[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH learn. Hello, there. Welcome to Mind the Kids. I'm Dr. Jane Gilmour, Honorary Consultant, Clinical psychologist and Child Development Programme director at UCL. And I'm Umar Toseeb, a Professor of Psychology at the University of York, focusing on children and young people's mental health and special educational needs. We're doing something a little bit different today. We don't have a guess, and we are going to borrow an episode from Mark's series of Mind the Kids. Umar and I will be discussing Tourette syndrome. This episode is called tics, education, education, education. It was towards the end of last year that I watched the movie, I Swear, and I was like, oh Jane, should we do a should we do an episode about this. So I'm really happy that we're doing it. And I think particularly in this episode, I come from a place of I've watched the movie, and then I know very little else about this topic, but I know that this is a special interest topic of yours. So you know lots and lots about this. So I'm hoping that I can pick your brain and ask you lots of questions about this. And hopefully, the people listening and watching will be in a similar situation to me. So we can try and get some of those questions across. Does that sound like a plan? Yeah, I'll do my very best. I can't promise that I know everything there is to but I mean, it was interesting that you're saying that you watched the movie, and it introduced you to a topic, and it tics and Tourette's, as is a special interest of mine because it's my clinical activity. So I watched the film too, but I watched one sirzar as a civilian, if you like, and I watched a second time as a psychologist. And it was interesting because obviously I wanted to think about what the film delivered and how accurate that might be in terms of psychoeducation, because this might be the first and only time, somebody learns about tics and Tourette's. So I was particularly interested in that. So what did you think of the film, first of all? I think it was definitely my kind of movie in that I thought it was an educational movie from a civilian point of view, if you can call it that. And I think that I learned a lot about, well, I learned, some about the condition itself. The movie itself, it captured my attention and it kept my attention throughout. Like I wasn't like, oh, this is boring. Like, oh God, I want to forward this bit. So I thought that was good. I really liked that. We had a journey that we went on with the main character. But yeah. No, I thought it was a good movie. Can I ask what you learned from it because you were an incredibly well educated person? So I'm interested to know what you learned from it, because that suggests to me that there's some really high quality stuff in there. So what I liked about it was the involuntary nature of the tics. I suppose we can talk about terminology, but I'm going to call it tics for now. My understanding prior to watching the movie was that around COVID, when everyone was like at home and stuff, there seemed to be some increase in tics, and there was some conversation in like popular media around, oh, this is driven by social media. And I wasn't quite sure what it was about. So I knew that it was involuntary, but I didn't know the extent to which these behaviours could be learned, or there could be a mass contagion event or not even catch it. You learn the behaviour off of the people. And I mean, that's so important because there are two sorts of ticks, the functional ticks, which what there was that, as I say, a sort of a huge, I think at Great Ormond Street they had an increase in about 200%, I think that's correct, in terms of referrals for ticks. And the vast majority of those referrals during COVID were functional ticks. And that has melted away. But those do have to some degree in those that are vulnerable a social contagion. Although, that's a slightly different thing again. And then there are the classic tic, if you like, that's associated with the neurological condition of Tourette's. So the challenge for all of us as professionals, clinicians is figuring out which, because they all look very similar. So the history and the presentation are key in doing that. But from public perception point of view, that's a huge task. So that's really interesting that you are recognising the difference between those functional tics that may have an emotional underpinning and the difference between those and the tics related to Tourette syndrome, which have a neurological underpinning. So I just want to just cover some terminology there, because you've mentioned a few things, and I'm not sure that I understand the difference. What's the difference between functional tics and the other one that you mentioned? Also, you've mentioned Tourette's. Like, is that the same thing, or is that something different? OK. So we're talking today about Tourette's and the tics that are associated with Tourette's. There are functional tics and tics associated with Tourette syndrome. Now, functional tics look very the tics associated with Tourette syndrome, but they come from a different cause. So let's talk about the tics related to Tourette syndrome, first of all, because that's the main focus of our discussion today. Now, these tics have a neurological basis, and we know that in order to fulfil the criteria for Tourette syndrome, you would have at least one phonic tic that could be a sound, a sniff, or a cough, or a whole word or phrase and several motor tics. So that's an involuntary movement, which could be an eyeblink, a twirl or a curtsy, something more complex as well. Now those vocal and motor tics would be around for at least a year, and then you would fulfil the criteria for Tourette syndrome. There are a number of tic disorders that are related to that, which are more transient and less severe, but they are in the same sort of spectrum. And then we turn we shift our focus to functional tics. Now, functional tics have no medically explained cause. And usually when we're working in the clinical setting, we usually explore that with the hypothesis that these functional tics are not related to having a neurological condition, but they are an expression of emotion. So it's almost like a summarising expression of emotion, usually anxiety. And so we treat the functional tics in a very different way to those associated with Tourette syndrome. We treat functional tics using cognitive behavioural methods, thinking about how to manage and express emotion. And we would treat the ticS related to Tourette syndrome using a variety of evidence-based behavioural measures or medication, and a variety of those. But the challenge is they look very similar. The history is the way of differentiating, and I can go into that in great detail, but it might be a tirade tomorrow morning. My follow up question there is, it seems to me that when we talk about mental health and there's an obvious physical origin, so you can pinpoint a part of the brain or something like that, people are much more understanding of that and will more likely accept that as a valid condition, whereas if we can't pinpoint some structural differences in the brain or something like that, then people are like, oh, well, is it a real thing. Is it not. So when you're talking about the two types of there, the functional one and the one that is associated with Tourette syndrome, in my head I'm thinking, so the one that's associated with Tourette syndrome, I can see what the underpinning thing is there, and I might have more sympathy for that or I do have more sympathy with that, whereas the functional tic I'm like, oh, well, I don't know. Is that fair? I would say it's a reaction I recognise, but I think the reality is those young people that have the functional tics. We call them medically unexplained tics. So we can't explain them with any scan or any way of identifying a difference, but that's also, by the way, true in a headache. I couldn't tell you how to identify headache physically. I'm relying on a young person or a person's a report of that. But the functional tics do sometimes evoke quite strong emotions from those around, because there is an assumption that this is put on, or it's in the old Freudian term, a sort of hysterical expression of emotion. The young person is not knowingly doing anything. They're having the same experience of tic, even though we can't find the cause for that as any other, and it's distressing, it's disabling and so on. But what we do know is with a particular approach to understanding and again, using psychoeducation for the young people and those around them, which is very often important in functional tics, about understanding what the functional tics, what they're doing in the system, and what they're standing for that young person will be a very important part of that. But yes, you're right, it's much easier if you like to make sense of something that you can point to and say, well, look, in Tourette syndrome, there is a high level of excitability in a particular the brain circuitry. And we can see that in a brain scan. And that allows us to say, yes, that's a real thing in inverted commas. A headache is a real thing, but I can't point to it on a scan usually. So that is another challenge. And functional tics is a really interesting topic, but I want to stick to the tics associated with Tourette's, because I think there is a danger that the messages can get so complicated that the psychoeducation that we would want to deliver will not come across with the clarity that we need to do. So we need to do two things. And one of them today, I think, is to focus on tics associated with Tourette syndrome. The second is being aware that there are functional tics. And perhaps we could do another episode on functional symptoms because there's a whole range of them, not simply tic like behaviours. And then when we're talking about tics associated with Tourette syndrome, you mentioned vocal and then motor. So I think within those two categories, what are the different types, and what does a motor mortar look like, and what are the different types and what's the range of things there as well, so we're just aware? So the classic picture in, and let's just call tics associated with Tourette's. We'll assume that we're talking about that in as we go forward. Otherwise, it's a bit of a mouthful. So tics in Tourette syndrome will classically start in young adulthood four or five, six or sometimes even younger. And motor tics will usually be the first tics. They start in the head and neck area. Classically, it will be an eyeblink or a shoulder shrug, so-called a simple motor tic, because it just involves one group of muscles. And then over time they may move through the body and become more complex. So complex motor tics might be, for example, a curtsy or a movement that might have a series of muscle groups associated with it. Again, this is the typical picture. After the motor tics are in place, if Tourette syndrome is going to develop, you may well also see a vocal tic or hear vocal tic. A simple vocal tic could be just a noise, a throat clear, a sniff. If there's a full word, or indeed a full phrase, it becomes a complex motor tic. And there can be a variety of a portfolio of those. Now, the challenge for psychoeducation in Tourette's is the only thing that's constant is change in turrets. So not only do the type of tics change so I might lose my eye blink. It might resolve and go away, but in its place I might have a shoulder shrug. And that changes. We can't predict why that would happen. And the other thing that happens is these so-called wax and wane so they can be more troublesome. And then they resolve to some degree, they settle down, they get more troublesome, whatever we do. Now, I want to come back just simply because we're talking about icewear, and there are some important aspects of this condition that have a fascination for the media. So the events of the last couple of weeks have really illustrated the importance of this particular issue, and that is that. Between 5% and 15% of individuals who have a full Tourette's diagnosis, there may be coprolalia. So they're complex motor tic may be a socially taboo word. Now the media is fascinated with this. And you can see why that might be the case, but that might include socially taboo words. And if you work with a young person who has Tourette's, you will hear a variety of extraordinarily expressive, socially taboo words and phrases. It's something that does happen. And typically in those young people that we see in the more complex cases, not always the case, but more complex cases. For example, I spoke to a young person not long ago who had been in the supermarket and she does not have coprolalia. She has a typical picture in Tourette syndrome. In as much as she does not have coprolalia, but she has quite violent motor and vocal tics. She was in the supermarket and the member of staff said, can you stop making that noise. You're bothering our customers. And she was very patient and credibly, emotionally mature. And she said, I've got Tourette's. I'm making movements and sounds that I can't help. Now the shop assistant said, you don't have Tourette's. You're not swearing. So you can see how a little knowledge is a dangerous thing. So for that young person, the characterization of Tourette's as being the one where they swear is singularly unhelpful for a day to day experience. And so you started by saying the events of the last few weeks. So let's talk about the social taboo bit. Why is it specifically phrases and words that are social taboo? Why not something else? As in like where does that come from? It's really interesting. There's lots of theories about that. It's not clear. But what is true to say is that the expression that is uttered is, first of all, involuntary and second of all, not chosen by the person. There is no choice in the portfolio of tics that young person might have. So, for example, I worked with a young person who had a series of really extraordinarily insulting phrases that he said at high frequency, and he stopped going out because he was so concerned that he was going to insult a member of the particular community that was associated with this phrase. And we had a different problem there, because he'd started to get depressed because he wasn't having any social connection. But the point is, I know this young person very well, and I know absolutely that his intent would never to be to offend someone, and that didn't reflect his own beliefs. It was a neurological expression and that utterance was involuntary. The phrase that is uttered is not a choice made by the person who's uttering that tick. Now, the reason that is particularly important is that in the BAFTA award, so I swear was nominated and won a BAFTA, we would all agree, I think a very well deserved. But John Davidson, who's the real character, who is at the centre of the I Swear film and has coprolalia, he's one of the minority of individuals with Tourette's who has coprolalia, and he has a history of saying a variety of socially taboo words. Now, he was in the audience and the microphone was fairly near him, I believe. There was an opportunity to edit. I don't believe that happened. And two actors were standing on stage who were Black, and he uttered a racial slur that was a tic. Those actors and everyone in the audience heard that racial slur. And that was really distressing, really distressing situation for those people standing on the stage, for John, both of those things are true. And so can I put a hypothesis forward and then you can tell me what you think. So we are all aware of-- we have a vocabulary that we use in life, and we're aware of words that exist in the world. And we are also aware that we shouldn't be using those words. And those words aren't acceptable to use. And we have and the cognitive inhibition to not use those words, and for some words, you just don't use them ever. And there are other words where you just know that you don't use them in this situation because they might not be offensive on the whole, but like in that context, they might be offensive. So we have that inhibition. So you don't use certain words in certain contexts and you don't use certain words altogether. Could it be that the people with coprolalia, that mechanism, which inhibits their use of certain words in context, is impaired in some way, so they just can't control, that inhibition mechanism just doesn't work, because I'm sure they are aware that it's not appropriate to use that word or whatever the words are, but the inhibition just doesn't happen. Well, you see, that suggests that there would be, that I'm making a choice of saying, for example, not swearing in front of the children. So maybe I swear sometimes, but I don't do it in front of my children. I make a choice to use a word that I sometimes use in different contexts. There is a neurological explanation for that expulsion of the word, but I think that is important to suggest that somebody who has a coprolalia, for example, would never utter that word ever, and would choose never to utter that word. The problem is the social taboo nature of this. Let me give you another example. This might really help illustrate it. I worked with a very young boy who came from a religious family, and he was religious. He found a very important framework in his life. Now one of his tics was disrespecting his God. That was one thing that he uttered as part of his tics. He found that incredibly distressing and would never have said anything like that. It was absolutely contrary to his belief, and it caused him huge distress. It caused his family great distress. And so allowing them and him to understand that this was not a belief that was hidden or something that he felt unconsciously was a lot of our work, because there is somehow, perhaps in his case, a suspicion is that really what I think. And it's just slipped out. That's absolutely not the case. The point is, it's socially taboo. And that person was seeing something that was precisely because it was offensive, the neurological network required it to be said because it's the precisely the thing they did not believe and did not want to say. So it's a very difficult to get that across, I think, in psychoeducation on a case by case basis, let alone in a media event. I'm going to pick up on something there. So when we're talking about socially to boutiques, I think what we're saying, it's important to know that it's not these people's underlying beliefs that are just manifesting in certain situations. These are not their beliefs. They do not believe this. It's just uncontrollable that these words and phrases come out, which is different to a person who, without Tourette's or without any sort of condition where they have certain beliefs, and then in some situations they do come out. So when someone gets very drunk and they say things, that's different because that might be their underlying belief that's coming out in a situation, but because their inhibitions are much lower, whereas when we're talking about socially taboo takes, this aren't these people's beliefs outside of that situation. It's just the context of that situation which is making these things come out. Is that correct? And that's a brilliant analogy to say, somebody who's drunk, who says something really, really awful. In Vino Veritas, there's always that suspicion. This is absolutely not the case in a coprolalia. It is not a reflection of any belief system. It is the fact that it is socially taboo and highly unacceptable, and very likely, I can't speak in every case, but every case I've worked with is highly likely to be highly offensive to the person who's uttering it too. So I'm trying to put myself in a situation where I'm on the street and the person who, I don't uses a racist slur against me. Now, my first response would to be upset because it's not a pleasant thing to hear. And so I think it's completely valid for people to be upset, irrespective of what the intention is or the other person's background, their condition or not. But then if somebody explained to me, well, the reason this is happening is because x, y and z, I think even in that situation, if there is a neurological condition which is causing that behaviour in that moment, I think it's still perfectly fine for me to be upset because I can't help how I feel about this situation. I'm like, I'm still upset that person's called me that thing. I'm still upset. And I think some people's upset might be toned down because it's like, oh, actually, now I understand. And then I think you do that internal monologue where you're like, well, actually, it's not their fault. It wasn't intended that wasn't their intention to upset me. I am upset as a result of that. But maybe I should, and you tone it down and you regulate your emotions. But, see, I think-- sorry to interrupt, because I think said a phrase that's so important. And I think it changes everything that they called you that thing. The word was uttered. You witnessed it. And that is highly upsetting and highly unacceptable, but it's not directed at you. And I think that shift might be absolutely key. It could be that the context is so charged that it invites a particular phrase, but it's not directed at you. And I think that must make a difference. I mean, you're talking in a very emotionally mature way, but I'd regulate my emotions. And yes, I mean, it is upsetting. It's is a really awful to witness and to be around that. I'm glad you said that because you're right. Somebody says something. I assume that they're saying it at me, to me, but they're not. They're saying it around me. It's not aimed at me. And I'm also trying to think of other situations outside of tics, outside of offensive terms that have been said around me, which is you can be upset by a situation, and then when you think of the causes of that situation, you realise that, well, they didn't intend to do that. They didn't mean to hurt me. They didn't mean to do this. But you're still it's fine. It's valid to be upset. I can't help being upset by this. And no amount of emotion regulation and trying to monologue with myself in my head is going to get rid of this upset. I am still upset about this. I can't help it. And I think that's also valid. Oh, absolutely. I couldn't agree more. And I think if somebody stamps on your foot and they mean, that's one thing. But if somebody stamps on your foot, they don't mean it, you still feel sore. So that emotion is because-- I mean, apart from anything, the historical context. And so on is so, so broad and deep that I think it's absolutely valid. And I think having permission to feel upset and offended is absolutely-- it's a shared response. And I think the person who's uttering it would share that with you. And I think everyone would agree that that's a fair response. Even if you have a context, it's highly upsetting. Shall we talk a bit about co-occurring conditions in my field with neurodevelopmental conditions. And they co-occur. So you have, I don't know, ADHD and you're more likely to have something else. What are some of the co-occurring conditions? Are there co-occurring conditions with Tourette's? Well, I'm glad you asked because it's one of my favourite topics, because one of the key aspects of Tourette's is that 85% of individuals will have a co-occurring condition, most likely in 60% or so of cases, ADHD, in 40% to 60% of cases, OCD, Obsessive Compulsive Disorder, up to 20%, although that's a very variable figure in the literature, may have features of autism, though a higher likelihood of learning differences, dyslexia, dyspraxia. And the other feature which isn't a diagnostic term, but it is something that families in particular find the most challenging of all is anger outbursts or rage or periods of rage. So an expression of anger that's disproportionate to the event. And if you ask families, they will say the rage episodes are the most challenging of all. Tics, ADHD, OCD, learning differences, the families find those most impairing to family life. And so actually, if we're in a clinic and we have a young person who has tics in front of us, it would be remiss of us not to ask about these other neurodevelopmental conditions. And it also, by the way, brings us back to your favourite subject, which is about the utility of these diagnostic terms precisely because there's so many co-occurring conditions, one wonders about the utility of our current diagnostic framework. And what's progress looked like in this field? So based on the conversation that we've had today and also before this, that the awareness of Tourettes has increased over the last few years, maybe even a decade or so, in my understanding. Has that been the case? And then the other question is progress in terms of the science, how has the science moved on compared to a decade ago or 20 years ago? Yeah, I think this is really interesting because in the film, we meet John when I think he's like he's going into secondary school in 1983, in rural Scotland. I can identify with so many of the aspects of that now. I did a focus group with young people to see what their thoughts are on the I Swear film, and in fact, it's going to be published in the CAM journal. And I asked, have things changed since 1983? And the young people said, I don't think much has changed because one of the young people gave this example. She went to see the film in a cinema, and she sat somewhere in the audience, and there was a front row full of adults, by the way, adult people who were overtly laughing at the character when he was experiencing distress when he was ticcing. And this young person said, well, that was a bit disappointing. I mean, what an emotionally mature thing to say, because she sat in the audience as these adults were mocking a disability. I mean, it beggars belief. So the young people said, I think there's an expectation not to say out loud your prejudice, but they suspected that there was still a degree of prejudice around about their disability, in particular. In terms of treatment, and there was a fantastic, I don't know if you may not have spotted this, but only a nerd would with spotless, but there was a character right at the end of, I Swear, Called Barbara morera. I think that's how you pronounce her. And in real life, she's the chief research officer in the University of Nottingham group, who's looking at a particular treatment, which I'll explain a bit more about in a moment. And the group of young people I spoke to were just delighted about that. They thought that was a really wonderful addition. And I thought, she's interesting. I wonder if that's the real person. And I looked her up like a nerd would and she is. So it was fantastic. Anyway, so there are a variety of different treatments, none of which will erase tics. A good outcome is a 30% decrease in frequency or intensity. So there are drug treatments. There usually are in the antipsychotic family of drugs. So they're quite heavy duty, and they're not appropriate for everyone and not one that some families want to explore. But there are two behavioural management methods, habit reversal training and exposure with response prevention. Now all of these, the medicine and these behavioural treatments have a medium effect size. So they are equal in terms of their impact, which is interesting. I mean obviously a hard line social model of disability protagonist would say that shouldn't be suppressing tics at all. That's an oppression. I mean, I would argue that young people should have the option to know that it is something that they could explore, but it is hard work. It's a difficult treatment. And I'm always blown away by these extraordinary young people that engage in really difficult treatment with a tenacity that I'm just I applaud. But this treatment that was described in the I Swear film right at the end was the Nottingham group's neuro pulse, which is a non-invasive rhythmic stimulation of the median nerve, so it looks a bit like a watch. It's worn on your wrist at a regular time every day, and it gets a decrease of about 25% in intensity and frequency of tics. There's a Maquis article that reviews that. You might be interested to look at that some good RCT data. So right now the neuro pulse is not available, but I suspect it will be soon, which would be really exciting to have another option. And I have two more questions for you. So the first one is about school. So my memory is a bit not great because it's been like two months since I watched the movie. But was there a part where he gets excluded from school because of it. Should we just talk about that a bit. What school experiences are like? And this is something, again, another young person I saw who was in rural Cornwall and her contemporary school experience was only a couple of years ago, and she said it was incredibly difficult. It was an exclusion and so on. I know young people that have walked around school with a series of pupils behind them mimicking their tics. I mean, there are a lot of very good experiences, but very many very difficult experiences of bullying and exclusion. In the film, he was punished for his tics. He was eventually, I think, sent to the equivalent of a pupil referral unit and excluded from mainstream school, which absolutely would not be something that would be indicated now. But there's still a lot to learn. So I know lots of young people. So for example, particularly in secondary school where there's a high turnover of staff and pupils. There is a perpetual education going on day by day to explain to staff and other students what the movements and sounds are. And so, that is quite exhausting, I think, as one young person said, to have to explain yourself literally explain yourself every day. That's a challenge. I mean, the other thing to just bear in mind, by the way, that there's a lifetime prevalence of about 20% in having a tic. So some people get a tick and it resolves completely, but that's about the same frequency of number of young people that have a brace, that wear a brace in their teeth. So the awareness in school communities and broader communities should be greater. So it's a bit of a puzzle for me about why it's not. So school requirements are mostly psychoeducational in nature, but sometimes there can be additional needs in terms of having let's say, separate invigilation for gateway exams so that if I have tic, I can tick in peace. And I'm not worried about disturbing somebody else because I'm in a stressful exam, and that's likely to exacerbate my ticks. So there are some practical things that schools do and my experiences teachers are once they have the framework, are wonderful at supporting these young people. And I hear many, many positive stories about teachers who are championing young people to navigate the educational system and do very well. It came to me, whilst you were talking that in towards the end of last year, there's a series called Educating Yorkshire on Channel 4, and I think in one of the episodes they share the story of a child who developed to take over the summer, I think, as in during the summer break and then came back. And that was really interesting to watch because I think that, yeah, it was interesting to see it in a school context. So I'd encourage people to watch that. And my final question for you is, and this is what we're talking about, psychoeducation. I find that, say you're on public transport, and there's always somebody who has something going on that you want to look at. So it might be a crying baby, or you might be two adults talking really loudly, or someone might have a child who is autistic, and they have experiencing sensory overload or something like that. And then your initial reaction is to look. And then in my head, I'm like, OK, you have to not look because this is awkward for them, or it might be awkward for them. So don't look at them. And so I'm just my question is, if and when we come across people who are having tics in public in a public space that we're around, what would a person who's experiencing that tic want everyone else to do? I mean, that is a brilliant question, and I wish we could bottle that, because the best thing that you can do is ignore the tics. Now, if you're talking to the person, don't ignore the person, ignore the tics. I sometimes say to young people, tics sometimes if you ignore them, they get so bored they give up and they go away. It's a social attention increases, probably the emotional sensation in that young person. And we know big emotions can be associated with exacerbation of tics. So ignoring the tics is very important. We have a QR code that we hand out to our young people so that if they're on a bus or whatever, and it's a long journey, they might want to share that so that people can scan that QR code and get some good, high quality information while they get on with their journey. Because the other thing to say is that if you do look around every time somebody makes a sudden noise or movement that makes you a human being. It's what we do. We, we're alerted to sudden movements and sounds until we have an explanation for them. And there's good reasons why that's the case. So that if we can get into a situation where we help everybody around, a young person who's taking to understand that ignoring the tics is the greatest thing they can do so that they can feel settled and calm and may be able to get on with doing whatever they're doing, whether that's a journey or you being in a school club or whatever that is. So ignoring the ticks is the best thing you can do. You don't need to point out the ticks are there. Some well-meaning people will say, oh dear, I can see you've got tics. What are they? Are they bothering you? And start to talk about the tics, thinking that is a way of showing empathy or sympathy. By the way, we should just differentiate between empathy and sympathy. So sympathy is usually a kind of lofty per you situation, whereas empathy is you and I are connecting over this without any power differential. And I've felt I've felt similar emotions to you at some point, and I'm connecting with you on that front. So it's not helpful to the young person to discuss the tics. It is helpful to talk about anything else, or even ask questions about any other topic. Ignore the tics. Don't ignore me. I think that's a really nice point to end on there, Jane. It's been a really nice conversation where I've learned a lot, and I'm hoping that the people watching and listening have also learned a lot. Umar, I just wanted to say thank you for your generosity of spirit, which you always bring to these discussions. But asking these questions from somebody with such a position of education is an absolute joy. So thank you for giving us the opportunity to discuss this. Next week we're going to be handing back to Mark Tebbs, who's going to be talking to Professor Julie Lowndes Taylor about supporting autistic youth transitioning into adulthood. And then Jane and I will be back the following week as we welcome Dr. Dawn Cutler and Guy Larrington about what it's like for a young person to be in a psychiatric Ward. 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