Management of ADHD-a GP perspectiveProfessor Geoff MitchellPrimary Care Clinical Unit UQ Faculty of Medicine

DSM-V requirements for ADHD diagnosisChildren -at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria (Older adolescents adults- five criteria)

PLUS Onset lt12 yrs old Causes significant social functional impairment Not explained better by another mental health condition ASD and ADHD can co-exist

Background

1992 ndash West Moreton Division of General Practice

1 How do you make a diagnosis of ADHD

2 How do you know stimulants are the right treatment for that child

How to diagnose ADHD

Contained DSM-IV definition of ADHD

Tear out sheets to give to parents teachers other professionals

Post back ndash three blinded reports on childrsquos behavior

Worksheet ndash Differential diagnoses to consider

Pilot testing

bull 10 blinded cases reviewed by Child psychiatrist for 1 hour

bull Compared diagnoses

bull GP could pick ADHD accurately Also picked that comorbidities were present but were not accurate with these diagnosis

bull Therefore ndash GPs could pick those cases where specialist input was important- Potentially could pick and treat uncomplicated ADHD

Can we prescribe Stimulants to the right children

Treatment Placebo

Placebo Treatment

Treatment Placebo

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

N-of-1 tests

Example of non-responder

Dexamphetamine Weeks 135 (and Pre-test)

Chart4

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

585

74

46

54

71

51

54

67

56

71

48

56

71

51

54

69

45

54

69

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean Pre-test		Mean Pre-test		Mean Pre-test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

DSM-V requirements for ADHD diagnosisChildren -at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria (Older adolescents adults- five criteria)

PLUS Onset lt12 yrs old Causes significant social functional impairment Not explained better by another mental health condition ASD and ADHD can co-exist

Background

1992 ndash West Moreton Division of General Practice

1 How do you make a diagnosis of ADHD

2 How do you know stimulants are the right treatment for that child

How to diagnose ADHD

Contained DSM-IV definition of ADHD

Tear out sheets to give to parents teachers other professionals

Post back ndash three blinded reports on childrsquos behavior

Worksheet ndash Differential diagnoses to consider

Pilot testing

bull 10 blinded cases reviewed by Child psychiatrist for 1 hour

bull Compared diagnoses

bull GP could pick ADHD accurately Also picked that comorbidities were present but were not accurate with these diagnosis

bull Therefore ndash GPs could pick those cases where specialist input was important- Potentially could pick and treat uncomplicated ADHD

Can we prescribe Stimulants to the right children

Treatment Placebo

Placebo Treatment

Treatment Placebo

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

N-of-1 tests

Example of non-responder

Dexamphetamine Weeks 135 (and Pre-test)

Chart4

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

585

74

46

54

71

51

54

67

56

71

48

56

71

51

54

69

45

54

69

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean Pre-test		Mean Pre-test		Mean Pre-test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Background

1992 ndash West Moreton Division of General Practice

1 How do you make a diagnosis of ADHD

2 How do you know stimulants are the right treatment for that child

How to diagnose ADHD

Contained DSM-IV definition of ADHD

Tear out sheets to give to parents teachers other professionals

Post back ndash three blinded reports on childrsquos behavior

Worksheet ndash Differential diagnoses to consider

Pilot testing

bull 10 blinded cases reviewed by Child psychiatrist for 1 hour

bull Compared diagnoses

bull GP could pick ADHD accurately Also picked that comorbidities were present but were not accurate with these diagnosis

bull Therefore ndash GPs could pick those cases where specialist input was important- Potentially could pick and treat uncomplicated ADHD

Can we prescribe Stimulants to the right children

Treatment Placebo

Placebo Treatment

Treatment Placebo

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

N-of-1 tests

Example of non-responder

Dexamphetamine Weeks 135 (and Pre-test)

Chart4

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

585

74

46

54

71

51

54

67

56

71

48

56

71

51

54

69

45

54

69

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean Pre-test		Mean Pre-test		Mean Pre-test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

How to diagnose ADHD

Contained DSM-IV definition of ADHD

Tear out sheets to give to parents teachers other professionals

Post back ndash three blinded reports on childrsquos behavior

Worksheet ndash Differential diagnoses to consider

Pilot testing

bull 10 blinded cases reviewed by Child psychiatrist for 1 hour

bull Compared diagnoses

bull GP could pick ADHD accurately Also picked that comorbidities were present but were not accurate with these diagnosis

bull Therefore ndash GPs could pick those cases where specialist input was important- Potentially could pick and treat uncomplicated ADHD

Can we prescribe Stimulants to the right children

Treatment Placebo

Placebo Treatment

Treatment Placebo

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

N-of-1 tests

Example of non-responder

Dexamphetamine Weeks 135 (and Pre-test)

Chart4

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

585

74

46

54

71

51

54

67

56

71

48

56

71

51

54

69

45

54

69

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean Pre-test		Mean Pre-test		Mean Pre-test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Pilot testing

bull 10 blinded cases reviewed by Child psychiatrist for 1 hour

bull Compared diagnoses

bull GP could pick ADHD accurately Also picked that comorbidities were present but were not accurate with these diagnosis

bull Therefore ndash GPs could pick those cases where specialist input was important- Potentially could pick and treat uncomplicated ADHD

Can we prescribe Stimulants to the right children

Treatment Placebo

Placebo Treatment

Treatment Placebo

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

N-of-1 tests

Example of non-responder

Dexamphetamine Weeks 135 (and Pre-test)

Chart4

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

585

74

46

54

71

51

54

67

56

71

48

56

71

51

54

69

45

54

69

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean Pre-test		Mean Pre-test		Mean Pre-test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Can we prescribe Stimulants to the right children

Treatment Placebo

Placebo Treatment

Treatment Placebo

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

Pair 1

Pair 2

Pair 3

N-of-1 tests

Example of non-responder

Dexamphetamine Weeks 135 (and Pre-test)

Chart4

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

585

74

46

54

71

51

54

67

56

71

48

56

71

51

54

69

45

54

69

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean Pre-test		Mean Pre-test		Mean Pre-test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Example of non-responder

Dexamphetamine Weeks 135 (and Pre-test)

Chart4

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

585

74

46

54

71

51

54

67

56

71

48

56

71

51

54

69

45

54

69

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean Pre-test		Mean Pre-test		Mean Pre-test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Chart4

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

585

74

46

54

71

51

54

67

56

71

48

56

71

51

54

69

45

54

69

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean Pre-test		Mean Pre-test		Mean Pre-test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Chart5

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

61

835

43

56

82

49

56

78

56

77

43

53

76

42

53

76

44

53

76

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Mean pre-test score		Mean pre-test score		Mean pre-test score
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Dean Mitchell Report			Weighted Scores
Self
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which Medication
mean pre-test		555		585		59		61
Week 1		51		54		52		56		placebo
Week 2		48		54		52		56		placebo
Week 3		48		56		49		56		active
Week 4		48		56		49		53		placebo
Week 5		48		54		54		53		NA
Week 6		48		54		49		53		NA
Parent
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		805		74		77		835
Week 1		85		71		70		82		DK
Week 2		79		67		79		78		Placebo
Week 3		82		71		84		77		placebo
Week 4		82		71		81		76		placebo
Week 5		85		69		73		76		active
Week 6		85		69		74		76		placebo
Teacher
	Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index		Which medication
mean pre-test		45		46		44		43		NA
Week 1		45		51		44		49		NA
Week 2
Week 3		45		48		44		43		NA
Week 4		45		51		44		42		NA
Week 5		45		45		45		44		NA
Week 6

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Score

Self report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Scores

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Scores

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Dean Mitchell
Oppositional traits
	Self		Parent		Teacher
Mean pre-test		555		805		45
Week 1		51		85		45
Week 2		48		79
Week 3		48		82		45
Week 4		48		82		45
Week 5		48		85		45
Week 6		48		85
ConcentrationAttention
	Self		Parent		Teacher
Mean Pre-test		585		74		46
Week 1		54		71		51
Week 2		54		67
Week 3		56		71		48
Week 4		56		71		51
Week 5		54		69		45
Week 6		54		69
Hyperactivity
	Self		Parent		Teacher
Mean Pre-test		59		77		44
Week 1		52		70		44
Week 2		52		79
Week 3		49		84		44
Week 4		49		81		44
Week 5		54		73		45
Week 6		49		74
ADHD Index
	Self		Parent		Teacher
Mean pre-test score		61		835		43
Week 1		56		82		49
Week 2		56		78
Week 3		56		77		43
Week 4		53		76		42
Week 5		53		76		44
Week 6		53		76

Self

Parent

Teacher

weeks

Adjusted Scores

Oppositional Scores

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Self

Parent

Teacher

Weeks

Adjusted scores

Concentration Attention

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Self

Parent

Teacher

Weeks

Adjusted Scores

Hyperactivity

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Self

Parent

Teacher

Weeks

Adjusted score

Conners ADHD Index

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Example of Responder

Dexamphetamine weeks 145(and Pre-test)

Nikles CJ hellipMitchell GK N of 1 trials practical tools for medication management Australian Family Physician 2000 29 1108-1112

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Chart1

Self

Parent

Teacher

T Scores

CognitionInattention Scores

41

48

42

41

48

42

51

48

42

80

73

48

80

73

56

48

51

51

51

49

45

80

73

42

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Pre-Test 1		Pre-Test 1		Pre-Test 1
Pre-Test 2		Pre-Test 2		Pre-Test 2
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Sheet1

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		57		41		36		39
	Pre-Test 2		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		73		48		45		44
	Pre-Test 2		48		48		45		43
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Pre-Test 1		45		42		47		42
	Pre-Test 2		45		42		44		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Sheet2

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

	James McCann Report
	Oppositional
		Self		Parent		Teacher
	Pre-Test 1		57		73		45
	Pre-Test 2		57		48		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Pre-Test 1		41		48		42
	Pre-Test 2		41		48		42
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Pre-Test 1		36		45		47
	Pre-Test 2		36		45		44
	Week 1		36		45		47
	Week 2		45		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Pre-Test 1		39		44		42
	Pre-Test 2		39		43		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

Sheet2

Self

Parent

Teacher

T Scores

Oppositional Scores

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Sheet3

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Self

Parent

Teacher

T Scores

COnners ADHD Scores

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Chart3

Self

Parent

Teacher

T Scores

Conners ADHD Scores

39

435

42

42

43

44

82

77

52

82

74

55

44

48

53

46

45

55

82

74

42

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Mean Pre-Test		Mean Pre-Test		Mean Pre-Test
Week 1		Week 1		Week 1
Week 2		Week 2		Week 2
Week 3		Week 3		Week 3
Week 4		Week 4		Week 4
Week 5		Week 5		Week 5
Week 6		Week 6		Week 6

Sheet1

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

	James McCann Results
	Self Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		57		41		36		39
	Week 1		60		51		36		42
	Week 2		100		80		45		82
	Week 3		95		80		45		82
	Week 4		60		48		36		44
	Week 5		57		51		40		46
	Week 6		95		80		45		82
	Parent Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		605		48		45		435
	Week 1		48		48		45		43
	Week 2		85		73		59		77
	Week 3		87		73		52		74
	Week 4		56		51		45		48
	Week 5		50		49		45		45
	Week 6		87		73		63		74
	Teacher Report
		Oppositional		Cognitive problems Inattention		Hyperactivity		Conners ADHD Index
	Mean Pre-Test		45		42		455		42
	Week 1		45		42		47		44
	Week 2		59		48		54		52
	Week 3		45		56		46		55
	Week 4		65		51		49		53
	Week 5		49		45		49		55
	Week 6		48		42		49		42

Sheet1

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Self Report

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

Sheet2

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Parent Report

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

Sheet3

Oppositional

Cognitive problems Inattention

Hyperactivity

Conners ADHD Index

Weeks

Adjusted Scores

Teacher Report

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

	Oppositional
		Self		Parent		Teacher
	Mean Pre-Test		57		605		45
	Week 1		60		48		45
	Week 2		100		85		59
	Week 3		95		87		45
	Week 4		60		56		65
	Week 5		57		50		49
	Week 6		95		87		48
	Inattentive
		Self		Parent		Teacher
	Mean Pre-test		41		36		39
	Week 1		51		48		42
	Week 2		80		73		48
	Week 3		80		73		56
	Week 4		48		51		51
	Week 5		51		49		45
	Week 6		80		73		42
	Hyperactive
		Self		Parent		Teacher
	Mean Pre-Test		36		45		455
	Week 1		36		45		47
	Week 2		36		59		54
	Week 3		45		52		46
	Week 4		36		45		49
	Week 5		40		45		49
	Week 6		45		63		49
	Conners ADHD Scale
		Self		Parent		Teacher
	Mean Pre-Test		39		435		42
	Week 1		42		43		44
	Week 2		82		77		52
	Week 3		82		74		55
	Week 4		44		48		53
	Week 5		46		45		55
	Week 6		82		74		42

Self

Parent

Teacher

T Scores

Oppositional Scores

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Self

Parent

Teacher

T Scores

CognitionInattention Scores

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Self

Parent

Teacher

T Scores

Hyperactivity Scores

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Self

Parent

Teacher

T Scores

Conners ADHD Scores

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

What are attitudes to ADHD management by GPs

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

GPsDid not want to be the primary providers of care for patients with ADHD Participants preferred referral diagnosis and treatment of ADHD

Concernsndash overdiagnosis and misdiagnosis ndash diagnostic complexity ndash time constraints ndash insufficient education and training about the disorder ndash misuse and diversion of stimulant medications

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

What are attitudes to ADHD management by GPs

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

What are attitudes to ADHD management by GPs (2002)

Roles identified by GPs were bull the provisional diagnosis of ADHD and referral to specialistsbull assistance with monitoring progress once a management plan was in place

education of the child and their family regarding the disorder bull liaison with the school where necessary

Perceived barriers to increased involvement of GPs were bull time and resource constraints of general practicebull concerns regarding abuse and addiction liability of prescription stimulants bull complex diagnostic issues associated with childhood behavioural problems bull lack of training and education regarding ADHD

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

ADHD ndash a non-specialist interpretation

Core features ndash

Inattention ndash primary problem

Hyperactivity

Impulsivity

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Consequences

Concentration is required to learn ndashrdquoteachabilityrdquo is impaired in ADHD

Lessons take longer to learn Organisation takes concentration and timendash organisation and planning impaired

Time management always a problemDisorganisationPoor performance relative to ability (eg unfinished assignments canrsquot manage time in exams)Underachievement

Same ldquodumb mistakesrdquo made over and over ndash ldquo Why donrsquot you listen to merdquoFrustration to those aroundMany interpersonal interactions have negative content

Mistaking failure to obey previous instructions as willfulness ndashget into trouble and donrsquot know why

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Negative feedback and carping from parents teachers peers- constant eroding of self-esteem ndash secondary depression anxiety

giving up

- high risk of underestimation of own abilities

- bullying teasing social isolation a risk

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Hyperactive andor Inattentive

Hyperactive ndash v common problem- distraction by external stimuli Very obviousBoys predominantly

Inattentive - - distracted by internal stimuli Tuning out of external environment Lost when tunes back in Not obvious Can be diagnosed after unexpectedly poor results more frequent in girls

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Inattention Impulsivity

Time management

Problems with driving and personal safety

Not thinking before acting At risk for unsafe behavior ndash drugs sex alcohol

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Peaks of diagnosis

Coincide with substantial leaps in demands The worse the ADHD the earlier the problems

Prep

Grade 3

Grade 6

Grade 1011 transition

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

ADHD ndash a spectrum disorder

Where do you draw the line

Where do you draw the line

Population proportion

Capacity to concentrate

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Other issues

Family history ndash Parental ADHD leads to disorganized families Family disorganization an independent confounder but additive

Capacity to pay attention is independent of intelligence

Can and does coexist with biologically determined behavior disorders AND environmentally determined disorders

BUT ndash can be and is present in the absence of these

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Outcomes of ADHD treatment and non-treatment

Evidence for some short term benefits of stimulant treatmentCochrane Database of Systematic Reviews

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015

Evidence for long term (six year) benefits the same with or without stimulantsPsychol Med 2018 Mar 131-7 doi 101017S0033291718000545

Long-term effects of stimulant treatment on ADHD symptoms social-emotional functioning and cognition Schweren L et al)

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)Storeboslash OJ et al Cochrane Database of Systematic Reviews Nov 2015DOI 10100214651858CD009885pub2

Improved teacher-rated ADHD symptoms28 Improved teacher rate behaviour on MPH39 improvement in parent rated Quality of life

No increase in serious (eg life threatening) adverse events 29 increase in non-serious adverse events compared with placebo ndashsleep disturbance (60 greater risk) - appetite suppression (266 increase in risk)

All very low quality evidenceMean time of observation 75 (range 1-425 days)

Specialist involvement

ldquoSimplerdquo ADHD and ldquoComplexrdquo ADHD

Simple

Inattention causing issues at schoolAbsence of defianceAbsence of anger

Presence of anxiety reactive depression poor self-esteem

ComplexADHD +-Defiance disruptive tendencies angerActing out

- Within GP skill set

GP approach to complex problems - Diagnosis

1 Murtaghrsquos diagnostic method (for most GP problems)

1 What is the probability diagnosis2 What diagnoses canrsquot I miss3 What is easy to miss4 Is this symptom from one of the Masqueraders5 Is this patient trying to tell me something

2 Mapping complex problems

Bec is a14 yr girl known for years brought in because her grades have dropped off Just started in Grade 10 Had done well before Always a bit dreamy Some bullying because she is always ldquooff the gridrdquo No alcohol drugs Apparently supportive family One uncle who dropped out of school had multiple jobs and never settled down School reports suggest distraction for years in spite of trying hard

X

School performance down Gr 10 Harder than Gr 9Modest teasing due to dreaminess

X

Usually capableSolid familyPossible FH of ADHD

ADHD

GP understanding of ADHD management

For Bec1 Exclude other potential causes ndash hearing vision sleep deprivation depression abuse etc

2 Consider whether the condition is longstanding or recent

3 Is DSM 5 met

3 Any behavioural comorbidities

4 If no to all above start stimulant therapy

Plus school counsellingpsychology

Rationale

ldquoSimplerdquo ADHD

Main issue is inability to focus and other things flow from that

Self esteem and peer behavior secondary

Rapid onset of treatment effect ndash review in 2 weeks will determine efficacy or whether specialist review is necessary

GPs and stimulants

Can prescribe in Qld without specialist initiation

Most GPs do not want to do that

Most happy to supervise treatment once specialist diagnosis and management

If doubt about efficacy consider N-of-1 test This is usually not necessary

Proportion of people prescribed stimulants by age and state

GP ability to prescribe is not misused

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

GP approach to complex problems - Diagnosis

1 Murtaghrsquos diagnostic method (for most GP problems)

1 What is the probability diagnosis2 What diagnoses canrsquot I miss3 What is easy to miss4 Is this symptom from one of the Masqueraders5 Is this patient trying to tell me something

2 Mapping complex problems

Bec is a14 yr girl known for years brought in because her grades have dropped off Just started in Grade 10 Had done well before Always a bit dreamy Some bullying because she is always ldquooff the gridrdquo No alcohol drugs Apparently supportive family One uncle who dropped out of school had multiple jobs and never settled down School reports suggest distraction for years in spite of trying hard

X

School performance down Gr 10 Harder than Gr 9Modest teasing due to dreaminess

X

Usually capableSolid familyPossible FH of ADHD

ADHD

GP understanding of ADHD management

For Bec1 Exclude other potential causes ndash hearing vision sleep deprivation depression abuse etc

2 Consider whether the condition is longstanding or recent

3 Is DSM 5 met

3 Any behavioural comorbidities

4 If no to all above start stimulant therapy

Plus school counsellingpsychology

Rationale

ldquoSimplerdquo ADHD

Main issue is inability to focus and other things flow from that

Self esteem and peer behavior secondary

Rapid onset of treatment effect ndash review in 2 weeks will determine efficacy or whether specialist review is necessary

GPs and stimulants

Can prescribe in Qld without specialist initiation

Most GPs do not want to do that

Most happy to supervise treatment once specialist diagnosis and management

If doubt about efficacy consider N-of-1 test This is usually not necessary

Proportion of people prescribed stimulants by age and state

GP ability to prescribe is not misused

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

2 Mapping complex problems

Bec is a14 yr girl known for years brought in because her grades have dropped off Just started in Grade 10 Had done well before Always a bit dreamy Some bullying because she is always ldquooff the gridrdquo No alcohol drugs Apparently supportive family One uncle who dropped out of school had multiple jobs and never settled down School reports suggest distraction for years in spite of trying hard

X

School performance down Gr 10 Harder than Gr 9Modest teasing due to dreaminess

X

Usually capableSolid familyPossible FH of ADHD

ADHD

GP understanding of ADHD management

For Bec1 Exclude other potential causes ndash hearing vision sleep deprivation depression abuse etc

2 Consider whether the condition is longstanding or recent

3 Is DSM 5 met

3 Any behavioural comorbidities

4 If no to all above start stimulant therapy

Plus school counsellingpsychology

Rationale

ldquoSimplerdquo ADHD

Main issue is inability to focus and other things flow from that

Self esteem and peer behavior secondary

Rapid onset of treatment effect ndash review in 2 weeks will determine efficacy or whether specialist review is necessary

GPs and stimulants

Can prescribe in Qld without specialist initiation

Most GPs do not want to do that

Most happy to supervise treatment once specialist diagnosis and management

If doubt about efficacy consider N-of-1 test This is usually not necessary

Proportion of people prescribed stimulants by age and state

GP ability to prescribe is not misused

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Bec is a14 yr girl known for years brought in because her grades have dropped off Just started in Grade 10 Had done well before Always a bit dreamy Some bullying because she is always ldquooff the gridrdquo No alcohol drugs Apparently supportive family One uncle who dropped out of school had multiple jobs and never settled down School reports suggest distraction for years in spite of trying hard

X

School performance down Gr 10 Harder than Gr 9Modest teasing due to dreaminess

X

Usually capableSolid familyPossible FH of ADHD

ADHD

GP understanding of ADHD management

For Bec1 Exclude other potential causes ndash hearing vision sleep deprivation depression abuse etc

2 Consider whether the condition is longstanding or recent

3 Is DSM 5 met

3 Any behavioural comorbidities

4 If no to all above start stimulant therapy

Plus school counsellingpsychology

Rationale

ldquoSimplerdquo ADHD

Main issue is inability to focus and other things flow from that

Self esteem and peer behavior secondary

Rapid onset of treatment effect ndash review in 2 weeks will determine efficacy or whether specialist review is necessary

GPs and stimulants

Can prescribe in Qld without specialist initiation

Most GPs do not want to do that

Most happy to supervise treatment once specialist diagnosis and management

If doubt about efficacy consider N-of-1 test This is usually not necessary

Proportion of people prescribed stimulants by age and state

GP ability to prescribe is not misused

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

GP understanding of ADHD management

For Bec1 Exclude other potential causes ndash hearing vision sleep deprivation depression abuse etc

2 Consider whether the condition is longstanding or recent

3 Is DSM 5 met

3 Any behavioural comorbidities

4 If no to all above start stimulant therapy

Plus school counsellingpsychology

Rationale

ldquoSimplerdquo ADHD

Main issue is inability to focus and other things flow from that

Self esteem and peer behavior secondary

Rapid onset of treatment effect ndash review in 2 weeks will determine efficacy or whether specialist review is necessary

GPs and stimulants

Can prescribe in Qld without specialist initiation

Most GPs do not want to do that

Most happy to supervise treatment once specialist diagnosis and management

If doubt about efficacy consider N-of-1 test This is usually not necessary

Proportion of people prescribed stimulants by age and state

GP ability to prescribe is not misused

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Rationale

ldquoSimplerdquo ADHD

Main issue is inability to focus and other things flow from that

Self esteem and peer behavior secondary

Rapid onset of treatment effect ndash review in 2 weeks will determine efficacy or whether specialist review is necessary

GPs and stimulants

Can prescribe in Qld without specialist initiation

Most GPs do not want to do that

Most happy to supervise treatment once specialist diagnosis and management

If doubt about efficacy consider N-of-1 test This is usually not necessary

Proportion of people prescribed stimulants by age and state

GP ability to prescribe is not misused

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

GPs and stimulants

Can prescribe in Qld without specialist initiation

Most GPs do not want to do that

Most happy to supervise treatment once specialist diagnosis and management

If doubt about efficacy consider N-of-1 test This is usually not necessary

Proportion of people prescribed stimulants by age and state

GP ability to prescribe is not misused

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Proportion of people prescribed stimulants by age and state

GP ability to prescribe is not misused

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Stimulant use rate by age age standardised

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Special issues ndash overdiagnosis

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Rationale

Definitions have broadened - Concern of under-recognition

Is there really under-recognition Threshold for treatment varies from state to state country to country Why

What are consequences of under-recognition

What are the consequences of inappropriate treatment

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Special issues ndash Adult ADHD

Rates of treated Adult ADHD are far lower than in childrenApproximately 23 of children will carry ADHD into adulthood

Why so lowEnvironment can be controlled by the individual ndash less need for attention time keeping

etcUnder-recognition in adults ndash not recognised and treated as well in their young years

Health professionals donrsquot ask the right questions

Concern at drug diversion so more caution in prescribingMost hyperactive symptoms moderate so not as obvious

Why importantUnder-performance relative to abilityImpulsive behaviour can cause trouble Disorganisation in daily life can cause a lot of problems ndash eg missing billsAppointments poor punctuality at work

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Transition to adult services ProblemsCost for low income people

Accessibility of psychiatric care esp in public system

Start early ndashin Gr 12 year

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Special issues ndash fear of misuse and abuse

ADHD medication overdose and misuse the NSW Poisons Information Centre experience 2004-2014Cairns R1 Daniels B2 Wood DA3 Brett J2 Med J Aust 2016 Mar 7204(4)154

RESULTS

During the 11-year study period 1735 intentional exposures to the four medications were reported to NSWPIC There was a 210 increase in intentional exposures to methylphenidate over this period whereas the number of dexamphetamine exposures declined by 25 Illicit use (defined as co-ingestion with alcohol or a street drug) increased by 429 across the study period At least 93 of overdose patients required hospitalisation Trends in exposures paralleled trends in the dispensing of these medications as recorded in Pharmaceutical Benefits Scheme data

Number of Methylphenidate prescriptions pa in Australia in 2014

877206

Research opportunity N-of-1 testing of melatonin for ADHD sleep problems

NHMRC funded

Details httpsmedicineuqeduaumynap-study

Facebook ndash MyNap study

Conclusion

ADHD is common and can be straightforward to diagnose and treat

GPs are very cautious about ADHD diagnosis and management

There are a lot of untreated adults in the community

Risk of abuse is there but very uncommon

Change in approach to a condition not unlike depression should be appropriate

• Management of ADHD- a GP perspective
• DSM-V requirements for ADHD diagnosis
• Background
• How to diagnose ADHD
• Pilot testing
• Can we prescribe Stimulants to the right children
• Slide Number 7
• Slide Number 8
• What are attitudes to ADHD management by GPs
• Slide Number 10
• What are attitudes to ADHD management by GPs
• What are attitudes to ADHD management by GPs (2002)
• ADHD ndash a non-specialist interpretation
• Consequences
• Slide Number 15
• Hyperactive andor Inattentive
• Inattention Impulsivity
• Peaks of diagnosis
• ADHD ndash a spectrum disorder
• Other issues
• Outcomes of ADHD treatment and non-treatment
• Slide Number 22
• ldquoSimplerdquo ADHD and ldquoComplexrdquo ADHD
• GP approach to complex problems - Diagnosis
• Slide Number 25
• Slide Number 26
• GP understanding of ADHD management
• Rationale
• GPs and stimulants
• Proportion of people prescribed stimulants by age and state
• Stimulant use rate by age age standardised
• Special issues ndash overdiagnosis
• Rationale
• Special issues ndash Adult ADHD
• Slide Number 35
• Transition to adult services
• Special issues ndash fear of misuse and abuse
• Research opportunity N-of-1 testing of melatonin for ADHD sleep problems
• Conclusion