To to welcome him to the floor is our very own nonexecutive director as part of the ADHD Australia board in, Patrick. Now I wanna make sure I absolutely get all of the, the, achievements in your lifetime correct. So bear with me while I muddle through doctor Patrick. But you're a life member of the Neurodevelopmental and Behavioral Pediatric Society of Australia and served on state and federal ADHD committees. And as I've mentioned, currently non executive director of ADHD Australia. Obviously, your your medical background is substantial as a developmental pediatrician.

And prior to that, you were the service director for the Lower North Shore Child and Family Health Service and senior staff specialist at Royal North Shore Hospital for over twenty seven years. Now wow. I hope I haven't abbreviated that too much, but, what what a vast and varied career you've had.

Right. Thank you. Because to your yeah. Are we ready to start?

Excellent. Okay. Now did were you able to get your slides done, Patrick? Ready to share?

No. Well, I I gave them on to you. I assumed you Alright.

I can do that for you. Two seconds. I have it ready for you. While.

You're doing that, I'll just tell you that having listened to that meeting the previous meeting, it was very impressive. They spoke well. There's a lot of experience, informed comments, and very interesting comments. So I thank people. It was really interesting to listen to that. I always enjoy listening to parents who have living those experiences. Yes. I've got forty years. I've been working with this history of development and especially ADHD for the last forty years. I also have a personal and a family history of it. It was interesting having worked with these kids for a while. I realized that it wasn't just them. It was actually me, which was very enlightening.

And so I've lived that experience as well. Fortunately, I've had some good supports and stuff. The other just I'll make a comment that, Rosie, about the the pregnancy. At the recent ADPAR conference, there was a session talking about that, And I think that the evidence now is that certainly for methylphenidate and Ritalin, there it is safe to take during pregnancy because, you know, the treatment during a for of ADHD during pregnancy is important for the the functioning of the people. The other general comment I want to make that relating to the delay in being able to see people is that you're aware of the current standard inquiry, and we'll be interested to see the outcome of that.

And but personally, I hope that that will broaden the variety of people who are able to diagnose and treat ADHD because it's such a common problem. Okay. General comments. Sorry. Starting off. No. This is a talk in two parts. We're talking about the tribulations. I'm talking mainly from the child's point of view, not denying that it impacts on siblings and parents, but that it's the trials and tribulations, but it's also the triumph that we can get when we successfully help these children. Next slide. Or do I can I do that? Kirsty? Okay. The comment, your child is not giving you a hard time. Your child is having a hard time. And I think that's sometimes hard to remember.

But there was one report that came out a few years ago now where that was highlighted when we looked at parents with ADHD children and they made a lot more negative comments about and to their child compared to the children who didn't have ADHD. So it is something that impacts on the kids and does make their life very difficult. Next slide. Now the age of onset, the hyperactives will usually appear in those early childhood. The inattentives don't usually appear till later, but often the hyperactive preschool or early childhood age then morphs into the combined type of ADHD with both attentional problems and hyperactivity as they grow older.

And as well as that, we then get a lot of secondary problems coming up at different stages depending on their subtype. Next slide. This is a busy one, but it's basically showing that in those early days, again, it's ADHD. But as the child gets older, if you're looking at that middle line, the 11 year old, where they're starting to really act out the learning problem, the behavior, the socialization. And then if you look further to the adolescent, then you're starting to see a lot of secondary problems which really complicate the whole issue of management. Next slide. Sorry, next slide. Yeah. And this is on the right. This is a history of the undiagnosed or undertreated. If you see a child who's got ADHD.

And often they do have an associated learning problem. So the first thing is that they're having troubles with their attention that leads to underachievement. The child then loses self esteem. They start getting very worried about will they do the right thing. So we then start seeing as they're progressing in school, socialization difficulties, behavioral difficulties in the classroom, but also at home, and an increasing incidence of anxiety. And then if this progresses, we start getting into the area of depression where the child loses all their motivation and can't see anything in the future except failure. And that's really the this line of of problems.

We don't want to see that progressing. That's why it's important to treat the kids well and to treat them early. Next slide. I'll go quickly through this, but as you can see here, the purple is the Joe average parents and their complaints. They all have problems in the early hours of the morning. But when you look at those all these other things in the morning, lunchtime, afternoon, in terms of the difficulties they're seeing compared to the non ADHD kids is very significant. So it's a a daytime evening problem. Next next slide. At school, the preparation on no medication, all the battles of getting them out of bed, dressed, breakfast, medication, and then getting them up to school with actually their belongings.

And that's the first stage of the day for the parents. Next one. And then at school, we've gotta deal with the teacher's frustrations, the child's inattention, and the performance anxiety I mentioned, the social difficulties when there are breaks, and after lunch the child is even more cranky, more frustrated, and so the behaviour and the attention get even worse. Next slide. And then after school, I always use not often, but I use that analogy of a hard day at the office. You come home. You let out of steam. And that's exactly what happens so often with the children. All that frustration that they've held in at school, they let out when they come home, and that relates to that oppositional behavior.

The annoying behavior. They irritate the siblings, the struggle at die dining dining table, trying to limit the use of IT, which is a big problem for all children, but it's exaggerated in the ADHD kids because they tend to get more obsessed with it. The trouble getting them into bed, and then, of course, holidays. What do you do? How do you entertain them? So a lot of problems. And what can we do to improve their lot? But it's also the lot of the family and other carers including the teachers and grandparents. Next one. Now this is a saying that I think is very true. To treat ADHD is easy, but to treat it well is difficult. And I think that's where that you do need that experience to be able to understand ADHD.

Well and all its manifestations and variations. And so I try and get that message to all the younger trainees and consultants. We need to work it harder than just treat it as a simple thing with giving them a few tablets and that's it. Next slide. So what can we do? Well, there's a list here and we'll go into this in a bit more detail, but one of the things that I think is so important is education of the caregivers and the child. I try and get the adolescents to start taking responsibility for themselves in terms of their management and medication, but so often, it's they're so resistant to it. It's a denial or they couldn't be bothered.

And sometimes I'll say to them, what's the name of the tablet you take? And they'll look at me strangely and say, oh, it's a it's a capsule, I think. And so it's really important that in that transition period, which you're gonna hear about more, that we actually educate the parents, but also the child as they're developing into adolescence and early on. The next thing is behavioral therapy. We can talk a little bit about that. Medication, we'll talk about. And then there are others that have variable scientific background. The one the the fish oils, the omega threes. The studies.

Aren't really terribly supportive of it, but, you know, some of the parents say to me that it works. And if it works, gee, we keep on with it. But it's in my mind, it's a secondary thing rather than the primary treatment. Diet and vitamins, we used to have the fine gold diet where everybody was running around and taking additives and things out, and adding vitamins. But again, that's now gone into disrepute because the evidence is not there. There's another one that you may have heard of is neurofeedback where they stimulate the brain in certain areas. It's still my review of this goes back to the mid eighties and it's still something that isn't really accepted as a routine thing that is worthwhile. But again, some parents find it useful.

And the new things that are coming on board are things where we are stimulating the brain, special areas of the brain, for example, for ADHD where they stimulate the frontal lobes to see if they can actually get it to work better. And these are the sort of things that latter one are things that we'll probably see more of in the future. Next slide. Now this is a busy slide, but the bottom line is that we used to have arguments about should there be behavioral treatment or should there be medication? And I think now the agreement is that we need to do both. And that's this is the the latest thing that's coming out from America, but it's also supported by, you know, The UK, Europe, and Australia that the combined approach is the best one. And.

The stand alone ones can be useful, but they are not seen as the primary and most effective interventions. Next slide. Now behavior therapy. And we all say, yeah, behavioral therapy is good, but we're learning now about what behavioral therapy helps whom and when. And there is certainly good evidence for what's called cognitive behavioral therapy for the older child and the adolescent. I think that's really now well established, and I certainly use it a lot. But for the younger children, they're not old enough to be able to work on this cognitive awareness of what's going on. So we need to use it more for parent management strategies to teach the parents how to get the children to behave appropriately.

How to set limits and what are the things that are going to make it easier for the child and the family as opposed to the untreated. And then we often get with these children and adolescents anxiety and depression. We see this in adults as well and that's where we need specific therapies aimed at those conditions. And for those we need a psychologist is the one that most people would know, but there are also people called ADHD coaches and if you go online you can see a list of those. These are people some are psychologists, some come from different educational backgrounds. But they are people that rather than working on anxiety and the the psychological problems, they try and work on practical strategies like time management, organisation.

How you do these. And these can be very helpful, especially for, again, the adolescent. And then we've got the school counsellor. Often they can be involved in this, but often I find that the school counsellors are so overwhelmed with work that they aren't able to give the children and the adolescents enough support. So we need to be able to use the outside people. And remember, you can through your GP or your paediatrician, you can get subsidised Medicare rebates for visits to psychologists, but unfortunately not for the ADHD life coach. Next slide. ADHD in behind and reading. Now often these children will come and they'll be underachieving. And we don't know whether this is part of the ADHD or is it a co existing problem.

So when we in this situation, I usually treat their ADHD with medication and behavioural support and then review them in light of what's happening. And quite a few times that you'll find that the child has picked up in their learning, but if in other situations where they haven't, then we know that it's a coexisting problem and then we need an educational assessment with therapy for that. So that's important. ADHD can certainly get you behind in your learning, whereas if you've got ADHD and specific learning problems, that's dyslexia, then we've got to address that as a separate issue. I always remember a boy from the country I saw years ago who was at the bottom of his class. And I treated his ADHD with Ritalin, and.

About a month later, the teacher said he's gone from the bottom of the class to the top of the class. You can imagine how excited his mother was. So it happens. But so what I'm saying is a lot of the learning problems are related to the ADHD, their difficulties with memory, focusing attention. So it's always important to treat the ADHD first in these situations. Next slide. Just no. Go on to the next one, I think. Forget that one. Practical guidelines for medication. Now I'm a paediatrician. I use a lot of medication for these kids.

But I'm supported by evidence. If you look now, I've got this, the Australian one, which has recently come out last year. We've got NICE guidelines, which are The UK ones, the European ones, and the American ones, all saying the same thing. Basically, the best combination is that of behavioral management and medication. Both work together. And it makes sense. If I've got a young child who's flighty, doesn't listen very well, and I'm trying to get the child to take in some behavioral advice, they're not gonna do it. Whereas when they're on medication, they're available, they're listening, they're remembering what you say, they're more likely to be able to incorporate those behaviors and improve their behavior.

So that's why I think a lot of psychologists now will send the kids along saying, look. We're trying to work with this child, but it's limited success. Can you please consider medication? Okay. Next one. Now I'm talking from the Australian perspective, for The UK people, but it's interesting that recently there's been a review came out where there's been a twofold increase in the overall incidence or prevalence of ADHD medication use. It's gone up significantly. Now some people say it's excessive, but if you think about it with five percent of children having ADHD and we're only treating one to one point five percent, maybe we're undertreating rather than over treating. Okay. Next one. ADHD medication.

That's what I'm talking about. It helps children take in the information and remember them. It complements the behavior program, assists the child's listening and completing tasks, allows the child to stop and think before acting. And it's the old story of success breeds success. If this child is all of a sudden starting to achieve, starting to get positive comments back, then that self esteem goes up and that interest in learning gets revived. Whereas if we have the child whose self esteem's down, getting performance anxiety, we have problems. Next slide. We'll just go through that quickly just to list from the early days to the present where the number of medications that are available has increased significantly. Next slide. Next slide.

And just remember Oh, okay. Just in terms of what I do, I think if the major condition causing the ADHD is actually another problem like severe anxiety or severe learning problems or depression, then I'll usually address that first. But if there's no significant impact of these things and the ADHD is is really there, but at the moment, educationally, behaviorally, are no problems, then I tend to look at behavior, and I do say try the fatty acids. But if it's impacting, then significantly on the academic, the behavioral, the social, or self esteem, then I always recommend active treatment. Now I talk to the parents about what are the options, and we discuss that. In some cases, parents will say, I'd rather just the behavioral.

Or I'd just rather see how the child goes over the next term. But I think that's and it's gotta be it's important for me that the parents and I are in tune. If we're not, then we've gotta talk about what is a good compromise. That means sometimes and quite often, I won't start medication on the first visit unless it's really clear and the child is really having problems. Otherwise, I like the parents and the carers to actually have a good understanding about ADHD so I send them away with a list of websites and books and literature so that they can become the local experts on ADHD and when they come back, we can talk about it and use the same language. Next slide. Okay. And I'm just talking about the options that have been proven, education.

Behavioral assistance, and working through the education system with school, and there'll be some time I think there's talks on that have been or will be later. The other three things parents being educated, the child being helped and assisted and education support, and then the bottom line but not of less importance medication. Next slide. Treatments not so proven, I've talked about those and I've talked about some things that are possible in the future such as the transcranial stimulation. Next one. Fatty acids. I won't go into that. You know, it's certainly if anything, there's some suggestion that it helps with learning problems, but the evidence for ADHD is is still really not there. Next one.

This is just a little couple of slides. This is a six year old boy, teacher prompting him. That's what he did. He had to write a little story in a drawing. Next slide. The next morning, he was given five milligrams of Ritalin, and the teacher left him to do his his story in his drawing. And I think you can see not only is the handwriting better, the content's a lot more. It makes sense and even the drawing is a bit more sophisticated. That was just on Ritalin. No change. We didn't do anything else. Next slide. This is another slide of a girl and you can see this girl was on medication in the morning where life was fabulous. And then when it ran out after lunch, absolutely nothing.

And this was a good test to see because we could the child became their own control. The morning, on medication, really happy. The afternoon, disaster. Next slide. And which medication do we start on? Now in The UK and Europe, the general trend is that children should be started on methylphenidate, Ritalin, or Concerta. Whereas with adults, they recommend starting on dexamphetamine. For adolescents, they say, we don't know. In Australia, we're a bit more liberal. It's basically based on the experiences of the paediatrician or the psychiatrist. But the important thing is if you've got real ADHD, eighty percent of these people will respond to either methylphenidate or dexamphetamine.

So that's why we use those two as the first line of treatment. Next one. And then we've got to work out is it short acting or long acting and that depends on the age. The younger kids often just need some medication in the morning and that seems to cover them for the day. The old child needs it for school time. A lot of the children as they get older, for behaviour or learning, or homework, they need to top up in the afternoon. And for a lot of the kids, if they're particularly inattentive, then I say to them, you can do it on school days, and if you want to, you can stop it on holidays and weekends. But I do have a rider to that because although it's, you know, attention, they often have organizational.

And time management issues which can impact on their functioning. And so I usually will recommend on the trial that they take it every day. So that gives them an idea not only is it helping them at school academically, but is it helping them with their general day to day activities and responses? And that's something that I I really do push because I think in some ways, in some of these adolescents, they function a lot better if they're taking it seven days a week. Next slide. This is a dose response, and you can see here when I'm talking, it's how much medication do you give these children. And on the the left hand side is, if you can read my writing, it's a response, and on the bottom, it's the dose.

As you increase the dose, the response hopefully improves. And then you get to what I call the sweet spot where you're getting a really good balance where the the good positive effects are high and the lower effect, the side effects are low. But as you continue to increase the dose, then you can see the response goes down because you're getting more side effects, and they're overwhelming the positive effects. So when we're titrating, we're trying out the child on different doses. That's what I'm trying to get to that sweet spot where the child is functioning optimally with minimal or very bearable side effects. Next slide. Just this slide is showing okay. Sorry. That's an old version. This is just a slide.

You can see there the time of the day and the tasks. And on the the, right hand side I'm sorry. This is a previous version of that. But you can see in the dark, we're giving short acting Ritalin. So if you're starting that, you've gotta give a dose in the morning. You give a dose at lunchtime or late morning, and then often you will need to give a dose at four in the afternoon for all that homework and settling the children down. And occasionally, the the paradoxical thing is sometimes if the younger children are very hard to settle at night to get them to bed, if you give them a small dose of Ritalin, they calm down and are able to sleep.

So that's a paradoxical use of that. And then we have the the short acting, and then we have a medium acting one, the Ritalin LA, which lasts about six hours. That covers most of school day. It's very good, but it's not quite long enough for the older kids. And in the older kids, we've got Concerta, which is a long acting Ritalin version, and we have Vyvanse, which I'm sorry. This slide this was previous version of it, which is very similar to the Concerta in terms of it. It lasts from when you take it in the morning till the early hours of the evening. And then we have longer acting ones called Strattera, and you might have heard of Intunev, which is a new one, which you take every day, and they're in the system every day. That.

Sounds good, but in fact, the problem with them is they're not strong enough to actually help in a lot of cases, but they can be useful as an adjunct. So what we do is try and cover the day. Now just the last thing, a couple of things, period off medication. That happens if the child's having problems with their growth because the side effect that we most commonly see is decreased appetite. Now usually, it's not too bad, and we can just build up their intake. But sometimes their the growth in terms of their weight goes down, and so we have a period off to see if that makes a difference. Sometimes the people think the child has grown out of it.

So we try them off. Sometimes the adolescents wanted to see if they don't they really still need it because often they are resistant. And sometimes the you'll see it that the people will report that it seems to have lost its effect, and they need more. Well, that may be. But often if you just take it off for a few weeks and then restart it, it's like it's rebooting. The effect seems to go back again to what it was before. Okay. Next slide. Okay. Just quickly, drug abuse. If you're on medication as an adult as a child and adolescent, your chance of having drugs associated problems as an adult is the same as the general population. Whereas if you're untreated ADHD, you probably have twice the incidence of substance abuse as an adult.

So if you look at that side of it, it's safer for you to be on medication. Next one. And it doesn't lead to abuse. And unless you've got a cardiac problem and we check for that when we're doing the assessments, it's safe to use. There's no increased incidence of heart problems even in middle aged people on it. Next slide. The future, the last slide, medication will continue to be needed, but there'll be new drugs coming out, hopefully better, more focused. And in my career, I've seen the effects resulting in major improvements for patients and their families. And we've learned we've been using these medications now for over sixty years. And so we've got a lot of experience.

And we're aware of them and been able to monitor them appropriately. And then there's another concern that's recently come up is are we using these medications as a restraint to stop the child? And the answer is no, we're using it to improve the child's behaviour and outcomes. And I think we're still in the stage of learning more about the brain and I'm sure in the future there will be other treatments that are available for ADHD. I mentioned one about this stimulation of the brain. It's still early days, but maybe in the future we might be able to avoid medication. But for the near future, medication, behavioural management and education are the way to go. Thank you for your time.

Thank you, Doctor Patrick Concannon. What a wonderful presentation and thank you for stepping us through the ins and outs of that and, obviously, your experience and relatable, interactions through your clinic. I thank you so very, very much. And right on time. So with, with the way that you've lined that up from a timings perspective. Again, I'm very appreciative of your time, and we hope you have a very wonderful rest of your day. Thank you, doctor Patrick Concannon. Pleasure. Thank you for the opportunity. Good luck to everybody.