We're on to part two of the Global ADHD Conference. Shock. We're running late already. And we've gotta catch up because, like, Australia are fierce. They are fierce. And so... But that was incredibly interesting. I'm extremely grateful for Edmund for opening up our conference. And it did segue very very nicely. Do you see how I did that earlier if I can't on navigating the no. Because we do have a social media, a lot of discussion around ADHD. A lot of... Some of it is very positive, very good, very useful. A lot of people learning about ADHD, recognising it themselves coming forward. And then there's a chunk of it, and this is all social media, right? Some good, some you know, not so good. And some of that advice.

Isn't ADHD and some people are struggling so much that they're jumping onto the idea that it's ADHD because they're looking for an answer when they are struggling. And a good assessment, we know that a chunk of people rightly get told we don't think it's ADHD. The assessment says no. And then there's not clarity on what to do next. And I'm extraordinarily grateful for Doctor Chris Abbott and Anupama Ghose who have come from Care ADHD to talk to us about it because it's a big question, it's incredibly important and it's not really been answered anywhere else. And it's quite a brave one and so I'm very grateful. So if I can introduce Chris Anupama.

Hi Henry, thank you so much for the introduction.

Well I'm absolutely thrilled. It's not the full introduction because I need to introduce you properly. You are Care ADHD's Chief Medical Officer. I'm your consultant psychiatrist. You spent years at South London and Maudsley, where you're... You were associate medical director for child and adolescent mental health services, working CAMS crisis team. So was a real sharp end of young people in health care. Anupama Ghose, you're the clinical psychologist. You lead ADHD... Sorry, Care ADHD clinical work in India for Bangalore from Bangalore. Your work based in... At ground based evidence therapies and your CDP DT, AT and T and mindfulness. And together you're gonna talk about.

A top threshold ADHD, how it overlaps with anxiety and trauma, how to get real and effective care of them today. Just take me very closely. I'm gonna... So thank you so much for doing this. We are... One of you, we're getting quite a lot of feedback from background noise. This is a a heads up. You might wanna mute when you're not talking. And over to you. Thank you.

Thank you, Henry. Really grateful for that introduction, and I'm really excited to be here. So thank you for coming to talk to us. And a very interesting topic that I think everyone is quite keen think a little bit about and one that we don't necessarily brush into the carpet, we don't face it head on when we say yes to a diagnosis. No can be very challenging to a lot of people. So I suppose today what I'm hoping we can leave you all with two takeaways nuggets. So first of all, if you are someone who's been told no recently or you're waiting for an assessment right now, we hope that the next hour makes you feel seen. And if you're a clinician, we hope that this gives you something to take back into your own practice.

So I'm gonna set the scene first of all and have a little think initially about a case. So first of all, this isn't an... A particular person. I'm gonna call him Tom. It's an amalgamation of lots of different cases because I feel most of those stories deserve to stay private. But this is just to give you a bit of an example. So let's imagine Tom. Tom is in his thirties. He spent years wondering why some things feel so much harder for him compared to others. Maybe he's had challenges through school. Maybe holding down jobs have been really hard. Concentration at work can be quite challenging. Finishing tasks.

Managing his time, all of these things to be getting on top of him. He finally works up that courage to go in after an ADHD assessment, which we all know cannot always be easy. So he's gone along to his GP, asked to be referred, and then he goes through all of the assessment, all of the rating scales, the individual face to face appointment, and then he's told, no. This is not ADHD. So Tom walks away thinking, but why? Why do I feel like this? Why do I struggle with all these things? And in a system like ours in The UK, no often means nothing. There's no follow-up. There's no next steps within the ADHD team. There's no pathway to follow. Diagnosis is often the door to get help.

It's over needs, I think, that's just been discussed. So if you don't get that diagnosis, where do you go? So, Anupama, I want to bring you in here because actually in India, Tom's story looks quite different.

Thank you, Chris. I'm delighted to be here to be able to present on this particular very underrated but extremely significant topic. So, actually, our partner in India is slightly different in a good way. So if we get a no diagnosis here, if we have a no in the assessment outcome, that isn't the end of the conversation. It is basically just a starting point which is telling us where to look next, what to explore next. So if Tom's diagnosis came back negative, we wouldn't worry. We would reassure Tom not to worry, and we would definitely not lose his fight. And this brings me to something that professor Edmund was talking about right in the previous talk, a needs based conversation. So rather than a diagnosis and a label based conversation.

We'd rather shift the focus to a needs based conversation with Tom. What is he struggling with? What does his day to day difficulties look like? What does he need help with? And moreover, just to highlight that in our therapeutic pathway in India, we have clinical psychologists, but we also have counseling psychologists working alongside each other. So it does not really matter whether, you know, a person needs clinical intervention or just general support to make their life better. So, you know, the counseling psychologist also helps with self esteem, stress, managing quality of life. If somebody has difficulty in time estimation, somebody has difficulty in forgetfulness.

All of that can be managed. So either way, we have a root for Tom. Tom didn't need to worry. We'll definitely look into what we can do and guide him better for the next steps. Over to you.

So, Anupama, before we dive into the why, I suppose I just wanna be really clear clear that ADHD assessments are standardized. Our diagnosis thresholds... So coming back to that term, we were just hearing thresholds. The thresholds should be consistent. So if you're told no in The UK, no is just as relevant in India, US, Australia. It doesn't matter where. It shouldn't be a postcode lottery. But I suppose that raises the real question. If it's not ADHD, then what is it? And for me, think that's probably one of the most interesting topics. It's around subthreshold ADHD. So by subthreshold, I'm talking about people who have the symptoms.

But it's not quite enough of them or they're not quite severe enough to get across that diagnostic threshold. So these people often have genuine difficulties with impulsivity, inattention, and it can be then really challenging to come to an assessment to be told, no. Sorry. That's not ADHD. And right now, at least in The UK, there's no clear path to these people. They don't have another condition, an adverse or common to be referred on for. They're just... But they're still struggling. There's still a label without a plan. And I suppose I'm being really clear here. These are for people who are struggling with inattention, impulsivity, hyperactivity, not those who may also have anxiety.

Depression, etcetera, because there would obviously be a pathway for them. But this is something slightly different. And I suppose two, I've just mentioned one of them, but two of those conditions often do come up when deciding is this ADHD, is this something else? Anxiety quite often needs to be considered and trauma as well, particularly in younger children, but just as relevant throughout the entire age range. Let me just give you a little bit of an example about why they overlap so much with ADHD. And I often use this example for clinicians when they're in training. So just imagine just for now something that makes you anxious. So let's just imagine it might be you've got a driving test tomorrow.

So you're not really concentrating on what I'm saying because you're thinking a little bit about, well, tomorrow, I'm gonna have to remember to do this. I'm gonna have to check this. I'm gonna have to remember, you know, the the group. All those kind of things. Your mind isn't in the present. You've also maybe got that adrenaline running through you, so you might be a bit fidgety. You might be playing with things. You might be pacing. And then also, if you're not really thinking about the here and now, you might be making impulsive actions. So all of these you can start to see mimic things like ADHD. Now that's just about driving tests. Let's imagine we have generalised anxiety disorder and that anxiety is there constantly.

Again, you can start to see why it is that some people might think, is this ADHD or is this anxiety? The key difference is in the history. You're very unlikely to have been anxious and to learn. Probably not gonna be the case. But ADHD symptoms, we need to have that history. Anxiety comes on later in life, often with a trigger sometimes a prevent, agent work that way. Nobody suddenly develops ADHD at 17 without any symptoms at all before. If something suddenly appears, it's likely to be something else. Anupama, I'm gonna ask you to come in again now. So just thinking about that sort of thresholds around ADHD, anxiety, trauma, is that something you often see in the assessments you carry out?

Of course. And as professor Edwin also pointed out, that because of a lot of social media awareness, very rightfully so, somebody who's been struggling for years, maybe decades together, when they see that, okay, these things seem relatable. They don't know, of course. Rightfully, they don't know. So they come up for an ADHD assessment, but probably they don't have ADHD. Probably they might just have some other clinical condition. Probably, they might just have some stressors which which is causing all of these difficulties. Right? So I believe it's very important that we manage the person's expectations even right before we start the assessment. Because somebody who's coming for an assessment.

I believe that they have already fought so much of internal conflict and overcome that to reach to this particular stage that they... You know, they have come to my clinic or they have come to the virtual session. So, of course, they are expecting some outcome. And, generally, if it's a negative outcome, we... A lot of times, we think that, if it's a positive outcome, people might take it up as a bad news. But for somebody who's expecting a neurolevelopment... Developmental diagnosis.

A negative outcome can also be a bad news as well. You know? Because that might mean that, oh, this also does not answer whatever I'm being troubled with. Then what has happened to me? What is wrong with me? So all of these questions come back riddling them again. So whenever I'm starting an assessment, I prefer to give them some overview of what the process looks like and also what we expect from the process. Because, you know, coming to an assessment doesn't automatically guarantee a diagnosis like you pointed out. It matters, you know, their childhood history, their adulthood history, life stressors, different context. So many things are important here. So I I like to tell them that it could be that we are looking at ADHD.

It could be that we are looking at ADHD mimicking symptoms for some other clinical condition, like anxiety, trauma, depression, something else. It could also be that we are not looking at anything clinical. But the very important point here is that when I say that we are not looking at anything clinical, does not mean that your problems are null and void. Maybe it's not a clinical condition, but whatever you're being troubled with, be that time blindedness, be that, you know, forgetfulness, inattention, feeling of restlessness, all of these are valid. Right? So whatever we find out from the assessment, we would definitely help you out. We definitely still work with you and support you. So I feel setting that stage right.

Even before the assessment is what makes or breaks the game as well.

So that's a little bit about the why. And I suppose what I'd like to now kind of spend a little bit of time thinking with you, Anupama, is what can we do to help? Can you tell us a little bit more around this?

Now let's imagine that we have done the assessment. We have done the outcome report. The... And the person on the other side of the table is, of course, very anxiously, quite apprehensively waiting. What has happened to me? What is the outcome? So it is very crucial on the part of the clinician to give the news well with a lot of empathy, with a lot of genuine concern. Because we can quite expect that there would be emotional reactions because this diagnosis, whether a yes or a no, whatever it is, could be life changing for that person. So managing the emotional impact that's coming up, being honest about whether they are feeling invalidated.

Being helpful or supportive regarding if they have had any stigma, if there's any mix they had had to... They had faced earlier, anything they would want help with... Just helping with all of that. So we we talk about psychoeducation. But I think even before that, breaking the news properly, of course, right... In the right clinical tech tech... I mean, terminologies, but also with the right amount of empathy, with the right amount of genuine concern, and managing all the emotional reactions, that is the first very important step. Because acceptance is not easy, but we we know through our clinical practice. And for this person, it's it might be their first twist with any kind of mental health services.

So just helping them through that process, being patient, co regulating their emotions, that is a very crucial step. After that, of course, coming to what next? How... What what can I do to make my life better? So that is where we offer them the different possibilities of treatments. Mostly, let me talk about therapy here because that is what I practice. That is how I help people. So, again, giving them the different options about the different evidence based modalities that we have. Unfortunately.

We have a lot. Most people know about CBT quite rightfully so because it has the largest evidence base. But we are, again, very lucky that all the other thought based therapies also have a very good evidence base for a lot of conditions right now. So talk about acceptance and commitment therapy. Talk about dialectical behavior therapy. Talk about trauma specific modalities where useful, mindfulness, relaxation approaches. All of these can be useful. And, again, helping them... Helping the, you know, person understand that we can also tailor these therapies according to your needs. So in every step, making them feel validated, making them feel important.

And, again, as I mentioned that we also have our counseling psychologists working alongside us in the pathway. So even if we find that somebody has not reached a diagnostic threshold for any diagnosis, that is fine. Because then the the counseling psychologist can help them navigate the issues they're dealing with. That could range from generalized anxiety, that could range from relationship stress, occupational stress, self esteem, quality of life, or multitude of issues. So we have both supportive therapy. We have client centered therapy. We have the counseling psychologist dealing with the nonclinical aspects of it, and we have the clinical psychologist dealing with acceptance complement therapy.

CBT, DBT, all of these there and when, know, you required. So this brings me to the different types of therapies and the different modalities that is available. But then it's also important to make the person understand why why therapy. Because, you know, they might have thought... They might have come to the process with a completely different mindset, with a... Hoping a completely different thing. And now I'm just telling them, so we'll not do that, but maybe we'll try out DVT or we'll try out ACT. Why? So it's again important that we break it down and make them understand that how this could make their quality of life better.

Again, I would draw from what professor Edmund was talking a little while back that it's very important that we move a little bit farther maybe from the need... I mean, the diagnostic labels from just reducing symptoms to improving the quality of life, to making the holistic life and its domains better. So it could be that we help a person with their self awareness. We help them adjust better to their daily life requirements. We help them with distress tolerance. We help them identify and manage their emotions better. We help them interact with people better. There could be a lot of things. And I think the biggest could also just be... Just giving them a clearer sense of why things have felt.

The way they have and why things have failed so hard. Again, just bringing the validation back in. So they understand that therapy would help them not just to reduce all of these difficulties, but to make life better.

There's something about goals there, isn't there, Anupama, that's so important to be able to kinda set those goals. And I just wonder if you could maybe tell us a little bit about how you might do that. How would you sit down at the beginning and set that so this is what we want to achieve?

Yeah. So, again, this is something for somebody who maybe has had a diagnosis of ADHD or did not have a diagnosis of ADHD. It is very important that along with the symptoms, we also identify how it is being affecting their different domains of life. That could be work, education, self esteem, people interaction, relationship, anything. Anything. And depending upon those, it would be better if you find out, say, the top three priorities.

The most problematic areas right now, and the ones that they would want to start with. And then we break it down to goals. Then we break it down to immediate goals, something that we maybe would attain in, say, the next one month. And, of course, realistically, they would be the smallest and the tiniest steps. Then a little bigger than them, the short term goals, something that maybe we are looking at a time frame of, say, six months. And, of course, the long term goals that where do you see yourself at the end of the process.

So this is how we set goals. This is how we also invite the person into the journey and make it a collaborative journey. And not that I am prescribing you with certain steps and certain techniques, and you just have to go back and follow that. Again, unfortunately, a myth, a lot of people hold about therapy. So just bringing them in, inviting them that it would be a collaborative process because it's your life. You know best. I'm just helping you with the clinical expertise and the tools that I have. So this is, I think, in a very nutshell about goals. And most clinicians, we follow the smart goal setting. So it has to be a realistic goal. It has to be time framed.

So that they also know what they can expect out of themselves and the process. Because, again, we have seen that a lot of people who have come into the process might have a lot of very high expectations from themselves. And, of course, when they're not able to fulfill that, can set them up for a lot of negative feelings, and we don't want to aggravate whatever they're already feeling. So it helps, again, managing expectations and setting realistic goals, and then getting started on whichever therapy or an amalgamation of therapies, whatever is suitable for that.

And I think this is probably why I feel quite passionate around this approach because it's needs based. What does that person need? Yes. Okay. We're saying you're not quite at threshold for diagnosis, but we still see you have these challenges. You have these obstacles in life. What do you need? And needs should be what lets you access care, not diagnoses. But, sadly, at least in The UK, we are stuck at the moment with diagnoses.

I think I think that we are having this shift in conversation as a very important step. And I think this is also what empowers people to go out and ask for what they need. So it it also doesn't come just from the clinicians, but from the community as a whole. So I think that's a great thing. Also, to bring in, like, a little bit of a personal information. So this reminds me of a very important learning that I hold very dearly to myself and my clinical practice. And something that I received very early on in my training and forms a foundation for my clinical practice is we were taught to look beyond the clinical symptoms and the diagnosis to the person. We were always taught that a diagnosis, whatever that might be, is a very important part.

But a part of their identity of their being. It is not their entire self. They are still a very much whole person with their needs, with their wants, desires, and everything. So I think this is also something that we, as clinicians, can carry forward into the therapy rooms or into the assessment rooms when we are going to meet any patient or any client. And I think this also gives us a slightly more positive approach because we are always so focused on reducing symptoms and, you know, ameliorating symptoms that maybe we we think of improving quality of life as a byproduct. But, again, it's not. The positive school of psychology, the positive psychotherapy talks about the fact that improving quality of life, happiness.

Are as important indicators as reducing symptoms. So I think that is also one takeaway I would want to impart to my fellow fellow clinicians as well. Not just to look at reducing symptoms, but maybe how to make the person more functional, more happier in their life.

And I feel this is something that India does do very well. I'm sure other parts of the world do as well. But this idea around, you know, a person, not a diagnosis, and being needs based. And it's something I'm really keen that we do develop in The UK and think a little bit around. Actually, it doesn't need to be simply medication or ADHD pathway. Anupama, one of the last bits, I suppose, just from you, I'd be really keen, how can we off, what can we signpost? I suppose, keeping in mind and where people from all over the world would be listening. What what... They're listening to you now. What would you suggest if they say that rings a bell back to me? What do you think?

I... Again, as you mentioned, the most important thing that... Because a lot of people from different kinds... Parts of the world may be listening to us, I don't think we can responsibly point people to specific services. But I think we can... We have given a little bit of an information for people to at least go out and know what to look for. Because we have support groups like, you know, ADHD UK. We also have a lot of support groups in different parts of the world. So it is important that you understand and you'll be aware of what are you looking for. And then you go out and you look at the correct pieces. It might be that the first support group or the first community that you reach out to doesn't suit you. Fine. Perfect.

Look out for the next one. That is also how you know that it's a process. It's not an end goal, and not clicking at first is also perfectly fine. It's not a risk. So it... It's fine. So, you know, looking looking out for communities, looking out for support groups, online, offline. Anything doesn't have to be serious. Could be book clubs, channel clubs, people just meeting over coffee and sharing their difficulties. That's a good start. So just look out in your vicinity, look out in your nearby areas. Of course, we have the beautiful.

Internet helping us these days and AI as well. So I think that is where we can put these to use as well. And what I've also seen is that they exist. We just don't look out enough. So there are there are a lot of these support groups. And these support groups could also, a lot of times, have information about what is happening in your country. So even if you don't know which hospital or which clinical service to reach out to, maybe these support groups have people who have the knowledge. So I think that could also signpost you to the right amount of... Right kind of treatment that you would require in your country.

And I think it's around, as you say, finding what is local to you. Web sites like ADHD UK, perfect place to go in The UK to get some of that information, get all that detail. I think one of the things that I've already said, I'm really passionate about there being other pathways in The UK that aren't ADHD diagnosis led. So something we will be working on. Watch this space. I I guarantee it.

Yes. Exciting. And, of course, just look out. Fingers crossed. Yeah.

So I suppose maybe just to start to wrap it up because I think we we have some questions, is fantastic. So I'm gonna stop talking relatively soon. But in summary, I really want people to know a no is not the end, and it should not be used as a judgment as to whether someone struggles and real or not. We can be really, really struggling and have significant challenges and not reach threshold for a diagnosis. That does not take away your problems at all. And we see you, so we want to be able to help. So that might be subthreshold presentation. It might be a overlapping condition like anxiety, trauma, or just the fact that, sadly, we're surrounded by systems that aren't terribly well built for a needs based population.

Which in theory would be the best way of creating a health care system. But, you know, that's what we're stuck with. We want... What we would like, what I would like, we, who care ADHD, but I'm sure ADHD UK and others, what we'd like people to hear is we see you, and we're not done trying to help you whether you have a diagnosis or not. We're very much committed to that. So a big thank you for listening. I really appreciate it. And, Anupama, thank you so much for sharing sort of India's role and how you're managing things in a different part of the world. I think it's fascinating, and I have learned so much since working with you. And my my eyes have been opened to all the endless possibilities. Thank you.

I think we might have some questions. We do. Well, thank you both. And a very, important topic and absolutely fascinating. And don't know Chris, you... You've been hijacked by builders who suddenly came by you, which wasn't planned. Obviously, there's been some comments in the in the chat and one of those things very sadly. We'll try and fix it in post. Obviously, not gonna do as much good in life. But... Yeah. Yeah. We... And... Yeah. So thank you both. And I thought... And also wonderfully wonderfully global, you in The UK. And from in India and Brexit. Yeah. Testament to our our world now and obviously what global companies are trying to do. Right. Our most updated question is I was assessed last year and I don't meet the threshold.

I still struggle with everything that made me think it was ADHD. Where do I go from here? And is it worth getting reassessed in a few years?

Anupama, I might ask you a few points.

Yeah. So one thing I would want to point out, as Chris also mentioned in the talk, is that whatever is the diagnosis outcome in one country, probably, most likely, it could remain same across parts because the diagnostic threshold and the guidelines that we follow are similar. But whether, you know, depending upon the reason you will see that's a no, I think that would give us an idea on whether you could get reassessed or not. Because if it's like there was a lack of childhood... Irrelevant childhood history or, you know, some other clinical details, then I would not suggest a reassessment, but maybe to look into the therapy pathway or just finding answers in a different way. Why I'm saying this is because a lot of times.

We tend to focus a lot on the assessment or on the outcome of the assessment because that just gives us some amount of mental peace, some amount of closure. And it is not always wise to keep running after that. But because we have spoken about the part b, it could also be that it is not ADHD, but the problems are valid. Definitely. So maybe shift the focus on how to make my quality of life better.

That's that's... Thank you. And it's very interesting. When you mentioned childhood history, it reminded me of a story someone I met a while back. He was looking to get diagnosed. He's actually in his his seventies. He's one of the oldest person there. And he was asked for childhood history in his form. He was given a default pack of forms. And I don't think you guys are right. And it said, please can we have your school reports? We need your parents to fill this in and ideally some some friends from your childhood. And he and he he just told me, he looked them in the eye and he just said, they're all dead. My parents are dead. My teachers are dead. Brutal. It's like the last dinosaur. Where are my friends? Like, and...

But showing that there there is a fundamental problem for some people where they actually... They they don't have them and it's hard to get And they might be not in contact with parents or the parents have passed. You know, I don't have my school reports. Like, it's... You know, those those...

Think one of the the biggest population, at least in The UK, that is underserved is the older generation. I think there's something around actually people who have lived their entire lives into their sixties and seventies, but still would like an answer. Why have I... Why is it being hard? And, actually, you're absolutely right. A lot of our assessments are built around very inappropriate models for someone who is in their sixties and seventies. So, you know, we're very lucky. We have older.

Adults consult psychiatrists working with us to think a little bit about how we actually do get some of that. Because we still need to be able to be confident that we're ticking the right boxes when we're making the diagnosis. That is important. But it has to be appropriate. Of the NICE criteria to evidence it and say, you're quite right in saying that we have to evidence it because these are the are the rules. But I think what you just said is if it's the the forms, might not be the approach, and it might be a different one.

Same we've looked after children as well. Sorry. I'm just saying same we've looked after children as well. People who have maybe been through multiple foster care homes, something like that. The history is not always there, so you do have to think outside the box.

And I think that's answered the second most upvoted question, which is what do you do if you've got no diagnosis as an adult based on the lack of childhood evidence? Which is almost in the brackets, they said almost impossible for them to gather reliably. Other indicators showing strong signs of ADHD, but childhood testimony wasn't there. What are the next steps? What actually aren't the next steps? Can you talk to them being Yeah.

So I think definitely think out of the box. I think we shouldn't just do a blanket no. I think it would be anyone at all. So the first approach is anyone that knew you, anyone at all, a sibling, a friend, to anyone you might still be in touch with. If the answer is still no, we go ahead and meet the person. I think even in a organization like ours that's mostly virtual, something like this, we'd say, actually, could we meet face to face? Because you get a better sense of problems face to face. There's a lot around observation.

And I would say, any evidence you've got, old GP records, anything at all, and we would do our best to work with that individual to to put the jigsaw puzzle pieces together. And sometimes you have to go on your clinical judgment as well. If you are sit sat there in front of someone who clearly is struggling with the symptoms and they think, this has been here all the time, you're gonna have to start to say, okay. That's fair enough. I think we do need to be thinking about how we support them. So I think sometimes it's around just clinical judgment and not being a computer says no kind of situation. Talk to them, not just rely on forms. Actually, you want to get onto the onto the skin of things and have a good conversation.

So... Yeah. I think just to add to this, I think this is also where the clinical interview comes into the picture as well as well as the mental status examination. Because what is the person doing right now? How easy it is to... For the person to hold their attention? How how fidgety are they getting? Like you mentioned, all of these are very big indicators. And just trying to understand and join the dots from their story because whatever they might be narrating as some incidents might actually give us very important, hints. So I think that and also understanding whether there are any comorbidities or any other stressors or anything, we'd be able to reach to a clinical understanding.

Whether or not we have the friend or the family or the person remembering the childhood history. Because quite normally, we also don't always remember what happened in our childhood. So I I think that's fine.

And I think we forget sometimes people... Individuals are the experts in their lives. You know? Yeah. Actually listening to their expertise, listening to their experience is so important. And actually, you know, I think there's all these people that worry, you know, you see it in the press, are people just trying to get that diagnosis for access to all these things, big things? It's not like suddenly it opens all these doors. It's actually just about getting help. And I think that's the key bit that we just can't kind of hide away from. People aren't coming Yeah. To... Gonna come and pull the the wool over our eyes. They're being honest. They're telling us our problem... Their problems.

And then our job is trying to work out, okay, how does this all fit together, and what's the best explanation?

Yeah. Again, because... Again, something that we were taught during our clinical training that all the assessments, all the cases, treatment, and status examination, pro form a, they are just there to help us understand the patient better, to help us understand the person better. So it... If it's it... If it's not that, you know, we are not able to put the person into the box, it's not the person's fault. Maybe we need to relook at our diagnostic criteria, at our forms and assessments. So, of course, giving most priority to the person and to their experiences, I think that is the most important tool which can be found.

And it it comes back to our key point, doesn't it? That this is a problem in a system that is built around diagnosis and not needs. We we get that problem.

This is perfect. We've got a question from. The approach Anupama described in India for people who are subthreshold sounds really valuable, especially for support and around self esteem relationships. How do you see this translating to... In UK NHS context, where services and ICB funding are often diagnostic condition specific, many people who do receive an ADHD diagnosis have limited access to post diagnostic psychoeducation or psychological support, while those who don't meet diagnostic threshold are usually discharged. How can we provide support for the subthreshold group without substantial changes in commissioning funding? Think.

I'd have to leave the message.

I think that's probably one for me if it's it. So I think the key bit that I and colleagues in my position will have to take on is trying to show evidence of impact. So anything we can do to test things through trials, through new interventions to show, actually, this is having a positive impact. So everything we do in our organization, we do outcome measures at every point. Because if we're not doing everything properly, if it's not working, if it's not having a positive impact, we're not gonna do it. So the key thing here is... So we're gonna take what we've learned from our amazing clinicians and clinical team over in in India.

And start thinking, like, how do we do this as a trial? How do we show that that impact? So actually, when we do talk to ICDs and they're saying, well, what do you offer us? We can show them and give them that pack of outcomes saying, actually, if you commission us to take all these individuals that have subthresholds, but are still kind of going in and out of services, being re referred, still struggling, we can do something. It's not gonna be easy, and I don't think this will happen overnight, but there's already shifting conversations around actually, does everyone need an ADHD assessment, or could we be doing it differently? Maybe we could be doing something differently.

I still would want individuals to have access to an ADHD assessment. I think that's really important. It helps us understand who we are. Not a great one for labels, but sometimes they can be helpful. And then I think there is something around showing people that no diagnosis does not mean no problem, no challenge, no difficulty. So again, evidence, evidence, evidence. We're gonna have to work really hard, and that's not just gonna be me. It'd be people like Professor Edmunds who is on before us. Lots of amazing researchers. I used to work with Professor Simon off, who's done a lot of work across UK and internationally.

These are the people that will be helping to drive forward a different approach, and we will do all we can to support that as well. I think it would also be worthwhile to mention here to just have a look at the Care ADHD.

Website just to see, you know, what we are doing and maybe we could help you.

Thank you. And we had another question. Watched my daughter in her ADHD assessment. She was 22 year old. She'd only just got her diagnosis and met the threshold. However, she masked very well and sat and talked politely and downplayed some traits. I wonder how how do clinicians really overcome masking? Because being told no... Well, the... Because being told no does not account for masking. I think the overall masking That...

Yeah. Masking is a great one and one that is so common both in ADHD and in autism assessments. So all our clinicians are trained on what masking is, what that could look like, how it appears in a session. And I think if you had someone who sat there for the full hour kind of holding themselves to get... Or even actually not necessarily holding themselves together, just a little bit, you know, okay. I'm gonna concentrate. I'm focused. But all the history, everything from the school, from the parents, all that is going, and this is not normal for that young person. This is unusual. We absolutely listen to that. We are... We're not going to just instantly go, no. They're fine. We know that masking happens. We know, again, stereotypical.

No. You shouldn't always go with stereotypes, but it does tend to be worse in girls. Not always. Absolutely see boys doing it and and guys doing it as well, but females tend to mask a little bit more. So, again, it's just also testing that, picking it apart, really kind of trying to get examples of, okay. This is great. You're doing really well now. It's great that you're managing school. What's it like when you get home? How... You know, are you exhausted? Is that challenging? Is that difficult? What's that like for you, Moe? What's it like for you, dad? Things like that. Anupama, I'm sure you've got thoughts as well.

Yeah. Of course. And I think, again, another bit that we find helpful is just going through the mental status examination really thoroughly, like, from the clinical perspective. So that might mean trying to get as much information from the cognitive assessments, from all of those little parameters to just help the person to help ourselves understand that what might be masking because at the end of the day, masking is just coping. And and if the person feels that they need to cope, that they have been experiencing some difficulty. Another thing coming from a very Rogerian principle, the client centered principle, is just trying to have that environment of calmness, approachability, that it's a safe space.

You don't need to be how you are with the outside world. You don't need to portray your... That perfect self. You can just be yourself. So maybe Raku building, something that we can't talk about enough as therapists, that also stands true in assessment and clinical interview sessions as well. So rapport building, building a safe space, building a calm environment, I think these could also be certain points which could be helpful from a therapeutic perspective.

Can I just very quickly? That that was a brilliant point, Anupama, there about being yourself as well. So one of the things we try and do in preparation for an assessment to say, please be yourself. Do not feel you need to put anything on show. Relax and be yourself. We need to see that.

Now our masking conversation is gonna segue very nicely to our next, which is hidden in plain sight, making sense for ADHD in women now. What I would like to ask though on masking, how... If you were talking to say a teacher and say... And describing masking, what's the difference between masking and, you know, toughing it out, the the sort of general slightly, you know, changing yourself to fit in. Like, where's where's the line? Like, what's the difference in masking and fitting?

And a very good question. I think it's probably around the amount of both emotional and physical effort. So we've all probably been in situations where we've just had to tough it out. You know, we've probably had a bit of a bad day. Maybe our presentations didn't go as well as we'd like. Something had gone wrong. You just... I'm gonna get on with it. It's fine. Masking is not like that. It's chronic. It's every day, all the time, and the level of exhaustion is significant, emotional and physical. Anupama?

I think I would just want to add on one more point is that when we talk about self in psychology, we talk about different aspects of different domains of our self because the self that I am at home, maybe winding down with a cup of coffee at night or... Maybe not at night. Maybe not a great example, but maybe winding down with a cup of coffee, I would not portray that same self when I'm in a meeting and quite rightfully so Because that would be my professional self. When I'm with my friends, that would be my social self. So we have all of these different selves at work always. But what masking is is, I mean, how it's different is with the amount of burnout it brings. It's it's having to put on that mask, having to.

You know, be that person who I'm clearly not. And in trying to maintain that, I'm burning myself out to a point that it is becoming difficult for me to function. So this is definitely very different from the different selves that we portray in different situations. This is becoming a completely different person because I feel that would be more acceptable. Or, you know, my tools have told me that would be more acceptable. But that is leading me to such an extent that I'm burning out, and I'm not being able to function. I'm not being able to show up. So I think that is how we differentiate toughening out or, you know, or just general concept of cells in different aspects and masking as a open behavior, I mean.

And I suppose it's also important to note long term, toughening it out is also not good for you. There's an awful lot of emotional burnout, anxiety, self esteem that can come from that. Just grin and bear it. So I think that's something that's, you know, really important to keep in mind because I think often also the younger generation have felt, oh, in my day, when they're smarter, they're on with it. Not the right approach. Just because we have to do it doesn't mean that they should have to do it kind of thing. That can also lead to significant mental health problems.

Yeah. I... And I think this is also very relevant from India as well because awareness is very new here. I think it's just a generation old here. So that is a very common line that we toughened it out. Why can't you? So I think that's a very important point that it brought out.

Yeah. And the world is different than the... What the toughness is is different. And we certainly see instances where parents are just being lazy. Like, I was able to, you know, I did this and that. Not recognizing the difference for their child, the difference the world that child exists in and all in all in between. Thank you. That was really insightful and and absolutely fascinating. Thank you. And I think particularly on all of it and obviously that discussion on masking, the difference of the price we pay being that big the big difference. You know, we've had more questions than we can answer. And some of them are more simple ones than I can answer, like, is it going to be recorded? Is there... Yes.

And it will be subtitled, so you can have the sound off, we will try and fix it in post. But, you know, one of those things sometimes these happen. Chris Anupama, you've been fantastic. Like, that was... You're very generous and kind because it's a difficult topic area. It's basically a topic area of people who like, thought they had an answer and then don't and are sad about it and confused about it. And and actually, as you exactly highlighted, there's a lack of resources generally. Although, I know you... Well, you carry that. She's... As you've said, is doing doing things there. But it... Yeah. You... I'm very, grateful for you taking on a tough topic and doing it so extremely well and and usefully. So thank you so so much.

Thank you. I'm gonna try and give you a round of applause.

But thank you very much.... For having us. Thank you for listening. Yeah.

Incredibly grateful to have, you know, put something useful and that being accepted for life. It's a big deal.

It's like... It's like... Thank you for for doing this. Right. Because it's so sad because otherwise you... The people who aren't part of it, what they don't know is that you... Like, I want to give you an applause because like, otherwise, what happens is you just kind of take your headphones off and wander off having done this big thing in front of lots of people, and it's it's it's just a very extraordinary experience. So I'd say thank you, and thank you very much. A final applause, and then thank you very much. Thank you. Bye, everyone. That's absolutely wonderful of them. It is a tough topic and I'm very, very grateful for them to... For doing it for...

Well, for Care ADHD, putting them out for Chris and Anupama for doing it. It's a big like, it's a difficult topic. And it's... It is one that comes up and it's one frequently. So thank you.