S02 Ep.10 - Modern Concepts of ADHD, Peter Hill

Hello and welcome. My name is Richard Taverner and I'm your host of Any Further Questions. You are listening to episode 10 of season 2. If you don't already know, all episodes of Any Further Questions are available to listen to on Spotify and Apple Podcasts, so please do go and check them out now. Joining me today is Professor Peter Hill to answer as many unanswered questions as we can in the time that we are allowed.

Peter is a professor and consultant in child and adolescent psychiatry. He has written and published a range of books, chapters and papers on the assessment and treatment of mental health problems in the young, particularly issues to do with neurodiversity and selective neurodevelopmental.

conditions on the 11th of march this year peter gave a lecture with the title modern concepts of adhd it's available to watch on our youtube channel and so for context it's probably a good idea to go and watch that before listening to us Hello Peter, welcome. Hi Richard, this is a privilege. Thank you, good to see you. Can we start by defining ADHD and tell me some of the main markers that can identify the condition?

I think there are two ways of thinking about ADHD. One is that it's a medical diagnosis for a condition that is recognized by medicine and quite often medication. is helpful in its management unlike any other neurodivergent condition. So it is a neurodivergent problem, but it has this curious... of responding to medicines, not completely and not in a cure way, but as a way of relieving the problems that it can cause. And those problems are essentially a triad.

of extreme hyperactivity, extreme restlessness, usually coupled with a measure of excitability as well. The second would be a difficulty in sustaining and maintaining concentration on a topic when somebody else wants them to concentrate. So they can concentrate. You have ADHD and you concentrate.

extraordinarily well on something that fascinates you, but it's when you have to concentrate on a task set by others that it gets a problem. And the third aspect is impulsiveness, and this is doing things suddenly, without thinking, is this safe? Or is this sensible? So in children, for example, it's typified by calling out in class without putting your hand up, that sort of thing, which is minor. And everyone does it, I expect. So these are...

Traits of hyperactivity, of inattention, difficulty with concentration and attention, and impulsive, sudden response behaviors. So it's that triad. So that is a pattern. that is pretty real. I mean, you can show that those three things relate to each other. But when it's associated with impaired functioning, when it's a problem for a person,

so that they have things that they need to do to sustain themselves or keep going in society or in a relationship or in a family, they find that hard because of their ADHD symptoms, then we can call it a medical diagnosis. But on the other hand... All those traits of restlessness, of difficulty with concentrating on something a bit boring and somebody else wants you to do, or doing things suddenly without thinking of the consequences, you can see those in...

Just about everybody, not quite everybody, but they're very, very commonly distributed. So the pattern can be recognized as a... type of personality but it's when it becomes impairing when it is associated with measurable disability then we can call it a medical diagnosis otherwise i think it's another way of talking about a variation of personality on a previous podcast i had Professor Francesca Happe, she deals in the research of autism, an expert in autism.

And she talked about an organization in America saying that they wanted to cure autism. And using the word cure, she took very against that word. And I wanted to ask you about... curing ADHD do you see that it's important to cure it or is it in a condition which people just need to manage I think it'd be crazy to talk about curing ADHD you can't you can't cure ADHD what you can do is you can help people by enabling them to concentrate a bit better and you can do that

perhaps with a few exercises, if they're old enough. This is the difference between adults and children. Trying to teach a child how to concentrate better, forget it. But you can use medicines which will increase concentration in both children and adults. And that's important for them. It's not a cure. It's much more like taking paracetamol for a headache. It will suppress the symptom, suppress the complaint, but it won't actually remove the cause.

So I don't think there's ever going to be a cure for ADHD. I can't see how that's going to happen. But there are important ways, psychological and medical, in which you can reduce the level of strain and stress for the person who's experiencing strain and stress. because of their ADHD. So those were my questions. Now we'll move on to questions we've had from our online audience, both on YouTube and on Slido. So thank you for those. The first question I have is...

If there's a visible difference in the development of the cortex, why can't a brain scan be used to diagnose someone with ADHD? That might prove possible, but at the moment, the research scanning instruments that are used are so powerful, they don't exist. in mainstream medicine. If you go to major university centers, then you're dealing with machines of 8, 10, 12 Tesla. They're very, very powerful.

And there is no comparison between those machines, those scanning machines, and the sort of scanner that hospitals need for their own purposes. So I think one difference is the intensity of the scanning. The other is... that although for a group of people, let's say a hundred people with ADHD diagnosed medically, You can do scans and you can show that there is a tendency, a significant tendency, for them to have problems with their dorsolateral, let us say, frontal cortex.

Whether that is true for every single one is unlikely because think about ADHD like so many of these neurodivergent neurodivergent problems, is this huge variation between individuals, quite rightly. You know, you can't understand an individual just in terms of a diagnosis or a label.

So I think because there's huge variation, although I can say across the board, there are problems with the dorsolateral prefrontal cortex, there are problems with the frontal poles of the brain. For any one individual, that may not be true. We don't have a finding that is... always constantly true in every single case of ADHD. But we can say that across the board, these are areas which don't seem to be functioning as well as they might be.

How should one go about managing their ADHD symptoms as an adult? Again, I think it depends whether you're talking about people who fulfill the criteria for the medical diagnosis, for which there are diagnostic rules. You have to have so many symptoms. It has to be impairing as far as their everyday functioning is concerned. For them, NICE, the organization that makes recommendations for treatment within the health service in England and to a certain extent Wales,

NICE will say for adults, you should start to think about medicines fairly quickly. Not everybody wants to take medicines. Not everyone needs to take medicines, but for the medical diagnosis, it's going to be a fairly significant problem. There are interesting psychological techniques that one can learn to manage one's life. And when we start...

talking in this area is going way beyond the diagnostic criteria. We're not talking about managing hyperactivity or impulsiveness or inattention. We're talking about how to run a life. And for that, you need... A cluster of skills and abilities, usually called executive skills or cognitive executive skills. actually go about running a life, where to start, where to finish, how to make choices, how to evaluate your own choices. You can teach people those with a bit of luck. It isn't easy.

But it's possible. And so I think a psychological approach, an educational psychological approach is very important. And then there are the basics. It's quite easy to demonstrate that exercise. It's important in relieving ADHD problems. It's important to know that a balanced diet, not a specific diet, but a balanced diet, is very important in minimising.

ADHD problems and getting enough sleep, which is particularly important for adult ADHD. That is essential if you don't have an adequate amount, particularly of deep sleep. at the beginning of the night, your ADHD will be worse. We had a question about autism. I mentioned earlier, Francesca Happe gave a... wonderful lecture about autism and I did a podcast with her so please do go and listen to that if you haven't already. Are there many overlaps between the two conditions of autism and ADHD?

Yes, there are very substantial overlaps. And the odd thing is that until nine years ago, you weren't allowed to diagnose both conditions. There was a rule in the medical diagnostic system that says you can't have both. That is wrong. You certainly can have both. And roughly speaking, 20 to 30% of ADU...

ADHD folk will have some traits of ASD or autism. And 20-30% of people with autism will have ADHD as well. So there's a very substantial overlap. It's one of the most important overlaps because it's so often overlooked. And we may get on to talk about the adequacy of assessments and treatments. And an adequate assessment should be looking for both in any one person because it may well be there. And I've had over and over again.

children who aren't concentrating in class and the teachers quite correctly say shouldn't we be thinking about ADHD as a reason for their poor concentration but actually when you come to meet the child The real problem is that they don't see the point of concentration because they're wrapped up in their own way of thinking rather than the teacher's way of thinking because they've got autism. Is it more common that...

ADHD is diagnosed first before autism or the other way around, or is it completely individual? I think it's pretty individual. What happens with children is that numerically... Number-wise, more children with probable ADHD are being seen by pediatricians, not psychiatrists.

In adulthood, they're definitely being seen by psychiatrists and just a few by neurologists. But there's a different pattern of service for children. And I think it depends who you see. I mean, the pediatricians will be pretty smart on picking up. ADHD and indeed possible fundamental physical causes for that. Whereas the psychiatrist will also be alert.

to autism. Now that's not a hard and fast difference between the two but it depends who you see first. What's your experience of the intersection of people who have ADHD and adverse child experiences and trauma if there is any? Well, my experience is, yes, it can happen. But of course, I've seen people that have been referred to me, and they're probably being referred to me because they're perceived as complicated cases, because that's been my trade.

I see complicated people. We do know that across the board, there's a higher rate of adverse childhood experiences, ACEs, in people with ADHD. It's not enormous. But the rate is, let us say, something more like 7% rather than the national average of something more like 3%. It's significantly up. So yes, there is a... An interesting relationship. And it's interesting because if one goes back 25, 30 years, a lot of people were saying ADHD doesn't exist. It's just a reaction to trauma.

It's a reaction to inadequate emotional attachment formation to parents, for example. Or it's a reaction to life-threatening trauma, such as one usually associates with PTSD. And people like Gabor Maté, who's a very charismatic and influential Canadian GP who's got ADHD, has written quite... impressive books arguing that trauma is easily overlooked if you're taking a developmental history to ascertain whether somebody's got ADHD. And he argues very persuasively that this is easily overlooked.

And if you've had an experience that is life-threatening, or you witness something that is life-threatening, and parents in violent struggles come into that group, And then you do notice that the agitation... that can come through because of anxiety, because in turn you've been exposed to a threatening situation, that can look like hyperactivity. You notice that somebody's preoccupation with their...

own security, am I safe here, is this okay, can look like inattention, and would be inattention. And you can sometimes see impulsiveness, get me out of here. Let's break up the situation. Let's do something outrageous as a way of escaping from a slightly threatening situation that can look like impulsiveness. So, yes, trauma can mimic ADHD. Trauma can coexist with ADHD.

But I think it's possible to unpick them. But it does need quite a bit of understanding and thinking and talking to do that. I suppose that's true with many other mental health conditions as well, your childhood and your experience in childhood. can have and probably does have an effect on how you live your life as an adult and how you experience your life. Yes, and it very much depends on what you mean by childhood because sometimes the adverse experiences come in.

in the early teens, for example, for girls with ADHD who often get missed because they're not as boisterous, they're not as aggressive, they're not as noisy. as the boys with ADHD. They're quieter. They are plagued by inattention. And they can be missed in childhood, but present in adulthood. When they do present, it's often because they've been wounded.

by some online bullying or letters, or there are actually cruel teachers left, but, you know, bad experience with a critical adult. So it can present, but the trauma can be later. And, of course... Plenty of adults with ADHD will talk about the collapse of their close relationships, the collapse of their marriages, the collapse of their relationship with their children. So the trauma may actually come after the ADHD.

has been established, but prolong it and protract it. It means less likely that they will grow out of it. And we've known this for 50 plus years now, that rows and fights within a family, for example. cause ADHD to persist in the children who might otherwise have grown out of it, as some do. We had a question, a more positive question. Is there any evidence for the idea that ADHD can be a superpower?

Well, it depends. If you say can be, your question was carefully crafted. Yes, it can be. And I've, you know, among the people I know professionally and indeed socially, I know people who are brilliant artists. brilliant comedians, brilliant entertainers on a broader basis, brilliant musicians, brilliant actors who also have ADHD. And if I talk to my brother-in-law...

and his wife, because they're both actors, they will say, well, half the acting profession's got ADHD. And of course, in a way, that is true. They don't really mean medical ADHD, which is what I started out.

talking about at the beginning of this. They're not impaired in their functioning, but there's some aspects of their personality. They're impulsive, they're lively, they don't concentrate too much, but who gives a toss? They can learn their lines, they can get on with it, and they can enliven a stage.

Yes, it can be, but I think usually it isn't. Usually, I think ADHD is a pesky nuisance for the people who are affected by it, particularly in school, of course, and particularly in highly structured jobs. I suppose as the viewer, you want...

the person on stage or the person on screen to be entertaining and you want them to be so that aspect of things is the entertaining part of their personality well I'm also impressed by um In some ways, being a children's doctor is an imperfect existence because you run on the description.

that other people give of this child, or you examine them physically. If you can actually get them to talk about what it is like, which is extremely difficult. Most children, of course, can't see the point because they assume you know already. because they assume that their thoughts are the same as your thoughts in quality. When you begin to get into the late teens and the 20s, particularly with bright people,

trying to help develop a program for university students. And ADHD is there. It doesn't stop people going to university. Then you learn about the inner world. of somebody with ADHD, and the cascade of thoughts and images, which is sometimes entertaining and wonderful, and enables them to ad-lib on stage, for example. But often, equally, it's distracting. There's just too much of it.

So I think the capacity to have many, many thoughts, many, many different thoughts is really important. And I think the ability to be adventurous is important. Adventurousness is probably why ADHD continues in the general population. It shouldn't. In evolutionary terms, it ought to be a handicap. It ought to be a problem. It's associated with a higher... rate of suicide and violent death, for example, across the board. So why does it persist? I think the answer is that it...

It is associated with adventuring, and if you're a small group of hunter-gatherers, for example, you need somebody to test those berries to see if they're any good, and they may or may not survive, but at least they've done it. They haven't stuck to the rules of the community. Somebody needs to swim out and test whether there are sharks in the deep water. You need that adventurousness for the sake of the community. So I think there are a number of ways of trying to answer the...

It's a good question. It really is a good question. Interestingly, it's a different way of thinking. It's sort of evolving the society, as it were. If you keep a society doing the same thing over and over again, they're never going to... So to have that different type of brain and that different type of thinking can be hugely positive. Yes, this has been demonstrated in studies of management, for example, people management in groups.

beyond a certain size of the group, you need somebody who's going to come in left field with a striking question. or observation or idea that nobody else has come up with because they are conventional. You need the conventional people to keep the show on the road and the wheels turning, but you also need that shaft of brilliance from time to time. And I think ADHD can contribute to that.

the case and some people complain bitterly about being distracted by too many thoughts in their mind but it can also be an advantage to the community in some instances.

We had a question about medication. Why does Professor Hill think there's such a shortage of ADHD medication currently and should we be suspicious about why this is happening? Professor Hill is about to give a very dull answer, which is that more people are asking for the meds than you can actually produce it. That's what I thought. I don't think there's a conspiracy. It's difficult to see what the conspiracy would achieve. I mean, drug companies want to sell medicines. And the more, the better.

I don't think there's an argument that they're trying to force the price up. I'm not sure what the questioner is alluding to. Well, there has been a suggestion that maybe the companies are sitting on great stockpiles of medicines to allow the price to rise because of scarcity.

doubt that. I really do doubt that. I mean, I have talked to two particular companies about this, both who are heavily involved in the ADHD medicine business. And one said, well, we just can't make enough. And the other said, well, we can make enough. But only just. Now, is that a bad sign that they can't make enough? Is it they can't make enough because we've got a lot of people with ADHD in society and a lot of new diagnosis? Yes. In my lecture, I showed a slide.

that showed the rate of prescription for adults and for children. And we are now in the UK, we're in England. in a situation where we are prescribing more for adults than we did for children. And that's never happened before in any way. In fact, a lot of the medicines thought not to be suitable for adults. crazy suggestion, but they're not licensed or approved because the companies haven't asked them to be. But I think it's just a case of demand exceeding possible supply.

Because this is an international business. I mean, these medicines are made in Israel, in India, wherever. And if you've got a factory that makes medicines... for companies you decide is it worth trying to do get into adhd medicines or shall we stick to painkillers seeing how adaptable our brains are

Is it possible that people could develop symptoms of ADHD later in life through daily habits of online distraction? Well, I think we're beginning to recognise that people can develop ADHD later in life. You don't have to have had it in... childhood. And it is usually the case that in adulthood you have had it in childhood. Partly that's artificial because one of the requirements for a diagnosis of ADHD is symptoms start before the age of 12.

So you're bending the data a little bit by having rules like that in place. But I think it's... It is possible that people are just beginning to argue that adult ADHD, which starts, let us say, in middle age, as opposed to having been present, is actually somewhat different. For example, that ADHD first recognized in middle age has a higher rate of associated subsequent dementia than ADHD that started in childhood. We actually had a...

brings us nicely onto our next question about dementia. Probably too early in terms of studies, but do we know of any data about neurodiversity with ADHD and dementia? Yes, we do. And it is true for ADHD and it's true for autism that both are associated with a slight rise in the rate of dementia.

What I find slightly frustrating is that people don't always define what they mean by dementia. There's a quite elegant study about ADHD and Lewy body dementia, for example, not Alzheimer's. But most people have just looked at Alzheimer's. Does it matter? But I mean, theoretically, yes, of course, it matters because they're two different neurodegenerative conditions. But yes, there is a slightly raised rate.

Whether that applies to other forms of neurodivergence, like dyslexia, I've no idea. I'd be jolly surprised if it did. But there is a question within that, that if we talk about neurodiversity in terms of differences between people, how do those differences arise? And if we argue that... Genetics are quite powerful in this area. Is it just that the genetics for dementia sit alongside the genetics for autism or for ADHD on the chromosome? Is it just like that?

They're there for the ride. Or is it actually a functional issue that if you haven't had an experience of sustained concentration and attention, does that mean that gets worse when you get dementia? We don't know. Can a patient be suffering from the AD part and not only from HD? Yes, indeed. Under an earlier diagnostic system, there was...

ADD, Attention Deficit Disorder, with hyperactivity and ADD without hyperactivity. That was then abandoned because the reality is that people shift between the two. And the vast... The biggest proportion of people just with attention deficit disorder have been hyperactive in the past, but they've grown out of their hyperactivity, as one often does. So ADD tends to be much more like the...

picture of adult ADHD. It doesn't have the hyperactivity there, though it may have had in the past. What happened nine years, ten years ago, when the Americans were revising their diagnostic schedule, is that we came... I say we, I mean I was peripherally involved in the discussions, but to no avail.

The difficulty is because of that, the people who just have attention deficit problems, usually with a bit of impulsivity, but not hyperactive. Most of those are adults, and they had been ADHD, but they've grown out of the age. Now, that's not always true. There are some people who have never, ever been hyperactive. Now, Eric Taylor had a study of this in South London.

which was able to show that there were people who did exist, who just had the inattention constellation of problems to do with concentration and distractibility and so forth, but had never been hyperactive. But the Americans wouldn't accept that. And I think they wouldn't accept it partly because it hadn't been done in America, but also because it raised questions. It was usually the treatment of ADD.

in adults is much the same as treating ADHD. It doesn't really make that much difference in terms of what you do psychologically and medically. So at the moment, yes, of course you can. And I touched on that in the lecture when I talked about cognitive disengagement syndrome, which is a purely inattention problem. And you can see that. And it doesn't have to have other ADHD symptoms, though often it does. So we're talking about another area of neurodivergence.

where characteristics of one condition merge into another and merge into another, and you end up with quite a fight about the boundaries between them all, which is one of the things I tried to tackle in the lecture.

What a question, interesting question. Are there any cultural or societal factors that influence the perception and treatment of ADHD? Oh, yes. Okay. I mean, you can't... I think realistically say ADHD is just a cultural construct. That's bonkers. But on the other hand, different cultures will view ADHD in a different way. And this becomes... quite, really quite difficult. Many years ago I witnessed a study being carried out. I was on the periphery looking at children in schools.

in Hong Kong, and children in schools actually around here in Acton, as it happens, in North Kensington, rather than Acton. It was North Kensington. And the ratings from the teachers in Hong Kong... were quite, quite different. When you started to look at them, it was perfectly clear, or a perfectly reasonable guess, that in Hong Kong, you sat quietly. You did not interrupt.

You could only speak when you put your hand up. Well, many schools have the same rule. And they would see any sort of fidgeting, doodling, getting up and moving around as deviant. Whereas in North Kensington, what the hell? Do what you like. Well, he was much more tolerating, much more tolerant. So yes, there are cultural differences in the way that divergence is perceived. And also cultural differences in how it is valued. And I think just at the moment, urban...

England at any rate, is coming around to the idea that ADHD is out there and we need to recognize it because people's education will suffer if it doesn't, people's jobs will suffer if we don't. Whereas in... It has been argued by some of the black commentators that actually it is still seen as a stigma. That if you diagnose ADHD, that's something you keep very quiet about. As it happens, I think the rates of ADHD and indeed autism are not very different between ethnic groups.

quite a few surveys and studies about this. It hasn't really shown up anything. It does in the States, and we mustn't learn from the States because their population structure is so different. It is not the same as post-colonial England.

I can't speak for Scotland, but I think it's probably that is the same. That's interesting because if you were to say one other country in the world that's most culturally sort of... the same as ours or similar to ours you would say it would be the states um but that's not a country you say that we should be looking no i don't think we should comparison um they recognize, officially recognize, a rate of ADHD that is twice that that we would consider.

scientifically correct. They're looking at rates of ADHD among school children of 11%. That's what they would anticipate. The international agreement is that the rate of ADHD is about 5% to 6%. 5.9% has been the figure that's been around this year. And because they see it much more commonly, because they treat it much more assertively than we do.

I think it is, from an ADHD point of view, a different world. And I think the reasons for that are probably true for lots of medical conditions. Americans, by and large, white Americans like medicines. I was about to say, is it true to say that American children or American adolescents are more heavily medicated than they are in the UK? Yes, they are.

That's very easy to demonstrate. It's been very well shown. It's a stereotype, but I just wanted to ask whether that's true. It is a correct stereotype. But on the other hand, the differences between states... in the United States in prescription rates outweigh the difference between countries. So you have some states where there's hardly any prescription and some states where there's an awful lot. And is that due to the population?

So would you say California, New York are more? Well, I don't think it is. It could be, and there could be a component within that, because by and large, the high prescribing states are in the southern states. That's not always true, but by and large. So yes, it might be, and it might be there because of attitudes that aren't rational. More political, maybe. Well, or associated with poverty, for example. Right.

You can, within a city, look at rates of ADHD as measured by questionnaire. I've been very careful what I say. So this isn't... necessarily medically diagnosed ADHD, but the rates of ADHD according to rating scales and questionnaires do tend to be higher in impoverished districts. Now that may be just no money. and bad food or it may be lead contamination from traffic, for example, which is a perfectly plausible suggestion. That's interesting. What is the latest on menopause and ADHD?

Does perimenopause exacerbate or mimic presentation? Does HRT help or is there any post-menopause studies? We had a menopause question in our autism podcast. I don't know whether you could shed some light on menopause and ADHD. Yes. It's been quite a... Well, I mean, the parents in the parents' groups' websites, which I added to your magazine, for example,

The women have been really very vocal about this. And we've known for some time that there is a peak in ADHD as it presents to clinics in perimenopausal, postmenopausal women. We've known that for a long time. And there's been much discussion about that. And I think there are two things to mention. One is that the fall in estrogen production, which is, of course,

the central issue in the menopause, actually will alter the impact of medicines. It can mean you need more medicines. It can destabilize your mood so that you get irritability and so forth, which then... magnifies the problems that your ADHD symptoms are causing you. So there are straightforward physiological and easy to understand, I think.

arguments. Yes, the HRT could come into that. It might well be very sensible to think about an estrogen boost, but the endocrinologists, the hormone doctors who are dealing with menopause, aren't necessarily... Tuned into ADHD they will be but at the moment. It's a new issue So there is that there's another issue which

is recognized by some of the senior people in the area, but not very well explored research-wise, which is that round about perimenopausal time, there are changes in your family. Your kids leave home. You lose the structure that is provided in your life by having to look after children. This is less and less true, of course, because children aren't leaving home.

By and large, there's a pattern whereby the children leave round about the perimenopausal area for their mothers, and that destabilizes the family because the mother no longer has the structure, the rhythm of caring for her. a child and making sure they do their revision and so forth, that's lost. It's adapting to a new state of life. Yes, it's adapting to a new state of life. So that needs to be thought of as well. You can't reduce everything to physiology.

The medication, what's it doing to the brain? Is it calming the brain down or what is it exactly doing to help manage the ADHD? We know quite a bit about medicines about ADHD. There's an awful lot of research on this, and we know quite a bit. We don't know everything. We know that the medicines that are most effective for ADHD, the stimulants and atomoxetine, for example,

We know that they increase the amount of noradrenaline, otherwise known as norepinephrine, and dopamine within the frontal part of the brain. We know that happens. We also know how that happens. We know how the molecules of any medicine get into the space between the nerve cells and promote connections between nerves functionally. And we can study that in quite a lot of detail. And I can explain, I don't think I'm going to do it now, how...

Some ADHD medicines are slightly different to others, but how a combination of two is often better than one. There are important differences between people in how they respond. But I think we know quite a lot about what the medicines are doing, quite a lot. What don't we know? What don't we know? We know quite a lot about the stimulants. We know less about the non-stimulants. We know, I think, enough. But there are some things...

use medicines for ADHD, you pretty well always start with stimulant medication. You start with one stimulant, and if that's no good, you switch to another. That is good practice. Because some people will respond better to one, better to the other. Not many people... will do better on non-stimulants. But sometimes you need to use non-stimulants because of the side effects and adverse effects that the stimulants produce in terms of appetite loss and disrupted sleep and so forth. Okay.

Has ADHD increased because of the reduction in perinatal mortality? Well, I don't think it has increased. Rates for ADHD have been pretty stable over the last, well, as long as people have been measuring them.

If you look at the rate in the general population, that's pretty stable. It hasn't peaked because of... COVID it hasn't peaked because of games on your phone you know it hasn't done that it's remained pretty rock steady but the demand on services has increased right but it's a very intelligent question because you would expect that better

Antenatal care, which this country isn't very good at at the moment, and better neonatal care, looking after sick babies, should reduce the rate. But there's nothing to show that that is definitely the case. That brings me on to a couple of questions we had on the NHS. The first question was, why is it widely reported that a private health diagnosis has to be redone if you want treatment on the NHS?

Is this true, and if so, why? Well, because there are cowboys out there. I used to work in a clinic in Oxford part of the time, and we were plagued. by one person who wasn't a doctor, who had set herself up to diagnose ADHD, and she would do it on a...

computerized vigilance test, which is not, you can't do that. It's not the way to do it. It is bad on so many different levels. But she would bring people in, she would sit them in front of this computer, and they would have to stab a button every time an E came up on the screen. Now, that can be a useful test if you've got lots of other things that you're looking at. It cannot be the only way to diagnose ADHD for two reasons. One is there are bags of people.

who get bored with that task and haven't got ADHD, but will score an ADHD type level on it. And the other is because it totally fails to examine all the other things you must do when you're assessing. ADHD, like what else is going on? What's their reading like? What's their hearing like? What's their vision like? Have they got an underlying condition that nobody's spotted yet? I've seen all of these things. So yes, there are cowboys out there. I expect there is good practice as well.

And the centre I still work in from time to time, but I don't see new patients, is, I think, pretty solid and reliable in how it goes about the business. with long interviews and seeing the child individually and gathering information from schools and other people in a systematic way and then coming to a considered diagnosis. It's bloody expensive. It takes time.

I mean, I used to allocate two hours for an assessment for ADHD in a child, and it was often not enough. I mean, it really is expensive. I would imagine that these tests can tell you some things, but the most important thing is just to have a chat with them. is to have human-to-human interaction. And that's the best way in assessing someone, is to talk to them.

rather than rely on a test to tell you something which may or may not be true. Like you said, it may give you a false... You're in great risk there, Richard, of provoking a rant from me. Diagnosing ADHD on rating scales is such bad practice. And I'm one of a group of people who are just trying to come up with a gold standard for ADHD assessment in children. And I may well fall out with other people in the group. So I'm saying this must be done personally.

You can't do it remotely. You can't assess a child's attention, concentration, reading ability through a camera when the child doesn't want to be there. And I think it has to be done. Maywell Park Company, other people will be saying, well, you know, we can't actually do that. Remote is more efficient. We can get through more cases. I'm saying we please don't want to do that. As part of our neurodiversity series, the Autism and Dyslexia podcast I did.

both of those podcasts had questions on AI, artificial intelligence, and how AI can help in ADHD. We didn't have a question about AI for your lecture, but I can imagine it reminded me of the fact that... ai just wouldn't be helpful in that stage of things but ai may be helpful once it's being diagnosed at a later stage what's your opinion on that

Well, there are two thoughts that come to mind immediately that I've been up against. One is that AI can help you write the letter. Yeah. I'm serious. Well, when somebody mentioned the idea that I might... give a lecture at Gresham College. I asked AI

what to say. And it came up with a really good GCSE level type. Don't be telling our provost that. No, I mean, it was quite good. Yeah, yeah, yeah. It's very accurate at the moment. It's fingered its way through the web and what is known and what... that's authoritative people have said. So I think it will certainly write the letter. I don't think plenty of my colleagues have discovered that, that once you've got the data.

Exactly, but still it's best practice at the beginning stages to have a human to have someone like yourself I can't think of an alternative Yes. I think as a children's doctor, I know fully well that children don't have votes. So the power of children's health is sentimental. Yeah. you know, people, children dying of cancer and that sort of thing, they need to be treated. But the difficulty is when you come to the more, the less visible problems, there is...

It's colossal double standards. If you're said to be injured by some obstetrician doing the wrong thing in delivering you, you can make a claim for... Millions, literally millions of poems. If that happens to you just through bad luck, rather than somebody who can be blamed, then you get nothing.

Well, not quite true, but you don't get very much. So we have extraordinary double standards about provision of care to children is one problem. This country isn't very keen on children in any case, as far as I can see. which isn't a reason for anything, but there isn't going to be a big spend on mental health, and there isn't going to be a big spend on children. There's going to be, I think there will be...

a lot of worry about what a good assessment is for all the reasons that we've hinted at. There are cowboys out there and I was looking at a practice in central London. The day before yesterday. And they were saying, well, we can do an assessment for ADHD for 485 pounds. And I think the answer is in central London, you can't.

Because your rents on your rooms are going to be so high, you'd have to be doing it remotely. And a little further down the page, I noticed all our assessments are carried out remotely. And I thought, this is just not the way to do it. I mean, £485 is a... It's less than one hour of a private paediatrician's time. Unfortunately, is there any way to change that? Or do you think that is that inevitably the way things are going to go?

Well, yes, I think there is. And I think it will probably come from the education sector as far as children go. For some time, the directors of education grouped around... North London in particular, have said we must have a standardized assessment for autism. We must have a so-called ADI, which is an examination of the child's behavior.

sorry, an ADOS, which is an examination of the child's behaviour, an ADI, which is a structured interview with the parents. We must have those. We haven't got those. We're not going to accept that this child has autism just because some stuck-up Professor Hill says he has.

And education have demanded that, and that's responsible and appropriate. Good. We end on a positive note. I've got one final question for you, but before that one, so thank you for... joining me the conversation has been really great and hopefully it's been helpful to someone listening either with ADHD or knowing someone that possibly has ADHD Our final question is, as somebody doing a report on the effects of ADHD, whose work would you suggest is key to analyse? Well, it depends what you mean.

by the effects of ADHD. These are the adverse effects, the bad news. I think if you're talking about the impact of... ADHD on the national economy. What is untreated ADHD costing the rest of us in terms of unemployment, in terms of family breakdown, in terms of educational breakdown? Then there are... A few surveys that are critical. There's one carried out by Demos, the think tank, D-E-M-O-S, a few years ago, which I think is quite reliable.

assessing what the cost, the financial cost of ADHD is. It was a study funded by a drug company. Okay. But I think it's all right. You know, one's always suspicious. Are they then being encouraged to overstate the position? And I think it's about time somebody overstated the position, actually, because I think it is that the cost of ADHD, untreated ADHD, is colossal. And it doesn't have to happen.

I think that is true. The person who is most often quoted is Schein, S-C-H-E-I-N, in the States, who's done an attempt to cost. for untreated ADHD internationally and for the states. And the figures are very high. And the more advanced the country is, the higher the figure is. There is a slight worry going on that this could be eventually a tax on less developed countries. In the same way that... industrialization maybe. We've got to be a bit careful about which standards we operate to.

So there's that aspect of who to look out for. I think generally there is an international study on the burden of ADHD. And I think if you want to get into that, the lead author, I remember a paper. 18 months ago was Samuel Cortese, C-O-R-T-E-S-E. I could look up the reference. But if you look...

Cortesia's first author, 2022. You'll find that he's published quite a lot. But there was that international study on the burden of ADHD. But if you want general stuff on the burden of ADHD, I think almost look at almost anything. by Steve Farone, F-A-R-A-O-N-E.

handout to the Gresham lecturer. I quoted a paper of his, which was published just a few weeks ago, which is a very good up-to-date statement of where we are with ADHD. So Steve Ferron. And we published that on our Gresham website. So if you go to our website and go to your...

Peter Hill's lecture page, Modern Concepts of ADHD, you'll find it there. That's for someone researching ADHD. So finally, if someone thinks that they have ADHD or they know someone, a loved one who has ADHD, what would your advice be for where to point them? I think the first thing you do is you talk to the school. Right. If it's a child. Talk to the school and say, what do you think? Because they can access support.

for children who have troubles with concentration and restraining themselves in class. And I think that's where you start. If you go at it medically and say, I want to see a doctor to get a diagnosis.

I think that your best bet probably is to ask your local general practice, because you may not get the GP, what the local community... pediatrician is doing for ADHD because the community pediatricians will often be more efficient in terms of seeing somebody quickly than the local child and adolescent mental health service, the local CAMs, because the CAMs... tend to be kept back for life-threatening conditions and there's a lot of that around at the moment.

post-covid so i think go to the school first yeah and then ask about what pediatrics is doing don't automatically go for child and adolescent psychiatry okay peter thank you very much Peter's was the last in the neurodiversity series we had at Gresham. The others was Francesca Happe and Maggie Snowling, who did lectures on dyslexia and autism, which you can find on our YouTube channel and our website. Peter, thank you very much for joining us. pleasure. Thank you.