 Good evening and welcome everyone to tonight's MHPN webinar. It's never too late to diagnose ADHD. My name is Nicola Palfrey. I'm a clinical psychologist and a researcher based in Canberra, Australia. My background is not in this area. So I'm just here to guide the others that know a lot about it. I've worked mainly in with children and young people experiencing trauma. So I'm an interested observer tonight. So firstly, I would like to start by acknowledging, and on behalf of MHPN, acknowledge the traditional custodians of the lands, seas, and waterways across Australia in which this webinar is being broadcast in which our webinar presenters are joining us from today. And I wish to pay my respects to Elders Past, present and emerging for the memories, traditions, culture, hopes of Aboriginal and Torres Strait Islanders, peoples, and welcome any Aboriginal and Torres Strait Islander people that are joining us tonight. So tonight we have a fantastic panel of people joining us to talk about this important topic, ADHD in older... Australia is not older necessarily, but in adults. We've sent through the panel bios. I'm not going to go through them tonight because we want to hear from them and not just spend too much time on them, but I'll just go through very quickly. We have Associate Professor John Cramer, who's a general practitioner joining us. Dr. Maddie Derrick, who's a clinical psychologist, offering her perspective and Dr. Roger Patterson, a psychiatrist as well. So first of all, just to get you to see who we're talking to tonight, I'm just going to start with an overall question. There's many areas that all of you could be involved in, but I'm interested. I'll start with you, John, first, if that's okay. What sparked your interest in this area and your passion about working in this field? Thanks, Nicola. Child number three out of four got a diagnosis at an early age, and then, you know, diversity kept rearing its... not so ugly head in my extended family, and I couldn't ignore it. I had to learn more about it. Fantastic. Thank you. So personal and professional perspective from you tonight, John. That's great. Thank you. How about you, Maddie? Are you interested in this field of work? So, my eldest John actually was my eldest, realising he had ADHD and my second quickly followed, and then myself and our dog, we say, has ADHD too, our Labrador. And so there's personal investment there in getting this space functioning for all the people with ADHD out there. But I think as well, just as a clinical psychologist, it's a really rewarding space to work in. You get so much progress and work with some really fun characters and have a good time at work in therapy. Great. Thank you, Maddie. And, Roger, lastly, how about you? What sparked your interest and passion for this area? Yeah, thanks, Nicola. Good to be with everyone this evening. I started in running a residential unit for children 30 years ago, and we had all sorts of difficult kids. And fortunately, I was sharing the consultant load with a pediatrician who one day said to this child that we've been battling with for a couple of months. Why don't you try a little bit of Ritalin? And my child psychiatry training had been a bit remiss in this. I said I was guided by her. And we started this child on Ritalin. And to my great relief, it was a miracle. But what really got me passionate was this miracle was not mainstream. And I've now spent the last 30 years in mainstreaming this life-changing treatment. And I think we're getting there slowly, and hopefully this will be part of that process. Fantastic. Thank you. So we've got a wonderful mix of expertise, professional, personal to share with everyone joining us tonight. So I'm going to run through the bit of housekeeping just to get that out of the way, and then we'll get into the juicy stuff. So other than that, let's get into it. So we've been sent through the learning outcomes for tonight. So really what we're looking to understand is an exploration of the symptoms experienced by adults who may be affected by ADHD. The benefits, while I bother getting a diagnosis later in age and a multidisciplinary approach to working with adults living with ADHD. We'll look at the signs and symptoms of ADHD and common co-occurring conditions. That's a hard thing to say. Discuss the use of appropriate language so we can fight against stigma and negative narratives. Goodness me. People living with an adult ADHD. As I said, the benefits of a delayed diagnosis and treatment and the benefits of using a multidisciplinary approach. So everybody has had the case study. We're not going to recap it in any great detail today because we'll expect that you've had a read of it and the panellists will be taking us through their approach if they were working with a case like this. So without much further ado, I'm going to hand over to Dr John to take us into the webinar. Proper. Thanks very much, John. Thank you, Nicola. Just to remind everyone, Brianna is 36. Been married to Ashley, who's a surveyor for eight years. They've got two kids, six and four. She's working part-time as a mental health nurse and she's running to strife. And as you can see from your knowledge of the case, she needs help now. She's in crisis. And what can the GP do to help? Because we are typically the first point of call. What resources are available as you scramble to see what you can do to help this woman who is in major strife? Next slide. Okay, so first thing to do is to validate her concerns. Her distress, her angst, it's all absolutely real and it needs to be validated. The last thing she needs is someone to undermine her genuine grief concern. From a medical perspective, you need to look for other causes of mental health crisis, depression, are there any threats of self-harm, et cetera. Finding out what resources are available immediately to her. So that's personal and professional. Family, everyone has a family and some are more able to assist than others but you've got to dig to find out. I put a range of referrals ASAP given a long waiting time to get in to see just about anybody. So the earlier you get the referrals happening the shorter, well, it won't make the waiting time shorter but it'll have the clock ticking down. You do need to keep your regular eye on them because as I said, she's in crisis. These days, thanks to COVID-19, we have telehealth item numbers and if that's more convenient for the patient they can be used to monitor things. One of the early things you'd be doing would be drawing up a mental health plan if there wasn't one existing which is going to help her with Medicare costs of some of the psychology visits. It's important to bring the nearest and dearest along so Ashley needs to come to the next appointment. There was a reference to her child, Louis, having ADHD. Now, we don't know whether he's floridly ADHD, whether he's treated, whether he's under control, whether he's not a major problem. You need to identify what's happening there because one of the ways to get her out of the crisis might be to address one of the needs of her children. Occasionally, some sort of medication might be needed in the short term and I'm not talking about stimulants. I'm talking about anxiolytics, something to help her sleep. Next slide. She needs a team. So, a GP is the best place to coordinate. She's going to need a psychologist. She's going to need to develop a lot of strategies. ADHD coaching is very important, particularly when you've got more than one ADHD individual in the same house, which is quite common. If you, after you've taken a good history, you think this is undiagnosed ADHD, then you know that she's going to have to see a psychiatrist because you may well need to have a trial of stimulants. A husband and extended family, if there are grandparents around who can take the children off her hands and give her a break, that's respite care. Relationship counseling comes into it, not immediately, but if she does proceed to have a similar trial, then she's going to have to renegotiate her relationships with all the key people around her. And also, she needs to be offered online education and links to various resources so she can learn more about it. Next slide. So, what happens henceforth? Why are you waiting for other things to happen? You've got to keep a close eye on this. You've got to monitor her degree of anxiety, pending other reviews. You've already initiated a psychiatry referral, but you know from dealing with other patients like this in the past that a psychiatrist is going to want validation evidence from the childhood of this person about ADHD type features going right back. Some people do have access to school reports. If there's no access to school reports, sometimes I'll ask a patient to get their parent to write a one-page reflection on their childhood. There are questionnaires, of course. We have the ASRS, which is a fairly simple one. A Diva 2.0 is freely available. She needs to be given access to information. After you've done your referrals, it's wise to make sure that the referrals have been received and appointments are in place so that you know how long you have to support the patient before the other people can kick in, as I've said below. So that involves booking a series of GP visits. Some of those could be on the phone by Telehealth. I've mentioned Louis. We don't know the status of his ADHD. If it's a problem addressing that or getting it addressed is a very important thing. In the very long term, she may come back to the GP or soon when prescribing if she's been confirmed to have the diagnosis of ADHD and the psychiatrist wants to send her back to a normal GP. Next slide. Okay, access, the elephant in the room. We all deal with this. It's one thing to recognize the crisis. It's another thing altogether to get the services mobilized and the patient seen. So waiting time. Many, many months for psychiatry. Now it's not their fault. There aren't enough of them. It costs. So if somebody can't afford six, seven, eight, $900 for an initial visit, they're going to be struggling. They've got to see someone that actually knows what they're doing when they get there. In the COVID age, we've had a fortunate kick on to telehealth. Virtual assessment can work quite well for some of these patients. And going back to the elephant in the room, we have to mention the absence of public sector mental health access for ADHD adults. That's a structural problem, a major structural problem in our healthcare system. Everybody here would be aware of that. And we have to try and do what we can to change it. Next slide. So while we're holding the fort, what can we do? Well, we've got a whole family here. So we have to look at all of their needs. They've mentioned if the ADHD, six-year-old isn't well-controlled, we might be picking up at the phone and trying to seek an early pediatric review for that child. Mobilising support networks. If they're extended family members close by, bring them in. Support groups, so ADHD Foundation, ADHD Australia, and so on. Coaches can, if they're not overworked, can respond more quickly than many professionals. It's important to confirm that the appointments are actually going to happen. If Brianna is so disabled that she can't manage at home, then her husband should be allowed to take some carer leave from work, and you might need to provide certificates for that. As time goes by, the referral that you've done for the psychiatrist can be enhanced by bringing back questionnaires that you've had completed, school reports, et cetera. And I've touched on using telehealth to monitor the condition. Next slide. Maddie, it's your turn. Thank you, John. So I want to just very quickly start with pointing out some things that jump out of the case study to me. If Brianna hadn't been questioning ADHD herself and her referral to men's psychologists or something else, these particular factors in her presentation would be alerting me that I need to consider ADHD amongst everything else there. The oldest someone with ADHD is the further removed their presentation seems to get from DSM criteria. And this is also the case for females and also the case with people with higher-than-average intelligence. We can get a lot of compensatory measures that people develop over time, whether they're aware that they're using them or not, and also masking that can make it hard to see the symptoms or the symptoms even look counter-intuitive. A great example being someone with ADHD saying, I'm so disorganised and their friend saying to them, but you're the most organised person, I know, you're obsessively organised. That's a really common thing we hear. With these secondary outcomes of ADHD, what happens when it's unrecognised and unsupported, untreated, we can end up with some coping habits, maladaptive coping particularly, which can start to look like other conditions. And this is where we can get a lot of misdiagnosis with ADHD. Next slide, please. So, I've pulled out the conditions that Breanna in our case has been diagnosed within the past. I think this is a really good set to, as an example, to highlight common things we see on referrals for people seeking ADHD assessment. And this particular set is very relevant to women, and I should say, as well with some of these, I keep saying women and females, there is increasingly aware of higher rates of gender divergence amongst people with neurodivergence, but do want to acknowledge that when I'm saying women and females, I do think that should be relevant to non-binary people as well. I've got a lot of information on this slide and the next one, so I'm just going to point out a few key things and I'll leave the rest for you to read, to your leisure. We're borderline personality disorder. This is one that a lot of women with ADHD will collect up before the ADHD diagnosis, often around the age of 18, 19. And if we think developmentally, where females are at this time in life, in terms of their life context, they're experiencing adult relationships in more sophisticated and intimate ways, but you couple that with emotion dysregulation and impulsivity and novelty seeking. And we start to get a pattern of experiences that looks like borderline personality disorder, but if we wait a couple of years, that can often change that point. Another pivotal time for women is having children. So if you think of what staying at home with a baby 24-7 looks like, it's absolute kryptonite for the ADHD brain. Thank you. Next slide. Oh, no, sorry. Back one slide. Wasn't quite ready for the next one. Thanks. It's, you know, the task of looking after a baby, it's monotonous, it's repetitive, it doesn't matter how cute they are, or changing nappies, pushing bottles, etc. There's nothing, there's no fuel in that for the ADHD brain that really relies on reward centre, reward pathway activation to get energised and activated. So for a woman with ADHD, it can be very draining every day, chronically, to get through that important boring stuff. And we see burnout really quickly, and we'll see low motivation, low mood, perhaps a lot of anger, perhaps numbness, and then we can end up with postnatal depression diagnosis, which may genuinely be co-occurring, or it may be secondary to the ADHD. Next slide. Thank you. Social anxiety is probably the most common thing that I see on referrals in terms of co-occurring or pre-existing conditions. With ADHD, I don't think I've ever worked with an individual who hasn't developed learned hypervigilance to negative judgement over time through their experiences. And this will commonly present itself in, by replaying social events and interactions over and over in their mind, ruminating, very hyper-focused, and checking and thinking about ways that they've possibly offended someone. There's been a faux pas, they've forgotten someone's birthday, or someone's mother died, or they didn't apologise enough for being late, or someone misinterpreted what they said and has taken offence, and when there is something detected that embarrassment and shame can be a really intense feeling, and very much look like anxiety, there's a different pattern that plays out compared to a genuine distinct social anxiety. I'll leave you to read the rest for those other ones. Next slide, please. So, the benefit of getting a diagnosis and intervention is, of course, what we all want, quality of life and well-being. That's a little chart here. Put together to try and highlight that when we combine pharmacological intervention with non-pharmacological intervention, we're really optimising that opportunity. There's a synergy that happens. Talk for hours about all the details of how, but it's a worthwhile pursuit at any age. It's not just about improving functioning. It's not the point of diagnosis and intervention alone. I find that it's about improving how comfortable someone is in their own skin, and even the later stages of life where there's not a lot of demands on you, everyone wants to feel comfortable in their own skin. And it's sometimes the case that people have been dismissed in their concerns because it's being said, oh, well, you're about to retire or your children have left home, and, you know, there's not so much demand on you now, whereas I think there is this other aspect that people need to consider. Next slide, please. And this is an excerpt from a piece of writing that a client of mine wrote. I think it really beautifully, she writes beautifully, captures what diagnosis achieves and particularly their very important and meaningful role that that shifting self-concept that happens, that movement towards feeling comfortable in your own skin. Next slide, please. So to get there and to get that lovely final self-actualization stage of therapy from a non-pharmacological perspective at least, we've got some tough roads ahead because we have the very deficit heavy model of the DSM to work within, even the name ADHD in itself carries a deficit load with it, and we've got a whole lot of stigma and public debate. So I think it's important, right from the get-go to be very conscious and methodical in working against that all the way through and buffering against those negative narratives. For me the starting point is to name it up, and John pointed out to validate them. This is a really really key stage and for some clients it's quick, they've done a lot of it themselves for others that they need to spend a fair bit of time there and there can be all sorts of grief that comes up and you can't hurry things and move forward until that person's been able to have that moment to process sufficiently. From there I find it really really helpful to use an environment fit framework. So rather than discussing challenges due to the cognitive profile inherent in the person we talk about challenges that are created due to the interplay between the cognitive profile that particular aspect of their cognitive profile and the environment and what it's demanding of them and we tend to talk about self regulation to summarize all the parts of ADHD. If we use that environment fit framework then we can talk about the challenges and then in a really balanced way switch to talking about the strengths and the opportunities with that exact same aspect of their cognitive profile and talk about environments where that could instead lead to a really positive outcome for them. Likewise with coping we definitely we're doing a bit of an audit on their coping habits and looking for the less adaptive coping and trying to replace that with more adaptive coping but equally perhaps even more so we're identifying what they have been able to do to cope and to survive and do as well as they have and people with ADHD due to strengths in their typical profile are really really resourceful and often done some amazing things and just need some help to be able to recognize that themselves. That's it for me thanks and Nicola over to you Roger. Thanks Maddie. I'm going to say a few words generally about ADHD and I'm going to take most of my evidence from the recently released guideline put out by the Australian Association Australian ADHD professional association when I say recent it's only a few weeks ago but you can get it on the website free and downloadable. Next slide please. Just to reinforce what other people have said today that language is important and we should talk about lived experience and care and difference in neurodiversity rather than some of the old fashioned stigma and pejorative language such as naughty brat trying to avoid that and other things. Next slide please. Now is concentrating important which is a fundamental aspect of ADHD after all. Well yes if you get out of bed each morning and have trouble concentrating your day is going to be stressful from the get go and as we've seen in the case of Brianna if you can't concentrate it gets in the way of all sorts of school work family life event situations you've got to be able to organize and cope otherwise it leads on to all sorts of comorbidity and often people seek solace with substance abuse we've heard the history in her family it's very expensive untreated ADHD in Australia costs the Australian economy 20 billion dollars estimated by a Deloitte report that's 20 billion which a lot of money it's quite common 800,000 people, children 5% adults 2.5% so you can see that adults sort of seem to grow out of it a bit although I suspect they just learn how to manage and cope with and focus on their strengths rather than their weaknesses a few more boys and girls in kids in adults it's pretty one to one with males and females and the rates of medication people often say we're over prescribing in fact we're generally under prescribing which is what we're trying to do with this mainstreaming exercise and other things is to try and get the prescribing rates somewhere up near the actual prevalence rate as you see children at 2% prevalence rate 5% adults prescribing rate 0.3% adults 2.5% so we're way under an adults and we need to do something about that without it there's all sorts of cost of productivity, education, justice system cost, health system costs etc just to remind us that it's called attention deficit hyperactivity disorder but it's really attention dysfunction because a lot of patients with ADHD can concentrate but only if they're really interested and they can hyper focus which can be a problem and if they're bored they sort of switch off completely so it's full on or full off when really a concentration should be like a dimmer switch a bit on a bit off not one way or the other and the common features as we heard apart from the concentration some people are very overactive and some are more dreamy and they're the stress in patients temper and comorbidity which is the key thing as Matty was pointing out is the rule a lot of other associated conditions emerge with with adults presenting they've had a lifetime of stress and no wonder they end up with all sorts of other conditions next slide please John mentioned some of the questionnaires in children the SNAP4 is popular because it's free a lot of pediatricians use the Connors in youth and adults ASRS which I use a lot or the Diva5 a structured diagnostic interview I tend to screen for emotional dysregulation as well which is very common in ADHD I use the DAS but there's other questionnaires there the DAS is free and readily available next please and there's the ASRS if they tick there's the first six questions in the DSM5 there's 18 questions for ADHD there's the first six which is the most important screen if they get four out of six in the gray area they're very likely to have ADHD next slide please and the other 12 questions are there if they keep ticking a few of those gray boxes it's looking very likely next slide please just a few words on the etiology what we're finding really was the ADHD brains it's sort of a good news story because they are underactive they are immature but they get there the good news is especially for women they tend to get there a bit earlier 25 for females the male brains mature around 30 or never unfortunately for some males and simulant medication may well help this maturing process rather than hindrance so it's important that we note that medication does not get in the way next please after getting into medication it's important that my patients understand what they're talking about so we talk about psychoeducation and accommodations and lifestyle the stuff that was made he was talking about I do it briefly and then they really need to spend much more time with psychologists and coaches doing it extensively next please for instance the questions often put to the first interview my dad says that ADHD is not real well he's likely to have it and is in denial but it is a bit genetic is it their fault? No that's very important they've been blamed for all sorts of things but this is not their fault will they grow out of it? Possibly what's the best treatment? A combination of medication and therapy and often in that order because once patients are medicated they do better in therapy they're likely to need to be on medication throughout their schooling and then often mid-20s or so they may be able to start coming off their medication it'll turn them into a zombie if they're taking too much and it's all about fine-tuning the medication and get it just right unfortunately I said to my patients this medication is not addictive and you'll have to remind yourself to take it so no it is not addictive next please and there's more things we talk about there is positive aspects of getting the diagnosis a lot of patients go through a grief and adjustment process quite a few patients are in tears at the first interview thinking oh how my life could have been different if only my ADHD had been treated much earlier and we discussed various environmental education employment issues, social issues be careful about substance misuse a lot of patients abuse alcohol and marijuana especially to try and calm the busy brain and especially for my teenage patients who are learning how to drive they must be very careful to take their medication at all times to improve their concentration next please so again some lifestyle modifications won't go through the whole list but it's important that ADHD treatment is seen as fine tuning the patients need to be able to have the basics of life right they need to be sleeping exercising calm in a good workplace getting help for their other issues of addiction, integration eating well and when everything is going well then the medication is the best chance to work because it's very much a fine tuning medication next please as they say ADHD is easy to treat but hard to treat well the stimulant medication and other medications are generally broadly helpful but to get them just right requires extra effort on the part of the therapist next please the medications that are particularly effective are the stimulant medications they're effective, they help wake up the analogy we use is the brain is like an orchestra but there's a sleepy inactive part of the brain the inferior prefrontal cortex but particularly which needs to be woken up so the whole brain the conductor can take charge of the whole brain dexamphetamine and methylphenidate are the two most helpful dexamphetamine invented in 1940 now we have some long-acting forms vivants and compounded dexamphetamine and methylphenidate invented in 1950 to copy dexamphetamine and we have some long-acting ones Ritalin, LA and Concerta and they're very effective as you can see at this table of medications methylphenidate and amphetamines are way up the top with very good powerful effect sizes at amoxetine the two other medications we use are also fairly high up look at where SSRIs for depression considered effective, not so good and antipsychotics for schizophrenia 0.25 next please they are effective and they are very clean they're a pleasure to work with the only tricky thing is to get the dose right so I'm Dr. Fine Shun, the Goldilocks method where not too hot not too cold just right, we have to get the dosage just right with this titration over the first days and weeks, aiming for that sweet spot maximum help, minimum side effects so I see my patients very frequently for the first six months and then gradually space them out once we decided what the dose is, I keep an eye on the blood pressure and weight, particularly in kids adults don't mind losing a few kilos but in kids we worry about it that's probably one of the most common side effects loss of appetite and height starts to slow height starts to slow, we've got to do something about it long term use is justified as long as it's effective so occasionally we have little breaks just to make sure it's still as effective next please now if dex doesn't work, we try Ritalin if that doesn't work, we try the long acting ones we keep moving around until we find something that's helpful I tend to with my patients, I start them on dex and fetamine for the first week and a long acting dex and fetamine, at least dex and fetamine by vans for the second week, so when I see them two weeks time, they will have had a trial of a short and long acting at varying doses to see what suits them I try and see them within two weeks, sometimes that's not possible for some patients who are fair way away but often my patients are now doing a lot of telehealth so I usually try and be fairly prompt for my first review appointment for the if after the first few weeks, they're not doing well on the dex or long acting dex we switch around and try Ritalin and long acting Ritalin, so within the first month they've usually had a trial of most of the medications for the little ease I tend to start with meatloft venendates a little bit gentler and not so many side effects but for mid teens and adults onwards I always start with dex and fetamine next please and we continue to try trading over the first few months and ideally patients stabilize on the long acting one but sometimes they prefer the short acting but long acting formulations are always better particularly for school kids and more even affect less misuse the final medication I find with a lot of my patients is a combination of some days the long acting some days they go back to the short acting sometimes they use the short acting to kickstart the day then take their long acting or maybe top up at the end of the day next please and long term news is the good news is that people don't change their dose much and I can see a lot of my patients six monthly or even longer with GP involvement some patients talk about the medication wearing off and next tolerance occasionally happens but not very often how often more one in 30 of my patients I guess and those patients are instructed to take some breaks one day a week few days a month or a few weeks a year it reboots and resets the system next slide please there are other medications just to finish off the last few slides Atamoxetine once daily originally an antidepressant but had some good attentional properties that's probably my next line guanfacine has come in over the last few years often very useful as an adjunctive given in the evening helps with the emotional dysregulation and with the concentration I use conidine a lot to help my patients wind down at the end of the day and also it winds down the hyperactivity of ADHD winds down the effect of stimulant medication very useful old-fashioned blood pressure pill not addictive not dangerous and cheap sometimes we look at some of the stimulating antidepressants and John was talking about what he can prescribe as a GP while they're waiting and some of the antidepressants such as bupropioncyban fluoxetine can be stimulating can be very helpful next please the good news is the medications for ADHD are cheap they hang on I think that's the wrong heading for this particular slide but this is a slide about the cost and the medications are very cheap which is good news Ritlin and Dex are cheap for all ages we run into slight problems if adults were diagnosed over the age of 18 when it becomes more expensive under 18 you can still get them cheaply but over 18 for newly diagnosed adults like Brianna she may be paying a bit more for Ritlin LA Concerta and Atomoxetine but they're not horrendously expensive which is good news next slide please there's going to be some handouts that I give them a lot of my patients handouts because you're chatting to them they're really in a state of shock after the first appointment and adjusting as I say the grief at the diagnosis of the lost opportunity so handouts are important and they will be handed out to you after the talk next please this is a busy slide but the good news is if you're going to be prescribing it for those prescribers out there on this webinar look up your state and look up what you need to do in terms of getting permission and how to allow these with GPs whether they need a urine drug screen what ages you're allowed to treat are stimulants allowed for other conditions other than ADHD well yes most states allow them for depression and by advanced for being cheating disorder and there are maximum doses there set by the states most of them have maximum doses so that's on the adpo website that you can go there and that's available for you next slide please and now the alternative therapies the good news is they well there are not many great alternative therapies in particular neurofeedback is still up in the air as to whether it's useful or not and the other ones you can see there they're tried but not terribly successful compared to the proven therapies of medication and cognitive behaviour therapy and coaching next slide please now of course we've mentioned that mainstreaming has happened that's been my life's task over the last 30 years but in some ways we're getting quite successful at it now but that's a problem because demand now outstrips supply so we're trying to get more pediatricians and psychiatrists we're trying to get more GPs co-prescribing and watch this space I think things are going to be free up over the next year or two next please and final slide all of you are encouraged to join the Australian ADHD professional association you can be a full associate or student there's room for everybody we're trying to make sure that there's evidence based research diagnosis treatment management of ADHD for everyone's benefit as we say bad practice anywhere good practice everywhere so I think that's it for me hand back to Nicola beautiful thank you everybody that's a lot of invasion to take in but it's lovely to hear everyone's perspective and hopefully we've got quite a bit of time for Q&A so we'll pick up on some of the questions and get into them if that's okay so I will run through some of the ones that we've come through if you've got questions remember you can put them in the question and answer section and send them through and I'll receive them here I've got a quick one which I think Roger it may you may be best place to answer there's a question about the ASRS is that also used for autism screening? No it's just the 18 items of the DSM-5 for ADHD so and it's freely available but no it's not for autism. Excellent okay thank you now this has come through from a number of people I can't name them all it's probably half a dozen or eight questions from different individuals asking about ADHD coaching what is it, who does it, what's involved so I think you've all mentioned it individually I don't know if anyone particular but I might start with you John you mentioned it to start off with could you give the audience a little bit of an idea of who might be an ADHD coach what do they do and how might people access them? Yes I'm fairly new but I'm becoming a convert given that when there's an ADHD individual in a house there probably be some others and therefore the household is chaotic some way to bring order into that chaos structure, routine can help everybody to function better now that's not a health discipline but it's common sense the ADHD individual just can't manage that due to the executive dysfunction so having somebody who can come in as an outsider and have greater credibility and help to create more functional routines within a household can be very very effective. Can I just add to that John that was I'm often told by my coaching colleagues that pills don't teach skills pills don't teach skills so my pills help the brain improve so it's ready to function but then they've got to learn various things that they should have learned from a young age they've got to play a quick catch up and they go off and see coaches and psychologists to learn strategies and skills so they can quickly come up to speed with their organisational skills and time management and relationship skills etc so that's why I'm putting that is you've got to reach them to teach them Yes. That's great. Maddie, did you want to add in? Yes, look just from the perspective of the guidelines, the clinical guidelines that came out ADHD coaching was recommended as that could be done it's one of those things where anecdotally you get a great coach and they do amazing work with people that it's early just for ADHD coaching in terms of research we just don't have enough studies to back that up sufficiently at this point to have given that a really strong recommendation in the guidelines but something to note is that a lot of what ADHD coaches do when they're doing good effective stuff with ADHD does sit within part of a CBT framework and there's more information about this in the guidelines and because ADHD and allied health professionals will incorporate aspects of ADHD coaching but of course it's much harder so ADHD coaches are a fantastic resource they're a lot more available at the moment if people are referring their patients and clients to coaches it's tricky because it's not regulated in the same way as things are for health professionals so perhaps just having some conversations with your patient or your client about what they're working on, what's being covered and checking that in the guidelines just to be sure that yes this coach is obviously very well trained and he's doing a good job with your person you're referring Great, thank you I've got a question that's come through in multiple different ways but I'm trying to pull them together so everyone who sent questions I can't go through all of them but I'm trying to kind of synthesise themes I might stick with you Maddie just to start off with and then we can throw to the others as well, to Roger and John. We've talked a lot about co-morbidity from a psychologist's perspective where do you start? In terms of teasing out diagnosis wise what's happening? Where to start we feel very overwhelming for a patient who's coming in and now as you say they might come in with all the letters after their name they've been helpfully attributed over the years and we've all seen that and then if ADHD gets added how do you know where to start with a patient because we talked about that grief and overwhelm and so forth so do you have a news going through to help unpack that for people? I think it helps that often if you are adding the letters ADHD to their list of conditions you're probably taking a few others away in the process and if you're explaining ADHD in a way to a client and they're not identifying it it's not gelling for them and they're not having huge penny drop moments then you're probably backing up the wrong tree because what invariably happens is at this point at least until we've had this huge increase in awareness around ADHD we all have gone through every other diagnosis searching for themselves for an answer for something that's that and felt right and seemed to explain their difficulties and whether they came across ADHD or it's something you've started gently discussing with them I find it's always a huge relief and if you are backing up the right tree then just that recognition and people very genuinely are quite blown away how could this have not been picked up before this makes so much sense and nothing else quite did so I guess I don't find it difficult to bring up where it can be difficult to bring up is with a parent who's not ready to look at that for their child and then yeah we need to try carefully we need to talk about focusing on the outcomes that we can achieve and dispelling some of the myths and the stigma it's probably worth saying that most of my patients come in already having had a label of anxiety or depression often on an antidepressant as well and then we discover that ADHD is a primary problem and when we start the ADHD treatment with medication and therapy often their emotional issues seem to just melt away and they can come off the antidepressant that is the emotional difficulties were secondary to untreated underpinning ADHD and not a primary comorbidity sometimes not, some patients have their ADHD treated perfectly and yet they've still got a coexisting anxiety or depressive illness that needs treatment in its own right but it's important to make that distinction between a primary or secondary associated emotional disorder Thank you, John did you have anything to add to that conversation? Just that it's not uncommon to find an adult that has been previously diagnosed with bipolar disorder and when you go into the fluctuations in the mood you realise that these are things happening on a daily basis rather than a weekly basis and that the original diagnosis needs to be reconsidered completely the other thing I'd mention once in a while you'll encounter an adult that is functionally illiterate they may or may not have behavioural or mental health issues but these are the people that have slipped through the system with dyslexia whatever else and fortunately they've managed to survive because there's been enough scaffolding around them but they just never learnt to read or write and if you can go into the background you will often find that it's something like dyslexia and ADHD is one of the common strategies to that condition Great, thank you there's a bit of a jumping off point from that and I wonder Roger if you want to address it there's been a question in the chat about medication with a patient who may we believe have the criteria for ADHD but has also had episodes of mania Yes, you've got to be pretty careful in that situation as John was saying sometimes bipolar can masquerade as ADHD but if you think that they may well have a manic illness as well then that really needs to be brought under control and then you can tackle the ADHD and it's worth tackling because if you manage their ADHD and generally decrease the amount of stress in their life that's likely to lead to less manic episodes in the future so it's not a contraindication but you first must stabilise the mania or full blown bipolar disorder or even psychosis in certain situations if they've had a brief drug induced psychosis for instance stabilise that before addressing the ADHD Yeah, so it's all that comprehensive assessment I suppose and history taking and why those different multiple sources could be really important as you're kind of gathering the information and history taking of people I can't stress enough what John said involving relatives I've got a child psychiatry background so I'm used to inviting relatives in but even my adult patients I say first interview please bring someone along with you and often they keep coming with them which I think is a fantastic resource for ongoing support and information so my adult psychiatry colleagues are probably not that used to having nearest and dearest in the room as well as the patient but I would urge them to adapt their practice and in fact in general I think it's in general psychiatry I think it's used not just for ADHD Thank you, there's again a lot of questions coming through and we won't get through them all but a couple of common themes one of which is again comorbidities or co-diagnosis or interaction I suppose between the two and the first one that's come through a number of times not unexpectedly is the role interplay between exposure to childhood trauma or complex PTSD and ADHD and I know this has been a topic for a long time so I'm wondering if anybody wants to weigh in on that in terms of again disentangling maybe early childhood experiences of adversity and trauma with some of the symptomatology of ADHD and how we might address that anyone want to leap in first I'm happy to I guess when we think there's a few angles on this we think about intergenerational patterns of ADHD but that's unrecognised and unmanaged and what can happen there the secondary outcomes particularly substance use is a coping mechanism then amongst we looked at a cohort of children with trauma I'd expect we'd find higher rates of ADHD if we had a really concrete biological marker that we could easily pull out and disentangle the two having said that there's plenty of people around with ADHD without any trauma at all I think the way I hope I'm speaking on behalf of other clinicians here as well in suggesting that if you have genetic vulnerability there for ADHD and experience trauma then it's much more likely that ADHD is going to be expressed and expressed with more clarity than it might have been without the trauma I think from an intervention perspective something that always comes up is people wanting to disentangle but is it ADHD or is it trauma and I kind of feel like at the end of the day if we've got those symptoms of ADHD then why wouldn't we treat them regardless of where the cause has come about we're talking about something that has happened with the development of the brain that is different on the end of the bell curve and to me it's a bit it's not useful to delay ADHD treatment because we're thinking it may just be trauma and what I think this is probably tied up in is actually a bit of stigma in the idea that bad parenting creates what people might think is ADHD and so parents to cause the trauma if the parents just get some parenting guidance due courses and supports then that will somehow magically turn the child's brain neurotypical thank you I think you make a really good point which we see a lot from different angles so I'm coming at it from that trauma background and people can get caught up on whether or not or how big or not the trauma capital T, little T might be and it's less about that more about what actually supports the child at a young person Nicola I'd like to comment I have a number of PTSD patients typically police officers and ambos and in recent times when I've learned of this link between trauma and ADHD I've started to inquire of the individual about their childhood and school experiences and so forth and I can think off the top of my head of about four, now this is an N-equal four trial it's not particularly scientific but in four of those cases they've had at least one child diagnosed and treated with stimulants for ADHD so there's a definite link I don't know what it is whether the ADHD individual is more vulnerable to stress, to trauma but I'd like to see some studies done on it if they exist I'd love to hear about them but I suspect they may not have been done My understanding is that there is increased vulnerability to PTSD when you have ADHD and from the lived experience perspective I think the intrusive imagery and the difficulty with controlling your attention and where it goes and being able to switch off replaying a car accident for example that probably adds to the development of PTSD alongside whatever genetic vulnerability is there but it's also interesting John that we're talking about police and ambos concentration of people with ADHD amongst emergency services in emergency wards in hospitals any environment where there's crisis you need to respond quickly it's not about necessarily planning long into the future those are environments that people with ADHD seem to thrive in Thank you Yes that's right and I've also heard and said that the ADHD individual thrives in a crisis where they do well in an emergency situation they may unravel afterwards but they're extremely competent during the event Yes We always joke at our house about my husband says well I'll be right in the zombie apocalypse where all the ADHD is in the house to look after me I would say as someone who's married to a chef there's a fair few in the hospitality industry where it's really useful to be able to manage a lot of things at once and I have competing demands Roger did you have anything to add on that topic or should we move on to millions of other questions we have Let's keep moving that was well addressed Excellent thank you Okay one of the things there's still lots of questions on coaching coming through and more information so I don't know if we can maybe send out some more information or if there's anything else I think people are kind of I don't know if we've conceptualised it enough for them so I think there's a register and we can attach that to one of the handouts after this session That's great, that is fantastic The other co-morbidity that people are asking about is autism and ADHD so I think it's a good idea to make sure that a coach is a coach you know what the credentials are so would we direct them to the guidelines Yes start the guidelines and Roger is an international coaching and ADHD so again I was thrown out to the panel anyone who wants to kick off that conversation around co-morbidity or differential diagnosis with young people or adults who may have both query both those sorts of things Nicola the figure that sticks in my mind is that approximately 50% of ASD individuals will have ADHD Now whether it's 60 or 40 or 50 doesn't really matter if you've got an ASD individual you've really got to look hard to see if the ADHD is there So assume maybe you know Disprove it Thank you It's a tricky differential big Venn Diagram we're always drawing up in supervision to nudge out the questions to differentiate the two but most of the time if we're at the point of considering ASD as a differential we're probably at the point of considering it as co-occurring or often a common outcome of an assessment might be ADHD with ASD traits or ASD with ADHD traits but yeah the crossover between the two is enormous that executive functioning impact is sits with both And again I think one of the things when we're talking about all these the co-morbidity the conditions or the ways that people move through the world it can be unhelpful to split them all out don't you think and other things that you think across all of these could be core components that each of you would speak with with your patients or clients about quality of your life and functioning and so forth does that make sense? I feel like sometimes we're like oh it's not that it's this it's not that so then we have to shift everything but actually core skills or adaptations you guys have talked a lot about that they have them already are there certain things that can be helpful to move away from specificity in a way into making people feel like they already have some competence does that make sense as a question are there any things that you often work with your patients about to help them feel to do that coaching and adaptation along with medication? Oh I thought I understood the question but I've just lost it now sorry Nicola maybe if John or Roger were following they could answer well yeah I mean it's a ASD and ADHC as John said they overlap a lot and it's important for us to detect it particularly when patients and their families looking for support NDIS will support ASD but they won't support ADHD unfortunately and so and ADHD tends to be much more responsive to medication of course and ADH and ASD more to behavioral strategies so yes there's important comorbidity and people are still slipping through I mean I saw a couple of adults at the end of last week and they come along they've never been diagnosed with ASD but just chatting to them they clearly had the good old fashioned Asperger's style of interacting and they warmed to the diagnosis they said that explains why people find me a little bit unusual and I usually monologue about my favourite interests rather than joining in a conversation appropriately and they didn't want to take it any further they were just appreciative of the psycho education and they understood where they were coming from so yes it's important to be aware of these things for all sorts of reasons I think probably something I could add Nicola is that the just in the time that I've been in this space in the last seven years there's been a movement away from ADHD treatment being very strategies focused and trying to correct to normal and more getting on board the neurodivergence train that the ASD community have led and the end goal being not wanting to be neurotypical and normal and appreciating your neurodivergence what it's worth yes certain environments with ASD for example certain environments but an aspect of someone's job that's really really important to them and a really good fit they might put everything they've got into some concrete approaches to social interactions to get parts as one tricky part likewise with ADHD we're not going to drain ourselves of resources we're not going to be neurotypical we'll work a lot on acceptance of this is just the way it is and we wouldn't want a good environment fit the phrase neurospicy has come across my socials lately and I really really like that one neurospicy covers it all well I think I think I asked a really confusing question I apologise I suppose I was thinking about what you guys have all been speaking about is particularly we're talking about adults they are they have managed and coped and in the case study just having a really difficult time but it is incredible what people have managed on their own so the adaptations they've made and the work arounds and so forth so I think you've all talked a bit about rejoicing those and maybe building on them so I've got a couple of really specific ones that I might try and flicks through before we go to recap yes there will be a recording of the session I'm not going to answer all of those questions I think this might be for you Roger can stimulant medication trigger a psychotic episode yes in theory but in practice very rarely when I first started many years ago with all the stigma and what have you associated with stimulants I was taught that one in four of my patients will become psychotic if I started them on dexamphetamine or Ritalin one in four so I started very cautiously now I would say I see perhaps a few a year where they have some paranoid ideation perhaps a brief psychosis if they've taken way too many often associated with some marijuana but in clinical practice fortunately it seems to be a very rare occurrence and if it does happen it doesn't necessarily exclude patients from being on stimulants if they've been on dexamphetamine they can trial Ritalin but you have to work closely with your local health department to get permission for that thank you sorry I'm just having a look there's lots of different questions coming through I think one of the things that I was really interested in that you might want to speak about a little bit because I've certainly experienced this as well with some clients I've worked with where this has been part of the mix is that adult diagnosis and grief around lost potential people that have felt themselves or been told that they never quite lived up to you know the very clever child that I might be identified as even gifted and then never obtaining that because nobody then picked up that they weren't able to complete tasks or so forth so I was wondering about each of you if you had those experiences and where can you start with those that you talked a bit about grief but just maybe chatting a little bit about that John did you want to chat a bit in the elephant front line with that? That's very important I've learnt that that can be the elephant in the room as well if you don't address it because once you've made a diagnosis and explained it to the patient then they look back and think how my life might have been different so I've learnt very quickly to acknowledge that regret tell them yes it's alright to have that regret but you've got to let it go because you can't change the past you can change the future but while you're doing that you can sometimes pick out some of the highlights of their life so far which may be related to the positive side of their ADHD that they would not have otherwise achieved without it Yeah that's lovely Maddie or Roger did this quickly before we go to wrap up anything you would like to add about working with that bit of the grief associated with Well I try and help people work with it in that they try and make the world a better place often they then join in with their local ADHD support group they start spreading the good good news about the condition so I try and help them work with the grief as you say John not to sort of dwell on it too much in the past but you're right you know Howard's Brianna she's 36 well she's probably only about a third the way through her life the way life's stats are going these days so the first third has been pretty stormy but she's done very well the next two thirds the sky's the limit and we start to talk about hope and potential and releasing the handicap side of the ADHD getting the lead out of the saddle bags if you like and who knows what might happen in the future yeah look I mean probably a slightly different tact and this is you know the psychologist in me we ultimately the person needs to be able to make that shift of it's okay I've got my future ahead of me or you know whatever the sort of more positive fruitful useful narrative is for them they need to be able to make that shift themselves and for some it takes a little bit longer than others but I feel this is where one of those ADHD strengths aspects comes in because yes people can get hyper focused on something unpleasant but they can also move on really quickly and I'm always surprised we can have someone who's absolutely devastated third session have been completely devastated and they come back the next week and they've just switched totally into strengths mode and they're away but I agree with John and I think Roger Benchard as well about pointing out their strengths angle so at that point I think when they're not ready for a psychologist out there and other people that no motivational interviewing stage a change model we want to think about what they're ready for change wise are they ready to shift out of grieving when they haven't been able to address that and repress the events of the past and how people have been treated them and the fairness or otherwise of that if they're not ready you can't push you just need to go gently with them give them the validation they need but if they're ready soaring ahead you're just going to really annoy them by focusing on the brief part so that that's where the real skill in reading where you client is that comes in. Perfect thank you amazingly we're almost out of time so I'm going to ask you all in the last minute or so to if you had one takeaway for the audience that have joined us tonight that have been merely engaged in what you've all been saying what would it be 30 seconds or a minute I'm going to go to you first John. Think of the positives ADHD exists in human society in 5% minimum some say up to 10% genes to that extent don't survive unless they have survival advantages in the long term view of human history so there are lots of pluses in there just look for them nurture them play to them scaffold when you need it but use your strengths. Beautiful thank you John Maddie In a similar vein to what John said for every good party you've been to good intervention you've used great holiday idea ADHD will undoubtedly be involved somewhere along the using that creativity, innovation, ingenuity so it's good to start looking out for it neurodivergence is really really important to where we've got to but also the way out from where we've got to but the other quick thing I wanted to say is working in this space is a really fantastic population to work with and we need practitioners so please don't be thinking it seems too complex there are so many practitioners in this space that can give you great models it's very practical and common sense it's really rewarding and very sustainable work join us please beautiful new guidelines to work with which is always nice when you're third and Roger round us out with well John and Maddie have told on my thunder it's a very rewarding condition to treat I mean that's how I got into it and that's why I'm still doing it because a lot of my colleagues say oh I wouldn't get involved and that's just drug seeking behaviour I want to come along and just get hold of dexies and whatever they are very genuine often coming to me reluctantly and I have to coax them into taking medication but once they do they engage with me engage with therapists and coaches it is a very rewarding condition to treat I would urge you all out there to please start if you're not already getting involved with the ADHD community embrace your neuro spicy I think it's a turn away alright guys we are at 8.27 well done we've done amazingly on time so I want to thank you all for your participation tonight and reassure everybody that yes the resources that we've spoken about the slides and everything will be available and yeah embrace the community the panellists have done a great job of pulling together those resources and places and spaces for you to connect and learn more please take advantage of that those of you wanting to know we always want a statement of attendance that will come out to you you'll get the resources please please please please do the feedback survey it's really quick and we really do look at it it shapes what we do next the topics the formats the discussion what you want more of them what you want less of so please either scan the QR code because we're very modern and up to date or click on the link at the survey because we do take great notice of it and it's really helpful for our panellists who give up their time to give them some feedback okay so coming up next we have webinars from MHPN as a podcast series check it out everyone loves a podcast when you're walking your dogs or driving along I would recommend them thoroughly we've got friends at emerging minds coming up on the 17th of November supporting the social and emotional well-being of children with higher weight so if that's of interest to you and your community please join in and the PHN series non-medical supports and programs for older Australians so spanning the lifespan there which is fantastic you can sign up through the MHPN website and if you get their news coming through so you'll never miss out on topics because they're always interesting as someone is facilitated a few I learn something more than something a lot every time the MHPN networks is the partnership with this ADHD which all of you guys are killing this tonight working with the Australian ADHD Professionals Association to establish a new practitioner network so those of you that are here tonight are obviously interested in this topic to bring practitioners together with the shared interest of ADHD so we'll send out information on that so please check it out and share it with colleagues that may not have been able to make it tonight because we all know the bigger the network in these fields the better we all learn from each other and collaborate and that my friends is just about it before we leave I just want to thank everyone for participating and the panelists of course for their knowledge and expertise and time and I'd like to acknowledge those people with the lived experience people and carers who've lived with a mental illness and those who continue to live with mental illness in the present and in the future and care for each other thank you so much everybody for your time this evening and we'll see you next time