And next coming up, we've got we've got my cofounder, the cofounder and trustee of ADHD, doctor Max Davie, talk about nonpharmaceutical interventions for children with ADHD. He's a he's a medical doctor. He's a pediatrician, and he is my long term friend. I have known him a long time, longer than I like care probably to to admit. Right. Without further ado, hello, Max.

Hello. Good morning.

Good morning. You're frightening me then because I was like, is he on mute? I didn't like it. That quiet pause at the start. So tell me, what's it like being on the roller coaster of ADHD UK? It's you we are both the cofounders.

Right? We've done this together. I mean, was a brilliant timing starting a small charity just before everything stopped. I mean, I thought that was, you know, a masterstroke on both of our parts.

Yeah. I mean, it's big. Yeah. Because we started and then lockdown happened. Yeah.

Yeah. I mean, it's been, you know, it's been it's been a ride. We've all learned a lot. And I think we're just sort of kind of, I don't know, getting ourselves kind of back on our feet again for the fifth or sixth time. But the thing is every time you get back on your feet, you know you can do it. So you just do it again.

Yeah. It's and I think that's a testament to what we try very, very hard to hide, which is how hard this is. And the huge challenges of being a very small charity with a community of two point six million people with ADHD and having to deal with terrible things. And I talked about it in my introduction, talking we're having articles saying, does ADHD exist? I mean, the deputy chairman of the conservatives saying ADHD is bad parenting. It's just like just these battles that.

It's constant. You're I know I have to say so publicly say, your determination in this has always massively impressed me. There have been moments when I'm like, oh, I'm just I can't do this anymore. But you've always just plugged away. You've just kind of come up with something and and got us and kept us going. Yeah. Thank you. So, you know, that's an amazing thing.

Well, thank you very much. And certainly, I talk obviously, I talk to other charities, you you watch when they like, people as we go as they go through, and it's happened with us, like, battle is just very wearing. And people it's very wearing. And because not only when people are attacking, not only they are trying to denigrate the whole of ADHD, but it's also undermining of each individual. It's undermining of me, of you, where they're just like ADHD doesn't exist. You're going back to them. And someone recently said, it's terrible. Some people are making ADHD part of their identity. Like, duh. I didn't choose this. You.

Would never say you would never say it's terrible for somebody to make autism part of their identity. You would that would be completely unacceptable thing to say.

So I don't you know, your physical disability or being dead. I I don't understand.

Yeah, I don't understand why this is something that you can be prejudiced about with impunity. Well, I do understand it, but I I don't think it's excusable. Like.

It it's like, no other condition gets this. Like, it's just in in the same way as far as I can I would It isn't a game of trying to work out who's got it working? I'm.

Not saying that others don't have it bad. Well, I mean, personality disorders probably have it terribly badly.

That's a fair point. Okay. This isn't a competition. Like, every yeah.

It's not a competition, but I've you know, those guys really do.

No. I think there's a there is a lot to be said there. Right. You've got a talk. You've got a whole.

I have got a talk. A whole adventure of knowledge. I didn't just nib on for a chat.

Oh, you could we could do this. Good now. Yeah. It's Right. Shall I put your slides up? You wanna do it?

Yep. I'm assuming someone's gonna put the slides up for me. Wonderful. So okay. Do I do this? Is that gonna work? Cool. Alright. So I'm gonna talk I just Henry's introduced me. The thing the thing I've got to sort of emphasize is that I am an an a perfectly ordinary NHS doctor serving. I'm gesturing towards the borough of Lambeth on my wall behind me. I I work in Lambeth. And I work for the NHS, and so we sort of scrape by, basically. So when I talk about the non pharmacological treatment of ADHD, I suppose I'm talking about well, this is what I'm talking about. It's basically the the person centered treat treatment of ADHD. Because in a sense, there's two things that you talk about when you talk about the treatment of ADHD.

One is the treatment of the ADHD brain and the other is the treatment of the ADHD person. And I think the evidence base now we'll talk quite a lot about evidence base in this talk and I please, I'll I'll have a look at the comments if people don't aren't following. But the evidence base looks very different if you're looking at the brain to what you're looking at when you're looking at the person. And I think that's a really key point. So it's I'm not saying that spoiler. It probably is the person, but I'm not saying that you could ignore the brain, but there there's a two different ways of looking at how you treat ADHD. And the answer to what the usefulness of non pharmacological methods of treating ADHD.

Depends on what the question is. As in, are you treating the brain or are you treating the person? So I will explain. I just do want to quickly think about medication quickly. If you focus on the brain, just focus on changing the brain, making the brain essentially less ADHD ish, which is a technical term that we doctors like to talk about. It's not. You know what I mean, though. They the whatever that x factor that defines ADHD, reducing that a little bit and making that a little bit easier to deal with in terms of at at a brain level, medication is effective. Does it reduce hyperactivity and positivity? It does improve concentration. We've got pretty good evidence for that at a studies at a at a population level. And, also.

If I'm starting medication for a patient, I'm pretty confident it's going to have that effect. I didn't use the word work because a drug doesn't necessarily work. A drug has an effect. Whether it works is depending on what you want to get out of it. Do you want to reduce your hyperactivity and pulse even poor concentration? Probably. But why do you wanna do that? In order to make your life better. And that's the extra step that I think isn't measured in necessarily in medical trials. Sometimes it is. Sometimes it isn't. But but if you're narrow about what counts as evidence and you're in terms of what you're measuring as in just the performance of the brain and you're kind of short in your duration of study, then medication is far and away.

Beyond everything else. Okay. But this wouldn't be a great talk about nonmedication management if that's all I had to say. But if you may take a person focus, two things happen. One is you have to be broader. A person is not just their brain. A person is not just their performance sitting in front of a TV screen clicking or not clicking a space bar. The person is the whole person. I mean, you know, obviously, you've been sitting watch watching this conference, and you don't need telling. But that has key implications for what treatment means because actually and we always talk the talk about this being about being patient centered in the NHS and in health care generally, but we get distracted by.

Let's just change your brain. Let's just make you perform better at these particular discrete tasks. Whereas actually what the person often comes to and with is I want my life to be better. I want the impairment caused by whatever it is that's happening for me to be reduced. And so this key concept of impairment doesn't get talked about enough. And I think that's where the non the nonpharmacological aspects of managing ADHD really comes in. So this is a graph that takes a bit of explanation, but I always have it in my mind when I'm thinking about ADHD. So this is kind of ADHDness. I call it hungry brain, know, you how hungry your brain is. It's a metaphor that I prefer for ADHD.

Other people might say busy brain or fizzy brain. Doesn't really matter. How ADHD your brain is is along this axis down here. And at some point, you make a diagnosis. That's not important right now. But let's say you are here. So most people with ADHD, just mathematically, most people with ADHD are in this ballpark. A few people are in this ballpark, but only a small number just by definition because it's a normal distribution. If you are here, what are your options? Well, you can take some medication, and that will nudge you in a more typical direction on this axis, and your impairment will go down a little bit. Okay. That's fine. You could do that. Or you could modify your environment.

Now this doesn't come from particular. This is mainly from my experience, and it's a mental model of how things actually work in the real world. There is evidence that some of the modifications do improve impairment, do reduce impairment, but it does need to be and that's what the NICE guidance says. It needs to be a wrap around care, and it does decrease impairment. So what happens is, basically, you shift the curve a little bit, if you think you're here and you reduce your you you modify your environment, look at how much impairment happened get gets reduced without changing your ADHD at all. And then maybe you can.

Try some medication and look where you are on the curve. A tiny change in your brain state will have a big effect on your impairment. So I think that's kind of really does underpin a lot of my approach is just that little curve. So I think maybe I could should have said before drugs instead of beyond drugs, but that doesn't sort of have such a ring to it. So what you get is you bring in all of these other things. You bring in gut health. You bring in exercise. You bring in mental health. You bring in all sorts of things. And then the question comes, well, what actually works at a person level? And what works at the brain level? Can have deal with that fairly quickly because not much does. What works at a personal level to help people.

With ADHD? And that's a very difficult question because research on how much people's actual lives improve over long periods of time is really difficult to do accurately. The longer the period and the more broad the focus, the less quality the research becomes. And so that is very difficult when you're trying to trying to assess evidence. Just that's just a point that underpins a lot of the debate about this. Okay. So this is my I have whenever almost all the time I make a diagnosis, I will kind of put my fingers up and say, I have a five point plan for you. Because I think people feel, okay. He's got a plan. Good. We got a plan. But the plan is not just I don't have the same plan for everything. These are just five.

Points that I want to make. One is education understanding, then brain health and support at home and wherever home is, support at either school. I don't do adult ADHD, but I've just put work in here and medication. I think that's a reasonable five point plan. Medication is deliberately at the end of that plan for the reasons I've outlined. So education and understanding. I think it's often misunderstood that what you need there's this phrase psychoeducation that's often used. It's used in the NICE guidance. People kind of bandy around. It's what we need is more psychoeducation. Psychoeducation, first of all, is not just sitting there listening to things. I mean, maybe this talk. It's kind of psychoeducation.

And sort of, you know, looking at slides of brain scans and nodding. That's not psychoeducation. Psychoeducation is a conversation. Psychoeducation is an understanding, taking what you understand now about the condition with somebody else and kind of refining and coming to a a shared understanding. And psychoeducation can occur within a family. Discussion within a family can be psychoeducation. And I think there there are two and for me, the education understanding is not about knowing what part of the brain is affected by ADHD. Spoilers. All of it, which is why brain scans are not that useful. It's about avoiding two sorts of attitudes and getting the right attitude at the beginning right in the middle.

So the attitude on the left of the slide is the kind of blaming attitude. And and both of these attitudes are kind of extremes, and they're almost kind of they're more it's more that people think that other people help them than actually anyone actually holds an extreme view of these. One is basically blaming the child, blaming the person. You know, you just just need to work harder. You're just being lazy. You just, you know, you just you just just don't wanna do it. You you're just trying to hiding behind whatever it is that you think you have. Just get on with it. And, obviously, we've all had that experience. We've all had that person in our lives. That's something to avoid.

The other extreme, of course, is what that person thinks you might be saying, which is, oh, I've got ADHD, so I can't do this. I've got ADHD, so I can't do homework. I've got ADHD, so I can't be at work on time. I've got, you know, all of those sorts of things. And what I always say, and this is such a basic thing, but actually, think it just has real power, is ADHD is a neurodevelopmental condition. I don't need to tell this audience what that is. A neurodevelopmental condition that makes some things more difficult, but nothing impossible. Nothing is impossible as a person with ADHD. But some things are very much more difficult and require much more support, mental energy, etcetera. And that's such a simple message.

But, actually, the implications of that just spool out if you actually think about it, any particular situation in the context of that. And I know that's really basic, but people get it wrong so much. And we've seen this week with sort of comments from Lee Anderson of the deputy chairman of Conservative Party. He clearly doesn't get it, which is sort of not really okay, but he's not the only one. So the second thing is the break is brain health. I'm not mad about the phrase brain health, but it does peep does make sense to people, and it is quite kind of now, if that if that makes sense. These are the things that have a really good evidence base for optimizing these being good for the.

To an extent, the brain, to an extent, the the the hyperactivity and impulsivity, to an extent, but also the overall well-being of a person with ADHD. So I'm gonna talk about these in a little bit more detail. So when you think about our exercise management, you know, using exercise to manage ADHD, I think some people might have in their heads, oh, I have to do planking or sort of unnaturally cheerful people trying to plank. Yeah. It looks horrendous. But, actually, what I think is much more important is just having an active life. I'm not mad about step count. I don't think a 100 10,000 steps or whatever is a magic number at all, but keeping moving as much as you can is very helpful in the short term.

And in the longer term for your mental health partly because it helps you to sleep. So walking the dog is my one of my kind of main bits of I don't walk the dog here, sadly, but it's one of my main bits of exercise. And I think that's what you need to focus on. Don't you don't need to get a gym membership to get the exercise you need to manage your ADHD. Sleep. Now people do get quite hung up on the duration of sleep. Now this is a a graph for 14 to 17 year olds. The same graph essentially can be drawn for any age of child and for adults. The point about the graph is that with this is healthy volunteers. It's not people who have a problem. The amount of sleep that people get is way really, really, really variable. And so you can therefore.

It's very, very difficult to say on the basis of an amount of sleep that is not enough or that is too much. What you need to look at is the individual. Are they rested when they wake up? I mean, the thing I I do ask about bedtime in in clinic, but when I ask about, well, what is it like in the morning? Because if the child is bouncing out of bed at six in the morning and they've only been they only got to sleep at at midnight and they're not sleeping in the day and they don't have a nap and they're fine, they are at this end of the distribution. It's a pain because sometimes you gotta be up with them, but that is that is how they sleep. And so giving them sleep medication to get them to a magic eight hours is a bit pointless.

So if but if they're not rested, then you may have a problem. So then then you've got the question is, what is the sleep consistent? Is the sleep pattern consistent? Sleep is a really ingrained habit of the brain, and it doesn't work properly unless it's ingrained and unless it's consistent, unless there's a rhythm to it. It's all about rhythm. So you've got to have consistency. You can't have a massive lion on a Sunday morning and then expect to be back in the groove to go back into your Monday, into your normal work or sleep pattern. Sorry. I know a massive lion on Sunday morning is brilliant, but if if you have a sleep problem, you cannot do it, basically.

And then, of course, there's the quality of sleep, and we have to think about the quality of sleep. So snoring, sleep apnea have a huge impact on quality of sleep, and drugs, and by which I include caffeine also and alcohol, have a huge impact on on sleep quality. So that's the sort of conversations that we have. We don't really have conversations. I mean, I I I record the duration of sleep, but it's not my main focus. It's the quality and and the effectiveness of sleep that is most important. And you can you can tell from those few remarks a lot of the things that we advise. You know, we advise consistency.

We advise going to bed so that you're rested the next day. We advise looking at the quality of sleep and avoiding the things that reduce the quality of sleep. We'd make referrals to ENT and so forth, and we do use medication to help sleep sometimes. Mood. Now, obviously, this is complicated because if you're saying, well, improving your mood improves your well-being, well, of course, it does. But it also I think it particularly, there is a combination of poor mood, particularly anxiety and ADHD, that really is multi you know, kind of they they kind of get you get into a vicious cycle, and they are more affecting they affect your well-being much more combined than they would individually.

So there's a kind of meshing there. And some of the most difficult cases that we look after in the service and then there's it's not difficult for me. It's difficult for families, and it's difficult for the young people themselves. The people who have most difficulty are the people who have that combination of ADHD and anxiety, particularly, and later in life, and ADHD and low mood, obviously, because those are quite high risk people. So definitely addressing mood. And one of the things that gets missed when a child, particularly a young boy, is aggressive or very kind of lashing out a lot or very oppositional is their their their anxiety gets missed. And and so that's something that I do talk about a lot. So it is a component of manage.

Management. It isn't something that will kind of immediately solve things. And, of course, other things will feed into your mood mood. You can't use it in isolation. So better sleep will improve your mood. Better exercise will improve more exercise will improve your mood, and, of course, the general support. So it's not something that you can look into in isolation, but it is definitely something that we need to address. The question is what is available to address it? Now again, we go back to this whole thing of what's evidence based versus what's actually helpful, and those two not the two same things. So CBT, cognitive behavioral therapy, is by far the best evidenced treatment for.

Anxiety and depression. No question at all. But that's the evidence, which is short term, relatively superficial measures of has your anxiety got better? Not has your life got better. Other therapies which take a broader view, so we're talking about psychotherapy or DPT or all of those other things, are probably, in some way, in some ways, deeper and get more to the root of some of the issues that you might be having.

But they're not as well evidenced because the evidence base doesn't suit the way that they work. I have some bias here because my wife is a psychotherapist or about to be a psychotherapist. So I really have a kind of it's really difficult and interesting conversations about, well, there's no evidence for this, but we know it works because we we do we do it on a personal basis, and the person tells us it works. That's very difficult from an NHS point of view in turn because the NHS only commissions things that have evidence base in that that narrow sense. So this is tricky. This area was really tricky. CBT if it works for you, great. If it doesn't work for you, then it's it can be difficult to know what else is going to help.

And I'm just interested to note that the medication for ADHD yes. Of course. If your ADHD is better, then your mood can improve. What about these other things? If you look at I've looked at a few things particularly around Facebook. You know, what are the other things people suggest, which are not drugs, which are supposed to be effective for ADHD? Diet supplements, mindfulness, biofeedback are the things that sort of come up. And I was just thinking about this. And the I was sort of slightly skeptical kind of moment, really. Basically, there is a curve. If something gets developed and tested.

The initial results are almost always really exciting. Partly because if the initial results were not exciting, they wouldn't get published, and partly because the initial results is often on quite small samples. And it's very easy just statistically to get a really impressive result on 20 people. If you start and then you start ramping it up to thou 2,000 people. And then you also start I'm getting distracted by the comments. Sorry. You start ramping up to 2,000 people, and you start being kind of more robust about it and kind of more of the kind of randomized controlled trials, in all conditions, the impressiveness of the research will decline over time. That is just what we expect. Unfortunately, for these particular aspects, diets.

You know, mindfulness and biofeedback, the drop the drop in the the impressiveness of the research, again, by the specific lights of what evidence counts as evidence in the NHS or within science has dropped off pretty quickly. One of the problems I have is that what's remained high is the value of these to marketers, people who want to sell you sell you a treatment or sell you something. And that's marketer's job. It's fine. But the fact that people have said it's been shown in science to work, it's not that much better than L'Oreal commercial, to be honest. It if it's not actually made it to professional guidance, it probably we don't know that it works yet at a population level. If it works for you, great. Brilliant.

But it we, as doctors, cannot recommend those things because we don't have the strength of research to actually be able to make those recommendations. So just to reiterate, these are likely to be helpful for some people. The problem is we cannot predict at this point who it's going to be helpful for. I think the classic example of this is mindfulness. Some people really, really benefit from mindfulness, and there's no question that specifically mindfulness is the thing that has helped them. I'm not questioning that for a moment. But other people with ADHD try mindfulness, and they hate it. But they persist with it because because they've been told it works. If it doesn't work for you, it doesn't work for you. Stop it, please.

Because there's no I mean, whereas if you've got something which is more evidence that, yeah, you're likely to get this effect, you can push through a little bit. But with these things, if if it's not working for you, please stop pretty quick because you're probably in that group within whatever study that you've done, the the group that for for which it doesn't work. And it may be that we come back and we get subgroups. So mindfulness might work for people who have ADHD and particular personality traits. Great. Then we can be more focused in our in in our recommendations. We'll see. I see that people are having a go. Yeah. I don't disagree. So support at home. So this is I I think there's.

Probably been mention of this already in the conference, but peer support, I think, is so important. One of the things I am proudest of in Lambeth is that we have a pretty active peer support network, and I will always always recommend that families join our peer support network when they are die when the child is diagnosed. Because I've got, what, twenty years of experience in ADHD, and I have ADHD, but I don't necessarily say that in clinic. The peer support network has centuries of experience between them of being a parent of a child with ADHD. And they've all of the situations that this one particular family in front of me are in.

Know, somebody in the peer support network has been in it. So why why would you not plug that in? The second thing that is quite helpful, and I know I've had a bit of a go at psychoeducation, I think we're we have some workshops and webinars in Lambeth. And I think if you can get onto a webinar, I think it's important that it's live, that you get the opportunity to ask questions. I'm not a big fan of just having stuff just kind of just watching something and not being able to ask anything about it because I don't think it's very engaging. What it where where do your questions go then?

So we're lucky we've got those locally, but if you haven't got stuff locally, you may need to find something from one of the organizations. And, of course, ADHD UK has very regular meetings for for a donation on every single subject you can think of related to ADHD. So that's one of the things that we in ADHD UK are most proud of. And then there are formal courses and support. And as as a parent with a d of a child with ADHD, you may be groaning a little bit at this point. You may have been onto a a sort of parenting course, or you might have been offered a parenting course and been a bit offended because you're you're a good parent. Why would you need a course to do this thing that you're doing?

And I just want to pause to explain why I think parenting courses are valid. And by the way, I have done one. If you think about three these three rows of an exam hall. Okay? So let's say, for example, that they they they just I wouldn't put it past the government, but there you go. That they change the they change it. So depending on what row of the hall, column of the hall, just for your pedants you pedants out there, There's a different pass mark. So this part this row has a pass mark of 90. This row has a pass mark of 60. And this row has got pass mark of 30. They could basically go home, can't they? And that would be grossly unfair and and a national scandal. And of course, the government won't do it because they won't.

But that's what it's like in parenting. Some people can be if you think about your parenting mark, how good a parent you are, most people, and I am parent three, are most of the time about 60%, 60% a good parent. I mean, you know, last time my daughter was trying to talk to me and I was playing on the PlayStation and I did not feel like a good parent. I had to say, I'm really sorry. I did was not listening because I was dying horribly. Please say again. So it wasn't a great parenting moment. She was a bit annoyed. So from but and for most of and and that's fine. And she has got ADHD, but she's she's she's cool.

But for a particular child with additional difficulties as long alongside their ADHD, a lot of the time, your pass mark for your parenting is 90%. And that is grossly unfair. You will have friends whose children are really easy and their pass mark is forty fifth 4030% even. They could do whatever they like and the parent the kids will still be fine. You are on a real knife edge as a parent of a child with ADHD. But there isn't any alternative. You don't want us not to be their parent. So therefore, you have to raise your skill level and your confidence level to 90%. And I think I don't know if people find that helpful. I find it helpful talking to people in clinic. So that is why you might need parenting intervention.

Not because you are sub you know, not because you wouldn't pass a normal exam. It's that you're, you know, you'll be you're you're basically having a you're being asked to be a super parent. And how can you be a super parent without training? Doesn't make any sense. You haven't you know, you you're not Superman. You haven't got how does Superman get his powers? It's his krypton, isn't it? I can't remember. You know what I mean. You haven't been bitten bitten by a radioactive parenting spider. I'm on safer ground with Spider Man. Right. So that what so what's the point about parenting? So parenting support groups should be facilitated groups. They shouldn't be chalk and talk. They should be you as a group learning together.

And there is really, really good evidence, excellent evidence. It's actually one of the most cost effective interventions for mental health that exists in the world. For oppositional behavior and for parental stress, really good evidence for reducing those things. But it does not reduce your ADHD symptoms. To go back, the brain focus doesn't make any difference to your ADHD symptoms. Okay? Right. Good. So if you're so actually sometimes I say, well, you've got lots of ADHD symptoms in your child, but actually he's not oppositional and you seem to be managing. I wouldn't worry about this yet. Do it later when it's when it's time. There is a little bit of a kind of tendency amongst doctors to say this is the treatment. It's not.

It's a treatment for a set of difficulties which are really common in ADHD but are not ADHD itself. Just to say. Oh, why is my oh, okay. Supported schools. I've just few things. I probably ask some school teachers on the call. They usually ask people who are in in the education sector. So there is not this is not a slide which is having a go at schools. I absolutely love my local schools. I think they're a tremendous job. But there are three things that are important say. One is ADHD is a specialist educational need. So if you have a diagnosis of ADHD, you need to be under that system.

Just by there's no question about that. And people have pushed back and said, well, he's bright or, you know, she's doing really well. No. It's a special educational need. It it requires you you may not need anything right now, but it means that you are on that on in that bracket. If what that requires, what that makes the school have a duty is to make reasonable adjustments. The school has therefore needs to make reasonable adjustments, and that's a duty in law. No question about that either. The question, of course, is what reasonable adjustments means. And in classic British law style.

It's left a bit vague. And reasonableness is actually a really interesting legal topic, but we don't talk about it now. Basically, it's what a reasonable person would think is reasonable, which is kind of circular, but there you are. So schools will that that's where the kind of gray area is, and that's where the push and pull comes. It's what is reasonable for this child in this school to as an adjustment to them. And there's all sorts we have all sorts of discussions about that. And that's where goodwill and working together becomes really important. It's really, really important to have an understanding a little bit of an understanding of the funding arrangements for schools when you're trying to get help for your child.

Schools sometimes are naughty. None of our schools, but other schools are naughty and say, we don't have any resources. They do. They had delegated funding for special education special educational needs from the local authority. They may not have enough, but they cannot say they don't have any. What they need if the the other thing that people talk about a lot is getting an EACP. Again, we don't have time to talk about that detail. But, basically, if the school have exhausted their delegated funding allocation and the child is still not making progress, by which I mean also being in class, not just academic progress. So if they're getting excluded a lot, they're in.

All these dreadful kind of reflection rooms that the secondary school send them to all the time. That is not making progress. That's not accessing learning. If it if if they're not doing that and the school have put everything in, then the child should go forward to an EHCP. This process, however, does need to have the at least the support of the school. And the really tricky bit is where the child clearly needs it, but for some reason, the school won't go down that road. But that doesn't happen very often in Lambeth because our school's a fab.

Then I don't I'm I have to say, I don't see adults in my clinical practice, but I am an adult with ADHD. So I guess I have a little bit of insight here. So were a few very, very short points about that. One is reasonable adjustments. Again, the the same principle of reasonable adjustments applies in work. You're you don't have to apply for reasonable adjustments. Your employer has a don't no. Lambeth has got its downsize, missus Robinson. Of course, some reasonable adjustments is the duty of your employer whether or not you apply for them or Like, that that's what they have to do. It's that's a a law thing. Access to work is a grant for specific things that you need for your work to to work effectively. So it could be equipment.

It could be training. It could be mental health care. Access to work seems, from what our experience, to be a pretty good scheme, I have to say, and people have got some really quite helpful things out of it. So I I I I have a go at the the government where I need where I need to, but, actually, this seems to be a pretty effective scheme. And there's obviously personal independence payments. I think, again, to be fair, the disability benefits system is built for.

Forty years ago and now is dealing with a vast a a very much larger number of people and a very much broader definition of disability. So there are genuine difficulties, but also a huge sympathy for people who are just trying to get some some a little bit of money so they can live their life, so they can get to work, and they're being bound up in quite a quite a difficult situation, quite a difficult system. There you go. That's me being even handed. So those are my things. Those are my so four things before medication. And so then where do you try when do you try medication? Well, the answer to that is once you have got the environment as good as it's going to be, not to.

Perfection, not to, you know, the ideal situation of so everyone being completely on side and, you know, all of the support you can possibly ask for and a 100% great patient parents, almost robotic in their calm and their consistency. That's not gonna happen. But as good as you're going to get in this situation with these people and that school, then I think you can have a think about meds. But I don't think you should do it unless you are in a really bad situation. I would say you don't do it until you've done those things. That's my particular view. And some people, you know, have different views, and that's absolutely fine. But that that would be my kind of view on this. Okay.

I'm not quite finished. So I'm just gonna do a summary, and then we've got some time time for questions, which is marvelous. So we need to treat the person the person and not the ADHD. So you the person the brain is part of the person, so medication is part of that. But I think focusing on I'm treating your ADHD is the wrong focus. I think we've we've we're trying to make people's lives a bit better, a little kind of nudging a few kind of inches at a time towards something a little bit more functional. So that's the first thing. And the second thing is to try and surround yourself with understanding and surround yourself with love, really. Find people around you who get you, you know, a teacher who gets you, a boss who gets you.

Anyone, friends who get you. It's really, really important to have those people in your life. And sometimes you need to leave things and leave relationships or leave schools or leave jobs if you don't have that understanding, and that's really, really, really, really tough. Do think about optimizing your brain health, but don't get sucked into things that are making claims if they don't work. I mean, try stuff by all means. Try stuff. Try supplement. Try mindfulness. Whatever. But if it doesn't work for you, let it go. Having said that, exercise, sleep, and mood are really well evidenced, and you should always focus on them.

And then try and get as much support from around the place as you can. So think think outside the box. Try and get support for you know, apply for access to work. Join the ADHD UK groups, connect with other people. Peer support is absolutely vital. And and those are the sorts of things I mean, sounds very, very basic stuff, but those are the sorts of things that we generally talk about in clinic, and and it seems to be what works. Okay. So we've got well, we've got some questions. I found that this when back when Twitter used to be fun, not so much a question or a comment. I mean, I think a lot of the things that people have put up are comments, and and that's fine. I'm not really kind of aiming that at this this audience. And if you have.

Questions, there's my email. I can't really answer clinical questions, but if you've got anything else, that's fine. And I'm still just about on Twitter, but but not really. Okay. Should we have a chat again, Henry?

I'm back. Yeah. Hello. Hello. That was wonderful. Thank you, Max. I thought that was you can see, obviously, all the comments coming in. I thought it was fascinating and really important. So thank you. Now people can put in questions into the chat, and we'll look through them. They go into the stream. You can also look through if you put it in go to globaladhd.com, you can see yeah, you can put post your questions there. So please do that. What do you think of so we've had a question around around medication someone submitted. Is there any evidence on long term effects of medication on on children, I. E, long long standing implications?

I I think there's two kind of ways to approach that. One is do they what what is the long standing effect on brain structure if you take a group of children who have not had medication versus those who have? And, of course, we have the the limitation that at this point, we're not randomizing people to take medication or not medication. You can't randomize a group for two years or three years or five years. It's not ethical, you know, because then people don't know what they're taking. You can only do that for short space of time. So after that, you look at brain you you you look at brain structure. And so there's the thing called the cortex, which is the kind of.

In a sense, the kind of thinky bit around the outside of your brain, much of which is in the inside of your brain is more kind of tracked connecting the other bits and the kind of emotional seats of the brains. The cortex of people who take medication is thicker than those who don't take medication. Okay. So that's encouraging. A thicker cortex is generally a good thing. And then you still think, well, okay. What about functionally? People who take medication over time do tend to have better executive function, for instance, so organization and planning. And the other thing that's quite always slightly impressed me is that so like in in Scandinavia, they have these huge registries of basically everyone in the country.

And they look at people with ADHD. And then they look at people who take medication versus don't take medication. And the vote the people who take medication, for instance, have half the levels of involvement with the police, by which I mean getting in trouble, not joining the police. And so, I mean, that's impressive on its own. Of course, you need to have a little bit of caution in interpreting all of that because the there's lots of differences between the populations which are not just whether they take medication or not. There may be lots of other factors of people who are dropping out of the health services, who have other issues, so they haven't can't they can't keep up with their medication.

So it's not just a medication effect. But nonetheless, I think overall, we've got to be cautious, but the evidence for long term effects of medication is mainly positive. I knew I knew I was gonna be asked about medication when I give a talk about nonmedication. It's like the elephant in the room. Don't talk about elephants. Give a talk about not elephants, Max. Okay. I gotta get questions about elephants.

I can't well, I'm I'm joining this fray. What about height for kids taking medication?

There is a small effect on height. No. It's a good point. There's about one centimeter effect on height at the populate at a population level. Individually, that is obviously gonna be more of a concern if you start early. If you start a six year old, then you're probably gonna get a bit more of an effect on height than one centimeter overall. We do monitor height, and I have to say we don't usually have a problem. I think maybe because I tend to give less than other people. But, obviously, if you're starting a teenager or or an adult, it doesn't really matter because they've done most of their growing already. But, yeah, one centimeter height is a.

Adverse effect. I mean, it's easy for me to say because I'm six foot three. I don't I wouldn't miss one centimeter of heights, but.

I'm I'm five foot eleven and three quarters. Yes. I know, Henry. I'm I'm bitter I'm bitter about that last thought.

I think we've been talking about your height for about thirty years. So anyway, anyway, you just have the misfortune of having tall friends.

It's really like it. It's gonna they can get things off high shelves for me. The it's actually it's a it's a pertinent question because a friend of mine who, like, is significantly more vertical challenged, his son is really worried and actually is not taking medication because he's so worried. Like, genetically, his genetic request is clear. And so that sent me to means a lot. And yeah. Do we know why height is impacted at all?

That's a really great question. I don't think we know exactly. I think it's something to do with the way that the medication might have an effect on metabolism, and I can't but I can't I think it might sort of route things from growth to other aspects of metabolism by the stimulant effect. I think the honest truth is we don't really know. And and I suppose we because it's only one centimeter, we're sort of not really.

Yeah. But, like, if you're We're not really kind of looking into a huge amount. Yeah. I think the issue is that some children are. Right? And and there's think there. I do think this this is not for you, Max. He's not in charge of all research into ADHD in the country and the world, just to be sure. But I think you Not yet. Situation. Yet. Not am I ever going to be. Working on it. The Yeah. I think I think actually so that people can make clearer decisions so they have really good data, more research, that would be useful. We've had some questions on supplements. We've had two, which is which is nice. So one is much more simple, which is what supplements would you recommend for ADHD?

And the is more detailed. Are magnesium supplements a good option? Are there any negative effects taken in general like there is for calcium ones?

So I just I suppose just to reiterate what I said in the talk, we don't recommend supplements. Not because we think that they're terrible or bad, but because we don't have good enough evidence at a population level that they work. If they if you try it and you and you find it really helpful, great. Good for you. But, firstly, most people I know who I work look after who try supplements doesn't really work. And, also, we don't the evidence is that if you look at the whole population, there isn't an effect at a population level from supplements. Because the problem you've always got, if you take something as part of an overall management of your ADHD.

And you feel better, well, how do you know that it's the supplements that make the difference? If you only if you're quite robust about it and you try one thing, you change one thing at a time, you might have a bit more of, you know, kind of confidence in knowing that that's the thing that's that's changed. But I'm I'm a bit wary about it partly from from any from anything else, they're quite expensive. And, you know, the families that we look after don't have a lot of spare cash. And, you know, I don't know. Maybe you use it to, you know, have a membership of the swimming pool. That I mean, if you've got a little bit of spare cash for your ADHD, go swimming. For me or, you know, buy a bike. We have that.

Those are the things that I think are much more important.

We have had a question. Are there any nonmedication so you'd be glad to hear. We're moving into nonmedication. Any non medication recommendations that can be suggested for adolescents when they experience hormonal changes and how these might affect their ADHD? And I think when we've been talking we've had groups where we're doing ADHD in women, and there's a growing group of people talking around medication altering during a woman's cycle, that there's different impacts we need to think about having slightly different levels during it. And so this hormonal impact, I think, is really interesting. Over to you.

Yeah. I mean, I I think there's a specific thing about the menstrual cycle, and I just have to declare my ignorance really. I don't know enough about it, and I we don't yet have recommendations about how to manage the menstrual cycle in the concept in in the context of ADHD medications. In terms of I'm always I'm always a little bit I always ask people what they mean when they say hormonal changes in adolescence because often what what you mean is that the the the often what is meant is the child has behavior has changed over a course of months as puberty goes up puberty.

Kicks in. But actually puberty is not just hormones. Puberty happens at the same time that there's a huge change in their life going to secondary school. Their social roles have changed. Their friendship groups have changed. Their brain is changing admittedly some somewhat under the influence of of hormones themselves. So when you say hormonal changes, what often what's meant is my child has become a teenager. What on earth's going on? And I think, honestly, the the recommendation I would make is to learn more about teenagers. And possibly, if you've maybe you've done a parenting course before, see if there's one specific to teenagers locally. Even if it's not specific to ADHD.

But understanding and getting and connecting with teenagers is a really different job as a parent to understanding and connecting with younger children. So, honestly, I would go back and review your relationship with your child and the way that you're and look at the way you're parenting and whether that's better, whether that can be improved. But in terms of the so there's menstrual cycle, I don't know. And puberty, I don't think it's supplements that you need. I think it might be just setting back.

I I do. Yeah. On someone's gone into that. Actually, we've had an additional question. What are the best strategies for children with ADHD to manage their moods? And they've taught my biggest issue growing up undiagnosed was mood. It was a lot of yelling and anger, and I felt anger management didn't help.

I didn't hear all of that, Henry. Sorry. Think you're break you I don't know if it's just me. You're breaking up a little bit.

I hope I hope it's just you. What are the best strategies for children with ADHD to manage their mood? My biggest issue growing up, undiagnosed mood, it was a lot of yelling and anger. I felt anger management didn't help.

Yeah. So I mean, don't I don't think they've got good evidence for anger management as such. And I think, basically, because there's nothing wrong with anger. Anger is not something that we should try and control or reduce. It's just something that we should think about what we do with it and how we respond to it. And the other thing that the person said, which is absolutely key, is to is that she wrote she got undiagnosed. So, you know, if you're basically if you're being if your mood's being treated, but your ADHD is being ignored, you're only treating half of at least, you know, at best half of the difficulties of the of the Of course, you're going to So what just but to answer to your question at at base level.

What are the recommendations for mood in ADHD? Obviously, diagnose the ADHD and manage the rest of things, and then be alert to the fact that this angry shouting person might be anxious. And that they're not just angry and shouting that that what what is the internal life of that person? What's going on for them personally? Just having that curiosity. And then if they do have an anxiety problem, then seeking appropriate treatment for it. I know that the treatment, particularly in The UK, is not adequate, And the availability is not adequate, but that is where we're at. And that's what's available.

Thank you. Someone's asked, they've asked multiple times, does prematurity increase the likelihood of ADHD and autism? It's a.

Prematurity. Yeah. I saw that question. Just posted a couple of times. Yes. A 100% it is. Prematurity is two two things to say about prematurity. The slightly premature baby, sort of 34, 35, so that's about five or six weeks early, often has fairly classic signs of ADHD to lots of kids. And what happens is that they get back to their two week check two year check, and the doctors say, yes. You're fine. Off you go. And then they arrive in kind of reception, and they're they're all over the place. And then they come see us. So that's quite a typical pattern, and they have reasonably typical ADHD symptoms and definitely, definitely more of it than the general population. So they should probably be.

I would argue they should be screened when they go into they should be tracked and screened when they go into reception. The very premature, so when you get down to the 20 when you get premature when down to twenty four weeks, the sort of the extremes, they tend to have obviously, they may have lots of difficulties with learning disability. But even, you know, you got to twenty eight, twenty nine weeks, you've got problems. Therefore, you tend to have a mixture of things, a weird, strange mixture of some ADHD features, some autism features, atypical features, things that don't really fit in with the diagnostic categories all that well. And so you often in those groups have to kind of work around the.

Just kind of describing the features and managing things in a pragmatic way rather than trying to fit them into your diagnostic boxes. It's a really interesting the the comeback is how is this a genetic condition? No one is saying that this is a straightforwardly just genetic condition. That's not true. What it is is most of the population risk for a risk for ADHD is the genetic loading. For this small population of people who are premature, they might not have been a had ADHD, but then they were premature and that's what triggered their ADHD. For the majority of the population, the heritability, I. E, the contribution of genetics to their ADHD is.

Something like seventy or eighty percent depending on the study that you I was about to say, I think, yeah. The one I created is seventy six percent. Yeah. So but but for that but but this but that's at the population level. In this subpopulation, it's not genetic. It's it's it's caused by prematurity. Equally, you know, kind of if you have a a head trauma, that can induce some ADHD symptoms. But it is not true, and I just want to push back against Lucy here. Trauma is not the only cause of sorry. Hang on. You said that you're not actually you're not you're not actually there's some really inappropriate stuff going on. Please.

There there is. Go away. But just to just to talk just to answer Lucy for a moment. Just.

To ask Lucy, I I just understand. I've read your comment properly. I think that there the evidence of trauma causing ADHD, the jury is is still out as to whether trauma as in emotional trauma can contribute towards ADHD. And I think it's certainly it's definitely an open question. It doesn't it doesn't mean that seventy out of percent at a population level does leave you a window for environmental factors to be important. We don't have the evidence so far. What I would say is that I suppose to go back to my little kind of graph, you can remember it now. For a given level of ADHDness, if you also have experienced trauma in your life, you're going your brain health is gonna be very much worse.

And so therefore, your impairment for a given level of ADHDness is going to be very much worse. And you're quite likely to be in a less positive environment if you're previously traumatized because because that's that's just how these things track. So I think it's a really complex issue, and I don't I I definitely think that looking that that examining the history the trauma history in a child who has ADHD can be helpful if something can be done now. The problem with fix I'm not I'm not saying anyone is fixating on on on trauma histories. But the problem with kind of trying to find a cause in trauma histories is that maybe something really bad happened to you in the past.

That may or may not matter for what you do now. If they're if it's if you're revisiting it and it's conditioning your responses, yeah, address that. But if it's just something that was a bit rubbish and now you've moved on, you don't have to dwell on it. I suppose that's the pragmatic way forward.

Max, that's been wonderful. Thank you so much. Thank you for well, thank you for being my, you know, cofounders. All you're doing in the charity. Lots of people don't know how how hard works within the charity and all he does. That was a wonderful talk. Thank you so much. Thanks for answering all.