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Full transcript below

Paula speaks with Clinical Psychologist Dr Lauren Breese about some of the complexities, controversies and opportunities around ADHD diagnosis, particularly in relation to work.

The conversation includes:

• what ADHD is and how it might impact people in the workplace
• gender differences in ADHD presentation
• thoughts on workplace adaptations
• controversies and misunderstandings about ADHD
• the importance of a rigorous assessment process
• benefits of seeking an ADHD assessment
• navigating conversations about ADHD with empathy and curiosity

About the speaker:

Dr Lauren Breese is a Clinical Psychologist and founder of ‘and Psychology‘ (an assessment and therapy service for neurodivergent adults) and ‘The Neurodiversity Practice‘ (a service supporting ND parents, as well as workplaces and mental health practitioners to embrace neuroinclusivity.

Instagram:

@_andpsychology_

@‌theneurodiversitypractice

Linked In:

www.linkedin.com/in/drlaurenbreese

www.linkedin.com/company/theneurodiversitypractice/

Lauren’s recommended resources:

Podcasts:

• The ADHD Women’s Wellbeing podcast
• The Hidden 20%
• ADHD Chatter
• The Neurodivergent Woman

YouTube:

• How to ADHD – Jessica McCabe

Books:

• How to thrive with Adult ADHD – Dr James Kustow
• We have a free recommended booklist for ND parents to download here: https://www.theneurodiversitypractice.com/book-list
• Download our free neuroinclusion at work checklist to share with employers: https://www.theneurodiversitypractice.com/business

I’d love to connect with you so do come and find me on LinkedIn or at my website and do check out the ACP-UK and everything it has to offer.

Follow and subscribe so you don’t miss an episode!

Transcript

Paula Redmond (00.38)

In this first episode, I spoke with clinical psychologist, Dr Lauren Brees, to explore some of the complexities, controversies and opportunities around diagnosis. Our discussion includes common misconceptions about ADHD diagnosis, gender differences and presentation, how ADHD may impact people at work, navigating conversations about ADHD and more. I began by asking Lauren to introduce herself.

Lauren Breese (01:12)

I’m Dr Lauren Breese, a clinical psychologist specialising in working with neurodivergent people. I’ve worked in neurodevelopmental services in the NHS for over 14 years. And in that time, I had the opportunity to work with neurodivergent people across the life span. So I started working in cams with children and families and then I moved over to working with adults at the national specialist autism and ADHD psychological therapy team. And I’ve also set up two new clinical services as clinical lead for neurodivergent adults, and I’ve taught at universities and conferences all about neurodiversity. Now, though, I predominantly work privately and I founded two companies, the first one is And Psychology, and that’s a service where I assess for autism and ADHD and provide therapy for neurodivergent adults. And also The Neurodiversity Practice, and there we provide more systemic support for the neurodivergent community. That means things like our online community called the Neurodivergent Parent Space and workplace and professional training to support the implementation of a neuroinclusive culture across different settings. 

Paula Redmond (02:35)

Yeah, brilliant. Thank you, Lauren. So we’re talking today specifically about ADHD. And I wonder if we could start with just a question about what is ADHD and thinking specifically about the context of work and I guess a second part to that question about how having ADHD can impact someone’s relationship to work, how might it show up and what kind of impact might it have in someone’s working life. But yeah, maybe let’s start with what is ADHD?

Lauren Breese (03:14)

So yeah, ADHD, it stands for Attention Deficit Hyperactivity Disorder, which unfortunately is quite a misleading name, because what we find is actually people who have ADHD don’t tend to necessarily have an attention deficit. They might have an abundance of attention actually and find it hard to regulate that. So they might find it very easy to attend to some things, but find it very difficult to attend to others. So more broadly, it’s a neurodevelopmental condition that is characterised by difficulties with self-regulation. So thinking about attentional regulation, emotional regulation, and also executive functioning difficulties or differences. So executive functioning is, you know, I always think of it like the little conductor in front of your, in your frontal lobe, in the front of your mind that’s helping you with organising tasks, planning, starting tasks, stopping tasks, kind of time management, things like that. And I suppose for a diagnosis of ADHD, we’re looking in two main areas. We’ve got hyperactivity and impulsivity, as well as difficulties with attention or inattention. And usually people might assume that hyperactivity might look like running around or, you know, an image of a little boy, a child, like running everywhere. It actually can be more subtle than that. So it can be kind of more internalised presentations, like racing thoughts, finding it hard to feel settled or being constantly on the go but that might look like pacing in the workplace for example or doodling. So yeah, we’ve got these two main areas which can be kind of represented by lots and lots of different characteristics and a combination of these. What we’re looking also for if somebody’s diagnosed with ADHD is actually that they are having an impact on that person in the sense that it’s really making it hard for that person in numerous areas of their life with relationships or at work, you know, in kind of multiple situations. That they’ve had those characteristics or differences since childhood, they might present differently or have presented differently in childhood, or people might have learned to suppress them. And we also need to be careful as well that they’re not characterised by other conditions, other mental health difficulties or other physical health difficulties. So yes, that’s kind of broadly what is ADHD.

Paula Redmond (06:07)

Yeah, great. And yeah, that question about when we’re thinking about people in the workplace. What kind of things do you commonly find with the people that you work with when they’re talking about the impact on themselves in work?

Lauren Breese (06:23)

Yeah, absolutely. It can be hugely debilitating. And I always find that it’s kind of two factors. Firstly, the characteristics of ADHD themselves can be very debilitating. So if you struggle to plan ahead or if you struggle to start tasks, tasks at work become quite overwhelming. Then, you know, time management, attending meetings on time, prioritising tasks, having a to-do list that can feel extremely overwhelming and finding it hard to work through it to a deadline. All of these things make being at work or in a traditional working environment very, very difficult. Also kind of schooling. But on the secondary level, I would say that you’ve obviously got these kind of practical things that people do struggle with that then make working hard. But often when I work with people, they have struggled with these things throughout their life. And as a result of that had very negative feedback. So there’s kind of an idea that children with ADHD might hear 10 negative things to every one positive thing in the day. I mean, I think that was potentially, I don’t know if this has been a research study, I think it’s more a professor who said it, but it’s a good guess around kind of people experiencing these negative critical comments around could you not just try harder? Why can’t you do it and that person can do it? You you’re always, you’re always doing that. You’re never able to complete a task. And so then what can happen is then. people can internalise this criticism and it becomes self-criticism. And what I see really commonly is on a practical sense, people being asked questions, for example, at work or being asked to answer something in a meeting. And then the processing speed or executive functioning, it potentially feels like they’re being put on the spot and there’s a well, they’ve had all of those previous experiences of being criticised and not necessarily being able to answer very quickly or had negative feedback on how they have responded. And this just sends them into that flight, fight or freeze mode. They’re in the threat mode. And then their mind goes blank. And it’s kind of a very, very difficult situation to be in because they can’t think straight. They’re very stressed. They do have potential like… or the difficulties that they have with the executive functioning and processing speed. But you’ve also got this extra layer of then criticism which then makes that worse. So, yeah, this is something I commonly find for people that I see in clinical practice, this kind of double warning of your ADHD symptoms and the kind of flight, fight or threat mode that they find themselves in in workplace scenarios. So that’s kind of very tricky. And I think just on a different note, I often see people might have changed jobs quite often. They might have kind of had lots of different experiences of work. People might tend to thrive in a different type of environment that’s maybe less traditional of a workplace.

Paula Redmond (10:06)

Maybe say more about that Lauren if you can. What are your observations around that?

Lauren Breese (10:11)

So, yeah, often we find that maybe a traditional, well, I think for people with ADHD, they can thrive with adaptations to their work environment. And these need to be put into place and to be thought about to kind of make sure a workplace is neuro-inclusive in its culture, but also its practices. So things like, you know, on a practical level, we know that people with ADHD sleep can be poorer and their sleep cycles actually can be different or kind of later onset of sleep. And so actually it really follows then that a nine to five schedule might not work for somebody with, you know, and, you know, other reasons on top of sleep, but that’s just one example. So it might be that outsourcing tasks that are potentially difficult for somebody like having a PA or having somebody to help organise a diary is just a really simple solution to something that somebody finds difficult. And so what I tend to find is I work often with people who have maybe left a traditional workplace and created their own workplace. Maybe they’re an entrepreneur or they created a space where they can thrive, they can be creative and they have the flexibility to outsource the tasks that they might find hard. And that can be very helpful for somebody with ADHD, but obviously it’s not always possible for somebody to kind of go and create their own business. So this is why we’re needing the kind of workplace adaptations to, and actually they tend to suit everybody. It’s kind of making workplaces more inclusive, which is incredibly important.

Paula Redmond (11:58)

Great. And as you’re talking, Lauren, was just thinking about what I’ve been really aware of in my own work, for example, in the NHS, but I hear this in other industries, fields as well, is that with the kind of move to more digital recording and more kind of data driven work practices, that there’s a much greater emphasis on the kind of ticking the boxes and filling in the forms and these kind of practices that help with data collection and much less emphasis on quality of work, you know, thinking particularly about healthcare, that what people get monitored on and assessed on and appraised on is, have you filled in all the right forms and ticked all the right boxes and, you know, is everything up to date on the computer system? Not, you know, how, are you doing in your work? You know, what is the quality of, of care that you’re providing the quality of interactions? And I guess I’m just thinking how, I mean, that’s challenging for everyone. But I think, you know, I’m imagining that if you have ADHD you might really struggle with those more, you know, administrative aspects of the work, how depleting, demoralising that might be in terms of the kind of work environments we now find ourselves in that emphasise that part so much more.

Lauren Breese (13:31)

Absolutely. I think that’s such a good point, And it’s frustrating. It’s, you know, I think you’re right. It’s the prioritisation of the completion of all the forms. Just you’re reminding me of, know, have you asked this question? Have you asked about something that may not be clinically related actually to what you’re working on? And I think, you know, one strength of somebody with ADHD is that they potentially can be quite creative in their thinking and are able to think diversely or outside of the box and may have lots and lots of different ideas. And there isn’t an assessment for that, there isn’t a kind of you’re doing a good job because you’ve actually come up with this idea about how to do things differently. Actually what we’re praised for is doing things exactly the same way and in this way and to tick this box and to be having it completed and yeah it is I imagine very challenging.

Paula Redmond (14:41)

Yeah, and people that I’ve worked with, who’ve been suffering from burnout, and that’s been a kind of a common theme for people either who are starting to kind of think about an ADHD diagnosis or who have one that, you know, the kind of burden of often duplicating work over and over, and never feeling like you can catch up, never feeling like you can do a good enough job because of this emphasis on those kind of tasks. It’s really difficult.

Lauren Breese (15:23)

And keeping things in mind and kind of that working memory and visual working memory which we know people with ADHD struggle with, and I think this also it’s reflected as well in I think the path of later diagnosed people. So what we might find is people struggle with all of those, well they struggle with these things in childhood, but they have either had the environment to help support them or they have learned ways that they can tick the boxes despite it perhaps being quite debilitating. And then as we get older, so, especially for women, if we’re thinking of our reproductive life cycle, our hormones fluctuate across the month, but also across puberty, after pregnancy, perimenopause and menopause. And what that means is at times, at key times we have a reduction in oestrogen, which also reduces dopamine, which is indicated in ADHD and other hormones. So we have this physical change, but also what coincides with that are lifestyle factors that add to the mental load, which, so we’re thinking about the extra burden of potentially childcare or planning for more than just one person, thinking about potentially being carers for the older generation. And this doesn’t just affect women, it also affects men, but we’re also seeing the combination of hormonal changes. And so what can happen is the demand outweighs the capacity. So where we have coped previously, there’s too much now to cope with in terms of the mental load and the checklists and the previous coping strategies haven’t worked necessarily or are no longer working, and we can then lead to this cycle of burnout. So yes, all of the admin tasks at work, but as well as all of these other things on top of the hormonal difficulties is, in my opinion, why we’re kind of seeing these later in life diagnoses, particularly for women. Yeah, when the kind of demand exceeds the capacity.

Paula Redmond (17:55)

And one of the other things that I was thinking about and that I’ve noticed more, I suppose, in my personal life than professional life, is there are people who for whom work is maybe a particular domain where they really thrive and the difficulties actually don’t show up in work that it might be, you know, the one domain where they’re able to really perform and really kind of meet their potential. But everything else is a struggle. And I guess that can be quite challenging when it comes to kind of understanding, thinking about a diagnosis or that being seen or thought about in work when it maybe doesn’t show up there.

Lauren Breese (18:45)

Yes, yeah, I think that that can be a huge challenge and I think, yes, you’re right in that ADHD can show up differently in different environments, so, which is why it’s so important to adapt the environment where possible to support somebody. But if somebody with ADHD finds something incredibly rewarding, for example, potentially quite novel or they’re able to really engage in it, then they, exactly as you said, could thrive. And we see this often as well at school when the structure is right and that it’s very validating, very rewarding, people can achieve. But it’s when those things, so either people can get into then a cycle of then potential hyper-focus and burnout where it’s very enjoyable to have that sense of achievement and that I’m doing well and kind of being able to do it. And then they might do that a lot, and then that’s exhausting. We can’t maintain ourselves at that level. We need time for rest. We need time for soothing. We can’t always be in drive, strive or throat mode. And so it can tend to kind of go into a boom and bust cycle in that sense where some people might end up being exhausted and then at home where they might feel more able to be in that soothe mode then that’s very challenging to maintain that kind of high level that they are achieving elsewhere. And I suppose, yeah, it’s helping somebody to find a balance between those, I suppose, ways of being because all are important, but how is somebody going to be able to thrive in all of the areas that are important to them? Because they might be, they might want to have more of a balance within that at home or at work.

Paula Redmond (21:04)

Yeah. We’ve talked a little bit about women and, and how things might affect women differently. And I wonder if you could say a little bit more about that, about how ADHD might present differently for girls and women and why that might be?

Lauren Breese (21:22)

Yeah, definitely. So we’re not very good at picking up on ADHD in girls and women. Traditionally, it’s been seen or kind of more recognised in boys. It’s interesting, there’s kind of research to show that more boys than girls have ADHD, but actually by the time puberty hits, that equals out a little bit which lends weight also to this idea that there are hormonal implications related to this. Generally, girls and women tend to be more inattentive than hyperactive, or their hyperactivity might present in a more internalised way. So, racing thoughts, more kind of subtle ways of fidgeting, doodling, I think I mentioned that earlier, but less so than kind of running around that you might see in kind of more of a boy presentation.

Paula Redmond (22:29)

And I guess I suppose that is part of why women and girls are under-diagnosed because their presentation doesn’t necessarily fit so easily with the diagnostic criteria.

Lauren Breese (22:47)

I think that’s it. So I think that the kind of research tend to, you know, tends to be skewed in that way and that we don’t, we don’t know necessarily what ADHD might look like in girls and women and that it tends to be based on a more of a boy male presentation. And I think this is why, yeah, we’re less good at picking it up. And in fact, I think what can be more likely to happen for girls and women is that they are misdiagnosed with another mental health difficulty like anxiety, depression, UPD, bipolar disorder. And this happens frequently. So, you know, women that I have heard from who have had a later diagnosis of ADHD, they might go to the GP and mental health difficulties are potentially the first thing that somebody is kind of thinking about, you know, more so than if a male went, this is from my clinical experience yeah, it’s this kind of diagnostic overshadowing that happens frequently for women. So we know that things like PMDD is more common for people with ADHD and kind of menstrual pain, but also like other physical health difficulties, like inflammatory conditions. And, you know, these then tend to overshadow an ADHD diagnosis. So what, you know, is helpful advice, I think, is to keep an open mind at that assessment stage. You know, we’re really, it’s incredibly important to be doing differential diagnosis with ADHD, but it needs to be on the table from the beginning as part of the discussion to be ruled in or out. And I think that it hasn’t been so the case for women.

Paula Redmond (24:39)

Yeah. And I guess there’s also something about masking and social expectations that might play a role in these different presentations. And I guess something about, you know, the internalisation of some of these symptoms that might happen more for women than for men.

Lauren Breese (24:59)

Yeah, I think so. I think it’s what do people expect of, of even play, you know, from an early age of playing for children. And is that running around the playground and being able to engage in sports, for example, or is that kind of sitting quietly and nicely and doing imaginative play. And it’s very gendered from the beginning. I think it’s potentially those narratives around being quiet and being good and being, you know, not shouting out, not being able to express your individual opinion, which I guess without being stereotypical can be internalised as being a good girl. And so you’re kind of suppressing from the beginning that urge to shout out or the kind of traditional hyperactive impulsivity that we might see for somebody with ADHD. You’re learning to suppress that for fear of negative connotations or not being encouraged to be yourself in that sense. So yeah, I find a lot of women tend to have had this experience.

Paula Redmond (26:14)

Yes. And I guess it’s also fair to say that this can be, you know, it’s a very topical conversation, you know, ADHD is around in the news a lot. And there are, I suppose, some controversies in the field around, and even in within clinical psychology around the diagnosis itself, around, you know, the kind of expansiveness of diagnosis and need. And I guess I’m aware of when I, you know, tell people that I’m offering ADHD assessments, it’s really interesting how people respond to that and I tend to get three types of responses, and I wanted to talk to you about those. So the three responses I tend to get are: Is that even a real thing? Like, is this not just an excuse for people being lazy or immature? The second is how come every second person now has ADHD, you know, everyone I know has it. This sort of idea of this sort of, you know, hugely increased prevalence and like how meaningful is this as a diagnosis if everybody’s got it. And the third one is, you know, this you know, Oh yeah I’ve got this friend who, you know, does this fidgeting thing, definitely ADHD. This sort of…

Lauren Breese (27:40)

I hear those too, yeah.

Paula Redmond (27:44)

So maybe if we start with the first one, this kind of question, like, is this a real thing? Does it exist or is it just an excuse? What would you say to that?

Lauren Breese (27:54)

Yes, what would I say? Yeah, it’s a shame because it’s a common, it comes up a lot. And I suppose it’s a shame for the people who experience ADHD, who have ADHD. It can feel very invalidating of somebody’s experience because if you have ADHD and if you know people with ADHD, it can be hugely debilitating. And there is a lot of information about, you know, we want to be neuro-affirmative and we want to see strengths as well as challenges. But in being neuro-affirmative, we can’t deny the challenges. You know, neuro-affirmative doesn’t just mean being relentlessly positive about something. So, I think that this is extremely challenging because it potentially invalidates some of the difficulties and real differences that people experience. I think what I would say as well is there has been hundreds of thousands of research studies on ADHD. And these say that ADHD is a neurodevelopmental condition. And so it’s interesting as to why we are questioning this in a potentially a similar way to some of the conversations we had about autism, know, years and years ago around, you know, very long time ago, autism is related to refrigerator mothers, which we know is not true. But we now seem to have accepted autism as being a neurodevelopmental condition, but ADHD, I feel like we’re still catching up. And, you know, there are neuroimaging studies of structural differences and functional differences in the brains of people with ADHD, particularly in the regions involved in impulse control, attention, executive functioning. And we also know from thousands of research studies is that there’s around a 80% heritability rate, which is about the same as height actually. So if you’ve accepted that, you know, if my mum’s tall, then I might be tall. But actually what we’re seeing is if your child has ADHD, your parents may also quite likely have ADHD. And yes, there are other risk factors involved, but there are even kind of new studies, you know, trying to think about the genetic expression of ADHD. And you know, we’re not there yet, there’s probably likely multiple genes involved, but, you know, I would say that there is a lot of evidence for the validity of ADHD and in the same way that, you know, autism and, you know, we would characterise that as neurodevelopmental conditions, we know lot more about how these present and how we need more research, but yeah, that they are real things. And I think questioning that can be quite invalidating for the people who do experience those real challenges.

Paula Redmond (31:09)

Yeah. And what about this, this the second point that I hear a lot, which is, you know, now every second person you come across suddenly has ADHD, and how does that, how do we make sense of that?

Lauren Breese (31:25)

Yeah, it’s so interesting. I was at a conference this year, an ADHD conference, and I think clinicians are also surprised at how interested people have been becoming in ADHD. So what’s interesting is to kind of separate it out a little bit. So what we know is the prevalence of ADHD is around 3% of adults in the UK. About, we know, probably about two million adults remain undiagnosed. So having clinical experience that’s, that you know I think 3% is potentially on the lower side, it may go up to about 6%. So for children it’s a similar percentage, around four to seven percent something like that. And actually the prevalence rates of these diagnoses haven’t changed, but what has changed is more of the incidence rates. So we are seeing more people being diagnosed. So, you know, yes, people are coming for assessment and diagnosis. And I think that’s related to a greater understanding, a greater awareness and communication about ADHD. It’s interesting it kind of coincided with the COVID pandemic in that I think I read something where it was in that year, ADHD was the second most Googled condition on the NHS website, and I think also like the increase in TikTok videos or like online videos about people’s experiences. And also what we’ve got is people working from home, people having a break from the traditional work setting and either seeing that they can thrive actually, or seeing that they really struggled and kind of wanting to learn more about that. And so I think it’s kind of been a, yeah, a bit of a perfect storm in a good way, I think, because it’s, we’ve got more information, more understanding, and people are seeking assessment. But I personally think that this will level off as we catch up, because we, I think we have been underestimating under diagnosing and assessing and we’re just playing catch up. So, you know, women, people of colour are still under-diagnosed, you know, and so I think there will be a point when this kind of levels off and I don’t think the prevalence rates will change. I think we’re just seeing more people coming forward and recognising. I think another thing also is happening for the older, I say older, I categorise myself in that bracket, but people are kind of coming later on and they may have seen their children struggle at school and they have received an assessment and subsequent diagnosis and then they’re starting to think about their own experiences. So this is very common for the people that I see in adulthood, it’s like, oh right, we didn’t have an understanding of that when I was little, but I really struggled with that, and that’s something that I still struggle with. So we’re getting better at recognising it, but we’re still not there yet. Like, even though there has been a huge demand, we’re still kind of underrepresented, I think, in this area. And particularly research needs to catch up too for women and people of colour, or, you know, and generally.

Paula Redmond (34:59)

Yeah, that’s a really helpful distinction between prevalence and incidence. That really kind of makes it clear. Reports on the news every day about, you know, years long waiting lists for people, and it is, yeah, kind of hard to get your head around those numbers. But yeah, that makes a lot of sense.

Lauren Breese (35:19)

Yeah, yeah, there’s a huge increase in demand. And I think people are surprised in the sense that, you know, we haven’t had that before in services. And so we’re trying, you know, services are trying to catch up and design themselves to be able to meet the demand, but we just haven’t had, or services haven’t necessarily had the funding for that. It has been a bit of a surprise, I think.

Paula Redmond (35:43)

Yeah. And the third kind of response I get is this like, Oh yeah, yeah, oh my gosh, my friend’s always late, or, you know, my husband is terrible at, you know, doing the dishes, he must have ADHD. And I guess, yeah, there’s something interesting in that about, you know, this combination of greater awareness of what that might look like but I suppose questions about the complexity of what a diagnostic process looks like, what, you know, what ADHD in its fullness means. And, I suppose sometimes that question of like, you know, what is a kind of trait versus a diagnosable disorder?

Lauren Breese (36:30)

It’s a great question. I think this is the flip side of sharing information on TikTok. Yeah, yes, it’s really helpful to have an increased understanding or awareness, but I think potentially misinformation can be shared. you know, I’ve seen videos of, I have an ADHD diagnosis and I do this thing, and as a clinician, that wouldn’t be something that I would associate with ADHD. But then that gets shared and people resonate with that and then say, well, I do this thing, does that mean I have ADHD? And actually, it’s very difficult because it kind of dilutes what is quite a rigorous assessment process. So to be diagnosed with ADHD, you will have had to have hopefully have undergone quite a rigorous assessment process, especially compared to other, I mean, it’s not a mental health condition, but you know, other mental health conditions, for example. So, you know, I think there’s that part of it, and I can tell you more about the diagnostic process in a second, but there’s also another part of it as well around, I think people, our evidence base hasn’t caught up yet either. So people who have lived experience of ADHD are describing their experiences also. So, so kind of maybe they, for, a really good example is talking about rejection sensitive dysphoria. We don’t have much research on that. We don’t, that’s not part of the diagnostic criteria at the moment. That’s not to say that it won’t be. But it’s a kind of example of how as clinicians, we’re also trying to catch up with people’s experiences and saying, okay, is rejection-sensitive dysphoria a significant characteristic of ADHD in the sense that it could rule in or out ADHD, or is it something that overlaps with other conditions that is also just part of the experience potentially, but it’s not enough to be included in the criteria, for example? So we’re kind of, I think, at that point where we don’t have a lot of research to back up or we’re still kind of a bit behind in that sense. So, but, in terms of the diagnostic process, it includes multiple parts, you know, a kind of general, a general interview with the client about what they’re struggling with, what they’re finding, potentially easier or what they’re finding hard. A more focused interview around specific characteristics related to the diagnostic manual for ADHD, as well as an interview with somebody that knows them really well. Information from childhood, that might include school reports or an informant, developmental history, even looking at reports from professionals or historical reports, as well as your clinician’s observation. So you’ve got multiple kind of triangulated information which is required. You’re also thinking about impact, which is hugely important. So the impact on somebody’s life. And then another huge part of the assessment process is the differential diagnosis, which is hugely important. So ruling out other mental health or physical health conditions. ADHD can look like different things, anxiety, or potentially trauma, PTSD symptoms, or autism. And so a clinician needs to be really skilled at being able to tell apart these different things and amalgamate all of that information from multiple sources to come to a diagnosis. So it’s quite a rigorous process, and yeah, I think I can see why, you know, people might say, I might have ADHD, I do this thing, which I think may come from more knowledge about it, but actually to have a diagnosis, you have to meet a set of stringent criteria which haven’t actually changed. We haven’t got looser with the criteria, which is another thing when we’re thinking about kind of diagnosis broadening, it’s not changed recently. And so, you know, people do have to have training in assessing as well. So it’s not just something that people can come to, you have to have had training in being an assessor. So, yeah, it’s quite an involved in-depth process.

Paula Redmond (41:22)

And I guess there’s, there’s something about the particular context that we find ourselves in at the moment with these long NHS waiting lists, but also, you know, it’s that the guidelines don’t stipulate a particular profession who is able to do the diagnosis. So, there are lots of options out there to seek private assessment. And I guess we’ve also heard kind of horror stories about people having quite inadequate assessments. But I guess as you say, when you, you know, really are clear about what a rigorous thorough assessment takes, that’s not going to be done in 45 minutes or an hour and a one off appointment. And as you say, I guess that’s something that I suppose a profession like clinical psychology is well placed to offer particularly around the differential diagnosis. So I guess that’s really important for people to be thinking about who might be seeking assessment that, you know, checking out.

Lauren Breese (42:25)

I think that’s it. Yeah, checking out people’s experience. People, you know, because I think people are getting interested in it. You want somebody that has had experience of, you know, working in neurodevelopmental conditions, you know, who are able to differentiate between mental health, physical health, and like you say, clinical psychologists are well placed to do that. And I think what I’ve found as well is the skills of a psychologist around formulation are, I very much value in an assessment process. So obviously you have an assessment, there’s no one tool to assess for ADHD. So you’re using lots and lots of information from different sources and potentially different tools to help inform your clinical judgement. But I think, you know, a clinical psychology assessment doesn’t stop there. It offers also, you know, in my practice offering a formulation around understanding somebody’s journey, experiences so far, what might be keeping them stuck, or, you know, what might have contributed to their current difficulties, which some other assessment processes may not take into account. So I think for me, a diagnostic process is more than just a yes or no answer at the end. It provides a clinical understanding or a psychological understanding alongside an answer, which I think particularly adults who may have, I mean, everybody’s different actually. People may just want an answer and want a yes or no diagnosis, but some people want a more in-depth understanding around, and what else? And recommendations related to that. So I think for me personally, that’s what I value in an assessment process. Something that is very neuroaffirming, that can take into account differences within the assessment process so that they can adapt the assessment to somebody’s needs, but also that kind of formulation approach on top of the diagnosis. I find very helpful and I think people find very helpful. I think it’s interesting as part of the assessment process, kind of thinking it’s not just a tick box exercise. A good assessment, it shouldn’t just be a tick box exercise. It should be more of a narrative, kind of thinking more broadly, you know, tell me about a time in the week that you struggle. Tell me about a time in week where you thrive. And so this I feel like characterises a kind of helpful assessment process in that it’s not just, would you say that you’re constantly on the go and driven by a motor, which is kind of one of the diagnostic criteria, for example, where people kind of say, Oh yes, that’s me. So kind of an assessment should be more of a two-way conversation, and a very curious conversation about where people are struggling and may not struggle. And with that information, you come to the clinical judgement or clinical opinion, which is perhaps where a good assessment lies rather than a kind of tick box exercise of the DSM criteria.

Paula Redmond (45:55)

Yeah. And I guess you’ve, you kind of touched on that, but I wanted to ask what you would say are the benefits of seeking an assessment, I guess, particularly for those people who might not be keen on pursuing medication as an option?

Lauren Breese (46:12)

Yeah, absolutely. And so medication isn’t the only option. And I think it’s, I think that having an assessment and subsequent potential diagnosis, it can really help somebody to understand themselves. So often the people whom I’m working with, they might’ve had a lifetime of feeling different, feeling misunderstood, knowing something is different but not able to put their finger on what that is or understand it and that can result in more self-criticism or more kind of downward negative comparisons. And actually being able to have an assessment and an understanding a diagnosis can help to validate somebody’s experiences, that it’s not their fault, it can very much be de-shaming for somebody and help someone to come to a place of acceptance and subsequently thinking about what they need to thrive. And having the language for that is incredibly important. It’s the, you know, it’s in a similar way that having the language for emotions is important. It helps to, to kind of regulate them and, and, you know, having a language for what somebody is struggling with can help somebody feel understood, validated, as well as find other people as part of a community, which we know is beneficial for people’s mental health. And there are also practical things people can access, like access to work grants or reasonable adjustments in line with the Equalities Act, evidence-based resources, so kind of practical things. But also on the kind of flip side, having undiagnosed ADHD can be quite risky actually. And this isn’t for everybody, but it’s associated with unfortunately poorer outcomes of mental health, of socioeconomic outcomes with undiagnosed ADHD. And this isn’t necessarily to say if you don’t have an assessment diagnosed, that is going to happen, but what we know is that it’s helpful to have understanding where there is some to be had so that subsequent support can be put into place and even if that support just looks like you understanding yourself better and being compassionate to yourself, that is helpful. I think because the risks are that people might be, it’s unlikely that somebody is undiagnosed ADHD and might not be struggling with other things like for example, they might be misdiagnosed with another mental health problem, for example, or diagnosed with a mental health difficulty that may be able to be supported if we also had the knowledge that they had ADHD and they would benefit from some adaptations around the therapy that they access, for example. So, I think, yeah, I think there are benefits to having an assessment that aren’t just medication. And I think on a practical note as well, I guess the NICE guidelines recommend, they say like pills and skills. So it’s not just the medication, there are also, I think like I mentioned earlier, maybe practical skills or tools, sorry, that somebody might be able to learn that can be supportive, but also the secondary aspects that may have come from your lifetime of experiencing difference, for example, potentially self criticism can also be addressed. So yeah, I’m quite passionate about kind of somebody kind of understanding themselves fully. But I think sometimes just on the caveat, as a caveat, it’s not always the right time for somebody. So, you know, you have to weigh up the pros and cons for your own circumstances as to whether it feels right and what assessment would bring, what would happen if the outcome was, yes, you have ADHD, what would happen if the outcome was no, you don’t have ADHD. So there’s a lot of thought that I recommend could happen before coming to the assessment. And it’s not always for everyone, but I do think that there are benefits, but there might be downsides for some people in their circumstances, know? So I guess it’s thinking about that for an individual, what makes sense for them.

Paula Redmond (51:07)

And as well as that, if I wonder Lauren if you have any advice for anyone listening who might be recognising some of these things might be resonating with some of the things that we’ve talked about for themselves, any other thoughts or advice?

Lauren Breese (51:23)

Yes, I think take your time, be compassionate to yourself if you can. Just kind of, I think this coming to this understanding tends to be a long process. It’s not just something overnight that you think, oh guess what? You know, I’ve heard, I don’t know how accurate this is, but you know, on average about five years to come to from the point of wondering to the point of assessment. But anyway, five years or not, it’s a long time. think from my clinical experience, it’s a long time that people have been wondering. And I think being gentle with yourself within that process is very important. I think in that sense, potentially asking the question can be helpful because there’s only so much wondering on your own that you can do. And so sometimes it can help to ask the question so that you know what to do next. And that, you know, because often I find also that kind of wondering phase, people might start to then second guess themselves, oh well, everybody struggles with that. So actually having somebody that you trust to help you grapple with this is useful. I think if you are at the process of wanting an assessment, checking out somebody’s expertise and qualifications and experience is incredibly important. There’s lots of misinformation out there, so finding websites that are trustworthy, that are providing evidence-based information is helpful. Thinking about the process of assessment, do you want a yes or no answer? Do you want more of a psychological formulation-informed assessment where you might seek out a clinical psychologist that can help support with that. Yeah, I suppose potentially talking to other people as well, talking to your family about what the impact of a diagnosis might be for you and what you feel that the benefits might be of that or the downsides.

Paula Redmond (53:33)

Thank you. And I guess another question, and this came in from one of our listeners about how to broach a conversation with someone, either a family member or, you know, a colleague who you might think that ADHD might apply. Any thoughts on how you might go about, or if you might go about having that conversation? If you see someone struggling and that this might make sense of that?

Lauren Breese (54:02)

This is really, it’s a very good question and it’s very tricky. I suppose there’s a lot of nuance that might be needed depending on the circumstances. So when we speak to workplaces, you know, The Neurodiversity Practice where we train workplaces and managers and employees, I suppose based on what we’ve said today, you know, for a colleague who may not know the person well, it might not be appropriate to kind of, because of the nuances that are involved in an ADHD assessment, to kind of, you know, having seen something online and they’re disorganised or something to mention it, that it may not be the right setting or you may not know somebody well enough to be able to approach that conversation. However, what we do know is talking about adjustments generally is helpful for employees and colleagues. So thinking about how we all thrive in the workplace and what’s needed. Perhaps, you know, having a checklist of things that some people might help and then, you know, having that for the whole team, not just singling out one person is, I think, a helpful way to go about even, you know, to kind of thinking about helping people to understand their own needs and what they can ask for. And often for managers as well, it’s helpful for that to come from them and the onus to be on them to be providing or asking about adjustments. So approaching it that way can be helpful. If you’re say like a manager or a colleague that you may need to kind of think about how can we support everybody to thrive in this workplace? Does that make sense? And I suppose for a loved one, I suppose these are very helpful conversations to have. Yes, they are sensitive conversations and should be dealt with accordingly with empathy and understanding and curiosity. But I also think being open about communication is is also helpful and maybe sharing things that that person has learned about ADHD and asking for that other person’s perspective on it and just opening the conversation can be useful. I feel like we’re moving away from ADHD and autism and other neurodevelopmental conditions being a taboo. So I think, you know, this it’s not a deficit, it’s a difference in the way people process information. So approaching it as such can be helpful in a really open and a very curious way that doesn’t feel judgmental or blaming or threatening in that sense. So I think that would depend on the relationship and how they’re able to communicate. But whether that’s sharing something or joining together with somebody in curiosity can be helpful.

Paula Redmond (57:25)

Great, well thank you so much Lauren for joining me today.

Lauren Breese (58:23)

Thank you so much Paula, it’s been a real pleasure.