We are so excited. We're so excited to have Phil and Lisa back. So they were on late last night talking about ADHD and medication particularly, and they are incredibly kind. So they are the well, two of the three of the senior leadership team of ADHD three sixty, CEO and clinical director, I hope I've got that right. And, just an extraordinary fountain of knowledge. And what they're doing, around changing ADHD and diagnosis in The UK is is is something else. So let me bring them on.

Hello, guys. Hi. Hi. Good morning. Good morning. And you've got you've had some sleep. Like, we have not had so much sleep. You still have not much, like, because you've left us pretty late, and you've come back pretty early. And I know the reason you've also timed this is because you've got such full days as well, and you're putting so much in. And it's a testament to to you, to ADHD three sixty, that you're doing this. You know, your day job is helping people with ADHD, and in your, like, not spare time, you're also helping people with ADHD in doing this and supporting this. It's a big deal. Thank you so, so much.

Thank you. And and well well done for seeing it through the night. I feel that I've been through the night with you, but and but not to the extent that you have. So congratulations on getting through the night and overcoming your technical problems and Thank you. Bringing the world together. I don't think there's ever been anything like this before, and it's actually a thrill and an honor to be part of this. But I have to put you on notice, Henry. If you don't get me a meeting with Adrian Childs, you you we will have your windows. Oh, gosh.

This is like this is this is a global threat now. This is terrifying. I know Don in the in the best jazz. Well, let let's see what we can we can do. It's he's yeah. He's a lovely, lovely man who Yeah. Very, very much wants to to to help make difference, which we we all do. So we're all all allies in this. I need to shut up and hand over to you guys. So I'll I'll hand over to you I'll hand over to you now.

Okay. And we're looking for about fifty minutes again, Henry. Is that okay? That sounds exactly perfect.

It's like you've done this before. Well, who would have thought? Welcome to Groundhog Day. Yeah.

And here we go looking at diagnosis and ADHD. And I think it's really important that we talk about the diagnosis for ADHD, and we talk about it in in a a learned and professional way because the truth of the matter is there's a lot of myths, there's a lot of fables, a lot of stories, not only about medicine, which we talked about last night, but also about the diagnostic process. And I think what we what we work with is trying to overcome stigmas stigmas of diagnosis, but also ignorance of diagnosis and diagnostic processes throughout throughout other agencies that that have not moved with the times. And and Henry very kindly said that we we are trying to be at the forefront, and we are at the forefront of ADHD medicine and treatment. And.

To get to the forefront and stay there, you've got to move with the times. You've got to be flexible and agile and and also clinically safe. And we come across a number of different things in our time. And Lisa and I and our other cofounders. So we've got Jen Lewis Neil, who's not with us to this morning, but Jen Jen was on the panel that wrote the NICE guidelines, NG 87. And and and and that gave us when we started three sixty a really unique insight into what went went on into the the writing and the passing of the guidelines. And not only what the words actually mean in in the documents, but actually the meaning behind those words and what the what they aim and strive for. So.

I think what what we'd like to talk about today is some of those things. And if we talk about I think we've we've set our stall out to talk about the NHS and and why we're in why we're in the position we are in The UK with NHS services. And let's not be critical of our NHS. Let's be supportive, but recognize the challenges they've got and why there's a place for private diagnostics. And then move into Right to Choose, what that's all about in in England, but also look at the ages for for for diagnosis and and why there are lower levels of age limits and.

What they mean. And I think if we were to talk through those things, Lisa, that would give us a good smattering of what we feel are the inbound inquiries that we have throughout time. Would that be fair? Yep. Absolutely. So let's talk about the NHS. Lisa and I started working on this twenty years ago, didn't we? And Yeah. You were running The UK nurse network and bringing nurses really into ADHD, which had been the the kind of sole ground of psychiatrists and pediatricians. And, of course, over twenty years, we've seen that massive change into nurses becoming experts in ADHD. Let's just talk about that for a second. Let's not lose the power of that and the work that you did twenty years ago with nursing.

When was that change, and how did that come about in terms of the diagnostic process?

I think when I started in ADHD, in 2002, it was very much a consultant medical lead. And then fortunately, the NICE guidance prior to 2018 changed the wording of who could diagnose and treat ADHD. And it didn't say doctor, it said suitably qualified clinician. So that opened the gateway for clinicians like myself to really take a lead in in ADHD. But it was, I think it's fair to say, quite a slow process in bringing that change forward and and and also still working in quite old fashioned systems and systems that don't like change or they don't like change quickly. So so it was very much driven by nurses going into schools and observing children whilst also assessing them in clinic and treating them and.

And titrating them. But in a world where appointments were probably not as often as they are for us, so maybe, you know, six weekly appointments, three monthly appointments, where optimization was was quite difficult. And I think it's fair to say that we've blown that out of the water really in how we do ADHD. But it was a very slow process back in 2002 to get to get a diagnosis. It might take three to six months to actually get diagnostic part, which is a lifetime for a child who's seven, eight or nine and actually the referrals for those children were a lot older than than they are now. So I was seeing teenagers who appeared beyond beyond reach because they'd missed so much and trying to change and help those teenagers was.

Almost impossible. So it feels like the dark ages now when I talk about it about that way of working, and we've come a long way, I think.

And if we if we, and if we accept that in in making that change 2,002 thereabouts and and and opening the market up, what what what we've also seen is that growth in social media and that that that massive change in media profile of ADHD. For me, it's something that was swept under the carpet, naughty boys, and we've seen it go through the it's not naughty boys into girls and women and then into into adults as well over our twenty years of working in this. And we've seen this this mushroom that's grown and grown and grown and grown. And and, of course, as you've indicated, our funding of the NHS hasn't grown in parallel with the awareness and the acute awareness of ADHD.

In in all of those age groups. And there you are there you are in 2002, taking the lead from, from the pediatricians and the psychiatrists who were swamped with overall mental health and starting that nuance of a special diagnostic clinic in a diagnostic diagnostic process for ADHD. And and it being under resourced still, but we've got the growing mushroom, less resources, and some pretty archaic processes. You you alluded to the most contentious there in the diagnostic process, and that'll be how nurses were sent to schools to assess people in the classroom. And and that was for me, when we look back historically, that that that use of a nurse to do that, to perform that function was.

A goodwill gesture for the diagnostic process that actually wasn't required anywhere in the diagnostic process and has become the urban norm that you must be assessed in the classroom and you must have. In fact, we we know psychologists and psychiatrists who still insist on going to the classroom because that's the way it happened in 2002. And I think it's a great thing to clear up right at the outset that within diagnostic process, you absolutely don't need to do that. You you and we work really hard with that. What NICE says and what the DSM says and what what they say is.

Of course, you know where I'm going now, Lisa, is that evidence of impairment in a setting other than the primary setting that we're talking about. So if the primary setting is home, we would need evidence of a second setting to prove that this isn't the home that is causing the impairments, that it's actually crossing over different boundaries. It may well be that the school are making that referral because they've got concerns about the impairment for the for the for the child. And we need evidence in the second setting, which may well be home or or or another club setting or scouts or something like that. And and, you know, talk talk for a second about.

The richness of where that second setting evidence can come from, Lisa, where it doesn't have to involve a clinical professional sat for a whole day or half a day in a school watching a child that we know has got impairment?

I mean, can get information from school and we often do get information from school, but that could be in a school report, for example, or behaviour logs or detention logs or you know parents get lots of information from school and in our system they can upload as much information as they like and they do. So it doesn't need to be us physically going in and observing that child in that setting, but gathering that written information is really important. But a second setting can be absolutely anywhere. A social setting, so another home, I. E. A grandparents home, for example, where they might go for a sleepover, so they're in a completely different environment with a different set of rules. It could be the.

The brownie leader or the club leader or the swimming teachers are really good one because if you don't follow rules in the swimming pool, then you can die. So swimming teachers are really hot on saying, you know, little Johnny can't come swimming anymore. So, you know, getting a snap questionnaire completed by the swimming teacher is a second setting. So it doesn't need to be school and indeed a lot of children, and I know this from assessing adults, a lot of kids mask in school. So depending on their personality type and the teacher and the school environment, they can often mask all day in school and not display much of their ADHD symptoms because they would.

Rather not be in school than demonstrate that behaviour and be embarrassed in front of the peers or be shouted at by the teacher or be given a detention for not sitting still. So you could equally miss a child who you went to observe in school because they were masking, And we know from experience that that often leads to depression, anxiety in adults. So I think it's important that we explore what the second setting looked like. And then in lockdown, for example, where would you go there? Do you not diagnose someone because they're not in a school environment or at homeschool children?

You know, do you not diagnose those children because they don't actually attend school? Absolutely not. You find a way of gaining that evidence somewhere else, and it's doable.

And I think that that's really important that when when we had COVID and we and we grew our business and and and saw a lot more people through COVID and still are because a classic interpretation of that second setting needed to be in assessments at school, and for two years kids weren't at school and closed down services. It wasn't the sole reason, but it was one of the reasons. And and being at the forefront of interpretation and the forefront of of analysis of actual child's behavior, we we were able to continue. And it's really important that we that we when we talk about the diagnosis of ADHD, we boost the myth, and and I think you've done that succinctly there, Lisa. And, of course, a homeschool child may be being homeschooled.

Because they're struggling to fit into the school setting, and they're struggling to be the best person they can be in an environment that doesn't encourage, doesn't respect their ADHD. I we we were on last night with with with Henry and his team. And just before then, I was I was on a conference call with a mom whose son has been trying to get an ADHD diagnosis, assessments and diagnosis from the local services in the NHS and been refused. And every day has to go and sit under a weighted blanket in the deputy head's office because the.

Child is no longer able to cope in school. And every day they're in they're they're they're in that that class that that nonclassroom classroom learning learning nothing, nothing, sitting under a weighted blanket trying to control behavior, and and can't get an autism or an ADHD assessment. And I'm just thinking, well, crikey, what the hell is going on here when we got that level of evidence. So school's second setting, completely different. Let's you talked there about snap and snap four, and I think that introduces screening and the purpose of screening. And and and medicine, we see screening as a really common approach to things that we say, for instance, somebody may have their blood pressure taken at their GP.

And that may screen them for other issues and other potential health health care issues. And we screen using for children, we use the snap four that you mentioned. And for adults, we use the the the ASRS that and and and snap four, Jim Swanson and his and his chums over in America produced this amazing questionnaire and then had it validated globally that what it did was discern by 26 questions, in fact, 18 relating to ADHD and eight relating to oppositional behavior. That that if the answers to those 18 questions fell into a certain numerical category score, if you will, I don't like the word score, but they're results. If your screening results were of this magnitude.

That will be a positive screen for ADHD and worthy continuing on the diagnostic journey. So it's a screen. It's a screen in and screen out. Now similarly, the ASRS has 18 questions, and that does a similar job. Now when we run the academy, Lisa, when we talk about the ASRS in particular, and that's that's published by the World Health Organization, its provenance is quite incredible. There's there's statistics that back up what a positive screen can mean for a non diagnosis of ADHD and just hit people with those numbers so we can understand the importance of an accurate screen in the diagnostic process. Then I'm going pick up why we screen so much. Yeah. So in the.

The SRS questionnaire, for example, so it's validated and it's used in clinical trials. And this, as Phil's alluded to, is 18 statements which are which are based around the 18 DSM criteria, but the first six statements, if you score four or more in the first six statements, that's classed as a positive screen, and it's 90% accurate. So if you screen positive in the SRS screening tool and you go on to have an assessment for ADHD, then there's a ninety percent chance of you receiving a diagnosis of ADHD. Now those six question statements take about fifteen seconds to complete, which I think is pretty incredible for six statements to be so accurate. But it is it is it is accurate, and it's what we use as our screening tool. And.

Will you also use that moving forward to see where the patient is in terms of optimization?

Indeed. So the point we're making in terms of the diagnostic journey, the treatment pathway for a patient is that we will use screening tools that are internationally validated. We don't write our own. We don't do our own thing. We use internationally validated tools, any clinician should, as a specialist, use validated tools. And that can accelerate the journey, And it can actually mean that we can crack on, with other evidence, medical history, mental health history, setting goals, mood questionnaire, sleep questionnaire, looking at all of those parameters that we that we look at. And we do it prior to engaging with the patients. It's all done online. So that when the patient gets to see a clinician, the purpose is to to.

Reinforce the all of the information that's been gathered thus far and triaged by that specialist, and we're ready to go into an assessment that is wanting nothing other than that interaction between two people, a clinician and a patient, and and to move forward in the diagnostic process. Now that gives me the opportunity to talk about the diagnostic process, doesn't it, Lisa, in terms of the way the way that we we conduct that, whether it's face to face or on Skype, it does not matter. And we've worked hard with European and American colleagues to to build protocols for Skype, and it actually works really, really well. Is there's two things going on? The first thing is that we follow and a clinician should follow.

A semi structured interview ascertaining the any levels of impairments, what they are, and what the characteristics are in relation to ADHD. And the reason that it's semi structured is that structure should follow and gather the evidence of the DSM, the the the manual, the international manual. I mentioned it last night, the book that's so thick that hardly anyone can afford it. And and by having a semi structured interview that follows a clinical pathway, when you get to the end of it, you you you know whether or not there is sufficient impairments and sufficient evidence to warrant a diagnosis.

But the second and more important thing that's going on throughout that whole process, and this is why things are done on Skype or face to face, they're not done on the telephone, is because your trained and skilled clinician is looking at you, watching you, and observing you, the clinical expression, and those clinical observations are hugely important to the evidence gathering to lead to the diagnosis. So your diagnosis process goes from all of the evidence gathering of all the mundane stuff, let's call it, sleep hygiene, sleep problems, mood, where are we with mood, the screening tool, your medical history, your mental health history, what other ailments have you had, what hospital visits have you had. There's also a risk assessment.

Making sure that that we're okay to crack on. That that's part one. Part two is the triage of that to make sure that when we go to assessment that we're doing the right thing for that patient. And and then the third thing is the assessment with that massive dollop of assessment observation, clinical observation taking place at the same time. If we wind that back, the one thing we should remember is that the assessment, whether it's for a child or an adult, can be emotionally traumatic. Because what we're encouraging, a good assessor is not ticking boxes on a form, and and and a good assessor gets underneath what's going on in life for that person and really starts to unlock.

Some of the things. You talked about masking before and kids masking in school. A good assessor gets underneath what the coping mechanisms have prevented other people seeing for a while, but the individual has suffered within themselves and unlocks quite a lot of emotional baggage, for want of a word, and and emotional trauma. And the skill is to get that out so that we know exactly what we're dealing with and then be able to put that back together at the end when we come around to the treatment pathway and and and sorting out treatment. Talk talk to us for a second, Lisa, about the journey that a patient goes on when when when going through their assessment with you and and our clinical colleagues, and.

What that means to them when we get to that endpoint.

I think what's interesting when you work across the ages, you get really rich information from your adult patients. And they often tell us that we are the first person in their life who understands them, and so they've had a good hour being asked questions that resonate and make sense, and they almost feel like we've been stalking them or we've literally opened up the brain and and can see their story. And I found that really sad that I'm the first person that's understood this 45 year old adult, but that is often the case. But what you can do in in in in that conclusion is allow them to feel that they trust you because you do do know them, so they then trust the treatment pathway that you are recommending to them and why.

And it's a really powerful process. And also we did obviously as an assessment, we're focusing on the difficulties around ADHD because without those difficulties then you can't receive a diagnosis, without impairment you can't receive a diagnosis. But then I also see it as my opportunity to talk about the positives of ADHD how ADHD can be a gift. So although in the assessment we're focusing on, you know, what's the struggle, it also gives me that opportunity because of that richness of information and that prep so I know what job they do and the story to actually then embrace the positives of ADHD and how that can be helpful in the future. So it's a real, you know, it is quite powerful to be in that position.

And done properly with all of that prep by the patients and by the clinician, that triage, that that structured assessment with those observations, that building of rapport, that building of trust, that emotional bond between the two. We we are mainly ready to go straight to treatments when we've got that diagnostic process confirmed, aren't we? And we and we move forward for the validated patients. And we you we get that expression quite a lot that I feel validated, that I've had these struggles, and people have struggled to understand me, and I've struggled to understand myself. And now I feel validated. And one's only got to look at our Trustpilot reviews for how often the word validated is actually is actually used. I've just just.

Had a flag from Henry in in the messaging system to say, if there are any questions, we're going to switch to q and a in about ten minutes. And Henry is going to pull some questions out and ask us them in about ten minutes. So if you've any questions, submit them through the q a section of the portal, which is globaladhd.com. Now we we talked earlier about NHS swamped from 2002 from the get go really when services really became alive and and funding it, unfortunately not. And it's very easy to drop into criticism of this. And that's not our job. Our job is to try and work alongside the NHS and work with the NHS and.

And accept that if you have a budget and you're the commissioner and you've got to work out where that budget goes, you're you're now playing decision maker on who gets care. And there will always be more important ailments and more important illnesses that demand some of that cash, some of that money. And at the same time, there's always controls over how much the NHS can have budget wise. So if we just accept that commissioners have a very difficult job and they can commission what they can commission and they can't commission other things without being critical. We we accept, therefore, that there is a constraint on what the NHS can do. Step in private services to help.

And and and what we've what we've tried to do, and and I'm sure there are others, is create a very affordable service that supplements the the the national provision in an affordable way that can help people. So if your child is coming up to switching school from junior school to high school, that tipping point there. That's important that if you're gonna have to wait three years, you know, three years into high school, you start working on GCSEs. Let's get on with it. Let's spend £900 to get on with it. And it sounds flippant to say that, but it's worth doing. It's similar on that run up to GCSEs or an adult about to lose their job or lose their relationship or substance abusing substances.

And and having a really tough time. And what what we've what we've got, the private sector has a responsibility, is to not be someone that sits in a fat cat office seeing one person a week at three and a half thousand pounds and rocking up in a Lamborghini. There's a responsibility for the private sector to support the National Health Service by taking some of that pressure off so that the the more, the fundamental cases that can be seen swiftly through private can can be moved on on their patient journey and then hopefully switch back into the NHS through sharing care with the GP, so that the the patient can move into an NHS funded treatment pathway.

And and I know, Lisa, you worked really hard with the communication with GPs to make sure we can shoehorn people back into that national process at at an appropriate time. And and that greater good is part of our pathway, isn't it? And, you know, I'd I'd like you to just talk about the values we have right from the get go when we were in Warrington choosing the color palette for our our brand. Do you remember? And you said to me, can we not do this for nothing, Phil? Do you remember? And Oh, good. This woman. When I picked myself up off the floor and said, oh, we're supposed to get a living out of that.

But talk about talk about what we do do and what can it's not about three sixty this. It's about what can be done in the private sector to support that national journey, that national board, isn't it? Yeah. Yeah.

As I say, I'm not a businesswoman. I think think a caveat to that, well, can we not do some of it for free? And to be fair, we couldn't really work out how to do that and be fair. So so what we did decide is that we'd have a range of packages of care. Now we have a silver package which we offer to our patients who are on universal credit because what Phil and I wanted was to be accessible to everyone regardless of, income. So we don't make any money on that package, but what it does allow, patients to do is afford what I think is the best care. So we offer, a significant discount, we also offer, a payment plan so they can fund their treatment over ten months at £58 over ten months. And, but the standard of care is no different.

To the to the gold package. So the silver package patients, evidence their level of benefit and receive a significant discount, but but receive the same care as someone on the gold package. And I think that's something that Phil and I are quite passionate about, that just because you don't have loads of cash floating around, you shouldn't have a substandard set of set of care. And I'm quite proud of that. And I don't actually know the numbers, the percentages of how many we have on silver package, but it's a fair few. And I think our patients appreciate it and we make it work. You know, we we have very few patients who go, no, I can't afford that or I'm not prepared to to fund that, you know.

And then we have a platinum package which is for our very complex patients, and that's a separate entity, but the gold and silver package are identical. The only difference is how how much a patient pays with the silver package.

And and that greater good is where private sector can support the National Health Service and take some pressure off those services that's, as we talked about, have grown since 2002 and spun out of control because demand has always been there but never recognized. Now that demand is recognized, government spending can't keep up with that demand. But there has to be there has to be some support from the private sector for that national good, and and and proudly, we we provide that. Now the next thing to spin into in in the closing kind of six minutes is this great big beast of right to choose in in the diagnostic process. And.

You know, it's worth just picking that apart for a second that We we've we've we've we've been approached by five or six NHS trusts, and I'm gonna put this out there. If anybody from a trust is listening or anybody wants to influence the trust, we can take on more in terms of NHS work, and we can do more to support the NHS. That's our commitment to the national ADHD good, especially with children. The trusts can commission us, and we will provide these services that we're talking about. And once you become a provider for the NHS, so let's say our our Lincolnshire contract, once we once we have satisfied the contractual requirements to to provide that service to the Lincolnshire commissioner.

We are then providing services to the NHS, not just the parochial geography of Lincoln, to the whole of the NHS. And that allows anybody to come to us under their choose their right to choose, their choice profile, could come to us and, and become a patient under the NHS because we are a provider of services to the NHS. And once once that happened for us as a service in terms of that diagnosis, Well, the world just went balmy. And and we we were getting 30 to 40 referrals through GPs a day.

And for the for some NHS clinics, that's two months of a clinic capacity, and we were getting that a day. And we've staffed up, trained up, and gone through the pain of growth and, you know, sort of whatever, to be able to try and meet that demand. And we are meeting that demand a lot better now because we weren't ready for 30 or 40 a day. We just weren't. Nobody could have been. But what we've not done is change the diagnostic process. So we've got we've got the big numbers, and and.

We we've we've had to grow the back office, and we're going through recruitment campaign right now for our back office staff. I think one of the pain points of being in rural Lincolnshire is finding the right staff for the back office when when most of Lincolnshire is covered in potatoes, leeks, and cabbages. And we you know, so the Central Manchester, Central London, find staff for fun in Lincolnshire. Proven difficult. But we we're growing the back office to be able to service the need to grow more clinicians, to service that need of right to choose, but the diagnostic process doesn't change.

Everything is the same, but the tab is picked up by by the NHS. We have a bit of a wait on that because 30 or 40 a day. But the important thing here is that you can go for an ADHD diagnosis both privately and through the state, through the NHS, and the process should be no different. The process should be agile. It should be getting you from a position of risk. An untreated ADHD is a position of risk, and it should get you into services and into treatment medically as quick as humanly possible. And if the service can do that, we are adequately managing risk on behalf of the national good. And and that's what Lisa and I have set out to do right from the very get go is to be part of something that is part of the national good. And.

Lisa, as well as saying as well as saying, can we not do this for nothing? Also, it beats me up every month saying, can we not pay ourselves more? Well, no, we can't because we have to pay all the people to actually prove to to to deliver this service on A child at university.

I need a need a pen. Me too.

And and, you know, we've now got sixty sixty staff providing this provision these rates that are affordable. And we said right from the get go, if somebody's on their backside financially, and that's normally generational because of the generation flow for ADHD, If someone's on their vaccine, we should be able to provide a service that costs less than a Starbucks every day and provide a service that that that diagnostically is a 100% safe and sound, but it costs less than a Sky package. And then the the the the the decision for the family is do you want sky or do you want a well child? And that, you know, those kind of decisions become.

Quite straightforward then. So that's the diagnosis process you've got. To to round that off, you should have a very swift and agile process that can manage risk very quickly and get that patient into treatments as soon as humanly possible. And for us, for a child, that's within a week or ten days. For an adult, it it can be about two months, three months with the waiting list, which is coming down as we recruit more. And and once you once you've been assessed and you've been diagnosed, you should move straight into treatment. And there should be no waiting time between those two because we know where we are, we know what we're at, and we know what we need to do. So you've got all of your prep.

Patients and clinician, triaged by the clinician. You've then got a risk assessment. You've got a diagnostic process linked to the international manual, which is accompanied by a huge skill set of clinical observations to make sure we can see the ADHD. We don't need to go to school. We gather that evidence from elsewhere, from school, from clubs, from grandparents, and those other things when we're talking about children, And and then we can move into treatments. And as the clock ticks into the last minute, the guidelines say that you you you you are looking for the age of five or six to start your process off and and and look at children. Reality says if you've got a child at four that's at extreme risk because of their hyperactivity.

Or impulsive behavior, you cannot afford to wait for their birthday to start looking at them and treating them. So in terms of any mom or dad, grandparents, or primary school, pre primary prep school, nursery school teacher who's got a child at the age of four or five who's demonstrating such risks, and we've had them. We've had children in hospital because of the injuries they're getting because of their risk taking behavior. We've had children who cannot possibly have the their best life because of their behaviors, because of their impulsivity and their their their hyperactivity.

Do not wait for that clock to get to six. Get to a service that can help you. And the only reason that medicine starts at the age of six is about the controls that were placed on the clinical trials for that medicine. The medicines are not unsafe beneath that. You don't get to six, and all of a sudden, becomes safe for you. And similarly, when you get to 16 or 18, medicines that are licensed for children only do not stop working on an adult. That's just pharmacology nonsense in the background. And the skill of the of the clinic, the skill of the clinician, and nurse, the pharmacist, the the team that work together, the GP, the skill of that person is to understand the medicine so you can be treated through that diagnostic process.

So it's important we see it as a supply chain. Literally, it's a chain of events that need to happen fluidly, quickly to manage risk for the patient. And if you're under six, don't worry about it. Just contact someone and get on with it. And if you get into 18, 19, and you switch it into being an adult service, then the medicine doesn't stop, shouldn't stop, and won't stop. And that whole diagnostic process falls together to manage risk. Henry. Well, hello.

Honestly, like, I've listening to you guys, it's it's been it's been amazing. I have to say also slightly heartbreaking. Like, it's like, you know, talking about the challenges in the NHS, I think I'd I I like, I I I know that there's I have absolutely like, the private sector in the NHS have always worked hand in hand. I've never we I think we've had this discussion before. Like, you know, when you go in an X-ray machine, it's not NHS. It's Siemens. Like, every single GP surgery is a private practice. Like, there's no it doesn't matter. Like, health care is what matters. Like, this philosophy that is overarching.

Philosophy, I think, can get can really get in the way. And I think you do a good job of managing because if that's not what you do. Lisa, when you talk about kids like masking in school, like, I mean, the amount like, and particularly what made me and it's gonna actually amazingly segue to our first question, was, like, with girls. Like, we know girls ADHD manifest slightly differently and and then masks slightly differently, and that girls are better at masking. And we've often we've had people talk about the Coke bottle analogy that a kid like masks at school and they get shaken up, shaken up, shaken up, and then when they come home, like, it's like and.

And actually, as an adult, like I know, when I'm in those situations, I've got to be, like, really, like, formal and look, you know, I you know, the suit can only do so much. Like, you know, like, try. Oh, god. It's hard work. And but you actually saying that is going to help so many people. Like, I can't underline how important that's going to gonna be. What is the lose it line, Lisa? First question from an anonymous caller called Phil. So.

I I described the lose it line. I'm just gonna do a quick diagram.

So so my my.

Patients, I don't know whether you can see this. Yeah. We can. So this line here is the lucid line. Oh, wow. Okay? And so my patients are hovering just below the lose it line. And and they look normal. They look like you are alright, and you wouldn't think they were bubbling below below that line. So people will say to me, oh, yeah. They went from naught to a 100 like that. And they go, actually, no. They've been at 99 all day, and then one little thing happens, and it's usually when they're coming out of school and the mom might say the wrong thing to them or another child pushes them and and it they just explode. And so, you know, the treatment for ADHD will bring that child from that losing line down.

So that if you function at this level and you have a little blip, we're not near this lunatic line. And, you know, that describes a lot of children, and and the masking is so key to why diagnosis is missed and why I'm seeing far too many adults who should have been picked up as children. And it leads to a lot of that anxiety, low mood.

Oh, we have that. Actually, wait. Look. Woah. Let's do that. Well, segue to that question. Obviously, see anxiety and depression so common in you. You gave some statistics earlier, which are very, very powerful. And actually, of the thing god. I'm gonna open. One of the things that I found so powerful about both of you, so as a charity, as an individual also, one of the great battles is describing ADHD and the detail of ADHD and communicating it. And something you both have in absolute spades, things like the Lose It line and other, I've been watching it, noting it a lot. You have these, these worked up communications that you've clearly put enormous thought on, which provide this wonderful point of clarity for people. They're so so hard.

To come up with. And when they're seen, they look really obvious. The lose it line looks really obvious. And I think some of the best things when this put in front of you are like, well, that's just obvious because it's so so good. Like and it's it's spectacular. Obviously, it's been a long night. Have ADHD. My ADHD exacerbates. I I can see like I've for people these are my notes of attempted things, like it's chaos. That's what I managed to write down. The brain is even further around. So probably best to right. The question on anxiety and then we we need to do the the there's a big question about ADHD in women which we've got to promise to people on, but we see a lot of people with anxiety, and someone just simply asked like.

What medication recommendation do you have Like, what's your thought process on that? Like, and, like, a disclaimer here, no visual medical advice is not a thing, like, you know, etcetera. Right. Back to you. So.

A lot of our patients are diagnosed with depression, anxiety, or both, and they're already treated for their anxiety and depression. And funnily enough, it's not working very well. Now treatment for depression and anxiety is working on the serotonin chemical. And I mean, ADHD, you've got a deficit in dopamine. So if you were to treat someone's serotonin chemical when they don't have a problem with serotonin, then you're gonna raise the serotonin level and probably end up with side effects. So you end up with treatment resistant depression and anxiety. Well, Phil and I talk about situational cheesed off patients who have depression and anxiety because of their untreated ADHD. They don't have a serotonin imbalance.

They have a dopamine imbalance because they've got untreated ADHD. Now seventy five percent of my adult patients come with a diagnosis of depression, anxiety, although if they've got ADHD and I treat them, ninety percent of those will not be depressed or anxious anymore. Now if they're already on a treatment for depression or anxiety, I don't ask them to stop. I say stay on it. Now there is a risk of a very, very rare risk of serotonin syndrome if you give someone a medicine that can also slightly raise the serotonin level. But we look for that. So it doesn't stop us prescribing when someone's on an antidepressant.

But we look for that serotonin syndrome. They've got a blood pressure monitor that we provide. We ask them to do the blood pressure and pulse daily. If the blood pressure and pulse goes up significantly, you stop your ADHD meds, you let us know. I've seen serotonin syndrome once in twenty years, so it's not going to stop me prescribing for their ADHD, but let's look for the serotonin syndrome. So so my my advice would be to treat their ADHD even if they've got anxiety in them and and optimize that treatment so we get their ADHD as on point as possible. And if they still have a resistant depression or anxiety, some patients can have.

ADHD, depression, anxiety that need treatment in their own right, then let's treat that. But ninety percent of the time, it's actually ADHD. And treat that ADHD and you'll treat your anxiety alone.

Thank you. That's important. Think it's just you said, do you remind what was the percentage of people you thought come through have anxiety, depression? Then come with anxiety, depression or both.

Yeah. So ninety percent of them are not anxious or depressed once we've optimized the ADHD.

Dan, you'll make me cry. Like, seriously, like, it's been long a bit, like, gosh. It's so important. Trying to train.

Train GPs that if they have this treatment resistant anxiety and depression, just do that ASRS questionnaire that takes about fifteen seconds because, actually, you could be missing something that's key and you can treat.

I mean, there's a paper on our website, and and we've we've labeled it SPO, which is situationally off Okay. Which describes.

We are allowed to swear. I don't know if you watched the Hairston one. Well, okay. We we don't have broadcast rules here. We're not gonna get dolled off by off gone. Hairston's Hairston's got a clinical reason to be able to swear at this. Except it was me who started it. But I I did it purposely. I him to be Yeah. Relaxed.

There's a there's a paper all about that anxiety and depression and how that builds up. And, you know, our research says from the age of six, people can remember an anchor back in their life. That's when it all started to go belly up and you couldn't you weren't mixing with friends. You weren't invited to parties. You weren't the person who was being invited to sleepovers. You were marginalized by friends, school, and so on. And you do become pissed off, and you get you you know, so we won't labor on it because you wanna move to women, and we've only got five minutes left. Well, we'll run we'll run until the a.

Little little long because it's too important. Well done, this person who put this question in. At last night's ADHD three sixty session, you said you would speak more in your seven eighty seven about treating women with ADHD medication differently to support their menstrual cycle. How do you treat women who are going through and actually I think could you ask because I would like, they've asked about going through the perimenopause and the hormonal experience seems to enhance the impacts of ADHD. How can we be empowered to manage their own medication to correlate with the rapid changing hormonal landscape and how does HRT interact with this? And like, I'd also like to know about girls going through puberty. And.

We'll overrun whatever you need. It's too it's too hard a topic, but over to you.

So we so we actually do something. So we we optimize our patients, and we're very passionate about that. But then Phil and I coined the phrase situational optimization. So what does that mean? So if I've got a patient who and they usually do tell me on on on assessment that they have certain weeks of the month that their ADHD seems to be worse than others. And so I so I bank that comment. And then and then I optimize their treatment as normal as I would do any other patient. And when I think I've got them to as optimized as I can possibly get them, I will ask them the question. Do you feel optimized the whole month, or is there a week in the month where actually you feel like your ADHD meds are not working as well as they could be?

And it's usually the week before the period. So if the answer to that question is yes, actually, there's one week where it's I feel like I've not taken my meds or they're not doing what they should be doing or they're not doing what they do the rest of the month, then what I do is I slightly increase the dose of medicine that week. And so so so, for example, I might optimize them on fifty milligrams of of of Lvance. So the week before, I might increase them to seventy milligrams. So they have one week at seventy milligrams and three weeks at fifty milligrams. And trust me, they know when that week's coming because the medicine's just not doing it. And then we do shared care on.

One week at seventy milligrams and three weeks at fifty milligrams. So that's how we situationally optimize our patients. And it's not every woman, and not every woman has issues with premenstrual symptoms. So I would say it's probably less than five percent of my female patients who need this situational optimization. But like like we said last night, you know, if we don't get every week optimized, that's a quarter of a lady's life that's not on point. And in my book, that's not okay for a quarter of your life to be suboptimal. So it's fairly simple.

But not many people are doing it. It's almost like, well, we've got you optimized. That's good enough. Go away. We'll do shared care, and you'll just have to have a really tricky week. And and Bill and I don't think that that's acceptable.

Henry, if I can jump in there, you you you just to move the discussion on because it's easy to talk about and think about a woman having a menstrual cycle as that kind of 25, 30 year old woman running a home and struggling with everything, and that's almost a classic cartoon image. But, actually, this starts from the age of 10, 11, 12, doesn't it, with the girls in society these days who who start to to to actually puberty early. And so this is actually a pediatric issue as much as it's an an an adult care issue, and that is definitely being missed on how we can help a young girl get through school.

For four weeks of the month, not just three. And and and and we train and we focus really hard on catching that. And and those are not easy conversations to have with a with a child patient. They're really not. And but the conversations that need to be had, and and when when that we go back to that assessment process, gaining that trust and that confidence in the clinician allows us and purposes to start having those conversations. And then you you you you question from from the contributor moves that conversation in into perimenopause and menopause for a woman when life gets really bloody tough. And, you know, you if you look at the menopause symptoms, they they in a lot of things, they mirror ADHD symptoms.

And that becomes tricky when you get to that that kind of 45 to 50, 60 year old lady who's who's now demonstrating symptoms that that at the time of her life when she needs sensitivity and help can put pressure on a relationship. And what we've got to be able to do is unpick whether that's the menopause or whether it's ADHD that wasn't caught before and and and now it's exasperated by the menopause or whether or not we've got someone in treatment. And now that you you we can see the classic signs of the menopause, it's as if the ADHD has got worse. In in fact, it hasn't, but what we've got is other hormonal situations going on that make ADHD.

Seem worse. But then again, we revisit the treatment plan, and that's the important part is that when we've got an adult on a treatment plan, we have to come back to review regularly, and that review goes back to a screening tool, goes back to a structured conversation, and we start to think about what else could be going on at this person's stage in life. And that review should be designed for a woman to start talking about the menopause, the perimenopause, and what do we need to do with medicine to change that? And one of our senior clinicians, Rebecca Whelan, is is currently focused on on studying the living daylights out of the menopause.

So that we can actually become national experts on this. Because what a lot of people do is study it and say there's a problem. What what doesn't happen a lot is and here's the solution. And that's the same with puberty and the menstrual cycle. There was a lot of research out there saying, I I'm a woman and for one week of a month, I'm not as sharp as I would be with my ADHD because I'm a woman and my menstrual but nobody doing bloody doing anything. So, you know, we cracked it for the menstrual cycle, and we're in the process of cracking it for for for the menopause. And frankly, as a middle aged man, I genuinely believe women deserve this.

And and we talk about the difference between women and men in ADHD symptoms. That's not the argument we need to be talking about these days. The argument we need to be talking about is giving adequate care and treatment for women so that they actually have the life their best life, not a life that some man has designed twenty years ago in terms of a clinical process. And I'm quite you can probably tell I'm quite passionate about passionate about this because this is this is the journey that clinical practice and diagnosis and assessment and treatment should be providing now is the the arguments of how women present slightly differently to men. Yep.

It it's actually not as profound as people say. Girls have been missed because we were looking for naughty boys, and we were looking for naughty boys alone. And twenty years ago, Lisa and I started banging the drum. It's not about naughty boys. It's about everybody who's got those impairments. And there was there was a lady with me yesterday in a in a leadership course I'm running here in London who who said, I've not got ADHD. I've got ADD. And so that doesn't exist. So what's really going on? She's, well, I I don't know. I've just got this I've been told I've got ADD.

I said, so if your brain is a computer and you've got 20 programs open and you're tabbing between each program constantly, how do you manage to write the letter in word when you visit it once every 20 concentration cycles? And she said, yeah, that's me. That's my ADHD. Well, that's no different to a lad with ADHD. It's just been missed because it's not physical hyperactivity, and that's all we were looking for twenty years ago. And we have to shift our lens to become people that do things about it, not just talk about it. Yeah. And I that's.

I I agree. That change of lens. So it's so all kids, regardless of gender, if they're predominantly inattentive, if they're not showing that height, you know, that trouble making, that we we have a more sophisticated tools today. We pick everyone up. And, I think that's exactly exactly right, which is, like, with your permission, run a couple of minutes. So just there's a well, a number of people have written a very similar question and I think one half you know the absolute answer for and the other would be good to know. And it's, I'm going to summarize them both. So it's people talking about the problem of private assessments and GPs, NHS GPs taking them on as shared care.

One of the parts of concern is that as a private provider to the NHS does shared care, like the shared care relationship there. And the other is as a private provider, so when you're doing a private assessment, how then shared care with an NHS provider can help. And a person is talking about that in their area, GPs have been instructed to not not to do private shared care. I just wonder if you'd be able to say a few words on that.

I I this is the biggest bone of contention in in in UK health care, I think, is the freedom that GPs have and the way that the whole the whole structure between private health care and NHS health care and shared care is is is constructive. It's wrong. It's fundamentally flawed. Now there's a there's a number of things in there. First of all, you you said before, Henry, every GP practice is a private practice. So we're not actually talking to NHS in private. We're talking private and private. And the private primary care of the GP world doesn't like to hear that argument, but that's the facts. We're dealing with private and private. So let's take away that layer. Let's take away that that that fundamental misbelief.

The fact that we're an NHS provider means that we're not talking private and private. We're talking NHS to private, and those standards are exactly the same. So we're busting myths, and we happen to have some very difficult conversations. The first thing I would say to anybody who's struggling for share care is you are covered by the Equalities Act. Twenty ten Equalities Act. You have a disability under that legislation by having your ADHD. And every decision that a public servant, a GP, makes in relation to you and your disability has to be qualified under the Equalities Act. Now that's a powerful tool to bring about some rethinking. Now we've tried it. We've been there. We've done it.

The better tool is to work with your clinical provider and gain the confidence and trust of the GP. And in doing that, your GP, we have brought we have brought many GPs into shared care with us because they actually can see what they're doing and and trust and work with us. There's also an emerging national guideline to shared care because at the moment, it's postcode lottery, and that shouldn't be the case So there's an emerging national shared care guideline coming out.

But guess what? It's got no teeth. It's a tiger that sucks the blood out or something as opposed to biting it because GPs don't have to adhere to it. So what's the blooming point of having a national shared care policy? But it's emerging, and the next thing to push with primary care is that there's actually an adherence to this national thing. So it's it's it's actually not a private NHS thing. There's as many GPs who don't share care with the with an NHS provider.

Than they would be with the private sector. This is the biggest pickle jar that we've got in in medicine at the moment is that the GPs are overworked, over swamped, can't do this, can't do yeah. You can't. So actually, push the services away from them and just come back for share care, and actually it needs a big strategic push. And I think that's one of the things we've talked about, Henry, is how can a charity like ADHD UK work with the biggest provider in The UK plus to actually lobby for change at the highest level to make sure that this problem of shared care is is managed more effectively. It's.

Embedded and the core point, which is very, very sad, is that GPs do have this discretion, and some of them are like are declining. And they can decline, I think as you said, both an NHS provider as well as a private provider. And it's a huge sadness. We do have to call it the we've overrun because you're you're just too damn interesting and insightful and knowledgeable, both of Like, it's your own fault. I like it. So I wanted to touch on before we sign up, like, of the things I do think is, like, deeply impressive about there's a lot deeply impressive about ADHD three sixty. But one of the things I is the the way you you you price and model. And you have very clear packages so people can know exactly what they're getting, and it covers.

The twelve month period so people can know with some other providers who remain nameless, you know, they they kind of get you in and do the assessment and then it's like money every month, there's money for the prescriptions, money for and it and it can become a very large sum of money. People don't know they're getting into that and that can cause real problems. Your focus, your bursary program for people on benefits. So where you so I think you said £54 a month is is a wonderful a wonderful thing. And the your other pricing is not so much, and I've certainly recommended people over over to you for that reason. Like, I think I think that it's a really great model. I know you're starting up an autism service shortly too.

Which I think it will be great. Obviously, we know there's a lot of a lot of crossover. I also wanted to share so at 3AM, our our feed went down. Oh, no. I wasn't here. Poor Anna and Terry, our night team, I I had this realization and very quickly we're able to resolve it. So we and there's a reason why we we planned for this. So we when we've been directing people, we direct them to the site, which has a live link, which takes you through. So it it was always set up so for this eventuality because we have a single pipe in. We knew it was it was something that could happen. But the one of the things that it then rendering is we get to see how many people between our start and 3AM have come to visit us. And it's 4,400 people.

Well done. Well done. So we're Congratulations.

That that was the halfway point roughly. So we are we are pretty excited about that. And we were actually I have to say a little bit like I obviously, it's been long enough. I've got got a little bit emotional like, oh, it's a big deal. And you've been a huge part of that. And I wanted to thank you so much for your for your involvement, for your support, for the work we're all trying to do together to change ADHD in this country and the work you do every day for for the people coming to you.

Henry, thank you. And it's humbling to hear those numbers and and to hear your praise. May you make a suggestion? Take this away. Lisa and I will come back with you. We'll do a webinar especially to go through the q and a, if you wish. Oh, that would be genuinely, that would be wonderful. We'll do a specific one that is completely patient led by the q and a, and we'll just rattle them off one evening and record it maybe for those that.

That we'd love because then we can put it in the site and give people information. With the with the Once you had some sleep.

And once you've got me in contact with Adrian Charles, just mention that again.

Then Lisa and I Dan is a deal maker. Yeah. Well Get stuff done. Okay. We're in business.

We'll come back and we'll just specifically rattle through those q and a to give people even more awareness to you've managed with 4,000 people over this twenty four hour period. It'll be more by the time the twenty four hours are up. Hats off to you and the team. Absolutely incredible. It's been a privilege to be part of this. It really has. Well, you've.

Been a big part of making it happen, so thank you very much. I've got to say, obviously, we're running late again. I should not be allowed to be in charge of clock. But, honestly, I it was very important to ask ask those particular questions. There and there are more important ones, and thank you for coming back to that. That's it. We say goodbye to you guys. Thank you again so much. Good luck with your days. And over to me in just my beautiful visage. We are going to well, we're moving on. So the conference continues. As you just heard at the halfway point, we've had 4,400 people join us. Like, we're pretty excited about that. It's a big deal. Obviously, we're bringing ADHD together globally, learning from each other, helping each other.

Changing ADHD globally, nationally, locally and individually. I came up with that line and I like it.