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ADHD science episode 14: Giorgia Michelinin
766 Plays7 months ago
Today we are joined by Giorgia Michelini, a researcher who has done so much great work on ADHD, but today talks to us about her study of EEG in the diagnosis of ADHD.
The paper we discuss is here.
email us as [email protected] to let us know what we can do differently, or better.
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Transcript
Introduction and Host Welcome
00:00:13
Speaker
Hello. Hello. I'm Max. I'm Tess, Davey. Welcome to the 14th episode of the ADHD Science Podcast. How are you Tess?
00:00:23
Speaker
Oh god, so many questions. I'm okay. It's not an unusual one for me to ask. You still caught me off guard. I did. My air levels are very soon, so I'm a bit stressed about that, but I'm going to live. Everyone crossed their fingers for tests to get brilliant grades. Yes. One like of this podcast equals one prayer. Yeah, that's a good one.
00:00:47
Speaker
A five-star review is five step five prayers for the price of one interaction. Exactly right. We're doing some great deals on this podcast
Guest Introduction: Georgia Michelinie
00:00:57
Speaker
today. Today on this podcast today we are going to revert to our normal format of an interview today with Georgia Michelinie. Georgia is a lecturer at Queen Mary's University
00:01:10
Speaker
Also does some work with Kings College London and is basically really interesting about all sorts of things But today mainly talking about the usefulness of EEG in helping with diagnosis of ADHD Very kind of really good chat actually basically someone who knows an awful lot about all sorts of different aspects of ADHD If you're thinking what's an EEG don't worry. We will get into that
00:01:37
Speaker
We'll get into all of that. So without further ado, we will get you into the episode, not too many more before we take a summer break while Tess does her A levels. And then we will just have to see how everyone feels when those are done. Yeah. All right. But anyway, for now, enjoy the episode. Enjoy.
EEG's Role in ADHD Diagnosis
00:01:59
Speaker
OK, hello, welcome. So we are joined today by Georgia Michalini. Is that how I pronounce that correctly? Michalini. Oh, there we go. 50-50. Lecture and researcher in psychology at Queen Mary's University of London. And we're going to talk about, well, we're going to talk about EEG and treatment and all those sorts of things. So welcome to the podcast. Thank you so much for having me. I was looking forward to it.
00:02:27
Speaker
So I picked up a paper of yours, which I'm going to read out the title and I think probably the first part of this podcast is going to be explaining what your
Research on EEG and Medication Response
00:02:39
Speaker
title means. And then I think people will go, okay, so just hang with us listeners, because it's going to start off a bit, a little bit rocky. And then we'll get to why this actually matters and why this actually really kind of made my ears prick up and some of your other work.
00:02:54
Speaker
as well. So it's electrophysiological and clinical predictors of methylphenidate, quanficine and combined treatment outcomes in children with ADHD. So let's unpack
00:03:05
Speaker
Well, let's unpack the first part unpacking that. So Tess, take away number question. Number question. Number question one. So in your research, what question were you answering? So it is true, first of all, that the title is a bit of a mouthful and it's partly because it's in a psychiatric journal.
00:03:27
Speaker
it's a little bit, it should hopefully be clearer for clinicians, but maybe it's a little bit less clear for everyone. So the study here did investigate measures that could be useful for predicting whether a child with ADHD will be likely or not to respond to certain medication treatment. So in terms of types of predictors,
00:03:51
Speaker
we investigated electrophysiological markers, so measures that would come from an EEG recording, and I'm sure we can talk a little bit more about that as well, as well as clinical predictors.
Discussion on ADHD Medications
00:04:04
Speaker
So that would be measures that could be routinely collected by a pediatrician, a psychiatrist, things like severity of ADHD or whether there are other mental health symptoms in the person, things like that. So they are a little bit more readily available.
00:04:20
Speaker
than the EEG recordings. With the EEG, it's essentially some electrodes placed on someone's scalp that are meant to record their brain activity in real time. So it is often used while people are doing absolutely nothing, so it's called at rest, or it can be used while people are completing a task during either, you know, in
00:04:49
Speaker
in the real world or on a computer. So in this case, for the study, we had children with ADHD complete a working memory task with this EEG recording their brain activity. And they did this EEG recording before they were put on three types of medication treatment for ADHD.
00:05:15
Speaker
One was methylphenidate. So it's the first line treatment for ADHD. It's a stimulant medication. The second one was guanficin, which is a non-stimulant option. So it is usually one of those considered when stimulants don't work. So if somebody does respond to stimulant or doesn't tolerate them well, they might try guanficin or other non-stimulant medication.
00:05:42
Speaker
And then the third type of treatment was their combination. So essentially people were taking both metafenetin and guanfosin together. And it was with the idea that their combined effect could create greater benefit in a way.
EEG and Treatment Response Prediction
00:05:58
Speaker
Now, the background of this was that there had been other studies in the same sample that have found greater effect of the combined treatment
00:06:11
Speaker
on ADHD symptoms and functioning relative to metaphenidate only or guampas in only treatment. So what we wanted to understand here was whether we could use some of these EEG measures as well as these more readily available clinical measures to understand why some people were responding better to these three types of treatment essentially.
00:06:38
Speaker
Does this clarify a little bit what the title is and what we set out to do? I mean, when you say, just for the audience really, but when you say stimulant medication, non stimulant medication, how would you describe the difference there? That's a great question. It's essentially a difference in how these different medications work. So
00:06:58
Speaker
stimulant medications work essentially trying to increase the level of dopamine and norepinephrine in the brain. So these are two chemicals that are strongly involved in
00:07:14
Speaker
things that underlie ADHD like attention, impulsivity, ability to control movement and things like that. So by increasing and stimulating the level of these chemicals in the brain, then the stimulant medication seems to have an effect on ADHD symptoms.
00:07:35
Speaker
non-stimulants are another class of medications that don't work on stimulating, but rather they sort of have an opposite action. So guantasin, as an example, is an antagonist of another type of receptor within the brain, and so it has a slightly different
00:07:59
Speaker
way of functioning. And that's why it's sort of an alternative option. When the stimulant option doesn't seem to work, then there might be the possibility that the non-stimulant type of mechanism would then be useful for people with ADHD. And then their combination sometime would then be even more beneficial because you might need a bit of both of these two mechanisms of action to then have some clinical benefits.
Effects of Stimulants vs Non-Stimulants
00:08:29
Speaker
Yeah, it's a very interesting distinction between the two and in a sense stimulants are more of an immediate hit. They kind of change the here and now of your brain chemistry and they wear off, they're broadly gone. Whereas the non-stimulants
00:08:46
Speaker
by sort of conventional clinical wisdom. And it certainly had been my experience. They take a while to kind of build up. They are much slower. You can see the stimulant effect within a few hours and then it wears out by the end of the day. Whereas with this non stimulants there may need to be weeks to take effect. It's almost like it changes the architect the way that your brain responds to things rather than just being in the moment.
00:09:15
Speaker
So does a non-stimulant have a longer lasting effect? They, I mean maybe Max knows better than me about this. I did ask him, but it's obviously. No, no, go ahead, go ahead. It's essentially the stimulant as a non-stimulant as well. They need to be taken continuously. So
00:09:34
Speaker
There are actually studies that show that discontinuing stimulant medication can have negative effects because they are not medications that you can take for a few months and then they will give you long lasting benefit. They need to be taken
00:09:52
Speaker
on a daily basis. And then sometimes with the stimulant effect, the good and bad thing of their very fast action is that you can, people sometimes decide to take sort of meds holidays, they say, or they will maybe not take them at the weekend because they don't need to sit still the whole day during the week and they can just be full of energy and be there.
00:10:20
Speaker
100% through self or during summer holidays they might have a break from medication but then when it is needed to say sit still at school or during work be focused all the time then that's where the medication can can help some people.
00:10:40
Speaker
Yeah, I mean sometimes in more seriously, you know if the medication is affected some of the Appetite so some of the younger children I look after where they're not really gaining weight During the because they're not really having enough calories Then you can take them on you can take them off the medication over the weekend. They basically eat all weekend Get up
00:11:01
Speaker
And another effect, one of the side effects that is known is on height. So some people actually, you know, there are studies that show that people that are children that are on stimulant medication don't grow as tall as they should. So that can also happen. I mean, it's a small effect, but it's certainly worth mentioning. Do you think that's connected to the lack of nutrients from the lower diet? I mean, the lower appetite, sorry.
00:11:27
Speaker
don't really know, maybe Georgia knows, but I don't think it's just the lower nutrients. I think there may be a more direct effect on growth hormone.
00:11:34
Speaker
Yeah, I actually don't know much about that. It's just one of those things where, you know, it is, there are, you know, treatments that need to be taken continuously. So they will have their side effects. And that's why it's totally fair for some people to not want all families, parents not to be keen on their children to take them continuously. But to go back to your question, Tess, yes, broadly speaking, if you're in a non stimulant, and once you've got past that first few weeks of getting it off the ground,
00:12:04
Speaker
I would say that also needs to be taken every day, otherwise the overall effect is going to start to tail off. But if you miss one dose, it doesn't really matter. But you do get a continuous effect from it because it's built up over those few weeks. There is also, it appears, an immediate effect from where you give the dose. It doesn't matter when you give the dose.
00:12:25
Speaker
during the day for non stimulants. And sometimes that can be helpful if you've got sleep difficulties or something else like that. But there's also this background hum of effect, I almost think of it as like a background hum of just generally calming things down. And that is a 24 hour phenomenon for the non stimulants. So if they can, if they do work,
00:12:45
Speaker
and they don't always work, which is one problem. They can be really, really helpful, super helpful. So how does this link to all of the, what was it, the EEGs?
Predicting Treatment Effectiveness with EEG
00:12:55
Speaker
Yeah, so that's the next question. And I guess that that's, you know, like the point that Max just raised is that they don't always work. So, and figuring out whether stimulant work or maybe non-stimulant would be better, or maybe you need both. It's a trial and error process that can take weeks or months.
00:13:12
Speaker
right so a child you know a seven-year-old child that is put on stimulant first they might try stimulants for a few weeks then they go back to their psychiatrist or penetration and it didn't really work very well so let's maybe try this other thing um maybe that doesn't work either and non-stimulant you need to actually wait for a bit longer to see whether it works a lot so you know
00:13:34
Speaker
months have passed and maybe let's try both of them together and maybe let's try something else you know more physical activity or let's do some behavioral intervention. All this can take months or years sometimes which in the time
00:13:51
Speaker
pan of a child can make a huge difference. It could be a whole school year wasted or with very significant difficulties and all this time that could really be saved and difficulties and struggles. So the whole idea of trying to identify measures that we can call biomarkers, for example,
00:14:15
Speaker
that would be able to predict response to these treatments is that that could really save a lot of time at the outset of somebody receives a diagnosis of ADHD and then there is a test that can tell them with some certainty
00:14:32
Speaker
that they will most likely benefit for treatment A and not from treatment B. And then their potent treatment A, they start showing effects within a few days or weeks. And then this trickles down to them having better quality of life, not having difficulties at school, things like that.
00:14:52
Speaker
Yeah, exactly. So our question two, what did you find? So the study here was an eight week trial. So by looking, we looked at these EEG markers alongside with these clinical markers, and we essentially found some patterns of EEG activity measured at
00:15:15
Speaker
from front to center regions of the brain, so we call it mid-frontal EEG activity, essentially from this kind of area, when people are not on video, not seeing, but the sort of the mid, the center of our brain, frontal regions. EEG measures from that era essentially was able to predict the amount of improvement in ADHD symptoms from pre to post treatment.
00:15:43
Speaker
In the clinical trial associated to this, all three studies, all three medications showed a degree of improvement. And so we wanted to figure out whether some EEG measures and clinical measures were able to tell us, predict this improvement essentially.
00:16:02
Speaker
And what we found was that, as I said, this mid-frontal EEG activity predicted symptom improvements in ADHD in response to these three treatments, but showing sort of like a different pattern depending on the medication that they were put on. So this essentially means that different profiles of brain activity
00:16:29
Speaker
may benefit from different types of treatment. So if you have sort of like EEG pattern 1 you might be more likely to benefit from one type of treatment. If you have another EEG pattern you might be more likely to benefit from another type of treatment.
00:16:52
Speaker
So this creates a sort of like a dissociation in the sense that it's then possible to kind of identify these individuals from our analysis that did show these EEG profile based on their mid-frontal brain activity and then see that they were more or less likely to respond to the medication that they were put on.
00:17:18
Speaker
Which is, which is amazing because it, like you say, it saves time, money and inconvenience and could lead potentially to better treatment. I'm kind of moved to ask of course, I must ask, how strong are the predictive, how strong is the predictive power of having, and we're not, I don't think you're right not to go into alpha, delta waves and big, you know. Yeah, it's like, to get into mouth or? Unnecessary Greekness.
00:17:46
Speaker
Nothing wrong with being Greekness. No Greekness is unnecessary. But you know what I mean, unnecessary Greek alphabet. How strong are the correlations? How strong a predictor would be, e.g. pattern one for... Oh, methylphenidate is going to work for you, therefore.
00:18:03
Speaker
Yeah, they are not huge effects. So the important thing to discuss is that these sort of EEG markers are not meant to be considered on their own. And that's actually something that we did also demonstrate in another analysis, shown in the same paper, where essentially we looked at what happened if we were combining this EEG predictor with the clinical predictors.
00:18:32
Speaker
The idea of this is that it would be most unlikely that you just want to predict the treatment outcome by recording their EEG activity. You have all this other information as well. So what if we throw them all in the mix to try and predict the treatment outcome? Because you would never just do it on an EEG. Yeah, exactly. So you would always ask the parents about the symptoms of the child, about the symptoms, how they're doing in school, and so on. So you have all this other information. How can we use it?
00:19:00
Speaker
And what we found was that the clinical measures on their own had the smallest predictive ability. So they were really not good at telling whether that child would be improving or not with the medication. So that's very disappointing for me. Yeah, but that's quite... I mean, it's not unexpected in a way. It's incredibly powerful. Why on earth have you not been predicting this all along? Good. Okay, fine. Yeah.
00:19:28
Speaker
The EEG measures on their own, they were doing slightly better, but still not to a great extent. But the combination of two types of information was what was actually giving us a little bit more accuracy. So we found that
00:19:46
Speaker
basically aggregating these clinical NEG measures predicted the future improvement in ADHD symptoms with twice as accurately than using the clinical measures on their own.
Combining EEG and Clinical Measures
00:20:01
Speaker
Okay so that's I mean twice as accurately as not accurate is still not it doesn't necessarily tell us it's brilliant. Yeah it's better. Yeah but it's better and what are the clinic do you want
00:20:13
Speaker
oh no um okay so let me know if i've misunderstood how EEGs work completely but don't you get like a bunch of different wave patterns and you can look for specific wave patterns to find which how did you know what you were looking for
00:20:28
Speaker
So the analysis, the sort of processing of the signal from EEG can be quite different based on different conditions that you want to look at. So it is one of the most common and well-known use of EEG is for epilepsy, for example. So with epilepsy, you get the recording, you're just like, oh, these wiggling lines, one,
00:20:51
Speaker
per each of the electrodes that you have on the person's head and then just from that with your neck and eye you are able to identify that some bits of it look a bit odd and that's where there is a sort of epileptic seizure and then that's that's quite a more straightforward type of analysis.
00:21:10
Speaker
when we want to identify EG markers associated with ADHD or depression or some other behavioral outcome we need to do a lot more digging and that means a lot of analysis of flying of these signals trying to quantify whether that signal is oscillating in a slow way or in a faster way and so the
00:21:35
Speaker
quantifying how much of these kind of faster waves and how much of these faster slower waves there are is one of the ways that we can use to get these types of EEG patterns that are used in more mental health research and vulnerable disorders like ADHD.
00:21:58
Speaker
Yeah, so there's not a specific pattern of waves that you're looking for, so it's not like it goes up a lot, and then up a bit, and then, you know. It's not like a signature, yeah. It's a little bit more difficult to identify. It's a lot of computer power, such as I can imagine. Looking at correlations and patterns in that way.
00:22:18
Speaker
I'm curious, what were the clinical, I know that they're not that powerful on their own, but what were the clinical markers that were significant in predicting treatment? The most significant ones were ADHD symptoms, the severity of ADHD symptoms, and then also levels of oppositionality and anxiety.
00:22:41
Speaker
Interesting. So just to just to spell that out, the more severe the symptoms, the more likely they are to respond. So it kind of depends on the on the measure. So of the clinical measures that were predictive of improvements after treatment, we found that greater
00:23:05
Speaker
levels of hyperactivity and positivity and well as oppositional behavior before the treatment were both predictive of greater improvement. So basically a child that shows greater hyperactivity and positivity and more oppositionality was then more likely to respond to these treatments. And then the other finding was a lower anxiety. So the children that were less anxious were likely to benefit from the treatments more.
00:23:35
Speaker
That's so interesting and this you may not have looked into this but one of the things that I find clinically is children who are more anxious before treatment are less likely to tolerate stimulant. Could well be yes so they they might be that they are responding less also because you know they are they just want to take it you know they might. When they can't cope with it how does that manifest? What do you mean by that? Well in a way
00:24:02
Speaker
I have this very simplistic way of explaining stupid medication, which actually kind of matches with how I experience them.
00:24:09
Speaker
I have taken them myself that they are a they're like a cup of coffee that lasts all day and like a cup of coffee stimulates you and if you have too much espresso you've probably you've never done it obviously Tess you've never overindulged in caffeine honestly any caffeine for me is too much especially when I'm already on my medication which I guess makes sense with this analogy literally having a cup of tea it's a cup of tea it's very different with milk so I suppose yeah
00:24:34
Speaker
Anyway, so a large amount of caffeine will give you the physical sensations of anxiety without the cognitive component of anxiety.
00:24:48
Speaker
you know, oh, I'm terrible, or I'm going to fail my exam, but you will have the same physical feeling in your body. And actually, that's the reason I stopped taking this stimulant medications because at a dose that was effective enough to actually make a difference to my symptoms, I was having during the middle of the day, this kind of physical sense of gnawing anxiety, even though I was in myself perfectly fine. I wasn't particularly anxious. But if I also was in my cell,
00:25:17
Speaker
Yeah, it was unbearable. So I stopped him. So I just I suppose I would I would sort of guess that I have authorised that that might be contributing that the anxious children pre-assess a pre-treatment are dropping out more because they're just not, they just can't manage it. Or they could only manage with really no dose.
00:25:39
Speaker
Yeah, maybe they could still be taking the medication as prescribed, but then they will sort of report a lower reduction in ADHD symptoms that might just be like a non-specific feeling of not feeling great because of this anxiety that is induced by the medication. So that makes a lot of sense. Another thing that is worth mentioning here is that these, you know, ADHD symptoms of positionality, anxiety,
00:26:08
Speaker
did predict treatment response, but in the same way across treatment. So that means that with these measures alone, you can say, okay, a child that is higher in hyperactivity will most likely respond to any of these treatment. So then that's not really useful because it doesn't tell you again, which one is more likely to work.
00:26:29
Speaker
So that's why the combination of the clinical measures with the EEG measures then gives us more precision in being able to say this treatment will be better than this other one. Yeah, exactly. And so if in the future we have access to that sort of biomarker at the beginning of treatment, then that would be really fantastic to kind of
00:26:55
Speaker
help us to predict what treatment we might be helpful. So I suppose that leads us on to our third question. It sure does. Our third question is, as always, what does this mean for people looking after people with ADHD?
00:27:12
Speaker
Yeah, it's, I mean, Max put it right that, you know, it is something that in the future could happen. So these are still experimental findings. It's a, you know, it's a trial that was relatively large for being a treatment trial of ADHD. We had about 200 children, but still the findings definitely need to be replicated in a larger sample across different contexts. You know, it was a US sample.
00:27:40
Speaker
it's not been tested in the UK or in other countries so that's something to
00:27:46
Speaker
and also across different types of people with ADHD.
Further Testing and Cost Benefits of EEG
00:27:52
Speaker
Of course, the ADHD community is not just one type. Here it was a study with mostly boys with ADHD, so we didn't really have the ability to tell whether boys or girls would respond, would have like the findings would be similar across the two. So again, it would be really important to really
00:28:15
Speaker
spread it across, trying to understand whether these findings would replicate across different ages in samples with a higher number of girls or women as well.
00:28:27
Speaker
And then people with different presentations of ADHD or co-occurring conditions. So like all treatment trials, they are quite selective in who goes in this trial. So they will exclude a bunch of co-occurring conditions. They will look for people with certain characteristics. So it really needs to be replicated in much larger sample, much more diverse communities as well.
00:28:57
Speaker
In the future, if this happened and all was replicated, it's all well and good, then the next step would really be to try and run more practical, pragmatic trials within primary care or specialist care.
00:29:21
Speaker
you know really test what is the benefit from for the patients for the family but also in a cost benefit analysis of using this new technology alongside the clinical measures versus just doing what we are doing now.
00:29:39
Speaker
So does this new way of predicting treatment response lead to better, faster response to medication, better quality of life for the patient and the family? And maybe does it also save money long-term? Because you can imagine that if you put somebody on the right medication from the outset, then you don't need to have
00:30:05
Speaker
too many follow-up visits where you continue changing medication and titrating a little bit and increasing, decreasing the dose. So maybe even though you would need this initial cost of the EEG technology and the technician that gives the EEG and somebody that analyzed the data, that of course comes with cost.
00:30:25
Speaker
But maybe there could be money saved in the long run. And so from a cost-benefit analysis, that might could then end up being beneficial. So all this still remains to be done. And to my knowledge, it hasn't been tested for any of these types of EEG markers.
00:30:43
Speaker
or in general, it's not something that is really done yet. With all of these measures kind of predictors of treatment outcomes, we are still very much in the more experimental and discovery phase of trying to identify measures that would be promising to then try to bring them forward for these more clinically relevant considerations. Yeah and I totally understand the excitement of this and I share something that I get asked about
00:31:13
Speaker
several times a week when we're starting treatment is you know how do we is there a way of telling what's going to work and it would be lovely to be able to say yes but we do still need to answer that question is is it going to save the money that we need would need it to say in order for it to be cost neutral i mean it doesn't have to i wouldn't say it has to be cost neutral if it also has benefits in terms of yeah better outcomes you know less exclusions from school those sorts of things but
00:31:39
Speaker
you know, cost neutrality would be a real help for trying to sell it five years in the future to the NHS particularly. But I think also in any kind of health system, cost neutrality is important. I wanted to ask a broader question because I know that you don't just work with EEG and you've recently published
00:32:04
Speaker
I think it's a review. I haven't actually read the whole thing. I just looked at it this morning. I have to be honest. I don't spend my whole time reading ADHD. And I'm also on holiday.
00:32:20
Speaker
I did look and you've done a review on treatment biomarkers more broadly. So is it worth it? A little bit at this point, a little bit of a sidestep into what the other biomarkers that you think are promising and where are we at in the field
Biomarkers in ADHD Research
00:32:36
Speaker
generally?
00:32:36
Speaker
Yes, so in the other paper that you are mentioning, we covered, it was a review, that's right, and we covered EEG biomarkers, but also biomarkers from MRI, as well as from genetic markers. So these three are really some of the areas where there is most research to essentially identify biomarkers or treatment response.
00:33:06
Speaker
It kind of like followed a lot of previous research that were focused a little bit more on just cognitive measures. So just measures of, you know, test of attention or memory on their own without looking at their underlying brain mechanisms. Now, all those cognitive markers didn't really show a lot of
00:33:28
Speaker
benefit over the clinical measures alone. So that's why that area has kind of been abandoned a little bit more. And in recent years, there's been a bit more enthusiasm towards these brain measures, either with EEG or MRI, fMRI.
00:33:45
Speaker
I have to say probably our assessment of the literature was that between the EEG and the MRI markers, we thought that the EEG ones might be a little bit more promising for two reasons. One is because of the type of findings that have come out that seem to be a little bit more convincing.
00:34:05
Speaker
Our study was one of them that seemed to be finding something promising for EEG. There have been some other ones that we also review of different types of measures from the EEG recordings. And then the second reason is also a practical one in terms of costs. So we were just talking about costs. The cost of doing an MRI or an fMRI for somebody is several hundred pounds.
00:34:30
Speaker
an EG will cost 25 quid approximately. So it's a lot cheaper. And here we're just talking. So much cheaper. So that is, and I'm not considering here the sort of technician time that would
00:34:47
Speaker
that would be added to both of these, essentially. But the actual materials that are needed for doing the EEG, that's a very cheap type of technology compared to MRI. So if we think of the scalability of this,
00:35:04
Speaker
of course EEG is a lot more practical. The other aspect is also another practical consideration is that with MRI it doesn't do very well with people when they're moving. You can think somebody with ADHD just lie there for one hour and don't move at all. I know you're six and you have ADHD but mind lying there for an hour completely silently and still.
00:35:32
Speaker
Yeah, so that doesn't do very well with that sort of what they're called motion artifacts. That's a little bit better. So it's a little bit, we are able to get around those a little bit better. So there's another consideration. Yeah.
00:35:50
Speaker
And then the third type of measures that are maybe even easier to get would be the genetics. And this is something that has become more of interest with the evolution of technology around genomics, essentially. So again, it used to be a lot more expensive to get someone's DNA and get their essentially
00:36:20
Speaker
that essentially get them genotype, which means they have a full idea of what their DNA looks like. And now it costs only, you know, a hundred pound or something. So that you just collect someone's saliva, you send it to a lab, and then very cheaply you can get somebody's genome mapped out, essentially. And what people in genetics now are doing is to
00:36:49
Speaker
essentially calculate what are called polygenic scores, which are measures of how many genes associated with ADHD that person has.
00:37:02
Speaker
Very roughly. Okay. So with this sort of measure, you're able to say, okay, that person has got very high risk for ADHD or high, um, diabetes for ADHD versus they have lower risk of liability for ADHD. And with that, um, single sample of saliva, you can get that same measure for ADHD, but for anything else.
00:37:28
Speaker
that has been studied in genetic studies. So you can look at risk for depression, for anxiety, genes that are associated with cognitive abilities, with educational attainment. So it really gives you, just with one single test, a huge amount of information about somebody's genetic makeup. So it's a very cost-effective type of test.
00:37:51
Speaker
But at present, it still has very little predictive power. So it has very limited ability to tell us whether somebody will or will not respond to certain treatment.
00:38:05
Speaker
And that's something that is possibly going to change in the future. So genetic research is very fast moving and they are identifying new genes associated with ADHD and other conditions every day. So these
00:38:22
Speaker
it's likely that these polygenic scores will become a lot more powerful in the future and then they could become more viable types of biomarkers for predicting treatment response or other types of outcomes but it's probably a little bit behind still. I suppose my the obvious question and it may be straying outside of your considerable reach in terms of as a researcher but still I'm going to try it
00:38:50
Speaker
People will only ever get this stuff done mainly once, so you'll get an MRI done once. How does that overlap with the work looking at using these diagnostically?
00:38:59
Speaker
to contribute towards a diagnosis of ADHD.
Challenges with Biomarkers in Diagnosis
00:39:03
Speaker
Yes. And that's also very interesting. So biomarkers of diagnosis is another huge area. And again, measures of EEG and MRI and genetics as well have been investigated to figure out whether they can be useful for improving the accuracy of our diagnostic assessments, essentially. There has been
00:39:24
Speaker
probably less headway in that sense, not because there has been less research, but because the findings have been very, very mixed. And you can look at EEG, you can look at MRI, genetics, that's kind of like general across this type of markers. And one reason that the field is thinking about is that
00:39:46
Speaker
There is just not one type of ADHD, of course. There is so much variability between all people with ADHD that it's very unlikely that you'll be able to identify one or even a set of biomarkers that will be
00:40:02
Speaker
confidently telling you that person has ADHD or that person has ADHD and is also autistic or they have ADHD and they may in the future also have depression. So it's a much messier picture. There's no one gene you're looking for.
00:40:21
Speaker
No I mean that's my impression of all of these sort of biomarker work is that the more you look the messier it gets and I think that's particularly, I think it excites me, it usually excites me partly because it is so easy to do and it's so dynamic and it's cheap and you know I think you could get, you could
00:40:40
Speaker
fairly easily build it into a workup for somebody with ADHD. But the MRI stuff, which people do get quite excited about, I've always been a bit sceptical of because it's so murky. And I found, you know, I think somebody did a paper looking at the different areas of the brain that have been implicated in ADHD and it's basically everywhere. Yeah.
00:41:01
Speaker
and everywhere and calling in different studies the opposite to another. And again, because of this huge variability in the population. Yeah, excellent. Speaking of the population, how about our penultimate question? Penultimate question. What does this mean for people with ADHD?
00:41:21
Speaker
For people with ADHD, I know it can sound like using these tests and you need to get a brain scan to be able to tell whether you'll respond or not to a medication. I know that not everyone in the community has been very enthusiastic about work on EEG and I know the autistic community in particular have been
00:41:43
Speaker
against the amount of funding that have gone into research or biomarkers with EEG or other types. So of course it's something that we need to be mindful of.
00:41:56
Speaker
It is worth just emphasizing why people are against it, just so we can kind of... Yeah, I was wondering about that. I think the argument is often that a lot of this research is very focused on mechanisms. So we try, we're looking at this brain marker and this brain activity to understand how, what's on the line ADHD, there's this region in the brain or this other region in the brain that works differently. And so it explains why people ADHD
00:42:25
Speaker
are more hyperactive or more inattentive. This is all well and good, but there is a lot of other research that could be a lot more clinically relevant and then actually be more likely in the short term to have an impact on people's lives. So the kind of
00:42:43
Speaker
argument for wanting to use EEG or other biomarkers in a more clinically applied sense is that you kind of get the best of both. So you can kind of understand what underlies it and what's going on, but also you can use this information for very clinically relevant outcomes, such as asking whether somebody is going to respond or not to a medication.
00:43:11
Speaker
if they're going to be put on stimulants or non stimulants. So in this sense, I feel like I'm hoping that the research in this direction, trying to understand clinical outcomes that are very salient for people and their families will have an impact. And the impact will be what we were discussing earlier. So rather than having to wait around for
00:43:35
Speaker
months or years until you find the treatment that works for you. You are kind of like saving all this time and from the outset, from the moment that you get a diagnosis, then your clinician will be able to tell you with a certain degree of confidence that this medication I'm giving you now is likely going to work for you and you will see effects within
00:43:58
Speaker
two, three weeks or even less than that. And that's something that is common across areas of medicine. You do a blood test and then you will receive a certain treatment and then your nutrition or your GP will be able to tell you, I'm giving you this prescription and you will feel better within a week.
00:44:21
Speaker
That would be, it doesn't always work. What can you do? Because blood tests are not really as accurate or useful as we think that they are. They're all great. Oh, and that just winds me up so much how much doctors love blood tests and that. Let's just find some blots and we'll figure it out. Yeah, exactly. Rather than just look at the patient. Anyway, that's just my particular soapbox. I'll step lightly off it. I mean, I actually, I get the critique of
00:44:49
Speaker
biological research in autism. I think it is fueled by a history of discriminatory attitudes, of course. And it is also that, you know, why are you looking into why we're like we are rather than helping us live our lives? I get that. But I think it's much it is a very different picture in ADHD. It's one of those areas where the two conditions actually diverge quite a lot.
00:45:13
Speaker
because there is a treatment for the core symptoms of ADHD, which there is not in autism. And what you're doing is basically how can we predict whether these treatments are going to work. So my prediction would be that you're not going to get that many ADHD people
00:45:29
Speaker
objecting once they understand your reference. Yeah, hopefully. Hopefully, this is a line of work that is well received. So yeah, and it's, but you know, it's got three votes from the idea. Okay, I think you're I think your search is fine.
Future Research and Community Involvement
00:45:48
Speaker
I can't vote because I'm not 18. Okay.
00:45:52
Speaker
But you know, involving people with ADHD in these solo decisions is so important and it's something that we are trying to do a lot more in our research. Over the summer we've actually with my group run a project with having a series of meetings with neurodivergent young people
00:46:14
Speaker
to identify new priorities for our work, so kind of identifying what our next funding application should be looking at. And it's been such a fantastic experience. We've learned so much and I hope it's been interesting and fun for these young people that work with us as well. And funding bodies are listening a lot more to people with ADHD, autistic people, people with all sorts of
00:46:43
Speaker
mental health conditions to really kind of try and follow what their priorities are. And I think it's fantastic. Yeah, and this links in very well. Seamlessly. Seamlessly. Well, we've just put in a seam now, which is kind of unfortunate. But with our final question, which is, what are you planning next? What's your next research question?
00:47:07
Speaker
Yeah, so kind of building on this study, more like community study that we run over the summer, we are now essentially looking to expand my group's research more in the direction of
00:47:25
Speaker
investigating why people with ADHD and neurodivergent people more generally increased risk for mental health problems over the course of adolescence and young adulthood in particular. So we are looking to do that using EEG measures again, kind of trying to figure out whether some of these EEG measures
00:47:45
Speaker
would be able to tell us whether somebody will or will not be at risk for developing depression in the future, for example, but also other types of measures that can be associated with these data outcomes such as
00:48:01
Speaker
you know information about their environment of course for mental health outcomes you know where you know the environment in which somebody is how much you know their social relationships for example the family connections are a lot are very important so can we use all this information to then be able to tell whether somebody who is autistic or somebody with ADHD
00:48:27
Speaker
would be a greater risk for developing depression or anxiety down the line. And that's something that I'm very passionate about and I think it's that one direction where neurodivergent people are really pushing. So I have been involved in
00:48:44
Speaker
And like mentioned in this, because it's such a fantastic charity initiative, Embracing Complexity is a coalition. Oh yes, I know them really well. Yeah, so I've been working with them for a few years and I was part of a special interest group on neurodivergence and mental health outcomes, really to try and investigate, you know, create greater awareness of mental health problems in neurodivergent people and, you know,
00:49:14
Speaker
essentially get more interest in this, more research in this overlap and involving people with ADHD and neurodivergent people in this is a very important part of it. So I hope that this research direction will be successful and useful. When we have a link, we have a link to our own podcast here. Is Embracing Complexity still run by other Georgia?
00:49:43
Speaker
Yes, she's actually, she's still kind of involved, but now there is another person, her name is Agata. Yes, Agata, yes. The need of the embracing complexity within Autistica, so yes. So, other Georgia whose surname I have forgotten. Harper? Hmm? Harper? No, Georgia Harper is one of the first people we interviewed for what was our previous podcast, which is the kind of princess of this podcast, Extraordinary Brains.
00:50:12
Speaker
to Georgia. She wasn't quite first, she was very early. I've known Georgia for a long time. It's fantastic. It's been great to work with them all. Don't listen to Georgia Harper's interview, which is a couple of years old now. Yeah, while you're there, listen to everything we've ever made. Finish this one for us. All 25 episodes of Extraordinary Brains.
00:50:36
Speaker
It's a big milestone for us, 25. Well, we have 12 episodes of this now, so... Oh, okay. We can drink in America now. Okay. Oh, that's 21. What are you talking about? It's not the number of podcast episodes you produce which allows you to drink alcohol. Yeah, I think it is. Okay, fine. That's what it means when it says on the wall of pubs under 25.
00:50:58
Speaker
Anyway, I think it's about time we wrap this up, so thank you so much. We hope to see you again sometime when you have another fascinating bit of work to do. Tess is now trying to extract the last bit of biscuit. No, I'm trying to get the last bit of tea out of my tea mug before I put it in the wash. Okay, all right.
00:51:23
Speaker
It's been a pleasure being on the podcast and chatting with you both. Yeah, thanks all for this great podcast that you're doing. Thank you very much. We'll look up the episode with George as well. Yes, exactly. All right. Speak to you soon. Bye bye. Bye bye. Bye.
00:51:38
Speaker
All right, so that was Georgia. All it remains to say is to please do share the podcast if you want to tell people about, you know, if you're enjoying it, if you find it useful. If there's a positive looking button on your screen, you should press it. Exactly. And if there is anything that you want us to talk about or do differently in the podcast, please do let us know. Contact us via ADHD UK, the charity that
00:52:05
Speaker
Sponsors us basically and helps us out with some support. So Other than that, we'll see you for our next episode. It's gonna be a Q&A Probably and hopefully in a week or so. All right. Bye. Bye