This is a Global Player original podcast. Hello, welcome to You're Wrong About ADHD. I'm Sam. This is...
Hello, Katie Brackwick. And we've talked before about the challenges of getting an ADHD diagnosis. If you haven't listened to that episode with Henry Shelford from ADHD UK, I would encourage you to go back and listen to what Henry had to say. Fascinating, fascinating episode about the picture of diagnosis around England.
Today we wanted to look a bit more at the actual process itself when you get in front of the psychiatrist, because lots of people report having different experiences. And there is a sense in the media, whether that's right or wrong, that some clinics are getting it right and some clinics are getting it wrong. Yeah, and it's a pain for us ADHDers, because that doubt in the trustworthiness of that process means that, you know, they can write articles in the broadsheets, which essentially go, well, is it even real if we can't believe that these psychiatrists are conducting these tests in the right way? And it is interesting for me, personally, I have to say, because my eldest, when he was tested before I was, did have...
it was a really, really thorough methodical process that also involved technology. You have to do various tests looking at lights on the screen and things like that. And for me, that wasn't the case. I did feel that the process was thorough and methodical, but there was no technology, and I wonder what that is.
Yeah, the first psychiatrist I saw, I had a Zoom call and I was diagnosed. And then for various reasons, I went to a different psychiatrist and I already had my diagnosis, but went there for titration to try medication. And I then had this sort of technical computer test where I sort of, you know, look at the screen and click the mouse and I saw different things. And there is a sort of standard clinical test, which is you sit and you have an interview with the psychiatrist and they look at your past history, and then there are these other technical tests alongside it.
So we want to dig into this a bit more. Professor Peter Hill is a consultant child and adolescent psychiatrist. He's the real leader in the field of child ADHD assessment. He wants a more standardised way to test for ADHD.
So we're going to get his view on how things are, how things need to change, and we'll speak to him in a moment. Professor Peter Hill, thank you so much for joining us on the podcast. Welcome. It seems like there's a growing lack of faith in ADHD testing among the general population.
Is that scepticism justified, do you think? And just how reliable is the current diagnostic process? I think it very much depends whether you're talking about children or adults. The practice of diagnosing ADHD in children is, I think, more reliable than the practice in adults.
And I know from personal professional experience that there are people around who are doing hit-and-run assessments of ADHD in adults, and I think that is poor. The recommendations for good practice on diagnosing ADHD in adults is a paper which was published just at the end of the last year by UCAN, the UK Adult ADHD Network, recommended two hours as a typical period for an assessment for adult ADHD. And that seems to me probably a battle right, though I have to say, when I was assessing children, I don't, I'm not in active clinical practice now, but when I was, I'd say, years ago, I would often have to take more than two hours to do it properly. I think doing it properly is shocking.
The importance of ADHD can be mimicked, as it were, by other things, and you've got to be sure that this is what you're talking about. I was going to ask you that. How difficult is it to separate ADHD and what ADHD is causing from other things like the effects of trauma or other mental health issues? Well, it can be very difficult.
The two, of course, can go together. They don't have to be one or the other. And this is often the issue with ADHD, is ADHD and what else? And that's why long assessments are very important.
So it goes beyond picking up whether this should be called ADHD or not to what else is going on, because of the quality of the lives they experience, particularly in childhood. So it becomes a moderately complex issue. Not only is this ADHD, and I'd like to say a bit more about that at some stage, but it's also, if it is ADHD, what else is happening? And what is the impact on people's lives?
Because you have to measure impairment of functioning. You have to measure whether it's messing up somebody's life in order to make the diagnosis. And is that another reason why perhaps the aftercare needs to be improved? And that's my personal opinion, in that people anecdotally and from my own experience will get perhaps a Zoom call diagnosis, and then it's off you go, titration, and then sort yourself out.
And actually what I needed was somebody to be monitoring me and helping me in that aftercare period. I should, I hope so, absolutely. I mean, you can sense a rant coming on. We're all for rant here.
Well, there's no point, I think, in diagnosing ADHD without helping somebody manage it, without, as it were, treating it. Though treatment, of course, is a big topic. Of course you must. And it's inherent in the NICE recommendations.
The NICE made a strong recommendation, if not a requirement, really, that there should be a post-diagnostic discussion of some length before offering treatment. So an explanation of what is going on, what has been going on in terms of assessment, and what the implications are for understanding and for managing both for the individual person and for the clinic or the healthcare professional involved. So that should be there. That is within the NICE recommendations.
And it's included, for example, in the recent publications that you can, I mentioned, about good practice, no standard practice in ADHD assessment. There should be this discussion about the findings of what those mean before even getting on to treatment. So it has to be there. And then you've got the whole issue about treatment, which can be trivialised very easily.
An overstressed, over-extended NHS clinic, I think this particularly applies to paediatric clinics, where the throughput is quite swift, that it must just be reduced to medicine and adjusting medicines. It's obviously much greater than that. I'm very much in favour of medicines for ADHD, but that's not the whole story. What else would you include in that treatment?
Depends on the age of the person, depends what they're doing, depends, depends, depends. But first of all, they've got to understand what I mean if I say they've got ADHD. What is the professional understanding of ADHD? How do I get that across?
Is it to do with paying attention? Well, that sounds like willpower to me. So I need to explain that it's about managing attention, for example. So the language and the terms become really very important.
That has to be got straight to begin with. And I think part of management is that. Then I think there are going to be adjustments that need to be made to the life that this person is leading and the influences and forces acting upon them, whether they be educational, whether they be jobs, occupation. So there needs to be some way of negotiating an arrangement with one's environment.
I'm being pompous. I completely agree. Does the current system set up to identify the complexities of ADHD? And we've talked about how Katie and I experience ADHD.
The parts of ADHD we struggle with differ. Is the current system set up to identify the complexities? And by that, I mean, one person's struggles with ADHD may be very different to another's. Absolutely.
Absolutely. There's nothing special, I think, about ADHD in that, because it complies to almost any medical diagnosis. But do you feel that the current system of diagnosis is getting to the heart of that? Or do you think it's ignoring that, crossing over that?
Well, I think it's under so much pressure, frankly. I think on some basis, yes, it certainly is. I mean, quite often, because I now work in the area of giving clinical opinions, I see other people's assessments. I've seen outstanding assessments of very, very high quality in this country, both within the health service and available privately.
And I've also seen rushed, inadequate, incomplete work that seems to just involve applying a label without much thought as to whether that is the right thing. So it's both good and bad. There's both over-diagnosis and under-diagnosis. We're not yet tackling the problem properly.
So what's the next step? How do we get to what you are describing? How do we reach the top of the mountain and get that kind of standardised diagnosis that you're calling for and that we completely agree with? I think the standards and drive are there within the NHS.
I'm only really familiar with children, teenagers and young adults. I don't know what happens after that. That's where I am interested and involved. And I think the way in which the education service has come on board in the last 15 years has been terrific.
And it is the education service that carry the cost of ADHD to the country, which is very substantial. ADHD is expensive for the country unless it's beat it. So you can feel other ramps bubbling, which I'll express some. But I think that we're getting much better at recognising and to hesitate to say the word treating, I think it's more supporting children and teenagers with ADHD.
We have yet, I think, fully to tackle the issue of neurodivergence generally in the occupational world, in the employment world. I do know that people are interested and committed to doing that. So I think it's a work in progress. There are the tests that are coming around and on which NICE reported just a couple of weeks ago that you use a bit of kit to measure restlessness or measure problem solving or measure vigilance altogether.
Now, these are becoming very sophisticated. And there are two that have recently come to everyone's notice, though I think one of them isn't totally released yet, which use virtual reality to set children in particular tasks that they must complete in VR, in virtual reality. And that can be saw. Now, those will be expected to adults.
In some cases, they have been. But the use of virtual reality to assess how an individual goes about solving a problem in a real-life setting is really interesting. But we don't really have quite enough information to know how helpful that is. It could just make the assessment more complex.
The other test that I think many people know about is the QB test, which is a test of restlessness and a test of vigilance combined. And that has been looked at really quite carefully over the last 10 years. Six years ago, there was a good, very good quality study down in Nottingham which showed that using a QB test can actually quicken things up. It can speed things up in an assessment.
It can't substitute for an assessment. Nobody's yet found a substitute. The last area I want to comment on, I think many people want to know so much about, which is the use of picking up the tiny little eye movements in association with attention and concentration. And this is brain games, which has been very well developed from the University of Barcelona and in particular from the attractively named Professor Super.
And his work, I am familiar with it and have been for several years. And this picks up little movements of the eyes that are essential for, or essentially associated with concentration. And in ADHD, in certainly both adults and children, as both studies have been done, those movements are less coordinated. So where you expect to see a little convergence of the two eyes when you're presented with an interesting stimulus, you don't see that nearly so clearly in ADHD.
And that looks like a very, very impressive way of assessing the physiological basis of ADHD, as opposed to the task performance area, which you see in the VR, the virtual reality, and the QB test. Professor Hill, before we let you go, I'm interested in what you said earlier. You wanted to talk about what is ADHD. What was it that you wanted to say about what ADHD actually is?
I think it's quite difficult to understand if you haven't got it, or if you're not married to it, or if you're not looking after it, as it were. I think understanding in abstract goes wrong. And I've seen journalists in print, print journalists, get that terribly wrong, because they just dismiss ADHD because they say it's a mild problem, and it's self-diagnosis, and it doesn't really exist. Now, that's horribly wrong.
So I do get quite so concerned about that. I think that trying to explain what ADHD is to a sceptical journalist can be hard, because they say these traits are present in everybody, which is pretty true. And therefore, people can make their own diagnosis, and then they can demand welfare benefits, and they can demand medicines, or basically we're going to sedate them with drugs, and that doesn't happen. All these myths arise, and what I think gets lost is that the medical diagnosis, the medical diagnosis of ADHD involves impairment.
It involves the problems of ADHD, messing up somebody's life and career and development, and their relationships and their work and all that sort of thing. So impairment is essential. We don't yet seem to have a word in English of describing people who have ADHD, but are not impaired, and they are around, and we need those people, and we need a word to describe their situation, because these are the people that benefit, companies that benefit socially, and they could have a politics. We like that, but we must, I think, differentiate between somebody who is exuberant and imaginative beyond the confines of their own rules and regulations imposed by others.
We need them without having to say they're sick, and therefore need medicines and so forth. We don't need to get into that, and if we only had a word, it would be terrific. I haven't heard a word used yet. It's a fascinating thought to end on.
Thank you very much, Professor Hill. That's everything from us for today. We'll be back on Wednesday with our bonus episode, and we'll be chatting about everything we've learned from our conversation with Professor Peter Hill, so do make sure you listen to that. Don't forget you can listen and subscribe to Your Wrong About ADHD on Global Player, or wherever you get your podcasts.
Thanks for listening. I'll see you next time. This is a Global Player original podcast.