{"version":"1.0.0","segments":[{"startTime":5.465,"endTime":8.965,"body":"My topic is modern concepts of A DHD."},{"startTime":9.185,"endTime":13.404,"body":"Now, that sounds a bit pompous, and I thought I was being very modern because,"},{"startTime":13.404,"endTime":17.624,"body":"um, one of my sources, which is quoted on the transcript, which you can, uh,"},{"startTime":17.624,"endTime":21.843,"body":"get online from the college website afterwards, and there'll be a few copies, I think"},{"startTime":21.843,"endTime":22.125,"body":"available."},{"startTime":22.825,"endTime":27.997,"body":"Um, I thought I was being pretty modern because I got an advanced copy of"},{"startTime":27.997,"endTime":33.17,"body":"Steve Cone's recent authoritative, uh, survey, uh, of modern A DHD, which was published only"},{"startTime":33.17,"endTime":34.205,"body":"two weeks ago."},{"startTime":34.525,"endTime":35.285,"body":"I thought, this is it."},{"startTime":35.405,"endTime":39.165,"body":"I, at least I'm not quite ahead of the game, but I'm not nearly there."},{"startTime":39.745,"endTime":47.005,"body":"And then I was trumped, um, a phrase to be used carefully, um, by Mr."},{"startTime":47.005,"endTime":48.045,"body":"Matthew Paris."},{"startTime":49.585,"endTime":53.949,"body":"The Gresham College lecture that you're listening to right now is giving you knowledge and"},{"startTime":53.949,"endTime":58.314,"body":"insight from one of the world's leading academic experts, making it takes a lot of"},{"startTime":58.314,"endTime":58.605,"body":"time."},{"startTime":59.105,"endTime":62.311,"body":"But because we want to encourage a love of learning, we think it's well worth"},{"startTime":62.311,"endTime":62.525,"body":"it."},{"startTime":63.465,"endTime":66.605,"body":"We never make you pay for lectures, although donations are needed."},{"startTime":67.105,"endTime":68.485,"body":"All we ask in return is this."},{"startTime":68.995,"endTime":71.205,"body":"Send a link to this lecture to someone you think would benefit."},{"startTime":71.505,"endTime":75.373,"body":"And if you haven't already, and click the follow or subscribe button from wherever you"},{"startTime":75.373,"endTime":76.405,"body":"are listening right now."},{"startTime":77.425,"endTime":79.045,"body":"Now, let's get back to the lecture"},{"startTime":81.675,"endTime":83.055,"body":"The day before yesterday."},{"startTime":83.595,"endTime":88.658,"body":"Uh, who has a very modern concept of A DHD, and I might, this is"},{"startTime":88.658,"endTime":93.721,"body":"in the Times Newspaper, in his opinion column, he says, he writes, I do not"},{"startTime":93.721,"endTime":98.784,"body":"believe in A DHD at all, except as a catchall for a whole gaggle of"},{"startTime":98.784,"endTime":100.135,"body":"unrelated ways people behave."},{"startTime":100.995,"endTime":105.207,"body":"Um, he then goes on to have a mild savage at autism spectrum disorders, but,"},{"startTime":105.207,"endTime":108.015,"body":"um, that, that is more modern than I can achieve."},{"startTime":108.595,"endTime":111.415,"body":"But in a way, I sympathize with him."},{"startTime":111.655,"endTime":113.935,"body":"I no wish to attack him."},{"startTime":114.645,"endTime":117.415,"body":"Well, I do actually, but I'm not going to \u003claugh\u003e."},{"startTime":117.675,"endTime":122.543,"body":"I'm not going to, I mean, I think if you start to think about A"},{"startTime":122.543,"endTime":124.815,"body":"DHD, it does seem a bit weird."},{"startTime":125.635,"endTime":130.495,"body":"Now, I am gonna talk about that, uh, the weirdness."},{"startTime":131.395,"endTime":136.345,"body":"Um, and I'm gonna talk a little bit about the way it's missed and how"},{"startTime":136.345,"endTime":138.655,"body":"important it is not to miss it."},{"startTime":139.015,"endTime":144.145,"body":"I want to mention why it's thought of as a neurodevelopmental condition and how expensive"},{"startTime":144.145,"endTime":145.855,"body":"it is for the country."},{"startTime":145.915,"endTime":146.975,"body":"And that means you and me."},{"startTime":147.875,"endTime":151.615,"body":"And, uh, then I'll return to this business of neurodiversity."},{"startTime":152.395,"endTime":158.41,"body":"Uh, and, uh, the contrast between differences and disabilities, uh, on indeed, occasionally a blessing,"},{"startTime":158.41,"endTime":160.015,"body":"uh, for us all."},{"startTime":160.755,"endTime":167.386,"body":"So, may I start by pointing out that A DHD has in its title at"},{"startTime":167.386,"endTime":173.575,"body":"the top, a red slash the formal title goes Attention deficit slash Hyperactivity Disorder."},{"startTime":174.195,"endTime":177.135,"body":"And that hints at alternative possibilities."},{"startTime":177.575,"endTime":180.472,"body":"I will say no more at the moment, but you'll see what I'm driving at"},{"startTime":180.472,"endTime":181.245,"body":"later on, I hope."},{"startTime":182.555,"endTime":187.937,"body":"Traditionally, uh, A DHD has been described in, in literature, uh, since the 18th century"},{"startTime":187.937,"endTime":191.885,"body":"and in medical literature since the beginning of the 20th century."},{"startTime":191.955,"endTime":193.205,"body":"It's not a new idea."},{"startTime":193.595,"endTime":199.304,"body":"It's a relatively new name for what has often be called hyperactivity or something rather"},{"startTime":199.304,"endTime":199.685,"body":"similar."},{"startTime":200.065,"endTime":205.859,"body":"And it's represented by a triangle, uh, between hyperactivity, which is, I think you can"},{"startTime":205.859,"endTime":207.405,"body":"understand what hyperactivity means."},{"startTime":207.665,"endTime":212.821,"body":"Um, and I'll explain in a minute, attention deficit, which nowadays we would call inner"},{"startTime":212.821,"endTime":213.165,"body":"tension."},{"startTime":213.235,"endTime":217.6,"body":"There's a subtle shift in the concept because I mean, people with A DHD don't"},{"startTime":217.6,"endTime":218.765,"body":"have an attention deficit."},{"startTime":219.505,"endTime":220.765,"body":"Um, I'll explain."},{"startTime":221.105,"endTime":226.791,"body":"And impulsivity, which means doing things very suddenly in response to a provocation or a"},{"startTime":226.791,"endTime":229.445,"body":"stimulus without any forethought of the consequences."},{"startTime":229.545,"endTime":232.405,"body":"You just do it not all the time, but it's a tendency."},{"startTime":232.665,"endTime":235.205,"body":"And that triangle is colored in."},{"startTime":235.345,"endTime":236.125,"body":"It has content."},{"startTime":236.795,"endTime":239.085,"body":"It's not just three unrelated concepts."},{"startTime":239.345,"endTime":240.085,"body":"And I think Mr."},{"startTime":240.085,"endTime":241.765,"body":"Paris got that a little bit wrong."},{"startTime":242.075,"endTime":245.965,"body":"They do actually cohere and they correlate with each other."},{"startTime":246.515,"endTime":248.885,"body":"That is, uh, easily observable."},{"startTime":248.885,"endTime":251.965,"body":"And there's quite a lot of literature about that nowadays."},{"startTime":252.065,"endTime":258.475,"body":"We don't talk about the triangle so much as a, a bisected circle whereby A"},{"startTime":258.475,"endTime":264.885,"body":"DHD combined presentation, I'm being very formal in the, my use of diagnostic terms is,"},{"startTime":264.885,"endTime":271.295,"body":"uh, a combination of inattention, which is what I'll call it from now on, and"},{"startTime":271.295,"endTime":273.005,"body":"hyperactivity combined with impulsivity."},{"startTime":273.625,"endTime":278.852,"body":"The Americans from whom this concept is, uh, well, they originated this concept, have never"},{"startTime":278.852,"endTime":284.079,"body":"been that keen on impulsivity, whereas the Europeans have always put it in there as"},{"startTime":284.079,"endTime":285.125,"body":"an essential component."},{"startTime":285.945,"endTime":291.786,"body":"But, um, under a little bit of pressure, it's now regarded as a combination of"},{"startTime":291.786,"endTime":292.565,"body":"hyperactivity impulsivity."},{"startTime":294.065,"endTime":297.685,"body":"And don't try and read all this, please don't read that."},{"startTime":298.085,"endTime":303.94,"body":"I put it up to illustrate that there is a list that all clinicians use,"},{"startTime":303.94,"endTime":309.405,"body":"a list of inattentive items so that people, for example, don't concentrate very well."},{"startTime":309.405,"endTime":311.205,"body":"They don't sustain attention very well."},{"startTime":311.205,"endTime":316.005,"body":"They get distracted, they lose things, they're forgetful and uh, and all that sort of"},{"startTime":316.005,"endTime":316.325,"body":"stuff."},{"startTime":316.345,"endTime":321.051,"body":"So you can see it's actually quite a complex task quite to understand what inattention"},{"startTime":321.051,"endTime":321.365,"body":"means."},{"startTime":321.585,"endTime":328.194,"body":"And then it gets worse 'cause it includes problems with self-organization, problems with getting it"},{"startTime":328.194,"endTime":334.803,"body":"all together so that, uh, disorganization number five doesn't, uh, can't meet deadlines for doesn't"},{"startTime":334.803,"endTime":335.685,"body":"complete tasks."},{"startTime":336.075,"endTime":341.045,"body":"There's something about organization in there which may prove to be a, a fundamental idea."},{"startTime":342.905,"endTime":347.165,"body":"The hyperactive, impulsive list is pretty well what you'd expect."},{"startTime":347.575,"endTime":354.009,"body":"These, um, are people and these illustrations are of children because A DHD originally was"},{"startTime":354.009,"endTime":355.725,"body":"only applied to children."},{"startTime":355.985,"endTime":360.055,"body":"And a lot of what we know about A DHD has been derived from studies"},{"startTime":360.055,"endTime":364.125,"body":"on children, which is a bit of a pain, um, in many ways 'cause it"},{"startTime":364.125,"endTime":367.925,"body":"doesn't do justice to the full idea of A DHD, uh, in adult life."},{"startTime":367.985,"endTime":372.265,"body":"But these are, these are are people who are on the go, can't still fidget,"},{"startTime":372.265,"endTime":375.405,"body":"can't wait interrupts, and uh, and so on and so forth."},{"startTime":375.705,"endTime":380.93,"body":"Now, you've got two lists of nine topics there, and that is important because your"},{"startTime":380.93,"endTime":386.155,"body":"first step on the diagnosis, if you're trying to make a diagnosis, is you've gotta"},{"startTime":386.155,"endTime":388.245,"body":"find six items on each list."},{"startTime":388.345,"endTime":391.405,"body":"Six from the inattentional list, six from the hyperactive impulsive list."},{"startTime":391.585,"endTime":396.157,"body":"If it's a child or five out of nine, uh, it's an easier target to"},{"startTime":396.157,"endTime":400.73,"body":"meet for adults have five outta nine on each list, and it doesn't matter which"},{"startTime":400.73,"endTime":401.645,"body":"six you choose."},{"startTime":402.505,"endTime":407.021,"body":"So the first weirdness is that there's not a list of six items that you"},{"startTime":407.021,"endTime":407.925,"body":"have to get."},{"startTime":408.315,"endTime":410.445,"body":"There's a, it could be any old six."},{"startTime":411.185,"endTime":416.835,"body":"And that I think, uh, for many people seems a bit weird, a bit strange,"},{"startTime":416.835,"endTime":417.965,"body":"a bit haphazard."},{"startTime":418.625,"endTime":423.782,"body":"But each of these items, if I go back for example, to, uh, one, each"},{"startTime":423.782,"endTime":425.845,"body":"of these has to be excessive."},{"startTime":426.235,"endTime":432.062,"body":"It's not just that people can't wait, of course people can't wait, but this is"},{"startTime":432.062,"endTime":434.005,"body":"really, really, really can't wait."},{"startTime":434.225,"endTime":435.765,"body":"People are noisy."},{"startTime":435.955,"endTime":440.226,"body":"Well, I mean, people can be noisy, but this is really noisy when it's excessive"},{"startTime":440.226,"endTime":441.365,"body":"and when it's inappropriate."},{"startTime":441.825,"endTime":447.872,"body":"So within that list, these items have to be excessive for the age and expectations,"},{"startTime":447.872,"endTime":449.485,"body":"uh, of that individual."},{"startTime":450.035,"endTime":453.045,"body":"They have to, it has to be pervasive across situations."},{"startTime":453.155,"endTime":458.525,"body":"It's not just being noisy in a club, a nightclub, that sort of club."},{"startTime":459.145,"endTime":465.873,"body":"Um, it, it's actually being inappropriately noisy, being unable to moderate the level of your"},{"startTime":465.873,"endTime":468.565,"body":"noise creation according to the circumstances."},{"startTime":469.105,"endTime":470.165,"body":"So it has to be excessive."},{"startTime":470.165,"endTime":472.325,"body":"It has to be pervasive across situations."},{"startTime":472.395,"endTime":474.085,"body":"It's not just in one situation."},{"startTime":474.475,"endTime":477.125,"body":"It's generally present in that person's life."},{"startTime":477.465,"endTime":478.805,"body":"It has to be enduring."},{"startTime":479.075,"endTime":481.325,"body":"It's not just how they were on Wednesday night."},{"startTime":481.955,"endTime":488.725,"body":"It's how they have been for months and years, and usually back to early childhood."},{"startTime":489.465,"endTime":492.805,"body":"Um, in formal diagnostic terms, it has to be before the age of 12."},{"startTime":493.145,"endTime":496.982,"body":"And that gets interesting, and I won't bore you with why it's interesting 'cause it's"},{"startTime":496.982,"endTime":499.285,"body":"not very interesting, but it's, it's early life onset."},{"startTime":499.285,"endTime":502.085,"body":"This is something that's been going on for most of somebody's life."},{"startTime":502.905,"endTime":507.325,"body":"So the word developmental comes in because of that."},{"startTime":507.425,"endTime":512.525,"body":"If I say something is neurodevelopmental, so these are our characteristics are present in the"},{"startTime":512.525,"endTime":513.205,"body":"general population."},{"startTime":513.395,"endTime":516.325,"body":"They are characteristics and behaviors that Mr."},{"startTime":516.325,"endTime":517.245,"body":"Paris observes."},{"startTime":517.345,"endTime":523.154,"body":"And they're characteristics that you can observe about yourself or your life partner or your"},{"startTime":523.154,"endTime":528.963,"body":"children, but they not necessarily would those people have them in excess across situations and"},{"startTime":528.963,"endTime":530.125,"body":"enduring for years."},{"startTime":532.825,"endTime":541.146,"body":"If you take six out of those nine items for two lists, there are, uh,"},{"startTime":541.146,"endTime":543.365,"body":"pretty well 16,900 combinations."},{"startTime":544.585,"endTime":548.416,"body":"So when I say you've gotta have six out of nine on one list and"},{"startTime":548.416,"endTime":552.247,"body":"six out of nine on the other, you think, yeah, okay, that's why the hell"},{"startTime":552.247,"endTime":553.525,"body":"of a spread of differences."},{"startTime":554.025,"endTime":560.147,"body":"And this is the first hint, I think I suggest to you that A-D-A-D-H-D is"},{"startTime":560.147,"endTime":563.005,"body":"a very heterogeneous, a very diverse condition."},{"startTime":563.785,"endTime":568.919,"body":"And, uh, just as I think, uh, Fran Hape was saying last week, uh, you"},{"startTime":568.919,"endTime":572.685,"body":"meet, um, one autistic person and you've met one autistic person."},{"startTime":572.785,"endTime":576.125,"body":"You know, people with A DHD are not all alike."},{"startTime":576.595,"endTime":577.805,"body":"They're very individual."},{"startTime":578.865,"endTime":580.005,"body":"So, and this is real."},{"startTime":580.305,"endTime":586.398,"body":"Uh, this is a study by, uh, silk and folk in Australia, 146 children just"},{"startTime":586.398,"endTime":586.805,"body":"recently."},{"startTime":587.265,"endTime":592.765,"body":"Um, well, not that recently, actually, God, 2019 seems a long time ago."},{"startTime":593.265,"endTime":599.085,"body":"Um, on 146 children in the study, there were 11,620 combinations."},{"startTime":599.325,"endTime":602.165,"body":"Somebody spent all afternoon working that out and counting them."},{"startTime":602.465,"endTime":607.253,"body":"So it is diverse, and this is actually one of the problems, but I can"},{"startTime":607.253,"endTime":610.445,"body":"I reassure you, there's a way of thinking about that."},{"startTime":611.065,"endTime":615.912,"body":"If I take those lists of nine items and say, you've gotta have six out"},{"startTime":615.912,"endTime":620.759,"body":"of nine on one and six out of nine on the other, then if I"},{"startTime":620.759,"endTime":625.607,"body":"represent those items by pieces of fruit, uh, there's your hyper impulsive list on one"},{"startTime":625.607,"endTime":629.485,"body":"side, six pieces of fruit and six pieces of fruit for inattention."},{"startTime":630.465,"endTime":632.645,"body":"And what happens when you put those two together?"},{"startTime":632.795,"endTime":633.445,"body":"What do you get?"},{"startTime":633.745,"endTime":635.485,"body":"You get fruit salad, \u003claugh\u003e."},{"startTime":635.595,"endTime":635.885,"body":"Yeah."},{"startTime":637.265,"endTime":641.399,"body":"Now, let's say that you move on to the next person or the next kitchen,"},{"startTime":641.399,"endTime":645.533,"body":"uh, and you get a slightly different list of six out of nine from a"},{"startTime":645.533,"endTime":646.085,"body":"hyper impulsive."},{"startTime":646.105,"endTime":649.247,"body":"If you have to take it from me, that is slightly different list and six"},{"startTime":649.247,"endTime":650.085,"body":"outta nine for inattention."},{"startTime":650.385,"endTime":651.285,"body":"And what do you get?"},{"startTime":652.575,"endTime":653.365,"body":"Fruit salad."},{"startTime":654.715,"endTime":658.405,"body":"It's not ouie, it's not stew, it's fruit salad."},{"startTime":658.665,"endTime":663.922,"body":"So you, although you have diversity in the components of A DHD, ultimately you have"},{"startTime":663.922,"endTime":665.325,"body":"something you can recognize."},{"startTime":667.385,"endTime":671.245,"body":"So you have five or six items on each list, that's not enough."},{"startTime":671.395,"endTime":676.516,"body":"Even if those are excessive and enduring and pervasive across situations, uh, and present from"},{"startTime":676.516,"endTime":678.565,"body":"early life, that's not quite enough."},{"startTime":678.585,"endTime":681.325,"body":"You also have to have an impairment."},{"startTime":681.985,"endTime":687.125,"body":"So the disability is wired into the definition, wired into the medical definition."},{"startTime":687.145,"endTime":694.645,"body":"You have to have impaired functioning, uh, impaired social functioning, academic functioning, or occupational functioning."},{"startTime":694.945,"endTime":700.518,"body":"So it's not just enough to be lively and a bit to shabby on your"},{"startTime":700.518,"endTime":704.605,"body":"concentration and a bit impulsive, uh, actually got to impair things."},{"startTime":704.665,"endTime":708.405,"body":"And this is, I think, a necessary condition for, for lots of reasons."},{"startTime":708.865,"endTime":714.999,"body":"Uh, one is that it, if you have a thing like that in a diversity,"},{"startTime":714.999,"endTime":720.725,"body":"sorry, in a, a diagnosis, uh, then that, uh, helps drive people towards services."},{"startTime":722.185,"endTime":725.205,"body":"So back to the, uh, bisected circle."},{"startTime":725.715,"endTime":727.525,"body":"This is a combination of attention deficits."},{"startTime":727.525,"endTime":731.931,"body":"Six outta nine of that minimum could be nine, outta nine, uh, and six out"},{"startTime":731.931,"endTime":736.045,"body":"of nine if it's a child on hyperactivity and pulsivity, five out of nine."},{"startTime":737.545,"endTime":743.195,"body":"The, one of the problems I have in, I mean, I chose to bring the"},{"startTime":743.195,"endTime":748.845,"body":"word concept, uh, into the title of this, um, illustrations are very difficult with concepts."},{"startTime":748.945,"endTime":751.445,"body":"Uh, you will form your own mental representation."},{"startTime":751.665,"endTime":753.245,"body":"So I hope you are very good at it."},{"startTime":753.545,"endTime":755.605,"body":"Uh, jolly difficult to, to illustrate."},{"startTime":756.105,"endTime":763.445,"body":"But, um, there we have the idea of combined presentation, A DHD, the commonest variant."},{"startTime":763.825,"endTime":769.789,"body":"And you can sense that the illustrations and images I've chosen are predominantly those of"},{"startTime":769.789,"endTime":773.765,"body":"children because that is where the condition was first identified."},{"startTime":774.515,"endTime":777.245,"body":"It's been typically described in childhood."},{"startTime":778.305,"endTime":783.559,"body":"And because it's been typically described in childhood and typically described in boys because in"},{"startTime":783.559,"endTime":788.814,"body":"clinics, boys have outnumbered girls, sort of nine or 10 to one, um, until very"},{"startTime":788.814,"endTime":789.165,"body":"recently."},{"startTime":789.825,"endTime":795.282,"body":"Um, I'll return to the question about girls and women later, but it's, the whole"},{"startTime":795.282,"endTime":799.285,"body":"concept has been driven by boys who are hard to teach."},{"startTime":799.285,"endTime":801.965,"body":"They're hard to live with, uh, and hard to be friends with."},{"startTime":802.225,"endTime":808.662,"body":"You know, it's, uh, actually those items that you've seen listed on those lists of"},{"startTime":808.662,"endTime":815.099,"body":"nine, uh, are very much driven by people's experience of boys who are squeaking wheels"},{"startTime":815.099,"endTime":817.245,"body":"who need to be oiled."},{"startTime":819.105,"endTime":826.131,"body":"Now, on those list of nine items, there's no single behavioral item that is always"},{"startTime":826.131,"endTime":828.005,"body":"present in A DHD."},{"startTime":828.545,"endTime":834.263,"body":"We can't say they're all, every single case of A DHD is pathologically forgetful, for"},{"startTime":834.263,"endTime":834.645,"body":"example."},{"startTime":835.265,"endTime":836.045,"body":"We can't do that."},{"startTime":836.145,"endTime":837.285,"body":"It doesn't, it isn't the case."},{"startTime":837.945,"endTime":844.271,"body":"So that is perhaps why, um, people have been led towards the idea of a"},{"startTime":844.271,"endTime":847.645,"body":"list within which you could have various combinations."},{"startTime":847.925,"endTime":852.825,"body":"'cause all those items on each of those lists of nine are valid and contribute"},{"startTime":852.825,"endTime":853.805,"body":"to the diagnosis."},{"startTime":854.085,"endTime":855.845,"body":"Ultimately, they all go into the fruit salad."},{"startTime":856.625,"endTime":861.802,"body":"And look, you can't leave one out and you, well, sorry, you can leave one"},{"startTime":861.802,"endTime":866.979,"body":"out, but you can't say it is always the case that fruit salads contain kiwi"},{"startTime":866.979,"endTime":867.325,"body":"fruit."},{"startTime":868.425,"endTime":870.525,"body":"Um, and as far as I know, they don't."},{"startTime":871.185,"endTime":874.405,"body":"So there's no single behavior item that is constantly present."},{"startTime":875.015,"endTime":879.925,"body":"There is also, I must tell you, no objective test for this diagnosis."},{"startTime":880.155,"endTime":881.405,"body":"There's no brain scan."},{"startTime":881.405,"endTime":884.165,"body":"There's no blood test, there's no EEG test."},{"startTime":884.165,"endTime":889.165,"body":"There's no genetic screen that will identify a DHD as opposed to anything else."},{"startTime":890.025,"endTime":897.475,"body":"So we do not have an objective test for something that other otherwise is readily"},{"startTime":897.475,"endTime":898.965,"body":"recognizable and measurable."},{"startTime":899.745,"endTime":904.495,"body":"And it can be graded on a dimension from severe to mild, which is, uh,"},{"startTime":904.495,"endTime":905.445,"body":"a useful thing."},{"startTime":906.465,"endTime":913.528,"body":"One does need a cutoff to, uh, illustrate how within the general population on the"},{"startTime":913.528,"endTime":920.592,"body":"left, there are plenty of people who are overactive and rather impulsive and, uh, can't"},{"startTime":920.592,"endTime":922.005,"body":"concentrate terribly well."},{"startTime":922.005,"endTime":924.405,"body":"And some are severely so, so that it becomes a problem."},{"startTime":924.745,"endTime":929.395,"body":"And the cutoff to identify those, if you can spot it on the right, is"},{"startTime":929.395,"endTime":932.805,"body":"a thin vertical line that represents where the disability cutoff is."},{"startTime":933.745,"endTime":937.645,"body":"Now, you may think that's not great 'cause how do you measure disability?"},{"startTime":937.795,"endTime":942.303,"body":"Well, you can actually, there are things like the we scale that you can use"},{"startTime":942.303,"endTime":943.205,"body":"to identify disability."},{"startTime":943.745,"endTime":947.445,"body":"Um, but actually different countries interpret that rather differently."},{"startTime":947.505,"endTime":953.259,"body":"So different countries quite often come up with different rates for A DHD in childhood,"},{"startTime":953.259,"endTime":959.014,"body":"the Americans are very keen to identify 11% of children as having a DHD, uh,"},{"startTime":959.014,"endTime":960.165,"body":"in this country."},{"startTime":960.505,"endTime":966.645,"body":"Um, a major survey done well now nearly 20 years ago, identified 2.4%."},{"startTime":966.785,"endTime":971.113,"body":"So huge differences between countries are called it a what is disabling and how it"},{"startTime":971.113,"endTime":972.845,"body":"is measured and how it's identified."},{"startTime":973.105,"endTime":979.461,"body":"So although that disability concept is very important, trying to measure it is somewhat end"},{"startTime":979.461,"endTime":979.885,"body":"cultured."},{"startTime":980.145,"endTime":983.525,"body":"Um, and from an international perspective, somewhat haphazard."},{"startTime":983.825,"endTime":990.782,"body":"But generally speaking, most people subscribe to the idea that about 5% of children will"},{"startTime":990.782,"endTime":993.565,"body":"have, um, this A DHD business."},{"startTime":994.585,"endTime":1000.317,"body":"Now, when they do, one of the things that comes through very strongly is that"},{"startTime":1000.317,"endTime":1006.049,"body":"you don't just have a DHD for most cases, pure A DHD, pure and simple"},{"startTime":1006.049,"endTime":1008.725,"body":"with no associated other conditions is unusual."},{"startTime":1009.345,"endTime":1014.885,"body":"80% at least of, uh, people, uh, notice my change of work."},{"startTime":1015.125,"endTime":1020.205,"body":"\u003claugh\u003e have something else going on in childhood that tends to be angry, antisocial behavior."},{"startTime":1021.105,"endTime":1027.232,"body":"And when, um, I sing, uh, surveyed, uh, attitudes towards A DHD in children quite"},{"startTime":1027.232,"endTime":1033.359,"body":"a long time ago, uh, what she found was that the general public see a"},{"startTime":1033.359,"endTime":1037.444,"body":"DHD as something associated with angry hostile, oppositional irritating behavior."},{"startTime":1038.385,"endTime":1041.325,"body":"And that can be dressed up in various terms."},{"startTime":1041.704,"endTime":1044.565,"body":"And I'll return to that topic, but there's a huge overlap."},{"startTime":1045.035,"endTime":1052.205,"body":"70% of boys with a DHD boys will also show aggressive antisocial behavior."},{"startTime":1054.115,"endTime":1059.249,"body":"When you take a step back from that and say, well, okay, what else is"},{"startTime":1059.249,"endTime":1061.645,"body":"quite likely to happen with A DHD?"},{"startTime":1061.825,"endTime":1065.005,"body":"The answer is other neurodevelopmental conditions."},{"startTime":1065.785,"endTime":1071.688,"body":"So that, for example, 21% of folk, oh, sorry, 2000% of children with A DHD,"},{"startTime":1071.688,"endTime":1076.805,"body":"uh, will also have a SD will also have an autism spectrum disorder."},{"startTime":1077.625,"endTime":1082.547,"body":"So this is quite a substantial overlap, which wasn't allowed in the diagnostic rules, uh,"},{"startTime":1082.547,"endTime":1084.845,"body":"until, uh, well, nearly 10 years ago."},{"startTime":1085.685,"endTime":1089.985,"body":"Previously you could have one or the other, but we now recognize that you can"},{"startTime":1089.985,"endTime":1092.565,"body":"have both and, and both is quite an issue."},{"startTime":1093.105,"endTime":1095.965,"body":"The same is true for things like ticks and dyslexia."},{"startTime":1096.195,"endTime":1100.925,"body":"Somewhere around about a third of children with A DHD will also have dyslexia."},{"startTime":1101.825,"endTime":1105.125,"body":"So there are these huge overlaps with dyscalculia."},{"startTime":1105.125,"endTime":1105.885,"body":"With dyspraxia."},{"startTime":1106.045,"endTime":1110.611,"body":"I saw a paper recently that argued that 90% of, uh, children with A DHD"},{"startTime":1110.611,"endTime":1111.525,"body":"also have dyspraxia."},{"startTime":1111.605,"endTime":1113.245,"body":"I think that's pushing it a bit."},{"startTime":1113.585,"endTime":1116.045,"body":"And it depends where you draw these samples from."},{"startTime":1116.065,"endTime":1121.033,"body":"If you just look at clinic populations, then you get these high rates of associated"},{"startTime":1121.033,"endTime":1121.365,"body":"problems."},{"startTime":1121.685,"endTime":1128.86,"body":"'cause that's what drives the referrals to clinics, because each of these associated problems magnifies"},{"startTime":1128.86,"endTime":1133.165,"body":"the impairment that is associated with A DHD diagnostically."},{"startTime":1133.945,"endTime":1141.082,"body":"So, um, very important overlaps with angry behavior in childhood, very important overlaps with other"},{"startTime":1141.082,"endTime":1145.365,"body":"neurodevelopmental disorders in childhood, in adults, the picture changes."},{"startTime":1146.265,"endTime":1151.085,"body":"The, the problems of dyslexia become less problematic with adults."},{"startTime":1151.865,"endTime":1156.721,"body":"The problems with ticks, uh, very often melt away, uh, and so on and so"},{"startTime":1156.721,"endTime":1157.045,"body":"forth."},{"startTime":1157.065,"endTime":1160.805,"body":"But in adults, you get a different pattern of coexisting problems."},{"startTime":1161.305,"endTime":1170.455,"body":"You get, um, high rates of anxiety disorders, uh, depressive disorders, substance misuse, mainly nicotine,"},{"startTime":1170.455,"endTime":1172.285,"body":"alcohol and recreational."},{"startTime":1173.385,"endTime":1177.506,"body":"Um, you get an association with antisocial behavior that I will return to later, which"},{"startTime":1177.506,"endTime":1178.605,"body":"is really quite strong."},{"startTime":1178.865,"endTime":1184.583,"body":"And we now recognize that sleep problems are really very common in adults with A"},{"startTime":1184.583,"endTime":1184.965,"body":"DHD."},{"startTime":1185.225,"endTime":1190.837,"body":"So again, you've got huge overlaps with other conditions, and it's almost as though A"},{"startTime":1190.837,"endTime":1194.205,"body":"DHD can also be visualized as a vulnerability factor."},{"startTime":1194.205,"endTime":1199.605,"body":"It means it's more likely that you will suffer from something, let say, like, like"},{"startTime":1199.605,"endTime":1199.965,"body":"depression."},{"startTime":1200.785,"endTime":1205.005,"body":"And though when you do, when it's another condition that adds to the impairment."},{"startTime":1205.625,"endTime":1209.765,"body":"And that has important, very important implications for assessment."},{"startTime":1211.185,"endTime":1217.135,"body":"It also means that the A DHD itself may be hidden so that people see"},{"startTime":1217.135,"endTime":1218.325,"body":"the antisocial behavior."},{"startTime":1218.355,"endTime":1221.925,"body":"They don't spot the A DHD, they see the substance misuse."},{"startTime":1221.925,"endTime":1223.445,"body":"They don't spot the A DHD."},{"startTime":1224.105,"endTime":1232.261,"body":"So there are problems about with overlap magnifying disability, um, and also hiding by and"},{"startTime":1232.261,"endTime":1232.805,"body":"large."},{"startTime":1232.965,"endTime":1238.382,"body":"I must just must just mention that although I've said, well, it's about 5% in"},{"startTime":1238.382,"endTime":1243.8,"body":"children, roughly speaking internationally, um, the rate of A DHD among the general population does"},{"startTime":1243.8,"endTime":1245.245,"body":"get less with age."},{"startTime":1246.195,"endTime":1251.989,"body":"It's been a very important political point to make, uh, that people who have a"},{"startTime":1251.989,"endTime":1257.783,"body":"DHD in childhood, an adult who may still have traits or persistence of A DHD"},{"startTime":1257.783,"endTime":1262.805,"body":"behaviors and symptoms, but the full diagnosis falls away as one gets older."},{"startTime":1263.355,"endTime":1265.405,"body":"I've no idea what an older adult is."},{"startTime":1265.525,"endTime":1267.685,"body":"I think an older adult is somebody older than me."},{"startTime":1268.305,"endTime":1271.285,"body":"Um, 79 plus."},{"startTime":1272.225,"endTime":1278.667,"body":"Um, so yeah, there is increasing recognition that A DHD can affect, um, those who"},{"startTime":1278.667,"endTime":1281.245,"body":"are graced with an older age."},{"startTime":1281.825,"endTime":1283.925,"body":"Um, but the rate for does fall off."},{"startTime":1284.045,"endTime":1288.965,"body":"And again, this is consistent with the idea of A DHD being a developmental condition."},{"startTime":1291.275,"endTime":1298.716,"body":"What makes it more likely that someone is going to have, get, possess, be possessed"},{"startTime":1298.716,"endTime":1300.205,"body":"by A DHD?"},{"startTime":1300.665,"endTime":1307.661,"body":"Not quite sure what the right verb is, but the short answer is genetics comes"},{"startTime":1307.661,"endTime":1312.325,"body":"through very, very strongly indeed the heritability of A DHD."},{"startTime":1312.325,"endTime":1319.725,"body":"The amount, the extent to which genetic explanations account for the differences between A-A-D-H-D folk"},{"startTime":1319.725,"endTime":1322.685,"body":"and neurotypical folk is about 80%."},{"startTime":1323.385,"endTime":1330.365,"body":"So it's heavily genetic, but it ain't one gene or even three genes."},{"startTime":1330.945,"endTime":1337.265,"body":"Uh, the most recent survey on a genome wide, uh, association study, uh, is that"},{"startTime":1337.265,"endTime":1343.165,"body":"there are 76 genes which are implicated in the production of, uh, A DHD."},{"startTime":1343.505,"endTime":1344.685,"body":"So it's polygenic."},{"startTime":1344.875,"endTime":1348.201,"body":"Yeah, there's a lot of genes involved, and some of those genes do other things"},{"startTime":1348.201,"endTime":1348.645,"body":"as well."},{"startTime":1349.025,"endTime":1353.239,"body":"One of the most strongly associated genes, um, a few years ago was a gene"},{"startTime":1353.239,"endTime":1354.925,"body":"that is primarily associated with dyslexia."},{"startTime":1355.625,"endTime":1360.252,"body":"So it depends where you get your sample from, but this is using a general"},{"startTime":1360.252,"endTime":1364.879,"body":"population sample, not a sample from people attending clinics where you might expect a high"},{"startTime":1364.879,"endTime":1365.805,"body":"rate of dyslexia."},{"startTime":1366.025,"endTime":1370.795,"body":"It is still the case that there are an awful lot of genes just as"},{"startTime":1370.795,"endTime":1375.565,"body":"there are for other, many other human characteristics, such as stature or intelligence, for example."},{"startTime":1376.545,"endTime":1381.358,"body":"And there's nothing within the genetic risk factors, the genetic factors that make it more"},{"startTime":1381.358,"endTime":1383.605,"body":"likely that you will show a DHD."},{"startTime":1383.605,"endTime":1387.976,"body":"There's nothing specific that you can use for diagnosis, which is a bit of a"},{"startTime":1387.976,"endTime":1392.347,"body":"problem because, you know, one hopes with a heritability of 80%, you'd be able to"},{"startTime":1392.347,"endTime":1396.719,"body":"say, right, we we'll do a quick PCRA quick, um, genetic, uh, glimpse of what"},{"startTime":1396.719,"endTime":1401.09,"body":"is going on in somebody and, and work out whether they've got, uh, a risk"},{"startTime":1401.09,"endTime":1401.965,"body":"of A DHD."},{"startTime":1401.965,"endTime":1402.565,"body":"You can't do that."},{"startTime":1403.135,"endTime":1404.885,"body":"There are too many genes involved."},{"startTime":1405.395,"endTime":1411.7,"body":"Heterogeneity, again, diversity again, within the A DHD world, little things are different one to"},{"startTime":1411.7,"endTime":1418.005,"body":"another, but we've still got a DHD as a recognizable condition that can be measured."},{"startTime":1420.095,"endTime":1422.365,"body":"There are going to be environmental risk factors."},{"startTime":1422.505,"endTime":1426.845,"body":"Of course, there are, um, that is especially true for polygenic conditions."},{"startTime":1427.305,"endTime":1432.456,"body":"But when you look at the hard evidence, the replicated evidence where several studies have"},{"startTime":1432.456,"endTime":1437.608,"body":"said the same thing, it's mainly to do with pregnancy and birth, and particularly being"},{"startTime":1437.608,"endTime":1442.76,"body":"born too sore too soon or too small, or in fact, having complications in very"},{"startTime":1442.76,"endTime":1445.165,"body":"early, um, weeks or months of life."},{"startTime":1445.665,"endTime":1447.165,"body":"So it's mainly obstetric."},{"startTime":1447.705,"endTime":1450.045,"body":"The big one, of course, is, um, alcohol."},{"startTime":1450.785,"endTime":1455.844,"body":"The children who in the womb were exposed to alcohol consumed by their mother are"},{"startTime":1455.844,"endTime":1458.205,"body":"really very likely to have a DHD."},{"startTime":1458.345,"endTime":1463.575,"body":"And if you look at the, uh, old category of fetal alcohol syndrome, the rates"},{"startTime":1463.575,"endTime":1466.365,"body":"of A DHD and that are over 90%."},{"startTime":1467.105,"endTime":1469.205,"body":"So fetal alcohol is a problem."},{"startTime":1469.785,"endTime":1473.885,"body":"Uh, fetal alcohol exposure is a problem, but mainly it's obstetric stuff."},{"startTime":1474.145,"endTime":1479.972,"body":"Now, there are other environmental risk factors that everyone's been very interested in, and you,"},{"startTime":1479.972,"endTime":1485.8,"body":"you can, uh, see newspaper articles frequently blaming, uh, too much looking at, uh, computer"},{"startTime":1485.8,"endTime":1491.628,"body":"screens, too much playing games, um, how too much lead in the atmosphere, these lots"},{"startTime":1491.628,"endTime":1495.125,"body":"of single factors, too much stress in late pregnancy."},{"startTime":1495.505,"endTime":1501.545,"body":"The difficulty is that those tend to be factors which are identified in small studies,"},{"startTime":1501.545,"endTime":1504.365,"body":"which have not really been sufficiently replicated."},{"startTime":1504.585,"endTime":1508.428,"body":"So I'm not putting those on the list, uh, because that just makes everyone feel"},{"startTime":1508.428,"endTime":1508.685,"body":"guilty."},{"startTime":1509.505,"endTime":1516.536,"body":"Um, I don't, uh, once you take out, um, the pregnancy factors, there isn't much"},{"startTime":1516.536,"endTime":1517.005,"body":"else."},{"startTime":1517.385,"endTime":1522.414,"body":"Uh, there is really no good evidence, for example, that too many computer games produce"},{"startTime":1522.414,"endTime":1523.085,"body":"A DHD."},{"startTime":1523.505,"endTime":1526.494,"body":"Uh, there is sort of, you know, a small study here, but not confirmed in"},{"startTime":1526.494,"endTime":1529.085,"body":"three other studies that have found it a bit difficult to get published."},{"startTime":1529.555,"endTime":1537.385,"body":"It's, um, I want to move on from risk factors that might lead somebody to"},{"startTime":1537.385,"endTime":1542.605,"body":"develop A DHD to what the dickens is going on."},{"startTime":1542.625,"endTime":1547.885,"body":"If I say it's neurodevelopmental, that word neuro for practical purposes means brain."},{"startTime":1548.785,"endTime":1552.685,"body":"Um, and brain is at the center of A DHD research."},{"startTime":1553.395,"endTime":1559.288,"body":"This is a picture that shows how the, the cortex, that's the surface of the"},{"startTime":1559.288,"endTime":1565.181,"body":"brain where so many nerve cells are that are involved in higher brain functions, like"},{"startTime":1565.181,"endTime":1568.325,"body":"thinking, for example, or, or memory, for example."},{"startTime":1569.105,"endTime":1576.292,"body":"Um, the cortex in a DHD on the top line is really not developing the"},{"startTime":1576.292,"endTime":1580.605,"body":"solid purple, thick, extensive cortex that one would hope."},{"startTime":1581.065,"endTime":1584.285,"body":"And these are ages 7, 8, 9, 10, 11, 12, 13."},{"startTime":1584.475,"endTime":1589.816,"body":"This is, uh, late childhood, and the cortex is just not developing at the rate"},{"startTime":1589.816,"endTime":1590.885,"body":"that it should."},{"startTime":1593.235,"endTime":1597.675,"body":"That I think, is very important because when you come to say, okay, well let's"},{"startTime":1597.675,"endTime":1602.116,"body":"take a wider age range and see what's going on, here's, um, a map of"},{"startTime":1602.116,"endTime":1603.005,"body":"the, the cortex."},{"startTime":1603.045,"endTime":1609.195,"body":"This is a brain side on, um, there are three key areas that, uh, are"},{"startTime":1609.195,"endTime":1615.345,"body":"involved, where the cortex has just not developed as much as it does in neurotypical"},{"startTime":1615.345,"endTime":1617.805,"body":"folk and in A DHD folk."},{"startTime":1618.345,"endTime":1623.704,"body":"Uh, the cortex is less well developed in this stuff, in the inferior frontal, the"},{"startTime":1623.704,"endTime":1629.063,"body":"front of the brain, the dorsolateral prefrontal cortex, which is, uh, very important in things"},{"startTime":1629.063,"endTime":1631.565,"body":"like working memory, which I'll explain later."},{"startTime":1632.065,"endTime":1634.765,"body":"Uh, and the parietal cortex, which is to do with the tension."},{"startTime":1635.265,"endTime":1640.188,"body":"Uh, the inferior frontal cortex is mainly to do with inhibiting a wish to suddenly"},{"startTime":1640.188,"endTime":1640.845,"body":"do something."},{"startTime":1641.555,"endTime":1643.445,"body":"It's the bit that's soluble in alcohol."},{"startTime":1644.905,"endTime":1649.762,"body":"And I wrote up, uh, a quote from, uh, Kacha Rubia who is the queen"},{"startTime":1649.762,"endTime":1653.325,"body":"of, uh, A DHD brain imaging, as far as I'm concerned."},{"startTime":1653.705,"endTime":1658.619,"body":"Uh, and, uh, that is, uh, word by word what she wrote in the article"},{"startTime":1658.619,"endTime":1663.533,"body":"by farone, which is, uh, on the reading list, the reference list of the transcript"},{"startTime":1663.533,"endTime":1668.447,"body":"of this talk, which you can get hold of, I guess, that A DHD is"},{"startTime":1668.447,"endTime":1670.085,"body":"due to immature brain structures."},{"startTime":1670.085,"endTime":1672.365,"body":"It hasn't developed enough in few K areas."},{"startTime":1672.745,"endTime":1679.184,"body":"I'm not saying that people with A DHD have got totally immature brains that would"},{"startTime":1679.184,"endTime":1685.624,"body":"be wrong, but there are these three areas where it does seem as though the"},{"startTime":1685.624,"endTime":1691.205,"body":"cortex has not developed sufficiently thickly compared with, um, uh, with neurotypical folk."},{"startTime":1691.505,"endTime":1693.325,"body":"And that also applies to the wiring."},{"startTime":1693.905,"endTime":1699.165,"body":"Um, please don't take that literally as an illustration of nerve tracts, but there are"},{"startTime":1699.165,"endTime":1703.725,"body":"an awful lot of nerve tracts that link parts of the brain together."},{"startTime":1704.505,"endTime":1709.367,"body":"And when one looks at the nerve tracts close to those areas that I was"},{"startTime":1709.367,"endTime":1712.285,"body":"mentioning there, then you find that they're poorly organized."},{"startTime":1712.635,"endTime":1714.965,"body":"They're not developed as well as they should be."},{"startTime":1715.425,"endTime":1721.29,"body":"And there are ways of measuring that, uh, which I can't show you except by"},{"startTime":1721.29,"endTime":1723.245,"body":"using rather complicated mathematical stuff."},{"startTime":1723.665,"endTime":1727.045,"body":"Um, and I, it, it's, um, too late in the day for that."},{"startTime":1728.485,"endTime":1730.885,"body":"I do want to mention that there are nerve tracks."},{"startTime":1730.885,"endTime":1734.045,"body":"Don't worry about the, the names, just look at the colors."},{"startTime":1734.355,"endTime":1739.286,"body":"There's a red tract that starts in the middle of the brain loops towards the"},{"startTime":1739.286,"endTime":1744.218,"body":"front, and therefore is closely involved with the frontal cortex, which is the in inhibitor"},{"startTime":1744.218,"endTime":1745.205,"body":"of impulsive behavior."},{"startTime":1745.745,"endTime":1751.485,"body":"Uh, and also, uh, the management of activity, motor activity."},{"startTime":1752.105,"endTime":1757.496,"body":"And there's a, a blue, uh, tract that does the same thing, but goes a"},{"startTime":1757.496,"endTime":1762.887,"body":"little bit further over so that that now links into the areas and the parietal"},{"startTime":1762.887,"endTime":1764.325,"body":"cortex that control attention."},{"startTime":1764.785,"endTime":1771.181,"body":"Now, I bring these nerve tracts in because the medicines that can be used with"},{"startTime":1771.181,"endTime":1777.578,"body":"great effect in A DHD, um, assist these nerve tracks in the jobs that they"},{"startTime":1777.578,"endTime":1778.005,"body":"do."},{"startTime":1778.555,"endTime":1781.925,"body":"They assist neurotransmission at the synapses."},{"startTime":1781.925,"endTime":1789.747,"body":"There's the junction between, uh, various nerve cells and those therefore, um, that nerve innovation,"},{"startTime":1789.747,"endTime":1796.005,"body":"uh, of key areas in attention, uh, working memory, uh, response inhibition."},{"startTime":1796.585,"endTime":1800.005,"body":"Um, I just put up, because I'll probably come back to that at some stage."},{"startTime":1801.065,"endTime":1804.53,"body":"Now, there's something else about the brain I want to mention, which I think has"},{"startTime":1804.53,"endTime":1805.685,"body":"been a very important idea."},{"startTime":1807.065,"endTime":1814.199,"body":"We have two, all of us have two sets of circuits in our brains that"},{"startTime":1814.199,"endTime":1818.005,"body":"control the style, which we adopt in thinking."},{"startTime":1819.465,"endTime":1822.525,"body":"And I want to talk about default mode thinking."},{"startTime":1822.545,"endTime":1828.226,"body":"The brain is always active, the brain's always at it, but it in default mode"},{"startTime":1828.226,"endTime":1828.605,"body":"thinking."},{"startTime":1828.605,"endTime":1833.885,"body":"When you're on your own and you are pondering, you are musing about yourself, about"},{"startTime":1833.885,"endTime":1839.165,"body":"recent memories, about things you'd like to do a bit of daydreaming, think about yourself,"},{"startTime":1839.165,"endTime":1844.445,"body":"think about close relationships, uh, what's been going on without trying to tackle a task."},{"startTime":1844.915,"endTime":1851.042,"body":"Your brain is using, um, default mode thinking it's default because it's not being asked"},{"startTime":1851.042,"endTime":1853.085,"body":"to do anything very specific."},{"startTime":1853.085,"endTime":1857.765,"body":"And let's be contrasted with task centered or task positive thinking."},{"startTime":1857.765,"endTime":1861.065,"body":"When you've got a real problem to cope with, you've got something that suddenly you've"},{"startTime":1861.065,"endTime":1862.165,"body":"gotta think about and do."},{"startTime":1865.795,"endTime":1871.772,"body":"This is, uh, active brain imaging of default mode thinking where you can see that,"},{"startTime":1871.772,"endTime":1877.749,"body":"um, we've got the brains go forward and backwards on this one, but there are"},{"startTime":1877.749,"endTime":1883.727,"body":"various areas in green where neurons associated nerve cells associated with default mode, musing, daydreamy"},{"startTime":1883.727,"endTime":1889.704,"body":"type thinking are, and there are already orange ones that are to do with task"},{"startTime":1889.704,"endTime":1894.885,"body":"centered mode, task positive thinking, and they're in different parts of the brain."},{"startTime":1896.425,"endTime":1903.405,"body":"Now, anyone can enjoy a little bit of, um, default mode thinking."},{"startTime":1903.475,"endTime":1908.11,"body":"It's quite nice, um, particularly when you're trying to get off to sleep, you know,"},{"startTime":1908.11,"endTime":1909.965,"body":"it's, um, musing, uh, about things."},{"startTime":1910.665,"endTime":1915.741,"body":"Um, but when you actually have suddenly have to do something, when you have a"},{"startTime":1915.741,"endTime":1920.817,"body":"cognitive task to solve, like an arithmetic, arithmetic problem of, um, offsprings homework or something"},{"startTime":1920.817,"endTime":1923.525,"body":"like that, um, so do it for them."},{"startTime":1923.865,"endTime":1929.181,"body":"Uh, then you have to switch off default mode thinking you turn it off so"},{"startTime":1929.181,"endTime":1932.725,"body":"that you can enter task centered or task positive mode."},{"startTime":1933.185,"endTime":1933.845,"body":"Are you with me?"},{"startTime":1934.865,"endTime":1935.085,"body":"Now?"},{"startTime":1935.225,"endTime":1938.445,"body":"The problem with A DHD is the brain doesn't."},{"startTime":1939.425,"endTime":1946.038,"body":"So you are in nice, cozy daydreamy default mode of thinking, and you are suddenly"},{"startTime":1946.038,"endTime":1949.565,"body":"faced with a problem that requires concentrated thought."},{"startTime":1950.505,"endTime":1955.365,"body":"Um, and you don't turn off the default mode."},{"startTime":1955.385,"endTime":1959.743,"body":"You may go into task centered, task positive thinking, but you don't switch off the"},{"startTime":1959.743,"endTime":1960.325,"body":"other stuff."},{"startTime":1961.105,"endTime":1965.925,"body":"So you look as though you are daydreaming in class or at work."},{"startTime":1966.505,"endTime":1968.845,"body":"You look as though you are not really with it."},{"startTime":1968.845,"endTime":1969.565,"body":"You are in a fog."},{"startTime":1969.705,"endTime":1974.405,"body":"You are in, uh, ah, I don't know, planet hill land or whatever it is."},{"startTime":1975.025,"endTime":1982.093,"body":"Um, but actually the problem there is that you can't turn that default mode thinking"},{"startTime":1982.093,"endTime":1982.565,"body":"off."},{"startTime":1983.745,"endTime":1987.325,"body":"Uh, and that's now, I think, been shown in a variety of studies quite elegantly."},{"startTime":1987.545,"endTime":1990.085,"body":"It doesn't apply to everyone with A DHD."},{"startTime":1990.085,"endTime":1993.325,"body":"This is not a test for A DHD doing that functional brain scan."},{"startTime":1993.355,"endTime":1999.44,"body":"It's not identify A DHD reliably, but it is a common problem within the heterogeneous"},{"startTime":1999.44,"endTime":2005.525,"body":"diverse area, uh, of A DHD and the way it is done by the brain."},{"startTime":2006.345,"endTime":2008.005,"body":"Can I talk about something slightly different?"},{"startTime":2008.005,"endTime":2008.125,"body":"Now?"},{"startTime":2008.205,"endTime":2011.725,"body":"I want to go back to talking about classification within diagnosis."},{"startTime":2012.865,"endTime":2016.879,"body":"Uh, you remember I showed you a circle that was bisected into a blue bit"},{"startTime":2016.879,"endTime":2018.485,"body":"and, uh, a ready orange bit."},{"startTime":2019.505,"endTime":2028.537,"body":"Um, as time has gone on, people have realized increasingly you can just have primarily"},{"startTime":2028.537,"endTime":2036.365,"body":"inattentive presentation, A DHD, or indeed, primarily, predominantly, uh, hyperactive, impulsive, A DHD."},{"startTime":2036.365,"endTime":2042.3,"body":"And when you do that, stone me if the two varieties of presentation don't actually"},{"startTime":2042.3,"endTime":2048.235,"body":"behave as though they were combined A DHD in their response to medication, in their"},{"startTime":2048.235,"endTime":2051.005,"body":"ability to be associated with, with impairment."},{"startTime":2051.465,"endTime":2054.125,"body":"And for practical purposes, they are still A DHD."},{"startTime":2054.125,"endTime":2060.557,"body":"They only half of that original circle of combined A DHD, the communist variety is,"},{"startTime":2060.557,"endTime":2061.844,"body":"is present now."},{"startTime":2061.985,"endTime":2063.205,"body":"You see what I mean by weird?"},{"startTime":2063.905,"endTime":2069.661,"body":"The, the concept does get a bit hard to think about, um, unless you're a"},{"startTime":2069.661,"endTime":2070.045,"body":"journalist."},{"startTime":2070.824,"endTime":2075.045,"body":"Uh, the, did I use the word think?"},{"startTime":2075.505,"endTime":2076.085,"body":"Yes, I did."},{"startTime":2076.425,"endTime":2082.057,"body":"Um, predominantly inattentive A DHD, which is the items on that first list I think"},{"startTime":2082.057,"endTime":2087.69,"body":"I showed you about not having difficulty with concentration, difficulty with self-organization, uh, difficulty resisting"},{"startTime":2087.69,"endTime":2093.323,"body":"distractibility and so on and so forth, is mainly as combined people who used to"},{"startTime":2093.323,"endTime":2098.205,"body":"have combined A DHD, but have got older, we could say grown up."},{"startTime":2099.145,"endTime":2106.295,"body":"So this is much more typical in biologically more mature individuals like women, um, and"},{"startTime":2106.295,"endTime":2113.445,"body":"in adults as opposed to children, whereas the predominantly hyperactive, impulsive, it's really rather typical."},{"startTime":2113.475,"endTime":2117.245,"body":"Most of the cases I've seen have been under the age of 10, they've been"},{"startTime":2117.245,"endTime":2119.005,"body":"sported, but then I'm a children's doctor."},{"startTime":2119.125,"endTime":2124.945,"body":"I would be seeing young children, I suppose, uh, but that it's a younger group"},{"startTime":2124.945,"endTime":2130.765,"body":"with a primarily hyperactive, predo, hyperactive, impulsive presentation, and you switch around between the two."},{"startTime":2130.865,"endTime":2133.445,"body":"Uh, this is something that gets even worse."},{"startTime":2134.505,"endTime":2139.64,"body":"But before I get onto that, um, A DHD in girls is I think, a"},{"startTime":2139.64,"endTime":2140.325,"body":"major issue."},{"startTime":2140.485,"endTime":2144.422,"body":"I mean, I think A DHD is a major issue for reasons I'll come back"},{"startTime":2144.422,"endTime":2144.685,"body":"to."},{"startTime":2145.145,"endTime":2148.845,"body":"The girls are much more likely to be inattentive in their presentation."},{"startTime":2149.035,"endTime":2151.325,"body":"They're not racing around on the go the whole time."},{"startTime":2151.325,"endTime":2155.285,"body":"They're not noisy, they're are not difficult and oppositional in class."},{"startTime":2155.945,"endTime":2157.685,"body":"So they don't get referred to clinics."},{"startTime":2158.435,"endTime":2163.005,"body":"They don't wear their parents out in quite the same way, but they are dreamy."},{"startTime":2163.515,"endTime":2165.725,"body":"They are in la la land."},{"startTime":2166.345,"endTime":2168.205,"body":"Uh, they look inattentive."},{"startTime":2168.555,"endTime":2170.605,"body":"They don't always respond when they're spoken to."},{"startTime":2171.145,"endTime":2177.223,"body":"Uh, and I'm talking about people who are excessive, enduring, pervasive, you know, it's not"},{"startTime":2177.223,"endTime":2178.845,"body":"just, um, everyone's daughters."},{"startTime":2179.625,"endTime":2184.725,"body":"Um, they are less likely to be identified because of that."},{"startTime":2186.225,"endTime":2189.645,"body":"As I said earlier, they're, they're not the squeaking wheels that need oiling."},{"startTime":2189.645,"endTime":2191.085,"body":"They don't get referred to clinics."},{"startTime":2191.085,"endTime":2194.125,"body":"They get mist because people just think, oh, well, she's like that."},{"startTime":2194.665,"endTime":2199.563,"body":"But actually she may be really struggling with, uh, keeping her work up to the"},{"startTime":2199.563,"endTime":2204.461,"body":"standard that her intelligence predicts at school, for example, she may be, have difficulties holding"},{"startTime":2204.461,"endTime":2209.359,"body":"down a job in, uh, in industry or in the office because she seemed to"},{"startTime":2209.359,"endTime":2211.645,"body":"be dreamy and not quite with it."},{"startTime":2212.945,"endTime":2215.085,"body":"So, and then people just think, well, you dare."},{"startTime":2216.265,"endTime":2218.925,"body":"And they may make misogynistic remarks for all I know."},{"startTime":2219.745,"endTime":2223.445,"body":"Um, they're much more likely to try and conceal that."},{"startTime":2224.035,"endTime":2227.165,"body":"They don't always, but they're more likely to try and to mask it."},{"startTime":2228.215,"endTime":2233.328,"body":"Those of you who heard Fran Happy's excellent presentation just a week or so ago,"},{"startTime":2233.328,"endTime":2238.441,"body":"uh, she was talking about masking, uh, the extent to which people with autism will"},{"startTime":2238.441,"endTime":2239.805,"body":"strive to appear normal."},{"startTime":2240.065,"endTime":2241.805,"body":"The same thing applies to girls."},{"startTime":2241.915,"endTime":2247.685,"body":"They strive to fit in, they strive to be, uh, good, um, in quotes."},{"startTime":2248.745,"endTime":2250.285,"body":"Um, and that is exhausting."},{"startTime":2250.915,"endTime":2256.223,"body":"They're also much more likely girls with a DHD much more likely to show emotional"},{"startTime":2256.223,"endTime":2257.285,"body":"reactivity to live."},{"startTime":2258.075,"endTime":2263.085,"body":"They, uh, they cry, um, they get upset, they get miserable, they get dis demoralized."},{"startTime":2263.085,"endTime":2264.485,"body":"Their self-esteem suffers."},{"startTime":2265.265,"endTime":2270.445,"body":"Um, they, their performance over time tends to be inconsistent."},{"startTime":2270.505,"endTime":2274.285,"body":"One of the consistent things about A DHD in girls is that it's inconsistent."},{"startTime":2275.145,"endTime":2281.163,"body":"And, uh, because of all this, it gets missed or it gets given the wrong"},{"startTime":2281.163,"endTime":2281.565,"body":"diagnosis."},{"startTime":2281.585,"endTime":2288.485,"body":"It gets labeled as, uh, anxiety or it gets labeled as personality disorder, heaven forbid."},{"startTime":2288.945,"endTime":2291.045,"body":"And the, the key concept is mist."},{"startTime":2291.225,"endTime":2295.045,"body":"So the treatment doesn't reach the person who would benefit from it."},{"startTime":2297.155,"endTime":2301.495,"body":"Let me say some of the same things about A DHD in adult life."},{"startTime":2303.005,"endTime":2311.301,"body":"This is, uh, a graph, um, which, uh, I, uh, is actually a graph of"},{"startTime":2311.301,"endTime":2311.855,"body":"prescriptions."},{"startTime":2311.965,"endTime":2314.335,"body":"It's not a graph of, uh, of prevalence."},{"startTime":2314.515,"endTime":2316.245,"body":"It is prescriptions."},{"startTime":2316.305,"endTime":2322.288,"body":"And this is, uh, important I think survey by Dawn Connolly in the prescriber's journal,"},{"startTime":2322.288,"endTime":2323.485,"body":"uh, last year."},{"startTime":2324.305,"endTime":2327.965,"body":"The blue line is prescriptions for adults with A DHD."},{"startTime":2328.345,"endTime":2331.365,"body":"The red line is prescriptions for children with A DHD."},{"startTime":2331.615,"endTime":2337.885,"body":"There are now adult, A DHD is increasingly recognized as something to be treated."},{"startTime":2338.865,"endTime":2345.899,"body":"Uh, and that I think illustrates where we are at the moment and where we"},{"startTime":2345.899,"endTime":2352.933,"body":"are with adults is that the presentation is much more likely to be inattentive, um,"},{"startTime":2352.933,"endTime":2356.685,"body":"compared with the, the predominantly hyperactive impulsive group."},{"startTime":2357.705,"endTime":2359.165,"body":"So it may still be combined."},{"startTime":2359.165,"endTime":2362.085,"body":"You're quite entitled to have combined A DHD as an adult, no problem."},{"startTime":2362.825,"endTime":2363.845,"body":"The bisected circle."},{"startTime":2364.385,"endTime":2369.548,"body":"But by and large, the adults with A DHD are predominantly inattentive, and it's a"},{"startTime":2369.548,"endTime":2370.925,"body":"much more subtle presentation."},{"startTime":2371.715,"endTime":2378.891,"body":"Fortunately, we now have the capacity to listen to what adults say about their own"},{"startTime":2378.891,"endTime":2380.805,"body":"experience of A DHD."},{"startTime":2381.745,"endTime":2384.205,"body":"And they don't say, I'm on the go the whole time, I'm noisy."},{"startTime":2384.925,"endTime":2386.565,"body":"I don't concentrate very well."},{"startTime":2386.565,"endTime":2387.245,"body":"They don't say that."},{"startTime":2387.715,"endTime":2390.725,"body":"They may say it if asked, but they say it's exhausting."},{"startTime":2391.555,"endTime":2393.485,"body":"It's knackering to have a DHD."},{"startTime":2393.545,"endTime":2398.963,"body":"So many say not everybody, because there's no feature that is constantly present in A"},{"startTime":2398.963,"endTime":2399.325,"body":"DHD."},{"startTime":2400.275,"endTime":2403.885,"body":"They, in my experience, grumble about their own forgetfulness."},{"startTime":2404.805,"endTime":2408.655,"body":"I, I go out shopping and I forget what I'm supposed to be doing, or"},{"startTime":2408.655,"endTime":2412.505,"body":"I come back with stuff that I didn't want because I couldn't resist the distraction"},{"startTime":2412.505,"endTime":2414.045,"body":"of special offers in the supermarket."},{"startTime":2414.905,"endTime":2420.961,"body":"Um, well, you know, don't we all, um, but mind wandering can be a real"},{"startTime":2420.961,"endTime":2421.365,"body":"problem."},{"startTime":2421.865,"endTime":2424.805,"body":"Now, mind wandering is something we can all do with a bit of luck."},{"startTime":2425.665,"endTime":2431.455,"body":"Um, good fun, but intrusive mind wandering where you cannot control the thoughts that are"},{"startTime":2431.455,"endTime":2437.245,"body":"flooding into your mind, one after the other in, um, unless you are interested in"},{"startTime":2437.245,"endTime":2443.035,"body":"free association, which I don't think many people are, uh, it's actually a pain to"},{"startTime":2443.035,"endTime":2448.825,"body":"have your mind cluttered up with one thought after another after the other linked tenuously,"},{"startTime":2448.825,"endTime":2452.685,"body":"or conversely, finding your thinking disappearing down a rabbit hole."},{"startTime":2453.065,"endTime":2457.855,"body":"And that phrase, rabbit hole rings in my ears from so many older teenagers and"},{"startTime":2457.855,"endTime":2462.646,"body":"young adults who just say, I, the problem is I get this thought and it's"},{"startTime":2462.646,"endTime":2463.285,"body":"so interesting."},{"startTime":2463.405,"endTime":2466.13,"body":"I just wanna pursue it further and further and further, and I get on the"},{"startTime":2466.13,"endTime":2467.765,"body":"rabbit hole and I can't find the way out."},{"startTime":2468.905,"endTime":2474.297,"body":"Um, and, uh, I've made the point about masking that adults will quite often say,"},{"startTime":2474.297,"endTime":2479.689,"body":"I have to strive to contain my A DHD to be more like what my"},{"startTime":2479.689,"endTime":2482.565,"body":"employer, my partner, my children want to be."},{"startTime":2483.465,"endTime":2488.66,"body":"Uh, and so they try and pretend and that it is one of the components"},{"startTime":2488.66,"endTime":2491.085,"body":"that contributes to the it's exhausting quote."},{"startTime":2492.465,"endTime":2499.26,"body":"Now, the other thing that adults I'm still on adults with A DHD struggle with"},{"startTime":2499.26,"endTime":2501.525,"body":"is weak cognitive executive skills."},{"startTime":2501.865,"endTime":2502.845,"body":"That's a mouthful."},{"startTime":2503.545,"endTime":2508.197,"body":"But what it means is that there's a group of higher ways of thinking and"},{"startTime":2508.197,"endTime":2512.85,"body":"living one's life, which have to do with planning and self-organization and organizing a task"},{"startTime":2512.85,"endTime":2517.502,"body":"and doing it systematically and seeing how far you've got and all the boring stuff,"},{"startTime":2517.502,"endTime":2521.845,"body":"uh, that one's taught in time management courses and so on and so forth."},{"startTime":2522.625,"endTime":2528.502,"body":"Um, actually manage it to complete a task set by somebody else, or even set"},{"startTime":2528.502,"endTime":2533.205,"body":"by yourself becomes exhausting because you lack the skills to do it."},{"startTime":2533.205,"endTime":2538.005,"body":"And this is a common issue, very common issue in adult A DHD."},{"startTime":2538.345,"endTime":2542.165,"body":"Not universal, nothing is, but it's a common one."},{"startTime":2542.905,"endTime":2549.752,"body":"And, uh, Russell Barkley, who knows everything about A DHD, um, we will say we"},{"startTime":2549.752,"endTime":2553.405,"body":"ought to be calling it intention deficit disorder."},{"startTime":2553.865,"endTime":2556.405,"body":"And his quip, uh, I think is quite a good one."},{"startTime":2556.415,"endTime":2558.485,"body":"These are people who know what they should be doing."},{"startTime":2558.485,"endTime":2563.045,"body":"They know what to do, but they can't get to do what they know."},{"startTime":2563.105,"endTime":2565.325,"body":"So they know what to do, but they can't make themselves do it."},{"startTime":2566.225,"endTime":2570.404,"body":"And I think that is quite a common issue in terms of self-organization and the"},{"startTime":2570.404,"endTime":2574.583,"body":"way you go about your life and the way you go about shopping, the way"},{"startTime":2574.583,"endTime":2578.205,"body":"you go about cooking, the way you go about managing your, your work."},{"startTime":2578.305,"endTime":2583.144,"body":"If you are trying to invent a new solution to a problem, intention deficits or"},{"startTime":2583.144,"endTime":2587.983,"body":"not to be taken seriously, I mean, Russ, I wouldn't want people to take it"},{"startTime":2587.983,"endTime":2590.565,"body":"too seriously, but he's, he's making a point."},{"startTime":2591.985,"endTime":2596.042,"body":"Now, all this means, I think, and this is just a quick comment before I"},{"startTime":2596.042,"endTime":2597.125,"body":"talk about something else."},{"startTime":2597.585,"endTime":2601.445,"body":"Um, that assessment of A DHD must be structured."},{"startTime":2601.585,"endTime":2602.485,"body":"It must be thorough."},{"startTime":2602.985,"endTime":2605.405,"body":"Uh, I suggest it should be done face to face."},{"startTime":2605.945,"endTime":2608.405,"body":"I'm very suspicious of remote assessment for A DHD."},{"startTime":2608.605,"endTime":2612.538,"body":"I actually don't think people should do it, because one of your things you're going"},{"startTime":2612.538,"endTime":2616.471,"body":"to want to know is, is this person should they wish going to be able"},{"startTime":2616.471,"endTime":2618.045,"body":"to tolerate medicines for A DHD."},{"startTime":2618.045,"endTime":2620.725,"body":"And you can't do that unless you examine them physically."},{"startTime":2621.705,"endTime":2625.725,"body":"And I get despair of remote assessment of A DH adhd."},{"startTime":2625.725,"endTime":2629.285,"body":"It's not good enough, but it also needs to be structured."},{"startTime":2629.625,"endTime":2634.078,"body":"One of the instruments like the ACE or the ACE plus or the diva needs"},{"startTime":2634.078,"endTime":2638.531,"body":"to be used so that people systematically ask about the associated conditions that contribute to"},{"startTime":2638.531,"endTime":2639.125,"body":"the disability."},{"startTime":2640.065,"endTime":2642.765,"body":"And so it must include a coexisting conditions."},{"startTime":2642.985,"endTime":2647.688,"body":"And I would argue that you should always have a witness to a witness, sorry,"},{"startTime":2647.688,"endTime":2652.391,"body":"that's a medical slang for somebody who can describe how the person in front of"},{"startTime":2652.391,"endTime":2657.094,"body":"you who may want to be a patient, if you see what I mean, actually"},{"startTime":2657.094,"endTime":2661.797,"body":"is so you don't just rely on what they say, you need somebody else to"},{"startTime":2661.797,"endTime":2663.365,"body":"say, oh, for God's sake."},{"startTime":2663.475,"endTime":2663.765,"body":"Yeah."},{"startTime":2664.625,"endTime":2670.125,"body":"Um, he often is, he, well, much less so the ratio of boys to girls,"},{"startTime":2670.125,"endTime":2672.325,"body":"of course, it's really quite high."},{"startTime":2672.395,"endTime":2676.165,"body":"It's somewhere around about four boys to one girl."},{"startTime":2676.525,"endTime":2676.805,"body":"Nowadays."},{"startTime":2677.065,"endTime":2680.085,"body":"The ratio in adults, um, is, is about more."},{"startTime":2680.635,"endTime":2682.405,"body":"It's getting close to one to one."},{"startTime":2683.185,"endTime":2687.618,"body":"Uh, but right at the moment, I would suggest it's, uh, two men for every"},{"startTime":2687.618,"endTime":2691.165,"body":"one woman with A DHD varies across the age range of adulthood."},{"startTime":2693.465,"endTime":2695.805,"body":"So I'm making a quick point."},{"startTime":2695.915,"endTime":2697.565,"body":"That assessment has got to be thorough."},{"startTime":2697.945,"endTime":2703.036,"body":"And the comment by Anthony, David and Quentin Deley, um, a couple of weeks ago,"},{"startTime":2703.036,"endTime":2708.127,"body":"that there's so much self-diagnosis of A DHD that this is wasting health service resources"},{"startTime":2708.127,"endTime":2709.485,"body":"is I think, valid."},{"startTime":2710.105,"endTime":2714.325,"body":"You know, self-diagnosis is okay, but it needs to be confirmed."},{"startTime":2714.325,"endTime":2715.925,"body":"It needs to be confirmed properly."},{"startTime":2716.345,"endTime":2721.102,"body":"And if it's confirmed as I know it is sometimes by somebody just collecting some"},{"startTime":2721.102,"endTime":2723.005,"body":"rating scales, that is bad practice."},{"startTime":2723.425,"endTime":2724.885,"body":"It really is bad practice."},{"startTime":2726.785,"endTime":2728.405,"body":"You, you sense a rant coming on."},{"startTime":2728.525,"endTime":2729.725,"body":"I I will suppress the rant."},{"startTime":2729.745,"endTime":2733.165,"body":"My frontal lo will, um, not allow me \u003claugh\u003e."},{"startTime":2734.225,"endTime":2738.245,"body":"The big question I think is whether we've got the definition of A DHD, right?"},{"startTime":2739.185,"endTime":2744.237,"body":"Um, clearly we haven't quite got it right because we started off talking about boys"},{"startTime":2744.237,"endTime":2747.605,"body":"'cause it was boys who, uh, services were presented with."},{"startTime":2748.305,"endTime":2752.285,"body":"And boys are a poor representation of the world in general."},{"startTime":2752.635,"endTime":2754.965,"body":"Well, sorry, mean poor, I mean inadequate."},{"startTime":2754.965,"endTime":2757.579,"body":"They're not in, you know, you've gotta look at, so you've gotta look at the"},{"startTime":2757.579,"endTime":2759.845,"body":"girls, you've gotta look at the women, you've gotta look at the adults."},{"startTime":2760.385,"endTime":2765.569,"body":"And the more we do, uh, the more questions are raised as to whether the"},{"startTime":2765.569,"endTime":2770.753,"body":"original definition, like six out of nine on a couple of lists, plus a, uh,"},{"startTime":2770.753,"endTime":2771.445,"body":"disability factor."},{"startTime":2771.665,"endTime":2772.405,"body":"Is that enough?"},{"startTime":2772.905,"endTime":2776.405,"body":"Is it enough to talk about inattention and hyperactivity impulsivity?"},{"startTime":2777.065,"endTime":2778.565,"body":"And I want just want to address that."},{"startTime":2781.545,"endTime":2786.15,"body":"One of the things that we now recognize in the last two years is cognitive"},{"startTime":2786.15,"endTime":2786.765,"body":"disengagement syndrome."},{"startTime":2787.545,"endTime":2791.165,"body":"That's used to be called slow mental processing."},{"startTime":2791.625,"endTime":2795.605,"body":"Before that it was called sluggish cognitive processing in the USA."},{"startTime":2795.605,"endTime":2801.205,"body":"But the word sluggish, um, I think probably doesn't tolerate European import very well."},{"startTime":2801.945,"endTime":2803.765,"body":"Um, should I be saying British import?"},{"startTime":2804.045,"endTime":2806.725,"body":"Probably I whatever it, it doesn't travel well."},{"startTime":2806.765,"endTime":2810.565,"body":"I don't like calling people sluggish or their thinking process sluggish."},{"startTime":2810.705,"endTime":2817.355,"body":"So cognitive disengagement syndrome is people who are pretty inattentive and pretty slow and quite"},{"startTime":2817.355,"endTime":2824.005,"body":"tend to be a bit scary in a fog is the phrase that's used over"},{"startTime":2824.005,"endTime":2829.325,"body":"and over again, who are slow to respond to questions and conversation."},{"startTime":2829.745,"endTime":2831.965,"body":"Uh, when they have to think about it, they don't have to think about it."},{"startTime":2831.985,"endTime":2833.285,"body":"Yes, of course they can be quite lively."},{"startTime":2833.285,"endTime":2838.932,"body":"I went to around to the house of, uh, somebody I know who is definitely"},{"startTime":2838.932,"endTime":2839.685,"body":"cognitively disengaged."},{"startTime":2840.035,"endTime":2845.523,"body":"He's fine with his mates, you know, within the sort of narrow discourse of male"},{"startTime":2845.523,"endTime":2848.085,"body":"bonomi as applied to 21 year olds."},{"startTime":2848.195,"endTime":2849.325,"body":"He's absolutely fine."},{"startTime":2849.705,"endTime":2854.486,"body":"But if I say, um, how do I, uh, which tube station do I get"},{"startTime":2854.486,"endTime":2854.805,"body":"to?"},{"startTime":2855.425,"endTime":2856.765,"body":"He has to stop and think about it."},{"startTime":2856.765,"endTime":2857.245,"body":"He's slow."},{"startTime":2858.305,"endTime":2859.445,"body":"Um, but accurate."},{"startTime":2860.425,"endTime":2864.165,"body":"Uh, so in a fog, they tend to be rather drowsy and new yawning."},{"startTime":2864.425,"endTime":2865.685,"body":"So this is a variant."},{"startTime":2866.035,"endTime":2872.462,"body":"This is one part of the predominantly inattentive presentation picture, which has now been quite"},{"startTime":2872.462,"endTime":2877.605,"body":"well described by Becker and, uh, teams who've renamed it cognitive disengagement."},{"startTime":2877.765,"endTime":2882.725,"body":"I expect that label will stick though it's only 18 months old so far."},{"startTime":2883.465,"endTime":2888.165,"body":"Uh, and those I, the question is, do we recognize this?"},{"startTime":2888.185,"endTime":2892.725,"body":"Do we recognize this pattern as a component of A DHD?"},{"startTime":2893.195,"endTime":2899.016,"body":"Some 20% of adults with inattentive A DHD fall into this group and can be"},{"startTime":2899.016,"endTime":2899.405,"body":"described."},{"startTime":2899.995,"endTime":2906.14,"body":"They can, some of them be described as having a DHD as well, but they"},{"startTime":2906.14,"endTime":2912.285,"body":"can also, if you look at that bar, extend outside the semicircle of predominantly inattentive."},{"startTime":2912.345,"endTime":2916.913,"body":"So it becomes an interesting possible contributor to the A DHD picture, but it seems"},{"startTime":2916.913,"endTime":2919.045,"body":"to exist on its own as well."},{"startTime":2920.705,"endTime":2926.525,"body":"The same applies to, um, deficient emotional self-regulation."},{"startTime":2927.065,"endTime":2928.485,"body":"I'm sorry, it's such a mouthful."},{"startTime":2928.765,"endTime":2929.405,"body":"DESR."},{"startTime":2930.385,"endTime":2936.76,"body":"Now these are people who, uh, tend to be pretty irritable and flare up with"},{"startTime":2936.76,"endTime":2938.885,"body":"anger and are minimal provocation."},{"startTime":2939.905,"endTime":2946.813,"body":"So they're emotional self-regulation, particularly with respect to anger is, is it's not great and"},{"startTime":2946.813,"endTime":2953.722,"body":"they're hard to live with and they're fairly fierce and they have a deficient inhibition"},{"startTime":2953.722,"endTime":2955.565,"body":"of anger and frustration."},{"startTime":2955.565,"endTime":2961.525,"body":"They can't seem to self-soothe everyone says calm down, but they can't actually calm down."},{"startTime":2961.585,"endTime":2968.565,"body":"It can't happen because they can't find a calmer reaction to substitute for their rage."},{"startTime":2968.945,"endTime":2971.085,"body":"And it goes on and on and on."},{"startTime":2972.065,"endTime":2976.485,"body":"You know, they don't calm down within minutes, still quick flare up, it grinds on."},{"startTime":2977.345,"endTime":2983.253,"body":"So there is deficient self-regulation and the argument is, lemme just look at my crib"},{"startTime":2983.253,"endTime":2986.405,"body":"sheet because I'm tempted to add something in."},{"startTime":2986.545,"endTime":2987.925,"body":"I'm not sure whether I'm allowed to."},{"startTime":2988.305,"endTime":2991.826,"body":"Um, I think I probably won't add it in, but you can sense that this"},{"startTime":2991.826,"endTime":2992.765,"body":"is a common problem."},{"startTime":2993.125,"endTime":2999.291,"body":"Probably 70% of male teenage with adult A DHD male teenagers will show this picture"},{"startTime":2999.291,"endTime":3005.458,"body":"and it can endure into adult life and it can make such people impossible to"},{"startTime":3005.458,"endTime":3007.925,"body":"live with for very obvious reasons."},{"startTime":3008.025,"endTime":3009.685,"body":"You are on eggshells the whole time."},{"startTime":3010.665,"endTime":3012.325,"body":"Um, and they don't like it either, frankly."},{"startTime":3012.905,"endTime":3015.005,"body":"Uh, they will often feel contrite afterwards."},{"startTime":3015.005,"endTime":3021.683,"body":"So whether they're able to confess to that is, uh, arguable, they can't seem to"},{"startTime":3021.683,"endTime":3025.245,"body":"detach their attention from the provocation they experienced."},{"startTime":3027.745,"endTime":3031.885,"body":"The difficulty with incorporating it into A DHD is that angry antisocial behavior."},{"startTime":3031.945,"endTime":3035.95,"body":"As I mentioned earlier, this is the slide I showed you earlier is common in"},{"startTime":3035.95,"endTime":3037.285,"body":"male A DHD in childhood."},{"startTime":3038.305,"endTime":3045.255,"body":"So we're suggesting this is a very specific form of anger as opposed to generally"},{"startTime":3045.255,"endTime":3046.645,"body":"oppositional defiant disobedience."},{"startTime":3046.985,"endTime":3051.285,"body":"Grumpy behavior is different from conduct disorder, which violates the rights of others."},{"startTime":3051.905,"endTime":3055.797,"body":"And I think in term, putting it into a clinical practice might be difficult 'cause"},{"startTime":3055.797,"endTime":3059.689,"body":"it may lead people just to dismiss the anger and say it's part of A"},{"startTime":3059.689,"endTime":3061.765,"body":"DHD, uh, and I will return to that."},{"startTime":3061.825,"endTime":3064.525,"body":"But at the moment I think it's quite tricky to integrate it."},{"startTime":3065.725,"endTime":3067.565,"body":"I wanna say something about working memory weaknesses."},{"startTime":3067.765,"endTime":3071.645,"body":"I don't mean that people with A DHD haven't got a memory."},{"startTime":3071.925,"endTime":3073.485,"body":"I don't mean that their memory doesn't work."},{"startTime":3074.395,"endTime":3082.045,"body":"It's um, it's what would happen if I said okay to them."},{"startTime":3082.355,"endTime":3085.263,"body":"Okay, I I'm gonna say some numbers and can you remember them and repeat them"},{"startTime":3085.263,"endTime":3085.845,"body":"back to me?"},{"startTime":3085.845,"endTime":3091.957,"body":"So I go 9, 8, 6 4 3 and I say, can you repeat that"},{"startTime":3091.957,"endTime":3092.365,"body":"back?"},{"startTime":3092.365,"endTime":3094.245,"body":"And they go, yeah, 9 8 6 4 3, what's your problem?"},{"startTime":3094.965,"endTime":3098.525,"body":"I say, well, the problem is now, can you repeat it back in reverse order?"},{"startTime":3098.945,"endTime":3101.725,"body":"And they go, oh, um, three."},{"startTime":3102.705,"endTime":3105.085,"body":"Um, yeah, next question please."},{"startTime":3105.545,"endTime":3110.782,"body":"Uh, and they actually cannot hold the stuff in mind in order to be able"},{"startTime":3110.782,"endTime":3113.925,"body":"to reorganize it and repeat it back to you."},{"startTime":3113.925,"endTime":3116.125,"body":"It's the reorganization that is working memory."},{"startTime":3116.395,"endTime":3120.778,"body":"It's reorganizing what you've heard in the previous 30 seconds in order to encode it"},{"startTime":3120.778,"endTime":3124.285,"body":"so that it can be then transferred into long-term memory, for instance."},{"startTime":3124.945,"endTime":3127.565,"body":"Now working memory weakness are common in A DHD."},{"startTime":3128.345,"endTime":3133.958,"body":"Um, last survey of my patient population, I did this on and compare notes with"},{"startTime":3133.958,"endTime":3139.571,"body":"somebody up country was, um, that it's probably 70% of, um, both boys and girls"},{"startTime":3139.571,"endTime":3142.565,"body":"with a DHD have a weak working memory."},{"startTime":3142.905,"endTime":3147.366,"body":"And if you remember that picture of the brain I showed you with the, uh,"},{"startTime":3147.366,"endTime":3151.827,"body":"a dors, medial frontal cortex patch that wasn't working, that's the bit that holds working"},{"startTime":3151.827,"endTime":3152.125,"body":"memory."},{"startTime":3152.235,"endTime":3156.205,"body":"It's not memory, it's being able to hold it and work on it."},{"startTime":3157.465,"endTime":3162.365,"body":"Now that can also occur outside the A DHD bisected circle."},{"startTime":3162.665,"endTime":3163.165,"body":"It could happen."},{"startTime":3163.165,"endTime":3167.085,"body":"For example, I used to run service for children with traumatic brain injury."},{"startTime":3167.355,"endTime":3171.405,"body":"Very common issue in traumatic brain injury, almost universal for instance."},{"startTime":3171.425,"endTime":3173.445,"body":"So it can arise for other reasons."},{"startTime":3174.665,"endTime":3179.853,"body":"Um, alcohol intoxication, you've probably noticed in people, you know, there are many other reasons"},{"startTime":3179.853,"endTime":3184.005,"body":"why you can't actually hold stuff in mind and think about it."},{"startTime":3184.945,"endTime":3189.328,"body":"So, uh, but people are arguing that there should be incorporated in the core diagnosis"},{"startTime":3189.328,"endTime":3190.205,"body":"of A DHD."},{"startTime":3190.205,"endTime":3191.325,"body":"And I concede why."},{"startTime":3191.865,"endTime":3195.987,"body":"The other bit that is very trendy, and I'm only mentioning it because it's fashionable,"},{"startTime":3195.987,"endTime":3199.285,"body":"is well not quite 'cause I, I think it is an issue."},{"startTime":3199.595,"endTime":3202.005,"body":"Rejection sensitivity dysphoria."},{"startTime":3202.385,"endTime":3207.972,"body":"You'll observe the folk in the A DHD academic world are very good at dreaming"},{"startTime":3207.972,"endTime":3211.325,"body":"up complicated phrases for something that's really quite simple."},{"startTime":3211.755,"endTime":3213.765,"body":"What I'm talking about here is sensitivity."},{"startTime":3214.545,"endTime":3220.161,"body":"Now I don't mean physical sensitivity to sensations, I mean sensitivity to being rejected or"},{"startTime":3220.161,"endTime":3221.285,"body":"ignored or criticized."},{"startTime":3222.185,"endTime":3227.285,"body":"Um, now people come back to me and say, yeah, you're talking about narcissistic personalities."},{"startTime":3227.565,"endTime":3229.325,"body":"I say, well, yeah, might be."},{"startTime":3229.425,"endTime":3234.212,"body":"You can get rejection sensitivity dysphoria an unpleasant state of mind, an unpleasant feeling if"},{"startTime":3234.212,"endTime":3237.085,"body":"you are super narcissistic and you can't take criticism."},{"startTime":3237.905,"endTime":3239.885,"body":"But you can also get it because you've got a DHD."},{"startTime":3240.725,"endTime":3244.253,"body":"I mean, you could have a DHD and narcissistic personality if you want, but so"},{"startTime":3244.253,"endTime":3246.605,"body":"that seems to be, to be over egging the pudding."},{"startTime":3247.265,"endTime":3252.64,"body":"Um, so rejection sensitivity dysphoria is important because it's common in A DHD and it's"},{"startTime":3252.64,"endTime":3258.015,"body":"exclusive as an experience that a sm a small slight, which could perhaps not noticed"},{"startTime":3258.015,"endTime":3260.165,"body":"by anyone else, can feel devastating."},{"startTime":3260.965,"endTime":3268.855,"body":"A powerful, intense negative emotion, shame, fear, anxiety, even fury, um, following a perceived criticism"},{"startTime":3268.855,"endTime":3276.745,"body":"or withdrawal of love and so forth, and is pursued in that the experience pursues"},{"startTime":3276.745,"endTime":3282.005,"body":"itself in one's mind by persistent negative self-talk I rumination."},{"startTime":3283.585,"endTime":3284.925,"body":"And they can't let go of it."},{"startTime":3285.595,"endTime":3290.666,"body":"They can't get over it, they can't move on, and they feel over time repeatedly"},{"startTime":3290.666,"endTime":3291.005,"body":"attacked."},{"startTime":3291.005,"endTime":3292.645,"body":"That is their general experience of the world."},{"startTime":3292.865,"endTime":3298.25,"body":"Now, it's important for folk with A DHD 'cause it does respond to one of"},{"startTime":3298.25,"endTime":3300.405,"body":"the little used A DHD medicines."},{"startTime":3300.405,"endTime":3306.325,"body":"It responds to guanine, which is intuitive, which is not that widely used."},{"startTime":3306.555,"endTime":3311.405,"body":"It's actually not technically licensed, whatever that means for adults in this country."},{"startTime":3311.905,"endTime":3317.389,"body":"But, uh, claims are made that some 60% of people with, uh, that sort of"},{"startTime":3317.389,"endTime":3321.045,"body":"rejection sensitive dysphoria, um, can uh, be helped with ine."},{"startTime":3321.185,"endTime":3326.124,"body":"So now, you know, now there are plenty of people around in the A DHD"},{"startTime":3326.124,"endTime":3331.063,"body":"community, um, patients in in quotes who say this should be part of A DHD"},{"startTime":3331.063,"endTime":3334.685,"body":"because it is so unpleasant and so pervasive and so common."},{"startTime":3335.065,"endTime":3336.645,"body":"We don't know much about it, frankly."},{"startTime":3337.305,"endTime":3342.165,"body":"So I'm mentioning it because it's in the A DHD chatter at the moment."},{"startTime":3342.275,"endTime":3346.725,"body":"It's in Attitude Magazine, which is a really useful resource by the way, online."},{"startTime":3347.305,"endTime":3348.605,"body":"Um, well, pretty well every month."},{"startTime":3349.265,"endTime":3352.325,"body":"So I mention those things."},{"startTime":3352.505,"endTime":3354.165,"body":"Now, what do we do about all this stuff?"},{"startTime":3354.385,"endTime":3356.125,"body":"Do we extend the diagnostic pattern?"},{"startTime":3356.735,"endTime":3358.805,"body":"These are the pat the issues that I've raised."},{"startTime":3358.805,"endTime":3363.365,"body":"Cognitive disengagement, deficient dimensional self-regulation, rejective sensitive dysphoria, working memory deficit."},{"startTime":3363.835,"endTime":3369.01,"body":"None of them are always present in A DHD, but then nothing is always present"},{"startTime":3369.01,"endTime":3370.045,"body":"in A DHD."},{"startTime":3370.515,"endTime":3377.845,"body":"It's heterogeneous, it's diverse, but it's still recognizable as an entity one."},{"startTime":3378.785,"endTime":3382.565,"body":"Um, this is, I'm ashamed of myself by saying all this."},{"startTime":3382.835,"endTime":3386.082,"body":"I've been ridiculed for saying this by so many people who think I should know"},{"startTime":3386.082,"endTime":3387.165,"body":"better and perhaps I should."},{"startTime":3387.545,"endTime":3393.245,"body":"But actually you can use medication as a probe to discover whether something is a"},{"startTime":3393.245,"endTime":3395.525,"body":"core A DHD future or not."},{"startTime":3395.705,"endTime":3400.549,"body":"And the reason for that is that if you, this is a paper, for example,"},{"startTime":3400.549,"endTime":3405.393,"body":"from a Norwegian clinic where they did something very simple, which is actually quite in"},{"startTime":3405.393,"endTime":3406.685,"body":"line with nice recommendations."},{"startTime":3406.685,"endTime":3411.965,"body":"You know what NICE is nice set out for what they regard as good practice."},{"startTime":3412.345,"endTime":3414.405,"body":"Um, and NICE is a deeply wonderful thing."},{"startTime":3414.405,"endTime":3416.285,"body":"But the trouble is he's always 10 years outta date."},{"startTime":3416.985,"endTime":3423.245,"body":"But within this study, which would've influenced them because it was published 11 years ago."},{"startTime":3424.515,"endTime":3429.465,"body":"Yeah, okay, you've got some, you've got some children with A DHD, you give them"},{"startTime":3429.465,"endTime":3432.765,"body":"methylphenidate, of which Ritalin used to be the communist form."},{"startTime":3432.835,"endTime":3438.291,"body":"Ritalin isn't used very much nowadays in my experience, but, um, if you give them"},{"startTime":3438.291,"endTime":3441.565,"body":"that, you get a response rate of about 72%."},{"startTime":3441.825,"endTime":3444.125,"body":"And this is what you hear over and over again."},{"startTime":3444.125,"endTime":3446.605,"body":"The response to stimulant medication is about 72%."},{"startTime":3446.865,"endTime":3447.525,"body":"No, it isn't."},{"startTime":3448.385,"endTime":3453.325,"body":"If you've tried methalate, uh, then probably three quarters of people will respond."},{"startTime":3454.145,"endTime":3460.187,"body":"But if you try dexamphetamine, which is what Dex stands for, sorry, MMPH is methylphenidate"},{"startTime":3460.187,"endTime":3462.605,"body":"mouthful Phite as somebody called it."},{"startTime":3463.345,"endTime":3468.43,"body":"Uh, then if you try one, then stop and then try the other, you get"},{"startTime":3468.43,"endTime":3470.125,"body":"a response rate of 92%."},{"startTime":3470.715,"endTime":3472.685,"body":"That is fantastic response rate."},{"startTime":3472.705,"endTime":3475.445,"body":"I'm not saying that everybody should have medicines, that's not my point."},{"startTime":3476.105,"endTime":3483.005,"body":"I'm saying that the medicines can result in symptom reduction in an astonishingly high percentage."},{"startTime":3483.065,"endTime":3488.99,"body":"One of the highest response rates in medicine, frankly, you know, we we're pretty well"},{"startTime":3488.99,"endTime":3494.125,"body":"up there with, uh, penicillin g you know, this is 92% response rate."},{"startTime":3494.385,"endTime":3502.2,"body":"Now, if you give these medications, the stimulant medications being dexamphetamine to ordinary people, you"},{"startTime":3502.2,"endTime":3504.285,"body":"don't boost their concentration."},{"startTime":3504.305,"endTime":3510.143,"body":"You don't reduce their hyperactivity unless they're bordering on the fringe of that bell shaped"},{"startTime":3510.143,"endTime":3515.981,"body":"curve and the red shade bit there, you can, but ordinarily people in the middle"},{"startTime":3515.981,"endTime":3519.485,"body":"of the bell curve, it doesn't do a thing."},{"startTime":3519.545,"endTime":3521.485,"body":"In fact, it can actually make things worse."},{"startTime":3522.285,"endTime":3528.825,"body":"Students who obtain stimulants, illicitly to help them with their exams, um, often do worse"},{"startTime":3528.825,"endTime":3531.005,"body":"than they would otherwise do."},{"startTime":3531.585,"endTime":3536.018,"body":"So stimulus aren't a, you know, used to worry that, uh, we'd better get the"},{"startTime":3536.018,"endTime":3539.565,"body":"whole population on stimulant medication, otherwise the Chinese will get there first."},{"startTime":3539.945,"endTime":3541.285,"body":"Uh, but it's not like that."},{"startTime":3541.945,"endTime":3545.405,"body":"Uh, stimulus don't help unless you've got something approaching A DHD."},{"startTime":3545.665,"endTime":3548.165,"body":"And if you do that, you've got a 90% response."},{"startTime":3548.275,"endTime":3550.845,"body":"This is very specific for A DHD."},{"startTime":3552.035,"endTime":3556.045,"body":"Well, it can help in dementia actually, but don't spread the word too much."},{"startTime":3556.515,"endTime":3558.565,"body":"Otherwise, there'll be none left for the rest of us."},{"startTime":3559.425,"endTime":3568.21,"body":"Um, if you want to distinguish these conditions, can you, can you say that cognitive"},{"startTime":3568.21,"endTime":3571.725,"body":"disengagement always responds to stimulant medication?"},{"startTime":3571.725,"endTime":3576.019,"body":"Well, actually we don't know it does sometimes, but are those the cases that have"},{"startTime":3576.019,"endTime":3577.165,"body":"also got a DHD?"},{"startTime":3577.185,"endTime":3577.965,"body":"We don't know."},{"startTime":3578.595,"endTime":3581.725,"body":"It's the same story with deficient emotional self-regulation."},{"startTime":3581.795,"endTime":3587.07,"body":"Some people with filthy tempers hot temper as it used to be called, um, will"},{"startTime":3587.07,"endTime":3588.125,"body":"respond to medication."},{"startTime":3588.125,"endTime":3590.685,"body":"We don't know whether those are just the ones with A DHD or not."},{"startTime":3590.985,"endTime":3593.685,"body":"And I'm gonna say the same about, um, working memory deficit."},{"startTime":3594.035,"endTime":3595.925,"body":"Sometimes it responds, sometimes it doesn't."},{"startTime":3596.145,"endTime":3599.845,"body":"But do we know whether the ones that respond also have an A DHD picture?"},{"startTime":3600.365,"endTime":3602.165,"body":"Actually, current science, we don't know."},{"startTime":3602.905,"endTime":3606.469,"body":"So I dunno if any of those, and rejection sense of dysphoria is a rather"},{"startTime":3606.469,"endTime":3608.845,"body":"different picture because we just don't know enough about it."},{"startTime":3608.985,"endTime":3613.045,"body":"We don't know enough about its response to medication, let alone guanine."},{"startTime":3613.305,"endTime":3613.925,"body":"So we don't know."},{"startTime":3613.945,"endTime":3617.325,"body":"So I'm gonna suggest that we don't include any of those features."},{"startTime":3617.985,"endTime":3623.002,"body":"I'm reacting, I I'm going back to saying, look, you know, we're doing all right"},{"startTime":3623.002,"endTime":3627.685,"body":"so far, roughly speaking with what we've got as core features of A DHD."},{"startTime":3627.685,"endTime":3632.805,"body":"If we, even if we haven't got the description right, we only talk about behaviors."},{"startTime":3632.805,"endTime":3633.845,"body":"We're not talking about the experience."},{"startTime":3633.845,"endTime":3639.325,"body":"We've gotta build that in first before bolting on these other behavioral syndromes."},{"startTime":3639.985,"endTime":3646.435,"body":"Um, the, uh, thing about A DHD is it's very, very, very expensive money down"},{"startTime":3646.435,"endTime":3649.445,"body":"the drain if you don't treat it."},{"startTime":3649.825,"endTime":3654.685,"body":"Um, the reason it's expensive is the people with A DHD tend to underachieve academically."},{"startTime":3654.715,"endTime":3658.605,"body":"They need as children special academic special educational provision."},{"startTime":3659.015,"endTime":3661.605,"body":"Their productivity is low, their earnings are low."},{"startTime":3661.605,"endTime":3665.525,"body":"Elegant study by David Daley showing with a sibling comparison."},{"startTime":3665.585,"endTime":3670.925,"body":"The sibling with, um, A DHD was earning not 20 grand, less, uh, per annum."},{"startTime":3671.465,"endTime":3673.205,"body":"Uh, it's, it's no good."},{"startTime":3673.345,"endTime":3677.8,"body":"And we've heard a great deal about the claims on disability benefits, which I think"},{"startTime":3677.8,"endTime":3681.365,"body":"are overstated very hard to get API p, um, on A DHD."},{"startTime":3681.785,"endTime":3683.765,"body":"And the treatment costs are tiny, frankly."},{"startTime":3684.545,"endTime":3689.256,"body":"Uh, so this is mainly the cost to services and the one, it's, it amounts"},{"startTime":3689.256,"endTime":3689.885,"body":"to billions."},{"startTime":3690.565,"endTime":3692.845,"body":"I haven't got up to date figures for the uk."},{"startTime":3692.945,"endTime":3696.845,"body":"The last figures I saw were 15 years ago, and we've come a long way"},{"startTime":3696.845,"endTime":3697.365,"body":"since then."},{"startTime":3697.905,"endTime":3704.346,"body":"The figures for, uh, for the USA in the Chiba survey was, uh, 20 billion"},{"startTime":3704.346,"endTime":3705.205,"body":"a year."},{"startTime":3705.745,"endTime":3711.765,"body":"The cost of A DHD treated and untreated $20 billion, uh, a year."},{"startTime":3713.185,"endTime":3719.005,"body":"The example I want to refer to, um, is we know that one in four"},{"startTime":3719.005,"endTime":3722.885,"body":"prisoners, one in four people in prison have a DHD."},{"startTime":3723.155,"endTime":3724.165,"body":"They're all blokes."},{"startTime":3724.165,"endTime":3728.285,"body":"Of course, one in four have A DHD."},{"startTime":3729.105,"endTime":3735.38,"body":"We also know from two studies I've mentioned, the original study by Lichtenstein, uh, that"},{"startTime":3735.38,"endTime":3741.655,"body":"in, in Sweden, that people who are on medication on A DHD medication are 30"},{"startTime":3741.655,"endTime":3744.165,"body":"to 40% less likely to offend."},{"startTime":3745.785,"endTime":3751.175,"body":"So the cost of not taking prisoners and offenders seriously in terms of assessments for"},{"startTime":3751.175,"endTime":3756.565,"body":"A DHD and offering treatment 'cause it can only be offered, is actually very, very"},{"startTime":3756.565,"endTime":3756.925,"body":"expensive."},{"startTime":3757.445,"endTime":3762.845,"body":"'cause the, the total cost for the prison service in the UK is 3.8 billion"},{"startTime":3762.845,"endTime":3763.565,"body":"billion pounds."},{"startTime":3764.715,"endTime":3766.205,"body":"Very, very, very expensive."},{"startTime":3766.545,"endTime":3771.012,"body":"And the last point I want to make is about neurodiversity that a lot of"},{"startTime":3771.012,"endTime":3774.885,"body":"what I've been talking to you about, things going wrong with the brain."},{"startTime":3776.345,"endTime":3780.045,"body":"And that may or may not be the best way of understanding."},{"startTime":3780.155,"endTime":3784.285,"body":"It's a valid way of understanding whether it's the best way can be discussed."},{"startTime":3784.595,"endTime":3791.898,"body":"Because the people who will advocate for a neuro neurodiversity approach will point out that,"},{"startTime":3791.898,"endTime":3799.202,"body":"that over medicalize the problem and fails to take into account the way in which"},{"startTime":3799.202,"endTime":3806.505,"body":"society currently fails to provide a positive environmental experiences where the, where the man touches"},{"startTime":3806.505,"endTime":3811.375,"body":"the world, uh, that is what that's been to supply."},{"startTime":3811.375,"endTime":3817.187,"body":"So we don't focus on the brain so much, they would argue, but we do"},{"startTime":3817.187,"endTime":3823.0,"body":"need to promote ways in which social change and social adjustment can provide positive and"},{"startTime":3823.0,"endTime":3823.775,"body":"affirmative experiences."},{"startTime":3824.075,"endTime":3827.575,"body":"And we don't just go on rating scales and symptom reduction."},{"startTime":3828.695,"endTime":3830.415,"body":"I think that is a powerful argument."},{"startTime":3830.915,"endTime":3836.15,"body":"Uh, but I don't personally go as far as saying, well, that means we reject"},{"startTime":3836.15,"endTime":3841.385,"body":"the cure model because the A DHD diagnosis itself incorporates an idea of impairment and"},{"startTime":3841.385,"endTime":3841.735,"body":"disability."},{"startTime":3842.445,"endTime":3844.135,"body":"That is how the diagnosis is made."},{"startTime":3844.135,"endTime":3845.335,"body":"We've gotta do something about that."},{"startTime":3845.835,"endTime":3852.872,"body":"And the most effective way, uh, I think is to combine, uh, the medical approach"},{"startTime":3852.872,"endTime":3859.909,"body":"of, uh, taking, uh, an idea of a disorder and symptoms, uh, and ex alongside"},{"startTime":3859.909,"endTime":3862.255,"body":"that, uh, adjust life demands."},{"startTime":3862.435,"endTime":3867.61,"body":"We do this with children all the time and children's doctors treating A DHD pediatricians"},{"startTime":3867.61,"endTime":3872.785,"body":"and child psychiatrists all the time, uh, uh, writing, uh, suggestions for a modification of"},{"startTime":3872.785,"endTime":3877.615,"body":"exams, for example, to take into account the fact that somebody has a DHD."},{"startTime":3877.955,"endTime":3879.935,"body":"And that seems to be perfectly sensible."},{"startTime":3879.935,"endTime":3880.975,"body":"It's going on now."},{"startTime":3881.395,"endTime":3884.695,"body":"So I don't think it's a question that doctors just prescribe medicines."},{"startTime":3884.695,"endTime":3888.935,"body":"They don't, they try and modify the demands placed upon people."},{"startTime":3889.675,"endTime":3895.669,"body":"But I think in terms of research, uh, it's, uh, important that new treatments are"},{"startTime":3895.669,"endTime":3901.664,"body":"evaluated not just on rating scales, not just on the nine items on each list,"},{"startTime":3901.664,"endTime":3907.658,"body":"for example, that I started off with, but by looking at how research on a"},{"startTime":3907.658,"endTime":3911.655,"body":"new treatment can justify the provision of more positive experiences."},{"startTime":3912.835,"endTime":3919.85,"body":"So if I'm right about neuro university being a good step forward alongside the more"},{"startTime":3919.85,"endTime":3923.125,"body":"traditional medical approach, it should complement it."},{"startTime":3923.145,"endTime":3925.685,"body":"It should exist alongside, it should not replace it."},{"startTime":3925.985,"endTime":3932.916,"body":"But the most important step in, uh, promoting, uh, sympathy towards neurodiversity is to educate"},{"startTime":3932.916,"endTime":3934.765,"body":"everyone about A DHD."},{"startTime":3935.065,"endTime":3936.725,"body":"And I hope I've contributed that."},{"startTime":3936.725,"endTime":3937.485,"body":"Thank you very much."},{"startTime":3943.435,"endTime":3946.441,"body":"I've had so many questions that I'm definitely not going to be able to get"},{"startTime":3946.441,"endTime":3948.045,"body":"through all of them in the time available."},{"startTime":3948.145,"endTime":3951.696,"body":"So I'm going to try and persuade Peter to come back and answer some of"},{"startTime":3951.696,"endTime":3955.248,"body":"them on a podcast on another occasion so that we can give everybody a fair"},{"startTime":3955.248,"endTime":3955.485,"body":"chance."},{"startTime":3955.865,"endTime":3961.307,"body":"And I'm gonna group some of these questions together to try and get you to"},{"startTime":3961.307,"endTime":3963.485,"body":"sort of group your response too."},{"startTime":3963.865,"endTime":3969.658,"body":"So there are many, many, many about the complexity of diagnosis, starting with two primary"},{"startTime":3969.658,"endTime":3970.045,"body":"themes."},{"startTime":3970.425,"endTime":3975.241,"body":"One, it's bloody difficult to get the diagnosis because the service isn't good enough anymore,"},{"startTime":3975.241,"endTime":3976.205,"body":"particularly CAM services."},{"startTime":3976.595,"endTime":3977.405,"body":"It's the first one."},{"startTime":3977.865,"endTime":3985.583,"body":"The second is you made quite significant observations on detailed high quality scanning that there"},{"startTime":3985.583,"endTime":3993.301,"body":"may be potential abnormal if, how realistic is it to relate and expect appropriate scans"},{"startTime":3993.301,"endTime":3994.845,"body":"to be done?"},{"startTime":3995.265,"endTime":4000.753,"body":"And the third is because of the complexity of making this diagnosis in the way"},{"startTime":4000.753,"endTime":4001.485,"body":"you describe."},{"startTime":4002.385,"endTime":4007.951,"body":"Surely this is an opportunity for really robust data collection and the implications of AI"},{"startTime":4007.951,"endTime":4012.405,"body":"to manipulate those data sets to improve the accuracy of these techniques."},{"startTime":4014.185,"endTime":4015.445,"body":"Yes, \u003claugh\u003e,"},{"startTime":4016.325,"endTime":4017.045,"body":"I rest my case."},{"startTime":4017.865,"endTime":4022.492,"body":"Um, I think brain scanning is, uh, if I was talking about brain scanning 10"},{"startTime":4022.492,"endTime":4027.12,"body":"years ago, I'd be showing you pictures about how areas of the brain light up"},{"startTime":4027.12,"endTime":4031.747,"body":"or don't light up in people with A DHD without a DHD, that's much less"},{"startTime":4031.747,"endTime":4032.365,"body":"possible nowadays."},{"startTime":4033.185,"endTime":4038.36,"body":"Um, the, the problem is in the technique, uh, brain scans are deeply wonderful, but"},{"startTime":4038.36,"endTime":4042.845,"body":"they don't, they're not very good at controlling, for example, for head movement."},{"startTime":4043.275,"endTime":4044.005,"body":"They really aren't."},{"startTime":4044.545,"endTime":4048.571,"body":"And you know, by definition, children at any rate with A DHD, do quite a"},{"startTime":4048.571,"endTime":4049.645,"body":"bit of head movement."},{"startTime":4049.825,"endTime":4051.285,"body":"That's how they get the diagnosis."},{"startTime":4051.905,"endTime":4056.908,"body":"And so actually stabilizing the head is a very simple task, but it's only in"},{"startTime":4056.908,"endTime":4061.245,"body":"the last five years that people have developed techniques for really doing that."},{"startTime":4061.245,"endTime":4065.021,"body":"And when you do do that, you are up against the other problem, which is,"},{"startTime":4065.021,"endTime":4065.525,"body":"yeah, sure."},{"startTime":4065.705,"endTime":4069.57,"body":"You can show that areas of the brain light up or don't light up according"},{"startTime":4069.57,"endTime":4072.405,"body":"to the task of which task, which is the fundamental task."},{"startTime":4073.105,"endTime":4078.075,"body":"It used to be resisting the temptation to drop bombs on people when you had"},{"startTime":4078.075,"endTime":4083.045,"body":"control in the MRI, um, tunnel of an aircraft with a, a load of bombs."},{"startTime":4083.345,"endTime":4087.188,"body":"And small boys find it very difficult to resist the temptation to drop bombs on"},{"startTime":4087.188,"endTime":4087.445,"body":"people."},{"startTime":4088.065,"endTime":4090.325,"body":"Um, we are way beyond that now."},{"startTime":4090.325,"endTime":4095.51,"body":"We have much more cognitively challenging task, but I don't think we're anywhere near using,"},{"startTime":4095.51,"endTime":4100.005,"body":"uh, scanning as a diagnostic tool, partly because of the subtlety of changes."},{"startTime":4100.845,"endTime":4103.645,"body":"I didn't go into the detail, but it's very, they're very subtle changes."},{"startTime":4104.024,"endTime":4104.365,"body":"So let,"},{"startTime":4104.455,"endTime":4107.365,"body":"Let's, let's move you back to the service inadequacies."},{"startTime":4107.385,"endTime":4107.604,"body":"Oh,"},{"startTime":4107.604,"endTime":4107.765,"body":"Yeah."},{"startTime":4108.154,"endTime":4115.125,"body":"Well, um, what I'm advocating is detailed assessment, which is incredibly expensive."},{"startTime":4115.984,"endTime":4120.991,"body":"Um, I've forgotten, does anyone know what the Wardley adult A DHD clinic are currently"},{"startTime":4120.991,"endTime":4121.325,"body":"charging?"},{"startTime":4122.305,"endTime":4125.165,"body":"Um, it's, I mean, that's not a private service."},{"startTime":4125.274,"endTime":4129.78,"body":"They charge other parts of the NHS, but I mean, it, it used to be"},{"startTime":4129.78,"endTime":4132.484,"body":"we we're pushing at sort of tens of thousands."},{"startTime":4132.484,"endTime":4136.005,"body":"So if you're really, really gonna do it properly, it's very expensive."},{"startTime":4136.984,"endTime":4139.165,"body":"Um, uh, is that justified?"},{"startTime":4139.475,"endTime":4141.444,"body":"Well, yes, it is, but not politically."},{"startTime":4141.524,"endTime":4143.005,"body":"I don't think we're ever gonna get there."},{"startTime":4143.125,"endTime":4144.805,"body":"I don't think there's enough political sympathy."},{"startTime":4145.305,"endTime":4149.592,"body":"Um, while there are articles in the Times saying things don't exist, uh, I don't"},{"startTime":4149.592,"endTime":4152.165,"body":"think we've got that, but I think we should."},{"startTime":4152.325,"endTime":4156.005,"body":"I I think it's, it's improper to do superficial assessments."},{"startTime":4156.265,"endTime":4157.725,"body":"And you had another interesting question."},{"startTime":4157.725,"endTime":4158.564,"body":"I've forgotten what it was."},{"startTime":4158.785,"endTime":4164.052,"body":"Of the, because of the, the large quantity of data that's required in order to"},{"startTime":4164.052,"endTime":4164.404,"body":"Yeah."},{"startTime":4164.404,"endTime":4165.484,"body":"Disentangle all of this."},{"startTime":4165.484,"endTime":4165.965,"body":"Yeah, yeah, yeah."},{"startTime":4165.984,"endTime":4167.845,"body":"Is this an opportunity for without doubt building"},{"startTime":4168.515,"endTime":4169.325,"body":"High quality data?"},{"startTime":4169.564,"endTime":4169.885,"body":"Absolutely, without doubt."},{"startTime":4169.955,"endTime":4174.386,"body":"Because I was in a meeting last week actually, where we were discussing just that,"},{"startTime":4174.386,"endTime":4177.045,"body":"that, uh, there is an AI program being developed."},{"startTime":4179.005,"endTime":4184.632,"body":"I think it's by Microsoft, um, to do just that, to, to do medical assessment"},{"startTime":4184.632,"endTime":4189.885,"body":"interviews for A DHD using, um, their version of AI that is being developed."},{"startTime":4189.944,"endTime":4190.165,"body":"Now,"},{"startTime":4191.375,"endTime":4193.805,"body":"Let's take one or two questions from the floor, if there are any."},{"startTime":4194.665,"endTime":4199.685,"body":"You mentioned, uh, self diagnosis, you know, as, uh, being problematic."},{"startTime":4200.585,"endTime":4206.162,"body":"But, you know, there's a, there's a lot of waiting, there's very long waiting times"},{"startTime":4206.162,"endTime":4208.765,"body":"now for, uh, to, to be assessed."},{"startTime":4208.825,"endTime":4209.045,"body":"Yep."},{"startTime":4209.145,"endTime":4214.526,"body":"For A DHD along with autism and other, you know, uh, other, you know, neurodiverse"},{"startTime":4214.526,"endTime":4214.885,"body":"conditions."},{"startTime":4215.175,"endTime":4220.947,"body":"Might that not contribute in some way to people tending towards self-diagnosis rather than waiting"},{"startTime":4220.947,"endTime":4225.565,"body":"as long as they have to do to get it confirmed properly?"},{"startTime":4226.075,"endTime":4228.365,"body":"Without doubt, without doubt."},{"startTime":4228.785,"endTime":4236.035,"body":"Um, the difficulty with self-diagnosis is that it's, I think it's appropriate, um, as a"},{"startTime":4236.035,"endTime":4237.485,"body":"way of self-identification."},{"startTime":4237.905,"endTime":4242.244,"body":"You know, it is possible that I have this condition or that condition, but I"},{"startTime":4242.244,"endTime":4246.583,"body":"mean, most of us who've Googled the pain in our knee, uh, or the sensation"},{"startTime":4246.583,"endTime":4249.765,"body":"we have in our head, find that there are numerous explanations."},{"startTime":4249.985,"endTime":4251.925,"body":"And I think it does need professional judgment."},{"startTime":4252.165,"endTime":4255.445,"body":"I do think it, I really do think it needs face-to-face judgment."},{"startTime":4256.305,"endTime":4260.605,"body":"Um, but it's entirely understandable that people will self record, self-diagnose."},{"startTime":4260.665,"endTime":4261.605,"body":"Of course they will."},{"startTime":4262.265,"endTime":4263.445,"body":"Um, I do it myself."},{"startTime":4264.225,"endTime":4267.541,"body":"Um, I'm not sure how good I am at it, but I, I do it"},{"startTime":4267.541,"endTime":4268.205,"body":"all the time."},{"startTime":4268.385,"endTime":4269.725,"body":"Oh, you know, one does"},{"startTime":4270.645,"endTime":4274.399,"body":"I, I know there's probably a whole separate talk you could do about treatment, but,"},{"startTime":4274.399,"endTime":4278.153,"body":"um, are there any newer treatments that are coming out in the fringes that are"},{"startTime":4278.153,"endTime":4279.405,"body":"particularly exciting for A DHD?"},{"startTime":4281.475,"endTime":4282.685,"body":"Well, yes and no."},{"startTime":4283.105,"endTime":4286.965,"body":"Um, of course there are new treatments, but they're up against it."},{"startTime":4287.285,"endTime":4292.885,"body":"I mean, the 92% symptom change figure is a card one to beat."},{"startTime":4293.105,"endTime":4294.765,"body":"But I mean, you, we must have that."},{"startTime":4294.885,"endTime":4296.685,"body":"I mean, treatment isn't just about pills."},{"startTime":4296.965,"endTime":4298.005,"body":"I mean, that can't be true."},{"startTime":4298.625,"endTime":4300.965,"body":"It always must involve a psychological component."},{"startTime":4300.985,"endTime":4305.863,"body":"It must always involve a lifestyle advice component that is, that just has to be"},{"startTime":4305.863,"endTime":4307.165,"body":"morally the right way."},{"startTime":4307.725,"endTime":4314.016,"body":"I think the newer treatments, uh, are largely involved in taking peripheral nerves and sending,"},{"startTime":4314.016,"endTime":4320.307,"body":"uh, sending signals up there on trigeminal nerve or older nerve, uh, to see if"},{"startTime":4320.307,"endTime":4322.405,"body":"that will alter brain functioning."},{"startTime":4322.505,"endTime":4325.405,"body":"And there're encouraging signs there, but they're not yet treatments."},{"startTime":4326.205,"endTime":4332.305,"body":"I think the other area that has been a lot of interest in is, um,"},{"startTime":4332.305,"endTime":4338.405,"body":"neurofeedback treatments where, for example, the brain's electrical activity can be modified by certain tasks."},{"startTime":4339.105,"endTime":4343.245,"body":"And, uh, Kaia Rubio, whom I mentioned earlier, was very involved with that."},{"startTime":4343.245,"endTime":4345.925,"body":"The results so far have not been that encouraging."},{"startTime":4345.925,"endTime":4348.925,"body":"There is a response, but it's not enormous."},{"startTime":4349.385,"endTime":4353.411,"body":"And, uh, so yeah, no, people are very keen to find that because you can't"},{"startTime":4353.411,"endTime":4356.365,"body":"just give pills to everybody with A DHD, that's not right."},{"startTime":4356.945,"endTime":4360.205,"body":"Um, it's gotta be pills plus, or it may not be pills at all."},{"startTime":4360.265,"endTime":4362.165,"body":"You know, we've gotta find other ways of doing it."},{"startTime":4362.165,"endTime":4369.098,"body":"But so far, the sort of psychological treatment methods usually based on CBT only really"},{"startTime":4369.098,"endTime":4370.485,"body":"apply to adults."},{"startTime":4370.755,"endTime":4375.883,"body":"Whereas, um, children and, uh, young people are still very commonly involved and they don't"},{"startTime":4375.883,"endTime":4379.645,"body":"always want to have the patience to do CBT type work."},{"startTime":4379.945,"endTime":4382.165,"body":"So yeah, there's psychological stuff that's still to be done."},{"startTime":4382.295,"endTime":4384.365,"body":"There is neurological stuff to be done."},{"startTime":4384.555,"endTime":4388.726,"body":"There's, uh, bio biofeedback stuff to be done, and people are very keen to pursue"},{"startTime":4388.726,"endTime":4389.005,"body":"that."},{"startTime":4390.225,"endTime":4394.564,"body":"I'm really sorry, we've only got time for one more question, which is this lady"},{"startTime":4394.564,"endTime":4398.325,"body":"over here has been waiting for a while and, um, don't forget that."},{"startTime":4398.325,"endTime":4400.485,"body":"Please send in your questions through the Slido."},{"startTime":4400.585,"endTime":4404.045,"body":"We will try and get them answered later on."},{"startTime":4404.425,"endTime":4406.925,"body":"It was really just a follow up to that last question."},{"startTime":4407.145,"endTime":4412.893,"body":"So both relatives and friends who have been diagnosed with A DHD and who have"},{"startTime":4412.893,"endTime":4418.642,"body":"medication and say that the medication is in fact extremely effective if they need to"},{"startTime":4418.642,"endTime":4424.391,"body":"settle down and do a task, really dislike the medicine because they feel that it"},{"startTime":4424.391,"endTime":4425.925,"body":"makes them not themselves."},{"startTime":4425.955,"endTime":4431.765,"body":"There's a real, um, mental disbe to taking the medicine."},{"startTime":4431.765,"endTime":4436.669,"body":"And I wondered if you could just speak a little bit more about how that"},{"startTime":4436.669,"endTime":4441.573,"body":"tension presents itself in people with A DHD, especially, I think in women, that, that"},{"startTime":4441.573,"endTime":4446.477,"body":"that anger and frustration is, from what I understand, often turned internally, and there's a"},{"startTime":4446.477,"endTime":4451.381,"body":"high correlation with all sorts of self harm that comes with a lot of people,"},{"startTime":4451.381,"endTime":4456.285,"body":"females especially who have a DHD that might be anecdotal, just in my personal experience."},{"startTime":4456.875,"endTime":4457.165,"body":"Yeah."},{"startTime":4457.365,"endTime":4463.223,"body":"I, I've never seen, um, self-harm promoted by A DHD medication, but I certainly have"},{"startTime":4463.223,"endTime":4464.005,"body":"seen social,"},{"startTime":4464.375,"endTime":4467.405,"body":"Sorry, I didn't mean that the, uh, self-harm was caused by medication."},{"startTime":4467.875,"endTime":4471.445,"body":"What I was saying was that A DHD, because it correlates with depression."},{"startTime":4471.505,"endTime":4471.725,"body":"Yes."},{"startTime":4471.785,"endTime":4473.605,"body":"And anger is very often turned internally."},{"startTime":4473.745,"endTime":4474.245,"body":"That's true."},{"startTime":4474.245,"endTime":4478.745,"body":"And then in girls, it can manifest in ways that, that violence may be some"},{"startTime":4478.745,"endTime":4480.245,"body":"concerns internally rather than external."},{"startTime":4480.525,"endTime":4482.365,"body":"Absolutely, yes, without doubt."},{"startTime":4482.785,"endTime":4486.125,"body":"Um, and the coexistence with depression is an extremely important one."},{"startTime":4486.545,"endTime":4490.885,"body":"Uh, they're one or two prominent people who've described their own experiences in that area."},{"startTime":4491.405,"endTime":4495.131,"body":"I think that one of the problems with a DHD medicine is, is you've gotta"},{"startTime":4495.131,"endTime":4496.125,"body":"find the right one."},{"startTime":4496.905,"endTime":4503.25,"body":"For example, feeling of socially social disconnection and social discomfort is not uncommon with teenagers"},{"startTime":4503.25,"endTime":4505.365,"body":"and adults who take methylphenidate."},{"startTime":4505.545,"endTime":4509.485,"body":"But it's very uncommon that people who take dexa, Liz Dexamphetamine."},{"startTime":4510.425,"endTime":4514.872,"body":"So, you know, if I have a young person who is saying, I don't like"},{"startTime":4514.872,"endTime":4517.245,"body":"the meds, they make me feel socially awkward."},{"startTime":4517.245,"endTime":4520.085,"body":"They make me feel disconnected, they make me feel not really involved."},{"startTime":4520.245,"endTime":4521.165,"body":"I don't want to talk to people."},{"startTime":4521.285,"endTime":4525.445,"body":"I switch them across to Liz Dexamphetamine pretty quickly if I can."},{"startTime":4525.985,"endTime":4530.165,"body":"And usually not always, usually they find that much more comfortable."},{"startTime":4530.165,"endTime":4534.171,"body":"So it's a question of finding the right medicine, but, uh, by and large, most"},{"startTime":4534.171,"endTime":4538.177,"body":"people are still taking methyl pholate, which is good, good stuff, but it doesn't suit"},{"startTime":4538.177,"endTime":4538.445,"body":"everybody."},{"startTime":4538.625,"endTime":4544.061,"body":"And it's, it's, again, it's find, it's the heterogeneity, it's the difference, the diversity within"},{"startTime":4544.061,"endTime":4547.685,"body":"the A DHD people, uh, that one has to explore."},{"startTime":4548.755,"endTime":4551.605,"body":"Look, ladies and gentlemen, it's been, um, so many questions."},{"startTime":4551.885,"endTime":4553.085,"body":"I mean so many more to answer."},{"startTime":4553.085,"endTime":4555.965,"body":"And I'm really sorry we haven't been able to get through them this evening."},{"startTime":4556.905,"endTime":4558.845,"body":"Um, professor Peter Hill, thank you very much."}]}