, I think one of the pieces here that are under the biggest debate is the marijuana removing the mental restlessness that people are experiencing and therefore they feel calmer or is it actually improving their cognition in some way?
I guess that’s a gray area. And of course, because there are laws about research on marijuana in this country, there isn’t enough research on marijuana to answer these questions yet because there are so many challenges to even doing that research. So, we don’t have any information on this question from science. But we do have information that people with ADHD are at a much higher risk of using marijuana regularly as adolescents and young adults.
However, there are cognitive effects of using marijuana that mimic ADHD symptoms, especially with respect to working memory and your ability to solve complex problems. You even see in some research that heavy marijuana use can impact IQ scores. It may be temporary, but how people do on those tests because their IQ does happen to those executive functions. So that’s another tricky one. If a person who’s smoking marijuana heavily is coming to you and saying they have ADHD, they might but it’s really hard to confirm that unless you understand what the person is like when they’re not smoking marijuana.
Dr. Sharp: Yeah. Again, I’m just thinking about how would you start to assess that? I think a lot of us probably evaluate adolescents who have been smoking relatively regularly up to the point of testing and then what do you do with that?
Dr. Sibley: If you’re lucky, you can get good reports from other people about that so you are aware of when the person started smoking regularly. So you can isolate that in time and try to understand that retrospectively by getting the input of people who know them or potentially looking at differences in school grades et cetera.
If you can’t gather that information and you don’t have confidence in the information that you have, then without the person having a wash-out period which may be completely impractical to get the person to do, unfortunately, you may not be able to find out what’s going on with enough confidence to be making a good diagnosis. You may have to wait.
Dr. Sharp: Yeah. Do you have a recommended wash-out period before testing somebody who’s been smoking relatively regularly?
Dr. Sibley: I don’t know if I feel comfortable saying that because I’m not sure that I could definitely verify that with science, but I think that you’ll probably look that up. Basically, you want to figure out what the research says about the cognitive effects of marijuana because there are acute ones, which means the short-term effects and how long those last. And when you can isolate that time period, then that’s what you’re looking to assess as a person after enough time that those effects would no longer be expected.
Dr. Sharp: I got you. I joked with Joe, not totally joking. We both live in states where marijuana is legal now and it’s getting to be more and more of a concern how to approach it. I think it’ll be important to learn more about that as we go along.
Dr. Sibley: Yeah, I hope that there’ll be more opportunities to do good research on that now that some of the laws are changing because there’s a lack of research. A lot of people’s impressions are based on hearsay or things people are saying online and we have to be careful about the quality of the information that we’re taking in.
Dr. Sharp: Absolutely. Well, I feel like I would be remiss not to spend at least some time before we’re done on the treatment part. And that’s the other side of what you do it sounds like.
Dr. Sibley: Yeah.
Dr. Sharp: What happens then after the assessment? What are you finding in terms of helping these kids and young adults?
Dr. Sibley: Well, there’s a number of approaches to treating ADHD that have evidence and work. So, we’re lucky that we can give people options. As I’m sure everyone knows, stimulant medication has historically been the first-line approach for treating ADHD, especially in people who are older and it is effective acutely.
One of the limitations to be aware of with stimulant medication is that it has a bigger impact on the actual cognitive ability that somebody is displaying than the impact of that ability on their daily life. I’ll give you an example to make that easier to understand.
A person with ADHD who takes stimulant medication pills will be able to be less impulsive, calmer, and potentially focus better, but it doesn’t necessarily have an effect on their daily skills. So, their ability to keep themselves organized and their ability to have good relationships with people. The reason for that is that it takes more than just having good cognition to be successful in those areas. And people with ADHD have a long history of struggling in those areas. So they may not develop some of the same skills that their peers did.
For example, if you think about a person who didn’t pay attention for most of elementary school, even if they start paying attention through medication a little bit better in high school, they still missed out on a lot of potential academic growth that they could have had if they were treated earlier.
In addition to medication, it’s often recommended that a skills-based therapy approach is also applied. And there’s a number of options for that. There are CBT approaches that are out there for adults now. There are also organization skills training approaches or family-based behavior therapy approaches for adolescents. Some of the work that I do is related to that approach.
So, basically trying to teach parents age-appropriate behavioral strategies for older kids and young adults. Things like making a contract with them about expectations and consequences for not meeting those expectations. Teaching people time management strategies. Teaching people ways to overcome procrastination. All those skills have been shown to be helpful to people. So, those are the two main approaches right now to helping people with ADHD: medication and skills-based therapy.
Dr. Sharp: Sure. And where does your work fit into that? You mentioned autonomy support and…
Dr. Sibley: I developed a program for teenagers that’s called STAND- Supporting Teens Autonomy Daily. This approach uses motivational interviewing and works with the parent and the teen together to help them identify what their common goals are, to help them understand what their family values are and the things that are most important to them because being a person with ADHD and parenting a person with ADHD is just a life full of dilemmas. You’re always having two things you care about come into conflict with each other. On one hand you want your kid to do their best in school, and on the other hand, you feel that you have to help them for 4 hours a night to get them to do their best in school. And maybe that’s not allowing them to become independent.
So, which is more important to you, their grades or their independence? And there’s no right answer to that. People have to look into their priorities and figure out their own personalized plan for navigating the adolescent years. So we spend a lot of time on that and let people figure out what skills they’re going to need to be successful and teach those skills to people. That approach is where a lot of my work has been.
Dr. Sharp: Got you. How is the research looking on that approach? Have you been able to conduct any quality research?
Dr. Sibley: Yeah, so my work has been funded by the National Institute of Mental Health on this treatment program which is actually in a book so people can read about it if they want to do it. And this program has been compared to normal treatment in the community which means if people are already taking medication, keep taking it. If people are already getting tutoring or help at school, keep getting it. And we showed pretty big changes over a year for the kids who did this 10-week therapy program with their parents versus the kids who didn’t.
And the big areas we saw changes to, in addition to just the severity of their ADHD symptoms, was their organization skills, how they’re getting along with their family members. And one of my favorites is that parents were way less stressed after participating in this program as well. So having an impact on the parent as well as the kid.
So we’ve done 3-NH studies on this. I think at this point we’ve had over probably 400 kids participate in this program in the clinic I’ve been working in. And it’s been really successful.
Dr. Sharp: That’s fantastic. I am just recognizing that out of all the folks I’ve interviewed who have written books, this is maybe the longest into the interview that we’ve gone without mentioning the book. I don’t know if that’s good or bad or what?
Dr. Sibley: That’s okay.
Dr. Sharp: I’m just noticing that. Thank you for being humble maybe and bad for me for not asking earlier.
Dr. Sibley: No, it’s totally okay. The people who are hungry for this information tend to find it anyway. And the other model that I’m doing right now that is really getting a lot of traction, I’ve been working with the US Department of Education on this one- teaching 11th and 12th-grade honors students how to deliver ADHD organization and motivational interventions to 9th graders who are coming into high school and really struggling with that transition. And that’s been awesome because from a public health perspective, if we can train people to give interventions that don’t cost the school district a lot of money, we’re going to be more likely to sustain them.
So these are kids who want to put this on the college resume that they participate in something like this. They want the community service hours that they need for graduation. They’re motivated to be interventionists and they don’t cost anything to the school district. So that’s been a really fun program to develop as well.
Dr. Sharp: Oh yeah. I’m sure that’s an easy sell for the school districts to have if you can get them on board. That’s really cool. And I should say too, we’ll have links to all the things that you’re mentioning in the show notes so that people can check out your book, your website, and so forth, and any other resources we might talk about.
Dr. Sibley: Sounds good.
Dr. Sharp: Yeah, this is great. I did want to ask, with that STAND approach that you’re talking about, is that something that could happen in a group format or is that more of a one-on-one family meeting with the parent and the kid or what?
Dr. Sibley: We’ve done both models and we’ve even done a study comparing two models to see if they are different. So you have a good question there. It turns out for most people who walk through the door, it’s equally effective and you see the types of gains I mentioned two minutes ago. However, the individual dyadic approach, and this was always about an 8 to 10 weeks once a week come in the outpatient type of thing. So people can do it in private practice.
The people who do not do as well in the group and need to be in this more individualized model tend to be parents who have ADHD themselves. They tend to benefit from that one-on-one support from a therapist. Parents who have depression also. And when there’s really high conflict between the parent and the teen. And that makes a lot of sense because in the group, what we’re relying on for the skills to take off in folks is other parents sharing what’s worked for them and being able to give advice to each other.
There’s a clinician who teaches the skills and then the parents process it together. But if parents are having trouble paying attention in those meetings or parents need someone to actually walk them through how they’re going to do those skills in a step-by-step way when they get home because they have trouble with the organization themselves, that one-on-one support is really helpful to them. And if the parents and teens are arguing a lot inside the group, then that’s tricky because they don’t get anything done. So we totally buy into this finding. It makes perfect sense with what we see in daily life.
Dr. Sharp: That totally makes sense. Well, that’s super cool. I mean, we’re always thinking of ways to provide access to the kids we evaluate after the evaluation and something like that would be fantastic.
My gosh, I feel like we’ve packed a lot into an hour. I’m very grateful that you were willing to sit down and talk through all of this and bear with some probably dumb questions at times. Before we wrap up, anything to add, any capstones for some of the topics we’ve talked about for anybody who might be out there listening?
Dr. Sibley: Well, I think one thing you said earlier, something that I like to emphasize to people is that it’s okay to not be sure with these really challenging diagnoses. I find one in doubt, the best thing to do is just consult with other colleagues and probably solve things together because ADHD is really hard to diagnose in adolescents and young adults for all the reasons we talked about.
ADHD is also really hard to treat in that age group as well. Sometimes you don’t see that the things you’re doing are working, but I always tell people, keep doing them anyway, because we know they will pay off. But sometimes things that you do today aren’t going to pay off for 4 years, and that shouldn’t stop you from continuing to do them and helping people who have ADHD slowly build a foundation of success that they can build on long-term.
Dr. Sharp: Got you. That sounds good. I appreciate that.
So I’m going to throw a curveball at you here before we wrap up like I do with everybody I interview regarding ADHD stuff. What are your thoughts/where are we at with research on neurofeedback as an intervention for ADHD?
Dr. Sibley: Well, you see a lot of different conclusions being drawn with reviews of the literature on that. Here’s what I tell people who are patients. There’s not as much evidence that neurofeedback works compared to medication and these therapies I’m talking about. And neurofeedback costs more money. So, if you want to try it and you don’t mind spending the money, go for it. But just be aware that it’s less likely to pay off than some of the other things and it is going to be a cost. So, I think people should draw their own conclusions. It’s tricky because the literature is giving us mixed messages on that.
Dr. Sharp: Sure. I feel like that’s right where I’m landing and that’s validating and just good to know. With you all that is steeped in the literature, I just want to make sure I’m not missing anything. And that’s pretty much verbatim what I’ll tell people as well.
Dr. Sibley: Yeah, because one week a review comes out and says that it doesn’t work at all, and the next week a review comes out and it says it’s the most effective thing we’ve ever done and get into the minutia of the science, but instead of doing that, just make sure people aren’t telling their patients to definitely go do it especially because it costs a lot. And if your patients are going to have a huge financial strain to do something that has a good chance of not working, that’s something I can’t bring myself to do. I want to make sure people are making informed choices.
Dr. Sharp: That’s fair. Well, thanks again for the time. This has been awesome. If people want to reach out and ask questions or learn more or get in touch with you, what’s the best way to do that?
Dr. Sibley: They can email me. My email is available online by just typing my name into Google. It’ll come up all over the place. I love connecting with people who are both in practice and people who themselves have ADHD and families of people with ADHD because those are the people who keep my work grounded. So, don’t hesitate. I’ll definitely respond to you if you do reach out.
Dr. Sharp: Okay, that’s great. Thank you so much.
Maggie, thanks for the time. This has been super informative and a good time. I feel like we covered a lot of ground. I know that people are going to take a lot away. So thanks. I’m really grateful for you and your time.
Dr. Sibley: I’m really grateful that you brought me on because this has been a really great time to reflect upon some of these ideas. So, thank you.
Dr. Sharp: Yeah, absolutely. Well, I hope our paths cross again sometime soon. Take care in the meantime.
Dr. Sibley: Yeah, same to you.
Dr. Sharp: All right y’all. I hope you enjoyed that interview with Dr. Maggie Sibley. You could clearly tell that she is steeped in this research and really knows her stuff. She’s been doing this for a long time. I just feel so grateful to be able to partake of some of that knowledge both in assessment and intervention for ADHD.
We covered a lot of ground. I would love to have her back and dive into some of those things a little more deeply, but this was a great overview and introduction to many of the things that she is working on. So run and check out her book. I am definitely going to do that and hopefully implement some of that in our practice.
All right. Let’s see. What is next?
Next, I think we’ve got an interview with Ross Greene coming up: the founder and originator of Collaborative & Proactive Solutions (CPS). It was a really good interview as well, so tune in and check that out next week.
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Okay, yall. Take care. I will talk to you next time. Bye, bye.