We have received apologies from Deputy Máire Devine and Senator Nicole Ryan. It is understood that Deputy Ó Murchú will be substituting for Deputy Devine for a number of weeks at least.

I am delighted to open the tenth public meeting of the Joint Committee on Drugs Use. In today's session, we will be focusing on substance use and neurodiversity. I particularly welcome our expert witnesses: from ADHD Ireland, Mr. Ken Kilbride, CEO, and Dr. Sonia Morris, board member; and from Trinity College, Dublin, Professor Catherine Comiskey, professor of healthcare modelling, global addiction and transformation, and Mr. Philip David James, assistant professor of mental health nursing. The witnesses are all very welcome and I thank them for attending today.

I am going to read a short note on privilege before we begin. All witnesses and members are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

I also remind members of the constitutional requirement that in order to participate in public meetings they must be physically present within the confines of the Leinster House complex. Members of the committee attending remotely must do so from within the precincts of Leinster House. This is due to the constitutional requirement that in order to participate in public meetings members must be physically present within the confines of the place where Parliament has chosen to sit. In this regard, I would ask any member participating via Microsoft Teams that prior to making their contribution to the meeting they confirm they are on the grounds of the Leinster House campus.

All opening statements have been circulated to members and will be published on the Oireachtas website after this session. As agreed, we will limit each opening statement to five minutes to allow plenty of time for questions and answers. I am conscious that a wide range of issues will be discussed today. If necessary, further, more detailed information on certain issues can be sent to the clerk to the committee for circulation to members. I should also mention that members will be in and out of the committee room during the meeting due to other parliamentary commitments.

I understand that Mr. Kilbride and Dr. Morris are sharing time and I now invite them to deliver their opening statement on behalf of ADHD Ireland.

On behalf of ADHD Ireland, I would like to take the opportunity to thank the Chair and members of the Joint Committee on Drugs Use for giving us the opportunity to present to them today.

To start, let us put attention deficit hyperactivity disorder, ADHD, in context. It is a neurodivergent that is primarily genetic, so it tends to run in families. It is a difference in how brains develop, which means it influences how you experience the world. It also means that it does not disappear on your 18th birthday and, for some, it can impact their function to various levels across the entire lifespan. Medication is available for ADHD, which supports functioning and is a recommended intervention in international guidelines.

For reference, there are probably 160,000 to 170,000 adults living in Ireland today with ADHD. The vast majority would be undiagnosed and unsupported in their ADHD. A recent Healthy Ireland survey from the Central Statistics Office indicated that 9% of adults in Ireland think they have ADHD. This is in addition to the children already identified. What services are available to people in supporting their ADHD? For children, there is the child and adolescent mental health service, CAMHS, but as awareness of the societal acceptance of ADHD increases, so does the pressure on the HSE to deliver those services. We see wait lists increasing for CAMHS, primarily driven by families looking to get their children assessed for ADHD, and open cases in CAMHS populated by ADHD service users.

In January 2021, in partnership with the Minister of State, Deputy Butler, and the HSE, ADHD Ireland launched the model of care for adults with ADHD. Since then we have seen a tsunami of demand and both child and adult services are struggling to keep up. It is estimated that 50% all new referrals into both the child and adult mental services in the HSE are for ADHD assessment, treatment and support. ADHD Ireland has also seen a massive surge in demand for services over the past three to four years and we are also struggling to keep up with that demand. This means that not every ADHD child and adult has access to services for timely identification and ongoing support. While this comes at a significant personal burden to some, it is important to stress that this is not true for all ADHD individuals. There is also a significant cost to Irish society, with the estimated socioeconomic cost of untreated adult ADHD estimated to be around €2 billion every year.

Where do ADHD and substance use overlap? We are immensely grateful to our colleagues in CityWide and Trinity College for delivering research on the interaction of neurodiversity with drug treatment services. This research shows that 51% of adults going through these services would screen for ADHD. This is a huge over-indexing against the general population but we see these figures reflected in other international surveys. We often say that the biggest challenge with ADHD is not the ADHD itself but the stigma and low self-esteem that it brings. We carried out research with UCD and the HSE which found that 20% of all ADHD adults had attempted suicide, 50% had self-harmed and 10% consider suicide as an option going forward. We also know that there are higher rates of anxiety and depression. This is significant when one bears in mind that we are talking about 160,000 to 170,000 adults in Ireland today. Without knowledge of ADHD and access to services which can help, simply put, people with ADHD self-medicate, primarily with alcohol and cannabis.

It does not need to be like that. We know that a combination of access to services and a societal shift towards a neuroaffirmative action approach can reduce the stigma and low self-esteem that can be true of many with ADHD, which can lead to self-medication and substance misuse. Neuroaffirmative action means changing attitudes, prejudices and unaccommodating environments across all aspects of society. This includes early childcare, schools, sports clubs and community groups, communal spaces and facilities, healthcare services, employment and third level institutions. This is relevant for every aspect of society, holding in mind that ADHD children become ADHD adults who continue to need both support and acceptance. Adopting a neuroaffirmative approach towards ADHD will ensure that supports and accommodations are put in place so that those with ADHD know they are valued and productive members of Irish society.

In looking to present solutions today, our primary message is that the risk of substance use and misuse, suicide and mental health challenges are greater for the ADHD population. Indeed, there is a long list of other challenges that can exist for some, but not all ADHD, individuals. To mediate ADHD and substance use along with the other overlapping challenges, we need a whole-of-government approach and strategy. In fact, we need everybody to come on board with this. While we are working on that, it is imperative that public services for adults and children alike are sufficiently funded and staffed by the Department of Health and the HSE and have a focus on ADHD care. In partnership with the HSE, ADHD Ireland remains fully committed to this agenda and it would only be proper to acknowledge the HSE's ongoing support which has helped to deliver innovative programmes such as our UMAAP initiative, developed in partnership with UCD and the HSE, which we know makes a difference to the lives of ADHD adults today.

The ADHD community over-indexes for substance use. We know the challenges and we know the costs, both on a personal and a societal basis. In keeping with ADHD Ireland’s mission statement to improve the lives of all those connected to ADHD, we need to reframe ADHD and neurodivergence more generally. We thank members for their attention and would welcome any questions and comments they may have. We look forward to engaging with the committee over the next couple of hours.

Thanks. I now invite Professor Comiskey to make her opening statement.

I thank the committee for the opportunity to address it today. My role here today is to inform the committee of the most up-to-date research, both Irish and international, on the topic of people who use drugs and are neurodiverse. I am based within the school of nursing and midwifery at Trinity College Dublin and hold a personal chair in healthcare modelling, global addiction and transformation. My background is in biomathematics and healthcare modelling. I have been conducting research on substance use and related topics since the early 1990s, with the emergence of the HIV-AIDs epidemic among people who use drugs. I am also the former chair of the scientific committee of the European monitoring centre for drugs and drug addiction and a current member of the scientific committee of the EU Drug Agency, EUDA. I have also advised the United Nations. Having said all that, what is most important to me is my work with Irish drug services since the 1990s. This is the work that I value most and I was delighted to be invited by CityWide to conduct research on people who use drugs and are neurodiverse.

What did we do? We looked at the prevalence of neurodiversity among people who use drugs according to the international literature. This is not just my work, but the international literature on the issue. Then we looked at the prevalence within Ireland, as identified within an online survey, and we looked at the experiences and needs of people who provide drug and alcohol services. What did we find? We found that there were no estimates in the literature of the prevalence of ASD among people who use drugs. I think we found only one estimate so there was a serious lack of evidence. The overall estimate of the prevalence of ADHD among people who use drugs and alcohol was 21%. When comparing rates across genders and substances, the highest rate of ADHD overall was found among women using benzodiazepines. That had not been found previously. When we brought the literature together, we found that and it is was estimated to be at 40%. Women using benzodiazepines in treatment was at 40%. The rates of ADHD were statistically significantly higher among males than females who used alcohol, cocaine and cannabis. Similarly, this study identified for the first time that the rates of ADHD were statistically significantly higher amongst females than males who used opiates. We are talking here about women using benzodiazepines and men using alcohol, cannabis and cocaine.

For the Irish element of the research, we conducted a survey of 288 participants and found that the prevalence of ADHD was 51%. The prevalence of ASD among the survey participants was 37%. We found out something that we did not know previously from the literature, which is that the prevalence of ADHD, at 64%, was highest among the LGBTQI+ group and the prevalence of ASD was at 57% among that group. Cannabis was the illicit substance with the most frequent use among the sample. No significant association was found between ADHD and people who have spent time in treatment and those who have not. This may indicate that people experiencing ADHD who are using substances are not necessarily entering treatment services, although they may benefit from services, given their substance use.

From the qualitative work we did with service providers we found that most service providers did not have any formal education or training in neurodiversity. Managing the needs of people who attend these services has been learned on the job using a trial-and-error approach. Communicating with and managing people with neurodiverse conditions posed a major challenge for service provider staff, particularly when providing services for people with ASD. For some service users it can take years to find an effective treatment programme based on their individual needs. Finally, the lack of a referral pathway through the Irish health system for adults who want to receive a formal diagnosis ADHD or ASD was a barrier. Providing appropriate support for those with mental health and drug and alcohol problems was raised by almost all the providers as a major issue for their service.

Our research makes the following recommendations: the application of a gender, sexuality, and drug of choice lens to ADHD awareness; modification to service processes and practices to ensure culturally informed communication; the provision of non-stigmatising, strengths-based services; an expansion of existing training to include a whole-service approach to immediate and long-term sustainable neurodiversity education; the provision of access to expertise in the development of integrated care pathways; and the dissemination of the Irish evidence and international consensus statements to ensure human rights and access to evidence-based processes. To summarise in a single sentence, we very much need training within substance use services. People are coming in the door who may not have a diagnosis. They may be having some behaviours and services are dealing with those but we need strengths-based approaches.

We have trauma-informed services. It is a buzz word. We need neurodiverse-informed services for people who use drugs.

I thank the committee for the opportunity to appear before it today. I have close to 25 years' experience working as a mental health nurse in Ireland, working in both mental health and substance use services. For the past two years, I have been an assistant professor in mental health nursing in Trinity College. I am also the president of the Irish Chapter of the International Nurses Society on Addictions.

The main point I would like to convey in my opening statement is the need for comprehensive, joined-up services when it comes to providing care to those with substance use disorders, and particularly those who have an additional comorbid condition such as ADHD or autism. A study of adults with ADHD in England was carried out by Matheson in 2013, in which a participant, an adult with ADHD, stated "Putting somebody with ADHD through a bureaucracy is torture. ... it’s like treating a diabetic in a bakery". I would like committee members to keep this statement in mind while I briefly discuss the development of services for those who have a substance use disorder and another mental health diagnosis.

In December 1984, 41 years ago, a mental health policy was published in Ireland. This was Planning for the Future, and Barry Desmond was Minister for Health at the time. This document states, at paragraph 13.42, that the psychiatric service has an involvement in problems arising from both the illicit use of drugs and the improper use of prescribed drugs. It states the official classification of psychiatric disorders of the American Psychiatric Association classifies drug abuse and drug dependence as psychiatric disorders, and that if drug abuse escalates psychiatrists will have the main responsibility for dealing with this problem.

Since this policy was published, the drug problem has certainly escalated, but the fact that substance use disorders are mental health disorders has not changed. Both the American Psychiatric Association and the World Health Organization list substance use disorders as a category of psychiatric disorder. For example, chapter 6 of the World Health Organization's ICD-11 diagnostic manual is reserved for mental, behavioural and neurodevelopmental disorders, where substance use disorders are listed alongside mood, anxiety and psychotic disorders. This makes sense as the treatments for substance use disorders are very similar and typically involve a combination of psychological, social and medical interventions.

What has also changed is the inclusive approach that was set out in Planning for the Future in 1984. By the time the next mental health policy, A Vision for Change, was published in 2006, we were told that "the major responsibility for care of people with addiction lies outside the mental health system", even though their substance use disorder is a mental health disorder. A study carried out in Cork city reported that 47% of those admitted to an acute mental health unit had a substance use disorder, either on its own or in combination with other psychiatric disorders. This is unsurprising as research generally estimates that at least 50%, and probably as high as 85%, of those who have a substance use disorder meet the criteria for an additional mental health diagnosis.

As Professor Comiskey outlined just a few moments ago, approximately 21% of those with a substance use disorder have ADHD. We have now arrived at a point when we have separate mental health, substance use and ADHD services. People with a substance use disorder often struggle to access mental health services, so much so, in fact, that the latest mental health strategy, Sharing the Vision, had to reverse recommendations made in the previous policy, A Vision for Change. This is because they were leading to the exclusion of those who have a substance use disorder from mental health services. This is just the sort of torture by bureaucracy the participant in Matheson’s study warned us about. Living with a substance use disorder is difficult and having an additional mental health disorder makes this more difficult. Likewise, treating substance use disorders is difficult and additional mental health problems only makes it more difficult. In the real world, this is how these problems present and so it behoves services to address this reality.

Regardless of the combination of mental health and substance use disorder, the best approach is when these disorders are treated concurrently. An international consensus statement about treating ADHD in combination with a substance use disorder was published in 2018 and can guide this work. It is recommended in the ADHD guidelines that the HSE has published. The current configuration of services means this work is likely to involve multiple services. I strongly encourage the committee to do everything in its power to ensure that those with a substance use disorder are not excluded from mental health services, that support is given to substance use services to develop the skills to identify and support those with additional diagnoses, such as ADHD and autism, and that mental health services are supported to provide interventions to those with concurrent substance use disorders.

To return to the study mentioned earlier by Matheson, another adult with ADHD said, "I was very lucky to get a diagnosis, but the diagnosis really is not very helpful without appropriate support ... it’s disgraceful there just isn’t a system". We need to ensure that those with substance use disorders can access appropriate treatment for any additional disorders they have, even though they have a substance use disorder.

I thank the witnesses for their opening statements. I will now invite members to put their questions to the witnesses. Members will have seven minutes for questions and answers combined. Once everyone has had an opportunity to engage, time permitting, we will have a second round.

I am the first speaker for the Fianna Fáil group. The Cathaoirleach will be joining us shortly. He sends his apologies. He is delayed at another meeting.

I thank the witnesses sincerely for their presence today and their expert contributions to our work. It really does enhance our capacity to make strong recommendations which, hopefully, will lead to meaningful change. I cannot thank them enough for this. The witnesses very eloquently articulated the nightmare that people who are suffering from substance misuse disorders and mental disorders live with. I very clearly heard Mr. James say they are one and the same, and how the ADHD community is over-represented in the substance misuse community. The figures and the pictures that Mr. James has painted are very stark.

The witnesses made some very strong recommendations. As a committee, our challenge is to take the interim report of the previous Oireachtas drugs use committee, with which, I presume, the witnesses are familiar, and make further recommendations. Do the witnesses think it is essential for us to make the significant systemic change that is required, as a society and a State, in our response to drug use and drug misuse? To achieve this, is it essential to repeal section 3 of the Misuse of Drugs Act? Perhaps Professor Comiskey will start and then I will come to Mr. Kilbride, Dr. Morris and Mr. James.

The answer is "Yes". I have interviewed so many people who use drugs and now, through this study, people who use drugs and alcohol and experience neurodiversity. Mr. James spoke about the torture that people are going through. I am in admiration of these people every day that I am doing this work, and this is why I do it.

I was in a school this week doing work with young children and I was with an 11-year-old boy. It was a DEIS band 1 school and I was thinking that this child was going in the wrong direction. There is stigma and the challenges that families are facing. In terms of this particular work, the stigma is there. There is a need for this to be main-streamed and, in a sense, to remove the stigma. We have managed to bring in discourse about trauma-informed services. We can do this. We have done it before for neurodiverse-informed services. The school I was in was a trauma-informed school, and I am sure it has training in neurodiversity as well, but this would be rare. We need this. What came up in the qualitative interviews were stigma and the torture that people are going through. We all know this is intergenerational. As already stated, I was interviewing an 11-year-old boy who was going around on a scooter with a mask over his face engaging in robbing. That was shocking.

Section 3 of the Act deals with the misuse of drugs and the categorisation of drugs. Does Professor Comiskey think it is essential that it be repealed in the context of all illicit drugs? Does she have any thoughts on that?

Alcohol is a regulated substance. At this stage in my career, I would go for regulation, to be quite honest.

Is that of all substances?

Yes. I do not like saying it because it is controversial.

It is difficult to say.

It is difficult to say, but at this stage of my career, who cares?

I have seen the research over 20-odd years. I met a gentleman on my way in here. He said he remembered me from the 1990s. I thanked him, recalling I was the first person to determine the actual number of people using heroin in Dublin. Everybody was saying it was 3,000. Merchants Quay Ireland was saying there were 10,000, and nobody believed it. The Garda was saying there were 6,000. We did the research and found there were 13,000. Therefore, I have been doing unpopular research for years. This is unpopular. At this stage of my career, I am saying that what is happening intergenerationally is not fair on families and that we need to do something about it. If what we are doing is not working, let us fix it. The members have an opportunity.

I thank Professor Comiskey and call Mr. James.

I am earlier in my career than Professor Comiskey, so I am going to be a bit more careful with my words. Professor Comiskey mentioned stigma. Probably the most stigmatised drug is heroin, and probably the least stigmatised is alcohol. However, the people who take longest to come to treatment, and whose percentage in treatment is the lowest, are those with alcohol-use disorders. I am not sure the two are definitely connected.

What does that tell us?

I do not have a very strong opinion one way or the other but believe that, where there is stigma, the challenge is when people with substance use disorders try to access other services. They are very much welcomed into substance use services and we try to get them in very quickly, but when they go to mental health services for additional treatment, they are often pushed back. There is stigma there, and that is the main stigma I would like to highlight.

Great. Gabhaim buíochas le Mr. James. I call Mr. Kilbride.

Words used here that have been used already include “nightmare” and “torture”. Why is it a matter of nightmare and torture for people with ADHD and other conditions associated with neurodivergence? It is because they simply have not been recognised and have not got any supports.

I am not the same age as Professor Comiskey. She is younger.

We are not ageist here; we do not discriminate.

When I was going to school, nobody was getting any supports. It is only in the past four or five years that we are seeing more widespread societal acceptance of ADHD. We have mentioned the figures around suicide. Apart from the suicide rate, there are higher rates of marital breakdown and unemployment. The prison population has a problem. We know it is becoming an epidemic across society as a whole. Stigma, as we mentioned in our presentation, is not about ADHD but about the way society treats people with it. If we can remove the stigma associated with the condition, it will help to sort it.

On section 3, I worked in alcohol services a number of years ago. At that stage, the economic cost associated with alcohol misuse was about €6 billion per annum. In the case of ADHD, there is a figure of €3 billion in terms of costs. Purely on a cost basis, let us look at a different way of doing things. If we can change the way society reacts to ADHD as a condition, we can mitigate the issues around substance use.

I am out of time and the Cathaoirleach is here. While Ms Morris is answering, the Cathaoirleach will resume the Chair. I thank the witnesses. I apologise because I will have to leave to do something else. I will be back, however.

I obviously agree with my colleague Mr. Kilbride from ADHD Ireland. Multitude variables are interacting. What we in ADHD Ireland wanted to emphasise today was stigma, but also prevention. So many supports can be put in place from very early on in a young ADHD person’s life that can prevent self-medication, or mental health issues, which our colleague at the table stated can often co-occur with substance misuse and abuse.

If AsIAm representatives were here, they would be talking about the Same Chance programme they have been rolling out over the past few years. We know that the substance misuse rate is higher in the autistic population, and even higher in the ADHD population. From an ADHD Ireland perspective, we would also like something similar to Same Chance for the ADHD population. This population faces the same societal barriers faced by other neurodivergent populations. The systems that have been set up over the years have been set up with the majority in mind, and it is only recently that we have become more cognisant of the fact that we are excluding members of society, leading to low self-esteem, mental health concerns, the turning to criminality, and a feeling of having been rejected by society. Also, according to the research, there can be a turning to substance misuse and drug and alcohol dependency.

The intervention needs to start at a very early age, starting with a societal change in opinion but also a changing of our service structure and how we conceptualise ADHD right from the very beginning, so that protective factors are in place for the ADHD population and so we are reducing the likelihood of substance misuse.

I do not have a particularly strong opinion on section 3. There probably would be no need to consider it if the supports were already in place and the ADHD population were not so marginalised.

I thank Dr. Morris.

Cuirim fáilte roimh gach éinne. This is wildly scary and interesting at the same time. My first question is for Professor Comiskey, just so I can get the figures right in my head. The overall estimate of the prevalence of ADHD among people who use drugs and alcohol was 21%. That is on the basis of international evidence. Does this cohort include not only people who take drugs but also people who, for want of a better term, have a substance use disorder?

They were people who either were in treatment or had problems with substance use. They were not necessarily fully diagnosed, but-----

I get it.

Not just your average cannabis user.

Exactly. I assume the same goes for those associated with the online survey.

Yes. The proportion in that instance was 51%.

I assume there will be attempts to follow up on that. It is a phenomenal number. If without evidence Professor Comiskey were to bet on the prevalence, would she be talking about 21% or 51%? There is a huge difference.

There is. For a start, 21% is high by comparison with the rate for the general population. When we went through all the international papers, we saw the rate was up as far as 60%-odd in some prison settings. Therefore, 21% was quite modest overall.

So, it is a conservative number.

Very much so. Depending on the setting, it could be much higher.

On some level, we probably need something comprehensive to be done in this regard.

I would love that.

I would be absolutely afraid of my life in relation to what the number would be. That just begs the question straight away. We know the issue involved, particularly if we are talking about neurodivergence, be it autism or ADHD, the comorbidities and the matter of getting supports. There has been no wild improvement in recent years. If we are talking very specifically about those with a predisposition to addiction, it is a question of preventive measures and supports we can deliver early enough. Afterwards, as already stated, it is about having a service that can at least address the fact that there is a considerable cohort of people who are going to have a dual diagnosis of addiction and ADHD, or ADHD and autism or another condition.

On the continuum, you start with prevention or you start early. That is why I really thought about the recommendations and discussed them with CityWide, ADHD Ireland and my colleagues. I thought about what was practical. Everybody understands the trauma-informed approach, so we should consider introducing a neurodiversity-informed approach. When I went to school, the bold children were in the corner or outside the door, and those children thought they were stupid. They were not. We were not informed. We need to take action across the continuum. One place to start would be in neurodiversity-informed services. We should start to introduce the appropriate language where it is needed: in the schools and, in the case of what is relevant to this committee, the drugs services. With regard to prevention, there is universal prevention and there is targeted prevention for children who may have a diagnosis or are awaiting one. We can follow the whole system and add to the system already in place.

If we had a perfect system, with supports kicking in straight away, a person could be screened before ever being assessed, bearing in mind all the issues that exist in relation to assessment. People who believe they have ADHD or who have a diagnosis have to be warned they are more likely to develop an addiction.

They are going to have a greater likelihood of developing an addiction.

I do not know about that. Not necessarily. I would not think so. That is why there is prevention. It is called "prevention" to prevent that happening, so that children understand themselves and they do not feel frustrated. They get the right treatment and they are in an environment that is neurodiverse-informed, so that the child's self-esteem, self-worth and whatnot is addressed.

I get it. Is it the stigma or is it also-----

We need more training. The training will reduce the stigma.

We need a greater level of research.

It is something that can happen. I am very practical. We can talk about changing the HSE and doing this or that, but this can be done. This is practical and it would be a lovely positive outcome if it were done.

I have seen some simplistic or simpler interventions. My wife works for the Changing Lives Initiative. I am not trying to plug it, but the idea is that it is for kids that screened with ADHD. It works with the family, the child and whatever else to create better circumstances at home, school, etc. That allowed for a whole de-escalation of meltdowns.

The whole-school approach.

Exactly.

I will add in one point about the training. CityWide has started this and it is putting its money where its mouth is. We are developing a free massive open online course, MOOC, on neurodiversity and the background. ADHD Ireland is supporting this as well. It is a small first step but CityWide and ADHD Ireland are putting their money into this. In Trinity College, Mr. James, other colleagues and I are developing a MOOC that anybody in the world can access. We will have the evidence. It is a very basic first step. We believe in responding to the problem and doing something.

That is good.

From a prevention point of view, it is recognised that children with ADHD are at a greater risk of developing a substance use problem. There are recommendations that people in CAMHS should be screened, not just those with ADHD, because they are also at increased risk. What we really need to do is have better screening in CAMHS for substance use problems to try to catch them early. If people are not getting diagnosed with ADHD until they are in their adulthood, then we are missing the opportunity as there is a good chance for intervention, but my understanding is that ADHD has to present before the age of 12. Dr. Morris might correct me on this. That means in the vast majority of cases the ADHD is there before the substance use starts, but if we identify those young people early and treat them, we can hopefully prevent it progressing into a more complicated picture of substance use.

Again, it would help if we had those therapies and means of assessment within schools or early learning facilities.

Deputy Ó Murchú's time has elapsed.

I am sorry. I must have missed that.

The next contributor is Senator Costello.

I apologise, as I came in late. It is kind of sad to hear about children with ADHD and the statistics on drug and substance abuse. If society was a little bit kinder and accepting of differences in personalities we would not have half the problems that we have. I understand that children with ADHD are given out to thousands of times more than the average child by the time they are six years of age. They get excluded from birthday parties and play dates. They do not feel they belong in the clubs they are in. They experience social isolation early. That can include from family members. It is quite understandable that this can happen for validation and self-esteem but I would not like to predict that a child with ADHD will become a drug user. There definitely needs to be a focus on extracting their strengths from them.

I have personal knowledge of ADHD and the process taken to diagnose it. Sometimes trauma can mask as ADHD qualities. It can take quite a long time. It is also important to find the right therapist. A focus on talk therapy is huge and finding a person that a child with ADHD can nearly look at as a role model and someone they feel accepts them. It is a huge step. They can also be influenced by such a person. The school system needs training in how to deal with children with ADHD as well. The people I know who have ADHD have super powers. They are very focused and strong when they take an interest in something. There needs to be a piece on the emotional maturity side of children with ADHD.

One point I have come back to a few times in this committee is how neurodivergent children are affected by getting a domiciliary care payment up to the age of 16 and when they get to 16 they are transferred to a disability payment. Do the witnesses think that is an issue? Do they come across children who think they are old enough to manage the money that is in their hands but that it can become a stumbling block? As they have access to money, people who prey on the vulnerable might see them as being more accessible to taking drugs.

It is well known that children with ADHD have an emotional maturity delay of about 25%. If you are dealing with a 16-year old, they have the emotional maturity of a 12-year old. With impulsivity, when they get into the wrong social group they can be easily manipulated. They can be the one asked to do the shoplifting, throw the brick through a window or whatever it happens to be because of the condition that goes with it.

I do not know if the Senator has listened to any of the talks I have been doing, but one of the figures I use when I am out doing talks is that it is estimated that a child with ADHD will receive 20,000 pieces of negative stimulus by the age of 12. This is what causes that low self-esteem. Then there is also what is called RSD. I do not know if the Senator is familiar with that.

Is that to do with rejection?

Yes, it is rejection sensitivity dysphoria in terms of emotional dysregulation. There is emotional maturity delay and emotional dysregulation. You get those two together at the same time.

That is the trouble. There is also a need for education around the medication for ADHD. Parents who face a diagnosis of ADHD in a child sometimes feel they are failing their child by putting them on medication for ADHD. There is a perception that they are taking the easy way out. There needs to be a whole education piece around the fact that this is a medication that can really let the child reach their full potential. I do not feel that message is out there strongly enough for new parents coming along. I do not know if the witnesses would agree with me on this but if a parent waits too long to get a child onto the ADHD medication, then it is a big deal for the child and they may refuse medication. It can be more of a struggle to get them into the habit of it, whereas if you start them younger it is easier, rather than delaying and feeling like a failure as a parent or that you are taking the easy way out. Is that something the witnesses come across? I certainly know how that feels.

It can be true obviously, although it is not true for everybody. It is very much a personal decision for a family about whether medication is the right route to go with a child. For an adult, it is an independent choice. All you can do is give the information about what the benefits could be. We also need to recognise that the ADHD medication is not effective for every ADHD individual. There needs to be less of an over-reliance on medication as the answer. There need to be other supports that are put in place alongside it. It is great that there is medication available. For an adult population it is only in the past few years in Ireland that we have public services available to adults with ADHD to access in order to avail of that. We know that there are vast populations within Ireland that still do not have access to those adult services. Even from a medication point of view, they do not have that.

I agreed with almost everything Senator Costello said and with Mr. Kilbride's comments about the number of negative comments that are made to an ADHD child. I agree with my colleague, Professor Comiskey, that there needs to be a neurodivergence-informed approach to service delivery across all aspects of society in order to prevent that from happening, so that our kids are protected against low self-esteem as they grow and develop.

Accessing therapy is all well and good but if those therapies are not adapted for a neurodivergent community then there are barriers to accessing the therapies too. While there needs to be trauma-informed care, I am in complete agreement that there also needs to be neurodivergence-informed care.

Otherwise the efficacy or the evidence base for improvement just is not present.

Medication on its own is not the right way. There will be talk therapy required throughout and that is so important as well.

I thank the Senator. Her seven minutes are up. Our next contributor is Deputy Graves.

I thank the witnesses for coming in and I really enjoyed reading through the presentations even before they gave them. There was a huge amount of information in them. In recognition of the fact that neither ADHD nor neurodiversity was included in previous strategies it is important that they are this time. For the witnesses from ADHD Ireland, if it was a case we were to include ADHD in the drugs strategy, what would they feel would be the important actions to have included and who would they see as being the lead people responsible for making sure they would be carried out?

What is important to emphasise is that it is not just ADHD; it is neurodivergence more generally. We have stark figures about ADHD but to single out ADHD in a policy is probably shortsighted.

I am thinking of both but am asking about what ADHD Ireland thinks.

Absolutely, the key changes are access to services, much like has been commented on across the table, starting at a very young age. The waiting lists for CAMHS across the country are very variable but overall when we look at the statistics of those who are on the waiting list for CAMHS, it is very rarely kids waiting for mental health interventions. It is the ADHD query kids who are waiting for assessment and identification. We have a real challenge with adult service provision in the country at the moment. The adult model of care has not gotten up and running across counties. The teams that are being established are really struggling with the demand for services. Much like every issue that is on the table at the moment, it is about resourcing. It is a cross-service approach that needs to happen. We do need more ADHD acceptance and awareness programmes integrated into schools, given the fact that, and Mr. Kilbride will let you know the prevalence, there is at least one ADHD child in every classroom across this country. The fact schools do not have access to ADHD-informed teaching methods and accommodations to be made within those settings means those children are already set up to have barriers to accessing the educational curriculum. Also, as was pointed out by other members here today, there are barriers to other aspects of community like the social engagement that comes from being in school such as birthday parties and those sorts of things. It needs to start there.

There is the stigma about accessing services in the first place. There are plenty of adults who present as ADHD who are unwilling to go to their GP to ask the question as to whether it is ADHD because of the stigma that is associated with what that might mean. While it is important to focus on service delivery specifically for ADHD, we also need to be focusing on how to make it more acceptable to be identified as ADHD in the first place, to act as a preventative measure for drug and substance misuse and self medication.

There is a lot of experience of parents who realise when they get their child assessed that they also have ADHD. They only realise when they get their child assessed that they are exactly like them and are going through the same thing.

I have a follow-up question for Professor Comiskey around the barriers to people accessing services. I am greatly interested in the MOOC. Will Professor Comiskey tell us a bit more about that because it sounds really interesting? Who would it be geared towards? I know she said it was online, and we have spoken about children not getting access to diagnosis, but will it be available for undiagnosed children or people who people who feel there is a problem they are presenting with?

Does the Deputy mind if, before I answer that question, I go back to her previous question? I was very much involved in the last drugs strategy so I am aware of the action plan, who is responsible and who is around the table. I will say that I am not at the table this time and that is a different argument.

Professor Comiskey and many others.

As I was at the table previously, I know how it works. I would suggest this is a whole-of-government approach and that within each Department - for instance, the Department of education - there should be something related to neurodiversity through maybe the SPHE programme and in the Department of justice through the Prison Service. They were all at the table in the past. I do not know who is at the table now; I just know who is not. They all had actions so I would get a sentence or half a sentence into those actions because the actions are accountable and measured. If is it not in the strategy, it is not accountable, not measured and it will not happen. That is in answer t the Deputy's previous question.

In terms of the MOOCs, they are fabulous. We have done one before. This is on informing people about learning from ADHD Ireland's materials and from the literature. It goes through what it is, explaining the background, how to inform a service, what best practice within a service is, being strengths based and pulling out the strengths. It is hosted on a platform that anybody anywhere in the world can access. MOOCs are a very nice first step and not expensive to develop. It costs about €30,000 to develop one of these. The one we developed previously was on addiction nursing and 4,500 people all over the world have accessed that. Once it is there, it is sustainable. We are not relying on whether a trainer has left a service or a teacher has left the school. If we could build upon that basic module we are doing at the moment with ADHD Ireland and CityWide we could develop one for schools because I know the schools are overrun with having to do this and that. I am doing a big evaluation of drug and alcohol use in schools but this is something a teacher could do. It is literally six hours over a period of three weeks so it is something that can be built on. It is not expensive and is very practical. That is an example of what can be done but we definitely need to get something in the actions. Actions speak louder than words.

I thank Professor Comiskey. In terms of the development of the strategy, one of the major concerns I have is lack of consultation and involvement by stakeholders. It has been raised at this committee on numerous occasions. Every group that comes in has not been consulted. The Minister of State, Deputy Murnane O'Connor, committed at the committee, and when I spoke to her yesterday, to wide-ranging consultation with all stakeholders. I asked her about the international perspective. They are actually working on their consultation programme at the moment and she hopes to have it next week. She did say alcohol would be included in the drugs strategy as well. When the opportunity arises the committee will get a draft and we should look at adding stuff to it as well. Can I have-----

Sorry Deputy, we have to move on.

I have to leave the meeting for about 15 minutes so I will come back then.

Absolutely, we will have a second round of questions.

I thank the witnesses for coming in. Just to reiterate what Deputy Graves said, we have advocated for those stakeholders who are not at the table to get back to the table because that issue has come up a couple of times at this committee. We have all been pretty unanimous on that. The witnesses have come during a good week as well. The Mental Health Bill is going through the Seanad at the moment. There have been a good few discussions and debates around dual diagnosis. I would be interested in any of the witnesses' thoughts on how we are supporting, or otherwise, people who are presenting with both an addiction and a mental health issue, or ADHD or anything that goes along with it? As we know, that is how people end up in addiction a lot of the time. They are self medicating from a young age. What are the witnesses' thoughts on our legislation and our gaps?

Yes, I think we have very good policies in Ireland. Our policies really make sense when one reads them, whether they are about ADHD, but the general consensus is that, if there is a substance use problem and a mental health problem both are treated concurrently. There was a tendency, and this is what was changed in the new mental health strategy, for one disorder to be treated first, usually the substance use disorder, and we would not treat the mental health issue. That is the theory and that is great. It is in black and white in our policy. The big concern is on the ground. That can vary from area to area. There would be services where one psychiatric team would be very open to treating somebody who has concurrent substance use problems and another team that may not be and that is a big barrier for people. It is basically a geographical lottery depending on one's catchment area and where one lives. I would love to see those kinds of things become the norm, that this policy is done.

The legislation is a different matter. I am not an expert on the mental health legislation. It is more about treating people against their will and there is not a tradition in Ireland of treating people for substance use against their will. The reality is that there will be a lot of people who will have, for example, a psychosis and a cannabis problem.

They would be treated for psychosis against their will but we want to make sure that substance use is not used as a reason to not have somebody access mental health treatment.

That issue has come up a good bit this week, where something is not proactively described in legislation but the policy is quite strong. Is Mr. James saying that the implementation of the policies is ad hoc?

It varies. It is similar to the ADHD policy, which is very good in principle. We have a problem in this country in respect of putting the resources that are needed into mental health services. We are below the average for European countries and developed countries in respect of the investment we put into mental health services. Those services lag behind. We have great intentions but the issue is with implementation. We need more resources. There is a shortage of mental health nurses, psychiatrists, psychologists, speech and language therapists, occupational therapists and everybody else. We need more investment and greater access to services.

I will ask Professor Comiskey about training with substance use. She talked about neurodiverse-informed services.

Yes.

Can we expand on that a little? Would Professor Comiskey see that being rolled out or supported through continuing professional development. CPD, for people who are already working in addiction services? How would she that being rolled out?

That is one way forward. The MOOC we are developing is particularly for people who are working in the drug and alcohol services. It is very basic training about what neurodiversity is, what ADHD is, what autism spectrum disorder is, and how people manage those things in a treatment environment. We know from studies that people might not be able to make a phone call if there is a lot of noise going on. They may not be able to keep an appointment. Appointments are then being missed. Another person said they found it difficult to go to group treatment or group therapy. It was not appropriate for them. Perhaps if the service had been more neurodiverse-informed, it would not have offered that person group therapy or told the person that they must attend at 3 p.m. or it is a failure on their part and they will not get treatment. We can do little things that would make a big difference. That is my basic understanding. Perhaps my colleagues will be able to say more.

In reference to what Professor Comiskey was talking about, I remember that we started doing adult support groups a number of years ago. We talked about using the phone and half of the adults in the group said they did not like using the phone. Whatever about employment or not going into college or whatever else, they said they do not like using the phone. Things such as that are happening on a regular basis.

We talked about the model of care, which was only introduced in 2021. The HSE, frankly, knows that it has struggled to get clinics up and running around the country. It has four or five clinics, each of which has 50% of the staff required. They all lack key staff. There is a big job to be done there to provide services. We had a discussion in Buswell's Hotel and asked how to treat or work with someone with ADHD. Mr. James had one answer and Dr. Morris has a slightly different answer. It was not a different answer, but Dr. Morris has a different perspective.

What is Dr. Morris's perspective?

That was me throwing Dr. Morris under the bus.

We had a very lovely and respectful discussion before coming over to the meeting. It was about joined-up service provision and the challenges with accurately identifying ADHD when there is a co-occurring substance misuse problem that is ongoing at the same time. If we take, for example, cannabis use, it will obviously have an impact on one's ability to sustain attention.

I work in child and adolescent mental health services, CAMHS. I am one of the clinical psychologists in those services. I do a significant number of ADHD assessments weekly. Young people who are recreational drug users come in and you can still tease apart ADHD from the impacts of drug use. Some of the challenges we have arise where somebody is dependent on a drug or is a heavy user of certain substances. It then becomes hard to judge what ADHD is and what the impact of drug use is. I agree with my colleague that there needs to be joined-up service provision and there need to be no barriers to accessing services. There still needs to be recognition of the fact that a focus on one challenge for an individual might need to be prioritised over identification in some instances. It means accurate identification. I have seen the aftermath of an incorrect identification and the consequences for an individual.

I thank the witnesses for their presentations. As a medicated ADHD person, I am delighted to hear that I have the emotional maturity of a 35-year-old instead of a 41-year-old. I feel a bit like I am winning. My diagnosis with ADHD completely transformed my life in many ways. It came with a huge grieving process that I did not expect. I had to remap my life through that new lens and understand myself in a completely different way. I did not realise the shame that existed. I did not realise that I would have parented differently if I had understood there was neurodiversity in the household. There were so many layers that I had to rethink and sit into with a new understanding.

It also made me think of all the years I spent working in drug services. Thankfully, I always had a natural ability to treat people how they wanted to be treated, regardless of a diagnosis. I could respond to how they wanted to engage in a service and whether they wanted to do group work or not. I was always very accommodating. Programmes should be tailored anyway. Regardless of any sort of other diagnosis, people engage differently and we should not be trying to fit people in. My experience of school would be an example of that. I worked in the area and have been obsessed with drugs policy and service provision since I was a child. If they had let me focus on that, I probably would not have been thrown out of school by the time I was 13. They were trying to make me do all these other things that I had absolutely no interest in. I was very capable, but thought I was bold, and this, that and the other, when I just did not care about what they were talking about. I wanted to do other things.

I think about all the people who end up being thrown out of services, spaces and schools being seen as difficult, rather than seeing that the institution with which they are trying to engage is far too rigid. Do we need to consider how services are run? In Ireland now, if you want to get into residential treatment, you may need to attend group therapy for six weeks to get into a treatment facility. There is no flexibility. There is complete discrimination there. Many people will not arrive with a diagnosis because they come from areas that are extremely under-resourced and under-served. Families do not have the money to pay for private assessments. You cannot base your service on somebody showing that they have a diagnosis. You have to be able to move and be flexible and find other ways.

Neurodiversity training is extremely important. I worry if a service is saying it is trauma-informed but does not already cater to neurodiverse people. If you are that trauma-informed, there is a natural way that you engage with people. If you were to treat everyone in a trauma-informed way, it would have been better for neurodiverse people in the first place.

Beyond the training, how does this committee go about creating a policy that is implementable so that people are not being pushed out of addiction treatment because they do not want to engage in groups? That is one consideration that stands out to me because I have had to advocate for people not to be put into group sessions. Do the witnesses think that is a culture that must change at a service provision level or is there a policy at this level that can make sure that happens at a cultural level?

It would be useful to build into policy a necessity for stakeholder engagement during the revision of how services are provided to take account of people's experience of accessing and engaging with a service so that change that is informed by the neurodivergent community is implemented into practice. As has been mentioned, we, as a country, are very good at developing policies. However, implementation is sometimes lacking. I also think that the re-evaluation of policy with the people to whom it matters most can often be lacking, too. I have heard many examples of some of the barriers to accessing a service, including the rigidity around the type of format in which therapy is delivered. We know about all those executive functioning challenges that are inherent to the ADHD community, including time management, organisational skills, completing homework between sessions for therapy and all those sorts of things.

I agree there needs to be more flexibility. How that gets translated into policy is very challenging. One of the things that springs to my mind is that the members of the neurodivergent community are becoming excellent advocates for themselves because of that reduced stigma. Allowing them to have a voice in service development is probably the most important thing to make sure it is prioritised.

There is something that comes up as a concern for me. I am not a drugs worker, but for some reason I seem to still act as one in certain communities. When I am helping people with referrals or trying to signpost them in particular directions, I find that somebody who has an ADHD diagnosis sometimes ends up in certain types of residentials that see them looking to go on ADHD medication as drug seeking. There is a real stigma being created by services. In the prisons, the prison doctors would not give ADHD medication, which they are only beginning to change now, because people were seen as drug seeking. For any sort of behaviour, whether it was impulse control, or getting into fights or getting frustrated, people were then being punished for something they were seeking help for. The criminality thing then comes on top of them because they are not getting what they need. How do we go about that? A lot of people who work in an abstinence space, even when it comes to psychiatric or mental health meds, come with the message that this is some sort of drug seeking, which is a threat to recovery. What are the witnesses' thoughts on that?

It goes back to the policies that are out there. The evidence-based practice is that both disorders need to be treated together. Unfortunately, if you work in a drugs service, there is a possibility that your service just sees people through a drugs lens. We are saying there needs to be more lenses than that. People are a lot more complicated than that in reality. You cannot work in substance use services effectively if you do not understand mental health in a broader sense. Sometimes, people need psychiatric medications. A lot of those philosophies that are very rigidly stuck to in services probably are not conducive to the kinds of policies we already have around the trauma-informed recovery approach. Those policies need to be looked at where they are very rigid and if they exclude people.

I have friends who thought they had broken their recovery because they accepted certain medications for certain conditions. That type of framework is absolutely appalling and just adds to more shaming of people.

Everyone is very eager to get in, so I will stop the Senator for a moment.

I warmly welcome the session we are having today. I thank the witnesses for attending and for their detailed submissions. The figures are very stark for the incidence of drug users who have ADHD. Others touched on it. I was very struck by another session we had on the prison system and the very high number - I think it was somewhere close to 80% - of those entering prison at the moment who engage in substance abuse. There is then this other layer of being neurodiverse as well and how ill-equipped our prison system is. Senator Ruane touched on how badly handled people are because of that lack of screening for neurodiversity. The big message that has to come out from today is that if we get the right diagnosis and supports in place for children at an early age, then we can prevent that self-medication later on in life.

There are two things I want to ask. On concurrent treatment, I hear very much what Mr. James is saying about the theory being there and then the breakdown and inconsistency of practice. Why has that emerged? How has that been allowed to continue? If a policy is in place, it is up to somebody to execute it. I had a quick look, but I do not know whether the Mental Health Commission has conducted research in this space as it is obviously the main advisory body to the Government on the implementation of mental health policy. I would like to hear a bit more about why we have that geographical lottery and where the failure has been.

The short answer is that I do not know. I think it is stuck at a local level. The policy is black and white: using substances should not be a reason for excluding people from mental health services. The way the old policy from 2006 was worded suggested they could be excluded, but there has been a lag in that changing in certain regions. I know both from when I worked clinically, up until two years ago, in substance use services for adolescents, and from talking to colleagues now doing research, even just casually, that still exists. There are certain kinds of teams that are very slow to take young people if they have a substance use history. My wife is a mental health nurse and I know that happens in adult psychiatry as well. All the research backs that up. All the anecdotal evidence and all the evidence from talking to service users is that it is very difficult for them, if they have a substance use problem, to access mental health services if they need them. It is not in every area, but in many areas. The policy is there. The Mental Health Commission looks at what happens in services. The problem is if people cannot get in, they are never seen by the Mental Health Commission and they never come on to that radar.

That is a fair point. We might check whether the Mental Health Commission has said anything in this space. If not, maybe the committee will write to it to suggest that guidance from it would be important.

The other thing is, obviously, Ireland is not on its own in this. Are there other countries that are well ahead of us in this space and are doing things particularly well? This is particularly in terms of that process modification piece in looking at substance abuse through a broader lens than just the substance abuse itself.

I will say something on that. ADHD Ireland might be able to give more detail. We looked at what is known as the International Consensus Statement on Screening, Diagnosis and Treatment of Substance Use Disorder Patients with Comorbid Attention Deficit/Hyperactivity Disorder. It clearly states, under treatment, "Consider adequate medical treatment of both ADHD and [substance use disorder] SUD." It then states: "Integrate the ADHD and other psychiatric comorbidity treatment with SUD treatment as soon as possible." This is saying you do not have to wait until somebody is not using substances to treat the ADHD. There is only a certain amount of evidence, but the international evidence at the moment, as good as it is or is not, is saying they should both be treated concurrently. Maybe there is a nervousness about that, as Senator Ruane mentioned. I am not in the medical aspect, so I do not know where that is coming from, but it is clearly in the international consensus documents that they should be treated concurrently, based on the evidence we have at the moment.

That is made all the easier when we know that somebody accessing the service is ADHD. On that co-treatment piece, if you are aware that somebody is ADHD and you think that medication would be helpful, both in tandem works. The challenges are if you do not have that identification piece in early childhood, and you do not have that confirmed identification even in early adulthood, that process of accurate identification becomes all the more concerning because it then limits psychiatrists' confidence in accurately prescribing ADHD medication.

On the same point, and to reiterate what Mr. James said, if you cannot get into the mental health services, you are not appearing as a statistic. We mentioned in our opening remarks that the wait-lists are generally populated, particularly in the children's service, by people waiting for an ADHD assessment. It is then about trying to get into the adult services. We know certain ones around the country put out letters stating their wait-list was four years long and they will get back to people sometime.

It is no list at all.

Yes, to be honest.

It is particularly cruel, if somebody is a couple of years on an ADHD waiting list to get assessed, and in that time develops a substance use problem, to then be told they cannot get assessed because they have got a substance use problem. They did not when they went on the list. That is kind of frustrating.

The Senator asked about services that are available. The consensus guidelines mentioned by Professor Comiskey mention the knotty problem of dealing with diagnosis of ADHD when someone is already using substances. There is international guidance. It is in the ADHD framework the HSE has published, so it is already part of policy. That is there to guide people. The Senator asked about services. There is a particular service I like in Australia, Orygen, which I think is in Melbourne. It takes this very broad view of mental health, where lots of services for young people - I think they work up to about the age of 25 - are available in one building. If people turn up looking for help with, say, a mood problem, and it is discovered they are smoking cannabis as well, services are just down the hall.

I am currently doing research and I was talking to someone who was originally working in an adolescent substitute service, but they were based in a building with social workers, CAMHS and various other services. They could nip across and have a chat with people. They have now been taken out of that building and siloed. This means those kinds of connections and informal things do not happen. The more we silo services, the more difficult access gets.

Absolutely.

I thank Deputy Sherlock. I call Deputy Burke.

I thank the witnesses for their presentations and for the work they are doing. It is very much appreciated. I want to check something about our educational system, in which we have done a lot of reform over the last 30 years. We have identified areas where there is a need for more supports, especially in relation to additional teachers and SNAs. Have we actually developed that connection between the schools and the parents regarding giving support to children? I am not sure we have done it. I am talking in particular about DEIS school areas. While a lot of work is being done within the school, there is then the connection between the school and the support the parents need. If a lot more was done in this area, could we end up with a better end result? Intergenerational continuation of existing problems was mentioned. That happened previously in respect of unemployment, for example. As a result of a lot of work being done, we have actually made a lot of progress. I was involved in a project where we had young people who dropped out of school and came to the attention of the Garda. When we did a survey of people who had been with us five years earlier, we found over 70% were in full-time employment, where at least two generations of the family had never worked. If we can make progress in this respect, surely we should make a better effort as regards making progress in this whole area too?

I will just say something briefly and then ADHD Ireland may know more. In terms of what we are calling here the whole-school approach, I have done research on this topic. When we want to bring in a change, whether in respect of children's eating habits, lifestyle or, in this case, ADHD, we need that whole school approach. The classroom presence is for so many hours, but then the child is going home. There is the situation if the parent is not informed. Again, if we are talking about actions, accountability and the next strategy, we could bring in a study on a whole-school approach in terms of developing ADHD in DEIS band 1 schools, for example. That could be an action. We could see if the pilot worked and the outcomes, and then do a long-term study on what happened to those children. I say this because the Deputy is absolutely right about children dropping out. We have addressed our education system. Employment is so much better now and we have so many different opportunities for different ways to progress through education, and we need to take that sort of approach with this issue. I agree with the Deputy.

Going back to the education system in relation to getting the message out there, are we giving enough support to the schools for them to get that message across? Could we be doing a lot more? Could we be advising of the risks that are there? While many young people are very much aware of the risks, many are also not aware of them. We have already seen this in an area like vaping, for instance. People have ended up with health issues as a result of vaping. I am not sure if we are doing enough in this whole area in relation to drugs to ensure young people know that once you start, there is always the risk you can get addicted at a very early stage.

Before maybe getting an answer from ADHD Ireland, in terms of prevention, the positive message actually reinforces the strengths of the child. In the context of ADHD and substance use, it is about building resilience in children so they feel they know how to say, "No, I do not want to have a beer because I have Gaelic football tomorrow morning" or "My dad is picking me up". In that way, we can build resilience based on strengths. It is similar in this area. I am not an expert in ADHD specifically, but I do know something about the whole-school approach and the best way for prevention is by building on the strengths of the child, and this requires the whole-school approach. I am sure ADHD Ireland would like to say what it thinks should happen in the schools in this regard.

I will just say in the ten seconds before I hand over to Dr. Morris that we recently changed our slogan. It is now about support, education and acceptance. The acceptance is the large part of it. Acceptance means having to move somewhere and do something. Very quickly, we have presented our position today that substance misuse is part of the bigger picture with ADHD in society. To improve this situation, where does it start? For us, it starts in schools.

I just want to touch on one other issue. The make-up of the population has changed dramatically. We have so many people in from a large number of countries and we may have some schools that may have up to 30 to 35 different nationalities in them. Is this going to prove to be a further challenge now as regards where young people are trying to blend in with the education system here and then trying to work through additional challenges they have? They may have had difficulties in the countries they were living in previously and they have come to Ireland. While there are a lot of supports, is this going to be a new challenge we are now having to face as well?

I am a big supporter of multidenominational education and the Educate Together ethos. My eldest child attends an Educate Together school. I think there are huge benefits to being educated alongside neurodivergent classmates and classmates from different cultures and traditions. I think that builds strength as a society, builds empathy and fosters that acceptance piece that can then be brought forward into other aspects of society outside of the school system. It is this whole-school approach.

I used to work in the school of education in DCU in the area of inclusive education. One of the programmes I was involved in teaching was reflective practice for student teachers. One of the exercises I would have had them do was to draw a classroom and have themselves represented as the teacher in it. Without exception, every year the students would draw themselves at the top of the class with students being seated in desks around the rest of the classroom. We have changed so much with regard to how we provide healthcare, and with regard to what our workforce looks like with teleworking and things like that. If we look back at pictures of schools that existed when they were first formed in the industrial era and what they are now, very little has changed concerning how we conceptualise how education is delivered despite the lovely changes that have happened in the curriculum over the years. Those schooling systems do not suit a large proportion of learners in the classroom. They do suit the majority, yes, but this is increasingly a smaller majority as we grow and develop as a society. We have the idea of English as an additional language in those schools, kids experiencing mental health concerns and kids who are neurodivergent. For a large part, the most traumatic thing about their childhood is their engagement with the education system and this is down to us failing to adapt our education system to a universal design approach, where every child is respected for their unique learning abilities and talents. I do not think we do that well enough yet.

I suppose where I am coming from is to ask about situations where a child has run into a particular problem and the parent does not know where to start as regards getting access to support. This is one of the issues I am raising because children may be very young when they come to Ireland and may not have access to services. I wonder if we are doing enough in this area to make sure people can access services to get that support.

On that point, the challenge we are having across the country is that the supports are just not available. Every support is currently overrun and there is not a service in this country without a waiting list for child access. If any sort of preventive change were to be implemented, this issue of access needs to be addressed first and foremost.

I thank Deputy Burke. We will do the second round. I am next on the rota. First, I apologise for not being present at the beginning of the meeting. There was a meeting of committee chairs with the Taoiseach, so I had to represent this committee there. I apologise. This meeting has been really fascinating. There are no economists here.

With that in mind, it is going to be a very unfair question, so feel free to treat it as such. How does a society that is possibly becoming increasingly informed about neurodiversity and ADHD and probably has good policies have terrible implementation? How much is that reckoned to cost the State in crude terms?

I would be happy to take this.

I thought you might be.

Lots of international surveys have been done on this. The original was a Demos survey done in 2018, entitled "Your Attention Please: The Social and Economic Impact of ADHD". This took ethnographic information from Denmark, because every time someone sneezes over there, it is recorded somewhere. It showed that the socio-economic cost was about €17,000 per person.

With a population similar to Ireland's.

Yes. It we take €17,000 for about 105,000 adults as the lower figure, it is about €2 billion per year. We have just finalised some research with UCD and the HSE on the socio-economic costs in Ireland. We have not published yet, but it is imminent. That is coming up with much the same figure, I am afraid. The socio-economic costs in Ireland every year, for undiagnosed and untreated ADHD, is about €2 billion.

That is extraordinary.

I am afraid so.

Then there is the human cost. I will push you on the human cost. We were talking about more prevalence of addiction and marital breakdown. Please continue.

We mentioned the research on suicide. Some 20% - 160,000 - of the adults in question have attempted suicide and 50% are self-harming. We know the figures on substance misuse. We know the prison rates. We know that they will have higher rates of anxiety, depression and other psychiatric conditions. The personal cost is huge and I am afraid we are not doing anything about it as a society.

I will quote a consensus statement on the evidence around ADHD:

People with ADHD are at increased risk for obesity, asthma, allergies, diabetes mellitus, hypertension, sleep problems, psoriasis, epilepsy, sexually transmitted infections, abnormalities of the eye, immune disorders, and metabolic disorders. [We have not even got to the psychiatric ones yet.]

People with ADHD are at increased risk for low quality of life, substance use disorders, accidental injuries, educational underachievement, unemployment, gambling, teenage pregnancy, difficulties socializing, delinquency, suicide, and premature death.

The 160,000 people Mr. Kilbride mentioned as a rough estimate of the number of adults in question do not live on their own. They have parents, children, employers, family, wives, and partners. The social cost of this is huge when all those potential negatives for people are brought out to their wider communities.

That is extraordinary.

The question is what we are going to do about it.

We are getting to it. I have three and a half minutes left.

I am the practical person here.

Does Professor Comiskey want my job?

To answer the question, we are going to use the resources that we have. Looking at the national drugs strategy, we need to make sure that it contains an action to delegate responsibilities to the Departments of education, justice, health. It only takes half a sentence, but I know that words are very important if we can get those actions in there. Let us start with something that we can do. One thing might be the Department of education bringing in something about neurodiversity or some sort of study to look at this whole-of-school approach and follow that through.

That is a really good suggestion. This committee was initiated following the Citizens' Assembly on Drugs Use. Our remit as a committee will be to deliver a report to the Government in June 2026. What would massively disappoint you given all of the effort you have made to come here today to share your expertise?

Great question.

We have seen much greater stakeholder engagement with ADHD Ireland. Last September, I was appointed by the Minister to the expert advisory group on suicide. We mentioned the fact that we had been talking with the CSO about how to redevelop disability surveys as part of the census next year. I am on the national oversight group for CAMHS. We are getting to the table, but it has only been in the last couple of years. I would hate to get to a point where we are getting to the table but we are still just being paid lip service do not get to make an input into the contents of the document, as Professor Comiskey was saying.

What would disappoint me? The committee members are sitting here as well as us. They are here longer than us. I would want the report to be included. Who is the decision maker? We can make recommendations but the question of who makes the decisions is what we need to focus on. Where are the decisions being made about inclusivity of voices and actions in the national drug strategy? I admire and love the work the committee is doing. The members are sitting here and I know they are busy people. We are also busy people and we are sitting here because we care. I am missing my Christmas lunch to be here. That is how dedicated I am.

We will speed things up, I promise.

It is not that. I would rather be here. We need to make sure that the members' voices from the report get transferred into the national drug strategy in terms of measurable actions.

Senator Ruane spoke about this matter earlier, but I am a medicated ADHDer, which is one of the reasons I can sit here for two hours.

Good for you.

I probably would not have been able to do so two years ago. That is because of the medication I take. In my own life prior to being diagnosed and getting medication, an understanding of what I was experiencing would have been helped by earlier awareness. That was at an individual level, but on a State-wide macro level, once you become conscious of what Mr. Kilbride just said in terms of the 160,000 people and the prevalence of all of the issues that Mr. James outlined, the world changes a little bit and you have to be able to react to it. That for me is where the work of this committee is, in terms of turning this into something concrete.

Is there anything the witnesses have not been asked yet or is there anything they would like to say in the brief time I have left? We will then go for a second round.

I thank the Cathaoirleach and Senator Ruane for saying that they have ADHD. We always talk about role models and to normalise ADHD in society, we need to see people who have the condition coming out and saying so but also showing that they are getting on with their lives.

Regarding challenges, as we said a couple of times in our statement, it is not everybody with ADHD. Forgive me, but there is an old saying about how, in America, ADHD impacts massively on two sections of society, namely, millionaires and the prison population.

As grim as it is, that makes total sense.

We have a choice.

I am thinking about that comment and stigma around substance use services. We are here primarily because we want to represent the clients of substance use services. I know we have parliamentary privilege here but I do not think many members would want to declare that they use cocaine or cannabis, because that is even more stigmatised than ADHD or most of the mental health problems we have. It really casts people under a shadow. It can affect their employment and their livelihoods. That becomes a reality when they attend services, if they are known to have a substance use problem. This can be an issue in maternity services, medical services or child and adolescent or adult mental health services. It casts a shadow over their care.

In fairness, I was going to come in with the point in relation to those with ADHD. We are all aware of certain outlier characters like Michael Phelps who can make really good use of that hyper focus in something of interest to them. It might have been interesting if we could have asked the Chair a couple of questions in relation to what he just said.

It is vital that we have a system that takes an all-of-school approach. Mr. Tiernan O'Neill, the principal of Corpus Christi Primary School, Moyross, appeared before the committee on disability. It is an outlier school. He spoke about services like therapies but also about psychologists. It was all of that. It was about having everything in the same place, which allows a lot of the issues to be dealt with. That is the system we need in general in order to facilitate people. It is that idea of the Portuguese model again, where they pulled the services out of special schools, put them into teams and then put them across mainstream schools. It just meant everyone benefited from what was needed. It allowed people to be caught earlier so that they might not need as much intervention later. When I heard this it prompted me to suggest that screening would be important. If someone has ADHD, there is an awful chance they will fall into addiction. I sensed that there was almost an over and back - a two-way thing - in terms of providing the supports and the resilience training, but that might not have been the case.

There is also an element of a predilection towards addiction, given the impulse control issues and all the rest of it, and-----

Most psychiatric disorders make you more likely to develop a substance use disorder. ADHD starts in childhood and leads to increased impulsivity. It is not rocket science to figure out that increased impulsivity in teenage years is probably going to make you more likely to try substances. Usually, people who have a mental health problem who start using substances are more likely to develop a problem with that - a substance use disorder.

The European Monitoring Centre for Drugs and Drug Addiction, EMCDDA, that Professor Comiskey mentioned she was involved with recommended years ago - I think it was in 2011 - that children attending CAMHS should be seen as a higher risk category for developing substance use disorders and should be screened appropriately. There has been much work done between CAMHS and the addiction and substance use services available for teens. In many places, they are very separate services and that makes this difficult.

We know the whole issue of whether someone should be in disability services or CAMHS, and they belong here and not there. There is a constant conversation about improving all of that, yet everything still exists in its own silo. We are dealing with multiple comorbidities before we even take addiction into play. It is a better all round system. It is not just an all-of-school approach, but an all-of-society one.

The witnesses' big ask here is first and foremost to talk about ADHD- or neurodivergent-informed thinking across the board. It is an absolute necessity that we get the lines within the national drug strategy and that that be reinforced in every Department it criss-crosses over.

Somebody else might like to go into whatever else we need to do to improve this. It is vital, in not only the training but everything, that we have follow-on research that we can present, as that would be phenomenal.

I can only give the witnesses four seconds to do that, Deputy Ó Murchú.

I just talk and ignore. I would assume you would have an ability to do that.

I might pass on to Deputy Graves and we will come back to Deputy Ó Murchú.

Very quickly, because I ran out of time on the last round, I was really interested in what the witnesses said about the World Health Organization and the American Psychiatric Association referring to addiction as "a psychiatric disorder." If we were to embrace that, do the witnesses think Government policy would basically be punishing people with psychiatric disorders if they were drug users?

"Punishing" is probably not the right word. There has been a trend in countries to separate------

Criminalising them.

Sorry, criminalising?

Yes. If they are criminalising drug users-----

This is a complicated one. At present, some of my research is about people accessing treatment quickly when they develop a substance use problem and one of the quickest routes people access substance use treatment is when they come via the court and criminal justice system. There are laws of unintended consequences here. If we decriminalise it, this might mean those people end up taking longer to access treatment. That is hard to measure and do. I do not have a nice answer on the logistics of the law.

It is a difficult argument, though.

It is not an easy one.

Become a criminal and get access. Do not become a criminal and you will not.

It is not even that. It is that many people, for example, who are using substances problematically, alcohol being a very good example of this, do not realise they have a problem. The example I frequently use in education is a 20-year-old guy who goes out one night and his girlfriend breaks up with him. He goes drinking with the lads. He feels really down and thinks about taking his own life, so he is brought to accident and emergency, which is what happens. The next day, he is mortified, he sobers up, he is basically told that, because he was intoxicated, he does not have depression but a substance use problem because that is what triggered him ending up on that bridge, and he is sent away to a substance use service. He does not believe he has a substance use disorder and is never going to go to that appointment. He thinks he has a "girlfriend who dumped him problem". The problem is our segregation of services means people's problems are broken down into these separate silos. If they do not agree with the silo we put them in, they do not get help. That is before we get to the waiting lists.

I might add to that. I am aware of Mr. James's research because I am working with him on it. His research also shows that people do not get transferred into addiction services through the schools, but they do in other countries. Our schools do not have that level of awareness at all.

We have done an international literature review on that and Mr. James's work has shown that, in Ireland, it is a ridiculously low amount. Somebody should not have to go through the judicial system - I do not want my child going through the judicial system - if they have tried cannabis at Electric Picnic or whatever. You want the schools to pick up on why that child is late or why they look half asleep and ask what is going on there. It is not happening at the schools.

I have a second very quick question. We have been discussing and pushing for several years for the HSE to have a dual-based diagnosis. Based on our discussions today, do the witnesses think that should now be a triple diagnosis? It could be addiction, mental health and neurodiversity, ADHD, etc.

In one of my earlier drafts of this, I wrote that we would end up with a triple diagnosis service but I was afraid to mention it because there was a fear people would take that as a good policy idea.

At least half of people who attend substance use treatment services have a comorbid psychiatric disorder, with some 20% having ADHD, but there are many others. In theory, we will end up with a situation where the number of people attending the generic substance use service is much smaller than the people attending the specialised dual-diagnosis service. That is before you get into the number of people who are currently attending mental health services who also may have a substance use problem that is not clearly identified and getting addressed.

Earlier, I mentioned the Orygen service in Australia. I have concerns that the more siloed we get, there will be more cracks for people to fall through. I like the idea of a service that says it is there to help people and asking what they need help with. Sometimes, you discover things you did not know. Someone might arrive, like that 20-year-old guy I described, for a mood problem and in the back of it you are seeing there are some substances there as well. It is a whole person approach.

I thank the witnesses.

I wanted to pick up on something Senator Costello brought up earlier about education and awareness for parents. I have spoken to some people who, when a child they know or a child of their own gets a diagnosis, are reticent about the introduction of medication. That is a stigma thing and a lack of awareness of the benefits. Not everybody takes the same dose or needs the same dose of a medication. We have seen in popular culture and movies over the years where the name of the drug is thrown about and is referenced in a negative way, which is stigmatising it. How can we better inform parents and wider society about the proper use of and respect for medication for ADHD?

We have been working with a couple of organisations and have a whole set of videos on our website on what ADHD medication is, how you take it and things like that. We have those tools there that are working. However, we know from our support line that there is a stigma around taking ADHD medication and there is a reluctance among parents. Certainly, there is that education deficit but medication can be part of the treatment protocols for ADHD going forward.

Are GPs readily signposting ADHD Ireland's videos to parents? The first port of call is often a GP, so if there is an unconscious bias on the part of a GP, does that get passed on? Is there signposting there and are people directed to the witnesses' website by way of protocol?

We find in the ages of eight to 12, four times more boys than girls get diagnosed. ADHD, as we mentioned, is not genetic, so it is 50% boys and 50% girls. Why are girls not getting picked up at that age? It is because it is not being seen and GPs do not recognise it.

It presents differently, does it not?

It does. For a girl sitting outside the clinic who is being quiet or is not causing a problem, the GP is going to say she is quiet and a girl so she cannot have ADHD. We have been working with the Irish council for GPs for the past few years. It did some recent research and asked GPs what their number one training need was. GPs are now saying it is ADHD. We mentioned 50% of people going into the HSE are looking for it.

They are coming through GPs. A lot of people go into their GP service because they think their child may have ADHD. GPs need that training. As part of the new integrated plan for adults, one of the levels we are looking to put in is training for GPs. There will be three levels of training. The first level, GP1, will train GPs to know and understand what ADHD is. After completing the second level, GPs will be able to prescribe medication, and they will be able to diagnose after the third. This is something that is coming in as part of the new integrated plan for adults. We have received the plan from the consultants, the board of ADHD Ireland has approved it and it is going through the approval process with the HSE. We mentioned earlier that the HSE does have the clinics, but they are all understaffed. We will have a new plan but getting it enacted is the next challenge.

I believe it is hard to get an assessment. A lot of people are paying a lot of money for private assessments.

Yes, I am afraid so.

The private sector is completely unregulated at the moment. There is no national guidance on what an ADHD assessment looks like, which is a huge challenge. In answer to the question about signposting to resources with regard to medication, when people present to a GP, it is with the question as to whether they have ADHD as opposed to further down the line, when they know they have ADHD, wanting to know what supports are available.

When it comes to GP education, the focus should be on the first level to begin with so that GPs will know what ADHD is and gain confidence to be able to recognise and support the individual in front of them to access the right services so that the individual can figure it out for themselves. The personal story of many adults is that when they have told their GP they thought ADHD was true, they have been shot down because of a lack of understanding of the diversity of presentation of ADHD, as Ken highlighted. Preventing that should be a key piece of the plan.

With regard to the stigma around medication, a lot of work needs to be done. The access to services aspect comes up again because there is no point in garnering widespread acceptance of ADHD medication if people cannot access it in a speedy way. For those people who are adamant that they will not avail of medication, an alternative treatment or support option should be available. ADHD treatment is currently confined to tier 2 or tier 3 of the mental health services, with very little available at primary care level. That needs to be developed too.

Do members want to ask any more pressing questions?

Can I follow up on the issue of parents and CAMHS? If a parent is told that their child cannot come to CAHMS if they do not go onto ADHD medication, they do not need us, basically. However, if they come to us and are accessing another service such as an OT, social worker or psychologist, they may revisit that because we will then be engaging with the parent to help the child. I am concerned about the people who are outside the services. If a parent comes looking for help, we should meet them where they are at and talk about what is going on. People change their minds and take different views. Some kids will never need medication and some will. That is a journey. It is not something that needs to be put in place at the first or second meeting.

Mr. Kilbride said the new integrated plan will mean that a person's first port of call will be the GP.

The Deputy spoke earlier about a single point of access. I do not know if Dr. Morris wants to talk about the concept of a single point of access or if we have enough time for that.

The single point of access is for child services, whereas the integrated model of care is for adults. They would not necessarily cross over. The new integrated model of care for adults is a revision of the previous model, which for lots of different reasons was not effectively implemented. It is to take the pressure off those specialised adult ADHD teams. There is a real reluctance at the moment among GPs to prescribe ADHD medication. It is seen as the remit of psychiatry. This change in the model is to encourage more GPs to get more involved in ADHD care management and support. That is a welcome change, as far as we are concerned.

It definitely is. We have gone through ADHD being included in the national disability strategy and have then discussed the means by which we put a fit-for-purpose, all-inclusive system in play. The idea of doing assessments in schools or even before that such that things are caught early is perfect. Beyond that, it is about building up that evidence base. Is there any evidence in relation to what percentage of those who have got the supports have fallen into addiction? Has there been a change in the percentage? I doubt there is any evidence at this stage, but it would be rocket fuel from that point of view.

We have talked about all of the challenges, including substance misuse and suicide, etc. However, all the research shows that outcomes improve when someone gets the right treatment. Whether it is medication or a combination of OT and speech and language therapy, once a person gets access to the right services, outcomes generally improve. If a person gets the right treatment at the right time, it will have a positive impact on their life.

Research has shown that treatment with ADHD medication reduces the incidence of accidental injuries, traumatic brain injuries, substance abuse, cigarette smoking, educational underachievement, bone fractures, sexually transmitted diseases, depression, suicide, criminal activity and teenage pregnancy. The sooner we get people treatment, the better. The research on ADHD is clear. It starts before 12; depression, anxiety and psychosis do not. People are ending up with no diagnosis in adulthood because the system has failed them. Whether it is through their school, family or other organisations, we have not picked them up. They have ended up as undiagnosed adults and they face those consequences because the system is failing them.

We are talking about ADHD, but when we did the research, we went looking for ASD as well. We did not find any literature on that. I think there were one or two papers. When I wanted to do an international comparison on the numbers, the literature was not there among people using drugs. That shocked me. People responded to our survey, but we did not see it in the international literature. If the committee is going to put any actions in its report, while the majority are people with ADHD, we have to remember the broader neurodiversity cohort as well. Let us not forgot about that.

When we take the whole bracket of neurodiverse people, sufficient research has not been done. It is even the fact that there is a disparity in relation to the percentages - 21% versus 51%. Professor Comiskey said that in some instances it is even higher.

It is up to 60% in the prison setting and that was ADHD, but we have nothing on ASD. We have the statistics on ASD in our study. I think it was 30 something per cent - I cannot remember offhand - but there is very little in the international literature. There is practically nothing. There is a real need for it.

We have to finish. I thank the witnesses so much. It was really informative. All of us who have listened to what they said will go away with a sense of what we need to do as a committee in terms of how this should be recognised. I thank the witnesses for their contributions and expert testimony.