[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. In this video, we're going to be talking about developmental pathways and how they influence outcomes, and this is outcomes in health, in life. And this is advantageous outcomes and also disadvantageous outcomes. So I'm Jessica Eccles. I am an associate professor in brain-body medicine at Brighton and Sussex medical school. And these are my wonderful colleagues and collaborators. Hello, do you want to introduce yourselves? Hi, I'm Ruchika Gajwani. I am a developmental psychologist by background and clinical psychologist by trade, and also an academic here at Glasgow University, as well as NHS Greater Glasgow and Clyde. I have a huge interest in understanding children and young people's trajectories over a lifespan. Hi, I'm Helen. I'm a professor of child and adolescent psychiatry at the University of Warwick, and we work very closely together. We literally have offices almost next door, and I've always had an interest in the problems and also the thriving of people who've experienced trauma in early life. And then that led into an interest in the interplay between trauma and neurodivergence. So that's me. So Helen, so I'm an adult psychiatrist and clinical academic. So I spend two days in the NHS and three days in research. And the NHS work is mainly in neurodevelopmental conditions at ADHD, autism, and Tourette's. But obviously, I'm working, yeah, with adults. But all adults were children. And I think that adult psychiatrists often forget that. And what is it in your experience as a child and adolescent psychiatrist and researching in this space that what led you to think about things in the way that you do? Yeah. Well, it was actually clinical insights. I'm also a clinician. And a number of years ago, I noticed that children that I worked with who've been abused or neglected tended to either not have mental health problems at all. And that in itself is fascinating, why some people resilient in the face of really awful experiences sometimes. But those who did have problems seem to have really complex overlapping problems, and those seem to often be neurodivergence. So often, there were things like ADHD, autism, and even tics in the base. And I was just thinking, how can a tic disorder be caused by this neglect? Because I think I'd come from a background where we believe that trauma caused all problems. So I'm going to leave it there. But that was how I got into this. That's how I got curious. Yes, and I want to pick up on two of those things. So one is-- I'm sure you get asked this all the time-- this idea of how do you distinguish between trauma and neurodivergence. And I'm sure our conversations will show you that it isn't as simple as that, is it? But tics is fascinating because-- tics and also some of these hypermobility features that I'm interested in. So something like-- I don't know-- the camera can see a narrow thin wrist, and you think, what is that? Well, it's a feature of this connective tissue, difference in the way the body is built. And when people say, how can you distinguish between trauma and neurodevelopment if you even need to? You say, well, I don't think trauma was related to the narrow, thin wrists and the long, thin finger. Yes, yes. And yet, and yet, a child who has or an adult who has a tic disorder, they will tic more when they're stressed. So there's all sorts of things that can become confusing in this space, I think. So for me, just noticing that clinically made me really curious. And then we Ruchika and I were lucky we had some colleagues in Sweden who had access, who were able to give us access to a massive twin study, which just overturned our view about it. But I wonder-- I mean, it might be quite nice to hear a bit first before we get into that. So Ruchika, before we get sidelined-- we're not sidelined-- before we go round lots of different tangents, tell us about how you got into this space and what your development in the developmental journey. I moved to the UK almost 25 years ago, and my PhD was in early intervention psychosis with young people who were seen as clinical high risk of psychosis, and we were looking at what are the under-researched areas at the time. And my supervisor at the time was really keen in looking at developmental pathways to health outcomes, particularly psychosis. And he mentioned trauma. And through my own experience of travelling from India, the Global South to the Global North, I remember asking really quite naively at the time, what does trauma have to do with anything? And interestingly, I think, was naive. We are asking similar questions, not so much what does trauma have to do with anything, but how does trauma really intertwine with people's experiences? And therefore, I shared research and interest in other things such as neurodivergence. I wonder, Ruchika. I remember a few years ago, so 25 years ago, thinking about early intervention in psychosis, this was like a really new thing, wasn't it? It was quite a hot topic. And I remember when I started my clinical academic training being sent to a masterclass at the Institute of Psychiatry. And there were lectures about migration and psychosis. And it was thought-- I'm not completely-- can't remember the literature completely. But there was this signal about this idea that somehow, having come from one place to another, made you more likely to experience psychosis, and there were lots of social theories. But I wonder if there are any other theories in terms of being an outlier, full stop. So I was having a conversation with a friend of mine, whose partner had gone in a deep dive on ancestry and discovered that they had lots of Irish relatives, and they had lots of relatives from Liverpool. And in England, there are very high rates of ADHD prescriptions in Liverpool and in Brighton. And my friend was saying, "do you think it's because these are ship building towns?" Now, Glasgow used to be a shipbuilding town, and the idea that there was this type of body type, which is the type I'm interested in, this sort of physical phenotype who preferred being out at sea, building ships or on ships and travelling the world was a different type of person to the type of person who might end up going down a mine or another form of job. Now, that sounds really quite bizarre, doesn't it? This idea of shipbuilding and ship sailing. But is there something about-- and obviously, you cannot possibly speak for all people who have migrated, but is there a sense that maybe there is something slightly outlying in the migration experience, the type of people who are motivated to move that might then perhaps be associated with other outlying features, like neurodivergence, which could in fact predispose to psychosis? And yeah, we did a little study last year or the year before. We looked at the whole cohort in our trust of first episode psychosis and found that we thought that 40% of them were likely neurodivergent and the likely neurodivergent people experiencing first episode of psychosis unfortunately had an age of onset of psychotic symptoms 10 years before and were using is like an awful world, but ended up in hospital twice as much and needed twice as much acute care. Yeah. Sorry. It's quite a big question, Ruchika. I've gone around on a massive tangent. No, not at all. I think it's really helpful to talk about other and what makes us different and what makes us the same, and I suppose Helen and I, our work has been around engaging marginalised communities, children, families. And so your question is really helpful and your reflections are really helpful. And what makes you feel different, so circling back to, I think, the idea of trauma, we know that actually subjective experiences of trauma have different outcomes to perhaps the objective. Now, nobody ever would say trauma or the experiences of adversity are a good thing. We know they go on to impact all sorts of outcome, including resilience. I think we forget that within our clinical practise that using the concept of multifinality from developmental psychology, you can have trauma can lead to experiences of psychosis and depression but also healthy outcomes. And I think that really got us thinking about, what else? What else? And one of the things I'm increasingly interested in is this thing about the interplay between neurodivergence and stigma. So I think your findings-- and other people have had similar findings. I think Chris Gillberg found that people who migrated to Sweden were more likely to have children and be neurodivergent. So what's going on there? There's something going on there. But then there's also the way we encounter health services. And one of the things that I wonder about, and this is circumstantial evidence. We know that Black and ethnic minority children in Britain are under the age of 18 are mentally healthier than their white counterparts. And most people don't realise that. But-- No, I did not know that, Helen. Over and over again, the British child and adolescent mental health surveys have shown that. And what's interesting is, there's also evidence that Black kids in states in the United States are more likely to be described as having disruptive behaviour when they have the same symptoms as a white child who's described as having ADHD. So we know that assumptions about adversity and marginalisation can often blind us to an absolutely barn door neurodivergence. And so I have a feeling that there's something going on there. If you're a Black parent, and you keep taking your child to be assessed, and everyone says, well, of course. Of course, they're hyperactive and impulsive, and they've got poor concentration. They live in the Peckham North estate, or you live in East Glasgow or whatever assumption is made about your background. And so you're not diagnosed, and you're not offered support for your neurodivergence. Then maybe it's not surprising that at the age of 18, you might be actually being taken into an adult psychiatric ward with psychosis on the Mental Health Act, because we know that there's a shift. So for me, there's something about-- something fascinating that we should be embracing about what makes people migrate, and then there's something about what do we do to them once they've been-- Yeah. --once they migrated. And going back to Helen's point about embracing, I think we have to embrace complexity. And what we mean by that is that systems are working with families. Complexity is not just complexity in the form of what, young people's presentations, but actually, the interplay between the context and service provisions and access and agency. So all of these really-- we end up seeing an individual and the diagnostic model can be helpful but also hindering to accessing services and agency. But coming back to the idea of trauma, we know that trauma is linked to physical health outcomes, as well as mental health outcomes. But sometimes I think we can have a reductionist view of trauma. And of course, the science and the mechanisms show that it's far more complex than this cause and effect relationship. And in trying to understand that, we went to our Swedish colleagues. That's right. I mean, back to that initial curiosity, my initial question was, is it true? Is my clinical hunch that children who have mental health problems in the context of trauma actually do have more complex, overlapping neurodivergence or not? I wondered if I was just getting the complex kids referred to me. And actually, so we looked in the CATTS study the Child and Adolescent Twin Study in Sweden, and we looked at monozygotic and dizygotic twins, identical and non-identical twins, where one had been maltreated and one hadn't. And what we were able to show was that actually-- the clinical hunch was even more marked than I'd expected. So we looked at-- well, the CATTS study had looked at traits of ADHD, autism, tic disorders and intellectual disabilities, and children who had three-- any three out of the four of those symptom clusters for more than six times as likely to have been abused or neglected. I would have left it there because my assumption was so strong at that time, along with all my colleagues, that trauma caused this. But it was-- it was a twin study, so the behavioural geneticist colleagues said, we can look at causality. And actually, what we found was that there were additional genetic factors causing both the abuse and neglect and the neurodivergence. Now, we were on a Skype call. That's how long ago this was. This was in 2016, I think. And I could see that Ruchika's mouth was like this. She had a big O-shaped mouth, and I had the same, and we were just both-- we were so shocked. And we both went away for a long weekend, and we both came back with, and we come to the same hunch. I mean, I don't know if you had the same [INAUDIBLE]. And it's surprising and yet not because these are potentially families, the intergenerational link, which we weren't able to assess in the CATSS sample. But you can imagine these intergenerational families with missed opportunities where neurodivergence and adversity or trauma has had that interplay, which is then gone on. So there was shared variance that explained this increased risk of maltreatment and neurodivergence in the CATTS data. And so it's really fascinating that when we're trying to unpick complexity, some of this is-- there's a story before the story. There's a story before the story. I think we both came to the hunch, and we haven't been able to prove this. But the hunch is that these additional genetic factors. It's divergence running in the family. So we've always talked about the intergenerational transmission of trauma, but I think more and more now about the intergenerational transmission of neurodivergence. Yes. And of course, the thing is neurodivergence in families can be a wonderful thing. Yeah. So we know from Edmund Sonuga-Barke's research, for example, that parents with ADHD can be better parents without ADHD. They're often more tolerant. I was that parent. I didn't work out that my youngest had ADHD until he was 14 because I was even more hyperactive than he was, and we just bumbled along together happily. So that can be fine. But if you then throw in council tax debt, getting sanctioned because you might be a parent with ADHD begets a couple of times to go to the job centre. And then all of a sudden, you're going to a food bank, and then you've got a virtuous circle flipping into a vicious circle. And that's so crucial to hold on to when we consider risk factors and protective factors because we have to understand context of people's lives when we're considering laxity that actually when you met somebody with experience adversity and neurodivergence, they'd be living in vastly different contexts to somebody else. So it's about understanding how we progress science with culture, with art, with medicine so we can understand both precision medicine along with personalised care. And also trying to improve universal design and justice in society. I mean, absolutely. I just wondered, a colleague asked me a little while back what it was to have the feeling that things that you thought were true, the dogma be disrupted, and what you two are both describing is at different phases because we're all different ages. We have grown up knowing different things. So when I was at medical school, I was very much taught that autism and ADHD affected boys nine times as much as girls. That was the big dogma. And then when I was in training, early training, it was like, the DSM and this idea of top trumps and that you couldn't have autism and ADHD together. And I suppose, you're talking about the moment in that Skype call where your mouth dropped. Maybe, yeah, something-- this was a seismic moment, and the work that you have gone on to do as a consequence and what that work showed has really led in some ways to a paradigm shift in how we contextualise the supposed binary between neurodivergence and trauma. And so my question to you, which was someone else's question to me, is how does it feel for the sands to shift like that but not only for those sands to shift? But you are leading your research programmes, and your colleague Chris Gillberg, Helen, really foundational in showing so many years ago that this idea of the essence framework that there's multiple intersecting elements of neurodivergence. And he was doing that long, long before the top trumps suddenly allowed you to identify both autism and ADHD in the same person. So I just wonder, what are your reflections, both of you, on that sort of-- I think it's disruptive. Oh, I find it so exciting. I mean-- and I think we're very similar personality wise in that sense. And I think Chris Gillberg is too in the sense of having-- there's a glee in realising you were wrong and realising then that there's a whole world of new questions to us. Yes, Because suddenly, the limits are different. And I remember thinking-- I found it a bit discombobulating. But when I was doing A-level chemistry, and you suddenly learned that the atom is not how you were taught the atom for GCSE. It's got a little hard marble. It's got waves inside it and things. Yeah, and then I really enjoyed doing the history of medicine for GCSE is part of my history. And then I did this history and philosophy of science at universities, my integrated degree, and was like, oh my god, there's march of progress business is not true, the whole thing. And it was actually quite anti-psychiatry, which we could think about. But the actual genuine pleasure after the initial discombobulation in learning what you thought was true is not and that this new way of seeing things actually opens up so much more because understanding this complexity means that we are less limited in our thoughts about intervention. Yes. I mean, the huge reflections because I think our services are designed to meet unmet need. But most part, I think people go into the profession with the desire to be helpful. But what happens is with that, we all have waiting lists, we all have a job to do, and services are designed, particularly in the Global North in terms of silos. We have ADHD clinics. We have mental health services. So where we are in this space is really trying to understand the public health approach, but within that to mental health, public health approach to mental health, but also within that, having targeted interventions. And that's a really exciting space both from the context of trauma and neurodivergence. Well, I would agree. And I think what's fascinating-- and I know you've had this experience too-- is, as scientists and as clinicians, we often think of it as hugely complicated. But often, when you talk to an individual who's struggling with this set of problems, it's not complicated. So for example, we've got a study where we're co-producing an infant mental health intervention with parents, and it's aimed at really stressed families. And the aim is to try and prevent the child having to go into child protection, and we wanted to introduce this concept of the interplay between poverty and neurodivergence. And initially, I would say the clinicians involved were probably a bit anxious about it. But for the reasons that you've just described, we're all up against it. These are infant mental health experts. They're used to doing relational, relationally focused interventions, and they were thinking, are you telling us that we need to think about autism and ADHD and intellectual disabilities as well. And the answer was, well, yes and no. You're not going to be in a position to be making diagnoses of parents because the waiting list lists are really long, or babies because they're too young. All we really want you to do is to think about it. Now, we then had that conversation with parents. And this group of parent collaborators it just so happened at the time were all parents whose children had been involved with social work. Some of them had actually been in care. They had the children back. At that time, all of the parents were in recovery from addictions. So these are parents who have really been through a hedge backwards. They all had tough times, and they got it. Instinctively. Exactly, but they also found it very destigmatizing that the revelation that the reason I keep missing my appointments with the job centre might be because of my ADHD, and I've actually been thinking about going and getting a diagnosis. It's such a relief in some ways. And so I think the beauty of this is, while, yes, once you put two concepts together-- you put trauma and neurodivergence together, you've got a bit more complexity. At another level, it reminds us what we all know, which is that actually we're all unique. Of course, we're complex. Even the human physiology is complex. So we shouldn't be afraid of that. And this is a framework, where we can start to describe ourselves in a way that we can describe it-- explain ourselves to other people, which I think is what you did in bridge with the young people. Yeah, absolutely. I've lost my train of thought. [INTERPOSING VOICES] --that I thought I would-- [INTERPOSING VOICES] No. Not at all. I was just thinking about the beautiful holistic assessments you did with those really high risk young people and how much misunderstanding is there still. Just as Helen was talking, I was thinking about how do you embrace complexity? You have dialogue. And so on the one hand, it sounds really simple, but on the other hand, it's naming the unnameable. And it's holding the unnameable. So as a society, I think we become very risk-averse. And that's been mirrored within services because we're all working really hard. And so how do we really meet complexity is where-- so we conducted an MQ funded research project with young people called the Bridge Project. And I mean, there have been numerous findings, along with actually young people telling us that there were several opportunities earlier on for early intervention and identification. So the person I've spoken about quite a bit, whose name is anonymized, is James. James was known as early as age four or five by an educational psychologist. He was being assessed for ADHD. His ADHD was left untreated and undiagnosed in the context of trauma. So his parents were involved with addiction services. James himself was in and out of foster care. And so there were several foster care breakdowns. He was involved with CAMHS. And unfortunately, he was expelled at the age of 13 and had multiple contacts with the youth justice system. And he wasn't referred to our project at the age of 25 by a certain psychiatrist. Now, there are several stories, such as that of James, where there are missed opportunities for early intervention. And this is something for all of us to consider within science, within services, within our context. That we've all been children before and how did we all link in together? So CAMHS and adult services can think about transitions. How can we within children's health think of working with education, with social services? And so I think trauma and neurodivergence are really important factors for us to consider, but they're everybody's business. I suppose following on from both of what you've been saying Ruchika and Helen is this idea of thinking beyond the binary. So what Helen was saying-- what you've both been saying about this idea of embracing complexity, I think, is absolutely fascinating from a brain-body perspective. So we often think of trauma and neurodivergence as these psychological or brain phenomena. But what we were jiving on about Helena about the tics and the narrow risks? Discovering that this seems to be associated with a particular body type, which is then in turn associated with a different flight or fright response, a different inflammatory response. It really was quite-- I think it's quite a disruptive notion but also an integrative notion. And I remember thinking when I was a very junior psychiatrist, junior psychiatrist-- heaven knows how or why are let loose on psychotherapy patients without a huge amount of training we have to say. And I was doing a psychodynamic case of someone who had a binge eating problem and wasn't really engaging with the fact that they had type 2 diabetes. And now looking back I think this particular person was neurodivergent. But I remember thinking, as you get bigger in space, you actually-- as a body, you end up taking up less space in people's minds. It's a sort of weird way of disappearing by getting bigger. And that if you have an eating disorder, that means that you get smaller and smaller. You end up taking up loads of space. There's so much worry in the room. Everyone is frantic, and so you've disappeared, but you've got bigger at the same time. So this massive paradox idea of getting smaller and bigger-- it's a bit like Alice in Wonderland. And the thing-- this is what I think about embracing complexity. It's that what you were saying, Helen, about these. These parents with all of these very challenging circumstances and this realisation that maybe neurodivergence underneath was a linking factor. This is the thing that excites me. And people probably might think I'm slightly mad. Is that as things seem to get more complicated, they're actually getting simpler because-- Yes, and I think that's so true. And one of the things-- so just a bit of context. We were all in the same room together just a couple of days ago, just a few days ago in Brighton. But what a pleasure that was. And we were working with an artist, physicist and bioengineer called Kimia Whether. And just to actually think about the mind, the body, right into the cells, and the fact that in some ways, the beauty of that is that any explanation is possible. So it's not necessarily-- it don't have to necessarily be about the way we think or the way we speak. It could be about the way we move. And one of the things-- one of your findings that I find most exciting, Jess, as someone-- I have ADHD, and I probably would have been diagnosed as a child with developmental coordination disorder because I kept falling down things. Yeah, proprioceptive surprise. And the fact that the bumping into things and suddenly falling down holes can be very discombobulating-- can give you psychological problems. It's such a simple concept at one level. Yeah, but this is what I think is beautiful about it. Is that-- so what we showed was that if you had neurodivergent characteristics, you're more likely to have emotion regulation issues-- specifically actually dissociation. But this was somehow linked to the sense of uncertainty about where you are in space. And your people-- probably other psychiatrists are thinking, what on Earth are you going on about? But when the patients read about it or think about it, it just seems to make so much sense. And it's also another example of one of these beautiful and frustrating paradoxes. So I hope it's not too much information, Helen, but I understand you are very interested in dance. I love dance. I love dance. And this is the thing about hypermobility and neurodivergence, and the things that I'm interested in. Is that the same thing that means that you can be as wonderful dancer also means you can fall over your feet. Exactly. I don't understand it. So my husband and I used to do salsa dancing, and we still could do salsa dancing if you put some Latin American music on. But I can follow. I cannot lead because I don't have the three dimensional skills. But I can get into my body, and I can follow-- no problem at all. So it's all very nuanced, and we're all very different. And if you're a siloed person, if you think it's got to be this or that, or that, or that, then that is going to burst your brain. Yes. Well, I think people keep silos because they think it will help them not burst their brain. But it's this idea of having categories seems to help keep things manageable, but it's actually realising that it's all-- If you realise it links, then in some ways makes easier things. Yes. I think it does. And you Ruchika we were talking, weren't about this idea of both and rather than either or-- yeah. It's the hyphen in between the connectivity and the relational connectivity between the individual, the families, the context, and the society. And I think we've got to hold on to that when we are considering trauma and neurodivergence and frame it within the larger context of people's lives. And somebody explained it really nicely to me that trauma is anything that impacts the nervous system. And by that measure, actually, most people would have experienced trauma in some capacity, but we have to understand the layers and nuances within people's experiences of trauma. And I don't know if this is going to be relevant, but having grown up in India largely, I'm reminded of communities that hold and embrace complexity differently. It's not better or worse. It's about, I think, just what you had said right at the start of this interview about what makes you feel different. And there's so much work that's done around loneliness, belonging, connectivity that actually when we are considering trauma and neurodivergence, we have to consider actually belonging within a larger community. I was thinking when you were talking the phrase, who picks you up when you fall? That it's that-- and in some ways our societies in the Global North have become so nuclear that there are fewer and fewer people to pick us up when we fall. And I think, personally, I think if we really want to get out of this service morass, we need to be bringing communities in. We need to be asking people who helped you, do you go to your gran? Is it your next door neighbour? Is it your flatmate? Who understands you? And that's one of the things I loved about the work you did with Bridge-- was actually helping people to understand what we would call your make and model. How does your genetic makeup that you were born with, and how has that turned into your personality with time and all the things that have happened to you? How do you then explain that to the people who can help you? And how do you not just explain that? How do they understand themselves, so it's the shared meaning making? And that comes back to the analogy of the dance. Because I think what's happening in the context of neurodivergence and waiting lists and assessments is that we're losing the shared meaning making. And so how do we continue to have these conversations within the wider context of people's lives? And I think you mentioned earlier Ruchika risk aversion, and I think one of the big problems is risk aversion. We're often afraid to talk to young people about risk. We're afraid to ask about suicidal thoughts. We're afraid to ask about psychotic experiences. And actually, people want to be understood. So I think this is a-- in a sense, for me, I think, you're absolutely right. The way to simplify this is to have a dialogue and to be unafraid to have these conversations. But to be unafraid-- Oh, sorry, Ruchika. To be unafraid to ask this question of-- our young people in our trial have told us you helped us name the unnameable. And I think that comes with both pride and shame. You have to be really gentle and shimmering between these concepts. Sorry, Jess. No, no, no, absolutely. Because it brought me back full circle to what Helen said at the beginning about this-- suddenly thinking about tics and trauma. And we mustn't be afraid to be curious and also to challenge our ideas. So most people think that tics and Tourette's is swearing and saying inappropriate things, but it is so much more. And when I do Tourette's assessments, often, particularly in Tourette's assessments, patients sometimes seem to think that I might be some kind of mind reader. They're like, how did you know that I do this weird thing? And no one had ever explained this. And this is mainly to do with some of the obsessive compulsive elements that are inherent to this impulsive, compulsive picture. But Helen, what you're saying about tics and neurodivergence and also differential susceptibility just done-- we have a neurodivergent brain body clinic in our NHS Trust, which myself and Hugo Critchley and Rebecca Jew set up. And what we have-- I have these undergraduate placement psychology students. And I was on a call with them yesterday, and I was kind of trying to show them-- I actually found it quite fun in SPSS-- how to look for patterns and how to do statistics. And what we found was looking at this very common scale, the PHQ 9-- so many people are using the PHQ 9. There's a question about have you had suicidal thoughts in the last two weeks, I think. And so we just binarized that and said, either no suicidal thoughts at all or any suicidal thoughts. And it's a really taboo subject. People are very worried about talking about suicide. And what we found was in our group of patients, who mainly had ADHD and autism diagnoses-- that the tic features were the best predictor of whether someone had had suicidal thoughts in this neurodivergent group. Now, obviously, we've got to refine these analyses and think about it, but I think it is because you have-- and this is how the brain and the body all interlink. But in the same way as you might have a compulsive movement to urge to move, you have a compulsive, intrusive thought, and that might have popped into your head. And it might be contextual, but it might not be. And you don't necessarily understand that it's an intrusive thought. And often in Tourette's, you get this sort of negativism thing, which is like you almost think the exact thing that you shouldn't. So pulling up a knife-- you think I should just slash my wrist, but you don't really want to. It's just a absolutely compulsive opposite thought. And when you talk to patients about this, and they begin to understand it, it really helps. I think it can be so transformative in helping make meaning of these experiences that very few people actually sit around and talk about. So if you are attending a mental health A&E, you get asked, do you have suicidal plans? Do you have ideation? Do you have plans? Do you have intent? I think we have to throw away that framework and realise that, unfortunately, it's content warning talking about suicide. That unfortunately we know that neurodivergent people are more likely to have that type of horrible adverse outcome and that the interplaying factors of impulsivity and compulsivity and emotion regulation issues all intersect, and that our traditional approach to risk just doesn't capture any of that nuance. But only by understanding that there is so much more to ADHD than inattention and understanding that there is so much more to tics than swearing, it opens up so much more meaning making. Exactly. The contextualising of risk is central, I think, to all of this. It's how do we understand risk is part of life? It's everywhere. The meaning of perhaps this feels a bit too out there, life and death. So within our Bridge project, we had an assessment on suicidality. It wasn't so much the assessments. We had a whole range of assessments, including neurodiversity and trauma, the adverse childhood experiences questionnaire. But I think what our young people told us, it's how you ask those questions and how we made sense at the same time. So I'll give you an example about the suicidality questionnaire. One of the questions is, do you see your life ending through suicide? Young people don't-- they've never been asked that question before. And you just take a moment because they would tick and say, yes. And there are several of these questions because it's about you being honest with them. You're not jumping in with a solution. Just in that moment, you're being alongside what it is that you're experiencing. So I guess, it's just really important for us to consider when we are thinking about the people who are coming to our services, how they experience the suffering and pain in day to day life, and they want somebody to be alongside them. And I think it's interesting, isn't it? Because I remember using the term respectful curiosity to talk about people's religious, and spiritual, and cultural beliefs as well. So it's all of that. I couldn't agree more because it's about context. And we did a study when I was a week trainee. And back in the day, we were curious, and the [INAUDIBLE] team that I was working in about, we were in an area where there were lots of people whose origins were from the Indian subcontinent, but they were not like-- this community generally was not coming to camps. The question was why. And we realised that what we were failing to do was to have that respectfully curious stance. And actually, the families that had come to the clinic were usually the ones where the child or the young person had really, really scarily dangerous, either suicidal behaviour or thoughts or were psychotic. So these were families where they were really in crisis, but nobody ever asked who was supporting the others. And it was often the local imam or the mother-in-law. And we just didn't ask about that. And we didn't ask about how people's faith could help them. So it's being curious about people around and having a dialogue. Yes. I think that's the thing, and it's fascinating. Before we met to do this video, I was involved in a conference, and one of the previous speakers was saying, oh, imagine in your mind's eye this-- da, da, da, da. And obviously, I'm in the green room of the talk. And I can't say anything. But I was like, imagine that not everyone imagines the way you do. And there is this really interesting brain-body thing. And actually, I've got this little YouTube channel, and we explore it in episode four about unusual sensory experiences about how some neurodivergent people or some people experience things very vivid-- mentally. And some people don't experience things in terms of visual, mental imagery, much at all. And we talk about aphantasia and hyperphantasia. And one of the really interesting things is that even as a psychiatrist and talking to psychologists, we make all of these assumptions all the time about how people think or feel. And I played this really interesting thought experiment on my mother. And I said, mother, tell me about how you catastrophize-- the woman neurodivergent, diagnosed with ADHD at 72. She says anxiety is the bane of her life. And it is absolutely true. And so she ran me through this series of catastrophic thoughts, and they were all highly visual. And I was like, mum, you are experiencing this in tech colour. And she said, yes. She says, it's horrible to be in my head. And I put myself in the same position. I decided I would have a very catastrophic thought. And I had a catastrophic thought. And I didn't picture it at all. I thought about it, but there was no image associated. And you might be thinking, what on Earth are we talking about? But I think when we think about risk and resilience, I feel as someone who doesn't have a particularly vivid mind's eye-- it doesn't mean I don't have any because I think people are often a bit reductionist. That actually, to me-- that particular feature of my brain, I feel, is somewhat of a blessing because if you think about it, this question of neurodivergence and trauma, and then you throw in this brain body angle, which is the angle that I'm interested in. So say that we know that the majority of neurodivergent people have this difference in brain-- in body structure that predisposes through basic laws of physiology to have an exaggerated fight or flight response. It's just the nature of how blood pools in the body and doesn't. So you've got this constitutional difference in how your fear is. You've got these brain differences in amygdala, and you're not-- your frontal lobe breaks aren't going on in the way that they should. And so you have a traumatic experience. And this perhaps explains why some people-- because not all hypermobile people have the same autonomic profile. It's different. How some people then experience hypervigilance and trauma differently. And then you throw into the mix of the hypermobile brain/body that is hyper vigilant and trigger happy for trauma. You throw in one of these neurodevelopmental things, like hyperphantasia and vivid mental imagery. And you're thinking, oh, my God, this is a recipe for flashbacks. This is a recipe-- it's a recipe for really struggling with trauma and coming back to what you were saying about what is even the role of trauma and the fact that almost everyone is in some ways traumatised at some point. This is the thing. What is the differential? But it's also-- I mean, there's an image of who is super sensitive to the environment and has hyperphantasia. Those things could actually be the key to unlocking a different future because they will be able to vividly imagine a different future. So I think the bottom line is that dialogue, isn't it-- it's about really helping to understand how someone ticks. And we all want to know. I mean, that's what we're all curious about. We all want to know how we tick and then how we interact with the world around us. And going on that journey with somebody is so much fun, isn't it? It's just finding out about this new person. I love what Chris Gill says. He says when he meets a new child and a new family. It's always a brand new learning experience. And I think that's the attitude we have to have. Curiosity and the concept of differential susceptibility that, Helen, you introduced used me to, but as a developmental psychologist, it just makes sense because you know the children who are sensitive to both good and bad outcomes. And I think if we can identify infants children earlier on, then we can really work alongside their strengths and their difficulties. And we can take the opportunities and help them thrive. And help them thrive and change trajectories for families. I've been giving a very cheeky lecture occasionally these days, which is called Life's a Bitch and then you Thrive. Yes. Because I mean, life's a bitch for all of us at some point. And it's like, how do you use that with people around you to move forward? And it's so interesting. I gave that lecture to medical students recently, and at the end of it, I was surrounded by refugee medical students. And they really felt heard for the first time. They were all talking about the difficult experience they'd had, and they'd said, one of the hardest things is that everyone thought they were broken. And they were saying, we're not broken. But I want to just have a little think about what you said. We all need to work out what makes us tick. And you were saying that in a kind of clock analogy. But if you took it literally, what makes us tick in terms of ticks, I obviously said, these unfortunate things about the suicidality. But then the flip side of that or the both and of that is I went to watch a band. And in between the band, there was a spoken word poet, like stand up, and did this amazing performance of what psychiatrists might say is clanging and punning and derailment and all of that sort of stuff. I mean, the person wasn't mad, but the idea was that what makes you tick makes you be a poet, a performer, have the words come to you, and rhyme in this particular way. And in the break, I happen to be having a vape with the spoken word poet. And I said, how does this stuff come into your brain? And he said, well, it's compulsive. I just think of this word, and then all of these other words come in. And I'm not sure. So we did this study, where we showed that hypermobile people were more likely to score higher on various psychological measures of creativity, problematic construct that you could reduce that sort of thing to numbers. But that that relationship was mediated by the presence of neurodivergent traits and most powerfully, childhood ADHD traits. And this is the sort of strengths and challenges. And it's never just one or the other. I mean, that's the other thing. I really don't like the superpower tragedy narrative. It's all of it in the mix. And what Helen was saying about parents in this very poverty, you've got this at the other extremes. Now, I'm not going around casting any diagnostic aspersions. But a friend of mine reminded me of a popular film about how a particular social network was born, and that was born out of a moment of rejection and then led to being one of the most powerful and wealthy people in the world. And we know that neurodivergence doesn't just cluster in poverty. It also clusters in highly successful-- seemingly successful professions and work quite closely with ADHD UK and Henry, the CEO, championing other CEOs and things, who have ADHD. It bridges the entire spectrum. I thought I could-- just as you were talking-- in that for anybody listening to this and thinking-- because we had conversations with our colleagues in Sweden. And I remember when we were looking at the overlap between neurodivergence and trauma, one of our colleagues said, well, if you add risk factors, you will have poorer outcomes. What's the magic? What's different about-- what is that you're proposing? And the plethora of studies that have shown that-- the birth cohort studies-- actually cumulative effects have poorer outcomes for cumulative risk factors. But actually, this isn't more than that. It's about embracing complexity. So we don't become either or. We become and. And it's just when you were talking about how we are split off even in our mind, and body, and physical health, and mental health, and trauma, that actually-- that we have to think about other factors, which we haven't even talked about yet in terms of emotional dysregulation, inflammation. Go on to make this picture even more complex and unique at the same time. And it's having that dialogue with the person to help them understand that every aspect is at least two sides of the same coin. Yes, exactly. And we were talking because we met all together only last week about this idea of the intersecting factors, the perfect storm. And in a perfect storm, that could actually have the straw that breaks the camel's back. And you could also have the key that unlocks the thing. And it isn't-- it's that contextualization that we've been talking about between the person, their genes, the environment, society, and understanding it all in all of its shades of grey. [MUSIC PLAYING]