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Paediatric attention deficit hyperactivity disorder (ADHD) in general practice

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Specific Interest Zoom Chair : Hi all, and welcome to tonight's Webinar pediatric Adhd. In general practice. My name is Claire Pearson and I'm. The education and Events officer for the Gp. Specific interest faculty, and i'll be your host for tonight.

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Specific Interest Zoom Chair : So just before we continue tonight, i'll run through a few housekeeping notes. This Webinar is being recorded and will be made available for you in the coming week to interact with us. You'll need to use the zoom control panel.

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Specific Interest Zoom Chair : If you cannot see a panel like what is displayed on screen. Hove your cursor over the bottom section of the shared presentation screen, and the panel will appear. We've put all attendees on mute tonight to ensure that the learning will not be disrupted by background noise. However, you still get the chance to interact with your peers using the Q. And a box at the bottom of the screen, and we will have a dedicated Q&a. Session at the end of the Webinar.

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Specific Interest Zoom Chair : So tonight's Webinar is worth one educational activity. 1 h for this 2023, 2025, Cpd. Trainer, and these hours will be uploaded within the next 30 days.

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Specific Interest Zoom Chair : So tonight i'll introduce our Gp. Host, which is associate. Professor John Kramer.

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Specific Interest Zoom Chair : associate, Professor John Kramer, has been a Gp. Since 1,981 based in Woolga with special interest in developmental, pediatrics, indigenous health, mental health, medical education, refugee health and palliative care.

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Specific Interest Zoom Chair : Dr. Kramer was an Re. Cgp. Representative from the Adhd Guidelines Development Group, from 2,019 to 2,022, and he is currently the chair of the Re. Cgp. Specific Interest Group Adhd Asd and Neurodiversity.

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Specific Interest Zoom Chair : So i'll now pass on the presentation to associate Professor John Kramer for our acknowledgment of country

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A/Prof John Kramer: Thank you, Claire, and welcome everybody tonight

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A/Prof John Kramer: from where each of us is joining to this Webinar tonight.

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A/Prof John Kramer: I wish to pay my respects to their elders, past, present, and emerging. I was speaking to you from Go Bungy, a country on the North Coast. New South Wales.

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A/Prof John Kramer: I'd like to introduce Slot Speaker, Professor Daryl Efron. They're also a developmental behavioral Pediatrician at Royal Children's Hospital in Melbourne.

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A/Prof John Kramer: the Senior Research Fellow, the Murdoch Children's Research Institute. an Associate Professor of the University of Melbourne Department of Pediatrics. It's for, says you just include a Dxd

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A/Prof John Kramer: Psycho Pharmacology, Models of care for children with neural developmental disorders.

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A/Prof John Kramer: He was a member of the guideline development great for the 2,022 Australian evidence based clinical practice. Guideline for Adhd.

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A/Prof John Kramer: So, Daryl, how do you

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A/Prof Daryl Efron: thanks very much. John? Let me

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A/Prof Daryl Efron: she am I

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A/Prof Daryl Efron: screen

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A/Prof Daryl Efron: that shade? Okay.

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A/Prof Daryl Efron: It looks great. Thanks, Daryl: All right. Well, good evening, everyone. Thanks for attending. So this session I've been asked to present kind of an overview of Adhd, with a with particular reference, of course, to a general practice

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A/Prof Daryl Efron: for about 30 to 40 min. I've got about 25 slides. I think I should be able to get through that in just over half an hour, and hopefully, we'll have some good time for discussion, and I understand you can submit questions in the chat.

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A/Prof Daryl Efron: which will, we'll try, and John will throw at me afterwards.

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A/Prof Daryl Efron: Okay. So the first description in modern times of Adhd I mean kids with these features it's always been a feature of childhood. It's a you know, like everything, a spectrum disorder.

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A/Prof Daryl Efron: But there's always been kids who have who have had Adhd features.

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A/Prof Daryl Efron: But I were first described in modern times at the end of the eighteenth century by a Scottish physician. So Alexander Krishin, who is the lovely term in his, in in a book called a History of the Passions and their effects.

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A/Prof Daryl Efron: and he described children who had features that are pretty much what the Dsm. Describes today. So mental restlessness with deficits in attention occurring across Situations home, and which is what we is, is a really important diagnostic

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A/Prof Daryl Efron: feature has to have. These 2 kids have to have symptoms both at home and at school. It begins early in life.

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A/Prof Daryl Efron: and he said it caused in term impairment in learning. So the basic idea

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A/Prof Daryl Efron: grouping kids with these features Hasn't changed much since then. In the mid nineteenth century there was a German

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A/Prof Daryl Efron: psychiatrist and children's book writer and illustrator, who had a popular character called Fidgety Feel. He wouldn't sit still and wriggles and giggles and so on. It was a classic hyperactive kid.

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A/Prof Daryl Efron: and then in 1,902, an English pediatrician. So George Still Stills disease juvenile arthritis gave a series of lectures to the College of Physicians.

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A/Prof Daryl Efron: in which he described 43 children. who were inattentive and impulsive and defined

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A/Prof Daryl Efron: and overly emotional and to use kind of Victorian language at the time of it's it's effective moral conduct.

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A/Prof Daryl Efron: and I won't Go through all of this, but it's it is an interesting history how these these kids and and more recently adults have been conceptualized through the twentieth century. So after the Spanish flu, when a lot of people had

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A/Prof Daryl Efron: in, there was a post posting cafe, this in this inhibition syndrome a behavioral disorder that was quite widespread. I've got a few things in this slide in Bold, which I think, a key moments in this history. An an American psychiatrist

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A/Prof Daryl Efron: in the 1930 S. Charles Bradley, was the first to administer stimulant medications. It's a long story which I won't go into the Ben's a drain to institutionalize kids with intellectual disabilities, actually, and not and noted a a a a observation.

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It wasn't used for behavior, but he noticed marked reduction in agitated and hyperactive behaviors

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A/Prof Daryl Efron: in different terms. We used over the decades recently, and was first developed by see the guy, he a Swiss company in the 1950 S. By an Italian chemist.

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A/Prof Daryl Efron: who named it after his wife Russia.

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A/Prof Daryl Efron: And then terms like minimal brain. Dysfunction we use Hyperactivity was very commonly described in 1960 S.

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A/Prof Daryl Efron: And then a Canadian psychologist. Virginia Douglas was the first to use the term attention deficit disorder in 1972, and that became the term used in Dsm. 3, and then for

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A/Prof Daryl Efron: and so on

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A/Prof Daryl Efron: so a useful working definition of Adhd is children who have developmentally inappropriate degrees of inattention.

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A/Prof Daryl Efron: impulsivity, and often, but not always, hyperactivity.

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A/Prof Daryl Efron: And if you want to be even more reductionist, it's effectively difficulties with self regulation.

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A/Prof Daryl Efron: The Dsm. 5 came out almost 10 years ago. Now it's 10 years ago.

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A/Prof Daryl Efron: and there were a few, not many major change. A few things that, I think was significant. Firstly, in decent 4 it was classed a amongst the disruptive behavior disorders. But in DC. 5 Ihd is grouped amongst neuro developmental disorders, and I think that's more appropriate.

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A/Prof Daryl Efron: The age of onset was lifted from 7 in Dsm. 4, which is a bit arbitrary, I think, to 12,

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A/Prof Daryl Efron: which I think, makes more sense. So kids need to have some features observed during childhood before adolescents.

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A/Prof Daryl Efron: Dsm. 5 describes some differences in adults. So

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A/Prof Daryl Efron: if you they need fewer symptoms from the list to to get over the line. We don't tend to count symptoms in clinical practice, but in a research sense you need definitions for different reasons, particularly for a search. So adults don't need as many symptoms

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A/Prof Daryl Efron: and alternate item. Wording was made available for adults, because up until then it was still gets out of season, classroom, and that sort of thing

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A/Prof Daryl Efron: which things were just not applicable for adults. And now these things, like feeling restless or losing your mobile phone.

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A/Prof Daryl Efron: And another important one which really followed. Clinical practice, I think, is.

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A/Prof Daryl Efron: they used to be an exclusion for pervasive developmental disorder. What we now call autism spectrum disorder, so that used to trump adhd according to the Tsm of course for many years before twenty-thirst anywhere we're diagnosing both a Sd. And the same patients. But now you're allowed to do that.

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A/Prof Daryl Efron: So here's some basic epidemiology. It's more common in boys than girls like all developmental disorders about twice as comedy boys

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A/Prof Daryl Efron: diagnosed more commonly in children than adolescents, not twice as often as you can see, and the prevalence estimates have been done in different countries around the world. There's a bit of variation, but

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A/Prof Daryl Efron: worldwide estimates down the bottom is just over. 5% of children have Adhd.

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A/Prof Daryl Efron: Not that many get diagnosed for a whole range of reasons.

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A/Prof Daryl Efron: and that there is in different countries, including access to specialist care, and so on.

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A/Prof Daryl Efron: And not all the kids who get diagnosed get medication, but overall prevalence if you went out into the community Anyway, in the world is about 5%.

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A/Prof Daryl Efron: I'm not going to say much about the neurobiology of Good whole. I could talk about that. But just just to make a point that it's it's more complex than was first thought When I first learned about this 30 years ago, it was thought very much pre frontal cortex in green. There was

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A/Prof Daryl Efron: the mind basis, and then it's got to be understood that networks of connections between the prefrontal cortex and the deep gray matter, and through to the cerebellum we're important.

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A/Prof Daryl Efron: and then subsequently the parrotal cortex and other brain structures, their particular activating system have been found to be important. So many parts of the brain are involved in in cognition and attention and learning and emotional control, and all that, all the underpinnings of Adhd.

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A/Prof Daryl Efron: It's a strongly genetic condition. We often see multiple members of one family, as you would know. It's not uncommon that after a child's diagnosed with a HD. A father, sheepishly goes back to his mother and says, no. What was I like to the kid, and

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A/Prof Daryl Efron: and she brings out the school reports, and he realizes that he he was just like his son

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A/Prof Daryl Efron: and guys and get some self diagnosed. Sometimes it's the mother. It's more commonly boys. So genetics is, is it? It's much more common in in monozygotic twins.

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A/Prof Daryl Efron: then maybe then, siblings so twin studies are the strongest evidence for the genetic loading, which is very high for this condition. But environmental factors are really important as well. So environmental factors, like the quality of parenting, and the quality of teaching. Don't can't cause adhd, but they can

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A/Prof Daryl Efron: either exacerbated, or they can provide protection against the the impairments of Adhd.

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A/Prof Daryl Efron: and you would know that we in in any condition their epigenetic markings that the environment leaves on the on the genetic profile of the individual, and these are often transmitted across generations as well.

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A/Prof Daryl Efron: So it's not in the DNA. It's in the regulatory James.

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A/Prof Daryl Efron: and with Adhd like any the disorders we see in pediatrics the functional impairments, which is what we're interested in down the bottom actually vary across developmental stages. And i'm sure you've had the the privilege really of of tracking kids across the years

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A/Prof Daryl Efron: from infancy, through the adolescence and kids who are vulnerable to developmental problems like Adhd and learning difficulties manifest differently through different developmental stages

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A/Prof Daryl Efron: and washing over all of that is is the child's individual temperament and personality. So you can see 2 kids who are at the same developmental vulnerabilities, but they can function quite differently. One month one wakes up and sees the world as a very dark, threatening place, and one sees it as a friendly, sunny place, and and that profoundly affects their functioning. And

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A/Prof Daryl Efron: you just born that way.

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A/Prof Daryl Efron: so adhd rarely exists on its own. There's travelling companions so common problems, learning disorders like dyslexia.

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A/Prof Daryl Efron: anxiety and mood disorders and the range of mental health problems, depression.

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A/Prof Daryl Efron: autism, spectrum disorders. I already mentioned ticks a common tick disorders to red syndrome.

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A/Prof Daryl Efron: developmental coordination, disorder. and most of the disruptive behavior disorders like and conduct this order in teenagers.

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A/Prof Daryl Efron: It's unusual to see a child who just has adhd alone, and sometimes the kind of problems cause more difficulties than the Adhd.

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A/Prof Daryl Efron: But very often we're managing multiple things at once. You know adhd and anxiety. That's that's bread and matter for pediatrics.

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A/Prof Daryl Efron: for example. some people think it's a it's a trivial problem, but it's not at least at the most severe end of the spectrum. It's not at all there. I

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A/Prof Daryl Efron: really quite significant effects on the individual and on people in the individuals world. So

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A/Prof Daryl Efron: for the individual. The quality of life can be really reduced. If it's not well managed, they can, under achieve academically

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A/Prof Daryl Efron: and in other realms of life and social isolation can occur.

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A/Prof Daryl Efron: and there are flow and effects for the other aspects of the child's world, particularly the family. It can be very stressful to have someone with Adhd in the Home.

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A/Prof Daryl Efron: and their impact on classrooms, playgrounds, workplaces, and the broader community.

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A/Prof Daryl Efron: As John mentioned in the introduction. there are new Australian guidelines for Adhd, John and I were on the working group for this.

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A/Prof Daryl Efron: and these have just been published, and I think

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A/Prof Daryl Efron: the clear we'll put the link to, so you can access these publicly available guidelines. It was, it's a very comprehensive document. It was launched a few months ago, and I'll just briefly describe the process.

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A/Prof Daryl Efron: and and some of the some of the information presenting today comes out of the very comprehensive review of the evidence that was conducted to develop these guidelines.

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A/Prof Daryl Efron: So it was piece of work that went. I heard 2,019 just mentioned. Then you can introduce John. I didn't realize that it's gone back that far, but it certainly took it at least a couple of years.

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A/Prof Daryl Efron: There was a guideline development group that was 23 members, and You can see representation there, including a range of health professionals, including allied health professionals, indigenous psychologists, and people with lived experience.

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A/Prof Daryl Efron: There were 2 independent chairs who were academics in related fields, but not experts, and not not not known, for they work in AD. H. Not having done work specifically in. I do, you know, absolutely fantastic.

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A/Prof Daryl Efron: One was the developmental pediatrician.

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A/Prof Daryl Efron: and what was a forensic psychiatrist now from different States.

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A/Prof Daryl Efron: There was a fantastic Methodologist who did the the bulk of the the the work reviewing the literature, and then she had some support along the way she was paid, and

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A/Prof Daryl Efron: we decided early on that the that we weren't going to do everything from scratch so nice the national issue for care and health.

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A/Prof Daryl Efron: health and care, excellence in the Uk. Which you would have heard of

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A/Prof Daryl Efron: do really good guidelines, and they had done it

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A/Prof Daryl Efron: for 80. I updated the Adhd guideline fairly recently in 2,018, so we started by looking at the we looked at many, many guidelines around the world, we decided that was probably the best.

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A/Prof Daryl Efron: So for any question that we address. We started by looking at what I said, and we either

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A/Prof Daryl Efron: either modified that, or or

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A/Prof Daryl Efron: or or review. We updated the literature, and and we worked from what nice it already produced.

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A/Prof Daryl Efron: We came up with a 111 recommendations, which were designed to be clinically useful and practical. It's striking that only 12 had strong evidence base to support them. 32, a clinical consensus, and 67 will what we'll call clinical practice points

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A/Prof Daryl Efron: and

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A/Prof Daryl Efron: we devised these according to developmental stage. So they were

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A/Prof Daryl Efron: and

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got recommendations that were applicable to preschool as children 5 years and under.

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A/Prof Daryl Efron: and then children, and in adolescence, and

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you know.

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A/Prof Daryl Efron: and they were in these 3 categories. The first was identification screening and diagnosis. including a description of high risk groups.

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A/Prof Daryl Efron: the prize and concept universal, screening effective the the the bottom line on that is, that it's not

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A/Prof Daryl Efron: recommended universal screening, but it is in high risk. Groups in this section talked about differential diagnosis and cut occurring conditions.

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A/Prof Daryl Efron: Then there was a section on multimodal treatment and support, including one of the information needs of the patient after diagnosis and what a important secondary outcomes

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A/Prof Daryl Efron: Things like parents, self-efficacy, family functioning, and so on.

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A/Prof Daryl Efron: And then the intervention was pharmacological and non pharmacological

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A/Prof Daryl Efron: Okay, so I'll i'll. I'm going to just say a few words about some of these things

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A/Prof Daryl Efron: which incorporates the work done in the go up for the guidelines. Excuse me, I've got a cold tonight.

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A/Prof Daryl Efron: Okay? So i'm just gonna say a few words about clinical assessment. It's not rocket science. Like most things in medicine, the essence of it is a good clinical history touching on the things I've mentioned like early developmental delays.

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A/Prof Daryl Efron: the the observation of symptoms in in childhood, not just in adolescence

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A/Prof Daryl Efron: and and history encompassing what it one of the functional difficulties, educationally, socially, and so on, and what it and what I the what's the child's mental health landscape, like? What kind of morbid problems might be present

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A/Prof Daryl Efron: physical examination of children's important it just to rule out anything else that might be that might be contributing to the child. So occasionally you might pick up some, you know, an underlying seam drive.

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A/Prof Daryl Efron: or you might find an incidental except.

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A/Prof Daryl Efron: and that's the

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A/Prof Daryl Efron: so. Kids need to be examined thoroughly at least once. We also need. Of course, if you, if you considering medication, it's important to check hot white and blood pressure regularly at each review.

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A/Prof Daryl Efron: But the other thing involved apart from history is what's called behavior, writing scales or or question is, and I've put teacher involved because the parent question is important. But that really just reflects the clinical history.

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A/Prof Daryl Efron: It it. If you can quantify these question, is it? It's useful to have the parent questionnaire. but it's essential to have a teacher questionnaire. So it's not enough for the parent to say

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A/Prof Daryl Efron: that there that the child struggling with Adhd symptoms at school. we need direct evidence from the teacher describing how the child's functioning in school, and and they actually symptoms.

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A/Prof Daryl Efron: And then, of course, we have a if we're lucky, we've got a report from other professionals who've assessed the child, and this is very variable, depending on what the concerns have been historically for that child. But we've often got a useful report from a psychologist or an occupational therapist, or

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A/Prof Daryl Efron: etc.

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A/Prof Daryl Efron: I'm. Happy to elaborate on any of these things during discussion, time.

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A/Prof Daryl Efron: management. There there are general things that we should do, which is just good pediatric care. And and you know about this. But I always like to talk about this when I talk about management of Adhd, or anything else. Lifestyle stuff is so important.

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A/Prof Daryl Efron: It's G piece. You know this very well. Sleep is a major issue for kids with Adhd often.

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A/Prof Daryl Efron: and

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nutrition is really important.

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A/Prof Daryl Efron: Many kids don't get enough exercise, and they can make the world of difference

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A/Prof Daryl Efron: to their alertness and their functioning. Their mood and and and use of electronic media is, of course, a major problem.

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A/Prof Daryl Efron: general health.

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A/Prof Daryl Efron: And then the school. How good is this? How good a fit is the school for that particular child, because some kids with that actually students will function better at one school, another depending on a range of a range of factors. How how much special needs support is often at that school, how how

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A/Prof Daryl Efron: responsive and supportive of their kids who learn differently and so on.

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A/Prof Daryl Efron: Has the child's learning Difficulties been assessed properly, and and if so, is it being addressed?

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A/Prof Daryl Efron: Are they getting remedial

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A/Prof Daryl Efron: education strategies for dyslexia, For example, Are they being bullied. That's very, very common in kids with Adh, and they can make life incredibly difficult for them and cause disengagement.

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A/Prof Daryl Efron: We can help get to a struggling socially to think creatively, help their families to think creatively about opportunities for social interactions outside of school.

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A/Prof Daryl Efron: We're always working with children's behavior, and that it always involves parenting and family dynamics more generally

00:25:19.820 --> 00:25:39.370
A/Prof Daryl Efron: classroom adaptations. It's always interesting to me that when we diagnose a child with Adhd, that the teachers often ask us, how how do we teach this child? And you know it's not our area of expertise as doctors, but most of us have lists of these sorts of things to help the child function better through the day.

00:25:39.530 --> 00:25:52.680
A/Prof Daryl Efron: if possible, reducing clutter in the classroom. I sort of keep this afternoon with a lighting was a real problem had like an instruction simple. Having written schedules, you can read the rest of the things on that list.

00:25:58.090 --> 00:26:04.760
A/Prof Daryl Efron: Reinforcement, finding all that, finding a good things that are going well for the child and rewarding them for that.

00:26:08.310 --> 00:26:13.630
A/Prof Daryl Efron: Okay, so i'll just say a few words about non pharmacological interventions, and then a few words about medications.

00:26:13.710 --> 00:26:27.710
A/Prof Daryl Efron: So this was looked at very carefully in the guideline process. and these were the only 3 for which there was good evidence, where we recommended that these things should be.

00:26:28.240 --> 00:26:30.970
Practice should be recommended to

00:26:31.750 --> 00:26:34.250
A/Prof Daryl Efron: children and adolescents

00:26:34.350 --> 00:26:47.580
A/Prof Daryl Efron: with Adhd. The Cbt. One, I think, is really only adolescents and Adults, that that has to risk. I'll show you in a second. But really it's the lifestyle challenges which I've touched on. Parent and family training can be very effective

00:26:47.750 --> 00:26:52.030
A/Prof Daryl Efron: adhd specific, and then cognitive behavior. Therapy

00:26:52.090 --> 00:26:56.220
A/Prof Daryl Efron: was recommended just for Adolescents and adults. There wasn't evidence for children.

00:26:56.850 --> 00:27:15.930
A/Prof Daryl Efron: Other things on this list, and there were others as well. But these are things that are commonly recommended could not be recommended, because the evidence wasn't strong enough now it's not to say they're not helpful. But there's not strong enough evidence to to recommend to parents that they invest

00:27:15.930 --> 00:27:26.040
A/Prof Daryl Efron: time, money, and energy and cognitive training strategies. These are being marketed quite quite strongly. You're a feedback school, based interventions.

00:27:26.450 --> 00:27:28.700
A/Prof Daryl Efron: adhd coaching.

00:27:28.960 --> 00:27:47.350
A/Prof Daryl Efron: and some people might be from Western Australia, where this is a most commonly practiced in Australia and peer support. Because now that's the to say that individual kids and and and adults might not have benefited from some of these things. It's just that when you look at the published evidence there wasn't wasn't strong enough to recommend them at this stage.

00:27:51.480 --> 00:27:53.480
A/Prof Daryl Efron: All right. So medications

00:27:55.960 --> 00:28:04.750
A/Prof Daryl Efron: as you would know the main medicines, so it's about 80% of kids who get diagnosed with Adhd in Australia prescribed a medication.

00:28:05.520 --> 00:28:09.540
A/Prof Daryl Efron: And that's about right. The overall right of prescribing of meds

00:28:10.030 --> 00:28:14.790
per childhood population. Australia is between one and 2%. It does vary

00:28:14.830 --> 00:28:24.500
A/Prof Daryl Efron: from state to State and within States, and at different time points where they surveys are done but overall there's not growth over prescribing Australia country into what

00:28:24.950 --> 00:28:27.230
the newspapers sometimes suggest.

00:28:28.400 --> 00:28:41.820
A/Prof Daryl Efron: The the stimulants are in red because they are the best, and there's 2 stimulants available in Australia myth up in a date. and Dex amphetamine that comes in 3 forms in Australia

00:28:41.840 --> 00:28:46.640
A/Prof Daryl Efron: short, acting with them medium, acting with them, and

00:28:47.090 --> 00:28:54.570
A/Prof Daryl Efron: I think I've got another slide describing the duration of action. and Dexter for the main comes as short acting and as

00:28:55.100 --> 00:28:59.910
A/Prof Daryl Efron: a program called vivance, which is effectively long it index amphetamine.

00:29:01.890 --> 00:29:09.760
A/Prof Daryl Efron: Then we have non stimulant medications. In the first place, to be marketed about 20 years ago was item, oxygen

00:29:09.920 --> 00:29:11.850
A/Prof Daryl Efron: tried names.

00:29:12.210 --> 00:29:32.420
A/Prof Daryl Efron: and more recently there's I've missed out the trade name. It's in Tun. If which is an Alpha agonist similar to Cloning, which is also I've been trying to be better than place, but I don't know if it is a very flexible drug with many applications, but it it it can help with Adhd

00:29:32.500 --> 00:29:43.620
A/Prof Daryl Efron: in general. This well, the the effect, size, the power. in reducing symptoms of the non stimulants is not as strong as the stimulus. The stimulants are the best.

00:29:43.640 --> 00:29:49.810
A/Prof Daryl Efron: No question. and about 3 quarters of kids prescribe

00:29:49.910 --> 00:30:02.920
A/Prof Daryl Efron: with Adhd, who prescribed the stimulant. Medication will respond. and that means a substantial reduction in symptoms with tolerable side effects. I think I've got a slide about sound effects in a Sec.

00:30:06.560 --> 00:30:18.040
A/Prof Daryl Efron: So the benefits of stimulants for kids with adhd improvements in sustained attention, and if it full behavior, so the having becomes less effortful, effectively

00:30:18.050 --> 00:30:33.370
A/Prof Daryl Efron: reduced emotional reactions to frustration or impulsiveness, and reduced extraneous measure activity, and we don't prescribe it for the third point there, just because the kids know I need banging and tapping. If they function well, you wouldn't prescribe medication just for that.

00:30:33.370 --> 00:30:40.330
A/Prof Daryl Efron: But it is kind of a fringe benefit. These kids are less annoying to their parents and teachers when they're less restless.

00:30:41.520 --> 00:30:48.540
A/Prof Daryl Efron: Other interesting effects is that kids with. I actually treated with stimulants.

00:30:48.550 --> 00:30:53.250
A/Prof Daryl Efron: comply with instructions from parents and teachers. Much better

00:30:53.380 --> 00:31:10.170
A/Prof Daryl Efron: and parenting style improves. You. Treat a child with Adhd, and you can. The parenting is more consistent and less harsh because these kids are really hard to parents. So parenting skills break down under the pressure of having a Dhd.

00:31:10.560 --> 00:31:25.480
A/Prof Daryl Efron: And possibly the most important is that over time for the patients, their a social standing improves. They start getting invited to join in group activities invited to birthday parties, and that means the world to them, and they

00:31:25.670 --> 00:31:27.020
A/Prof Daryl Efron: in their families.

00:31:30.260 --> 00:31:35.690
A/Prof Daryl Efron: side effects of the stimulants, and the one to remember is appetite, suppression.

00:31:36.040 --> 00:31:40.410
A/Prof Daryl Efron: The vast majority. Almost all kids treated with stimulants

00:31:40.510 --> 00:31:47.870
A/Prof Daryl Efron: have suppressed appetite during the day. They eat less lunch. It's very unusual Not for this not to happen.

00:31:47.880 --> 00:32:04.180
A/Prof Daryl Efron: We can usually get around that without too much difficulty. But we tell them upfront, of course, and they have a good breakfast before their medication, and they usually hungry at the end of the day, because the medications worn off. I'll often have a big meal, or have a big snack at, you know, 40'clock after school.

00:32:04.380 --> 00:32:08.170
A/Prof Daryl Efron: and then, you know a good dinner at 5, 30, or something like that.

00:32:10.190 --> 00:32:19.490
A/Prof Daryl Efron: There's a range of other side effects that are sometimes seen, but much less frequently. These include irritability and depression or withdrawn sort of behavior.

00:32:19.720 --> 00:32:24.180
A/Prof Daryl Efron: Emotional blunting. So kids kind of lose their spark

00:32:24.290 --> 00:32:34.980
A/Prof Daryl Efron: happens in maybe up to 10% of kids anxiety, which is a common pre-existing condition with these kids can be made worse by stimulus

00:32:35.270 --> 00:32:41.480
A/Prof Daryl Efron: ticks can be made worse by stimulants. If you give it too late in the day it's half, and to fall asleep.

00:32:41.880 --> 00:32:48.220
A/Prof Daryl Efron: and rarely but well described his psychosis and mania.

00:32:53.090 --> 00:33:00.300
A/Prof Daryl Efron: This slide shows the range of duration of the the products on the market in Australia at the moment.

00:33:00.760 --> 00:33:02.550
A/Prof Daryl Efron: So

00:33:02.610 --> 00:33:08.240
A/Prof Daryl Efron: the first 3 of Methyl candidate in the next 2 after the gap and dex amphetamine.

00:33:08.270 --> 00:33:13.380
A/Prof Daryl Efron: So make a friend that comes in 3 preparations. The tablets last a few hours.

00:33:13.520 --> 00:33:18.570
A/Prof Daryl Efron: so they need to take it 2 or 3 times per day, including dice at school at lunch time.

00:33:20.260 --> 00:33:22.010
ritual, and all I

00:33:22.380 --> 00:33:33.040
A/Prof Daryl Efron: confusingly is long acting, but it's the middle one, last about 4 to 6 h, usually occasionally up to I. The drug companies is 8 h, but that's actually unusual.

00:33:33.490 --> 00:33:42.190
A/Prof Daryl Efron: and then concert her last between 6 and 12 h. I've got an idea. It's sometimes on the last about 6 h actually.

00:33:42.220 --> 00:33:54.850
A/Prof Daryl Efron: but it typically 6 to 10, something like that occasionally as much as 12, Sometimes it lasts too long, and it's time for the kids to fall asleep. But it's a really good smooth preparation for teenagers

00:33:55.130 --> 00:34:02.860
A/Prof Daryl Efron: with the alternate stimuli text amphetamine. There is the tablets which last a bit longer than Ryland tablet to that 4 to 6 h.

00:34:03.780 --> 00:34:12.449
A/Prof Daryl Efron: and there's 5, and which is list ex amphetamine. It's got a loss in amino acid attached to Tex amphetamine, and that's cleaved off after absorption.

00:34:13.190 --> 00:34:17.070
A/Prof Daryl Efron: and that lasts a similar duration to concert

00:34:19.050 --> 00:34:25.440
A/Prof Daryl Efron: Some kids respond better to one similar than the other. We can't predict that. So you just try one or the other

00:34:29.280 --> 00:34:30.880
A/Prof Daryl Efron: a few practical tips.

00:34:32.739 --> 00:34:46.630
A/Prof Daryl Efron: We normally start low, because, like caffeine, it's hard to predict how sensitive the the patient will be to the stimulus. So we start by and just gradually tie trade up. There's no no reason to go up too quickly.

00:34:46.679 --> 00:34:48.300
A/Prof Daryl Efron: It's not an emergency

00:34:48.429 --> 00:34:58.510
A/Prof Daryl Efron: when I say, start 7 days. What I mean by that is, there are quite a lot of kids who only take medication on school days, because the main problems are academic.

00:34:58.600 --> 00:35:13.610
A/Prof Daryl Efron: But I always, even for those kids where that's the intention I always suggest they take it 7 days a week for the first month or so, so the parents can observe the effects on weekends, because the parents are more in tune with the kids than the teachers or

00:35:13.720 --> 00:35:18.410
A/Prof Daryl Efron: or other people in the child's life, so they might pick up on subtle side effects.

00:35:19.840 --> 00:35:28.560
A/Prof Daryl Efron: and it's important to document the script that you're right. Most of us are moving to electronic scripts these days, which makes it easier

00:35:28.740 --> 00:35:34.540
A/Prof Daryl Efron: because it applies to really only to the short acting preparations. They can be abused

00:35:35.310 --> 00:35:43.620
A/Prof Daryl Efron: because they can be crushed and used as powers in different ways. So you know, from time to time.

00:35:43.830 --> 00:35:49.710
A/Prof Daryl Efron: as i've said, there's often multi-generational heavy HD. And risk taking behavior. Substance. Abuse is more common in these

00:35:49.810 --> 00:36:07.740
A/Prof Daryl Efron: in these in people with a HD. So from time to time any of us have been caught out with someone getting hold of the child's tablets and using them. So just be a bit careful. But really it's just the short acting. So most of the time we use long activities. We switch after a child has demonstrated response to short acting

00:36:07.800 --> 00:36:13.990
A/Prof Daryl Efron: stimulants, we usually switch to long acting. It's more convenient, and that's what the families normally want, and it's in its

00:36:16.880 --> 00:36:28.380
A/Prof Daryl Efron: There's some evidence that frequent appointments, and we might come back to this in because it's in discussion, because it's so hard to get frequent appointments for anything at the moment

00:36:28.420 --> 00:36:36.920
A/Prof Daryl Efron: but type titration of the dicing frequent checking in with the families with information from teachers.

00:36:37.180 --> 00:36:41.810
A/Prof Daryl Efron: may improve both adherence and the effectiveness of medication.

00:36:41.840 --> 00:36:47.180
A/Prof Daryl Efron: and you can use various symptoms scores. For this. There are models of this

00:36:47.290 --> 00:36:50.710
A/Prof Daryl Efron: not so much in Australia, but in other parts of the world.

00:36:50.780 --> 00:36:54.330
A/Prof Daryl Efron: usually with practice nurses doing this sort of thing.

00:36:58.390 --> 00:36:59.930
A/Prof Daryl Efron: Okay.

00:37:00.630 --> 00:37:04.370
A/Prof Daryl Efron: you know. Nearly done all right for time. I think so.

00:37:04.430 --> 00:37:06.820
A/Prof Daryl Efron: This is a depressing slide.

00:37:07.120 --> 00:37:15.070
A/Prof Daryl Efron: Long-term outcomes people with Adhd Q. To the HD or an increase risk of almost every negative outcome you can think of.

00:37:15.080 --> 00:37:16.610
A/Prof Daryl Efron: You can see the list there.

00:37:16.630 --> 00:37:24.870
A/Prof Daryl Efron: Academic failure, early dropping out from school smoking substance, abuse, range of adult mental health problems. You know.

00:37:24.920 --> 00:37:29.480
A/Prof Daryl Efron: low occupational standards, unemployment, motor car accents, and so on.

00:37:31.600 --> 00:37:39.350
A/Prof Daryl Efron: So increased risk that doesn't mean they're doomed to this by any means. Lots of people with that Htt: very, very well.

00:37:39.860 --> 00:37:49.530
A/Prof Daryl Efron: This this is just statistically. There are an increase risk of all these things. And, for example, if you, if you go to prisons and do Retrospective

00:37:49.660 --> 00:37:56.210
A/Prof Daryl Efron: interviews with a prison population is very high rate of Adhd, many of which have not been diagnosed.

00:37:56.310 --> 00:38:04.860
A/Prof Daryl Efron: although increasingly people with a HD. Are getting treatment in prisons, which is a good thing. But this is this: this is people that each day

00:38:04.870 --> 00:38:12.280
A/Prof Daryl Efron: all right, increase risk of all these things, however, they can also do really well, and he's just a few examples

00:38:12.340 --> 00:38:32.620
A/Prof Daryl Efron: of people who are said to have had Adhd. and you can probably recognize most of those the most I was discussing with John earlier, and he's got other examples. But Michael felt the swim of the my successful Olympics swimmer. Perhaps the most successful in the athlete of all time, definitely had adhd no question. He was on

00:38:32.670 --> 00:38:49.510
A/Prof Daryl Efron: so with good support from us and other health professionals, and with their families most importantly, kids with Adhd certainly can do very, very well, and we've happy, successful lives, and that's what we should be having to help

00:38:49.670 --> 00:38:50.910
A/Prof Daryl Efron: and achieve.

00:38:54.050 --> 00:38:58.480
A/Prof Daryl Efron: So Thank you. I'll stop there and look forward to the discussion.

00:39:00.110 --> 00:39:05.490
A/Prof John Kramer: Thank you, Daryl. A lot of questions in the chat room, and obviously

00:39:05.570 --> 00:39:11.960
A/Prof John Kramer: the voting filter to say which the more popular ones and

00:39:12.970 --> 00:39:21.290
A/Prof John Kramer: i'll start with this one. Darryl. What are your thoughts on a trial of stimulants to confirm diagnosis?

00:39:23.410 --> 00:39:25.260
A/Prof Daryl Efron: Thank you.

00:39:26.350 --> 00:39:29.800
A/Prof Daryl Efron: So the stimulant medications.

00:39:29.820 --> 00:39:33.810
A/Prof Daryl Efron: and not really helpful for a diagnosis.

00:39:33.820 --> 00:39:41.210
A/Prof Daryl Efron: Anyone will perform better with stimulant medication on board. Like most people feel better with coffee.

00:39:41.320 --> 00:39:50.160
A/Prof Daryl Efron: and, in fact, they've been some some studies in the 19 seventies, and from high functioning teenage children of I think it was Harvard Academics at

00:39:50.320 --> 00:39:52.890
A/Prof Daryl Efron: at in in Boston.

00:39:52.950 --> 00:39:57.340
A/Prof Daryl Efron: who were treated with Dex amphetamine, and

00:39:57.360 --> 00:40:09.910
A/Prof Daryl Efron: just to show that they had improved cognitive performance in the classroom, and they did so. The the treatment response is non specific, and that creates a real.

00:40:09.970 --> 00:40:24.810
A/Prof Daryl Efron: sometimes real ethical difficulties. There's a group that I mentioned to John when we, when he first invited me to do this talk a few months ago, and that is sometimes we get referred pretty high functioning teenagers in year, 10 or 11,

00:40:25.060 --> 00:40:38.390
A/Prof Daryl Efron: or 12. His parents say they're doing well, but I know he could do better if he just focused to live. He he's! He's above average, and these are usually very well function well educated families. We don't see them often, but sometimes.

00:40:38.470 --> 00:40:46.010
A/Prof Daryl Efron: and that rise a a and I want, would you and he he's always been a bit die dreamy, and I wonder would you prescribe the stimulus?

00:40:46.050 --> 00:40:58.750
A/Prof Daryl Efron: So this this is in the realm of cognitive enhancement, and it's a very, very difficult area. I know that's not what your question was directly about, but it's just to make the point that you can help anybody focus a bit better with. You know medication. It Doesn't: prove that

00:40:58.870 --> 00:41:01.090
A/Prof Daryl Efron: to diagnose our HD. You need to have

00:41:01.350 --> 00:41:06.420
the symptoms across settings, and it needs to be causing functional impairment due to those symptoms.

00:41:08.210 --> 00:41:11.270
A/Prof John Kramer: Okay, thanks to that, there's another question

00:41:11.640 --> 00:41:24.250
A/Prof John Kramer: given. The large delays within the system be that public or private system in a child being referred with suspected Adhd.

00:41:24.260 --> 00:41:30.730
A/Prof John Kramer: what are the consequences of delayed diagnosis and intervention where needed.

00:41:32.350 --> 00:41:34.920
A/Prof Daryl Efron: Yeah, that's a fantastic question. Then, when

00:41:35.980 --> 00:41:42.260
A/Prof Daryl Efron: we think about a lot. and I don't know the answer. I don't know if anybody knows the answer.

00:41:42.430 --> 00:41:56.890
A/Prof Daryl Efron: You parents are naturally always interested in this, and concerned about this, and from their perspective, you know a 6 months delay or a 12 month. Delay is a big deal. My hunch and and my experience

00:41:56.950 --> 00:42:03.170
A/Prof Daryl Efron: from seeing kids of range of severities at different stages of life when they first diagnosed

00:42:03.220 --> 00:42:12.710
A/Prof Daryl Efron: over 30 years, is it probably doesn't make it much difference at all if you delayed by you or 2 before you start. That's my hunch. I've got no evidence to back that up.

00:42:12.770 --> 00:42:28.290
A/Prof Daryl Efron: But you know, par, there's often a sense of urgency about getting queue. Once it's rise Once a teacher rises it with a parent. They come to you, and I said they need to see the intuition. You know it's kind of as quickly because they need to get the child on medication.

00:42:28.300 --> 00:42:34.590
I I I think we need to help calm the waters in those situations, particularly at the moment, so I had to get appointments

00:42:34.680 --> 00:42:42.490
A/Prof Daryl Efron: first appointments with the general practitioners, and then with pediatricians and psychologists, and so on. It's a really tough situation.

00:42:42.540 --> 00:42:55.110
A/Prof Daryl Efron: The health landscape at the moment. So I I try to diffuse those situations and and say what I actually believe, and that is that I don't it's not going to be in the long term away, make much difference if there is a delay of some months, or even a year or so

00:42:55.440 --> 00:43:04.830
A/Prof John Kramer: before starting treatment, I don't know if I would be, John, if you have a different view on that. But it's the

00:43:05.150 --> 00:43:07.240
A/Prof John Kramer: Us. The Gp. Feel

00:43:07.330 --> 00:43:14.960
A/Prof John Kramer: fairly suspicious. Yeah. Idsd is explaining the problems in the child that's been brought to you.

00:43:15.190 --> 00:43:21.390
A/Prof John Kramer: There's nothing to stop you providing that information education about Adhd

00:43:21.550 --> 00:43:33.900
A/Prof John Kramer: that is, non pharmacological. In other words, you can educate the parents that I dst. You can talk to them about the importance of routines. You can talk to them about sleep. Hi, Jane.

00:43:33.910 --> 00:43:38.250
A/Prof John Kramer: you can talk to them about no screens before bed for an hour or 2.

00:43:38.290 --> 00:43:46.830
A/Prof John Kramer: The blue light effect I've noticed that it's in school seem to be taught about that as well. And often when i'm giving that little spiel.

00:43:46.910 --> 00:43:53.330
A/Prof John Kramer: I give a a not a recognition. So there's a lot of things that you can do during that time.

00:43:55.600 --> 00:43:58.060
A/Prof John Kramer: Okay, I'll move on.

00:43:59.820 --> 00:44:01.810
A/Prof John Kramer: There's a question there

00:44:03.860 --> 00:44:10.290
A/Prof John Kramer: masking in schools having a negative effect on teacher Question has.

00:44:10.320 --> 00:44:15.630
A/Prof John Kramer: I would certainly say, I've seen that. But, Darrell.

00:44:16.370 --> 00:44:17.830
A/Prof John Kramer: how do you

00:44:18.150 --> 00:44:24.500
A/Prof John Kramer: search or see through a relatively normal teacher questionnaire when you feel?

00:44:24.670 --> 00:44:26.460
A/Prof John Kramer: But there is something going on.

00:44:28.520 --> 00:44:39.840
A/Prof Daryl Efron: Yeah, it's a it's another really good question and a difficult one. and it's a scenario that does come up doesn't it where the parents say, I know I have one yesterday

00:44:39.860 --> 00:44:43.550
A/Prof Daryl Efron: with like your old girl, the parents saying.

00:44:44.610 --> 00:44:50.210
A/Prof Daryl Efron: and I had a question of it. It wasn't about it. It was about general functioning, one aspect of which was attention.

00:44:50.270 --> 00:44:59.710
A/Prof Daryl Efron: And I think there's what you're talking about where the parents started to mothers, and they both said that we know that she's really struggling at school. We know she masks.

00:44:59.940 --> 00:45:06.620
A/Prof Daryl Efron: and the teacher just doesn't say how difficult it is for her to get through the school Down she comes home exhausted.

00:45:06.630 --> 00:45:20.340
A/Prof Daryl Efron: but the teacher reports no symptoms functioning well above average, academically or average academically, and no, no observable difficulties with behavior or attention. So I think it's a really really difficult territory.

00:45:20.480 --> 00:45:26.820
A/Prof Daryl Efron: This this, this concept. It's being talked about a lot of them at the moment, particularly in relation to girls and women.

00:45:26.910 --> 00:45:43.230
A/Prof Daryl Efron: and I wish I had an intelligent response to that, because it, you know, I keep saying we go back to teacher reports of symptoms, but you're absolutely right sometimes. It's that that can be quite subtle, particularly in the child, is not behaviorally disturbed, which is more often the case with girls.

00:45:43.430 --> 00:45:47.090
So I think we like with everything we use our clinical

00:45:47.100 --> 00:45:51.160
A/Prof Daryl Efron: now and over time we try and get to know the child.

00:45:51.180 --> 00:46:02.880
A/Prof Daryl Efron: and you know, sometimes we might make a diagnosis or start medication in a child, even if the teacher is not reporting many symptoms. You want some degree of symptoms report in the classroom.

00:46:03.740 --> 00:46:09.090
They're going to stick to your professional guns to some extent, but we don't necessarily need to have the full hand. I don't think.

00:46:09.280 --> 00:46:23.050
A/Prof Daryl Efron: if it if we've known the child over a period of time, and there's a consistent pattern, and there is other evidence, such as fatigue and anxiety, and enormous stress around the around school, which which by which it

00:46:23.270 --> 00:46:36.750
A/Prof Daryl Efron: which you might think of manifestations of of the masking or the cost that that that comes at. So it's a long way to answer. But I I I think it's a really good question. It's a difficult scenario, and I suspect different pediatricians play that differently.

00:46:36.930 --> 00:46:41.530
A/Prof John Kramer: Yeah, thanks, Daryl. And i'd observe also that the Dsm.

00:46:41.880 --> 00:46:44.240
A/Prof John Kramer: So I've actually says the

00:46:44.560 --> 00:46:51.140
A/Prof John Kramer: problematic behaviors need to be present in at least 2 settings. Now, school and home are the 2 common ones.

00:46:51.270 --> 00:47:01.630
A/Prof John Kramer: But I found that if you get evidence, for instance, if the child has behavioral problems in out of school as care, or when with grandparents

00:47:01.640 --> 00:47:05.620
A/Prof John Kramer: that can make that criteria in in terms of

00:47:05.790 --> 00:47:19.970
A/Prof John Kramer: okay, what I'm: all settings. The other thing is that I've observed at times teachers are reluctant to fill out a question day, positively because it's it, of giving the child a label

00:47:21.210 --> 00:47:30.750
A/Prof John Kramer: I I've had that experience myself with. They've been various behavioral incidents reported in the playground. And yet the questionnaire from the teacher comes back

00:47:30.840 --> 00:47:35.030
A/Prof John Kramer: quite UN remarkable. So sometimes you have to

00:47:35.110 --> 00:47:37.820
A/Prof John Kramer: by a season. We've all got our own.

00:47:39.640 --> 00:47:52.410
A/Prof John Kramer: Okay, not an important question here, Darrell, in simple terms, and this is side of the stimulus work to help with Adhd symptoms. What would take it would make them even more hyperactive. So the paradox.

00:47:52.420 --> 00:47:57.080
A/Prof Daryl Efron: Yeah. Yeah, look. We pretend that we know

00:47:57.230 --> 00:48:13.800
A/Prof Daryl Efron: It's the answer to that. The textbooks will all say, you know the dopaminergic agents, and there's some sort of soft evidence that people with adhd have a that's been a dominant theory since 1970 S. There's not really good evidence for that.

00:48:13.800 --> 00:48:30.560
I think it's a non-specific effect. At least it is don't mean to some extent. No no adrenaline boost in the system? That's true. That's what these medications do. But why? How that results in improved focus? I think it's still very poorly understood

00:48:30.560 --> 00:48:36.540
A/Prof Daryl Efron: to spot an enormous amount of research into the the the pharmacology.

00:48:37.940 --> 00:48:40.040
A/Prof Daryl Efron: So it's it's really

00:48:40.650 --> 00:48:54.070
A/Prof Daryl Efron: the essence of it is that it's it's an observation. So we know these drugs, and you know, adrenaline, we know these drugs help with attention. But how that all works is really not well understood, and parents often ask that because you think

00:48:54.070 --> 00:49:12.220
A/Prof Daryl Efron: technical stimulant, it is a paradoxical effect. So I. I just sort of frame it in that. It's like When we have coffee we can just really focus on one thing and distract out other things from our mind while we fill in a boring tax form, or do something that's inherently of low interest. That's essentially what I is to use

00:49:12.220 --> 00:49:29.380
A/Prof Daryl Efron: difficulty more difficult, even average harnessing the mental energy for an activity that's of low intrinsic interest. Kids with that HD. Of course, can focus really well on things they're interested in, but it's things that are not of high value to them like a spelling sheet or a math worksheet

00:49:29.540 --> 00:49:40.900
A/Prof Daryl Efron: that most kids can just harness the mental engine. Just do it because they know that that's what they teachers and parents want them to do. But kids with adhd find that an enormous effort and the stimulants reduce the effort required to do that.

00:49:40.940 --> 00:49:45.770
A/Prof John Kramer: Yeah. Okay, thanks. Now there's another question that slipped to the head of the queue.

00:49:45.880 --> 00:50:00.020
A/Prof John Kramer: That is, when a Gp. Is going to be able to do more, 5 in terms of diagnosing and in certain circumstances trading. Now we could spend all night talking about that I would simply observe that

00:50:02.090 --> 00:50:15.720
A/Prof John Kramer: provision of stimulant medication is regulated and the State Health Department level. So there is never going to be one single answer for the whole of Australia. There's a lot of work going on to bring GPS

00:50:15.870 --> 00:50:24.690
A/Prof John Kramer: into more and more dog guys and some kind of trading type of scrubbing. But

00:50:25.070 --> 00:50:31.860
A/Prof John Kramer: it's got to be down on this type of state basis, even if that's in the logical. But that's a common world structure.

00:50:33.120 --> 00:50:36.110
A/Prof John Kramer: So, Daryl, do you have anything to add to that?

00:50:37.380 --> 00:50:40.730
A/Prof Daryl Efron: Yeah, I thanks, John. I I do.

00:50:41.410 --> 00:50:59.920
A/Prof Daryl Efron: I I there's no problem with the with it. It. It it's not a difficult diagnosis to my, because i'll, as you know, and as I've described tonight, so it's I i'm very happy with GPS or or psychologists diagnosing adhd. If if you get the right information from, As I said, parents and teachers

00:51:00.180 --> 00:51:05.370
A/Prof Daryl Efron: and you've looked for differential diagnoses, and you're doing everything else we've discussed.

00:51:06.790 --> 00:51:18.770
A/Prof Daryl Efron: So that's not. That's not difficult, but the the key thing is access to stimulant medication. and it's as John has described. It's complicated. I I think I mean I

00:51:19.140 --> 00:51:35.430
A/Prof Daryl Efron: you you. In general practice you manage many more complex problems than adhd it. It can be complex, but it's often not that complex, even when it's one or 2 come over it's compared to many of the problems you deal with in in aged care and

00:51:35.590 --> 00:51:46.560
mental health and diabetes, and everything else. So it it. It it it's, it's frustrating. I think the general practitioners are not in the and not

00:51:46.840 --> 00:51:53.580
A/Prof Daryl Efron: easily able to prescribe. Of course you can, under the supervision of pediatricians or psychiatrists in most states.

00:51:53.670 --> 00:52:06.770
A/Prof Daryl Efron: but in practice it doesn't seem to happen very much, and I I think that's a shame, and I hope that as we move forward, we can find ways for GPS to be much more involved in con managing, including co-prescribing.

00:52:07.410 --> 00:52:12.690
A/Prof John Kramer: Correct Thanks, Clara. Now, really what questions just coming from the West.

00:52:14.140 --> 00:52:22.030
A/Prof John Kramer: Essentially it's happened. GPS: better prepare patients being referred to pediatricians or psychiatrists

00:52:22.220 --> 00:52:28.640
A/Prof John Kramer: in that always. What constitutes a good referral? What will have the pediatrician

00:52:28.700 --> 00:52:29.680
A/Prof John Kramer: to

00:52:29.990 --> 00:52:35.820
A/Prof John Kramer: more quickly. R. To the inclusion that needs to be raised and start effective management.

00:52:36.050 --> 00:52:47.340
A/Prof Daryl Efron: Yeah. Great question. And I think it's a really important one for families, because we can get one visit ahead of the game if we get information served up to us

00:52:48.330 --> 00:52:58.980
A/Prof Daryl Efron: by by the Jp. Plus or minus. As I've said, psychologists and species and and other people. But you can just do what we've been talking about. You can get parent and take your questionnaires.

00:52:59.000 --> 00:53:01.770
A/Prof Daryl Efron: You can, you know, get

00:53:01.770 --> 00:53:24.610
A/Prof Daryl Efron: a a good history, and we get some fantastic referrals from GPS that talk about the sleep contributing factors like Sleep deprivation, excessive screen time and nutritional deficiencies, and so on. And the family history of mental illness, and all all that information. If we've got that all up front, then we're starting the you know, half a consultation ahead of the game.

00:53:24.760 --> 00:53:32.660
A/Prof Daryl Efron: so you can make a big difference to to us. But most importantly to the families. You can say one visit.

00:53:34.310 --> 00:53:36.020
A/Prof Daryl Efron: Yeah. So

00:53:36.110 --> 00:53:47.730
A/Prof Daryl Efron: it's just gathering up that information that the the question is are easily accessible and free. We usually use the van to build parents and teach you questionnaire these days, which are easily accessible on the Internet so

00:53:47.960 --> 00:53:55.910
A/Prof Daryl Efron: when we get all that information, it's fantastic and it makes our jobs easily, but most importantly, it's efficient. It's it's time for everybody.

00:53:57.250 --> 00:54:01.420
A/Prof John Kramer: Okay, thanks, Daryl: here's another really important question.

00:54:01.800 --> 00:54:09.430
A/Prof John Kramer: Do you think there is a higher prevalence in boys, or a higher rate of diagnosis that different things, of course.

00:54:09.570 --> 00:54:28.990
A/Prof Daryl Efron: Yeah. So it's clearly a high rate of diagnosis. But it does that reflect the true difference in prevalence. Look, the under diagnosis of girls has been increasingly understood, and it was highlighted in our guideline, John, you know so and and more recently women.

00:54:28.990 --> 00:54:38.330
A/Prof Daryl Efron: So when I first learned about Adhd, it was said that the gender ratio was 3 or 4 to one, and now we say it's about 2 to one.

00:54:38.490 --> 00:54:45.080
A/Prof Daryl Efron: and it might be close. It might be less than 2 to one if you know what I mean. So, girls

00:54:45.340 --> 00:55:00.200
A/Prof Daryl Efron: generally not. The heavily just goes to that H. They usually not behaviorally disruptive. Sometimes they have it, they more often not, and so they stick under the radar. So we absolutely need to be. Lift our game in relation to girls.

00:55:00.330 --> 00:55:10.250
A/Prof John Kramer: Good thanks. Now, another question. Could you say a bit more about nutrition? And and I guess i'll expand that to include

00:55:10.620 --> 00:55:12.760
A/Prof John Kramer: mocker nutrients on side.

00:55:14.160 --> 00:55:17.260
A/Prof Daryl Efron: Yeah, there's been a lot of work done

00:55:17.290 --> 00:55:27.380
A/Prof Daryl Efron: on diet and Adhd and various nutritional deficiencies. It's been mostly disappointing. There's no clear pattern.

00:55:27.450 --> 00:55:31.490
A/Prof Daryl Efron: There are some kids in there, some relatively soft evidence of.

00:55:31.580 --> 00:55:46.310
A/Prof Daryl Efron: I may get 3, and I make a 6 fatty acid deficiencies, and certainly for supplement kids with Adhd a a a proportion, get some benefit more with their learning than their attention, actually that from

00:55:46.350 --> 00:56:05.830
A/Prof Daryl Efron: fish oil, and make it 3 fatty acid, so there's no harm in doing that. But the evidence isn't strong. But there's some week evidence. So for mild adhd what we're not using medication, I would normally make sure they're getting a bit of oiling fish once or twice a week, and if they not been, I recommend fish oil, and sometimes it helps to some extent not powerful

00:56:05.830 --> 00:56:16.990
A/Prof Daryl Efron: beyond that, the important things of usual things. I. An environment B 12 in particular. There's interest in a whole range of other micro nutrients, but no, no good evidence.

00:56:17.480 --> 00:56:24.570
A/Prof John Kramer: So I just had an observation that our deficiency seems to be particularly common in this population.

00:56:25.510 --> 00:56:27.900
A/Prof John Kramer: and I don't know why.

00:56:28.950 --> 00:56:33.800
A/Prof John Kramer: Next question: what are the long-term outcomes with stimulant medications?

00:56:35.590 --> 00:56:38.500
A/Prof John Kramer: I guess I would add my question

00:56:38.660 --> 00:56:42.740
A/Prof John Kramer: there any adequate studies done? Prospective studies.

00:56:44.630 --> 00:56:59.320
A/Prof Daryl Efron: Yeah. Well, you know the answer to your question, John, that they they are not so again. A really really important question for which we don't have, and probably never will have a good answer. I mean, if you think about it scientifically to answer that question.

00:56:59.700 --> 00:57:06.160
A/Prof Daryl Efron: you'd need to get 2,000 8 year old, with an adhd

00:57:06.590 --> 00:57:15.020
A/Prof Daryl Efron: with significant impairing adhd that where medication treatment is indicated. and take half of them

00:57:15.400 --> 00:57:22.950
A/Prof Daryl Efron: for 10 years. and keep the other half on place that. and that study is never going to be done.

00:57:23.020 --> 00:57:27.230
A/Prof Daryl Efron: So so we just don't know what what we do know is that

00:57:29.110 --> 00:57:38.030
A/Prof Daryl Efron: untreated adhd the significantly at the severe range is associated with a whole range of negative outcomes. No one has shown a frustratingly that

00:57:38.060 --> 00:57:45.830
A/Prof Daryl Efron: the trading Idh day you can't put your hand on your heart and say, kids are going to do better at school or stay in school longer, or

00:57:45.840 --> 00:57:49.440
A/Prof Daryl Efron: a better outcomes.

00:57:49.460 --> 00:58:07.600
A/Prof Daryl Efron: Parents will swear that it makes the world of difference teach as well. So it makes common sense that if a child's functioning better turn by term year by year, then the prospect for longer term success or increased, but it's it's not. It's. It's almost unprovable.

00:58:08.060 --> 00:58:09.610
A/Prof John Kramer: Yeah. Yeah.

00:58:09.620 --> 00:58:17.100
A/Prof John Kramer: okay, thank you, Joe. There's another question that's asking about separating from

00:58:17.110 --> 00:58:18.940
A/Prof John Kramer: complex post-traumatic

00:58:19.210 --> 00:58:21.380
A/Prof John Kramer: through that.

00:58:21.400 --> 00:58:31.230
A/Prof John Kramer: And but is a common issue particularly the more complicated. I'd say cases and

00:58:31.430 --> 00:58:45.110
A/Prof Daryl Efron: I think we're all right to hear what you think they do. Yeah, I mean it's throwing tough questions at me, but really important ones, it's a really important question, and of course I don't have a simple answer to that. But let me just ramble a bit

00:58:46.120 --> 00:58:48.970
A/Prof Daryl Efron: the symptoms of Adhd and on specific.

00:58:49.450 --> 00:58:54.550
A/Prof Daryl Efron: So if if you're if a kids unhappy, they'll be distractable.

00:58:54.830 --> 00:59:05.240
A/Prof Daryl Efron: and that might be for a whole range of reasons. So for kids got learning difficulties that might be that the sole calls. If they're in attention, they're finding the work too hard, or if they're being bullied, and

00:59:05.270 --> 00:59:11.540
A/Prof Daryl Efron: obviously, if they've had a really disruptive early childhood with with trauma. So

00:59:11.620 --> 00:59:16.650
A/Prof Daryl Efron: we see lots of kids as pediatricians as you do in general practice.

00:59:16.780 --> 00:59:21.310
A/Prof Daryl Efron: We've experienced trauma in early childhood. They all almost

00:59:21.330 --> 00:59:22.490
A/Prof Daryl Efron: all have

00:59:22.520 --> 00:59:33.570
A/Prof Daryl Efron: symptoms of Adhd, and sometimes it's quite severe and it's very difficult to separate. What are the intrinsic developmental weaknesses about child.

00:59:35.290 --> 00:59:44.130
A/Prof Daryl Efron: and what consequences of the environment? So we have to take a pragmatic view. We have to give

00:59:44.180 --> 00:59:48.320
A/Prof Daryl Efron: trauma-informed care, which includes, of course.

00:59:49.210 --> 01:00:06.960
A/Prof Daryl Efron: counseling and therapy of different types. And you know. I'm sure quite a bit about that. So we we run with the the the Trauma and the psychological Therapies alongside symptomatic Treatment of Manifestations, one of which is often adhd, so

01:00:06.960 --> 01:00:25.730
A/Prof Daryl Efron: would we use stimuli Medication if there's been a history of trauma. Yes, we often do. Y. We often do it, and it'll help the child function better, and we'll help them be more amenable to trauma, informed psychological interventions as well, because some of these kids are so dysregulated that that they cannot possibly engage with therapy, nor ignore with school.

01:00:26.240 --> 01:00:32.720
So stimulus medication is often an important part of the whole program. But of course, on the one that

01:00:33.000 --> 01:00:37.900
A/Prof John Kramer: yeah, you can certainly have 5. I' the observation in

01:00:38.080 --> 01:00:44.030
A/Prof John Kramer: talking about that outpatient in my with Ptsd. In recent times I've started to think

01:00:44.120 --> 01:00:46.630
A/Prof John Kramer: what this patient they have.

01:00:46.700 --> 01:00:51.840
A/Prof John Kramer: and way more often than it ought to be present.

01:00:51.930 --> 01:01:04.050
A/Prof John Kramer: They are assigned. So I have a personal theory, but it's a relationship, perhaps, and maybe next week it the adult ideas, the Webinar that will be addressed in more detail.

01:01:06.160 --> 01:01:10.380
A/Prof John Kramer: There's another question. Is it lifelong therapy?

01:01:11.740 --> 01:01:15.580
A/Prof John Kramer: If you start early, that more chance of coming off as an add off.

01:01:19.540 --> 01:01:21.620
A/Prof Daryl Efron: So

01:01:21.660 --> 01:01:22.890
A/Prof Daryl Efron: when we started.

01:01:23.030 --> 01:01:34.400
A/Prof Daryl Efron: child, with Adhd on stimulants, we start with the trial usually a month or 2, and if they've had a really good response, then we normally recommend treatment for at least a year or 2.

01:01:34.570 --> 01:01:47.140
A/Prof Daryl Efron: The there was a really nice study in New South Wales, published a few years ago. They tried in Australia the average time a patient with idea it Sorry, child with Adhd stays on stimulants is 2 years

01:01:47.710 --> 01:01:57.420
A/Prof Daryl Efron: with a lot of variation around that quite a lot just for a few weeks. They didn't tolerate it, and quite a lot for quite a few years. some some for you know, every decade.

01:01:57.450 --> 01:02:11.780
A/Prof Daryl Efron: So there's every variation in the book, and there's a proportion of teenagers who want who choose to continue to have tribute to adult life. Some do some Don't.

01:02:12.080 --> 01:02:30.860
A/Prof Daryl Efron: And then, of course, there are newly diagnosed adults which you'll be talking about next week. So there, there's no straightforward answer that question, except parents are always interested in that. So it's an important question, like all the questions you've raised tonight. So I always say, look, you know, I say, what what I've just said to you, let's let's say how it works. If it works well.

01:02:30.860 --> 01:02:37.360
A/Prof Daryl Efron: we'll be at least 6 to 12 months, maybe a couple of years, and we at every point we're reviewing benefits and side effects

01:02:37.410 --> 01:02:45.080
A/Prof Daryl Efron: and opportunities to come off medication. A likely to arise at some point, whether that's next year or in 5 years it's to a week. Time will tell.

01:02:45.180 --> 01:02:48.560
A/Prof John Kramer: Yeah, there's another question that relates to.

01:02:48.820 --> 01:02:52.970
A/Prof John Kramer: but the broader spectrum of

01:02:54.170 --> 01:02:56.820
A/Prof John Kramer: digestion, of various substances

01:02:56.880 --> 01:03:01.480
A/Prof John Kramer: during pregnancy. What are the various effects? This group?

01:03:03.380 --> 01:03:08.890
A/Prof Daryl Efron: Yeah, there's a whole range of embryonic euro toxins that can

01:03:08.950 --> 01:03:24.340
A/Prof Daryl Efron: results in Adhd phenotype and alcohol is probably the most important one, so it's adhd symptoms. Adhd. Phenotype is is a part of the fatal alcohol, syndrome, spectrum disorder syndrome.

01:03:24.340 --> 01:03:29.530
A/Prof Daryl Efron: but there's a whole range, of others in in some parts of the world, like the United States.

01:03:29.650 --> 01:03:47.610
A/Prof Daryl Efron: Methamphetamated cocaine, you know embryopathy is is common, and that causes an adhd profile. The the symptoms are h to a a non-specific end. Almost any insult to the developing brain will cause adhd in addition to other other symptoms.

01:03:47.610 --> 01:03:52.180
A/Prof Daryl Efron: So if I viral infections as well in user I can cause that.

01:03:52.250 --> 01:03:59.960
A/Prof Daryl Efron: So there's there's a long list. But I I agree with starting with alcohol, because that's probably the most important epidemiologically.

01:04:00.180 --> 01:04:03.550
A/Prof John Kramer: Yeah, this question about chicks also.

01:04:03.810 --> 01:04:12.430
A/Prof John Kramer: when so that it's is that a country indication. Jerry Day to stop

01:04:13.330 --> 01:04:18.370
A/Prof Daryl Efron: another really good question. So ticks are coming in

01:04:18.380 --> 01:04:31.300
A/Prof Daryl Efron: primary school age kids, you know, particularly boys and tourette syndrome is about about 1% of kids. So it's a more severe end, and the risk is much higher in kids you've got adhd.

01:04:31.350 --> 01:04:41.960
A/Prof Daryl Efron: so it's not uncommon that we see ticks in kids with Adhd. It's not a kind of indication to stimulants. But Of course, as I've said.

01:04:42.420 --> 01:05:00.790
A/Prof Daryl Efron: we need to tell parents that it's possible that the ticks will get worse when we trade with stimulants. It doesn't always happen, and sometimes the ticks get better. The child is feeling better because this is just feel when we many kids can. Actually they just feel more confident when their brain is less busy.

01:05:00.790 --> 01:05:09.780
A/Prof Daryl Efron: and they're calmer, and they're having more success, including social success. So if they're less anxious and anxiety is one of the main drivers of ticks.

01:05:09.870 --> 01:05:25.290
A/Prof Daryl Efron: so ticks not infrequently get better with stimulants, but sometimes from time to time they get much worse and you have to stop. But that's okay. When you stop, they revert to their pre more the the the the the severity that they had before you started the medication.

01:05:25.850 --> 01:05:43.820
A/Prof Daryl Efron: If it's very severe, Of course you would try to avoid stimulants. If the If the correcting is very, very severe, then you would, and I run it to right clinic, and I see those patients, but that's unusual, but common bread, and but it takes a common in Idhd, and that's not a reason to to deprive them of steam.

01:05:43.820 --> 01:05:46.040
A/Prof John Kramer: There was another question about.

01:05:46.050 --> 01:05:52.230
A/Prof John Kramer: Occasionally some children will have a fairly flattened mood or effect with stimulants.

01:05:52.260 --> 01:05:54.960
A/Prof John Kramer: Why is that? And what can you do about it.

01:05:55.680 --> 01:06:14.640
A/Prof Daryl Efron: Yeah, there's been some research showing that certain gina types, and it's to do with the C. O. Mt. J. And I think I might have that wrong. Someone will correct me. Is this some Australian research that informed that by fly away you you would know, John, in in New South Wales.

01:06:14.640 --> 01:06:20.160
A/Prof Daryl Efron: So there's probably a genetic basis to that.

01:06:20.240 --> 01:06:35.460
A/Prof Daryl Efron: and it, but it's hard to predict, and we don't do genotyping before we start medication, but it's a real entity. It's not common, but maybe happens in, you know, 5 to 10%. And if it happens, it persist so you have to stop the medication.

01:06:36.100 --> 01:06:36.940
A/Prof John Kramer: Yeah.

01:06:37.240 --> 01:06:46.430
A/Prof John Kramer: okay, I've just been that we're going at the time, and i'm sorry we haven't been able to address all those questions.

01:06:46.770 --> 01:06:53.630
A/Prof John Kramer: I did talk with Darren Clare about tried to do remaining questions

01:06:53.710 --> 01:07:00.650
A/Prof John Kramer: justice and get you some more material. But we have to

01:07:01.660 --> 01:07:07.980
A/Prof John Kramer: call to help there. and I remind you that we've got the adult version of this Webinar next week.

01:07:09.820 --> 01:07:20.610
A/Prof John Kramer: I'd like to on behalf of the Rsa. Gp: Thank everyone for attending very big. Thank you to our guest. So I said Professor, from for sharing his knowledge

01:07:20.950 --> 01:07:26.790
A/Prof John Kramer: a passionate enthusiasm. We will send you a follow up Webinar evaluation, email

01:07:26.930 --> 01:07:38.790
A/Prof John Kramer: the slides along with the list of resources mentioned in the Webinar in the coming days, and we will, as I said, take that of your questions and attempt to do, suggest to them in the future.

01:07:38.790 --> 01:07:50.090
A/Prof John Kramer: So thank you. And good evening, everybody, and thank you especially to dial for by himself available and presenting so well, and thank you to play for organizing

01:07:50.260 --> 01:08:01.520
A/Prof John Kramer: and for adults next week, and we have our special interest group. and you'll be hearing more from us in the near future. Yeah, anything further?

01:08:01.880 --> 01:08:06.100
Specific Interest Zoom Chair : Oh, that sounds great. Thanks so much, John, and thank you. Everybody for attending and thank you, Darryl.

01:08:06.630 --> 01:08:08.860
A/Prof John Kramer: Good night. Everyone.


Other RACGP online events

Originally recorded:

21 March 2023

Join Assoc Prof John Kramer (Chair, RACGP Specific Interests ADHD, ASD and Neurodiversity) facilitates this webinar with leading paediatrician, Assoc Prof Daryl Efron (Royal Children’s Hospital, Melbourne) on updates regarding treatment of paediatric ADHD in 2023.

Referencing the newly available Australian evidence-based clinical practice guideline for ADHD, they will discuss identification and co-management of paediatric ADHD in general practice.


Learning outcomes

  1. Identify screening, investigation, diagnosis, and management tools for treating paediatric ADHD to support patients and their families
  2. Outline resources available for patients, families and GPs whilst treating paediatric ADHD

This event is part of . Events in this series are:


Assoc Prof John Kramer
Chair, RACGP Specific Interests ADHD, ASD and Neurodiversity

Adjunct A/Prof John Kramer has been a GP since 1981 based in Woolgoolga with special interest in Developmental Paediatrics, Indigenous Health, Mental Health, Medical Education, Refugee Health and Palliative Care. Dr Kramer was an RACGP Representative on the ADHD Guidelines Development Group 2019-2022. He is currently the Chair of RACGP Specific Interest Group - ADHD, ASD and Neurodiversity.


Assoc Prof Daryl Efron

Assoc Prof Daryl Efron is a developmental-behavioural paediatrician at The Royal Children’s Hospital, Melbourne, Senior Research Fellow at the Murdoch Children’s Research Institute, and Associate Professor in the University of Melbourne Department of Paediatrics. His research interests include ADHD, psychopharmacology, models of care for children with neurodevelopmental disorders. He was a member of the Guideline Development Group for the 2022 Australian evidence-based clinical practice guideline for ADHD.

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