← ADHD Experts Podcast
ADHD Experts Podcast
546- Living with ADHD: It’s Different for Women – an Expert Roundtable
01:30:30
Five experts — Lotta Borg Skoglund, M.D., Ph.D.; Ellen Littman, Ph.D.; Andrea Chronis-Tuscano, Ph.D.; Diane Miller, Psy.D., M.Ed.; and Maggie Sibley, Ph.D. — discuss ADHD in women, including different symptom presentation, stigma, barriers to...
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- [00:04]
A
Welcome to the Attention Deficit Disorder Expert Podcast series by Attitude Magazine.
- [00:14]
B
Hi everyone, my name is Annie Rogers and on behalf of the Attitude team, I am so pleased to welcome you to today's special ADHD Experts panel discussion titled Living with adhd. It's different for Women. Today's free roundtable is made possible with support from Play Attention. ADHD presents unique challenges for women, often overlooked and misunderstood. Play Attention is inspired by NASA technology and backed by Tufts University research designed to strengthen executive function, helping you navigate focus, organization and emotional regulation with confidence. Plus, every Play Attention program includes a personal Focus coach to customize your plan and guide you along the way. Click the link on your screen to schedule a one on one consultation. Visit www.playattention.com for adults to learn more. Attitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content. Now we know that historically ADHD was considered a predominantly, if not exclusively male disorder. For generations, girls went without proper diagnosis and treatment because clinicians were looking for boy presentations of adhd. Even parents and teachers didn't and sometimes don't understand how ADHD affected the lived experiences of girls differently. Why? Because scientific research has long neglected ADHD's profound impact on females, we now know that untreated ADHD can have serious and even life altering consequences for women and girls. We know this because women with ADHD have been telling us this for years, telling us about the heavy burden of living in a world that's not designed for them. About how untreated ADHD causes turmoil in their closest relations relationships and how it affects their performance in school and at work. How it shreds their self esteem. Today, Attitude has convened a very special panel of experts who have a front row seat to these lived experiences of women with adhd. Together we will discuss the need for more research and the importance of an open exchange of ideas to increase understanding and support. Our esteemed panelists today include Dr. Ellen Littman. She is a clinical psychologist in New York and has been described by the American Psychological association as a pioneer in identifying gender differences in adhd. She is a co author of the book Understanding Girls with ADHD and a contributing author of 57 articles and numerous chapters devoted to these topics for more than 35 years. Dr. Lada Borg Skogland is an associate professor at Sweden's Uppsala University Department for Women's and Children's Health. Her research focuses on the role hormones play in women with ADHD across the lifespan. She leads the pioneering research Group Goddess ADHD Dr. Andrea Cronus Toscano is the Joel and Kim Feller professor at the University of Maryland and director of the UMD ADHD Program and UMD Succeeds College ADHD Clinic. Her research focuses on understanding early predictors of developmental outcomes for children with ADHD and developing novel treatments that target these early risk factors. Her work also focuses on families in which a parent and a child both have ADHD. Dr. Diane Miller is a clinical psychologist specializing in adult ADHD, racial identity issues, and sex therapy at the center for ADHD in Philadelphia. Dr. Maggie Sibley is a clinical psychologist at Seattle Children's Hospital and professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. She is a chair of the Diagnostic Subcommittee for the APSAR Adult ADHD Guidelines and also is the author of Parent Teen Therapy for Executive Function Deficits and ADHD Building Skills and Motivation. On behalf of the Attitude Team, thank you all so much for joining us today. Before we start our discussion, I will encourage our live audience to submit your questions at any time in the comment box. We will turn to your questions at the end of today's conversation. I will also note that the insights and ideas discussed today will be featured in Attitude's upcoming summer issue, which is our first ever women's issue. Visit attitudemag.com subscribe to ensure that you do not miss it. Okay, to begin today's conversation, Dr. Lipman, you have been working to bring the lived experiences of women with ADHD to the forefront of research and patient care for decades. From your point of view, why do you think so? Why have so many women gone undiagnosed and untreated over the years?
- [06:21]
C
Okay, thanks Annie, and I'm happy to be here. And I'm going to piggyback on your intro in order to try to make that point maybe in a way that it hasn't been heard before. The way I think of it is I call it the chasm, and that is the abyss between what we understand in the dsm, the Diagnostic and Statistical Manual, where the criteria are based on boys observable behaviors. And then what we're trying to compare them to when we look at women is women don't want to have observable behaviors. They are determined to not have observable behaviors that show them to be different. So women put tremendous time and energy into masking and in some way hiding those behaviors. If we're looking behaviorally, we're not seeing anything. On the same continuum, women internalize their experiences and they cannot be observed after puberty when there's estrogen in their systems. What might be observable might be anxiety or depression, which is one of the ways in which they might be misdiagnosed. But there's really a disconnect between the idea that women are trying so hard to, when they're seeing a clinician, to be people pleasing to. They're responding to gender role expectations that direct them to control their behavior and look really appropriate all the time. And so if you're looking for hyperactive or other behavioral symptoms, you're not going to see them that way. We're more likely to understand women's internalized experience in terms of their functionality across the lifespan. But those are all things that women are experiencing internally, struggling with in isolation, maybe moving towards perfectionism as a way of controlling these symptoms. But all of these, all of these actions are really behaviors, unfortunately, to create an inauthentic picture that they expect to be more socially acceptable. Being socially accepted is something that is very important to women. When they go to a clinician, it's an interesting thing. If they go to a clinician in the week after their period, they look really together and they may feel really good and the clinician may say, well, you can't possibly have add, you're functioning so well. Then that same woman may be seen a week before their periods and they may be tearful and they may be feeling hopeless and still they won't be diagnosed necessarily with add. They may instead be told, well, you may have some depression and some anxiety. So in other words, that sweet spot of meeting the criteria for DSM is almost impossible for women. Which goes back to when I first got into this field. It was in response to saying that girls were ADD wannabes. And unfortunately, 35 years later, it isn't so different in that what is being looked for is something that women are not going to show. And the things that women need to have people understand within them, those are the questions that are not being asked, those are not on any assessment instruments. And they continue to be alone and feel alone and feel dismissed and have their credibility questioned. And those are the things that I'm concerned about.
- [11:33]
B
Wow, that was a really powerful overview, Dr. Lipman. What I'm hearing is really confluence of factors that due to societal expectations, women are more likely to internalize their symptoms. And the research has not been done for clinicians to understand what the signs of those internalized symptoms may be. And so our girls continue even today to be under diagnosed. I guess my follow up to that is we do see an increase. We know that the greatest increase in diagnoses today are among adult women. Why do you think that is that there seems to be a breaking point. And can you just touch on a little bit about the consequences of not getting a diagnosis or treatment until later in life?
- [12:33]
D
Sure.
- [12:35]
C
I think I'll start with that part of it. Women are referring themselves and they're referring themselves because they have access to information that is not necessarily coming the route through research and studies, but reading it in places like Attitude magazine and even young people TikTok on Instagram. And those are populations we never could reach before. And so it is an awareness that there's something out there. But very often the clinician may not agree.
- [13:22]
E
And.
- [13:25]
C
For example, you know what we know now about high estrogen and low estrogen states, which I was referring to before, something that if people are not aware of that, I mean, there's going to be no way of understanding why people would look so different in those different situations. And there isn't a way for women to have a foothold to basically say that this is my experience and that that does not meet any of the criteria. So constantly being sub, sub, I don't want to use academic words that won't be helpful. But the fact that they will not.
- [14:27]
F
Be.
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C
They, regardless of what their symptoms are in terms of being emotional, trouble regulating their emotions, they will, that will not be seen necessarily as a symptom. That will be seen as just women expressing themselves in a way that may not be direct. And so basically they are begging at this point simply for acknowledgement of the fact that there are so many different presentations. But they all have to be taken into account in terms of we're showing you what we want to show you, thinking that that will get people diagnosed, but of course it doesn't. And the better that you look in your presentation, the more likely you'll be among the last to be diagnosed. And so this goes back to the first part of your question. What happens if they're diagnosed later? They've spent a decade or two or.
- [15:50]
E
Three.
- [15:52]
C
Having no scientific overarching understanding of what's going on. They fill in the blanks in the stresses, the stressors and their challenges with what they understand, which is saying something about their own character rather than understanding there's an explanation for it and that affects their self esteem. And as those issues become cumulative and they feel worse and worse about themselves, they isolate themselves more and more. They compare themselves harshly to their peers. They may cope in ways that are not healthy for them and still there's only just now starting to be a place where they can find some support and some normalization of their experience.
- [16:54]
G
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- [17:28]
B
How hormonal fluctuations can impact diagnosis and treatment, and this is an area of specialty of another of our panelists. Dr. Skogland, you have been studying the effects of hormonal fluctuations on girls and women with ADHD across the reproductive cycle. This is an area of research that has long been neglected. Can you help us understand how ADHD symptoms do change during the menstrual cycle and how that might impact a woman's or a girl's chance of diagnosis?
- [18:09]
F
Yeah.
- [18:10]
A
Thank you. And thank you also, Dr. Littman, for this nice introduction and I'm really happy and honored to be here to talk about this important issue. But first of all, I have to say that how girls and women react to hormones, it is highly individual and, and as it has been pointed out here, there is so little evidence to rely on. But we do know that naturally cycling women from puberty to menopause experience dramatic fluctuations of circulating sex hormones, and that sexual hormones like estrogen and progesterone have direct access to the brain and are involved, and that there are receptors in all the areas that we know are involved in difficulties and challenges that we are seeing in individuals with adhd. But there's also a growing number of studies suggesting that women with adhd, on a group level at least, may be more sensitive to these fluctuations across the cycle compared to women without adhd. Just to refresh the knowledge about the female cycle, using a typical cycle of 28 days, we know that the first two weeks, day one to 14, is the follicular phase, where estrogen levels are rising, peaking around day 14, triggering ovulation. And women with ADHD, again on a group level, will say that they have better control, usually of their ADHD symptoms, just as Dr. Liftman actually suggested in.
- [19:50]
F
The beginning of her talk.
- [19:54]
A
And following then ovulation, typically, then day 15 to 28 is the luteal phase and the progesterone is the dominating hormone. And we know that during this period, even women without ADHD often describe negative mood and also physical symptoms. We can call it PMS or pmdd. And women with ADHD often also report less control over their ADHD symptoms and some may even experience that their ADHD medication may be less effective during this premenstrual period.
- [20:30]
F
Then.
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B
And I assume, but maybe I shouldn't, that many clinicians are unaware of the impact of hormones on medication and that could complicate treatment.
- [20:47]
A
Yeah, yeah. And also because it depends, you know, ADHD is not a homogeneous disorder, not for women and not for men either. So the hormonal, the effect on the reaction of the hormonal fluctuation can also be dependent on the individual ADHD profile. So if you have an individual profile that is more defined by impulsivity and hyperactivity, then the days around ovulation where the estrogen levels are high can be the most disruptive for you because then these high estrogen levels can potentiate dopamine, can potentiate the ADHD medication if you're on a stimulant, and then actually increase and result in risk taking behaviors. So even though it may be for the person or for the woman associated with basically positive emotions and energy, the result can be equally devastating if this positive energy results in you wanting to go out partying, drinking alcohol, taking drugs, driving maybe too fast or under the influence, shopping a lot or ending up in difficult situation that you have to manage for the rest of your period because of these days where you are overstimulated. And again then, if your ADHD profile is more of a classic, like you say, ADD type, defined by maybe difficulties in energy regulation, getting your energy up, and maybe a lot of depressive symptoms and anxiety, the higher estrogen around ovulation may come as a very welcome energy boost and a mood boost. And instead you suffer tremendously from depressive symptoms and rejection sensitivity. And so around the weeks or days premenstrually. So it can look very, very differently. And also that we don't know very much about treatment. And there are just a small, and to my knowledge, just one small study from the Netherlands, from Maxine de Jong and and Sandra Coy's group that have actually explored cyclic or flexible dosing that increasing the dose around the premenstrual period. So we don't know, but we suspect and we think and the theoretical model is there. But again, so much that we don't know and we have very little as clinicians, very little support and guidelines to rely on. We really have to make individual assessments for every woman and discuss her hormonal profile.
- [23:37]
B
Yes, and there's some interesting new research that I know many of you are aware of, I believe it's Dr. Martell on the impact of estrogen and progesterone. Yes. And she's contributing an overview of her research to the summer issue of Attitud. I think that we're excited to be able to present that sort of visually to help people understand. Yeah.
- [24:07]
A
So excited to take part of Dr. Martel's research as well.
- [24:10]
B
Wonderful. I do have a. I'm looking at the questions that we're receiving here today, and I would be remiss to not touch with you, Dr. Skogland, on perimenopause and menopause. Again, I understand the research is scant, but what can we tell people about? There are literally hundreds of people in the comments now asking, why now? Why in my 40s and 50s am I finally getting this ADHD diagnosis? Why did things go haywire for me? What do we know?
- [24:45]
A
Well, so I think also continuing on what Dr. Littman was discussing, that we missed and we fail to identify the girls and the young women, and we have just published a study where we can show that girls and women are diagnosed four years later. So girls and women will be missed for a longer time. So that is one of the questions. And it's not, you know, so.
- [25:17]
B
Far.
- [25:18]
A
In our history where we actually didn't talk much about adult ADHD and even less about adult females with adhd. So I think that is one explanation. But then we also have this complex interaction with the hormones where we know that women just with and without ADHD will be affected cognitively and physically when we go through perimenopause these years around menopause. And the challenge here is to try to disentangle. Is this something, is this cognitive symptoms that is actually most probably related to hormonal changes during perimenopause, or is this a person who have lived with undetected ADHD for her entire life, been able to mask, as Dr. Lichtman say, been able to cope to find strategies while the strategies is no longer holding up, when also this hormonal hit to the brain comes in the perimenopause? We don't know very much about that, but we do have some studies showing that women without ADHD in perimenopause gets improved cognitive functions from central stimulants from ADHD medication and vice versa, that women with ADHD seem to respond really well to menopausal hormonal treatment, HRT or mht, and that their ADHD symptoms seem to answer to that as well. So this is an extremely important topic where we, where we are just scratching the surface, but we have to use our common sense, I think, and we have to realize that ADHD is a childhood disorder. It's not a childhood disorder, but, but it's, it's, you are born with it or you develop it early on in life and then it can be missed and diagnosed in adulthood. But if you have no symptoms of ADHD and then you get ADHD symptoms in your mid-40s, then hormonal factors might be the best hypothesis to start with. Again, you have to be super individual. You have to have this collaborative discussion with your clinician and a very open, I guess, mind in this shared decision.
- [27:58]
F
Making when you go forward.
- [28:00]
E
Right.
- [28:02]
B
That was very helpful. We've talked about some important inflection points. If puberty being one perimenopause menopause, motherhood is another big one. Dr. Cronus Toscano, you have been working with mothers with ADHD who have children with adhd, which we know is quite common, and wondering, what do you see as some of the most common challenges in this family dynamic? Can you offer some insights and strategies for those mothers with ADHD who are raising neurodivergent children as well?
- [28:45]
D
Well, thank you, Annie, for inviting me today to this wonderful panel. I've learned so much already, actually, when the reason that I first became interested in this was when I was in graduate school and I was assessing so many kids with adhd. And during the assessment, mom would pop out of her chair and say, oh my gosh, I forgot my child at the bus stop, or would say that all these symptoms that I was asking her about and her child sounded like her or sounded like her spouse or partner. So I do think that one of the reasons or one of the, the key times when women might get identified is when they have a child who is being evaluated for adhd. So when I think about challenges that mothers with ADHD experience, I think about sort of two buckets. First is the executive functioning challenge of parenting. So things like planning, organization, problem solving, forgetfulness. And as we all know, parenting requires a great deal of executive functioning. And when the child also has adhd, mom is put in a position of having to provide even more external structure and scaffolding for the child to be able to teach them those organizational skills. Yet when the parent also struggles in this area, it could be really tough to maintain things like calendars to do lists and parents might need extra support in this area. The second sort of bucket is the emotion regulation aspects of parenting. So as Ellen and others have mentioned one of the key features of ADHD in adults is this ability to regulate one's own emotions. Even though this feature isn't in the dsm, we know that this feature is prominent for many people with adhd. As has been mentioned, every individual with ADHD is different and struggling with different types of symptoms. But when emotion regulation difficulty is present, it might be even harder to for parents to maintain their cool when they have a challenging child who might be pushing their buttons even when they don't mean to. So patience is another sort of way that moms with ADHD might struggle. They might have a hard time if their child with ADHD is moving slowly when they're getting ready in the morning and they know that the bus is coming and the child just keeps getting distracted instead of sort of moving through their daily routine. That can be really hard for moms with adhd and they might lose their cool, which is going to contribute to them feeling poorly about themselves as a parent. And so we know that other stressors that come along with adhd, things like financial stress, work stress, relationship stress, these can all build to make difficulties in parenting even worse. So how do we help parents?
- [32:07]
A
Well.
- [32:09]
D
We'Ve developed an integrated parenting program for parents with ADHD who have children with adhd because a lot of times we know that these parents might not take time to get help for themselves. Right. Many parents put their kids first and they take care of the child's every need, but they might not take the time or feel like they're just too busy or overwhelmed to take a second to help themselves with their struggles. We've folded in help for the parents ADHD with the types of parenting strategies that we know have been studied for years to help kids with adhd. All of these interventions for kids with ADHD require a parent to be extra structured, very consistent, very calm and patient, which we know can be hard for any parent. But especially for parents who are struggling with ADHD themselves, we work with them on lots of different types of organizational skills and cognitive behavioral skills. In terms of organizational skills, we work with parents on keeping a calendar system, and that means just one calendar. A lot of times moms with ADHD might have a home calendar and a work calendar. And so when you have different calendars, sometimes you might end up getting yourself double booked. So we really work with them to have just one calendar where they put every single activity, including things that they need to do for themselves. We help them with keeping a prioritized to do list where they write down every single thing that they need to do. And we work with them to discover, well, do I really need to do all of these things? Am I putting way too much pressure on myself as a parent? We work with them on prioritizing and weeding out those things that may not be really necessary so that they could focus on the things that are most important. We also really try to emphasize to parents with ADHD the value of taking care of themselves, the value of kind of finding time to do the things that they enjoy so that they can be in a happier, more relaxed place when they're with their child and can really go all in on parenting when they're with them. And sometimes parents tell us, there's no way I can take time to do things for myself, but we really do work with them on finding those little opportunities throughout the day. It might be listening to a podcast on the drive home from work or other small things like that that they could really build into their day to day to really prioritize themselves and then to watch how that can help facilitate more positive interactions with their kids. And we also teach them mindfulness and relaxation, again, so that they could remain calm, ignore some of those minor annoying things that children with ADHD might do, like talking loud or being constantly moving. And I would say most of all, we tried to work with them on giving themselves grace, right? Not being too hard on themselves. We heard from the other speakers so far about how many parents in general, but particularly I think moms with ADHD might get down on themselves, might feel like, this is my fault or this is too hard to say, that parenting is really hard. The Surgeon General came out a couple of months ago with an advisory on parent mental health. Parenting is hard for everyone, but when you have ADHD yourself, you don't need more blame. What you need is support around those very skills that you're trying to teach your child.
- [36:18]
B
Wonderful. I think Dr. Krones Toscana, what your comments also underscore for me is something that maybe we take for granted, but I would like to repeat it, that we're really learning more and more that ADHD is part and parcel with executive function challenges, also with emotional dysregulation challenges, something that Dr. Russell Barkley has talked about for a long time, but has been perhaps slow to permeate into the larger world, that this is real, that ADHD for most people brings executive function challenges, just like you were mentioning. And when you're not only responsible for your own planning, prioritization and execution, but also that of your child or children and perhaps your a significant other. It can be, you know, downright impossible. So I just think that's, that's important to stress. And thank you for those insights. And I would love to turn to Dr. Miller, a different perspective. You have been working specifically to shed light on the unique challenges that black women face when it comes to ADHD diagnosis and treatment. And I'm hopeful that you can tell us about some of the barriers that are specific to black women and keeping them from getting the care that they really need and deserve and what impact that has on them, on their mental health, their careers, their relationships. Thank you. That would be wonderful.
- [38:07]
F
Thank you so much for having me. I feel so appreciative to be a part of this amazing panel. You all are like, making me think I need to publish some stuff too, because you're so distinguished. But I did want to highlight there. There are several major barriers that prevent black women from getting the diagnosis and care that they need. And the consequences are actually really significant. One of the biggest issues is that ADHD in black women is often completely, completely overlooked or worse, misdiagnosed as something else. Like Dr. Lippman referenced earlier, women generally don't want to be observed, and black women at times make it a point not to or specifically are taught not to be observed. And that's in order to navigate some of those safety concerns that are pretty real in terms of racial and gender biases. And typically they are at fault for a lot of that, as society might habit. And because of that, we're, because we're still working through, like that clip, that classically held view of adhd. Many clinicians don't immediately see it. Instead, they misinterpret the symptoms as mood disorders like anxiety, depression, like we've mentioned before, or even worse, bipolar disorder, which is a pretty stigmatizing mental health diagnosis. Actually. Drs. Stoglin mentioned how these fluctuations in hormones can contribute to symptom presentation that can actually mimic some of these manic symptoms that clinicians can utilize as a basis for diagnosis. I actually had a client who was misdiagnosed. And one of the key things that she noted was this feeling of wanting to run to city hall and back. And that was taken as a manic symptom when really she was just trying to describe the type of energy that tends to flow through her body, which is more hyperactivity than it is a manic symptom. And so this is particularly dangerous because these diagnoses come with complete different treatments. So instead of receiving some of Those helpful interventions, which was likely already difficult for a black woman to even get into an office to say, hey, I'm having these difficulties. What they tend to face is being prescribed medications or even being in therapy, modalities that don't actually address their actual challenges. So that leaves them feeling frustrated and even more misunderstood. Like I mentioned, I've worked with some of these women who were given multiple mental health diagnoses over the years without anyone actually considering that ADHD might be a root issue. This actually delays access to the right treatment and profoundly damages the self esteem. It becomes more of something is inherently wrong with me when in reality it is just their brain is working way different than anybody else's. Secondly, Black women often don't recognize their own symptoms of ADHD because they've been so conditioned to push through struggles on their own. And symptoms tend to align with society's stereotypes of black people as a whole. Emotionally unstable, lazy. Many of us grew up hearing that we had to be twice as good to keep up and to be recognized as even half as much as a person. And so when executive function issues make it hard to keep up, instead of seeking help, we internalize it as a personal failure. I just need to try harder. I just need to grind. I need to prove that I am not who they think or say I am. Which leads to overcompensating, overworking, overachieving and constantly masking these struggles to appear competent. That works until it doesn't. Eventually that leads to this burnout and this anxiety, this feeling of I am a failure. And sometimes even the physical health issues that we're mentioning can pop up like these migraines, chronic fatigue, high blood pressure even. And now folks are even talking about this connection with autoimmune diseases and the impact of chronically high levels of cortisol in the body. It's an exhausting cycle and that many black women don't even realize is tied to undiagnosed adhd. And lastly, we can't ignore that many black women don't seek out care due to this well founded mistrust of the healthcare system. Black women have historically been over pathologized and mistreated in medical settings and that history hasn't disappeared. Many women fear just being dismissed, judged over medicated, and so either they and so tend to avoid even seeking out a diagnosis because they don't even know who to trust. And for neurodivergent brains, it's all or nothing with us, right? If the task looks daunting and is riddled with High probability of rejection or harm versus help. Do we take the chance? Usually we don't. And so we see that those long term impacts just are massive for black women and just continuing deteriorating mental health career tends to then suffer because we're trying to keep up in all of these different areas in our life. And it's hard to figure out is this me? Is this my brain? What is actually happening? Am I just a failure? And so it causes so many different complications in your life that even relationships are difficult because if folks don't, I can't express how I'm feeling, why I'm feeling, how do I expect anybody else to understand? And so in a community where social connection is especially important because of the historical othering, many black women feel isolated and misunderstood and then they don't necessarily have these tools to be able to even figure out how do I get myself out of this world?
- [44:25]
B
That perspective is so valuable. Thank you so much Dr. Miller. And to dovetail on your last point, we got a a comment from one of our attendees today who said as a black woman, I have hidden my ADHD by creating friendships to help me complete tasks. I was diagnosed at the age of 55 and just started taking medication. I'm still trying to figure out an appropriate therapy for myself. So that leaning on community is really clear in that comment and I'm sure there are many others. Just as an aside, we have received some 337 questions so far today ladies. So I think we have hit a nerve. So I will turn to Dr. Sibley a little preface. A few times today we have mentioned the dsm so very quickly, that is a diagnostic Help me identify massive statistical manual of oh gosh, help me out some mental disorders.
- [45:30]
D
Thank you.
- [45:31]
B
I never want to say that. And basically this is what is used to diagnose many disorders, including adhd. And we're using the fifth version currently, which is not terribly updated, more than a decade old I believe. And so I wanted to give that background that this is generally what is used to determine if an individual meets the criteria for either inattentive, hyperactive, impulsive or combined type ADHD. So separate from that, Dr. Sibley has been involved with the American Professional Society of ADHD and Related Disorders, known as apps. And this organization has been working separately to create clinical guidelines for diagnosing and treating ADHD in adults. So we should note that most developed countries already have national and regional guidelines for ADHD care in adults. These US Guidelines are drumming up a lot of excitement and we wonder. Dr. Sibley if you can tell us sort of what we would expect from these guidelines and how they might help address the needs of women with ADHD and overall how they might influence diagnosis.
- [47:07]
E
Thank you. So the DSM 5 since 2013 has been our system as clinicians for deciding who qualifies for a clinical diagnosis of adhd. And the Abstart Initiatives job is, unfortunately, we don't have the authority to rewrite the dsm, even though I've got all kinds of ideas about how we might do that. But what we need to do is help clinicians if they are going to use the dsm. How do you use this in a way that is most likely to identify the right people as meeting criteria for adhd and also make sure people who don't meet criteria for ADHD aren't mistakenly given the diagnosis. And so I'm part of the Diagnostic and Screening Subcommittee. I'm the chair of that committee. That committee is seven women and two men. So I hope you rest assured that we have very much been thinking about women's issues as it comes to diagnosis in our work. And our job is really to look at the DSM criteria. There's a symptom checklist of 18 symptoms right now that folks are often aware of. But there's also other criteria in the DSM related to age of onset that we might expect in someone with adhd. How many settings they might be experiencing the symptoms in, what kinds of impairments they might have, and also how to tell the difference between ADHD and something else that looks like adhd. And so for all those pieces of the diagnosis we're going to go through and we're going to make suggestions and recommendations for clinicians for the best way to a gather the information they need to be in an empowered position to make the right choice, but also how to troubleshoot tricky situations and give advice and guidance about how essentially we might be able to overcome some of the known structural issues that can affect a woman getting diagnosed, how to recognize impairments that might be more common in women. So while we can't rewrite the dsm, we can certainly try to put footnotes to it that can help people do a better job, specifically with women. And so that's one thing we really care a lot about on my committee.
- [49:21]
B
Wonderful. And we know that clinician awareness is a big piece of this puzzle. And I know that apps are working with organizations, including Chad, on plans for educating clinicians as well as patients. I wonder if you're able to just talk about that and why it's so important that these guidelines dovetail with an effort to improve education.
- [49:52]
E
Well, as it applies to women, I think there's two really big issues here. One is that ADHD often underlies other concerns that women are being diagnosed with coming for their first contact with the mental health system because of anxiety, depression, a substance use problem. And so one thing is that clinicians working in those settings often miss the ADHD that's responsible for sort of like, you know, bringing those things on. Often those other disorders are consequence of adhd. And so I think one thing we want to be thinking about is how can this clinician education empower people to like, make system level changes where we're screening, for example, to make sure that we're catching people where they're likely to be. But also if our clinicians are not confident in diagnosing adult ADHD and specifically not confident in diagnosing ADHD in women, they're going to play it safe. And that's one thing that I think is tricky here, is that a lot of folks are a little afraid to diagnose ADHD in women who maybe didn't show clear symptoms when they were younger because there's stigma against, as providers, there's often stigma against being somebody who's just handing out ADHD diagnoses.
- [51:10]
B
Right.
- [51:10]
E
And so there's, there's system level factors on the provider side as well as the patient side, but with good information and clear guidelines that a clinician can point to and say, hey, I'm following these, you know, it's not me being somebody who's being irresponsible here. Then I think we're also going to bring the whole country on a better playing field in terms of like, what's acceptable, what are the procedures you should follow. And we'll probably see opportunities for people to follow best practices because they're clearly outlined what they are.
- [51:43]
B
We are so hopeful, we are waiting with bated breath, very excited for the guidelines later this year. Thank you, Dr. Sibley. I'll start with round two of some questions and I may sprinkle in some related questions coming from our audience here. But I did want to circle back to Dr. Lipman and a theme that I'm seeing in the comments today that we discussed prior is how diagnosed and treated or not, ADHD has a very profound impact on a woman's self esteem and can trigger imposter syndrome feelings, among others. And breaking that internal narrative of not being good enough can be incredibly difficult to do. And I wonder if you have some insight in things that can help women to make them understand again, diagnosed or not, I guess that they're not personal failures, that their challenges stem from neuropsychological root.
- [52:59]
C
Okay, well, as I think I said before, in terms of as their diagnosis is more and more delayed, they're spending more and more of their lives finding an explanation that really is about their own self doubt and their sense of self is getting battered. And as, in fact, you had mentioned in terms of some of the people asking questions about sort of midlife and perimenopause and menopause. And it's not a coincidence that developmentally at the time that women are losing one of their best pieces of scaffolding, which is estrogen, in their systems, at the same time that their challenges are much greater and their responsibilities are more complex in terms of perhaps children, families, homes, aging parents. All of those things are happening when they have even less and less support. And it is a daunting process, add or not, but it's almost a panicky feeling when this is truly overwhelming. And I think that is the word that most women use most often to describe it. And since at this point in time we're spending, women in general are spending over a third of their lives in menopause, which is, you know, it's, that's an intense statistic, but, you know, so they're, even if they didn't struggle early in their lives, they are in a position where they, as they, they may not recognize and many clinicians don't recognize the price that is paid for the loss of estrogen. So that women are judging themselves really, really harshly. And it is very difficult to help. I mean, that is essentially what we can do. We can't change brain wiring, but we can help them reframe the way they understand how they function in their lives and how to label what they see in terms of their own behavior and how to view themselves in a more forgiving lens where they can understand that they are doing something with a different set of strengths and weaknesses and that everyone has a unique set. That idea that the societal expectations for women, which even though just about everyone rejects them as antiquated nonetheless by osmosis and by our mothers and time in the world, those things still get in. And so everyone is judging themselves and they internalize those judgments so that even they are saying, oh, I must be overreacting, I'm being too sensitive, when in reality that is not necessarily the case at all, and that everybody's brain is responding to the way it's necessary for that stimulation from their histories. They're not choosing how they're going to react. But the more that they hear comments like you're overreacting, they start to really buy into that. And so there's a lot of reframing to do. And it's a long process. But people who are willing to go on that journey end up feeling empowered and believing in themselves in the way they didn't before. So it certainly can be done. But we need a lot more clinicians to be recognizing that that is the situation and that women are not volunteering the pain that they're experiencing in just how they see themselves in the world.
- [57:39]
B
Women are not volunteering the pain they're experiencing. That's a very powerful statement. And in your experience, is cognitive behavioral therapy an important piece? And I wonder if Dr. Lipman or others on the panel can talk about specifically. We had the question earlier to Dr. Miller about looking for the right therapy, and we've heard that cognitive behavioral therapy can be quite powerful in tearing apart these messages that we tell ourselves.
- [58:20]
D
I was going to say we do focus on this a lot with the moms that we work with, and I was going to talk about that in a little bit, but could talk a little bit about it now or let's segue.
- [58:35]
B
Yeah, I think it makes sense. We'll piggyback.
- [58:37]
D
Yeah, yeah, yeah. So as Maggie mentioned, a lot of women with ADHD who've been struggling, you know, with, you know, feeling like they maybe aren't meeting others expectations or getting a lot of negative feedback or are really anxious about, you know, not missing anything, they do develop anxiety and depression over time. So one of the things that we work on with the moms that we work with, as well as the college students in our clinic is it's all based in cognitive behavioral therapy. We try to work with their thoughts, feelings, and behaviors in terms of thoughts. We try to bring their awareness to any unhelpful thought pattern. So, for example, do they have unrealistic expectations for themselves? Are they discounting the many things that they're doing well or the things that they're accomplishing and instead over focusing on what didn't go well or the things that they didn't finish or that they might have missed? Do they feel like they have to take everything on themselves? As I mentioned before, it's perfectly fine to say no to certain things and to call in supports when it feels like it's too much in terms of behaviors. We help them to really take a closer, close look at how they're Spending their time, you know, how much time are they spending doing things that really don't matter, that you know, aren't in line with their values or what's important to them or things that really aren't bringing them joy in the day to day? Like, well, for college students a big thing is video games. But for moms, sometimes we hear, you know, maybe they're spending a lot of time on their phone doom scrolling, looking at social media, Netflix binging, or others might be accepting volunteer roles or invitations that they're really not that excited about. And so we kind of look at, well, you know, why and how could we sort of, you know, insert a pause before you agree to do something that might take time away from other things that you know, that might lead to less overwhelm and to give you more time to do things that really make you happier. And so, you know, that involves really looking at someone's values. So if religion is really important to them, figuring out a way that they can make time to go to church or synagogue or mosque or wherever they worship, or to pray, or if their health and wellness is important to them, how can we make sure that they get their steps in or get some exercise every day? Or if reading books is something that just makes them really happy, how can we make sure that they can fit in sometime to either read or listen to some books? And if, you know, if they think about taking time for themselves as something really big, like going away for a weekend, that might seem completely out of reach. But as I mentioned before, figuring out little ways to insert things that bring joy into their day to day. I worked with one mom who used to say that when she'd come in the door from work, she knew everyone would be bombarding her with demands and she had lots of negative thoughts about dealing with homework. Time with her teen with ADHD when she got home and she used to park around the corner from her house, bring her sneakers, go for a walk in the neighborhood, get back in her car and then drive home so that she could actually get some time for herself? So those are some behavioral things. And then finally, to combat stress and other negative emotions, we work with moms to practice relaxation and mindfulness skills again so that they could put their oxygen mask on first. And then the last thing I'll mention, and I know that sleep is also affected by menopause. So all of these things are related to one another. But sleep is such a critical factor for both moms and kids. And we know that when we don't get enough Sleep, it affects our executive functioning, our mood, and we always say a tired mom is a cranky mom. So even the routines around sleep are really hard for our families. With adhd, it's critically important for both the parent and the child. Even though there's still this pull, like there's still work to be done, either I open my laptop after the kids go to bed, or that's the time when I can spend time with my partner, or that's the time I could actually read my book. We try to help support them in balancing all of these different demands so they can prioritize their wellness.
- [63:52]
B
Right. So important.
- [63:54]
D
Yes.
- [63:57]
B
I would love to Turn back to Dr. Skogland. I'm going to pivot a little bit on my question to you just based on what I'm seeing in the comments. And that is we've talked a little bit about what are sometimes called the comorbid conditions that are common with adhd. Basically these can be conditions that are, that coexist with ADHD anxiety being the most common, depression. But we're gaining a lot more understanding about the fact that ADHD almost never exists in isolation. So this is a bit of a broad question, but how can women talk to their doctors about this fact, especially women who are perhaps experiencing perimenopause, menopause or post menopause, and really highlighting the fact that it's not an either or proposition and that they need a holistic evaluation and care plan. Sorry, that is very broad.
- [65:14]
C
Oh, I think we've.
- [65:17]
B
Could you check your mic, Dr. Skokland?
- [65:20]
A
Sorry, I was just so excited, so I just threw myself into my answer. No, because it is a huge question, but it's such an important question because ADHD almost never travels alone, especially not in adult women. So, so, so we have to, we have to expect that. And that can be difficult because you may have been misdiagnosed previously. So discussing your comorbid anxiety and depression treatment for that may be almost like a trigger for some women. And again, we need to kind of try to bring in this holistic perspective because otherwise we will go down the wrong path because ADHD and ADHD medication is very effective for ADHD symptoms. But if you have a distinct anxiety or depressive disorder, you need to have evidence based treatment for that as well. And then ADHD medication may not and often is not sufficient. So we have to expect that. And when I talk about this, and also in our research we try to paint this picture where ADHD and also sometimes autism and artistic traits is kind of like the background noise, it's a background vulnerability factor. And then you have to map the other comorbidities on top of that. And when you look at someone's medical record, 40 plus women with ADHD, you might get the impression that all your colleagues before you have completely lost their minds because she has 10 or 15 other psychiatric diagnosis. And in Scandinavia we have all this beautiful records so we can just really map all these diagnostic codes on top of each other. But when you try to disentangle and dissect it, it becomes really what women with ADHD actually talk about and how they describe their life. Because they go into this as Ellen, Dr. Lettman was talking about, they fly under the radar as girls, but they enter our radar with comorbidities. So they come to our youth centers and to our clinics with depression, anxiety, eating disorders, maybe even self harm, suicidal behavior. There's a plethora basically of comorbidities and trying to get your healthcare provider to discuss this and also then bring in the hormones. That is for many clinicians a tall order. And then you may have to come prepared to self advocate for, you know, for actually being viewed in this holistic perspective because it's so important because otherwise you will miss essential pieces of the puzzle for this medical decision making. Right. So, so I usually, I advise my, my patients to basically think as a researcher themselves because in waiting for the research to catch up, we have to, I guess think as researchers and make ourselves N equals one or the other study basically on our own life and everyday experience. So try to log and track data, objective data about hormonal fluctuations, how that affect your ADHD symptoms, how that affect other comorbidities across life and then obviously map out your menstrual cycle if you are not naturally cycling. Also bring in or make a lifeline of how impairing symptoms can, can differ across life regardless of if you expect them to be associated with hormonal changes or ADHD or something else. Also list all your medications, don't forget herbs and, and supplements. And then also write down all the questions that you have and try to bring them into to the meeting that you're the you have. So it is often a situation where women with ADHD have to self advocate and then you need to come prepared and sometimes you have to actually advocate to get the holistic perspective in your situation.
- [70:01]
B
Yes, and I think somebody wanted to add on to that. Dr. Karenis Toscano, did you want to add?
- [70:09]
D
Yeah, I did want to. I loved everything that Dr. Sglin had to say on this topic. And it made me think about the recent work that we've been doing in more disadvantaged areas in Washington, D.C. and just thinking about absolutely that we want people to go in prepared, to self advocate with all their records and everything. But I think that there are two major challenges there. One is that it is so much harder for people with ADHD to have their records and to have their thoughts organized, to have their records organized, to be able to kind of be prepared. One of the things that we do, even with our college students, where we're sort of teaching them to self advocate in terms of their medical and psychological care, is that we need to work with our patients to write down the questions that they're going to ask, that we can help them construct that bulleted list that they need to make in terms of talking about things with their different providers and to coordinate care. And I really do think that A, this is so much harder for people with adhd. But second of all, that there are enormous mental health disparities in terms of comfort, sort of asking questions of a provider or of a school or in the workplace, around, you know, things like accommodations or around, you know, being able to get sort of the care that they need in different areas of their lives. And for example, we saw that with kids with ADHD in terms of who gets services or accommodations in the school setting, that children of color, children whose parents don't speak English as a first language, or parents with less education are less likely to, to feel comfortable advocating for their kids. And so I think that we can't ignore the fact that with education and privilege, it's easier to ask those questions. About a year and a half ago, I participated in this National Academy of Science work group on adult adhd. And we did this two day workshop. And one of the things that came up is that many times when someone raises a question to a provider about might I have adhd, that oftentimes that could be perceived as medication seeking. Right. And that especially comes up, I think, for people of color and other groups. And so that sort of reinforces this idea that maybe I shouldn't be advocating for myself. Because now instead of someone listening, it's almost like I'm getting accused of being, you know, medication seeking. So I just wanted to bring up those couple of points.
- [73:25]
B
Yes, thank you. And this actually segues. I wanted to ask Dr. Miller.
- [73:35]
A
What.
- [73:35]
B
Can we, we just talked about all these barriers and what can we do to, to alleviate some of these barriers for black women who face all of the, all of the above plus, you know, the strong black woman stereotypes, systemic racism, lots of other things. Is it about, in part, improving, well, just our cultural understanding or how can.
- [74:10]
D
You see.
- [74:12]
B
The industry at large, the medical world, better serving this population?
- [74:21]
F
Yeah, for certain. I really like Andrea, what you highlighted, because it's really true. I even had a cousin who, very educated, went in trying to seek medication and was immediately thought up to be medication seeking. So it really doesn't matter sometimes for a black woman, whether you're educated or not, how you present yourself. Folks will still have this idea that you're trying to seek out medication, which you are, but, like, for assistance and for help. And part of that is some education for both clinicians and the public in general in these communities about ADHD and normalizing the conversation and how it shows up. One of the difficult things is finding providers who are open to having conversations, even about their rationale for diagnosis. You should be able to ask your clinician, hey, what did I present that kind of aligns with this diagnosis? Because that one will help you understand why this is appropriate if you don't necessarily think so. And it provides that conversation and comfort that, like, we can have these conversations. And it's not even if I'm asking a question. I'm not seen as being combative or trying to divert my treatment in a specific way. But that openness is so helpful because that provides folks with a feeling of safety coming in, of establishing that trust and connection that my provider actually has my back and is not also working against me and trying to get access to treatment. And some of that is just, we need more black clinicians in these spaces because they at least are able to be those who advocate. I've often had folks come to me and say, you know, I have having difficulty talking with my provider. Can you be a part of that conversation? Because at least, hopefully, me being a provider will provide or create a better space of having a conversation. Provider to provider versus there's being this power dynamic between a clinician and a client. I think right now is really hard in terms of systemic change with a lot of the things going on. But I think normalizing at least some of these experiences so they can have even the words to describe what's happening for them to providers. If you can't necessarily be a part of the conversation, what are those words that I can use to accurately convey my experience that's inherently difficult with neurodivergent brains and feeling like you're often misunderstood or not or not communicating in a way that clearly, clearly defines what you're experiencing. And so can we talk about what are the words that actually conveys this even to the degree that I might not be highlighting my difficulties as intense as I'm experiencing it. And that is going to be really critical in diagnosis. You have to have a certain amount of symptoms or severity to even be clinically diagnosed. And so am I accurately representing my experience in the suffering? And unfortunately that strong black woman stereotype makes that very difficult because have I even seen how people describe their experience without struggle, the part of struggle, there's pride in some of the struggle. We need to let go of that. It's not great to work on hard mode constantly that there's no prize at the end of the race for that. How. And I think disentangling this idea that I have to be strong and what strength even means, I think is really something that can at least benefit black women in actually portraying the reality of your experience. Nobody wants to always be independent, always self sacrificing, always this in control. I got it. We don't always have it. And it's okay to not always have it because at the very least we can figure out how do I actually ask for help and actually get the help I'm asking for? What are those words? Who are those people that I feel safe with to be able to do that? And I think seeing some of the like reconstructing how we view even what strength means, I think is part of the conversation that is needed to at least be able to get the care that we actually need.
- [79:20]
B
There's pride in the struggle. That's. Yeah. Thank you so much for that, Dr. Miller. And it actually is a perfect segue to what I was hoping to ask Dr. Sibley and everyone. Two themes I'm seeing quite a lot in the comments. So it's a two part question. One is what questions can I ask a potential provider clinician to screen and see if they are, As I think Dr. Lipman said earlier, willing to be open minded about ADHD in adults and ADHD in women in particular? Are there some questions people can ask to make sure they're finding a provider who will help them? And listen, part two is how can I contribute to the solution? Is there research that I can participate in, insights that I can offer with my lived experience with ADHD? Dr. Sibley, I'll start with you and then everyone is welcome to chime in.
- [80:30]
E
Let me start with part two because that one I feel like is a good one for what I do first. So I think one of our Shared priorities between the ADHD community and those of us who are researchers and providers is better defining what ADHD is and getting that sort of formalized in the DSM when it comes out with the next edition, which would be the DSM 6, which it took 12 years to make the DSM 5. So I don't know when the DSM 6 is coming out, but I think there's this. We both have, like, a part to play if you're an individual with adhd. We need diverse, shared perspectives of your lived experience. We need to crowdsource what some of those new, better defined symptoms of ADHD for women would be.
- [81:31]
F
And.
- [81:31]
E
But one thing that I try to share with folks is that it's not just about what do most people with ADHD experience. And then let's put that in the dsm, because it's trickier than that. There's a difference between a symptom that a lot of people with ADHD experience and a symptom that's going to help a provider tell the difference between someone who has ADHD and someone who has something like adhd. And so that's where the research has to come in. We have to take all of y' all's good ideas about, like, what you know, you're experiencing, and then we have to put it to the test with thousands of people and see which ones, either individually or as a set, help us tell the difference between someone with ADHD and someone with really high anxiety, for example, who's having trouble concentrating because of that. And we have to make sure that it's not just the folks who have the loudest voices that are involved in this research. It's people who maybe have a unique experience with ADHD or unique background that are exactly the people who are the providers are going to miss. And so there are lots of opportunities to get involved in research. And I would, I would tell people, if you're, if you're feeling moved by this, you know, like, let's all work together. You know, I know that there's a few groups that are doing this. I know that in the Netherlands, Sandra Cooley has a big worldwide ADHD women's study that maybe we can link to. The Duke ADHD Girls center is doing a lot with crowdsourcing and adhd. My humble group is doing stuff with diagnosis, symptoms, and adhd. You can get involved in all this, right? Just reach out to the researchers. And I think that's where I want us to kind of. I want this to be a united group of people who all share a common goal and hope that it wouldn't be sort of like not liking the providers because they're missing folks a lot. Because I do think there's a lot of great providers out there who are trying to do their best. And I think it's our job to humbly listen to people with ADHD and try to do right by them. So I'll stop there with that part of the question and maybe give it to the others.
- [83:40]
B
For the first part.
- [83:45]
C
I wanted to say something about that was a great answer of what needs to happen in the future. But that is our future. And right now women have to figure out how to live their lives without the benefit of research supporting what their next move is. And what happens sort of in the meantime to that chasm. How can we bring those sides closer together? Because there's still so much shame and so much stigma and without the scaffolding of studies that direct them, they need to find a place where, I think, as you used the term before Annie, imposter syndrome, where they at least can find what often is called their tribe of people who are experiencing the same thing. Because we are talking about the lived experience. And the lived experience is still a lonely one in that they have to find someone who is going to hear their struggles, which are individual and are still valid. And I think that's the issue is that for them to feel that their issues are valid even when research has not yet identified them.
- [85:33]
F
Yes, everyone's gone.
- [85:37]
B
Oh no. I would love to say that we're hearing in the comments quite a bit this desire, this need for community, and that perhaps today was a step toward that. And I just want to say that attitude, we are ready and willing to be part of the solution for that. And our team will reach out to everyone who has registered for this event today and brainstorm a way that we can continue to connect as a community, sharing the lived experiences and also just offering support. We'll give that a little bit of thought. But we will in the meantime be sure to link to the research that Dr. Sibley mentioned so that everyone can see where they can make contributions to lead to future benefit. Sadly, I will report that. Well, last year attitude published in consultation with all of today's experts through the top 10 list of research priorities that would benefit women with ADHD. And we were honored to meet with the White House Initiative on Women's Health Research to discuss those priorities. That initiative has been shut down. And so it is more imperative than ever for those of you who are listening to participate in the research that Dr. Sibley mentioned and to be part of, you know, it is, it is really up to this community to push forward. Not that it hasn't always done that, but to continue that push. And so we hope that our summer issue will be a step in that direction and that today's conversation was as well. But there's a lot of work remaining. Goodness, we are just about almost out of time. I do want to quickly thank our sponsor once more play attention for hosting or for making today's roundtable possible. I also want to thank all of our panelists. Your contributions not only to this event, but to the science and the research that is benefiting now and will benefit women with ADHD is truly remarkable and priceless. We so appreciate everything that you do and for making yourselves available to the Attitude community, I also want to thank a special thanks to Attitude magazine's Editor in chief, Carol Fleck, who planned and orchestrated today's event really beautifully. So thank you to Carol and to all of today's listeners. I lost count here. We had we're up to to more than 600 comments and questions logged from today's audience. I want you to know that the Attitude team reads every single question. We're going to use your questions and your insights to help guide us as we provide more content to serve this community. So if we didn't get to your question today, please know that we will be paying attention to it and we hope to address it in the things that we do. So thank you to everyone who listens for the event resources go to attitudemag.com this is going to be podcast 54 6. You can get a recording of the roundtable. It'll be available in a few hours. As I mentioned, the summer issue is our women's issue. It will be out in May. You will hear some of the insights from today's conversation in that issue and if you aren't already a subscriber, please visit attitudemag.com subscribe Sign up today so you make sure you get that issue. And we do have a resource center online. I will point you toward that. And it's got Personal Stories, Scientific Insights, a free ebook that details those 10 research priorities that I was mentioning earlier. You can see those links on your screen. But as we wrap up today, I just want to end by again thanking from the bottom of my heart Dr. Lipman, Dr. Skoglim, Dr. Cronus, Toscano, Dr. Miller and Dr. Sibley. Thank you so much for your contributions to today and to this community at large.
- [90:41]
A
For more Attitude podcast and information on living well with attention deficit, visit attitudemag.com that's a D I T U D.
- [90:50]
B
E M A G dot com.
- [91:00]
G
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