Modern Concepts of ADHD - Peter Hill

Attention-deficit hyperactivity disorder (ADHD) is a combination of hyperactivity, impulsiveness and inattention which significantly impacts those living with the condition. The medical approach to the ADHD pattern of behaviour has been very successful in childhood but the results have been somewhat less impressive in adulthood. This has led to a reappraisal of both causes and treatment in both age groups.

Should the conventional, neurotypical world accommodate people with ADHD as different, rather than disabled?

This lecture was recorded by Peter Hill on 11th March 2024 at Barnard's Inn Hall, London

The transcript and downloadable versions of the lecture are available from the Gresham College website:
https://www.gresham.ac.uk/watch-now/adhd

Gresham College has offered free public lectures for over 400 years, thanks to the generosity of our supporters. There are currently over 2,500 lectures free to access. We believe that everyone should have the opportunity to learn from some of the greatest minds. To support Gresham's mission, please consider making a donation: https://gresham.ac.uk/support/

Website:  https://gresham.ac.uk
Twitter:  https://twitter.com/greshamcollege
Facebook: https://facebook.com/greshamcollege
Instagram: https://instagram.com/greshamcollege

Transcript

0:05

My topic is modern concepts of A DHD. Now, that sounds a bit pompous, and I thought I was being very modern because, um, one of my sources, which is quoted on the transcript, which you can, uh, get online from the college website afterwards, and there'll be a few copies, I think available. Um, I thought I was being pretty modern because I got an advanced copy of Steve Cone's recent authoritative, uh, survey, uh, of modern A DHD, which was published only two weeks ago. I thought, this is it. I, at least I'm not quite ahead of the game, but I'm not nearly there. And then I was trumped, um, a phrase to be used carefully, um, by Mr. Matthew Paris. The Gresham College lecture that you're listening to right now is giving you knowledge and insight from one of the world's leading academic experts, making it takes a lot of time. But because we want to encourage a love of learning, we think it's well worth it. We never make you pay for lectures, although donations are needed. All we ask in return is this. Send a link to this lecture to someone you think would benefit. And if you haven't already, and click the follow or subscribe button from wherever you are listening right now. Now, let's get back to the lecture The day before yesterday. Uh, who has a very modern concept of A DHD, and I might, this is in the Times Newspaper, in his opinion column, he says, he writes, I do not believe in A DHD at all, except as a catchall for a whole gaggle of unrelated ways people behave. Um, he then goes on to have a mild savage at autism spectrum disorders, but, um, that, that is more modern than I can achieve. But in a way, I sympathize with him. I no wish to attack him. Well, I do actually, but I'm not going to <laugh>. I'm not going to, I mean, I think if you start to think about A DHD, it does seem a bit weird. Now, I am gonna talk about that, uh, the weirdness. Um, and I'm gonna talk a little bit about the way it's missed and how important it is not to miss it. I want to mention why it's thought of as a neurodevelopmental condition and how expensive it is for the country. And that means you and me. And, uh, then I'll return to this business of neurodiversity. Uh, and, uh, the contrast between differences and disabilities, uh, on indeed, occasionally a blessing, uh, for us all. So, may I start by pointing out that A DHD has in its title at the top, a red slash the formal title goes Attention deficit slash Hyperactivity Disorder. And that hints at alternative possibilities. I will say no more at the moment, but you'll see what I'm driving at later on, I hope. Traditionally, uh, A DHD has been described in, in literature, uh, since the 18th century and in medical literature since the beginning of the 20th century. It's not a new idea. It's a relatively new name for what has often be called hyperactivity or something rather similar. And it's represented by a triangle, uh, between hyperactivity, which is, I think you can understand what hyperactivity means. Um, and I'll explain in a minute, attention deficit, which nowadays we would call inner tension. There's a subtle shift in the concept because I mean, people with A DHD don't have an attention deficit. Um, I'll explain. And impulsivity, which means doing things very suddenly in response to a provocation or a stimulus without any forethought of the consequences. You just do it not all the time, but it's a tendency. And that triangle is colored in. It has content. It's not just three unrelated concepts. And I think Mr. Paris got that a little bit wrong. They do actually cohere and they correlate with each other. That is, uh, easily observable. And there's quite a lot of literature about that nowadays. We don't talk about the triangle so much as a, a bisected circle whereby A DHD combined presentation, I'm being very formal in the, my use of diagnostic terms is, uh, a combination of inattention, which is what I'll call it from now on, and hyperactivity combined with impulsivity. The Americans from whom this concept is, uh, well, they originated this concept, have never been that keen on impulsivity, whereas the Europeans have always put it in there as an essential component. But, um, under a little bit of pressure, it's now regarded as a combination of hyperactivity impulsivity. And don't try and read all this, please don't read that. I put it up to illustrate that there is a list that all clinicians use, a list of inattentive items so that people, for example, don't concentrate very well. They don't sustain attention very well. They get distracted, they lose things, they're forgetful and uh, and all that sort of stuff. So you can see it's actually quite a complex task quite to understand what inattention means. And then it gets worse 'cause it includes problems with self-organization, problems with getting it all together so that, uh, disorganization number five doesn't, uh, can't meet deadlines for doesn't complete tasks. There's something about organization in there which may prove to be a, a fundamental idea. The hyperactive, impulsive list is pretty well what you'd expect. These, um, are people and these illustrations are of children because A DHD originally was only applied to children. And a lot of what we know about A DHD has been derived from studies on children, which is a bit of a pain, um, in many ways 'cause it doesn't do justice to the full idea of A DHD, uh, in adult life. But these are, these are are people who are on the go, can't still fidget, can't wait interrupts, and uh, and so on and so forth. Now, you've got two lists of nine topics there, and that is important because your first step on the diagnosis, if you're trying to make a diagnosis, is you've gotta find six items on each list. Six from the inattentional list, six from the hyperactive impulsive list. If it's a child or five out of nine, uh, it's an easier target to meet for adults have five outta nine on each list, and it doesn't matter which six you choose. So the first weirdness is that there's not a list of six items that you have to get. There's a, it could be any old six. And that I think, uh, for many people seems a bit weird, a bit strange, a bit haphazard. But each of these items, if I go back for example, to, uh, one, each of these has to be excessive. It's not just that people can't wait, of course people can't wait, but this is really, really, really can't wait. People are noisy. Well, I mean, people can be noisy, but this is really noisy when it's excessive and when it's inappropriate. So within that list, these items have to be excessive for the age and expectations, uh, of that individual. They have to, it has to be pervasive across situations. It's not just being noisy in a club, a nightclub, that sort of club. Um, it, it's actually being inappropriately noisy, being unable to moderate the level of your noise creation according to the circumstances. So it has to be excessive. It has to be pervasive across situations. It's not just in one situation. It's generally present in that person's life. It has to be enduring. It's not just how they were on Wednesday night. It's how they have been for months and years, and usually back to early childhood. Um, in formal diagnostic terms, it has to be before the age of 12. And that gets interesting, and I won't bore you with why it's interesting 'cause it's not very interesting, but it's, it's early life onset. This is something that's been going on for most of somebody's life. So the word developmental comes in because of that. If I say something is neurodevelopmental, so these are our characteristics are present in the general population. They are characteristics and behaviors that Mr. Paris observes. And they're characteristics that you can observe about yourself or your life partner or your children, but they not necessarily would those people have them in excess across situations and enduring for years. If you take six out of those nine items for two lists, there are, uh, pretty well 16,900 combinations. So when I say you've gotta have six out of nine on one list and six out of nine on the other, you think, yeah, okay, that's why the hell of a spread of differences. And this is the first hint, I think I suggest to you that A-D-A-D-H-D is a very heterogeneous, a very diverse condition. And, uh, just as I think, uh, Fran Hape was saying last week, uh, you meet, um, one autistic person and you've met one autistic person. You know, people with A DHD are not all alike. They're very individual. So, and this is real. Uh, this is a study by, uh, silk and folk in Australia, 146 children just recently. Um, well, not that recently, actually, God, 2019 seems a long time ago. Um, on 146 children in the study, there were 11,620 combinations. Somebody spent all afternoon working that out and counting them. So it is diverse, and this is actually one of the problems, but I can I reassure you, there's a way of thinking about that. If I take those lists of nine items and say, you've gotta have six out of nine on one and six out of nine on the other, then if I represent those items by pieces of fruit, uh, there's your hyper impulsive list on one side, six pieces of fruit and six pieces of fruit for inattention. And what happens when you put those two together? What do you get? You get fruit salad, <laugh>. Yeah. Now, let's say that you move on to the next person or the next kitchen, uh, and you get a slightly different list of six out of nine from a hyper impulsive. If you have to take it from me, that is slightly different list and six outta nine for inattention. And what do you get? Fruit salad. It's not ouie, it's not stew, it's fruit salad. So you, although you have diversity in the components of A DHD, ultimately you have something you can recognize. So you have five or six items on each list, that's not enough. Even if those are excessive and enduring and pervasive across situations, uh, and present from early life, that's not quite enough. You also have to have an impairment. So the disability is wired into the definition, wired into the medical definition. You have to have impaired functioning, uh, impaired social functioning, academic functioning, or occupational functioning. So it's not just enough to be lively and a bit to shabby on your concentration and a bit impulsive, uh, actually got to impair things. And this is, I think, a necessary condition for, for lots of reasons. Uh, one is that it, if you have a thing like that in a diversity, sorry, in a, a diagnosis, uh, then that, uh, helps drive people towards services. So back to the, uh, bisected circle. This is a combination of attention deficits. Six outta nine of that minimum could be nine, outta nine, uh, and six out of nine if it's a child on hyperactivity and pulsivity, five out of nine. The, one of the problems I have in, I mean, I chose to bring the word concept, uh, into the title of this, um, illustrations are very difficult with concepts. Uh, you will form your own mental representation. So I hope you are very good at it. Uh, jolly difficult to, to illustrate. But, um, there we have the idea of combined presentation, A DHD, the commonest variant. And you can sense that the illustrations and images I've chosen are predominantly those of children because that is where the condition was first identified. It's been typically described in childhood. And because it's been typically described in childhood and typically described in boys because in clinics, boys have outnumbered girls, sort of nine or 10 to one, um, until very recently. Um, I'll return to the question about girls and women later, but it's, the whole concept has been driven by boys who are hard to teach. They're hard to live with, uh, and hard to be friends with. You know, it's, uh, actually those items that you've seen listed on those lists of nine, uh, are very much driven by people's experience of boys who are squeaking wheels who need to be oiled. Now, on those list of nine items, there's no single behavioral item that is always present in A DHD. We can't say they're all, every single case of A DHD is pathologically forgetful, for example. We can't do that. It doesn't, it isn't the case. So that is perhaps why, um, people have been led towards the idea of a list within which you could have various combinations.'cause all those items on each of those lists of nine are valid and contribute to the diagnosis. Ultimately, they all go into the fruit salad. And look, you can't leave one out and you, well, sorry, you can leave one out, but you can't say it is always the case that fruit salads contain kiwi fruit. Um, and as far as I know, they don't. So there's no single behavior item that is constantly present. There is also, I must tell you, no objective test for this diagnosis. There's no brain scan. There's no blood test, there's no EEG test. There's no genetic screen that will identify a DHD as opposed to anything else. So we do not have an objective test for something that other otherwise is readily recognizable and measurable. And it can be graded on a dimension from severe to mild, which is, uh, a useful thing. One does need a cutoff to, uh, illustrate how within the general population on the left, there are plenty of people who are overactive and rather impulsive and, uh, can't concentrate terribly well. And some are severely so, so that it becomes a problem. And the cutoff to identify those, if you can spot it on the right, is a thin vertical line that represents where the disability cutoff is. Now, you may think that's not great 'cause how do you measure disability? Well, you can actually, there are things like the we scale that you can use to identify disability. Um, but actually different countries interpret that rather differently. So different countries quite often come up with different rates for A DHD in childhood, the Americans are very keen to identify 11% of children as having a DHD, uh, in this country. Um, a major survey done well now nearly 20 years ago, identified 2.4%. So huge differences between countries are called it a what is disabling and how it is measured and how it's identified. So although that disability concept is very important, trying to measure it is somewhat end cultured. Um, and from an international perspective, somewhat haphazard. But generally speaking, most people subscribe to the idea that about 5% of children will have, um, this A DHD business. Now, when they do, one of the things that comes through very strongly is that you don't just have a DHD for most cases, pure A DHD, pure and simple with no associated other conditions is unusual. 80% at least of, uh, people, uh, notice my change of work.<laugh> have something else going on in childhood that tends to be angry, antisocial behavior. And when, um, I sing, uh, surveyed, uh, attitudes towards A DHD in children quite a long time ago, uh, what she found was that the general public see a DHD as something associated with angry hostile, oppositional irritating behavior. And that can be dressed up in various terms. And I'll return to that topic, but there's a huge overlap. 70% of boys with a DHD boys will also show aggressive antisocial behavior. When you take a step back from that and say, well, okay, what else is quite likely to happen with A DHD? The answer is other neurodevelopmental conditions. So that, for example, 21% of folk, oh, sorry, 2000% of children with A DHD, uh, will also have a SD will also have an autism spectrum disorder. So this is quite a substantial overlap, which wasn't allowed in the diagnostic rules, uh, until, uh, well, nearly 10 years ago. Previously you could have one or the other, but we now recognize that you can have both and, and both is quite an issue. The same is true for things like ticks and dyslexia. Somewhere around about a third of children with A DHD will also have dyslexia. So there are these huge overlaps with dyscalculia. With dyspraxia. I saw a paper recently that argued that 90% of, uh, children with A DHD also have dyspraxia. I think that's pushing it a bit. And it depends where you draw these samples from. If you just look at clinic populations, then you get these high rates of associated problems.'cause that's what drives the referrals to clinics, because each of these associated problems magnifies the impairment that is associated with A DHD diagnostically. So, um, very important overlaps with angry behavior in childhood, very important overlaps with other neurodevelopmental disorders in childhood, in adults, the picture changes. The, the problems of dyslexia become less problematic with adults. The problems with ticks, uh, very often melt away, uh, and so on and so forth. But in adults, you get a different pattern of coexisting problems. You get, um, high rates of anxiety disorders, uh, depressive disorders, substance misuse, mainly nicotine, alcohol and recreational. Um, you get an association with antisocial behavior that I will return to later, which is really quite strong. And we now recognize that sleep problems are really very common in adults with A DHD. So again, you've got huge overlaps with other conditions, and it's almost as though A DHD can also be visualized as a vulnerability factor. It means it's more likely that you will suffer from something, let say, like, like depression. And though when you do, when it's another condition that adds to the impairment. And that has important, very important implications for assessment. It also means that the A DHD itself may be hidden so that people see the antisocial behavior. They don't spot the A DHD, they see the substance misuse. They don't spot the A DHD. So there are problems about with overlap magnifying disability, um, and also hiding by and large. I must just must just mention that although I've said, well, it's about 5% in children, roughly speaking internationally, um, the rate of A DHD among the general population does get less with age. It's been a very important political point to make, uh, that people who have a DHD in childhood, an adult who may still have traits or persistence of A DHD behaviors and symptoms, but the full diagnosis falls away as one gets older. I've no idea what an older adult is. I think an older adult is somebody older than me. Um, 79 plus. Um, so yeah, there is increasing recognition that A DHD can affect, um, those who are graced with an older age. Um, but the rate for does fall off. And again, this is consistent with the idea of A DHD being a developmental condition. What makes it more likely that someone is going to have, get, possess, be possessed by A DHD? Not quite sure what the right verb is, but the short answer is genetics comes through very, very strongly indeed the heritability of A DHD. The amount, the extent to which genetic explanations account for the differences between A-A-D-H-D folk and neurotypical folk is about 80%. So it's heavily genetic, but it ain't one gene or even three genes. Uh, the most recent survey on a genome wide, uh, association study, uh, is that there are 76 genes which are implicated in the production of, uh, A DHD. So it's polygenic. Yeah, there's a lot of genes involved, and some of those genes do other things as well. One of the most strongly associated genes, um, a few years ago was a gene that is primarily associated with dyslexia. So it depends where you get your sample from, but this is using a general population sample, not a sample from people attending clinics where you might expect a high rate of dyslexia. It is still the case that there are an awful lot of genes just as there are for other, many other human characteristics, such as stature or intelligence, for example. And there's nothing within the genetic risk factors, the genetic factors that make it more likely that you will show a DHD. There's nothing specific that you can use for diagnosis, which is a bit of a problem because, you know, one hopes with a heritability of 80%, you'd be able to say, right, we we'll do a quick PCRA quick, um, genetic, uh, glimpse of what is going on in somebody and, and work out whether they've got, uh, a risk of A DHD. You can't do that. There are too many genes involved. Heterogeneity, again, diversity again, within the A DHD world, little things are different one to another, but we've still got a DHD as a recognizable condition that can be measured. There are going to be environmental risk factors. Of course, there are, um, that is especially true for polygenic conditions. But when you look at the hard evidence, the replicated evidence where several studies have said the same thing, it's mainly to do with pregnancy and birth, and particularly being born too sore too soon or too small, or in fact, having complications in very early, um, weeks or months of life. So it's mainly obstetric. The big one, of course, is, um, alcohol. The children who in the womb were exposed to alcohol consumed by their mother are really very likely to have a DHD. And if you look at the, uh, old category of fetal alcohol syndrome, the rates of A DHD and that are over 90%. So fetal alcohol is a problem. Uh, fetal alcohol exposure is a problem, but mainly it's obstetric stuff. Now, there are other environmental risk factors that everyone's been very interested in, and you, you can, uh, see newspaper articles frequently blaming, uh, too much looking at, uh, computer screens, too much playing games, um, how too much lead in the atmosphere, these lots of single factors, too much stress in late pregnancy. The difficulty is that those tend to be factors which are identified in small studies, which have not really been sufficiently replicated. So I'm not putting those on the list, uh, because that just makes everyone feel guilty. Um, I don't, uh, once you take out, um, the pregnancy factors, there isn't much else. Uh, there is really no good evidence, for example, that too many computer games produce A DHD. Uh, there is sort of, you know, a small study here, but not confirmed in three other studies that have found it a bit difficult to get published. It's, um, I want to move on from risk factors that might lead somebody to develop A DHD to what the dickens is going on. If I say it's neurodevelopmental, that word neuro for practical purposes means brain. Um, and brain is at the center of A DHD research. This is a picture that shows how the, the cortex, that's the surface of the brain where so many nerve cells are that are involved in higher brain functions, like thinking, for example, or, or memory, for example. Um, the cortex in a DHD on the top line is really not developing the solid purple, thick, extensive cortex that one would hope. And these are ages 7, 8, 9, 10, 11, 12, 13. This is, uh, late childhood, and the cortex is just not developing at the rate that it should. That I think, is very important because when you come to say, okay, well let's take a wider age range and see what's going on, here's, um, a map of the, the cortex. This is a brain side on, um, there are three key areas that, uh, are involved, where the cortex has just not developed as much as it does in neurotypical folk and in A DHD folk. Uh, the cortex is less well developed in this stuff, in the inferior frontal, the front of the brain, the dorsolateral prefrontal cortex, which is, uh, very important in things like working memory, which I'll explain later. Uh, and the parietal cortex, which is to do with the tension. Uh, the inferior frontal cortex is mainly to do with inhibiting a wish to suddenly do something. It's the bit that's soluble in alcohol. And I wrote up, uh, a quote from, uh, Kacha Rubia who is the queen of, uh, A DHD brain imaging, as far as I'm concerned. Uh, and, uh, that is, uh, word by word what she wrote in the article by farone, which is, uh, on the reading list, the reference list of the transcript of this talk, which you can get hold of, I guess, that A DHD is due to immature brain structures. It hasn't developed enough in few K areas. I'm not saying that people with A DHD have got totally immature brains that would be wrong, but there are these three areas where it does seem as though the cortex has not developed sufficiently thickly compared with, um, uh, with neurotypical folk. And that also applies to the wiring. Um, please don't take that literally as an illustration of nerve tracts, but there are an awful lot of nerve tracts that link parts of the brain together. And when one looks at the nerve tracts close to those areas that I was mentioning there, then you find that they're poorly organized. They're not developed as well as they should be. And there are ways of measuring that, uh, which I can't show you except by using rather complicated mathematical stuff. Um, and I, it, it's, um, too late in the day for that. I do want to mention that there are nerve tracks. Don't worry about the, the names, just look at the colors. There's a red tract that starts in the middle of the brain loops towards the front, and therefore is closely involved with the frontal cortex, which is the in inhibitor of impulsive behavior. Uh, and also, uh, the management of activity, motor activity. And there's a, a blue, uh, tract that does the same thing, but goes a little bit further over so that that now links into the areas and the parietal cortex that control attention. Now, I bring these nerve tracts in because the medicines that can be used with great effect in A DHD, um, assist these nerve tracks in the jobs that they do. They assist neurotransmission at the synapses. There's the junction between, uh, various nerve cells and those therefore, um, that nerve innovation, uh, of key areas in attention, uh, working memory, uh, response inhibition. Um, I just put up, because I'll probably come back to that at some stage. Now, there's something else about the brain I want to mention, which I think has been a very important idea. We have two, all of us have two sets of circuits in our brains that control the style, which we adopt in thinking. And I want to talk about default mode thinking. The brain is always active, the brain's always at it, but it in default mode thinking. When you're on your own and you are pondering, you are musing about yourself, about recent memories, about things you'd like to do a bit of daydreaming, think about yourself, think about close relationships, uh, what's been going on without trying to tackle a task. Your brain is using, um, default mode thinking it's default because it's not being asked to do anything very specific. And let's be contrasted with task centered or task positive thinking. When you've got a real problem to cope with, you've got something that suddenly you've gotta think about and do. This is, uh, active brain imaging of default mode thinking where you can see that, um, we've got the brains go forward and backwards on this one, but there are various areas in green where neurons associated nerve cells associated with default mode, musing, daydreamy type thinking are, and there are already orange ones that are to do with task centered mode, task positive thinking, and they're in different parts of the brain. Now, anyone can enjoy a little bit of, um, default mode thinking. It's quite nice, um, particularly when you're trying to get off to sleep, you know, it's, um, musing, uh, about things. Um, but when you actually have suddenly have to do something, when you have a cognitive task to solve, like an arithmetic, arithmetic problem of, um, offsprings homework or something like that, um, so do it for them. Uh, then you have to switch off default mode thinking you turn it off so that you can enter task centered or task positive mode. Are you with me? Now? The problem with A DHD is the brain doesn't. So you are in nice, cozy daydreamy default mode of thinking, and you are suddenly faced with a problem that requires concentrated thought. Um, and you don't turn off the default mode. You may go into task centered, task positive thinking, but you don't switch off the other stuff. So you look as though you are daydreaming in class or at work. You look as though you are not really with it. You are in a fog. You are in, uh, ah, I don't know, planet hill land or whatever it is. Um, but actually the problem there is that you can't turn that default mode thinking off. Uh, and that's now, I think, been shown in a variety of studies quite elegantly. It doesn't apply to everyone with A DHD. This is not a test for A DHD doing that functional brain scan. It's not identify A DHD reliably, but it is a common problem within the heterogeneous diverse area, uh, of A DHD and the way it is done by the brain. Can I talk about something slightly different? Now? I want to go back to talking about classification within diagnosis. Uh, you remember I showed you a circle that was bisected into a blue bit and, uh, a ready orange bit. Um, as time has gone on, people have realized increasingly you can just have primarily inattentive presentation, A DHD, or indeed, primarily, predominantly, uh, hyperactive, impulsive, A DHD. And when you do that, stone me if the two varieties of presentation don't actually behave as though they were combined A DHD in their response to medication, in their ability to be associated with, with impairment. And for practical purposes, they are still A DHD. They only half of that original circle of combined A DHD, the communist variety is, is present now. You see what I mean by weird? The, the concept does get a bit hard to think about, um, unless you're a journalist. Uh, the, did I use the word think? Yes, I did. Um, predominantly inattentive A DHD, which is the items on that first list I think I showed you about not having difficulty with concentration, difficulty with self-organization, uh, difficulty resisting distractibility and so on and so forth, is mainly as combined people who used to have combined A DHD, but have got older, we could say grown up. So this is much more typical in biologically more mature individuals like women, um, and in adults as opposed to children, whereas the predominantly hyperactive, impulsive, it's really rather typical. Most of the cases I've seen have been under the age of 10, they've been sported, but then I'm a children's doctor. I would be seeing young children, I suppose, uh, but that it's a younger group with a primarily hyperactive, predo, hyperactive, impulsive presentation, and you switch around between the two. Uh, this is something that gets even worse. But before I get onto that, um, A DHD in girls is I think, a major issue. I mean, I think A DHD is a major issue for reasons I'll come back to. The girls are much more likely to be inattentive in their presentation. They're not racing around on the go the whole time. They're not noisy, they're are not difficult and oppositional in class. So they don't get referred to clinics. They don't wear their parents out in quite the same way, but they are dreamy. They are in la la land. Uh, they look inattentive. They don't always respond when they're spoken to. Uh, and I'm talking about people who are excessive, enduring, pervasive, you know, it's not just, um, everyone's daughters. Um, they are less likely to be identified because of that. As I said earlier, they're, they're not the squeaking wheels that need oiling. They don't get referred to clinics. They get mist because people just think, oh, well, she's like that. But actually she may be really struggling with, uh, keeping her work up to the standard that her intelligence predicts at school, for example, she may be, have difficulties holding down a job in, uh, in industry or in the office because she seemed to be dreamy and not quite with it. So, and then people just think, well, you dare. And they may make misogynistic remarks for all I know. Um, they're much more likely to try and conceal that. They don't always, but they're more likely to try and to mask it. Those of you who heard Fran Happy's excellent presentation just a week or so ago, uh, she was talking about masking, uh, the extent to which people with autism will strive to appear normal. The same thing applies to girls. They strive to fit in, they strive to be, uh, good, um, in quotes. Um, and that is exhausting. They're also much more likely girls with a DHD much more likely to show emotional reactivity to live. They, uh, they cry, um, they get upset, they get miserable, they get dis demoralized. Their self-esteem suffers. Um, they, their performance over time tends to be inconsistent. One of the consistent things about A DHD in girls is that it's inconsistent. And, uh, because of all this, it gets missed or it gets given the wrong diagnosis. It gets labeled as, uh, anxiety or it gets labeled as personality disorder, heaven forbid. And the, the key concept is mist. So the treatment doesn't reach the person who would benefit from it. Let me say some of the same things about A DHD in adult life. This is, uh, a graph, um, which, uh, I, uh, is actually a graph of prescriptions. It's not a graph of, uh, of prevalence. It is prescriptions. And this is, uh, important I think survey by Dawn Connolly in the prescriber's journal, uh, last year. The blue line is prescriptions for adults with A DHD. The red line is prescriptions for children with A DHD. There are now adult, A DHD is increasingly recognized as something to be treated. Uh, and that I think illustrates where we are at the moment and where we are with adults is that the presentation is much more likely to be inattentive, um, compared with the, the predominantly hyperactive impulsive group. So it may still be combined. You're quite entitled to have combined A DHD as an adult, no problem. The bisected circle. But by and large, the adults with A DHD are predominantly inattentive, and it's a much more subtle presentation. Fortunately, we now have the capacity to listen to what adults say about their own experience of A DHD. And they don't say, I'm on the go the whole time, I'm noisy. I don't concentrate very well. They don't say that. They may say it if asked, but they say it's exhausting. It's knackering to have a DHD. So many say not everybody, because there's no feature that is constantly present in A DHD. They, in my experience, grumble about their own forgetfulness. I, I go out shopping and I forget what I'm supposed to be doing, or I come back with stuff that I didn't want because I couldn't resist the distraction of special offers in the supermarket. Um, well, you know, don't we all, um, but mind wandering can be a real problem. Now, mind wandering is something we can all do with a bit of luck. Um, good fun, but intrusive mind wandering where you cannot control the thoughts that are flooding into your mind, one after the other in, um, unless you are interested in free association, which I don't think many people are, uh, it's actually a pain to have your mind cluttered up with one thought after another after the other linked tenuously, or conversely, finding your thinking disappearing down a rabbit hole. And that phrase, rabbit hole rings in my ears from so many older teenagers and young adults who just say, I, the problem is I get this thought and it's so interesting. I just wanna pursue it further and further and further, and I get on the rabbit hole and I can't find the way out. Um, and, uh, I've made the point about masking that adults will quite often say, I have to strive to contain my A DHD to be more like what my employer, my partner, my children want to be. Uh, and so they try and pretend and that it is one of the components that contributes to the it's exhausting quote. Now, the other thing that adults I'm still on adults with A DHD struggle with is weak cognitive executive skills. That's a mouthful. But what it means is that there's a group of higher ways of thinking and living one's life, which have to do with planning and self-organization and organizing a task and doing it systematically and seeing how far you've got and all the boring stuff, uh, that one's taught in time management courses and so on and so forth. Um, actually manage it to complete a task set by somebody else, or even set by yourself becomes exhausting because you lack the skills to do it. And this is a common issue, very common issue in adult A DHD. Not universal, nothing is, but it's a common one. And, uh, Russell Barkley, who knows everything about A DHD, um, we will say we ought to be calling it intention deficit disorder. And his quip, uh, I think is quite a good one. These are people who know what they should be doing. They know what to do, but they can't get to do what they know. So they know what to do, but they can't make themselves do it. And I think that is quite a common issue in terms of self-organization and the way you go about your life and the way you go about shopping, the way you go about cooking, the way you go about managing your, your work. If you are trying to invent a new solution to a problem, intention deficits or not to be taken seriously, I mean, Russ, I wouldn't want people to take it too seriously, but he's, he's making a point. Now, all this means, I think, and this is just a quick comment before I talk about something else. Um, that assessment of A DHD must be structured. It must be thorough. Uh, I suggest it should be done face to face. I'm very suspicious of remote assessment for A DHD. I actually don't think people should do it, because one of your things you're going to want to know is, is this person should they wish going to be able to tolerate medicines for A DHD. And you can't do that unless you examine them physically. And I get despair of remote assessment of A DH adhd. It's not good enough, but it also needs to be structured. One of the instruments like the ACE or the ACE plus or the diva needs to be used so that people systematically ask about the associated conditions that contribute to the disability. And so it must include a coexisting conditions. And I would argue that you should always have a witness to a witness, sorry, that's a medical slang for somebody who can describe how the person in front of you who may want to be a patient, if you see what I mean, actually is so you don't just rely on what they say, you need somebody else to say, oh, for God's sake. Yeah. Um, he often is, he, well, much less so the ratio of boys to girls, of course, it's really quite high. It's somewhere around about four boys to one girl. Nowadays. The ratio in adults, um, is, is about more. It's getting close to one to one. Uh, but right at the moment, I would suggest it's, uh, two men for every one woman with A DHD varies across the age range of adulthood. So I'm making a quick point. That assessment has got to be thorough. And the comment by Anthony, David and Quentin Deley, um, a couple of weeks ago, that there's so much self-diagnosis of A DHD that this is wasting health service resources is I think, valid. You know, self-diagnosis is okay, but it needs to be confirmed. It needs to be confirmed properly. And if it's confirmed as I know it is sometimes by somebody just collecting some rating scales, that is bad practice. It really is bad practice. You, you sense a rant coming on. I I will suppress the rant. My frontal lo will, um, not allow me <laugh>. The big question I think is whether we've got the definition of A DHD, right? Um, clearly we haven't quite got it right because we started off talking about boys'cause it was boys who, uh, services were presented with. And boys are a poor representation of the world in general. Well, sorry, mean poor, I mean inadequate. They're not in, you know, you've gotta look at, so you've gotta look at the girls, you've gotta look at the women, you've gotta look at the adults. And the more we do, uh, the more questions are raised as to whether the original definition, like six out of nine on a couple of lists, plus a, uh, disability factor. Is that enough? Is it enough to talk about inattention and hyperactivity impulsivity? And I want just want to address that. One of the things that we now recognize in the last two years is cognitive disengagement syndrome. That's used to be called slow mental processing. Before that it was called sluggish cognitive processing in the USA. But the word sluggish, um, I think probably doesn't tolerate European import very well. Um, should I be saying British import? Probably I whatever it, it doesn't travel well. I don't like calling people sluggish or their thinking process sluggish. So cognitive disengagement syndrome is people who are pretty inattentive and pretty slow and quite tend to be a bit scary in a fog is the phrase that's used over and over again, who are slow to respond to questions and conversation. Uh, when they have to think about it, they don't have to think about it. Yes, of course they can be quite lively. I went to around to the house of, uh, somebody I know who is definitely cognitively disengaged. He's fine with his mates, you know, within the sort of narrow discourse of male bonomi as applied to 21 year olds. He's absolutely fine. But if I say, um, how do I, uh, which tube station do I get to? He has to stop and think about it. He's slow. Um, but accurate. Uh, so in a fog, they tend to be rather drowsy and new yawning. So this is a variant. This is one part of the predominantly inattentive presentation picture, which has now been quite well described by Becker and, uh, teams who've renamed it cognitive disengagement. I expect that label will stick though it's only 18 months old so far. Uh, and those I, the question is, do we recognize this? Do we recognize this pattern as a component of A DHD? Some 20% of adults with inattentive A DHD fall into this group and can be described. They can, some of them be described as having a DHD as well, but they can also, if you look at that bar, extend outside the semicircle of predominantly inattentive. So it becomes an interesting possible contributor to the A DHD picture, but it seems to exist on its own as well. The same applies to, um, deficient emotional self-regulation. I'm sorry, it's such a mouthful. DESR. Now these are people who, uh, tend to be pretty irritable and flare up with anger and are minimal provocation. So they're emotional self-regulation, particularly with respect to anger is, is it's not great and they're hard to live with and they're fairly fierce and they have a deficient inhibition of anger and frustration. They can't seem to self-soothe everyone says calm down, but they can't actually calm down. It can't happen because they can't find a calmer reaction to substitute for their rage. And it goes on and on and on. You know, they don't calm down within minutes, still quick flare up, it grinds on. So there is deficient self-regulation and the argument is, lemme just look at my crib sheet because I'm tempted to add something in. I'm not sure whether I'm allowed to. Um, I think I probably won't add it in, but you can sense that this is a common problem. Probably 70% of male teenage with adult A DHD male teenagers will show this picture and it can endure into adult life and it can make such people impossible to live with for very obvious reasons. You are on eggshells the whole time. Um, and they don't like it either, frankly. Uh, they will often feel contrite afterwards. So whether they're able to confess to that is, uh, arguable, they can't seem to detach their attention from the provocation they experienced. The difficulty with incorporating it into A DHD is that angry antisocial behavior. As I mentioned earlier, this is the slide I showed you earlier is common in male A DHD in childhood. So we're suggesting this is a very specific form of anger as opposed to generally oppositional defiant disobedience. Grumpy behavior is different from conduct disorder, which violates the rights of others. And I think in term, putting it into a clinical practice might be difficult 'cause it may lead people just to dismiss the anger and say it's part of A DHD, uh, and I will return to that. But at the moment I think it's quite tricky to integrate it. I wanna say something about working memory weaknesses. I don't mean that people with A DHD haven't got a memory. I don't mean that their memory doesn't work. It's um, it's what would happen if I said okay to them. Okay, I I'm gonna say some numbers and can you remember them and repeat them back to me? So I go 9, 8, 6 4 3 and I say, can you repeat that back? And they go, yeah, 9 8 6 4 3, what's your problem? I say, well, the problem is now, can you repeat it back in reverse order? And they go, oh, um, three. Um, yeah, next question please. Uh, and they actually cannot hold the stuff in mind in order to be able to reorganize it and repeat it back to you. It's the reorganization that is working memory. It's reorganizing what you've heard in the previous 30 seconds in order to encode it so that it can be then transferred into long-term memory, for instance. Now working memory weakness are common in A DHD. Um, last survey of my patient population, I did this on and compare notes with somebody up country was, um, that it's probably 70% of, um, both boys and girls with a DHD have a weak working memory. And if you remember that picture of the brain I showed you with the, uh, a dors, medial frontal cortex patch that wasn't working, that's the bit that holds working memory. It's not memory, it's being able to hold it and work on it. Now that can also occur outside the A DHD bisected circle. It could happen. For example, I used to run service for children with traumatic brain injury. Very common issue in traumatic brain injury, almost universal for instance. So it can arise for other reasons. Um, alcohol intoxication, you've probably noticed in people, you know, there are many other reasons why you can't actually hold stuff in mind and think about it. So, uh, but people are arguing that there should be incorporated in the core diagnosis of A DHD. And I concede why. The other bit that is very trendy, and I'm only mentioning it because it's fashionable, is well not quite 'cause I, I think it is an issue. Rejection sensitivity dysphoria. You'll observe the folk in the A DHD academic world are very good at dreaming up complicated phrases for something that's really quite simple. What I'm talking about here is sensitivity. Now I don't mean physical sensitivity to sensations, I mean sensitivity to being rejected or ignored or criticized. Um, now people come back to me and say, yeah, you're talking about narcissistic personalities. I say, well, yeah, might be. You can get rejection sensitivity dysphoria an unpleasant state of mind, an unpleasant feeling if you are super narcissistic and you can't take criticism. But you can also get it because you've got a DHD. I mean, you could have a DHD and narcissistic personality if you want, but so that seems to be, to be over egging the pudding. Um, so rejection sensitivity dysphoria is important because it's common in A DHD and it's exclusive as an experience that a sm a small slight, which could perhaps not noticed by anyone else, can feel devastating. A powerful, intense negative emotion, shame, fear, anxiety, even fury, um, following a perceived criticism or withdrawal of love and so forth, and is pursued in that the experience pursues itself in one's mind by persistent negative self-talk I rumination. And they can't let go of it. They can't get over it, they can't move on, and they feel over time repeatedly attacked. That is their general experience of the world. Now, it's important for folk with A DHD 'cause it does respond to one of the little used A DHD medicines. It responds to guanine, which is intuitive, which is not that widely used. It's actually not technically licensed, whatever that means for adults in this country. But, uh, claims are made that some 60% of people with, uh, that sort of rejection sensitive dysphoria, um, can uh, be helped with ine. So now, you know, now there are plenty of people around in the A DHD community, um, patients in in quotes who say this should be part of A DHD because it is so unpleasant and so pervasive and so common. We don't know much about it, frankly. So I'm mentioning it because it's in the A DHD chatter at the moment. It's in Attitude Magazine, which is a really useful resource by the way, online. Um, well, pretty well every month. So I mention those things. Now, what do we do about all this stuff? Do we extend the diagnostic pattern? These are the pat the issues that I've raised. Cognitive disengagement, deficient dimensional self-regulation, rejective sensitive dysphoria, working memory deficit. None of them are always present in A DHD, but then nothing is always present in A DHD. It's heterogeneous, it's diverse, but it's still recognizable as an entity one. Um, this is, I'm ashamed of myself by saying all this. I've been ridiculed for saying this by so many people who think I should know better and perhaps I should. But actually you can use medication as a probe to discover whether something is a core A DHD future or not. And the reason for that is that if you, this is a paper, for example, from a Norwegian clinic where they did something very simple, which is actually quite in line with nice recommendations. You know what NICE is nice set out for what they regard as good practice. Um, and NICE is a deeply wonderful thing. But the trouble is he's always 10 years outta date. But within this study, which would've influenced them because it was published 11 years ago. Yeah, okay, you've got some, you've got some children with A DHD, you give them methylphenidate, of which Ritalin used to be the communist form. Ritalin isn't used very much nowadays in my experience, but, um, if you give them that, you get a response rate of about 72%. And this is what you hear over and over again. The response to stimulant medication is about 72%. No, it isn't. If you've tried methalate, uh, then probably three quarters of people will respond. But if you try dexamphetamine, which is what Dex stands for, sorry, MMPH is methylphenidate mouthful Phite as somebody called it. Uh, then if you try one, then stop and then try the other, you get a response rate of 92%. That is fantastic response rate. I'm not saying that everybody should have medicines, that's not my point. I'm saying that the medicines can result in symptom reduction in an astonishingly high percentage. One of the highest response rates in medicine, frankly, you know, we we're pretty well up there with, uh, penicillin g you know, this is 92% response rate. Now, if you give these medications, the stimulant medications being dexamphetamine to ordinary people, you don't boost their concentration. You don't reduce their hyperactivity unless they're bordering on the fringe of that bell shaped curve and the red shade bit there, you can, but ordinarily people in the middle of the bell curve, it doesn't do a thing. In fact, it can actually make things worse. Students who obtain stimulants, illicitly to help them with their exams, um, often do worse than they would otherwise do. So stimulus aren't a, you know, used to worry that, uh, we'd better get the whole population on stimulant medication, otherwise the Chinese will get there first. Uh, but it's not like that. Uh, stimulus don't help unless you've got something approaching A DHD. And if you do that, you've got a 90% response. This is very specific for A DHD. Well, it can help in dementia actually, but don't spread the word too much. Otherwise, there'll be none left for the rest of us. Um, if you want to distinguish these conditions, can you, can you say that cognitive disengagement always responds to stimulant medication? Well, actually we don't know it does sometimes, but are those the cases that have also got a DHD? We don't know. It's the same story with deficient emotional self-regulation. Some people with filthy tempers hot temper as it used to be called, um, will respond to medication. We don't know whether those are just the ones with A DHD or not. And I'm gonna say the same about, um, working memory deficit. Sometimes it responds, sometimes it doesn't. But do we know whether the ones that respond also have an A DHD picture? Actually, current science, we don't know. So I dunno if any of those, and rejection sense of dysphoria is a rather different picture because we just don't know enough about it. We don't know enough about its response to medication, let alone guanine. So we don't know. So I'm gonna suggest that we don't include any of those features. I'm reacting, I I'm going back to saying, look, you know, we're doing all right so far, roughly speaking with what we've got as core features of A DHD. If we, even if we haven't got the description right, we only talk about behaviors. We're not talking about the experience. We've gotta build that in first before bolting on these other behavioral syndromes. Um, the, uh, thing about A DHD is it's very, very, very expensive money down the drain if you don't treat it. Um, the reason it's expensive is the people with A DHD tend to underachieve academically. They need as children special academic special educational provision. Their productivity is low, their earnings are low. Elegant study by David Daley showing with a sibling comparison. The sibling with, um, A DHD was earning not 20 grand, less, uh, per annum. Uh, it's, it's no good. And we've heard a great deal about the claims on disability benefits, which I think are overstated very hard to get API p, um, on A DHD. And the treatment costs are tiny, frankly. Uh, so this is mainly the cost to services and the one, it's, it amounts to billions. I haven't got up to date figures for the uk. The last figures I saw were 15 years ago, and we've come a long way since then. The figures for, uh, for the USA in the Chiba survey was, uh, 20 billion a year. The cost of A DHD treated and untreated $20 billion, uh, a year. The example I want to refer to, um, is we know that one in four prisoners, one in four people in prison have a DHD. They're all blokes. Of course, one in four have A DHD. We also know from two studies I've mentioned, the original study by Lichtenstein, uh, that in, in Sweden, that people who are on medication on A DHD medication are 30 to 40% less likely to offend. So the cost of not taking prisoners and offenders seriously in terms of assessments for A DHD and offering treatment 'cause it can only be offered, is actually very, very expensive.'cause the, the total cost for the prison service in the UK is 3.8 billion billion pounds. Very, very, very expensive. And the last point I want to make is about neurodiversity that a lot of what I've been talking to you about, things going wrong with the brain. And that may or may not be the best way of understanding. It's a valid way of understanding whether it's the best way can be discussed. Because the people who will advocate for a neuro neurodiversity approach will point out that, that over medicalize the problem and fails to take into account the way in which society currently fails to provide a positive environmental experiences where the, where the man touches the world, uh, that is what that's been to supply. So we don't focus on the brain so much, they would argue, but we do need to promote ways in which social change and social adjustment can provide positive and affirmative experiences. And we don't just go on rating scales and symptom reduction. I think that is a powerful argument. Uh, but I don't personally go as far as saying, well, that means we reject the cure model because the A DHD diagnosis itself incorporates an idea of impairment and disability. That is how the diagnosis is made. We've gotta do something about that. And the most effective way, uh, I think is to combine, uh, the medical approach of, uh, taking, uh, an idea of a disorder and symptoms, uh, and ex alongside that, uh, adjust life demands. We do this with children all the time and children's doctors treating A DHD pediatricians and child psychiatrists all the time, uh, uh, writing, uh, suggestions for a modification of exams, for example, to take into account the fact that somebody has a DHD. And that seems to be perfectly sensible. It's going on now. So I don't think it's a question that doctors just prescribe medicines. They don't, they try and modify the demands placed upon people. But I think in terms of research, uh, it's, uh, important that new treatments are evaluated not just on rating scales, not just on the nine items on each list, for example, that I started off with, but by looking at how research on a new treatment can justify the provision of more positive experiences. So if I'm right about neuro university being a good step forward alongside the more traditional medical approach, it should complement it. It should exist alongside, it should not replace it. But the most important step in, uh, promoting, uh, sympathy towards neurodiversity is to educate everyone about A DHD. And I hope I've contributed that. Thank you very much. I've had so many questions that I'm definitely not going to be able to get through all of them in the time available. So I'm going to try and persuade Peter to come back and answer some of them on a podcast on another occasion so that we can give everybody a fair chance. And I'm gonna group some of these questions together to try and get you to sort of group your response too. So there are many, many, many about the complexity of diagnosis, starting with two primary themes. One, it's bloody difficult to get the diagnosis because the service isn't good enough anymore, particularly CAM services. It's the first one. The second is you made quite significant observations on detailed high quality scanning that there may be potential abnormal if, how realistic is it to relate and expect appropriate scans to be done? And the third is because of the complexity of making this diagnosis in the way you describe. Surely this is an opportunity for really robust data collection and the implications of AI to manipulate those data sets to improve the accuracy of these techniques. Yes, <laugh>, I rest my case. Um, I think brain scanning is, uh, if I was talking about brain scanning 10 years ago, I'd be showing you pictures about how areas of the brain light up or don't light up in people with A DHD without a DHD, that's much less possible nowadays. Um, the, the problem is in the technique, uh, brain scans are deeply wonderful, but they don't, they're not very good at controlling, for example, for head movement. They really aren't. And you know, by definition, children at any rate with A DHD, do quite a bit of head movement. That's how they get the diagnosis. And so actually stabilizing the head is a very simple task, but it's only in the last five years that people have developed techniques for really doing that. And when you do do that, you are up against the other problem, which is, yeah, sure. You can show that areas of the brain light up or don't light up according to the task of which task, which is the fundamental task. It used to be resisting the temptation to drop bombs on people when you had control in the MRI, um, tunnel of an aircraft with a, a load of bombs. And small boys find it very difficult to resist the temptation to drop bombs on people. Um, we are way beyond that now. We have much more cognitively challenging task, but I don't think we're anywhere near using, uh, scanning as a diagnostic tool, partly because of the subtlety of changes. I didn't go into the detail, but it's very, they're very subtle changes. So let, Let's, let's move you back to the service inadequacies. Oh, Yeah. Well, um, what I'm advocating is detailed assessment, which is incredibly expensive. Um, I've forgotten, does anyone know what the Wardley adult A DHD clinic are currently charging? Um, it's, I mean, that's not a private service. They charge other parts of the NHS, but I mean, it, it used to be we we're pushing at sort of tens of thousands. So if you're really, really gonna do it properly, it's very expensive. Um, uh, is that justified? Well, yes, it is, but not politically. I don't think we're ever gonna get there. I don't think there's enough political sympathy. Um, while there are articles in the Times saying things don't exist, uh, I don't think we've got that, but I think we should. I I think it's, it's improper to do superficial assessments. And you had another interesting question. I've forgotten what it was. Of the, because of the, the large quantity of data that's required in order to Yeah. Disentangle all of this. Yeah, yeah, yeah. Is this an opportunity for without doubt building High quality data? Absolutely, without doubt. Because I was in a meeting last week actually, where we were discussing just that, that, uh, there is an AI program being developed. I think it's by Microsoft, um, to do just that, to, to do medical assessment interviews for A DHD using, um, their version of AI that is being developed. Now, Let's take one or two questions from the floor, if there are any. You mentioned, uh, self diagnosis, you know, as, uh, being problematic. But, you know, there's a, there's a lot of waiting, there's very long waiting times now for, uh, to, to be assessed. Yep. For A DHD along with autism and other, you know, uh, other, you know, neurodiverse conditions. Might that not contribute in some way to people tending towards self-diagnosis rather than waiting as long as they have to do to get it confirmed properly? Without doubt, without doubt. Um, the difficulty with self-diagnosis is that it's, I think it's appropriate, um, as a way of self-identification. You know, it is possible that I have this condition or that condition, but I mean, most of us who've Googled the pain in our knee, uh, or the sensation we have in our head, find that there are numerous explanations. And I think it does need professional judgment. I do think it, I really do think it needs face-to-face judgment. Um, but it's entirely understandable that people will self record, self-diagnose. Of course they will. Um, I do it myself. Um, I'm not sure how good I am at it, but I, I do it all the time. Oh, you know, one does I, I know there's probably a whole separate talk you could do about treatment, but, um, are there any newer treatments that are coming out in the fringes that are particularly exciting for A DHD? Well, yes and no. Um, of course there are new treatments, but they're up against it. I mean, the 92% symptom change figure is a card one to beat. But I mean, you, we must have that. I mean, treatment isn't just about pills. I mean, that can't be true. It always must involve a psychological component. It must always involve a lifestyle advice component that is, that just has to be morally the right way. I think the newer treatments, uh, are largely involved in taking peripheral nerves and sending, uh, sending signals up there on trigeminal nerve or older nerve, uh, to see if that will alter brain functioning. And there're encouraging signs there, but they're not yet treatments. I think the other area that has been a lot of interest in is, um, neurofeedback treatments where, for example, the brain's electrical activity can be modified by certain tasks. And, uh, Kaia Rubio, whom I mentioned earlier, was very involved with that. The results so far have not been that encouraging. There is a response, but it's not enormous. And, uh, so yeah, no, people are very keen to find that because you can't just give pills to everybody with A DHD, that's not right. Um, it's gotta be pills plus, or it may not be pills at all. You know, we've gotta find other ways of doing it. But so far, the sort of psychological treatment methods usually based on CBT only really apply to adults. Whereas, um, children and, uh, young people are still very commonly involved and they don't always want to have the patience to do CBT type work. So yeah, there's psychological stuff that's still to be done. There is neurological stuff to be done. There's, uh, bio biofeedback stuff to be done, and people are very keen to pursue that. I'm really sorry, we've only got time for one more question, which is this lady over here has been waiting for a while and, um, don't forget that. Please send in your questions through the Slido. We will try and get them answered later on. It was really just a follow up to that last question. So both relatives and friends who have been diagnosed with A DHD and who have medication and say that the medication is in fact extremely effective if they need to settle down and do a task, really dislike the medicine because they feel that it makes them not themselves. There's a real, um, mental disbe to taking the medicine. And I wondered if you could just speak a little bit more about how that tension presents itself in people with A DHD, especially, I think in women, that, that that anger and frustration is, from what I understand, often turned internally, and there's a high correlation with all sorts of self harm that comes with a lot of people, females especially who have a DHD that might be anecdotal, just in my personal experience. Yeah. I, I've never seen, um, self-harm promoted by A DHD medication, but I certainly have seen social, Sorry, I didn't mean that the, uh, self-harm was caused by medication. What I was saying was that A DHD, because it correlates with depression. Yes. And anger is very often turned internally. That's true. And then in girls, it can manifest in ways that, that violence may be some concerns internally rather than external. Absolutely, yes, without doubt. Um, and the coexistence with depression is an extremely important one. Uh, they're one or two prominent people who've described their own experiences in that area. I think that one of the problems with a DHD medicine is, is you've gotta find the right one. For example, feeling of socially social disconnection and social discomfort is not uncommon with teenagers and adults who take methylphenidate. But it's very uncommon that people who take dexa, Liz Dexamphetamine. So, you know, if I have a young person who is saying, I don't like the meds, they make me feel socially awkward. They make me feel disconnected, they make me feel not really involved. I don't want to talk to people. I switch them across to Liz Dexamphetamine pretty quickly if I can. And usually not always, usually they find that much more comfortable. So it's a question of finding the right medicine, but, uh, by and large, most people are still taking methyl pholate, which is good, good stuff, but it doesn't suit everybody. And it's, it's, again, it's find, it's the heterogeneity, it's the difference, the diversity within the A DHD people, uh, that one has to explore. Look, ladies and gentlemen, it's been, um, so many questions. I mean so many more to answer. And I'm really sorry we haven't been able to get through them this evening. Um, professor Peter Hill, thank you very much.