Could we one day help identify ADHD by looking at the brain?
That is the question at the beginning of this episode of Care Visions Family Talk, in which Lucy speaks with Dr Monica Berntsen, introduced as a practising neuropsychologist who has spent more than a decade working with people with ADHD and autism.
The discussion begins with the way ADHD is currently assessed.
Dr Berntsen describes existing assessment as heavily subjective and questionnaire-based. She says that what is now known about the brain can potentially be used to “highlight and enhance assessments”, while stressing that this would not remove the existing methods or the clinician.
Lucy asks why that subjectivity matters.
Dr Berntsen describes ADHD as an observable pattern of behaviour that can cause implications for work, education, relationships and other areas affecting quality of life. But she says symptoms alone do not tell the whole story because someone can have attention deficits or hyperactivity profiles without those necessarily being ADHD.
She discusses a number of theories about ADHD and then looks at how its description has changed over time.
Dr Berntsen talks about an early emphasis on hyperactivity, the later introduction of attention into the picture, attention deficit disorder and eventually the recognition of ADHD in adults. She also discusses changes to symptom thresholds and says referrals have increased beyond the clinical capacity available to see people.
Subjectivity and bias are another part of the conversation.
Dr Berntsen says different clinicians can interpret diagnostic criteria differently. She specifically discusses women and girls and says they can present differently from the stereotypical “bouncing off the wall kid”.
The conversation then turns to genetics and environment.
Dr Berntsen discusses the biopsychosocial theory and describes an interaction between genetics and environment. She says people can have genes that never activate and genes that do activate when they are in an environment where their predispositions become live.
The discussion then moves to the increase in ADHD numbers. Lucy asks whether the increase is down to the environment, or whether it could be related to the way some diagnoses are being made. Dr Bernsten talks about people looking for explanations for why they struggle to meet the demands of their lives. She also discusses social media, awareness of ADHD symptoms and the fact that symptoms associated with ADHD can relate to other things.
Trauma, sleep and stress are discussed too.
Dr Berntsen uses the idea of mental “tokens” to describe resources. She gives an example in which somebody has a certain number of tokens available but the demands of their day cost more than they have.
She says that if someone does not sleep well, those resources are not replenished. Stress and anxiety also cost resources, and she says cognitive functions including executive function, planning and organising can then be affected.
Those difficulties, she says, can “absolutely look like ADHD but isn't”.
Lucy then asks why the twenty-first century should be particularly stressful given the wars, recessions, poverty and other environmental stresses experienced in previous decades and centuries.
Dr Berntsen talks about pressure to be “good enough”, approval and disapproval, community, support around families and children spending more time on devices.
The conversation then asks what ADHD itself means.
Dr Berntsen says this depends on which theory is being applied. She gives her own perspective that ADHD is “probably a normal variant” of how brains have evolved to process attention, engagement and motivation.
She says:
“I don't think it's a disorder, to be honest.”
Lucy asks about phones, social media, stimulation and school pressure.
Dr Berntsen says she does not think what has changed is children’s brains. She says what has changed is the amount of information processing they are being subjected to and the expectations placed on them.
They then discuss why a child can concentrate for hours on something they love but not for twenty minutes in school.
Dr Berntsen says they get more reward from the activity they enjoy than from somebody talking about something in which they are only mildly or moderately interested.
Lucy also asks what ADHD looks like when it is not hyperactive.
Dr Berntsen describes lack of motivation, lack of interest, difficulty making decisions, difficulty starting things, moving between tasks without completing them and hearing the first part of an instruction but forgetting the rest.
She says these things can appear from the outside as laziness or as though someone cannot be bothered to listen.
The psychological effect of being treated in this way is discussed next.
When Lucy asks about the cost of spending years believing or being told that you are lazy or disorganised, Dr Berntsen answers “psychological impairment”. She talks about confidence, self-esteem, self-fulfilling prophecies, work and relationships.
Parents, teachers and schools also form part of the conversation.
Dr Berntsen says she would like parents and teachers to be curious and not stick too closely to their theory. She discusses confirmation bias and gives the example of a child who struggles in the morning.
The later part of the episode turns to EEG and the technology Dr Bernsten is working on.
Earlier in the interview, she corrects Lucy to make clear that her company is developing software rather than the headset itself.
Dr Berntsen compares the possible usefulness of EEG in psychiatry with the usefulness of an ECG for a cardiologist. She explains that EEG measures electrical activity and talks about the information that can be collected from different areas of the brain.
She is explicit that EEG is not itself a diagnosis.
She says:
“EEG doesn't diagnose for you. It is objective insight that you use as an add on.”
Dr Berntsen says the system being developed would integrate clinical information already collected with an EEG recording and produce a report.
The conversation also covers medication and treatment.
Dr Berntsen discusses patients she believes have ADHD whose brain activity does not show the pattern she anticipated. She gives an example of how this could affect whether she would consider stimulant or non-stimulant treatment.
She also discusses neurophysiology in relation to other conditions, talking therapy and sleep deprivation.
Dr Berntsen explains that EEG measures electrical activity from brain cells. She says the headset they use has five electrodes and describes the areas about which it provides information.
Towards the end of the episode, Lucy asks about trials.
Dr Berntsen says the first stage is for psychiatrists to test the system. She says a second stage will be a clinical validation trial handed over to an academic partner.
When asked what would show that the system has worked, Dr Berntsen talks about getting data that is consistent across practitioners, with clinicians' interpretation of patients being consistent with the output.
She says they hope to involve at least 50 psychiatrists and confirms that the trial being discussed involves adults rather than children.
Finally, Lucy asks what ADHD diagnosis and treatment might look like in the future.
Dr Berntsen says she thinks more neuroscience technology will be developed and diagnosis will become more nuanced. She talks about differences between male and female presentations and between children and adults.
She says:
“Not that I want more people diagnosed. I want more people to have an accurate diagnosis.”
The episode ends with a discussion of whether EEG could play a role for psychiatrists in the future. Dr Berntsen says it is “a bit early to tell” and that “we'll just have to wait and see.”
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