Hi, we are the ADHD Skills Lab podcast. My name is Skye. And my name is Sarah. And we will be your hosts, chatting to you about practical ADHD strategies you can use, the research behind some of these strategies, as well as interviewing other professionals with ADHD about how they've developed skills and working through struggles in their lives. You might know us from Unconventional Organization, where we talk about this kind of stuff all day long. So we're super excited to have you along and we're going to chat through it together.

Welcome to our ADHD research recap. This week we're gonna be having three very interesting papers. We are gonna talk a little bit about internet delivered therapy for people with ADHD. We're gonna talk about some of the emotional differences that's one study found in terms of gender and ADHD. And then we're gonna start with a slightly more controversial paper, at least we definitely had an interesting conversation about it, about self-report. measures of ADHD and what that means in terms of diagnosis. So lots to jump into this week.

Internet delivered cognitive behavioral therapy for adults with ADHD - A randomized controlled trial

But we'll start by talking about the paper on Internet-delivered Cognitive Behavioral Therapy for Adults with ADHD. This was actually a randomized controlled trial, which was pretty cool. We don't usually see a randomized controlled trial in this case. Basically, it just means that they randomly assigned people to one group or another, or in this case, actually, to three different groups. And this study was from Internet interventions. So clearly they did have a focus on wanting to talk about interventions with different Internet supports. So yeah, Sarah, do you want to take us through a little bit about what they looked at and what they found? Yeah. So this study obviously was looking at the efficacy of Internet delivered programs. So like, are these going to improve your ADHD symptoms? They specifically wanted to assess the CBT program. Before we jump into it, do you want to just tell us a little bit about what CBT is for those who maybe haven't come across that before? Yeah, so CBT is the short form for cognitive behavioral therapy. It's one of really the most common forms of talk therapy. It's sort of regarded as like the gold standard of therapy, although personally, I believe that's an outdated view. I think the research is starting to support that. Yeah, it's one of those things. Some people love it. Some people don't find it as helpful. We've both experienced CBT and have found other methods of therapy helpful, although therapy has overall been helpful. It's very much focused on cognition and what you think and how that affects how you behave, essentially. Very much what it says on the box. So the sample size was 104 people. They put 36 people in the internet-based CBT. program, they put 37 people in the internet based relaxation training program and 31 people remained in the treatment as usual program, for lack of a better word. That was their control group. They had a randomized control trial, like I said at the beginning. So they put these people in to these different programs. It wasn't based on what they enjoyed the most or what they liked. It was very much based on just what they were randomly assigned to. So what was the relaxation training condition? Do you want to tell us a bit more about that, Sarah? These different programs were all sort of 12 week add-on programs. So the treatment as usual was basically, you know, a patient's standard medication and psychiatric care. So the ICBT and the IART were sort of add-ons, like additional treatments that they got enrolled in, basically, they were 12 week programs. based on quote unquote well-established treatment manuals. These were done on the web. They did mention that there was a double authentication situation to log in, and my brain flagged that as accessibility issue. It is funny. You do want it to be, yeah. But every time someone says, you have to get your phone, I'm like, well, I always have my phone except for this moment. So we're not opening that. And both of those internet programs followed the same structure. So it was like text and media divided into modules. You know, there was educational stuff, therapeutic techniques, regular homework assignments. And this is the important part. Participants could not skip ahead to future modules. You had to wait to be granted access to the next module after your homework was reviewed by the clinician. So like no hyper focusing on this. I imagine that was probably quite good for retention, like turning into a long-term memory, but also, yeah, difficult to get into. Yeah, interesting to actually see it through to the end. So the ICBT was sort of a combo of a bunch of different therapies, actually. So CBT, DBT, which is dialectical behavioral therapy, and ACT, which is acceptance and commitment therapy, just sort of like a fusion of the most widely used therapeutics. Yeah, just a fun theme. Talk therapy moments. Yeah. And the I-ART was based on a well-established, supported by the research manual called Applied Relaxation. Yeah, which I had never heard of before. I was interested in that idea of what it was, especially when we get to the results and we see the effect that it had. Speaking of the results, they actually tested this at different times. They did a pre-test assessment. a post-test assessment, a three months post-test assessment, and a one year post-test assessment, which was very, very cool because they weren't just interested in whether you felt better immediately after. They actually wanted to know what about later on, which I thought was very, very cool. So what did they find, Sarah? Because they did not expect to find what they found. So both additional interventions improved ADHD symptoms significantly. There was no significant difference between the modalities and these improvements remained at the one year follow-up. It was just pretty intense. Yeah, that's really awesome. They expected to find that the ICBT would be superior. They did not. Yeah, no relaxation. We need it as well. We'll take it in all its forms. Yeah. All of those assessments were basically measuring things like your depressive symptoms, stress, quality of life, functional impairment, which we have talked about in the past as being just like struggles functioning in various sectors of life. And there was improvement in all of those areas on both treatment groups. Yeah. No, and I thought that was very, very cool. In terms of limitations, they did mention that there were quite small samples. But they still felt like the sample size was pretty good, but it could be bigger. 104. I mean, it's a randomized control trial. So again, that does, that does give you a little bit more oomph in terms of your power and all that kind of stuff. It was pretty good, but that was just one of the limitations that they had. In terms of what this means for us, like what are the actual implications? What are the practical strategies? I mean, I think it's a huge. shift in terms of a discussion of in-person versus online, because obviously, online interventions for ADHD, we're not saying that because we're online, they are more accessible for people who are maybe unable to go to the cities where this stuff would be found. They might be cheaper, they might require less funding because they can be done online. It was really interesting to see. that they did have this benefit both immediately and long term, because I think a lot of people are talking now about online versus offline for many, many things, because obviously that's a big shift and transition that we're having. Yeah. I mean, part of the conversation has always been that a multimodal approach to treatment is just the best thing you can do for yourself. So like therapy and- coaching and medication and meditation and really like most combinations are going to be better than nothing. Yeah. And yeah, so just making the and more accessible in an internet format and having research to suggest that it is effective and sustainable. That's amazing. I can't wait to see what they do with this. Yeah, no, I definitely and it's also just interesting to see that like Yeah. CBT, which they sort of the gold standard didn't have the necessary effects, but ADHD support in general did ADHD relaxation support. Cause both of these were ADHD specific ADHD, CBT, they both were very helpful. So basically, you know, give us ADHD strategies, ADHD supports, you know, in whatever format we can access as accessible as possible and we will use it and hopefully benefit from it was kind of what the study was, which was a really cool like. positive study. We've had a few tough ones in the last couple of episodes. So it was nice to have this one and kind of talk about the positives as well. Yeah, absolutely.

ADHD-related sex differences in emotional symptoms across development

Well, let's jump into the second study that we looked at, which was a little bit more tough to read. It was about ADHD related, six differences in emotional symptoms across development. And this was from the European child adolescent psychiatry paper and as always, it came from this year. And they particularly were interested in looking at emotional symptoms across developments. They were looking at people ages eight to 18, and they were looking at things like emotional dysregulation in general. So this could be irritability, anxiety, and depression and looking at whether there was a gender difference for ADHD specifically. And for those of you who perhaps are less aware of this kind of research, There's a lot of research to say that there is a gender difference for people who are not ADHD. So the fact that they did or did not find a gender difference in ADHD doesn't mean that's specific to ADHD, but it was still really interesting to look at. Yeah. So Sarah, do you want to take us a little bit more through what they what they did? Sure. So they had a sample size of 417, again, aged 8 to 18, 264 of which had ADHD. ADHD was assessed using the parent report scale. They did also do some clinical interviews, I think, to corroborate the ADHD status. They used additional parent report scales to sort of measure symptom severity and things like that. The interesting thing about this study, I thought, was that it wasn't originally designed to be longitudinal. It says in the paper that they sort of fell into additional funding and so were able to expand. We love the incidental additional funding. Yeah, I mean they sort of entered into like a weird limitation in that way though because now instead of having all of their sample size measured at the same points in time, now they have some measured at two points, some measured at three points. They tried to control for that statistically, but I just thought that was really funny. I wanted to point it out. The time between measurements ranged from one to six years. Yeah. They particularly looked at emotional dysregulation. Yeah. So what did they kind of look at within that? Right. So all of that stuff was also measured by self-report scales, parent-report scales. So they were looking at things like anxiety levels, depression, affective reactivity, which just means how swayed can you be, I guess? Sort of like emotional lability is another one of those sort of similar synonyms. But they didn't come right out and say like, this is emotional dysregulation. They sort of just cited a bunch of different studies and used a bunch of different scales to look at that. Yeah. They're trying to get like a map rather than kind of focusing on specifics. Yeah. That's really interesting. And so they found that in ADHD children, there were higher levels of emotional dysregulation compared to neurotypicals. Perhaps unsurprising to those of you who've been listening to this podcast. There's a lot of research that. That shows that. But they also found that boys with ADHD, they showed a decrease in emotional dysregulation with age, which I thought was really interesting. Adolescents, they showed similar levels of emotional dysregulation to neurotypical peers. And for girls, that was not the case. Girls did not show a decrease in emotional dysregulation. They had high levels of irritability and anxiety that persisted to adolescents. Although, you know, for neurotypical girls, that was also the case in adolescences historically been a big factor or not a big factor. But when they do these studies in just the general population, adolescence is usually a trigger time for when they find this emotional, emotional differences. Yeah. So they did find that depression decreased over time for girls with ADHD, but increased for neurotypical girls. So it was kind of a whole mix of different interesting Somewhat I thought, somewhat I didn't thought. What do you think, Sarah? I mean, this puts me in so many different directions, just all speculation, of course. Yes, this is only one study. Yeah, but what's really interesting about adolescence in particular is, that's when our prefrontal cortex starts to develop more so beyond the child. The amygdala shrinks over time as well. That's just like a separate piece. So I'm wondering how that- factors into all of this? I can't help but wonder if the reason that boys start to do better, I guess, is that they have less pressure to behave in a certain way. I mean, there are so many different ways for an adolescent boy to just exist, but there are only a certain number of ways for girls in adolescence to exist. This was the case for neurotypical girls and girls with ADHD, which was I think really interesting because often we're talking about emotional dysregulation with girls with ADHD. I think in previous studies, we've talked about, I wonder what this would look like in the general population. In this case, depression increased for neurotypical girls, but not for girls with ADHD. But girls with ADHD struggled with emotional dysregulation, with anxiety. specifically being I think a higher factor for ADHD compared to neurotypicals. So yeah, we're all out here struggling apparently when it comes to adolescence if you're a woman and you're experiencing that space basically. This one's really tough. They did mention that they would have liked to see other or use other measures of emotional dysregulation and not just use the rating scales. So I wonder if that's true. could change things in some way. Yeah. The other thing is that sort of they said that they have like a lower number of female participants. And so the differences that they saw in the sex groups might not be as accurate, but I can't help but wonder if the reason why some things get better for people with ADHD over time is like part of a resilience conversation. Yeah. Well, I did wonder a little bit about again, one of the things they didn't necessarily talk about was that these people have been identified as having ADHD. And then there were neurotypical girls, but were those neurotypical girls identified as having anything, you know, like, why there's a lot of under diagnosis as well. Like if I, as a young person wasn't diagnosed with ADHD, because it didn't fit the female mold of ADHD, which is quite a limited mold, I would also become increasingly frustrated. Also, not only that, but when you're diagnosed with ADHD, you receive actual help and ideally proper treatments that are developed to help you learn how to manage these symptoms. We don't know. I guess not. Exactly. Like, and we don't know that was what they necessarily did, you know, but we do know these people were identified as needing additional support. So I did wonder if that. may have had an effect as in they were getting the support to manage their emotional dysregulation compared to their neurotypicals. Yeah, neurotypicals. And there might be if we know from the research, there probably is a group of undiagnosed women in that space, girls in that space. So there's also that conversation. Yeah. And not having access to a diagnosis just means that you're probably not getting that psycho education. Yeah, exactly. I also thought it was really with ADHD showed a decrease in emotional dysregulation in adolescents. And I did wonder like, what does that mean about how we approach like younger boys and what they can do versus adolescent boys and what they can do? Like, you know, we talked about the idea of there's many ways to, you know, to exhibit gender at different ages and stages. And it did make me wonder if. Do we relax at that age? Like there was a lot of like gender expectation conversations that were coming up for me as well when we were having that conversation. So it was interesting. It didn't tell us anything. I guess what's the sort of practical takeaway in terms of this. It's interesting. I guess the practical implication is really that, you know, what we know to be true. or at least a lot of research indicates is true with neurotypical populations, which is that women struggle more in adolescence with emotionality and emotional dysregulation compared to men is merit here in this study. But also there's a lot more to it than that. And there's certain groups that appear to be doing better and certain groups that appear to not be doing better. And they don't really know why, they didn't really say why, but it could be. partially the support they got or resilience or a whole bunch of different factors that I would love somebody to look into Yeah, I mean I was just gonna say that if you've got ADHD kids in the house hang in there You know if you've got regular kids adolescents in the house also hang in there Well, according to the research both Both are the case for this one. Yeah. Yeah Also, it's never too early to start teaching a kid how their brain works and how to self-regulate. So big advocate for that. Yeah, I think that's a really good point because I wouldn't be surprised if that has having an effect on maybe some of the interesting differences we're seeing here is how much support they have. To go to the previous study, people who were doing the CBT and their relaxation support, they did improve over time. So yeah, a lot of this is about. the importance of teaching people how to self-regulate, which is honestly something I will say as a young person growing up. I was not taught how to self-regulate. I was taught how to stress, how to study. Maybe that was just me, but that was my experience. Self-regulation was very much a post-university based conversation. The earlier we can have it, definitely the better. I think we do that more and more. You see that more and more. Yeah, I saw it a lot in the virtual learning space that we got into during COVID. Sort of the schools really tried to teach the kids like grounding techniques and breathing strategies. And like, it was just wonderful to see and I am pleased to report it has remained in the curriculum. Yeah. Awesome.

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The Ability of Self-Report Methods to Accurately Diagnose Attention Deficit Hyperactivity Disorder: A Systematic Review

Then the third study that we're looking at today, it's really interesting. It's not a study per se, it is a literature review. It's a review of studies, which historically we talk about as being more useful because of the fact that they're combining a bunch of different studies. This one is an interesting perspective on that. We'll get into it. But basically, they looked at the ability of self-report methods to accurately diagnose attention deficit hyperactivity disorder. This was from the Journal of Attention Disorders. What they were looking at was, are self-report symptom scales useful and accurate when diagnosing ADHD? I just want to flag here, they're not talking about DSM diagnosis with a psychiatrist. They're talking about self-report symptom scales that you might get with a general clinician. More so, which is interesting because I didn't actually know that they did this. I think different countries do different things. Most of the time when you talk about diagnosing ADHD, you talk a lot of the time about going straight to a psychiatrist and that kind of thing. So yeah, what were they looking at? Their initial search pool of literature was 1812 studies and only 20 of those were included. They were looking specifically for studies that measured the specificity and sensitivity of self-report screening tests. They looked at like four different ones. And these studies were divided between functions. So some of them were designed to tell a person who has ADHD from a neurotypical. And some of these tests are to discern like ADHD versus some other psychiatric condition. They referred to that as their clinical sample. Yeah. This was really interesting. So the first type of test, the tests that they use to tell ADHD from neurotypicals were great at identifying people who do not have ADHD. Yeah. If you were neurotypical, basically they could tell. Yeah. Which I think is quite funny. Yeah. So some threshold results were reliable, which is cool. However. in the second kind in the clinical sample where they were telling ADHD from other psychiatric conditions, none of those self-report scales had a specificity score greater than 90%, which means it's basically one of those null hypothesis situations. So I already know that my client does not have ADHD. What is the chance that this test shows my client doesn't have it? Not 100% reliable. Yeah. And they particularly talked about how they struggled to discern ADHD from other issues, you know, so depression, other things. They also did discuss the idea that ADHD, non-ADHD individuals could pretend to have ADHD for a variety of reasons, including access to stimulant medication, which I understand, but I feel like we talk about that so much in different ways that... It's not always the most helpful conversation to have when you do have ADHD and you're trying to access support. But they did mention that as a possible factor in why this was hard as well. Yeah. I mean, they even come right out and say that only two of those rating scales perform better than chance at identifying whether somebody has ADHD or whether they have another condition. Yeah. And not that much better than chance. Yeah, it was like 60, 66% or something like that. Yeah, exactly. So they were kind of saying that like, having an initial screening for ADHD is a cost effective first step, if you want to know if you don't have it basically. But results show that it's much better ruling it out rather than confirming it. And they sort of talked more about, you know, clinicians who use self report screening tests. You need to be aware that this is a factor and that they need to undertake a rigorous evaluation of clients. They included the importance of objective reviews of past history, which we've talked about before and how complicated that can be, opinions from knowledgeable additional sources, evaluating whether symptoms have caused substantial impairment historically and currently, and then ruling out other factors such as anxiety, depression, symptom over-reporting, or addiction factors as well. which is pretty much what you hear in most conversations about diagnosing ADHD. But they were really trying to hammer home the concept that it's not self-reporting on its own, doing a checklist does not mean that you have ADHD. It is tricky because some of these scales are diagnostic interviews for the DSM. So I can see like one of them is actually for the DSM. So it is possible that you would get a clinician who didn't look at wider areas of ADHD, but it's also tough because not everyone has access to their historical records or a person in their life who's going to diagnose them with ADHD or all of those kinds of things. So it sort of didn't give us a lot in that way. Yeah, I feel like this is just beating the drum again about the need to diagnose people in a more comprehensive way. Basically, they were saying that if you are a clinician and you're only using self-report scales to diagnose people, you probably shouldn't be doing that. Yeah. Because yeah, it just could be completely wrong and like missing part of the picture, you know, like a 10 question. survey on your mood isn't enough to diagnose someone with depression necessarily. Yeah. I think the interesting thing, the conversation that we had before coming on, there's two pieces. One of them was that this is true, but maybe what we need to do is take this out of the soul space of clinicians at that point and bring in something else, something like neuroscience or something like that where you are seeing. interesting things, you know, obviously no one's brain is exactly the same. You're not necessarily going to see the exact same things, but if there was a more accessible way to do a scan and a self assessment, then maybe that would provide a little bit more of something for people who just can't find reports from their teachers saying that they have ADHD and also how helpful is that if we know that girls specifically are asking. So there is that conversation, or if you have parents who admit that you are lazy and this is not an ADHD thing, that could be a factor. So it is true, but it is not very supportive of, okay, but what about all the people who do need to be diagnosed with ADHD? Yeah, it doesn't really offer next steps. It just sort of highlights the issues. Yeah, and sometimes research does that, but we have seen this. Yeah, I think that was the thing that was a bit frustrating was like, okay, cool, this is good. It's a systematic review, I totally get it. But we have talked about this. It might be time for us to talk a bit more about our outcomes. And obviously, a study can't do everything, but it is something that I think, if it came across our desk again, I think I would just mention that it had happened rather than go into it in any depth. What I'd love to see. coming out next is some studies of, okay, cool. What are we gonna do about it? Because we can't just leave people with ADHD with this weird like, well, maybe it's not real. You don't know. Anyway, bye space. Like that's not what we should be doing here. So frustrating. It is, it is. And then, you know, maybe I'm speaking specifically from the space of having watched that UK documentary that came out at the beginning of the year, which was essentially. another version of a similar conversation. And yes, totally understand it, but we do need solutions. If the clinical community is not going to provide those, then maybe we need to talk about bringing in multimodal supports to do that. That's just my personal view. I think that you're totally right. I mean, as you mentioned in the beginning, pathway to diagnosis is sort of varies by country. And I know that Here in the United States, there are many ways you can go about getting diagnosed with ADHD. If you're a child, you can go to your pediatrician. If you're an adult, maybe you just go see a therapist who has a doctorate. Maybe you go see a psychiatrist. Maybe you go see a neuropsych person. There are lots of pathways. Not all of them are covered by insurance, nor are they accessible, cost-effective. Yeah, some of them are really expensive. Yeah, which is why this is so frustrating. And I think it's been so complicated in other countries like the UK, because they only do have that one pathway and it is taxed. Yeah, no, definitely. It's tricky. It's very, very tricky. And yeah, I'm sure, you know, if you guys have anything you want to add to the conversation, by all means, send me an email because I know this is a big. A lot of people have different perspectives and a lot of people come from different countries where there are different ways to do this and different accessibility. For example, I don't know how many people would just be able to do neuroscience. Certain areas are obviously not going to have access to the equipment to do that compared to other areas. So there's so many conversations to have here, but I would love to start having those conversations in research more and more rather than just. more of a negative slant towards people with ADHD, which is how this came across a little bit. The other thing we did want to flag, because obviously we've been doing this for a couple of episodes now, is that while there is such a big focus on diagnosing people with ADHD in terms of medication, when it comes to clinical stuff that we've been reading about, how they decided who had ADHD in research is really different. Like a lot of research that we've read. They decided that a group of people were ADHD based on just a teacher's self-report or just a parent's report and they didn't necessarily discuss whether they even used the DSM diagnosis or whether this person had a diagnosis. It was just a study of ADHD symptoms and therefore you could say well we found that this person who has ADHD symptoms does things differently from this person who doesn't. So In some ways, the user of these sort of self-report measures or more general measures was actually the research community a lot of the time based on what we've read so far. When you made that connection, it blew my mind and I'm still sitting in it. Because you're so right. I mean, we have this diagnostic manual so that it's the thing we use and even the research community is not strictly. holding to that guideline and then making a whole bunch of assumptions and assessments of the ADHD community when we haven't really verified whether or not it's really the ADHD community. Yeah. I thought that was really interesting because one of the things that we talked about a little bit was when we read the paper and we read it in full, we look at how it's made, how the methodology, and then we can go, okay. This is a parental report. I think there was one last episode where they didn't really talk to the kids, and they didn't really talk about whether the person had ADHD. That's why they use the term ADHD symptoms rather than ADHD diagnosis. But when you're then referencing that study in another study and another study, is that specific very important piece of information coming across or not? Because often it feels like that's getting lost a little bit, because it's hard for us even. we have to read it to be like, oh, okay, this person might not have ADHD, they just have ADHD symptoms according to their teacher or according to themselves or whatever it is. And that's fine if that's how we wanna sort of codify ADHD in the research, but then the research can't turn around and say like, oh, well, this person's faking it. Yeah, that was kind of the conversation we had. That felt really unfair. Yeah. We're like, hang on. So yeah, I think if there is, you know, a conversation to be had, and I think there is, it needs to be had within the whole community, including the research into this community. Or if it's not, then the fact that this is ADHD symptoms and not an ADHD diagnosis needs to be a limitation that is referenced and mentioned across all of the studies so that we don't end up in a position where somebody is making a decision based on a group of people that were not particularly strongly verified as even having ADHD. Okay, I think that was a rant. I don't know. I think that it was really important though. I'm just like, oh, I'm kind of scared to bring this out now. But yeah. I mean, obviously this might not be correct. If you have different perspectives on this and you have something that you think is a good factor that we are missing, then please by all means tell us because we want to learn and we want to develop and grow in the research space. But it was just, it was something that has come up in the past and it was just worth discussing here because at the end of the day, what our focus is on is very much on empowering people who are not ADHD. clinicians to understand ADHD research, and we're on that journey as well. But yeah, interesting study, Sarah. Did you have anything else you wanted to add? I think to tie it back to the original purpose of the study, I would just say that if you are in doubt about something that you've been told by a medical professional, always get a second diagnosis, a second opinion, we would say. you can do that with your body doctor and your brain doctor and there's nothing wrong with that. If you have had a diagnosis, one of the things that can happen a lot is that getting support can feel like maybe you don't deserve it because maybe you didn't get all of the different ways that you can be diagnosed according to the current gold standard of how you can be diagnosed and you can't necessarily afford to be diagnosed again. You didn't know that was something that needed to be done. You just paid a lot of money often to somebody who diagnosed you according to what you knew to be the best way of being diagnosed at the time. If you are in that position and you're listening to this podcast and you're starting to feel a bit anxious about whether you actually do or do not have ADHD, I can't speak to the medication side. Like I said, I really want to have somebody on who can speak to the medication side. But in terms of executive functioning strategies, you are allowed to use executive functioning strategies no matter who you are. And you're allowed to find them helpful no matter who you are. If you are somebody who finds that you struggle with time blindness or you feel like you need transition times, then go for it. Do that. It's okay. That's loud. We do have different ways of working. And like I said, I'm not going to speak to the medication side. That's not my area, but in terms of executive functioning strategies, they are open to all, all who need them. The ADHD community is not here to gate, keep our executive functioning strategies. Exactly. It's not. If you got diagnosed with ADHD or if you think you have ADHD, then try them out, see how you like them. And, you know, even the people who've gotten diagnosed using the most efficient system of possible, we'll still find that maybe time blindness is not as much of a struggle for them as it is for somebody else and all of those kinds of things. And we'll bend these strategies and adjust them according to their needs and their lifestyle. So we're all different in that way. Hopefully that was a more positive ending to that conversation. But yeah, thanks so much for coming along with us today on three very interesting studies. And again, if you wanna talk about this with us at all, feel free to send me a message. I'm always happy to chat. Otherwise, we will see you again in two weeks for the next research recap. Bye. 

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