Ambassadors, welcome, doctor Sai and doctor Shy. I'm thrilled to have you both here. Many will recognize Dr Shy Mashru from the deep dive series that he and I do together. There are podcasts looking into one topic as deep as we want. I think one ended up being over three individual sessions so that we the aim is to do a topic so that we know absolutely everything to do with it and it shows that his depth of depth of knowledge as well. He's a consultant psychiatrist. He's the founder of ADHD Health Clinic And Doctor. Achuthan is also a consultant psychiatrist specializing in neurodevelopment psychiatry and works with Shy in the ADHD Health Clinic. And they're to be talking about ADHD and autism. And I'm I'm gonna hand welcome both of you.

Hi, guys. Hi. To see you too.

We can see you clearly, and we can hear you loudly. So perfect. I'm gonna hand straight over to you, and your slides will be popping up shortly. Welcome and thank you.

Thanks. Okay. Perfect. So today's talk, we're gonna talk about ODD HD, which I'm sure a lot of the viewers who are very okay with with this terminology. We're gonna try and understand autism and ADHD and how it can present together and recognizing the sort of emerging recognition of dual neurodivergence. So Henry's already introduced me, but my name is Dr Shy Mashru. I'm a consultant psychiatrist. I I work in in an NHS ADHD service that I used to be the medical lead for, I also am the founder of the ADHD health clinic, which is a private CQC registered clinic. We do online ADHD assessments as well as autism assessments for adults and in the next month for children as well. I will leave doctor Sai to introduce himself.

Hi there. I'm doctor Sai Achuthan. I'm a consultant psychiatrist working alongside Shy as well. I'm also an author. Three of my books will be published over the span of October this year in November. It's unmasking autism, guidance to ADHD, and my personal autobiography. Background wise, general adult consultant with, numerous decades of leaderships and senior management kind of a concept over here across the private sector. And alongside that, you know, I specialize very focused on substance misuse, personality disorder, and neurodevelopmental disorders at the moment now.

Right. And And, just to one other unique thing that, doctor Sai does. I think you have an involvement in the Royal College of Psychiatrists as well in the Yeah.

I thought I'm just gonna introduce everything later on as I move on. So, yeah, I'm also the, chair of the Royal College of Psychiatrists in the Southwest, part of England. Alongside that, I'm also the chair of the mental health approval panel for Midlands and East Of England as well over here. Yeah.

Yes. Doctor Doctor Sai is a very, very modest man. And and one thing that's very unique that he does in our service is a combined, online autism, and ADHD assessment. So, that's very unique indeed. Okay. So, I mean, there's a long agenda here, but we are gonna go into AudHD in in in quite a bit of detail. So I'm gonna I'm gonna move on from this slide. Over to you, Sai.

Yep. Perfect. Thank you, Shy. So I'm gonna start off by saying this disclosure statement. Right? All ADHD is not a recognized formal diagnosis under the DSM five and the ICD 11. We need to be very, very clear about that. But but there's a but over here. A lot of senior consultants, you know, do agree, and the neurodivergent community as well do agree on the statement of all ADHD over here. A combination or an overlap between ADHD and ASD over here. So this is more of a clinical emergence where we start looking for things a little bit more differently and how the stereotype, you know, when we talk about autism, when we talk about ADHD. So this is something which we need to be very, very mindful.

You know, while all ADHD is clinically observed and now is researched at the moment now and I remember Shy used to tell me this, you know, it's now in the infancy stage at the moment now, Sai. You know? This the part of it is that we are hoping, you know, with a lots of experience of ours research as well. We are hoping there'll be a future change in terms of the diagnostic experience with DSM six, more than ICD 12, you know, emphasizing lots on the all ADHD over here. Back to you, Shy.

So in terms of learning objectives, we want you to try and understand the definition and origins of ADHD, recognize the clinical presentation patterns, and grasp the challenges in diagnosing co occurring autism and ADHD. We also want to explore the gender differences in ADHD, how it can manifest differently between males and females, and where there's an emphasis, which I'm sure many people have heard of, on female masking. And we're going to review briefly The UK and global prevalence data and trends. And then we also want to learn about diagnostic assessment strategies, medication considerations in this particular population of patients, including contraindications, and the importance of early childhood developmental evaluation.

Now the next part of it, let's talk about the historical context. Three d s m five, what we've realized is that it was very focused on the male gender, right, and on the western backgrounds as well rather than the entire population of the world. I know we have the ICD 10 as well alongside the ICD 11 and the DSM five TR as well. But one thing we need to be very, very mindful of pre DSM five, you could see the rate of autism or ADHD diagnosed was much, much lower. The reason why this happens is because it was very, very strict. The criteria was very strict and was flowing toward years and years of, you know, unrecognized ADHD and ASD. Then the DSM five broke through. We started seeing a little bit more number of people getting diagnosed.

With ADHD and ASD at this point of time. Alongside that, a lot of us might think, oh my god. Am I actually overdiagnosed? Am I underdiagnosed? What's going on here? No. Let's take it back. Let's take it a notch back over here.

What we are trying to do is trying to keep people aware. That's the reasons why we have lots of this kind of forums, you know, conference where people become much more aware of the struggles they've been having for years and years. And this is what happens after the DSM five. Hopefully, fingers crossed me and Charles having lots of discussions about this in terms of the DSM six and the ICD 12. There'll be much more of a breakthrough. Now we start understanding all ADHD much better at this point of time as well. Now we look at the clinical observations.

Those days, what we tend to do, a lots of it was clinical observations. Now we come up with, you know, standardized tools. We come up with objective tools. We come up with screening diagnosis. But all of these things, there is something which we are lacking very, very clearly. One, gender, the differences. The other one is the cultural context here as well. So these are the things we need to think about in the near future. The other part of it, if you can see, community of the neurodivergence is growing. This is what we need to support. We need to help, you know, grow. And a lot of people, you know, when I was reading through the chat box earlier because a lot of people were saying, you know what? I think.

Humans are evolving towards the all ADHD kind of a concern. I was reading through the whole chat box in the morning itself, and it was really good to see, you know, what this interaction is between all of this over here. So it's it's wonderful to see here, Shy. That's one thing I'm always passionate about. You can go to the next slide then.

So yeah. So Sai, over to you to actually to explain this.

So the all ADHD part, you know, as I mentioned earlier, it's not a formal recognition. I don't want anyone to get confused over here. It's not a formal recognition. It's not formal diagnosis by the DSM 500 CD ten and eleven, but it's agreed upon by consultants, psychiatrists. It's agreed upon various MDTs alongside neurodivergent communities as well, reflecting the experience of each other. Right? Now we'll discuss a little bit about the clinical recognition, more the clinical utilities con concept here. All ADHD presents a very significant challenge here. I'm gonna give you a very clear example. Right? So what happens is that when you go for an ADHD assessment.

What happens that you'll discuss with the consultant very, focused in regards to the ADHD, and you will try to present so much more in regards to ADHD, but forgetting all the other parts of the autism you are actually struggling with. So I always mention the differential diagnosis must be there in terms of, know, what any captures, anything, you know, the consultant sees that it might reflect autism. That's something which we need to look into very, very clearly as well. And the other part, language use, which is very, very important. What we hear, identity, the first language. What we say, being autistic.

And having ADHD creates a unique challenge. The terms when we discuss with people as well, we discuss with people around us, our neurodivergent communities and everything. We need to emphasize the importance, you know, ADHD is keep things a little bit more mellow. Autism kind of a cancer. Just keep things mellow. You don't have to identify someone to an extent in such a way and label them. It's just more of the language used to help each individual sustain the growth. Then we move on to the next one. We're gonna talk a little bit more about the global prevalence of all ADHD. It's a combination ADHD and ASD, which, you know, there's lots of research has been completed. ADHD co opers nearly one third of the autistic kids.

And remain undiagnosed in those with very significant amount. Now if you look on the the slide over here, you can see thirty two point eight percent ADHD in autism. Now you see a subthreshold of ADHD in autism, then you see autism in ADHD. Do you know how it's it's now reversing things The sense that, you know what, if you go for a clinical presentation of ADHD, how many of them get picked up with the autism component over here? If you go for an autistic presentation, how many of them get picked up in the ADHD component here? It's very, very important to understand this, you know, especially as research grows and becomes all ADHD over here. Next slide, Sean.

Now this is the interesting part. You know? We're all based in The UK, and and one of the major things, you know, we wanted to discuss a little bit more about, you know, the chair of the vice the chair of the Royal College in the Southwest position over here. We need to make sure that, you know, they are sufficient support, you know, in regards to all of this turbulence as well. We need to verify this data. We need to understand what's been going on over here. If you look into this track, ADHD rose from four point seven percent to six point four percent in learning disability groups and point four percent to point six percent in general population.

I know there's a huge cry all over, you know, Instagram, social media. We ensure I have discussions almost every single day at night on nine to 10:00, you know, just reading through a lot of Instagram, social media, Twitter, and how else we can help them as well. You know, are we being overdiagnosed? No. That's not number one, I told you very earlier, right, is the awareness. We become much more aware of ourselves. We become much more aware of our surroundings. We become much more compassionate and understanding towards other people who actually struggles if the word they wanna use struggles or, you know, have all ADHD or ASD and ADHD combination together. Then we look into the other part of it. Right? The increase.

From eighteen point four percent to twenty four point eight percent in autism in low disability groups, and the prevalence of autism remains stagnant. There's something very surprising over here. Why is it remaining stagnant? What's been going on? The criteria has been maxed a little bit more. We have more understanding, more awareness. The thing that the stigma is still there. People are worried to get the diagnosis. It sounds it sounds I'm not saying it sounds fancy, but it sounds oh my god. After all, autistic spectrum is much more difficult to approach and understand, but don't be just worried about the label. We are here to support every single individual.

Next one, sir. So I'm just gonna talk about the co occurrence statistics. Around three in ten autistic adults also meet the diagnostic criteria for ADHD, And estimates indicate that between twenty to fifty percent, so up to half, of adults diagnosed with ADHD also meet the criteria for autism will present with significant autistic traits. There might be subthreshold as well. So there's a lot of underdiagnosis challenges. Only fifteen point eight percent of those with co occurring autism and ADHD have been previously diagnosed. So that highlights significant gaps in identification and clinical recognition, at least across The UK health care systems.

There's also a lot of service demand. So ADHD related NHS online resources were the second most viewed in 2023 with 4,300,000 visits. That reflects an increased public awareness and that there's a growing demand for diagnosis and support services. But there are marked disparities in diagnosis rates and waiting times across England's regions with some areas experiencing delays that are beyond acceptable standards. Over to you, sir.

Now, you see, The UK diagnostic trends, there's growing diagnosis rate reflecting on the improved awareness, as I mentioned earlier, and the service demand. We are facing a huge service demand at this point of time, which is actually quite taxing for the entire country as well, but it still remains undiagnosed. It still remains significantly undiagnosed, especially for the adults above the age of 50. I'm gonna give you an example over here. Right? The reason a lot of us above the age of 50 kind of have this feeling, you know what? I've lived my life through the entire struggles. You know? So you know what? I'm not gonna do anything much about it. This is my life now. No. That's not the way to think. The way to think is that.

What are my struggles in the past? Does it reflects does it reflect any mental health disorder? Does it reflect autism? Does it reflect ADHD? Or maybe combination of both. You know, that validation is extremely important. And you say fifty fifty is very, very young. You know? I would say 50 is young. If not, I'll be looking very old after that. So I just wanna make sure 50 is very young for everyone. We need to progress. We need to understand at 50 years old, even though you're gonna be diagnosed now, how are you changing your environments? How are you changing yourself?

You know? How are things gonna improve for you? We need everyone to come on a level playing field rather than giving a particular person a better playing field comparatively to the other. Support needs to be there for everyone requires who requires it at this point of time. Over to you, Shy.

So this is a very interesting concept around masking. And we we've used the term high IQ, and I know that might sound a bit controversial. But when we say high IQ, we're talking in a medical sense here. Right? So the paradox of high IQ masking. So individuals with high IQ often develop sophisticated coping strategies that hide neurodivergent traits. And that masking actually delays the recognition of bored HD symptoms. That complicates diagnosis, and it delays access to support. And that I've seen, although siocene as well is is more probably more common in women than men. High cognitive ability means that you use problem solving and social mimicry to navigate challenging situations. But those compensation.

Strategies, whilst they might be temporarily adaptive, they lead to exhaustion and overlooked difficulties. That eventually leads to emotional overwhelm and burnout. And particularly, as Sai mentioned, when you, you know, reach a certain age where you're going towards perimenopause and menopause, there's an interplay with sex hormones in females, and that makes that emotional overwhelm a lot more pronounced. There's a concept called the twice exceptional concept. That refers to gifted individuals who are also neurodivergent. They exhibit both advanced intellectual strengths and ADHD related challenges that need a tailored assessment and intervention approaches. The a q 50 and the a q 10, which are common autism screening tools.

Might be less useful in patients, particularly in female with high IQ, potentially. And ADOS does not capture cultural differences, which is what Sai had mentioned earlier. So this type of assessment needs a lot of clinical experience and expertise. Masking in you know, what do we mean by masking? So masking involves consciously or unconsciously suppressing your neurodivergent behaviors to conform to social norms to try and avoid stigma or exclusion. That causes social camouflaging, so individuals use learned social behaviors and mimicry to appear neurotypical, hiding traits such as inattentiveness or social awkwardness in everyday interaction. There's a level of cognitive compensation.

So high intelligence allows the development of coping strategies that mask your challenges, such as using advanced problem solving to manage your attention difficulties. And then over time, that just depletes your energy. Sustained marking with it requires so much mental effort. It leads to exhaustion, burnout, and delayed recognition of your needs. And I hear so many patients come to me saying they feel completely overwhelmed and burnt out. Over to you, sir.

And now let's talk about gender and masking in female presentation. Internalization is one of the most things which affects females over here with all ADHD, exhibiting, you know, emotional dysregulation traits, inattentiveness, anxiety rather than over hyperactiveness, you know, making symptoms always less visible. This is the other part where the cross cultural context comes into the picture as well. Now having worked into two different continents, and this is what we tend to look into much more, when we're taking into the fact of the Asian community kind of a concept over here, what happens is that, you know, we tend to have lots of somatic symptoms, which basically means, you know, headache, giddiness, nausea.

Kind of a consistent effects rather than the inattentive component over here. You know, alongside that as well, looking into someone in the eyes kind of a concept over here in an Asian community is completely different. It's extremely different. It's more rude looking to someone in the eye, especially someone who's older to you as well. And you always place your head down and you bow yourself and you and you go. Different context, different cultures, Japanese, the Asians, you know, in terms of the Chinese.

And the the Indians, and we've got lots of different variations of cultural difference. So we need to be very, very mindful about this as well. And then, you know, in in in the British culture as well, in the entire populations of Western culture, lots of things have been internalized very, very clearly. Social mimicry, what happens is that, you know, when you are younger, you always feel the fact that.

Oh my god. I'm looking at someone else at the moment now. I'm trying to observe their behaviors, and I'm trying to make sure that, you know, everything works out well so that I be I make friends with other people. So you are employing things that you are imitating other people, masking all of those things as well. Then we look into perfectionism and pressure. Just imagine this. In your mind, you're gonna do every single thing in a very particular order or in a perfect condition.

But you're unable to do it. There's so many things rushing through your mind at one point of time, and you automatically struggle to articulate your thoughts. You think, you know what, it's better to give up at times. Then burnout comes into the picture. Lots of things need to discuss very, very clearly, again, the delayed diagnosis. We have kept this so long, so far, and it masks us a lot. The ADHD component, one of the differential diagnosis is bipolar. Right? The ASD component. The different diagnosis can be anxiety, depression as well. Lots of personality disorder comes into the ASD component as well. So all of these needs to be understood very clearly.

And that's why you need very public history and someone who's in a specialist level to do this for you as well. And back over to you. So what are the consequences of masking? So, well, as you mentioned, immediate exhaustion.

So constantly suppressing natural behaviors that consumes immense energy, leads to chronic fatigue. So you get patients that get diagnosed with chronic fatigue syndrome, emotional depletion, confusion of your sort of identity in some sense. So prolonged masking blurs self perception, causes uncertainty about what your true authentic identity is, and that increases psychological distress. Because you're masking, you might delay access to support. So that can result in either late diagnosis or, in some ways, even worse, misdiagnosis, in my opinion, which can might even lead to the wrong intervention let alone delay intervention. And.

Then the long term impact is that, eventually, if you're feeling burned out for long periods of time and anxious, etcetera, you become depressed, that can have impacts on your relationships because of due to sustained emotional strain and feeling isolated even within a relationship because the other person just may not understand this. In terms of differential diagnosis and the challenges, autism and ADHD share symptoms such as attention difficulties, executive dysfunction, social challenges. That complicates a clear diagnostic separation. And that was the reason, I mean, why I think Sai and I are mentioning about having.

You know, you really gotta see someone that has quite a level of expertise and knowledge of both and how they look together. High IQ and giftedness can mask neurodivergent traits leading to under recognition or misattribution of symptoms to talent rather than a condition. Mood disorder confusion, emotional dysregulation, and internalizing symptoms look like other mood disorders or other anxiety disorders, and then that complicates the diagnosis. People get put onto potentially the wrong treatment. There's a concept of signal single diagnosis bias. It's it's it's you know, clinicians, some clinicians might focus on one diagnosis because it's easy just to put things in one box for for people, but they miss the comorbid presentation.

And the comorbid presentation can look a little bit different. So that results in incomplete treatment and support plans. And that's why at our clinic, Sai does the sort of comprehensive assessment, which is a combined assessment of ADHD and autism together to look at the traits when they're in within the same individual.

Now we're gonna distinguish, you know, all ADHD from autism alone and then later on with ADHD alone. Right? Autism characteristics. I was I was telling Shy about this, and Shy knows this very well. You know? I wanted to give everyone here an example, you know, of routines, repetition behaviors kind of a concept over here. Right? Okay. Every day, I wake up at 07:00 in the morning. Not 07:01, not 06:59. Right? I wake up at seven, walk into the toilet.

Brush my teeth from left to right, top to bottom, two minutes on top, two minutes on the bottom. I only use Oral B toothbrush and toothpaste. As I said, I'm not here to actually do brand loyalty of Oral B. No one is paying me any money in regards to this, but I just wanna make sure that you guys understand, you know, when we say routines, repetition behaviors, and what we are looking into as well. That.

Walking to the shower shower gels in my hands divided into four. Each segment of my hair has the shower gels, wash from top to bottom, left to right, walk out, dry myself. My clothes are all aligned to an extent where short sleeves to long sleeve, left to right, lighter colors to darker colors, left to right. Right. I've already preplanned what I'm wearing the night before. And Shy always tells me the same thing, Sai. Your food, you know, your food. What's wrong with your food? You know? And I was like, but, you know, I I know that I'm Asian. I know that I'm Asian. I know my mom tells me, son, you have to like curries, but, no, I don't like curries. I love my Sunday roast.

I love my Sunday roast. You know? So I love my pork cracklings and everything of those. What happens over here is that I start with the least favorite food and then moving on to the most favorite food. I have a very specific order of things which I I eat at this point of time as well. So, basically, meaning that, you know, I start with my vegetables and then my stuffing, my Yorkshire, my meat, and then finally the pork cracklings as well. My books are all aligned to an extent alphabetical order's author's earnings. Do you see kind of a a criteria kind of a thing moving on to your mind in terms of the autism part of it, you know, deep special focus? If you ask me anything about Pokemon cards, I can give it to you. I've.

Got collections of Pokemon cards still back in Malaysia with my mom as well. So a lots of things I have, you know, hypersensitivity kind of a concept. The social withdrawal, a lot of people feel that social withdrawal basically means that, you know, you withdraw yourself from every single individual. No. No. No. That's social isolation. That's the important part of it. You want to try to make friends. You want to try to do things with others, but you feel that I can't. It's best not to because people misinterpret what I'm trying to say. People tend to do a lot of other things, and I don't want to end up in a fight. I don't want confrontation.

It's best for me to be alone. But that is the part which we get a little bit more worried about here. Right? Now the ADHD unique features, you know, the internal conflict, you know, between us. Let me take you through something now. Right? I have planned my routines. I wanna do it, but I can't do it. But if I do it, I thrive really, really well. I just can't do it. You know, that mental exhaustion comes into the picture as well. And the paradoxical effect of, you know, hyperfocus, once I sit down on something, I can complete the task. But after three, four days of hobbies, I'm gonna move to a different task and move to a different task. Your ADHD combination with your autism over there, high focus, goal ahead.

Spent quite a significant amount of money for the hobbies and everything alongside myself, spent a lot of money on Pokemon cards, matching the gatherings, all of those, Dungeon and Dragons as well. And then we move towards a lot of other things as well, that desire of social connection. I can rock up to Shy and say, you know what? Shy, hello there. And then I'm just stuck. Nothing is flowing out from my mouth. I'm hoping that Shy will say something, but he stood there as long as I'm me as well thinking not to say anything as well. So those are the things we tend to look very, very clearly in regards to this. And the emotional, you know, rapid response in your mood changes very, very often what people this can happen is that they can mimic.

The mania depression kind of a concept. The mood fluctuates very quickly at times as well. So you need to be very, very mindful. It's the way you present yourself. It's the way you speak on your symptoms will determine what's gonna happen after this. So you need to be very, very focused on this to understand yourself as well here. So next thing, we move on to the OAHD and ADHD alone. Right? The marked activities, the motor restlessness.

I used to remember, as I say, you know, I'm able to bring cross cultural things into the picture. I used to fidget quite a lot. You can see now I'm standing with you guys, and Shy is very relaxed over there and having a conversation. I'm standing over here, and I'm trying to have a conversation with lots of, you know, hand gestures. You know, I used to be younger, and mom used to say, son, why are you fidgeting? The ruler. No safeguarding against my mom. I love my mom. The the ruler comes into the picture and snap on my hands. Okay. So now I learned I shouldn't be fidgeting, so I stopped myself, and then I have this inner restlessness keep going on in regards to that. Those are the things we tend to look to, the impulsive behavior, reckless.

Driving, gambling, you know, excessive drinking of alcohol, drugs, those kind of things takes into picture. The attention span tends to at a picture. I want you to think of this. You know? If you have a pen, one tip pen, it's easy for you to write your whole thoughts of it. Just imagine you have a five different different colors. You know? It works really well, but you struggle to actually click it one by one. You tend to move it all five together down, so it gets stuck. And your mind is just so muddled. It's like, no. I've got lots of things I wanna explain, but I can't explain. So that's what we're talking about if you get stuck over here. Now the presence of steaming behaviors.

Beyond just the simple fidgeting, you know, it's more of the rocking behaviors, your hand tapping, your skin picking, your biting, your chewing. All of those comes into picture as well. But as I said to you earlier as well, the internal conflicts of the routines and the novelty seeking kind of a concept over here, strong pattern recognition. I don't know how many of you guys in the past when you're younger has done this. I know I've done it. I am not sure Shy has done it before. I've never asked him. But, you know, when you have a pavement, you have the tiles.

Then you should always think, oh, I should I should jump on the first tile to the next tile without crossing the cracks on the butt. And someone will say, is this superstitious? What's going on here? Lots of pattern recognition, you know, volumes. Your your your pattern of volumes as well on the TV. You know, you need to have even numbers or something something on those or even odd numbers kind of things. We see things in a very pattern organized manner as well. Those are the things we have taken to account as well, Shy. Next one, Shy.

Sorry. I got over to you over to you.

Yeah. So what happens in this comprehensive assessment approach, Nava? Spending time with the patient is very, very important. Spending time with the clients, spending time with the service users, spending time with the patient. Right? Very important. Developmental history plays a huge crucial part of the assessment here. What happens is that we need to understand because it's a of pervasive developmental disorder, so we need to understand more in regards to this. So if you can't get family members to help you in regards to that, you know, developmental path.

When you were younger, until your teen years, you know, you would have had one best friend when you were younger. Try reaching out to them. Try reaching out to them and see, you know, any possibility if you could recall.

A little bit more about myself when I was younger. You don't have to ask them to fill up the forms if they don't want to. There's gonna be more texting for them as well, but you can just ask them questions. You know? This was what happened when I was younger. How do you resonate? What was going on there? As long as you have some kind of informants report, someone who has who knows you long enough kind of a if you ask me, I think more than five years is good enough, to be honest with you, right, to understand yourself. But I'm not gonna say that we're gonna make a cutoff point at the moment now, but what I'm saying that for me, if you're shy, we understood five years and a lot of other consultants. We we appreciate five years kind of a.

Process here. Then the cognitive testings, Shy mentioned this very, very clearly. The high intellectual, the highly functional individuals, right, the cognitive pathway processes. We need to understand that the weights for kind of a concept to assess your intellectual capacity to a point where we understand that you're extremely gifted. You know? If you're talking about Einstein, you're talking about, you know, people of Galileo and every one of those, you know, if you think about it, you know.

Do they have autism or not? Do they have ADHD or not? They were so focused on their jobs. They could go over and over and over in regards to the same thing as well. So what we are trying to do now here is that, you know, the entire public and the entire clinicians submit this for the what we're trying to do is to understand the capacity, understand the functional levels, understand the intellectual levels, and then guide to the entire assessment approach. It's very important. This is what we call individual assessment. We're not giving a generic assessment to everyone. And then we have the observational behaviors over here as well. The consultants and alongside of yourself, you know, discussing about, you know, what's the struggles.

We're looking into the similarity in what you filled up in the report and what you're presenting at the moment now, picking up the mental states as well, understanding, you know, because a lot of things can mimic physical health as well. We need to get those physical health pathways. I don't want everyone to start focusing that, you know, if I'm running towards this, it's only gonna be ADHD and ASD. We need to think about the physical health. We need to have differential diagnosis very, very clearly over here as well. We use a specialized tool. As I said, you know.

Earlier, I think, Shy and I discussed a little bit more of the ADOS, ADIR concept. You know, I know that it's a gold standard tool. I understand that. But, you see, this was developed way, way long ago. There are lots of cultural differences was not taken into account. What about the gender pathways here as well? I'm not saying that it's not a gold standard. I'm saying it's still the gold standard, but adjustment needs to be made. Clinician base needs to take the seats in this. Very, very important. We need to make sure that the clinician is able to make that judgment, make that decision. Right? Not simply with the clinician's judgment. I'm saying the additional help can have can be present, but.

The clinician needs to make the help of this kind of decision making going to here. Right? Then next one.

So medication considerations. So, obviously, stimulant medications, methylphenidate has been regarded as an as first line of treatment showing about seventy percent favorable response Atom amphetamine based stimulants offer an alternative stimulant option, but they have varied effectiveness actually in ADHD. So that's an interesting difference. Nonstimulant options like atomoxetine, guanfacine, clonidine are used when stimulants are contraindicated or poorly tolerated. I will add one note to that bit of the slide that that, actually, nonstimulants can be quite effective with emotional dysregulation as well, maybe even more so than stimulants, actually. Stimulants may actually have reduced effectiveness in autism compared to ADHD only cases.

We have to be careful for monitoring for side effects. People with sort of comorbid autism can be far more sensitive to side effects of these medications, so you have to do a very gradual titration. And then usual side effects of these meds are things like appetite loss, sleep disturbance, and mood changes. So you have to have really sort of quiet expertise when you're managing that type of titration and medication. ASD traits can become more pronounced. If you're medicating someone who's got both autism and ADHD and you take away the ADHD, the ASD starts looking more prominent. Sensory sensitivity can increase with treatment. Hyperfocus can become more prominent. They may become more inflexible and more introverted.

Executive function will improve. So as say, it does need senior expertise to titrate meds in such cases. Antidepressant considerations. So SSRIs are common antidepressants that are used. They increase serotonin levels. It's so fluoxetine or what was famously, you know, manufacturer of Prozac was probably the most studied SSRI in autism, and it was often prescribed for anxiety and low mood. Sertraline is is favored for fewer drug interactions, while citalopram and escitalopram pores are less common. Hi. Can are you guys still there? Oh, okay. I think we're back.

I hope everyone can still Yep. We can be up. Back. There was a problem in this end. You're back. Apologies.

Right. That's alright. So there we are. Okay. So SSRIs show actually limited effectiveness for core repetitive behaviors or attention symptoms in ADHD. Their primary use is to manage coexert occurring anxiety and depression. And a lot of the research suggests that there's minimal benefit for autism specific repetitive behaviors. And, actually, if your anxiety and depression is coming from your neurodivergence, that may also improve with ADHD or, you know, certain types of medication. Side effects of SSRIs, increased agitation in this type of patient. Suicidal ideation can increase, and that needs close monitoring. And SSRIs can also cause gut upset. So a careful risk benefit analysis is essential.

And you need a lot of expertise, especially when you're combining stimulants, for example, with antipsychotics or mood stabilizers. Polypharmacy challenges. So polypharmacy means when you have multiple medications on board, patients with ADHD often receive combinations. They've, you know, been misdiagnosed or maybe on different lots of different treatments. So polypharmacy can increase the risk of drug interactions, additive side effects. So there's a constant need for regular review and ongoing assessment by a really experienced expert to to manage the treatment of this type of patient. Sai, I think you wanna do this one?

Yep. Yep. I'm doing the future research. As as we start off the whole conversation today, we understood that, you know what, we are still in the infancy stage at the moment now. Right? Like, just take it, for example, we are still, like, the pre DSM kind of a concept in terms of the all ADHD component over here. Right? So there's lots of things needs to be developed at the moment now. There's lots of comorbidities we need to think about as well. Right? We can look into lots of comorbidities like, you know, for example, dyspraxia. You know, all of those needs to be, you know, placed in a significant amount of research over here. You know, you need to understand, you know, hypermobility.

Lots of the less than loss syndrome. This all the comorbidity comes into play. So clinical treatment and research is very, very important here, especially in the pharmaceutical side of things and alongside, you know what, the psychological support as well, the ADHD coaching, the psychotherapy, which, you know, acceptance commitment therapy, we're looking at to the CBT kind of a focus all over here. Right? Just more in regards to it. Just a few more here. Diagnostic tools need to change. We can't be fixated with the what we've had in the past and continue using them. We need to have more in-depth, adaptive diagnostic tools as well. Most importantly.

You know what we wanna do here. We want a better outcome for everyone. We want to measure the quality of life. We want to make everyone progress, thrive. That's the most important thing we wanna do at the moment now. It's creating awareness, validating your feelings. Those are the things which is extremely important, signposting you to the right resources, which is gonna be provided. Those are the things everyone needs to share and understand. You know? That's the main thing we wanna do as clinician. Know, comparatively everywhere in The UK, the clinician in terms of ADHD, autism, combo. What we want to do is that we wanna make sure that all of us thrive in this population kind of a general concept, you know, not having stigmatization.

Between one and another over here. Shy?

So clinical assessment protocol that we use at the ADHD health clinic. Look. There's a lot on this slide, and I am conscious of time. So I'm gonna summarize a little bit here. The first step is screening. So, you know, we want to get we we have developmental screening reports for children's, particularly. We're we're talking a teacher and parent rating scales, medical and family history summary. We're just information gathering initially. The next step is evaluation. So, particularly, the combined assessment that Sai does is a very detailed assessment. It takes two to two and a half hours. It's a full cognitive assessment, structured interview, but Sai will not just look at ADHD and autism, how it impacts you.

Have you have any other potential mental health conditions going on. The next phase is dating. Considering other differential diagnostics, looking at the person as an individual, looking at their strengths, but and then also their challenges, and tailoring intervention to that patient. That's the important bit. And then the last stage, of course, is feedback and planning. So, obviously, providing a comprehensive report for a patient to look back on, but also collaborative treatment planning, which might involve even other health care professionals as well and ongoing monitoring. Mhmm. So especially if you put on things like medication, an ongoing review of that as well is very important. Yeah. So sort of the key sort of takeaways.

ADHD is not currently in the diagnostic classification, but we, in the industry, certainly recognize this condition. So early identification and tailored support does lead to better outcomes as you would expect. Complex presentations do require personalized approaches. We emphasize collaboration. Successful management depends on strong partnerships amongst families, health care providers, educators, other community organizations. Sharing knowledges and and resources, fosters understanding, and it reduces stigma. And finally, I think senior expertise is needed with this, particularly this type of patient, and it does require skilled and senior expertise due to well, first of all, to understand other comorbid conditions.

So you can even recognize this, and due to the risk of adverse outcomes when prescribing medication. So having the knowledge of that and what to look out for. And just to just to end off, you know, as mentioned earlier, we are the ADHD health clinic, so we provide online ADHD assessments, autism assessments, and Sai, in particular, does this combined online autism and ADHD assessments for adults. And in the next month, we'll be doing children services as well. Thanks a lot. Thank you, everyone.

Hopefully, you enjoyed it. Thank you. Thank you. I did well, I've I've seen lots of comments in the in the chat from people who clearly I saw that as well. I'm not sure that I've seen. I found it very we actually don't get all the comments. So some of the comments, for example, from Instagram don't come through. And I've seen some really interesting things said. So it's clearly resonating with people. It's clearly a big deal. And I can't thank you enough for doing it. And obviously, we lean on your expertise all the time and shine the deep dives. And actually, more than that. When we have people coming to us with additional problems or questions or needs, he's, know, we go to him and helps us and it's actually an.

Extremely big deal that he does that and he gives that time all for free and donating it to help people understand ADHD and ADHD and autism and it's absolutely fantastic. Sai Achuthan, I can't thank you enough. You're both wonderful. I genuinely really love that. And I always love the lived experience when you're talking about your set up site at home. It's actually, it'll be it'll be it'll be inspiration it will be inspirational for many people going, you know, he's a doctor, he's succeeding and, you know, he's he's.

Also open about his autism now and how it's impacting him. That's actually a big deal. People don't hear that, so thank you. I've got to jump. I'd love to chitchat forever and ever. I've got to jump. Apologies for everyone, especially Sai and Shy on the ident suddenly appearing. It was really powerful. Thank you very much.