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ADHD science episode 13: a Q&A with Max!
635 Plays8 months ago
We have something a little different for you!
We have asked the lovely followers of ADHDUK on social media to ask us questions and they have responded enough to fill 3 episodes!
This is part 1 in which we break down the biology and neurology of ADHD, talk a lot about the hungry brain and why epigenetics may or may not be a breakthrough.
Recommended
Transcript
Introduction to Hosts and Podcast
00:00:09
Speaker
Hello. Hello. Welcome to the... I. I started a sentence and then stopped it. Welcome to the ADHD Science Podcast. Welcome. I am Max Davey. And I am Tess Davey. And for these ones, I'm going to just quickly say what my expertise is. My dog just don't know the dog. And the dog is here. My expertise is I am a dog dad.
00:00:32
Speaker
No, I am a ADHD specialist, a pediatrician, and I run, I do a lot of ADHD clinical work and
00:00:41
Speaker
also trustee of the wonderful charity ADHD UK. Let's go.
Episode Format: Q&A Style
00:00:47
Speaker
And what we're doing today is slightly a little bit different for those of you who have listened to the podcast before. Which hopefully you have and if you haven't, do that after this. Come on, treat yourself. All two seasons of delectable interviews with scientists from around the world.
00:01:06
Speaker
And who are you Tess? I'm Tess Davie, I've said that already. I don't have any qualifications really. I have ADHD and I like to talk about ADHD and that is everything really.
00:01:20
Speaker
But you are a questioner. What does that mean? It means you question things, you ask questions, and you wonder about things. Oh, that was a question. What does that mean? Yeah. Very good. Wow. Excellent start. I'm a scientist, I heart really. So this episode is a bit different. We're not going to interview anyone. Not because we've run out of interviewees. No, we've got to. But because we just fancied doing something else.
00:01:39
Speaker
we're doing a cheeky Q&A aren't we we are doing a cheeky Q&A so what we did we did a shout out on the social mejuzz as I think the kids like to call it which you should totally check out by the way and
Social Media Questions Collection
00:01:54
Speaker
we asked for questions about the science of ADHD. Now what we got were some things that were questions and some things that were kind of questions and kind of not. So I've tried to turn as many of the points made into questions and hopefully we can do this again. When we do it again we will definitely record and remember what people's names are who've asked the questions because at the moment I don't actually have that information for complicated reasons.
00:02:19
Speaker
So we've just got the questions, we don't know who asked them. It kind of doesn't matter but it's nice to get a shout out for people who ask the question. So if your question gets answered, hooray for you! But I don't actually have...
00:02:34
Speaker
your name in front of me. Sorry. Please let us know. Okay, so are we ready for question number one? Question number one. It feels weird to not have a separate intro to episode. Yeah, it does, doesn't it? But it feels so odd. Okay. Should we have like a little stinger? Yeah, let's play our intro. No, let's play our intro again. Okay. Go.
00:02:59
Speaker
And we're back!
Is ADHD a Physical Entity?
00:03:03
Speaker
So what is ADHD from a scientific perspective? So this is such an interesting question because
00:03:12
Speaker
From a scientific perspective also almost suggests, you know, what is ADHD in the brain? And that's actually not the right answer. ADHD is a cluster of symptoms that tend to cluster together within the population. Yeah.
00:03:31
Speaker
and are valid as what we would call a construct because the people who have this cluster of symptoms tend to respond to medications, other interventions in roughly similar ways. So it isn't actually
00:03:49
Speaker
there isn't a thing in your brain that you can call ADHD and I think that's really really important partly for the other discussions that we have and this has been difficult for people to accept and has led to some I think quite disingenuous or dishonest actors saying
00:04:08
Speaker
Well, that means that ADHD doesn't exist. And that's not true. There are lots of medical diagnoses that are constructs, like constipation or asthma, are constructs. There's no thing in your gut, which is constipation, but it is a cluster of symptoms that responds in certain ways.
00:04:26
Speaker
Yeah. So what you're saying is that the condition is defined by what it causes rather than what it is. Exactly. In itself. Yeah. That's a really
Challenges in ADHD Diagnosis
00:04:35
Speaker
good way of putting it. Yeah. Um, so is it true that ADHD can be caused? Well, we don't know the cause of ADHD. That's one. I think that's right. It can be associated with things. And I think that you can, I mean, we'll kind of go onto that a little bit with some of the things it can be associated with, but certainly there are,
00:04:54
Speaker
Insults to the brain that can be associated with later ADHD quite strongly and of course It would be silly not to think that there's some causal link between those two those Between something that's linked in that way Right, but we have to be careful and not assume that the links are causal until we have you know sort of good evidence for it
00:05:16
Speaker
yeah falsifiability theory and all that yes thank you okay speaking of um identifiable things which like
00:05:27
Speaker
I suppose, cause ADHD. Does that kind of link into the second question which I've just read? Yeah. I haven't read these in advance so this is as much a surprise to me as it is to you. It's a journey test, it's a journey. It is a journey. What are the specific neurobiological differences within brain structure and neurochemistry? Lots of words. Lots of words but the answer, surprisingly, is that there are none. None.
00:05:52
Speaker
So what I mean by that is not that if you look on brain scans you cannot find differences that on average ADHD people are more likely to have. What I'm saying is that there is nothing that you can find in a brain scan
00:06:07
Speaker
that will tell you that that person has ADHD. Yeah, so if you found out that people with ADHD are more likely to have this particular thing and this particular part in the brain, that doesn't mean you can do a brain scan of somebody without ADHD, see that same thing in that same area and be like, oh.
00:06:24
Speaker
you have ADHD exactly exactly right it's comorbidity is that what they call it not really i think what it is is that there are some correlations between certain patterns of brain chemistry and structure and having ADHD so it's more likely to than completely deterministic exactly exactly so
00:06:45
Speaker
I think, I mean, we haven't had a guest talking about imaging and ADHD yet. We have invited a few people and we haven't managed to get them on yet. We're very happy to do that. But ultimately, the answer to the question is, if we're looking for, you know, the golden, the kind of, you know, the golden ticket or the, you know, sort of Willy Wonka kind of thing of, you know, here's the change, here's the thing, the kind of the particular change that everyone with ADHD has and no one with ADHD hasn't.
00:07:15
Speaker
That is not going to happen. I mean, it would be so convenient if it did. Yeah, but it is not going to happen. We've had three decades of research of imaging people with ADHD and it is just not going. I just don't think it's going to happen. I don't think it's plausible at this point.
00:07:28
Speaker
Okay. Question number three. Yeah.
ADHD and Brain Development
00:07:31
Speaker
How does ADHD relate to the... Oh, I thought that said pro C. So I was like, what does that mean? How does ADHD relate to the process of brain development from infancy to adulthood? Good question. It is a good question. If you read that question, what do you think it... What do you mean? What do you understand by it?
00:07:48
Speaker
I'm gonna have to read it again. I'm guessing that that means how much does ADHD affect your development, right? So I think that's how I kind of took it as well. I think, I know I've just said that ADHD is not a thing in your brain but it is definitely a difference
00:08:11
Speaker
that your brain how your brain responds to the world is different because of your ADHD yes in quite a reliable way and because it's about responses to the world rather than brain structure i think it's useful and important to use things like metaphors and people use other different metaphors for ADHD don't they they sort of the Ferrari without the brakes and all of that sort of stuff my favorite one
00:08:37
Speaker
is the hungry brain. So, the hungry brain is a brain where... I'm telling you, he loves the hungry brain. I love the hungry brain. The hungry brain is, and if you imagine, there's a level of stimulation at which all of our brains are happy and comfortable, and there's a level of stimulation that you're actually getting. And that, at different times of day, different situations are going to be more or less what you want. You know, there's going to be more or less stimulation in your environment than you're comfortable with.
00:09:07
Speaker
with ADHD.
00:09:08
Speaker
you are chronically short on stimulation. And what do brains eat? They eat stimulation. That is physical stimulation, emotional stimulation, video game stimulation, YouTube videos, stimulation. You don't need to bring that around. But people with ADHD, and I didn't mention the top of the episode, but I have also got ADHD, are chronically short on stimulation. And so that drives a lot of the symptoms. Now, so that
00:09:37
Speaker
hungry brainness persists throughout brain development. So the brain throughout person's neurodevelopment from infancy to adult remains a hungrier brain than their peers. That's what ADHD is. Within that, there is huge variation, partly because the rest of development is moving on apace. So an ADHD... So go on.
00:10:04
Speaker
No, hang on, hang on. I feel like we need to go back to the question really quickly here and talk about what do we mean by development in this case. Are we talking about physical development? Are people with ADHD shorter? I don't know. Are we talking about psychological development? Personality development is a whole other thing. What part of development are you referring to in your answer? That is a great question. I suppose I'm talking about the process of the development of skills of which a component is personality.
00:10:34
Speaker
Okay, so we're just talking about like...
00:10:36
Speaker
psychological development. Yeah. Okay. Yeah. Yeah. Yeah. Yeah. Continue. Thank you. Very, very good clarification. Um, and I think psychological development or what we would in pediatrics, we would talk, we would talk mostly about the development of skills is intimately bound up with your environment. So if there are certain skills that are necessary when you get to school or when you get to secondary school or when you go to a new house and you kind of go and live with some new people,
00:11:06
Speaker
all of those bind into how your brain is like and produce how well you function in your environment. So it's a bit of a difficult question but the take home is that your hungriness is always there, how it manifests really depends on your age, on your context and on what else is going on in your brain, what other differences you might have.
00:11:31
Speaker
Okay, I think I understand up to a point. I think there was a lot of words in that last little section there, but I think I'm with you. Okay. So, the way that the ADHD brain affects development is that you are so hungry for stimulation all the time, which I can definitely relate to, that you don't have time for other things.
00:11:53
Speaker
it's that you are that was no i think it's not that you don't have time for other things you you you may get distracted so for instance your social interaction skills if you have ADHD are often not always less developed because you haven't had the
00:12:11
Speaker
mental what's the what's the word you haven't had the practice the kind of concerted practice of building up your social interaction skills why because often your interactions have been quite brief they often have been impaired by impulsive behaviors you might have experienced rejection socially as you go up through life so just taking that one
00:12:36
Speaker
aspect of your development, your psychological development, which is your ability to make and maintain friends, that is impacted by your ADHD. Can you apply that that way of thinking about it to other important life skills like, you know, being able to like good table manners, you know, haven't been focusing on
00:12:57
Speaker
on learning good table manners because you know you've been eating your food too quickly so that you can go back to watching youtube or or you've been focusing so much on sitting still for long enough that you don't get shouted at that you actually haven't had the mental bandwidth was the word i was looking for to actually learn this other stuff right so it's that you
00:13:19
Speaker
It's not that there's something different about the way that you learn, it's just the things that you're learning are different, right? I think it affects the whole process of learning different skills. Because you are doing those skills differently. Yeah, to an extent, but also because your kind of mental bandwidth, your mental energy is being diverted to other things.
00:13:46
Speaker
And also, because often as a person with ADHD, you've experienced rejection, you've experienced failure and being told off for things much more than other people, and all of that affects your ability to practice skills. Yeah. This is a very tricky question. It's a very tricky question. And it's going to require a lot of editing, I think. Does being born prematurely increase chances of developing ADHD?
Prematurity and ADHD Risk
00:14:14
Speaker
Yes, it does. That's a very simple answer to the question. Yes, it does. How? Well, as I mentioned earlier, there are a number of different potential insults. So what I mean by an insult to the developing brain is something that can interrupt
00:14:31
Speaker
the way that the brain is developing. If you think of the brain either before or after birth as kind of flowering like a beautiful flower within the baby. Flowering like a flower. I'm very good at metaphors, me. Flowering like a flower. Flowering like a rose within the baby's skull. So anything that will affect that process of its
00:14:54
Speaker
flourishing and growing within the brain may be connected with ADHD. And again, as I said earlier, the connection, there may be some associations and we can't be sure that they're kind of causative. But what we know is babies who are premature will develop their grey matter and their white matter within the brain in a different way. So the grey matter, if you think of the brain as like a cauliflower,
00:15:20
Speaker
Okay, I love doing that. Yeah, so the grey matter is the kind of bunchy bits around the edge. Okay, and the white matter is the bit that connects all the bits. Okay, and I'm with you. There you go, grey matter and white matter. Perfect. So they both develop in different ways for people who are premature and that is a plausible reason why they develop ADHD. I mean, what this all comes back to is just the fact that we can't pinpoint one cause for ADHD. Exactly.
00:15:46
Speaker
And I feel like that's where we're going to just keep coming back to with a lot of these questions because it's so it's very frustrating that we don't fully understand.
00:15:55
Speaker
No, and we probably never will. I mean the conception of ADHD, the way we think about ADHD, will probably change in the next 20 years. Yeah, I'm excited. I'm ready. I'm tired. Okay, can we pause the recording for just one second because there is paint tape on the ceiling.
00:16:18
Speaker
And we're back. Okay, I'm back.
How Do ADHD Medications Work?
00:16:20
Speaker
Take on the ceiling. Right, it's gone now. Okay. Tess is now happy. Next question. Okay, where are we? Oh my god. How do the different medications work? I was going to ask you this and then I never did. Okay, well now you can. How do the different medications work? So. Can I guess? Go on then. Is it a reuptake inhibitor?
00:16:46
Speaker
Yes, I mean... Yes! Back of the net! Let's go! I mean, the truth is that we don't fully know. We know that the drugs... So there are two sorts of drugs, broadly speaking. There are stimulants who act more on a dopamine pathway and there are non-stimulants that act more on what we call a noradrenergic pathway, noradrenaline. Okay, pause. I hope you're going to explain both of those things.
00:17:13
Speaker
It sort of doesn't matter, both dopamine and noradrenaline are substances that are secreted within the brain and act as signals between the different brain cells. Yes. So the brain is composed of trillions and trillions of nerve cells called neurons and these neurons connect and communicate with each other
00:17:39
Speaker
via neurotransmitters. Dopamine and noradrenaline are neurotransmitters.
00:17:46
Speaker
And remind me the difference between neuro-adrenaline and adrenaline. I always forget this. It doesn't really matter. They're slightly different hormones. I think it matters in my exams. It doesn't matter in this case. It doesn't really matter for this purpose. But I'm going to get dragged into the molecular biology of it, partly because it's a long time since I read it up and I can't completely remember. So that's why I'm saying it doesn't matter. No, it also really doesn't matter. There's these neurotransmitters helping our neurons communicate in our brain.
00:18:14
Speaker
yeah and we know that the drugs that we give affect the levels of neurotransmitters within the brain and we know that when you put a neuron in a petri dish
00:18:26
Speaker
in a lab and you give, say, for example, methylphenidate, it will increase the amount of dopamine that gets secreted by this neuron by blocking the reuptake. Fine. And I'm correct that it's not producing more of the neurotransmitter. No. So when a neurotransmitter, this is my understanding, completely feel free to stop me. Okay. That's fine. That's fine. Neurons secrete neurotransmitters to go to the next neuron, right?
00:18:56
Speaker
then they absorb the neurotransmitters and what these drugs do is stop the neurotransmitters from being absorbed. So it's not making more neurotransmitters, it's just stopping them from getting hoover back up. Yeah, broadly speaking, yes. But what that actually means in practice, in a real brain,
00:19:16
Speaker
We are not completely sure. So generally speaking, both classes of drug will increase the amount of neurotransmitters around the brain. But how that actually connects to what they do in terms of how it feels to have them in your body and how it feels to be a person on these medications is a bit unclear if I'm honest. Yes.
00:19:38
Speaker
I again want to go back to the metaphorical level. Are you glad? I'm going to go back to metaphorical. If you think about the hungry brain and you think about the gap between how much stimulation your brain is comfortable with and how much stimulation you're receiving, stimulant medications, a bit like coffee or caffeine,
00:20:00
Speaker
will increase the amount of stimulation that your brain is experiencing so it's closer to where your brain is comfortable. So that whole tension, that whole hunger, that whole restlessness reduces.
00:20:14
Speaker
I mean, I find it strange that there can just be stimulation, like not from any source. Yeah. It's just there. That's crazy. It is, isn't it? How does that work? That's a really interesting question. I mean, you just told me you don't know. But I think it works by affecting the neurotransmitters.
00:20:32
Speaker
Yes. Within the brain. So it's, and it isn't that there's no, it could be that there's no, I suppose if you took medication and then you were in a sensory deprivation tank, you still would feel understimulated.
00:20:45
Speaker
Yes, no, it's not, it doesn't automatically adjust to your stimulation level, it just gives you a little boost. I think probably what it will do is amplify the stimulus, the stimulation, the stimulus, stimuli that you are experiencing, the stimulating experiences that you're experiencing in your environment and make them more stimulating. Yes. So a bit like, again, a bit like coffee does.
00:21:09
Speaker
So I think I think that's the way to explain stimulants non stimulants. I think I've rather mysterious actually So non stimulants they act to Increase the amount of noradrenaline in some parts of the brain, but we don't really know where and the other thing is they seem to me as a clinician to have two actions
00:21:32
Speaker
one is they have a kind of immediate action so after you take a non-stimulant you will experience the little buzz that you get which is a little bit like a stimulant buzz to be honest with you yes and it isn't that different it there are differences between the drugs because they tend not to cause um
00:21:48
Speaker
agitation and appetite loss that are quite a problem with stimulants. So you get a little bit of a buzz with the non-stimulants but I think also the non-stimulants over time seem to decrease this gap between why your brain is and where your brain is comfortable. So they have a bigger short-term effect and then like a kind of subtle long-term. Yeah exactly right, exactly right. So that's basically how they work and we've talked about the neurotransmitters but I think the more important level to think of it is
00:22:16
Speaker
they make your brain less hungry and less and and reduce that tension. You and this hungry brain. I love it. I'm telling you it's crazy. I love it. So question answer summary, we don't really know but they change neurotransmitter levels. Yes and and actually how it feels is that your brain is less understimulated. There's your half answer. Right. What half answer? Well yeah we can't.
00:22:42
Speaker
I could charge for this, you know! Alright, go on. It's not me trying to be rude. It's just the facts. That's only half the answer because there's nothing else we can do. Yeah, I agree, I agree, I agree. You know, maybe I've got... Maybe after I've gone to university and got my degree and I've become the world's leading neuroscience... Professor of neuroscience. Then we'll see. Okay, fine. You know what? We'll get back to you. Yeah. Okay. So... Okay. Why don't ADHD meds work for every ADHD year?
00:23:10
Speaker
So I think we have to go back to our previous answers. Because ADHD is not the same for every brain, it makes sense that drugs that act on the brain vary in their effectiveness for ADHD. So for me ADHD drugs didn't really work out. No.
00:23:31
Speaker
you're for you they're working out right now quite well so that may reflect a difference in our brains yeah i mean there's lots of other signs that we may have differences in our brain
00:23:43
Speaker
Yes, lots and lots of them. Such as our disagreements about the state of my room. Yeah, I'm not the tidiest person in the world either, but to be fair. So I think that's part of it, is that because ADHD does not reflect a single type of brain, it makes sense that there is a great variability in how much the medication works or doesn't work for people.
00:24:10
Speaker
And I mean, I think some people, I don't know if this is your belief, but some people believe that ADHD can be caused environmentally. So it's not something you're born with, it's not something that's built into your brain, it's something that you can develop, right? I don't know how I feel about that personally, but some people believe in it. If you're going from that approach
00:24:29
Speaker
then meds aren't going to do anything. Yeah, exactly. Which is why I don't go with that approach. Because meds tackle your brain on a purely biological level. And if you're looking at a method, if you are a believer that ADHD is not
00:24:44
Speaker
caused biologically or is not entirely caused biologically. So, okay. It's either this stress model, I know this one. So let's, so let's, so let's unpack this a little bit. Yes. So there are two components in a way to ADHD. There is how ADHD your brain is and I'm not going to say hungry, I'm not going to say it, I'm not going to say it.
00:25:04
Speaker
It's how ADHD your brain is. That is biological. There's very, very good evidence that partly things like the link with prematurity, the link with other things that happen in your developing brain. And the link with just straight up genetics. And the very high, what we call heritability, the very strong contribution of genetics, even though we don't find a specific gene, and we never will, the contribution to
00:25:33
Speaker
iatogically heterogeneous. What? No, you're accusing me of using long words. Look at me go. OK, fine. Basically, it runs in families really strongly. Yeah. Exhibit A. Oh, family. Oh, family. So I think that's really important. I absolutely reject the idea that ADHD is environmental completely. However, what is environmental is the relationship between how ADHD you are and how much trouble it causes you.
00:26:03
Speaker
Yes, the intensity of your, if that's something that you can quantify, the intensity of your symptoms. Well the intensity, the amount of impairment that is caused by your ADHD to your life. Yes. So how much of problem your ADHD causes you is intensely bound up with your environment.
00:26:20
Speaker
Yeah, so if you are somebody who... I mean, again, how on earth do you measure this? If somebody has less ADHD in their brain somehow, but they've had an environment in which their symptoms have become really debilitating, meds might not be the best path for them. Possibly. Because a lot of their troubles are caused by the way that their ADHD has interacted with their environment rather than the ADHD itself.
00:26:47
Speaker
And by which I mean also their internal environment, so people who've suffered trauma in the past, sometimes will not respond well to ADHD medication because that's not necessarily the thing that's causing the problem, even though they might have ADHD. In this scenario, does environment just refers to anything that's not innate? Anything you weren't born with is the environment. So trauma, in this instance, is the environment. Exactly. That's not what it means.
00:27:14
Speaker
It is what it means, but it's fine. So basically, why don't ADHD meds work for every ADHD
Misconceptions About ADHD Medications
00:27:20
Speaker
-er? Because our brains are all different. We are not all equal. Yep. Moving on. The link... Oh god. This one's in a different font. Tess can only read one font.
00:27:31
Speaker
I know. It's not even any different fun. It's just bigger. Okay. The link between stimulants and whoa. Amphetamine. The link between stimulants and amphetamine based street drugs. The risks versus the benefits of stimulants and some clarity on wither stimulants really are like cracked and neurotypicals. Okay. So I love this one. I was just like, what? Through the wither in there as well. So.
00:27:58
Speaker
medication given for ADHD is in the class of stimulants amphetamines, street drugs and cocaine and other things like that are also in the class of stimulants meaning that and in that they will have there are some similarities in the way
00:28:18
Speaker
that they act on the brain. They're uppers. So they will all amplify and emphasize how stimulated you feel. Caffeine as well, right? Caffeine as well. Much weaker version. But that's the point. That's where the resemblance ends. They have no other resemblance really to street drugs.
00:28:47
Speaker
They are diverted and misused, but mainly by people who don't have ADHD who want to take ADHD medication to improve their studies. So it's quite a big problem in universities, particularly in the States.
00:29:02
Speaker
But actually, they don't make you high. Can you take them? They don't make you high, exactly. No. They just make my brain a little clearer. Exactly. But I've heard stories that ADHD meds have completely different effects on neurotypicals and neurodiversions. Do you think that's true?
00:29:19
Speaker
Well, I think yes, to an extent. So what it seems to be the case is that there actually aren't benefits. If you do not have ADHD and you're entirely neurotypical and you take ADHD medication, it doesn't improve your focus. No. Which kind of makes sense because you don't need it. It's like there's a standard line of focus.
00:29:40
Speaker
Yeah. And the meds don't just plus one to your score, but they take your score plus one closer to what is, well, quote unquote, normal. You're quite close to using a D&D analogy here, aren't you? Oh God, sorry. So if you're already on that, well, normal line, then meds aren't going to do anything. Yeah. Plus one charisma. Oh God. Yeah. I mean, basically that's true. So I think
00:30:09
Speaker
In a way, I really wish that we had a different name because they're some of them are called, you know, Liz dexamphetamines and dexamphetamines. But they are, although if you look at them as a kind of, you know, one of those kind of molecular structures, they look kind of the same as amphetamines. So just they're just not they just act in completely different ways. But on like a chemical level. Yeah.
00:30:32
Speaker
How similar are they? This is completely unrelated to their effects because, you know, they're quite similar. They look quite similar. Just molecularly, they look quite similar. Okay. Things can look very, very similar and have completely radically different approach. I mean, you know, H2O. H2O and H2O2. Yes. Radically different. Very different. One molecule. But this is just out of curiosity. One atom actually. Not one molecule.
00:30:56
Speaker
Oh, shut up. Okay, go on. Out of curiosity, what were you saying? Out of curiosity. You know when you look at like esters. Yeah. And alcohols. Yeah. Is just like, what is it they said? Amphetamines. Yeah. Is that a group? Yeah. That's a group.
00:31:11
Speaker
It's kind of a group, yeah. And they fall under that. Yeah. Okay. This is me just applying the most basic chemistry knowledge in the world. Yeah, I mean, my chemistry is not great. I did GCSE. I was terrible at it. Well, there you go. I was quite good at it, but it was a long time ago. A long time ago.
00:31:28
Speaker
Okay, are we ready to move on? Yeah, I think we basically answered that question. Did we? So basically, you know, it is, stimulants are the opposite of crack for neurotypicals. They are absolutely not crack for neurotypicals because they don't work.
00:31:45
Speaker
Why do people in the U.S. take them so much? Is it because they think they work or because they do? I think because they think they work and also because of course if you take anything thinking it's going to work, particularly if you spent money on it. Plus e-ball. Plus e-ball. We need to make a theme tune for that.
Can ADHD Have a Biomarker?
00:32:00
Speaker
I think we just did. Okay, how close are we to a biomarker slash biomarkers for ADHD so that we can bring ADHD understanding into the 21st century
00:32:10
Speaker
and help cut the unacceptably long diagnostic waiting periods. So this is a question that could be described as a leading question, it's fair to say. So I've sort of answered some of it is when are we going to find a biomarker for ADHD? I don't think we are. Biomarker meaning little thing we can identify in the brain and we can point at it and go ADHD, there you are. Exactly right. I do not think it is going to happen anytime soon.
00:32:38
Speaker
I mean, again, it would be so nice if we could bring it into the 21st century and help cut the unacceptably long diagnostic weight. Okay, so let's break that down into several components because what it's kind of saying, this question is kind of suggesting is, if there was a biomarker, we could go down to an MRI scanner, have our MRI scan,
00:33:06
Speaker
be diagnosed with ADHD, bish bash bosh, off we go. Yeah. And that that would therefore reduce the unacceptably long waiting list because it would be quicker than going through the rigmarole of an actual assessment. So my response to that is,
00:33:24
Speaker
It is possible that that would help in just diagnosing ADHD. But when you're assessing somebody who might have ADHD, you never just assess ADHD unless you are bad at your job. No, I'm not. Well, I'm calling people out. If you're just assessing ADHD and your only interest is, has this person got ADHD or not? Not how do they function? Are they sleeping okay? What's their appetite like?
00:33:49
Speaker
What's their mental health like? Yeah. How are they functioning in school and work? And how can we help them with all of those things? Yeah. Then you're not doing a good assessment. I mean, it's like what you mentioned earlier. ADHD is a collection of symptoms. Yeah. There isn't a biome. I would, I mean, again, I really empathise with this question because, you know, we talk about how ADHD has all of these biological links. And so it's only logical to assume that that means it has a, like a biological... Oh, what's the word? Like a...
00:34:19
Speaker
Like a manifestation. A biological manifestation in your brain. That is a really logical connection to make. But we just can't find one. No. Exactly. We just can't. Exactly. And I'm really sceptical that we have a will. It's possible. I think we may get to a point where brain scans become useful.
00:34:38
Speaker
or brain EEG becomes useful in trying to reinforce our suspicions that somebody might have ADHD. But being a standalone test, we are so far off and we're not getting any closer. So I think we should not think about that.
00:34:58
Speaker
Frankly, and the unacceptably long waiting lists are due to underfunding. They're due to chronic lack of funding, specifically for ADHD. ADHD has never been since it's become a more commonly diagnosed condition. The government have turned an absolute blind eye. This is very much a UK thing and I know that there are different issues in different parts of the world.
00:35:23
Speaker
But in the UK, the government has absolutely pretended that this is not a problem and stuck their fingers in the ears. I think it's just so viewed as just not being able to focus. And there is so much more to it than that. And it's also viewed as a bit of a fad. And if they just ignore it, it'll go away. Exactly. And I mean, I think
00:35:45
Speaker
that even if you are just looking at the not being able to focus thing there's so many like secondary consequences of that that people just don't really think about absolutely yeah i don't know i i think it's it's not a hugely disputed thing that ADHD is overlooked no no it's not controversial the people who are overlooking it don't want to get into the dispute because then they would have to address that they're overlooking it right what was the question so the next question no well not necessarily the next one oh no the next one
ADHD and Autism Comorbidity
00:36:12
Speaker
Okay, cut out of this a little bit. Oh, I was just talking about co-morbidity. Yes, you were. How does the co-morbidity with autism work? I was going to write an essay about this. Go on. Because I was really interested in this link, and then I just realised I didn't have any idea. And not many people had any idea. And if you're writing that kind of essay, you need a lot of sources. You need a lot of sources. So the co-morbidity with autism and ADHD, how does it work?
00:36:42
Speaker
I think the point, the point is that we've talked a lot about how... Pause. Oh. Coability. Autism ADHD. That just means that they occur together quite a lot. Thank you. Continue. So we've talked a lot about the fact that there isn't a single change, a single marker for ADHD. The same is true of autism. Yeah. So if you think about a certain change in the brain that might increase your odds of ADHD by 5%.
00:37:10
Speaker
Right. It's not a marker, it just might increase your chance of having ADHD. I'm with you. Very likely that the same change within the brain will also increase your odds of autism. Okay, why? Because it seems that the changes of ADHD, the difference of ADHD and the difference of autism seem to come often from the same processes in a way that we don't really understand.
00:37:39
Speaker
So could you give me an example of the kind of brain change that we're talking about here? Like what's an example of a brain change? Let's go back to the example of prematurity. Yes. So premature babies who are premature are more likely to have both autism and also ADHD because the insults of the brain, the way that the brain is developed will predispose them to both of these changes because in ADHD, there is obviously the hungriness of the brain or whatever.
00:38:08
Speaker
And the eye roll is starting to become increasingly large. But in autism, it's more to do with understanding other people's intentions and getting inside other people's heads. Often it's seen, and this is controversial, but often it's seen as a difficulty with what we call theory of mind.
00:38:30
Speaker
So it just looks like the same processes which interrupt the development of these quite sophisticated processes within the brain, the same processes can affect both of those skills. So it's not that one of them causes the other, it's that they're both caused by similar things. Yeah, exactly right.
00:38:48
Speaker
How does that what does that imply when you're looking at things that are very opposite in ADHD and autism symptoms? So I think it makes sense with symptom overlap. Yeah, sorry like problems with social interaction as you mentioned exactly Yeah, but there are some things which are very different in ADHD and autism Which I don't think are explained entirely by that theory No, but I think
00:39:16
Speaker
But I think, they're not explained by that theory if what you're expecting is that a particular genetic change will only push you in one way. But what I'm saying is that it's not just that the changes will push your brain in a particular direction. There is an overall genetic weighting towards difference. Okay, yes. That makes a lot of sense. Yeah? Okay. So your genetics will make your brain just be different.
00:39:47
Speaker
and in lots of different, lots of different, different ways. And I think, you know, often this is difficult for clinicians because you're right. Sometimes the symptoms overlap, so you're not sure if somebody's difficulty with social interaction is due to their ADHD or due to their autism.
00:40:04
Speaker
And you have to be quite careful teasing out actually what it is about their social interactions that breaks down, which takes time, which means, you know, you can't just do it on the scan. Equally, sometimes people have these opposing
00:40:19
Speaker
kind of symptoms. So their ADHD might make them have a tendency in some contexts to be very talkative and talk, you know, and very kind of outgoing, but their autism with the anxiety that often goes along with autism in other contexts might make them very unwilling to speak. So that can make them quite, that can lead to all sorts of presentations that are really difficult to unpick. And that's why these assessments are complex and take time.
00:40:49
Speaker
Especially with women. Especially with women. We have a question about that in a minute. Oh, do we? Well, look forward to that everyone. That is very interesting. Okay, right.
Epigenetics and ADHD Development
00:41:00
Speaker
Epigenics. We're going to need to explain what that is. Epigenetics. Epigenetics. That's not what this says. It says epigenetics. Oh, yeah.
00:41:09
Speaker
Epigenetics of ADHD. Okay, don't mock people's spellings. Epigenetics. I thought this was your type. I think epigenetics is the thing they were going for. I would not have made fun of you if I didn't think it was my dad who wrote that. Okay. Epigenetics of ADHD and the high rate of concordance with ASD within families. So, again, an ADHD and autism spectrum disorder question. Exactly. But specifically referring to genetics in the family.
00:41:35
Speaker
So I just want to get this term epigenetics out of the way because for quite a period, it's been sort of a bit of a buzzword. All it means, all it means is the process by which your genes affect how your brain develops or how your body develops. Explain again. So, okay. So let's say you have your, your genes are like a recipe for yourself. Love that.
00:42:04
Speaker
Epigenetics describes the process by which your environment... So there isn't like a one-to-one correspondence between your genetic recipe and how you turn out. It doesn't determine everything. Environment also determines how you turn out as a person, as a human being, as an organism, you know, all of those things. Epigenetics just describes the process by which your environment affects
00:42:33
Speaker
the expression of those genes and how much genetic influence there actually is on the final product. The creation of the phenotype. The creation of the phenotype. I mean, you will notice this if you listen to these episodes a lot. I will try and relate anything my dad says to just anything that I understand. Okay. Anything I understand, I will try to apply it in absolutely anywhere I can. So the epigenetics simply describes that process of look at how much
00:43:01
Speaker
how your environment affects your genetic manifestation. Exactly, this whole manifestation thing again. So it's a good word. That is exactly, that is all it, that's all it is. And in fact, so it may be, and we don't know yet that there are certain things about early environment or trauma that make certain genes become more expressed and therefore your tendency towards ADHD becomes actual ADHD. Don't understand
00:43:30
Speaker
So, okay, that's absolutely fine. Let's say your genetics sets you up to have a 60% chance of having ADHD. Right. There is a little bit of a way of looking at it, but I'm with you. Okay, so you might have one upbringing, which means that you don't, this doesn't actually happen. You may have another upbringing, which may be more stressful. Die with the stress model. Exactly. So I think that's the element by which you can have another way that environment can influence
00:44:01
Speaker
how ADHD you are potentially by influencing epigenetics. The problem with that model is we don't actually have evidence for it actually happening yet.
00:44:12
Speaker
Oh, I mean, is part of that because you can't identify how much of a disposition people have? Yeah, part of it is how muddy the whole evidence is. Yeah, you can't look at somebody without ADHD and be like, oh, they had a 20% disposition. So it must be an environmental thing. But you can look at all of the associated genes and see how many people have. True. That's very true. So you can do a little bit of that.
00:44:40
Speaker
Right. That's very interesting. So question was epigenetics of ADHD and the high rate of concordance with ASD within families. So we talked about comorbidity with ASD and ADHD and how it's linked to just developmental differences.
00:45:01
Speaker
How does that link to familial aspects and how does that link to epigenetics? So I think so when I first thought about this question I thought well it doesn't really link to epigenetics but I'm sort of willing to accept that it might do. Broadly speaking
00:45:18
Speaker
Autism and ADHD run in families because families are biologically very similar and to the extent that they are biological phenomena that your ADHDness or your autisticness is determined by your biology broadly then of course it's going to run in families, of course it's going to be
00:45:39
Speaker
families are going to be concordant, which is what that means, as regards, so we are concordant as regards ADHD, you and me. True. For real. However, epigenetics might, it possibly could add an extra thing into the mix whereby the fact that you have the same environment amplifies that tendency for families to have the same
00:46:06
Speaker
I'm coming back to the point where the point that ADHD is a collection of symptoms. Yeah. And whether some symptoms may not directly come from the ADHD, but rather from the environment. Yeah. And that that may, it doesn't give you ADHD, but it may push you over the line for diagnosis. Do you think that that is? It is plausible, but of course,
00:46:28
Speaker
you can't say on one hand that ADHD is a cluster of symptoms and then that a symptom doesn't come from the ADHD because the ADHD is the symptoms. That's true. That's a really good point. But you know, if there was a way to look at where symptoms came from and then you found out that you had this, the way that you socialized was, well, maybe not caused by the way you were raised by your ADHD parents, but
00:46:55
Speaker
influenced. Yeah, I mean that makes sense as well, doesn't it? If you live in a family where everyone's very, very talkative, chances are, you're also, excuse me, I'm in this family too. Go on. If you live in a family where everyone is very talkative, then you will start to be imprinted with the idea that being very talkative is a typical way, a normal way of
00:47:18
Speaker
being and therefore you will be... Then I'm contradicting my own statement because there's no biological thing that means that you're going to talk a lot. Okay. There's a possibility, I believe it, I mean again, I have no expertise in this,
00:47:38
Speaker
that there are biological changes within the brain that can mean that there are certain changes, like the understimulation thing, that mean you're more likely to talk more, but the way that you're raised is really going to affect the way that that manifests. Yeah, exactly. I think it's perfect.
00:47:55
Speaker
Let's go. There we go. Tess has cracked it. I've cracked it. And we are now on the last question of this episode. I had another question. I've forgotten it. Oh, yes. I really, really wonder before we move on. I am so curious as to how this changes with adopted children in ADHD families. Right.
00:48:20
Speaker
because that has got to be a whole other, what is it they say, can of worms. Kettle of fish. Kettle of fish. Kettle of fish. I've never heard.
00:48:29
Speaker
You've not heard kettle of fish. You've got the fish in a kettle. It's not on a roof. It's an old phrase. Kettle meaning pot. How small is a fish? It's not an actual electric kettle. It's an old word for pot. I mean, I just, uh-uh. The Victorians had a way with words. That's kettle fish. They had a way of life, man. Kettle fish. Anyway, all right. Well, the thing is, I talked a bit earlier about a heritability. Yeah.
00:48:55
Speaker
Future Max here, heritability is the extent to which a particular trait or condition is inherited as opposed to being acquired. And it kind of goes from 0 for something that's entirely acquired to 100, which is something which is entirely inherited. I didn't make that quite clear enough. That is all.
00:49:15
Speaker
And heritability estimates are based on what are called twin studies and twin studies essentially are based on adoption because what you do in twin studies is you study twins that have been raised together and you compare them to twins who have not been raised together.
00:49:32
Speaker
Yes. Um, so all of the, all of the estimates of heritability, the very high estimates of heritability kind of come from adoption studies. I mean, again, there's that other thing of, if you look at the environmental aspects being adopted as a whole process, depending on what age you got adopted, you might have like existing trauma. Exactly. And then again, depending on the circumstances of the adopted child's parents, you might not be able to look
00:49:59
Speaker
at their family history with ADHD and autism. So there's all sorts of issues with actually being able to research this in a perfect world where we could get an entirely representative sample of people who have been through trauma, people who, well, you know, cut that bit out, where you could get an entirely representative sample. This would be something great that we could look into, but I just don't know if it would be possible. It might be possible, but the results probably wouldn't be very good.
00:50:25
Speaker
No, I mean, but we, I think we have tried and I think what, you know, what I'm saying is that the adoption literature has really supported the idea that ADHD is primarily biological, at least in some senses. What's the take home of
Biological vs Environmental Influences on ADHD
00:50:41
Speaker
this? And then maybe people who are either adopted themselves or are adopters or foster carers, that if your child is presenting with ADHD symptoms,
00:50:50
Speaker
it's quite likely that they just have ADHD. Yeah. But their previous trauma or previous experiences will of course influence how their ADHD tendencies and traits manifest in the world. But it won't, it won't have given them ADHD. No. That's not, that's the point. That's a very good way of putting it.
00:51:11
Speaker
That's your second take home. Please make sure you're taking notes, there will be a pop quiz. They will not be a pop quiz. Don't worry, there won't be a pop quiz. Okay, last question.
ADHD Misdiagnosis in Women
00:51:20
Speaker
Why ADHD in women is often not seen or misdiagnosed by other diagnoses? God, I wish I'd written my essay on this! Ah, okay.
00:51:30
Speaker
Your essay was very good, Tess. I wouldn't, you know, don't have regrets about it. I'm going to write another essay. I wrote my essay about autism because there's a similar issue with this in autism. Yeah, women being misdiagnosed and not being diagnosed.
00:51:45
Speaker
So I think there are two main thrusts to this. I actually don't know the full answer and we have but we have had some interviews, Ana Maria Patera, who talked about this, talked about masking our very, not first episode, the first episode we recorded, not the first episode we put out.
00:52:00
Speaker
Um, but yeah, you have to say to a book with anna maria batura and I will put actually incidentally if there are uh episodes of this show which Maybe of relevance to this. Uh, these questions. I will put links in in the show notes. Um The test is now torturing the dog for a reason Right answer your question. I think the broad
00:52:23
Speaker
thrust of this should be twofold. In childhood, often girls with ADHD are not picked up because the presentation is much less disruptive than boys. So boys with ADHD are often picked up because they are getting in trouble and as part of the process of how are we going to keep this person in the school, etc., someone thinks about ADHD.
00:52:47
Speaker
Yeah. I mean, a huge part of ADHD is impulsivity and a huge part of being raised as a woman is self-control. Yeah. And so when you get those two things overlapping, it means that all of this impulsivity is kind of compressed and pushed down. So you don't get it in school, which is where a lot of, because when you're getting it, I don't know if this is true for everyone, but when I was getting my diagnosis, a huge input into it was from my teachers at school.
00:53:16
Speaker
Yeah. So if you're not presenting in that way at school, that's going to hugely affect your chances of getting a diagnosis. Exactly right. Let alone a referral because a lot of people's parents don't really know what ADHD is. No. Right? But teachers, and so therefore the responsibility kind of does fall on the teacher a little bit. Yeah, a little bit.
00:53:37
Speaker
And then if the teacher isn't picking up this behaviour because the behaviour isn't being exhibited at school, they're not getting that referral, let alone the diagnosis. They're not even getting seen by a doctor. Exactly, exactly, exactly, exactly. So that's, I think, a lot of the dynamic when it comes to girls and school. When it comes to sort of adult women, I'm afraid to say that quite a lot of the
00:54:01
Speaker
women being missed is to do with the way that women are viewed in the medical system. I think people make assumptions that women have anxiety and depression unless proven otherwise and women who are struggling with
00:54:17
Speaker
maybe disruptive behaviours or behaviours which are self-destructive or which are antisocial will often get slapped with a kind of, and I do use the word slapped because I don't, I'm not a big fan of these diagnoses with like a personality disorder diagnosis. What do you mean?
00:54:35
Speaker
So, well, a personality disorder diagnosis is kind of, and I'm probably maybe being a bit unfair here, but it's always seemed to me to be being a bit like you have a little bit of a broken brain and that means that you respond to things in a way that isn't positive and isn't helpful.
00:54:55
Speaker
So you have a tendency to be over emotional or you have a tendency to be impulsive or you have a tendency to act in self destructive ways. Right. All of which are features of ADHD.
00:55:07
Speaker
That's true. But I mean, which, because there's a lot of personality disorders in the diagnostic. Oh, huge numbers, narcissistic and antisocial and blah, blah, blah. Is there a specific one that you're talking about here? Because there's a lot of personality disorders. So a lot of, I think, I mean, I don't, I mean, I don't want to necessarily advise somebody who has, for instance, a personality disorder diagnosis to immediately march down to their doctor and demand to be reassessed.
00:55:32
Speaker
However, we do see quite a lot of people who have a diagnosis of borderline personality disorder being reassessed and eventually getting a diagnosis of ADHD. That's one example or autism. So that's one example. You know, that's not to say that if you have borderline personality disorder that you definitely have ADHD because you might just have borderline personality disorder. You may have borderline personality disorder. I know it's a controversial diagnosis. I mean, it's very frustrating as well because people with borderline personality disorder
00:56:02
Speaker
Well, oh, I don't know if this aligns with your beliefs, but I don't know. Go on. I mean, people with Borderline Personality Disorder probably won't be taken as seriously because people don't see it as a real disorder. Yeah. Because, and whether or not you think it's a real disorder, like people who are struggling with these things still deserve to be taken seriously. Exactly, exactly. They absolutely do. And because not only is it massively diagnosed by
00:56:26
Speaker
women, but it also is often misdiagnosed, so it's not seen as like a real disorder. No. And it's seen because it's a personality disorder, it's almost seen, and there's evidence for this in the research literature, it's seen as something that you can't treat. You just have to support the person. You can't actually treat them.
00:56:50
Speaker
I mean, it's something that's built into the brain, but that doesn't mean you can't tackle the symptoms. Well, ADHD is a classic example. So to go back to the question, I think there's slightly different things going on, but ultimately underneath it all is expectations of girls and women and how they are kind of
00:57:07
Speaker
socialised to be quiet and sociable and how that means that they don't present in typical ADHD ways. And it may be that there is something biologically different about women with ADHD that influences how hyperactive and disruptive they are. But I think culture is really important here. And I think that we are, I think, getting better at picking up ADHD in women and girls, but we have a long way to go.
00:57:39
Speaker
That probably is a good point to finish since we've been recording for an hour. Oh my god, how are you? We're talking for an hour. Which is the length of our normal, well it's a bit longer than our normal episodes actually. I'm telling you, time flies when you're not spending the whole time making sure your face looks okay in the little picture of yourself in the corner. You know, I spend the whole time just touching up my hair. Listen, if you are listening to an episode of our podcast and I've been quiet for a really long time, you know what I'm doing.
00:58:04
Speaker
Are you fiddling with your hair? Right, so that is episode one of our epic three episode episode Q&A miniseries. It's a trilogy. It's a trilogy. The others will probably be shorter. But we thought we would lay the scientific groundwork for ADHD today. And I think we have. I think we've exhausted ourselves. We've certainly exhausted the dog. And now I have to go to another meeting. So it's a good time to stop. I'm going to have a nap. Bye bye. Bye bye.
00:58:34
Speaker
Play the intro again. So one thing I forgot, we would do not have advertising on the podcast and we're not going to monetize the podcast, which is an awful word, but there you go. What we would really like to, if you enjoy our content, if you've enjoyed that episode, then please do go to the ADHD UK website and donate to the charity. It's a charity. It is a charity.
00:59:00
Speaker
They support us, they provide us with backing and they pay for the... It's not going into our pocket. No, no, we make no money from this. I'm a trustee of the charity, but I obviously don't get paid by them either. I'm a cancer. What? That's why I stole some. Oh, okay, fine. Cut that out. I hate my life. And yes, if you could give anything you can give to benefit the charity, that would be really, really great. All right. No pressure.
00:59:29
Speaker
No prash. Bye! Bye for real this time. Play the intro again!