In this episode of PodMD, Australian trained Paediatrician Dr Kai Ismail will be discussing the topic of ADHD, including what ADHD is, the risks of the condition, recent developments in treatment, the GPs role in the treatment of the condition, when a GP should refer and more.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Kai Ismail

    Kai is an Australian trained Paediatrician with a special interest in developmental and behavioural problems, neonatology and newborns, respiratory and gastroenterological conditions as well as paediatric acute care.

    Today, we’ll be discussing the topic of ADHD.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Kai, thanks for talking with us on Pod MD today.

    Kai: Thank you for having me.

    Question 1
    The topic of today’s discussion is ADHD. Kai, Can you give our listeners an overview of what ADHD is?

    Kai: So attention deficit hyper activity disorder, ADHD, or sometimes known as ADD without the hyper activity component. So it’s a long-term problem that’s centered on the five main areas. Number one, the children can easily distractable, which they fail to give a close attention to details or to stay on task. Secondly, is the hyper activity and the inability to sit still. So we include like always fidgeting, leave the seat, and they always on they’re always on the go. The third thing is the impulsivity, where there is always difficulty to wait for their turn, blurts out the anwsers and they talk excessively. The fourth one, which is the failure to organise or to plan tasks and also they often lose things as they are always forgetful and needing a constant reminder. And Lastly, because of this impairment, they always feeling frustrated. And sometimes it can be, alot of emotional dysregulation. So all of this impairment, they must present in two or more settings, and we usually compare where the children spend the most of their time, which is at home and at school.

    Question 2
    What are the symptoms of ADHD and how do you decipher this from kids being kids?

    Kai: Okay, so that is a good question. So in children, it is always essential to consider their developmental stage. The problem arise when there’s stress or maladaptive behaviour for the kids is outside the normal limit of the child’s age and also the child’s development. This may often be seen as having emotional and behaviour problem, according to the adults perception, but this may be misunderstood. So I would give you an example of a three year old boy who is hyperactive being restless, always on-the-go, and he does not like to go to sleep. So is this boy being hyper active? The answer is not. So most parents who have the contact believe that their children may have ADHD when this behavior in fact is in the normal range. So most of the two to three year old boy, they are over active and have a short attention span, which is a normal. But if the behavior is present in the older child, which is more for example after the age of four or five years old, and it happened at home and at school, then yes, we can consider ADHD as part of the differential diagnosis.

    Question 3
    What are the risks of the condition going undiagnosed?

    Kai: Yes. So if we do not detect this early, or we do not start early treatment, so basically there is always a risk of having the learning difficulties and the academic starts to decline further. And this is mainly because they aren’t able to focus, and is also associated with some component of language and speech disorder because of the impairment, usually about 60 to 80% of ADHD kids, they have underlying depression and anxiety disorder, which can exacerbate the symptom of ADHD much worse. And it also, they are also at a higher risk of having the oppositional defiant disorder and conduct disorder.

    Question 4
    What are the treatment and management options?

    Kai: So in terms of the treatment it is multifactorial. Number one, behavior management by a child psychologist is always important. Number two, the school and the teacher have to be more involved, usually it is preferred for the children with ADHD to sit at the front of the class, away from the window and also the doors. They also will need some constant reminders and assignment calenders for them. The next management is the medication. So there is always a misconception about the stimulant medication that people always thought that it is the main management to fix the ADHD. So the purpose of starting a stimulant is for them to learn at school so that their academic does not get further behind. And also for them not to get more trouble at school, it is important to know that once the stimulant medications starts to wear off, usually after 2 to 3:00 PM, which is after school, the children with ADHD will return to their baseline symptoms.

    So it is important to know that, essential treatment to for them is to have the connective beheaviour management. So talking about the medication, as all the GPs are aware we got two types, one is the short acting and the long acting. The short acting usually have about three to four hours coverage. And for the example, it’s the ritalin and the dexamphetamine and for the long acting usually it can cover six to twelve hours, and this will include Vyvanse, ritalin LA and Conserta. So all the stimulant medication, where do they do is they will increase the release and result to inhibit the reuptake of dopamine and the norepinephrine. There’s also a second line medication for the non-stimulant medication, such as intuniv and strattera, which we usually reserve this one for the not responsive, or have been experiencing some severe side effects from the stimulant medication.

    Question 5
    Have there been any developments in treatment recently or are there any in trials or development now?

    Kai: So for the past few years we do have newer products that have a less side effects, and also has been tolerated better by most children. And this is called Vyvanse. They also starting to use more of the intuniv or it is known as the Guanfacine. So the Guanfacine has been here for quite a long time and the adult physician, they always use them especially to control the high blood pressure for the old people. And so also for the past few years, we also have starting to use it more often for the second line treatment, especially those having some issue with the weight gain secondary to the severe loss of appetite from the stimulant medication.

    Question 6
    Is there a connection between children with ADHD and adults with ADHD?

    Kai: So basically children with ADD or ADHD, that it may proceed into adulthood, especially for the inattention, but for the hyper activity it tends to diminish over time.

    Question 7
    When should a GP refer?

    Kai: So basically GP can always refer to us when you suspect ADHD because one of the reasons is that only pediatricians or the child psychiatrist can prescribe a stimulant medication. Also it is ideal to refer when they also have started to have reelected problems such as learning difficulty sleeping problem, excessive impulsivity, or is there any underlying, severe anxiety or depression.

    Question 8
    What role does the GP play in the management of the condition?

    Kai: So we, as a pediatrician, we always appreciate for GPS help, especially when we started on the stimulant medication. So really appreciate if the GP can monitor the complications of the stimulants by always monitoring the blood pressure the weight and the [inaudible] how the appetite is doing, and also to look for any ticks performance, and also to have this assessment on the sleep pattern. And also we really appreciate for GP to make sure that the child and the family are connected to the child psychologist for the long-term ADHD and anxiety management.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on ADHD.

    Kai: Okay so the take home message number one, that children with ADHD, they have issues with inattentive impulsivity, and sometimes overactive, but not all the children have with this symptom have ADHD. So it’s very important to consider the development of the child, whether is it appropriate of the age. The number two is always remember that the main management is the connective behavior management through the child psychologist. The stimulant medication is only for the purpose of the school, so that they wouldn’t be getting behind in term of the academic and to avoid them for getting into more trouble at school. And lastly, that children with ADHD is really important to have for the other problems to be addressed as well, especially for learning difficulties, social skills anxiety and poor sleep.

    Thanks for your time and the insights you’ve provided.

    Kai: Thank you. And I hope that all the GPs have learned something today. Thank you.

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.