#08 - Nicole Ennis-Oakes - ADHD, Attention and the Nervous System: What We Get Wrong Artwork

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#08 - Nicole Ennis-Oakes - ADHD, Attention and the Nervous System: What We Get Wrong

December 30, 2025 • Eddie Jones

0:00 | 1:11:36

In this episode of The Applied Mind, I’m joined by Nicole Ennis-Oakes, clinical psychologist and Director of Neuronexus to unpack ADHD without the hype, oversimplification or misinformation.

We break down what ADHD actually is — and what it isn’t — exploring common misconceptions, why the condition is so often misunderstood and how it can profoundly impact attention, relationships, emotion regulation, identity and daily functioning across the lifespan.

Nicole brings a grounded, clinical lens to diagnosis and assessment, discusses why accurate profiling matters and explains how thoughtful planning and support can genuinely improve quality of life for neurodivergent individuals. We also touch on the broader neurodiversity framework, overlapping presentations and why “one-size-fits-all” approaches consistently miss the mark.

This conversation is for anyone who:

Has ADHD or suspects they might
Supports someone with ADHD
Feels confused by conflicting information online
Wants a clearer, evidence-based understanding of neurodiversity

No shortcuts. No buzzwords. Just clear psychology applied to real life.

Enjoy!

If you are interested in learning more - check out the following links!

https://www.healthdirect.gov.au/attention-deficit-disorder-add-or-adhd

https://www.psychiatry.org/patients-families/adhd/what-is-adhd

SPEAKER_01 0:00

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SPEAKER_00 0:46

Yeah. Go for it. Alright. Nicole, welcome to the show. Thank you, Ed. Been looking forward to it.

SPEAKER_01 0:53

Yeah. So uh for those that are listening, this is gonna be kind of a two-episode um series, if you will, and we're gonna do ADHD and autism. Um today we're gonna be talking about ADHD. So before we jump into that, can you just give us a bit of an overview as to who you are, how you got here, what your experience is?

SPEAKER_02 1:17

Yeah, so basically um I started out working in organizations. So I was doing not as an organizational psychologist, but as a management consultant, um, working with leadership and culture in corporate teams. I really enjoyed that. And then I'd always wanted to do psychology. I had started it when I left school, but I also wanted to travel and go overseas and have fun. So um applying myself at that age probably, you know, I found a bit difficult. And so um, yeah, I realized when I was probably in my early 30s as a management consultant that I'd be pretty limited unless I went and did a um yeah, undergrad at least degree, which was the original plan to become um an organizational psych. And then I just didn't stop there. And I went on to do my honours and then started practicing as a provisional psychologist and got into the area of neurodevelopmental disorders, which I absolutely loved, because it covers all areas of psychology. Um, and I like the variety and the ability to kind of um go in and do deep dives across a number of different things rather than just sort of staying focused, um, I guess on one thing like anxiety or whatever, you know. I I I believe very much in being an a really like knowing as much as you possibly can and being really good at what you do. Um, but there's so much of that to to cover in neurodevelopmental um differences, and that's what I what I loved about it. And so I've been doing that pretty much from day dot um and moved up to the coast, and then I've worked in pediatric-only clinics, and then for the last um five years I opened up um a clinic of my own focusing purely on neurodivergence. So, and neurodivergence across the lifespan. So, not only, you know, in pediatrics, but then um the transformation into young adulthood and um right through middle age up to old age now. So, and understanding how I guess those neurodevelopmental differences impact individuals depending upon what age they are, what what their individual goals and and unique um interests are, and how their differences of the differences in how they're wired impacts their ability to be able to function in certain environments and um achieve those things that they need to on a daily basis, but also those things that they want to.

SPEAKER_01 4:03

And so what is it that you do kind of day-to-day now in your clinic mostly?

SPEAKER_02 4:09

So mostly what we're doing is we've moved into an area called neuroprofiling. So one of the things that we've learned in the past, um, I mean, and this has been an ongoing, really an ongoing um thing since I first got into neurodevelopmental disorders, was the fact that um there was in Australia, we don't really operate necessarily. Well, the clinics out there, in my experience, at least, you know, which is only to be fair on the New South Wales Central Coast, which is not, you know, across the board, I I wouldn't be able to generalise that across the board, but even so, like in looking for supervision, you know, from anywhere in the country, um, we're not necessarily advanced when it comes to understanding neurodevelopmental differences. And um in the past 10 years in particular, there's been a huge amount of research that's gone into that area and the the um the landscape has changed a great deal. And so we are focused over at Neuronexus now on neuroprofiling. So rather than being able to take any particular person and putting them into a group, which is how most studies are done, you know, you take a um like a um a population of people that are affected by, say, for example, autism, and say, okay, they're they're they're more of a um uh a group where they've got similar features per se. And so we'll run um an intervention and we'll see whether or not you know that has an impact, a positive impact on that population as opposed to or compared to a population that does not, that is not impacted, um, for example. Um and essentially it's not really a fair way or a or a way of looking at it that's going to be particularly useful to those individuals because being such a spectrum of disorders within that one group, the variance is huge in terms of how it how those wherever it is, whatever features of of themselves of or of their wiring are affected by the autism, for example. I mean ADHD is also neurodivergence, but you know, our focus has primarily been on autism and ADHD affects about up to 75% of that population as a co-occurring condition. Um, that we've got to look at them individually, that it's of of no use to uh cluster them together and make assumptions based upon that, because um we the interventions, the support, they uh they don't work. It's not an effective way of doing it. So neuroprofiling is is understanding each unique individual and looking at uh well what uh what is their neurodevelopmental difference? Um, because the first thing which has been difficult is getting the correct diagnosis or identification in the first place. That can take people years to find someone who can actually give them an answer to what is actually going on in the first place. And many of them have been treated for a number of years for not the problem. So identifying the problem accurately, but then more importantly, then being able to go into that and identifying, well, what features specifically are impacting this person. Because you know, just because somebody has a difference doesn't mean it's a it's not a disability, it's it's a it's a difference. Uh disability generally comes in where there's a mismatch between that neurology and the environment that that person needs to um function within. And so we're interested in in giving a person that map, that that I guess, control, you know, the controls to how they're wired, so then they can navigate to where they want to go based upon that knowledge.

SPEAKER_01 8:26

And so kind of current practice is very neuro-affirming, strength-based, positive outlook, if you will. There's a conversation happening now as to this is you know good practice in terms of harm prevention and being positive for the client's sake. But how important is it to have a full picture as to what the diagnosis actually entails? And so, you know, when you're diagnosing someone with ADHD or autism, you want to be strength-based, focused as to this is what they're good at. But say, for example, if you're diagnosing a child and you're doing some education with parents, how important is it to really kind of discuss the challenges that they might face?

SPEAKER_02 9:14

Very so strength-based is really like what that means is yeah, I see that as really a part of neuroaffirming and and it's the opposite to what we used to focus on. And we still do, like when we identify a person, say with autism, um, for the NDIS, um we there is nothing strength-based in the reports that we've been writing to date. There is now an allowance in the the plan from you know, the government plan from 2025 to 2031 that that those um reports will be more neuroaffirming. But the the requirement is for the diagnostician, which is often either a clinical psychologist or a psychiatrist, although that's quite rare that a psychiatrist will do a diagnosis for autism per se. They're far more prevalent and likely to be doing ADHD diagnoses. Um, but essentially otherwise it's a multidisciplinary team, so a registered psychologist andor um a speech pathologist who um will do those. And the idea is to highlight the deficits, to highlight the challenges, uh, because that's what the funding is for, essentially. And so when we look at now a neuroaffirming or a strengths-based approach, it's about not only looking at the challenges, because it's important to look at those challenges because those are the areas that um these individuals are often held back from. You know, they're they're held back by those challenges because of the environments that they are forced to be in. And um, you know, children in school, for example, is just a perfect example of that. Um, you know, that's quite the assault to many autistic neurologies. Looking at, hey, this isn't not, this isn't a problem that we want to fix. This is a person who's put together perfectly, and we're trying to put them into an environment that is not matched to that neurology. Anybody when they're put in an environment that's not matched to their neurology, in other words, they might be either in pain or too hot or too cold or um, you know, there's too much light or too much noise, they don't, you know, they're there something's too tight on them, they're uncomfortable or whatever. That person's not going to function as well as they might if they weren't in that environment. And if they are functioning well in that environment, it's likely going to be costing them a lot more of their energy to be able to maintain that, you know, that appearance or that what appears to be, yeah, calmness on the surface. It's it they're they're burning energy at a at twice the rate of the other person, you know, for for want of a better term.

SPEAKER_01 12:08

Kind of focusing on ADHD for today, in layman's terms, what is ADHD? How does it present in younger populations, if you will?

SPEAKER_02 12:16

So ADHD is a very real condition. There's been a lot of questions over the years as to whether or not, you know, it's um it actually exists. It definitely does. You know, when you when uh an EEG is done, um you can see the different brainwaves happening in a person with ADHD versus a person without it. And ADHD essentially is an individual who struggles to do a number of things, but they all pertain to the area of executive functioning. So being able to focus and maintain concentration on something that perhaps is not particularly compelling for them or interesting. So as a general rule, a person with ADHD is able to maintain focus on something that really interests them. In fact, they can hyperfocus on that, you know, become highly engaged in it. Um in in and be very difficult to get their attention to play, you know, to attend to something else. Um, but they find it as a general rule difficult. So, like sitting in university, if you you're doing a topic that you're really not overly invested in, or if you're in a position in the room or whatever where you know you're not getting enough sensory input, um, because there are sensory processing differences in ADHD as well, then you're gonna find it very difficult to maintain attention. So being able to get the information into your brain in the first place, so into your short-term working memory is going to be more challenging. You know, when we look at the the dopamine theory of ADHD, that is because um there are fluctuating levels of dopamine that a person has with ADHD. So there's not enough typically. So, you know, that does not enable them to maintain focus and attention for any length of time. There is often differences in short-term working memory as well. So the capacity of the working memory can be somewhat smaller, and the ability to download information from the working memory can also be impacted. So that can be slower per se. But essentially, it takes seven or so days for us to consolidate a memory. And so when we learn something new and novel, we need to be able to maintain that information long enough for it to be processed through the hippocampus into a memory, and so that can be something that is impacted in ADHD, and certainly inhibition, so control of impulse that that is quite impacted in ADHD. So the ability to be able to stop myself from doing something that I want straight away, but that I need to discipline myself to do a bit later, you know. So what they call set shifting, so being able to focus from move from one task to another can be impacted as well. So if I'm in a situation where I'm working and then I've got to then stop and then shift my attention to something else, that can also be impacted. And then my communication can also be impacted as well, primarily because I'm not necessarily stopping and thinking fully about what I'm saying before it might come out of my mouth, you know. And I could be highly energized and looking for a dopamine high. You know, you often hear people say, oh, he's out there looking for a, you know, for a dopamine high. And that's because people think that that dopamine is this the happiness, I guess, um chemical, chemical or neurotransmitter, but in fact it's the novelty chemical. So dopamine is about novelty. It enables us, we're we're interested in seeking something that that um gives us a thrill because it's novel. Um and that's that's why when we're low in dopamine, we tend to not be overly um, you know, we might not, we might be inattentive, so it can impact sort of like I'm not really focusing on anything, I'm just kind of off with the fairies in my own world, or I'm looking for that high, so I'm seeking that um dopamine input because I love the feeling I get, you know, when I do something that's quite novel and unique and new and it doesn't bore me. Yeah. So if I've got ADHD, I'm quite intolerant to boredom.

SPEAKER_01 16:56

Yeah. A pretty common misconception, especially a few years ago, was ADHD was the kids that were bouncing off the walls or they were troublemakers in school. And I think that there's that one kind of segment of ADHD, the the hyperactive impulsive, that everyone kind of somewhat knows. But then we've got all these other categories of ADHD that no one knows. And yeah, I think the other misconception was ADHD goes away as you grow up. I think the the stat was 50 to 66% of people will still s show symptoms throughout their lifetime. You know, how much would be higher if masking was not really a thing anyway?

SPEAKER_02 17:39

Just in in terms of what you're saying there, you know, like you're right in that it does show up in many different ways. So the person who struggles to be organized and sequence things, so plan, sequence, um, keep time, keep to time. There's there can be that time blindness. Um, so there's so many things that, you know, can can ADHD impacts. In fact, I would consider it to be a very impairing condition to have, you know, difference to have in this day and age, you know, in terms of how much we're meant to fit into a day, how much we need to organise our things and our time and and achieve, it's quite, it's quite um, it's when it shows up, you know, when there's so many things a person can with ADHD might be able to cope with a certain load of work expectations or activities in a day as part of their role in life, you know, both from an occupational perspective, but in in as a friend, as a as a parent, as a as a you know, a uni student or whatever whatever role it is that you're in, there is more and more expected of what we should be achieving, you know, that benchmark continues to increase. And once I guess, you know, the difference is ADHD is per se will will kind of peak at at a much lower level, you know. So it's like once they reach that threshold of, hey, I can only manage this must much in a day, yeah, right. And once it's it starts to exceed that, then they can run into problems as opposed to the person who can multitask and swap between those tasks and manage their time and you know, see the big picture and then backward plan, you know, sequence things all the way down to the detail. Um so there are those, those factors there that, you know, that come into consideration. But probably over the years, I guess the most frustrating thing that we see in particular in pediatrics are parents who will come into the clinic with a very fixed view on medication per se. And it's not necessarily a fixed view on medication because they're not parents who necessarily have a problem administering medication. So if their child had a headache or if they had diabetes or some kind of heart condition or something, there would be no problem administering medication in that sense. But because it's a medication for the brain, often it's associated with their own experiences in school. We can come across quite blocked viewpoints of how effective medication is, whether or not, you know, they they believe that their child requires that medication. And the frustrating part is always is the evidence base that they have have decided made those decisions on.

SPEAKER_01 20:56

What are some of the concerns that they have?

SPEAKER_02 20:59

So particularly people who were in school in the 70s, 80s, 90s, even up to the early 2000s, where often, you know, it would be that the naughty kids were the ones that were diagnosed with ADHD. And and it would be, oh yes, you know, like Bob or whomever he's been diagnosed with ADHD, and he's on Rittleum or he's on medication for that, you know. And but we wouldn't see any difference in his behaviours, you know, he it there was still these disruptive behaviours. There was like there were still things that we could observe in the playground or in the classroom or whatever that you know he was doing that the medication really didn't seem to work. And then that person in their experience may have gone on to um, you know, be unemployed or or be, you know, some kind of delinquent or criminal or something like that, or otherwise, you know, just was unsuccessful generally. And so the the feeling was, yeah, well, you know, that the medication didn't work. Um, he was given, you know, he was stigmatized because of it. So, you know, everyone knew that he was on medication and it was ADHD, and so everything that he did was attributed to that, and it didn't, it wasn't of any use, so I don't want that for my for my child. So the intention is coming from a very protective, positive place, except that the questions around the validity and accuracy of that information that that hasn't occurred, you know, it's just been accepted that he did have ADHD, that he was on medication and that the medication did not work. Um, and then as a result of that, the outcomes that that person experienced in their life was due to both the stigmatization and um the ADHD and the fact that, you know, the medication was not effective. And of course, there's nothing evidence-based about that. There are many, many questions when we go back and we think, well, that was our our formulation from you know childhood for starters, but we we we don't really know what his condition was. We we don't know whether or not he had early childhood trauma, whether or not there were parental issues at home, whether or not it was autism or some other condition, um, whether or not you know there were other learning disorders and factors there that you know hadn't been taken into consideration a chromosomal abnormality, any of those factors. We certainly have no evidence that he was actually diagnosed with just ADHD and that he was administered an ADHD medication, and then that after observation that medication didn't work. There's absolutely no evidence behind our belief that, you know, we would have no idea, the most of us about that, what happened in the mornings and and you know what happened at home and what observations were made about that that particular individual. So therefore we have no way of knowing why they wound up where they did. You know, it could be uh a lower like lower cognitive abilities. Um we just really have no idea, but we make these assumptions based upon what we think are good hard facts. But when you actually look at them, there is nothing factual about the information that we've based, this conclusion that ADHD medication is not a good thing. It actually flies in in face of the evidence, which is very much about medication. Some, you know, some out there, um uh Dr. Russell Barclay, you know, will be very who's world-renowned expert in the field of ADHD and has been for many, many, many years been quite vocal about the fact ADHD is primarily treated by medication and that unless the individual is medicated for their ADHD, then environmentally based or or psychotherapy-based interventions are limited in their effectiveness. Russell Barclays, Dr. Russell Barclay's terms is people with ADHD know what they need to do. So going in and being told what they need to do in terms of keep to time, you know, put a timer, um, you know, uh set an alarm, keep an organizer, they know those things, right? ADHD is actually a problem with being able to do what you know. And the issue there is dopamine. By increasing the level of dopamine, it increases a person's ability to focus and concentrate, stop and think, plan and organize. So it it lights up that executive functioning system. So, in essence, if you think of it as a car, it's like, you know, you're running a four-cylinder car, but there's some kind of problem in the, you know, in the engine somewhere and not enough fuel is is getting through, you know, to activate all the cylinders. So it's kind of running on, you know, maybe two cylinders. So the the hardware's there, and there's actually, you know, it works, but there's a blockage or there's a there's there's just a a cause and and the causes of well, why isn't this person supposed, you know, you just focusing on that dopamine theory. Why why is it that they're not producing enough of that?

SPEAKER_01 26:19

It's not the it's not the driver, it's the system.

SPEAKER_02 26:22

Yeah, that's exactly right. And so when they are provided with enough dopamine, then the system works. So it's you know, whereas in if you look at somebody with um, say, an intellectual disability, the the underlying neurology is is is different. So it wouldn't matter how much um education, for example, or dopamine you give that individual, that the neurology is not there for them to function at a higher level. Um, and so with ADHD, it most certainly is in some cases, you know, we can see a difference on cognitive assessments alone. Um, when we test a child with ADHD uh when they are medicated versus when they are not medicated. And this is in a one-to-one environment. Um, in a testing room, we can see a uh an IQ point difference of up to 20. Yeah.

SPEAKER_01 27:19

Wow.

SPEAKER_02 27:19

So it's quite significant, you know, when, yeah, and and therefore in a learning environment in particular, it impacts working memory and executive functioning, you know. And you can sometimes see it's not diagnostically, we don't, we don't base any diagnosis on it, but often you will see this pattern of um a higher general intellect with lower cognitive proficiency around um working memory and and processing speed. So what it essentially means is that the the general intellect is there, but the ability, I guess, to access, utilise, and learn is lowered because of the ADHD. And then the more interference you add into that individual's environment, so when we test and we test a child who is not medicated, and we see a cognitive difference between their general intellect, so their verbal and perceptual reasoning, so their, I guess their their um image or their their picture um uh language and learning. So they're the two general ways, you know, that we measure intellect, um, our visual and our our um verbal intellect. And then we look at, well, then how well do we use and access those two intellectual domains? It's the ADHD impacts the efficiency and speed of that and accuracy as well. That little person is not absorbing as much in that environment, and the more interference we throw into that, what we would see that may well be impacted in from a one-on-one assessment will generally be far worse in a classroom environment where there's so many more competing elements in the environment for that little person or big person to pay attention to.

SPEAKER_01 29:12

Yeah, definitely. I think especially with the younger kids as well, it's like you're getting the symptom presentation from you know you're getting three or four inputs, so you're getting parents' views and then you're getting teachers' views and whatnot. But then how do you generalize the symptoms when they're going into school and there's you know, three or four different variables that are contributing to that? And then their presentation at home is completely different.

SPEAKER_02 29:37

So well technically, well, yes and no. Um ADHD, you kind of take that with you everywhere. Autism is you can get a completely different like people sometimes say it's like Jekyll and Hyde, you know. ADHD to a far, far lesser degree, you know, you don't if you're inattentive and you're a bit of a, you know, live a daydreamer, and and in the past, girls uh who, you know, whole a whole or generations of girls have presented with inattentive ADHD have been undiagnosed because they're quiet, you know, they're off there like thinking about other things. And yeah, you know, so um I think certainly when a little person goes in, so somebody who's quite hyperactive um and and impulsive goes into the classroom, you know, they can get riled up and and you'll see you'll see the behaviours because they're spinning and they're climbing and they're moving and they're talking and doing basically everything because they're they're not entertained by what's happening in front of them. They can't maintain focus and concentration.

SPEAKER_01 30:43

And remembering the same at home as they will be at school then.

SPEAKER_02 30:46

Yeah, so it's like at school it's going to show up because they're primarily at school to learn. So it's going to be really obvious if they can't sit down and if they're not following the instructions at home, they might be given more of a free reign. Yeah. So they're running around, they're playing on swings and that sort of stuff. But the hyperactivity itself will be there.

SPEAKER_01 31:06

Yeah. It's just you know it's just in the environment, it's more accepted. Yeah.

SPEAKER_02 31:10

Yeah, correct. You know, and and it's how that behavior's interpreted. As as a person moves into adulthood, um, that hyperactivity that existed when they were younger can often just move into their brain. So they're thinking about a thousand things, you know. And they're not spinning around, running around in a shopping center, you know, yeah, driving everybody crazy. But they they might be the busiest person, so they've got to be doing something all the time. And that can be translated actually into something really positive. They're people that just get stuff done. Um, but you know, when we if we were to talk about the the impact of that in relationships, yeah, it it's not it doesn't always end well. Um, you know, those type of people can be quite um frustrating to someone who just wants to sit back and relax.

SPEAKER_03 31:58

Yeah.

SPEAKER_02 31:59

Um, and then, you know, when we we looked, you mentioned earlier about, you know, well, what do do people or do little people with ADHD become big people with ADHD? And and yeah, I think about 66% of the of the time they they do not grow out of their ADHD. Um, and they become big people with either inattentive combined or hyperactive ADHD. And it's just as devastating at each level of life that they go through in terms of its outcome. But one of the things that the research really does um support is that those little people who have been medicated for their ADHD in their earlier years, um, the the both the severity and the likelihood of them having ADHD into adulthood is is significantly reduced. So either they don't have ADHD, so the population whereby, you know, they they took a population, and this has been repeated on numerous occasions, um, and and warrants probably, you know, a really deeper look if you're talking about just the impact of medication for ADHD as a way of treatment. It's both preventative for um ADHD into adulthood or it's preventative for um severity of symptoms. So they either were tested as you know, a much higher proportion of that um treated in childhood population go on to have ADHD into adulthood or their symptoms are significantly less severe. And that to me is is profound because, you know, whether irrespective of your opinion on medication for ADHD or not, um people worry a great deal, as they should, you know, and ask all of the questions of um the pediatrician or the psychiatrist around, you know, the side effects of medication. But there is not enough focus on the side effects of not medicating.

SPEAKER_03 34:17

Yeah.

SPEAKER_02 34:18

That's the insidious side of, you know, you can see side effects of medication.

SPEAKER_01 34:25

Yeah.

SPEAKER_02 34:25

They're there in front of your face, you know. Um at the end of the day. Yeah, but but the side effects of not medicating are, you know, are something that and are not discussed enough in terms of the impact.

SPEAKER_01 34:39

So you have parents that are bringing concerns up about medicating. Is this the way that you would kind of you'd provide some education as to what it would look like if you don't?

SPEAKER_02 34:48

Very much so. Um in our because we're really dealing with somebody who just has straight out ADHD, when you're looking at we we work with complex neuroprofiles. So basically there's several diagnoses from um autism through to um, you know, impacts on language as well as ADHD anxiety, um, and there's there can be health impacts as well, like in terms of how it impacts a person's gut and digestion, uh, their immune system. And you know, they may have had epilepsy or may have epilepsy, that's quite, you know, a common co-occurring condition. Um and so when you look at ADHD, and again, you know, Russell Barclay uh has been quite vocal about the fact that you know he he's he he said that he reports that ADHD medication is effective in 90% of the population affected by ADHD. Um, however, most people are not treated. Now, when you look at the fact that in autism and ADHD, it it having ADHD and autism together exacerbates the problem and makes it more than just a simple combination of those two things. It's really important that we provide some education around um the impact of both the ADHD and the importance of asking the you know the the person or the child's treating um psychiatrist or pediatrician about the benefits of medication as well as the side effects and for them to cover the side effects of not medicating. And that's why it's you know, in in terms of what we do working with a multidisciplinary team, when you're looking at complex neuroprofiles like that, it's important to have a doctor, you know, that's part of that that that person's um um support team to ensure that all of those factors are properly covered, you know, um, because yeah, um autism also impacts the executive functioning system in in different ways.

SPEAKER_01 37:14

And so kind of coming back to the the co-occurring side of things, when you read through some of the literature, I a common description is secondary ADHD and adult onset ADHD, but they're not established diagnoses, but they're just concepts. Dr. Mapu talks about you might have a kid that's very intelligent and sails through primary school relatively fine, but level of demand or work that they need to do is very cohesive with other people, and then they get to high school and it becomes very independent focused, all the scaffolding for support is taken away. Now they're, you know, failing, talking about that so-called adult onset or the the later kind of onset ADHD. Is that what it's really referring to, do you think?

SPEAKER_02 37:59

I'm not familiar with his work, but uh but upon hearing what you're saying, I would say that that what he's talking about would be in relation to the fact that it's not necessarily started during adolescence. Being a neurodevelopmental difference, what essentially that means is it can show up at any time during development because we're not we're not fully developed until, you know, particularly the brain until males are a bit later, and you know that there's a between 25 to 30 and women, you know, generally two years kind of yeah, ahead either way. Now, that being the case, until that person has fully matured, there are developmental differences that can show up, you know, and that means, and differences do not necessarily mean deficits. You know, and that's the biggest thing that we're looking at even in ADHD. You know, just because somebody has a neurodevelopmental difference does not mean that it's a it's actually uh a difference that's a deficit.

SPEAKER_03 39:06

Yeah.

SPEAKER_02 39:07

In many ways, it can be a difference that's an absolute um positive, you know. Um, and there's many, many, many examples of that, you know, notwithstanding the whole new pile of information or influx of information that's come in with AI and and the development, you know, a lot of that is driven by neurodivergent minds. Yeah. Um, and so, you know, the the question is, is a deficit or a disability occurs in in it's the environment, you know, is is that neurology um going to be um effective or can it function effectively effectively in that environment? So I think that when it comes to understanding when these differences show up, it can be any time prior to the person um reaching maturity. And it's generally where they meet the threshold of what they can cope with. So, you know, often the transition between primary school and high school where there is a drop in supports and there is an expectation of more independence, you see big differences in development generally in what in a neurotypical population. Um, and those differences tend to be greater in a neurodivergent population. And it's just got to do with, okay, I've reached the threshold now.

SPEAKER_03 40:30

Yeah.

SPEAKER_02 40:31

Or, you know, I was okay when I was supported, I functioned quite well. But here are the challenges now around independence. And so it's always been there, it was always going to be there, and now we're in an environment that is showing up that particular difference.

SPEAKER_01 40:50

Yeah, it's yeah, it's a good way to describe it, I think. Because it's yeah, it's it's been there the entire time, but it's not being dysfunctional until they required to kind of moving into more of the diagnostic side of things, I think uh the little research I could find on it. Previous diagnostics saw ADHD, this is back in the 40s almost, as minimal brain damage. And then it was moved to hyperkinetic disorder of childhood, uh, ADHD, well sorry, ADD with or without hyperactivity, and then into ADHD, primarily inattentive, hyperactive impulsive combined. And now we've got primarily inattentive presentation, hyperactive impulsive presentation and combined. What's your opinion on the categories that we're putting everyone into with ADHD and diagnostic?

SPEAKER_02 41:45

Those categories change with the research over the years. Um, we think that we're about 10 to 15 years behind in terms of what we see in a clinical environment to when it actually shows up in the research because we research things and gather an evidence base after we identify something may or may not be a thing. Um we test that hypothesis and we need to be able to check its validity and its reliability until we reach a um a threshold of evidence that we can we can say, okay, now this is a this is a bona fide theory. It's a valid theory. I think it represents definitely the experience over the years that, well, not everybody shows up with ADD, you know, attention deficit disorder, because we know that some people with a a ADHD hyperfocus, right? So it's like it's an intensity. They do two, like it's a lot of it.

SPEAKER_00 42:40

Yeah.

SPEAKER_02 42:41

So um they they can become, you know, quite um, they can be quite active. And that might be, you know, like when you're intensely focused on something, it's over. It's a lot of. Um, they can move around, you know, they can sort of need to constantly move, or that they've got a seemingly great amount of energy that is either either expressed in a in a way that's useful, um, depending on who the judge is, or not so much. Um, but then the girls were the ones who those girls that were inattentive, that are off daydreaming or or in a yeah, in a non-attending state, which is that, you know, kind of just in neutral. I think of it as a car. It's like I'm I'm not really hurtling along. I'm I'm just sitting there in idle and I'm I'm off until something salient comes along and I've got to attend to it. That's sort of how I see it. And then there's some, you know, it's it's quite common for people to be, you know, I guess have less energy off with the fairies in their own world, so to speak. And yeah, hey, you know, come back. Are you listening? Yeah, like what are you doing? So, and then others that can sometimes show a combination of those two states. Um And they think that that's a person who presents with fluctuating levels of uh dopamine. So sometimes they have um not enough and sometimes they have too much.

SPEAKER_01 44:12

Kind of coming back to some more of the literature here, uh one of the ideas was when you're having the the hyperactive impulsive type, this study compared it with kids that had ODD and ADHD, and they talk about the externalizing behaviours that come along with that. But one thing they highlighted was that you don't see that with the inattentive type. So when you have the ODD compaired with the hyperactive type of ADHD, you would have all these externalizing behaviours, but the inattentive type was just this mental chaos, but it didn't come out, and so they were just sitting there like there was so much going on and they were looking around, they weren't really engaged, but then they'll come back to the conversation and then they'll be like, Oh, what? What are we talking about again? They were half engaged, set almost disassociated. Um how how do you distinguish between the the inattentive internal monologue and just the the hyperactive externalized behavior?

SPEAKER_02 45:09

Generally through observation, like so you like in a in a child, you'll see um you'll you'll it'll be pretty obvious, like you'll see that child will be moving around a great deal, like they're looking for things to keep them entertained, they're talking, they're you know, they're constantly feeling every moment and not attending to the thing that they should be attending to. And sometimes they can be doing that as well because that focus and concentration, there might be too much information that they're confronted with, it's just too overwhelming. And they just can't hone in on, you know, generally we we can pay attention to say seven plus or minus two pieces of information at any given time. Now, if there's a lot going on visually, like and from a sensory perspective, they can become overloaded and then they'll look to to kind of keep themselves entertained that that that isn't doing it. They can't focus on any one thing, it's too much. So I'll chat to the person next to me, or I'll oh, that's shiny over there, I'll go and look at that. Yeah, they get distracted by other things that come into, you know, they're not holding this one goal, and so you know, I've got a t-shirt that's like says ADHD, you know, oh look, there's a squirrel. Like it maybe it's just kind of like I get distracted on the way, yeah. On on numerous other things, and so um that that busyness, it's like I'm always, oh, look at that, you know. So then I'm off there, and I'm like, what was I doing? I can't remember, I'm not holding this goal in my mind.

SPEAKER_00 46:39

Yeah.

SPEAKER_02 46:40

Um, whereas if I'm inattentive more so, I'm looking, and it might be that I don't understand or I can't hold my focus long enough to understand. It's not, it might be an internal dialogue. If it is an internal dialogue, you know, that's why we've always got to be careful. Well, what what is that internal dialogue? Is that is that driven by anxiety? Is it driven by um other preoccupying thoughts? Is it is it trauma related? Like what is it content-wise, that because that that busyness in there of overwhelm will often happen as a general rule, like for information overload, you know, perhaps in the hyperactive mind. Um, and we just need to be like, you know, that how it's been described to me often in clinic is just like I'm I'm not interested or I don't understand, or I really like the idea of, and so I just drift off into that space.

SPEAKER_00 47:42

Yeah.

SPEAKER_02 47:43

I'm there thinking about, oh, this is what I've got to do on the weekend, or you know, and because I'm just not into whatever's happening, and I'm not going to be running around, I'm not trying to engage other people, or it's I I don't need to expend energy physically and get up and go and do things I'm perfectly happy off in this other world that I'm living in, you know, and and I could be imagining anything, you know, um, if I'm imagining concerning things, then we need to be looking beyond and saying, okay, well, it might be AHD, but other things like um, well, autism certainly, but anxiety disorders, um, learning disorders, uh, and any number of any other, you know, of of um psychological, psychologically based issues, you know, um or environmentally based or physically, you know, physical um health issues could be preoccupying that person. So we we can't just assume automatically that oh that's that's ADHD, they're not paying attention. Um a much, much deeper dive needs to happen every time to find out well, why aren't they able to focus and concentrate?

SPEAKER_01 49:04

Anxiety can present with a lot of similar features to ADHD.

SPEAKER_00 49:09

Yep.

SPEAKER_01 49:09

The study that I read pointed out that because there's so much education on what ADHD is now, people will consume that content and then they'll build this kind of idea in their head that they have ADHD and they might not, and they've just got anxiety or trauma and there's some issues there, and then they go and present themselves to get diagnosed, but they've learned so much about the disorder they kind of present with the symptoms. Yes. Uh so how do you kind of how do you ensure that your diagnosing is valid when people are coming in with their own interpretations of what it is and they're maybe overexpending some of the symptoms that maybe aren't so dysfunctional for them in day-to-day life, you know, not implying that it's conscious, but the battery of assessments that you would use needs to be quite broad.

SPEAKER_02 50:00

You're not, you know, we don't ever just use one assessment. You know, there's a diagnostic interview, you want to get the history of that person, you want to um find out everything that you possibly can about their childhood, their development, their experience at school, actually, you know, potentially assess somebody on a um psychometric test to see how they perform from that perspective, or any one or or a number of those ones can be conducted and then get feedback from others around them. So from home and or work and or school, you know, teachers, university, whatever, then have a look at the thoughts, like how that person's thinking and what what is happening if they're not attending, you know, like what are they thinking of during that time. Really do some thorough, like there are some pretty standard patterns for ADHD. And it always starts in childhood, you know. So if, you know, even those this this adult onset, if you will generally see that, you know, um there'll have been indicators during those early childhood years around um, you know, the that they needed additional support. And when they had support, they they did well, or um, you know, some some way of something that alludes to an inattentive or a hyperactive profile at some point. Um, but as a general rule, when you uh get to know that person and you do a really thorough investigation involving their own self-report um observations, psychometric assessment, you know, standardized assessments, uh, you'll come to a reasonable conclusion as to um, you know, what might be impacting that person. And then as psychologists, we don't, we don't medicate. We will do a referral as a general rule and say to a psychiatrist or a pediatrician, you know, we're sending this person. Can you review the information? These are the assessments that we've conducted and we've had a chat with such and such and recommended that they talk to you about the um the benefits or not of trialling a medication. And and then when they get to that point, you know, a medication, if if it is administered, it's then about assessing the impact of that medication and how that person functions. And of course, that's out of our hands. That's that's the domain of the the the medical professions.

SPEAKER_01 52:35

Yeah. And so there's been a bit of debate online with uh you mentioned before uh Russell Barclay and Rob Maphu as well, who was I was speaking about as well. And they talk about combining, you know, running diagnostics for ADHD, but also running an IQ and certain other metrics as well. Barclay kind of argues that it's it's not very important to run an IQ test or other other metrics for solely for diagnosing ADHD. And Mapu's kind of of the opinion that it helps to rule out other disorders that could be affecting their presentation. What's your opinion? Should you solely run diagnostics only for ADHD if you're if that's the disorder you're trying to test for, or should you run it to rule out other disorders as well?

SPEAKER_02 53:24

The answer on that depends completely. So with our clients, where there's often multiple co-occurring conditions, we would generally run an IQ assessment as well. Like that there's a lot of nuances to that to answer that, you know, and a lot of it that there's affordability for starters, you know, for the from the individual perspective. So what what can they afford? Like an IQ assessment is an expensive assessment.

SPEAKER_01 53:53

Um and then when you overlay that points as well, was what's actually doable.

SPEAKER_02 53:58

That's right. And so if if it's quite obvious that an individual does not have an intellectual disability, then it's certainly very, very feasible to run an ADHD assessment without the cognitive um component because um because well there's a couple of factors that that relate to that. And that is that if they're at a pre-diagnosis stage, then you don't want to be assessing ADHD and then looking at also assessing IQ at the same time. And the reason why a number of psychologists get nervous about that, including myself, is because when you test somebody who does have ADHD, so say this person goes on to have ADHD and it it impacts their working memory quite profoundly. And so we run a cognitive assessment as well, then again, we're going to get potentially this big difference between what their IQ actually is, so the full capacity of their IQ when it's got, you know, when it's operating on all cylinders, so to speak, versus what their IQ is when they're they're not operating, you know, they don't have enough dopamine, for example, or the brain is not regulated. Yeah. And so for some people that's a difference between telling the individual andor parents that their child or that they've got a, you know, an IQ within the average range, like and and much the same as everybody else, versus they've got an intellectual disability. Yeah. You know, so I mean, if we look at 70, an IQ, uh, you know, a cognitive score of say 70 on your standardized, like say your whisk, for where we start to say, okay, this is now we're we're now in the range of intellectual disability, you know, depending on then the the functional assessment that also needs to go with that. Um between, you know, 70 to potentially 90, which is kind of in that average range, right? And that's a pretty big uh that's a pretty big result to give someone. And then we need to say to them, um, but we're not a hundred percent sure that that's the case, um, and we can't test now for another two years.

SPEAKER_00 56:34

Yeah.

SPEAKER_02 56:34

So if in our case, if we're doing an autism assessment, which is a big uh diagnosis in and of itself, and then we go ahead and we've done an IQ assessment, and then we're telling parents that uh potentially, you know, there's also an intellectual disability because uh the impact of the ADHD is is quite significant on the working memory or executive functioning. Yeah, um, that's a lot to take on in terms of information that may or may not uh represent an accurate picture of that person's capabilities. So if we can see that IQ is not impacted, you know, we can see that there's there's um they're presenting with cognition that that is in alignment with, you know, or similar to to the age expectations, then you wouldn't go ahead and charge that. You know, it it would be do the diagnosis. And it depends on how certain you are on that diagnosis too. It depends on what the results of the of your other assessments are. And then once medicated, if that's the the choice of treatment, then we will do the cognitive assessment because then we're getting an image of what that person's capability is versus, and particularly where there's co-occurring ASD, yeah, you know, versus what that person's going to be, uh I guess their functioning capacity when they're not medicated, which will be worse when they're out there in the classroom or at work or whatever.

SPEAKER_01 58:14

Yeah. And so kind of going more into the medication, when is it appropriate to medicate? When is it not?

SPEAKER_02 58:19

That's for a doctor to answer. So I, you know, I'm not a doctor, so I can't um provide a definitive answer on that. But speaking as a psychologist on that, I would think that, you know, the time to medicate is when the person is it's confirmed that yes, there's there's highly well, we can never be in in psychology 100% sure. At least most of the time. If there's a chromosomal difference or whatever, yeah, we we can do a blood test or or an assessment for that and we can get the results back and be certain that there is or is not you know an impact or a difference in the chromosomes. But for the most part, you can't do a blood test for ADHD, right?

SPEAKER_03 59:01

Yeah.

SPEAKER_02 59:01

You can you can do an EEG, but you know, even that is not diagnostic in and of itself. So we're always gathering information and coming to the most likely logical like answer. But there's always got to be that knowledge there that you know you can never become stuck in that because when new evidence presents itself, yeah, we need to re-hypothesize, you know, we need to, we need to retest and re-check that we're we're still landing at the same place. But when it's been established that it is most likely ADHD and we can see that there is a significant impact of of ADHD or of the ADHD on that person's functioning, then I would think that it's that's when I would do a referral to a psychiatrist or a pediatrician to ascertain whether or not, you know, um a trial is is the next step of medication.

SPEAKER_01 59:58

Are people with ADHD more susceptible to excessive screen time and phone use? Yes.

SPEAKER_02 1:00:04

Yep, definitely. Um, and that's because it's about set shifting, it's about being able to shift their attention. Um uh social media offers a lot of novelty. And so being able to discipline myself to go and do the things perhaps I need to do or I should do versus doing those things that I want to do. There are a number of um mental health challenges that can also come along as a result of ADHD. So, you know, generally people who have got ADHD, you know, will have heard many more negative comments about themselves throughout their life. So, Ed, I told you to go and do this. How many times do I have to tell you? Yeah, you know, stay focused. What are you looking at? Where's your homework? You know, like I've I've asked you to do that, right? I'm gonna take that off you. You know, they they often are in trouble a lot, okay? Um, and because they're not following instructions, they're not paying attention, they're losing things, they're disorganized, you know, they're not on time, they're not so there's there's a lot of negative feedback often that that individual has received throughout their life. And so their self-esteem and sense of identity can be quite severely impacted by that. And so being online and getting involved in something that's distracting takes their mind away from that's what there's there's so many avatars around now, you know. And like the the avatars, oh it's almost like, you know, they represent what I want to be, you know, that that's this is the good me. This is this is me in my my at my best or in my, you know, when I'm when I'm inattentive, this is who I am. And so I can escape into this world where I don't have people at me. In fact, I'm a, you know, I'm a I'm a uh a Green Beret or a Navy SEAL or a some kind of person with a lot of power and respect. And I'm good at this gaming and and I can actually stay focused and concentrate because it entertains me, it gives me novelty at every moment and every corner. Um I succeed here, you know, I'm willing to take risks and I don't die, I just get another man back. And yeah, you know, this is not a real world situation. So absolutely, people with ADHD are far more prone to being undisciplined when it comes to social media and um gaming and things like that. And they say things without, you know, they might be more reactive online and things like that too.

SPEAKER_01 1:02:41

Yeah. Yeah. Romantic relationships. What's the kind of presentations you're seeing there?

SPEAKER_02 1:02:47

So ADHD in particular, um, people with ADHD in relationships, you know, the studies show that there is more of a propensity for them to not be faithful. There's certainly a higher rate, for example, of teenage pregnancies in in um ADHD in relationship with with um a person with ADHD, you know, you're looking at all of those, their their ability to organize, plan, stick with something, focus, and you know, be disciplined to follow, to follow through. Um, like so, you know, if you're looking at okay, they want to increase their credentials or something like that, the chances of them sticking with that course, following through on that are um are far more or more unlikely comes back to novelty. So tolerance of boredom, the ability to, you know, focus, so paying attention to detail, getting the kids ready for school, organizing all of their homework or lunches and doing things in a timely manner, being able to, you know, I guess um think about things before they go ahead and do them. So there's the propensity for addictions, definitely. You know, gambling and and alcohol consumption and drugs and things like that, that inability to kind of just, you know, this is what, you know, we we we do these things only every now and then that because it feels good, that that attraction to, you know, that that novel feeling, that good feeling. Um, the list goes on when it comes to, you know, sometimes people get so hyper-focused. I've had um people where their partner with ADHD has literally just forgotten about them at say Bunnings or something. They've literally just gone, right, I'm going and I'm gonna go and I've got this plant now and away I go. So they're not coming back up to the big picture and going, hang on a second, I've got, you know, such and such to let my my wife or my husband or my kids in there, yeah. Um, driving into work, leaving their kid in the car, forgetting to drop them off to, you know, daycare or whatever.

SPEAKER_03 1:04:54

Yeah.

SPEAKER_02 1:04:54

There's there's all of those factors that can um, you know, money management is another huge one. So budgeting and and and being able to discipline oneself to, you know, you know, you you you can't you can't go and buy that shiny thing that you want, you know, we need that for over here. Yeah. So there's many, many ways that um having a relationship with a person with ADHD can be quite frustrating if you do not struggle with those same differences. And then the propensity for them to kind of be attracted to each other is about familiarity and understanding. Oh, me too, you know, I struggle with that. So the expectations are often altered. Um, because though the individual with ADHD is not so great at those things, well, then they tolerate it more in another person. Whereas when you don't share that same neurology, it's it's far more difficult to any similar to the, you know, that that double empathy kind of theory in in autism in that you know. There actually isn't an issue with empathy, people who are autistic. It's that you know, neurotypical individuals don't understand how autistics empathize and vice versa. But when there are two autistic individuals together, empathy is not a problem. And the same with two neurotypicals together.

SPEAKER_03 1:06:21

Yeah.

SPEAKER_02 1:06:21

Um you know, but yeah, so that's why it's it's it's that similarity and familiarity. But again, you know, when the negative side of double ADHD comes out, yeah, it it can look, you know, mum and dad have got ADHD, and then generally because it's it's quite, you know, it's a heritable trait that children are likely to have ADHD. And so they show up to school with, you know, who knows? Or dedications missed, and you know, yeah, the lunch box isn't matching what's meant to happen and you know, they're bowling in. Yeah, it's quite we see a lot of that where it's just uh, you know, a genetic load in a family and and it's chaos.

SPEAKER_01 1:07:03

So there's a lot of talk, it's been overdiagnosed. Uh ADHD is becoming more prominent in society. What's your take on that?

SPEAKER_02 1:07:12

Yeah, look, the the over-diagnosis question um always pops up. Like so when we learn something new, as the there's been a huge amount of research that's gone into ADHD over the years, and that continues as we learn more and more, which is which is the way you know we we want things to go, is to deepen our understanding of these um of these different presentations and make sense of them so that we can best support individuals who present with you know variations in neurology. Um so there's always the you know the question of are we overdiagnosing? Um and very much so it is that the research supports that there is fundamentally there's been a severe underdiagnosis um of ADHD, and that is particularly a big a big problem in adulthood. So that you know ADHD was like, okay, that's a childhood issue. Um by the time you reach adulthood, it it's disappeared, and so we will um forget about it after that. And so that that has left a great deal of adults who, you know, may have been supported by um ADHD medication when they were younger, um uh with symptomology into adulthood that looks very different, uh, depending upon what what age they are and where they are in life and you know their circumstances. But I think that the the fair answer is that there is some overdiagnosis, yes, because we always have an issue with um clinicians who perhaps are working in the area of neurodevelopmental um differences and you know disorders who do not have the depth of understanding of of of that area that are jumping into diagnostics in that space. Um, and then also people are able to come in and and and mask that they have ADHD and answer those, given that we do not have a definitive, you know, um way of measuring like blood test or um any type of scan that that tells us definitively that the person does have ADHD. So there's there's certainly those two factors. Um, but then there is also underdiagnosis as well. So conversely, we still have a huge amount of adults and kids, you know, that are underdiagnosed, they don't they don't have a diagnosis and who would um whose functioning would improve a great deal on a daily basis if they were treated. Um and that's because um either they're not seeking, you know, um intervention or or an answer as to why perhaps things may not be going how they'd like them to, or they don't see them as an issue, or they don't know that they're able to get a diagnosis, and then people's belief in whether or not it even exists. So both exist simultaneously. There is both over-diagnosis and underdiagnosis going on at the same time, but I would say for the vast majority of cases, there would be an underdiagnosis. We've got generations of people with ADHD who would have definitely benefited from um treatment in that space, and that didn't happen.

SPEAKER_01 1:10:39

So how often do you see that you're diagnosing a child and in that process one of the parents goes, Oh, wait a minute.

SPEAKER_02 1:10:47

Oh, dick, 90%. Yeah, well, I I wouldn't I would have to say, yeah.

SPEAKER_00 1:10:52

Yeah.

SPEAKER_02 1:10:52

A lot. Yeah, a lot. It's it, yep. The apple often does not fall too far from the tree. Yeah, yeah. And so, yeah.

SPEAKER_01 1:11:03

Well, thank you so much for your time. I appreciate it. Uh, you're welcome. And for those that are interested, you'll be back for an episode on autism.

SPEAKER_02 1:11:10

Yeah, yeah, absolutely. I'd love to come back. So, yeah. Um, I really appreciate you having me on. Thank you very much. Thank you. Cheers,