EP 160: ADHD Meds, Demystified

Deciding whether to try ADHD medication can feel overwhelming for many parents.
 There is a huge amount of misinformation online, and the decision can feel heavy, emotional, and confusing.

In this episode, I sit down with Consultant Child and Adolescent Psychiatrist Dr Giovanni Giaroli to break down what ADHD medication actually does in the brain — in clear, parent-friendly language.

We explore:

• How ADHD medication works in the prefrontal cortex and executive brain
• The difference between stimulant and non-stimulant medications
• Why finding the right medication is often a journey of careful titration
• Common side effects and what parents should realistically expect
• How medication interacts with autism, anxiety, OCD and PDA profiles
• Why medication alone is not the whole picture — and how sleep, exercise, nutrition and support work alongside it

Dr Giaroli also explains why ADHD medication has one of the strongest evidence bases in child psychiatry, while still requiring a personalised approach for every child.

If you are navigating this decision for your child, this conversation will help bring clarity, reassurance, and science to the discussion.

Giaroli Clinic

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Transcript

Welcome & Community For ADHD Parents

Dr Olivia 0:05

Welcome to the Send Parenting Podcast. I'm your neurodiverse host, Dr. Olivia Kestel, and more importantly, I'm mother to my wonderfully neurodivergent daughter, Alexandra, who really inspired this podcast. As a veteran in navigating the world of neurodiversity in a UK education system, I've uncovered a wealth of misinformation, alongside many answers and solutions that were never taught to me in medical school or in any of the parenting handbooks. Each week on this podcast, I will be bringing the experts to your ears to empower you on your parenting crusade. If you're parenting a child with ADHD and feel like you are constantly in a minefield, walking on mines that are exploding, you're exhausted, you're second-guessing yourself as to whether you can even mother your child and wondering why nothing seems to work, you're not alone. I've been there and so have the other moms who are in the ADHD Warrior Mom membership community. We are done blaming ourselves and we are ready to come together. You will learn in this community evidence-based tools, real support, and a community that truly understands. We have group coaching weekly and we have master classes every month with global experts, and once a month we take care of ourselves with some self-care that is easy to do and gives back and refills your batteries. Because honestly, no one is a perfect parent, and being an ADHD mom is super, super difficult. You need the right support and you need the help to get through the day. So please come and join us. Um, links in the show notes, or you can just go to sendparenting.com backslash join, and you can see more details about our membership. Now let's get on to the episode. We are going to be talking about ADHD medications. Now, this is one of the aspects of treating children and adults with ADHD. There are other aspects like support at home and at school, sleep, good exercise and nutrition. We're not going to touch upon those today. We're really going to laser focus on ADHD medication because we are going to leave the session with a lot of knowledge that is based on solid research and clinical practice. And that's where our guest speaker here comes in, Dr. Giaroli, because he is not only founder of the Girolli Clinic, which is where my daughter has been diagnosed with ADHD and is still a patient there, but he also is a consultant child and adolescent psychiatrist specializing in autism and ADHD. And he's worked clinically with children and families and brings not only science, but also real-world experience. So the formatted so Dr. Giaroli, welcome. Thank you for taking your evening to be with us.

SPEAKER_03 3:01

Thank you so much for having me actually here.

Dr Olivia 3:04

I like the new hairstyle. It suits you very well. It's been a while since I've seen you.

SPEAKER_03 3:09

There's been some few hair lost in the meantime. That's why you're there.

Dr Olivia 3:16

But it's lovely to have you here this evening. And I thought what we could do is really start at the beginning because there's so much misinformation about ADHD medication and what it actually does. There's a lot of stuff on social media that gets really confusing. So I thought maybe if we could start, if you could explain and kind of, and I know you always do in parent-friendly language, how ADHD medications work in the brain and why we use them.

SPEAKER_03 3:41

Yes. So we know a bit about this medication and quite a fair bit. In general, with medication and brain, we know only a portion of what the medication really does. However, we feel that in terms of ADHD medication, we have a quite a good understanding of what they do and where they work. So in general, all ADHD medication to be effective for ADHD symptoms, so to target the core symptoms of ADHD, which are inattention, distractability, impulsivity, and hyperactivity. So this again, I repeat inattention, distractability, impulsivity, and hyperactivity. These are the core symptoms of ADHD that are targeted by the medication. In order for them to work, they have to have some effect on the frontal part of our brain, which is called the prefrontal cortex. So they need to work on this part, exactly, pretty much behind our forehead. This is the prefrontal cortex, which is which is responsible for the highest function of our brain and to coordinate other parts of the brain. So this is our executive board. This is where the executive board of our brain sits, sits in the prefrontal cortex. There are other areas of the brain, such as the precuneus, which is the parietal areas or the cerebellum. This is gets very complex. We know that definitely for sure prefrontal cortex, executive board of our brain is involved. What the medication does is it change neurotransmitters at this level. And what it does is balance what we think there is a slight imbalancement when it comes to noradrenaline and dopamine. So there are two main neurotransmitters, which I mean the main way, the way that the brain in this area communicates between each other, between neurons. They communicate via this neurotransmitter, which is dopamine and noradrenaline. So what the medication does is change, and we can go more into details exactly what they do, change the levels, the amount of these neurotransmitters in these areas.

Dr Olivia 6:02

Okay. And so that makes that brain area work better in layman's terms.

Executive Function And The Sleepy Gatekeepers

SPEAKER_03 6:08

In layman's terms, we know that this part of the brain is slightly hypoactive, which means that this part of the brain is slightly sleepy in ADHD, children, adolescents, and adults. It means that, and we've seen through pet studies, you know, MRIs and functional MRIs, which means through imaging, we have seen that these brains fire less than we would expect it to fire. So, what do we do to wake up this part of the brain, this um this prefrontal brain, is to rebalance the neurotransmitter, so give them more neurotransmitter available to communicate. We give them a voice, we give the neuron a voice by increasing dopamine and noradrenaline in this part of the brain for this board that is a little bit sleepy, this kind of executive board that's all like, you know, just snoozing.

Dr Olivia 7:09

And it's interesting because when you think of like ADHD and hyperactivity and impulsivity, you'd think that the that the brain is very active. But actually, that area of the brain is slower.

SPEAKER_03 7:21

It is much slower. And actually, I would I like the example of a gate and gatekeepers. Imagine a gate, a big gate, a big, you know, French gate of you know of Versailles, you know, massive gate, two people, one on each side, that they're there to open and close the gate. This is the executive board, pretty much. This is what it does. It allows signal in and it allows signal out. Um, but in order to get the right signal in and to get the right signal out, and I just give you an example, for me to say the right thing, for me to say, I'm having a really bad thought about that person, I'm not gonna say that, I'm gonna say something different. So for me to open and gate and close the gate in the way that that correct message comes out of my mouth and not the bad things that I'm thinking at the moment, or I'm in a very crowded environment, or I'm in a classroom and my friend next to me is talking, the teacher is talking. For me to shut off my friend and listen to the teacher, so I need to shut the gate and open the other gate. So, do you see what I mean? This filter mechanism of the brain, this is what the executive board does. Imagine this gate wide open, constantly wide open. Everything comes in, everything gets out. So this is a problem of the filter. So this gate needs to open and close for me to really select what I'm looking at, what I'm listening, what I'm saying, what I'm doing. So you can see the inattention, you can see the destructibility, you can see the impulsivity in action or verbal impulsivity. So for this gate to open and close, I need to wake up, give coffee to these very sleepy gatekeepers, and this is my dopamine and not adrenaline.

Dr Olivia 9:04

That's a great way of putting it. And then you can control what's going on versus being out of control with it.

SPEAKER_03 9:11

Correct.

Stimulants Vs Non‑Stimulants Overview

Dr Olivia 9:12

That's really fascinating. And so, you know, you talk about that there's different types of medication to get those gates kind of working. Um, maybe we can now delve into a little bit what are the different types of medications and how do they work on those areas in the brain, and why is it something that we choose to give our children to help them?

SPEAKER_03 9:33

Absolutely. Imagine again that these keeper, these gatekeepers are normal people like us. Some people like tea, some other people like coffee, some other people like both. So our brain is a little bit like that, has sometimes a preference, sometimes doesn't have a preference. Unfortunately, we don't have the ability to ask the gatekeeper, what do you prefer today? Would you like a coffee or would you like a tea? We need to second guess. And this is the idea of prescribing, you know, of what do we prescribe? What this gatekeeper would like? Would like coffee, would like tea? So our medications that are a little bit like coffee and tea, they are different. They're very different, the medication that we have for ADHD. There are four licensed and labeled approved medication by the BNF, the British National Formula. The four medications. Two are stimulants, two are non-stimulants. Then there are other medications, we call them second liners. However, they don't have an approval from the BNF. They can be prescribed, but namely only when everything else has failed. Yeah. So this goes into the complex prescribed. In general, the vast majority of children and adolescent and adults will respond to one of the first four medications. Vast majority. Approximately 95%, 90 to 95% will respond to either of these four medications. So we will know that we'll like coffee or tea at the end of the day. Some people will like chai tea or something like that. And yes, we can go like that. But in general, let's let's stick to coffee and tea. So let's imagine that our coffee is our stimulants, you know, and that we have two types of stimulants, two types of bean, Arabic bean and maybe Ethiopian beans. So we got different types of coffee. So we got the stimulant medication. And in general, we have known, and you know, nice guidelines in the UK, so National Institute of Clinical Excellence, they suggested the first liner in general. The first people tend to like coffee to begin with. So we give coffee to begin with. So we give methylphenidate to give to be giving with. So of the two stimulant medications, we have methylphenidate, which is our first liner. Then we have dexamphetamine of its preparation, which is dexamphetamine or less dexamphetamine. These are the two stimulant medications. Some people might like tea instead, or some people they try coffee and they realize they don't like coffee and they would prefer tea. And that's where you're in on stimulant medication. We have two types: we have atomoxidine, atomoxidine, and we have guanphen. So these are the four medications that you have heard of, which is methylphenidate, dexamphetamine, or at least dexamphetamine, and we have guanphen and we have atomoxidine. Two stimulants, two non-stimulants. In general, our brain is non-preferential, which means that they both like coffee and tea and is the same, they all will work. But some of our brains, some of our some people, some of us, will have a preferential response, which means they will respond either to stimulants or to non-stimulants. And uh it's impossible at this stage of knowledge for us to predict if our gatekeepers wake up with coffee or wake up with tea. So this is a little bit of, we can go more into details, exactly what they do, but this is the broad in a broad brush, what medication, uh, what are the type of medication for ADHD?

Dr Olivia 13:05

Yeah, and I think we will go to that in a little bit, but I'd like to take a little step back too. So we've kind of talked about the gatekeepers, we've talked about how we can get the gatekeepers awake, um, and we've talked about executive functioning. And you know, that I you know, I've heard and read a lot in the research, you know, with kids with ADHD, they have about a 30% delay in that kind of executive functioning. Can you talk a little bit about how medication kind of negates that gap to a degree for some children? And I've heard that some of it's up to 100%, others it's less, and they need more support. So that it kind of allows children to function at uh their chronological age versus their ADHD age, so to speak.

Maturation Delay And What Meds Help

SPEAKER_03 13:48

Some of the theories um quite supported, um, Philip Shaw, for example, theories of uh the delayed maturation at different stages of the brain. So the brain mature in a backwards frontal way. So, and uh we know that in children with ADHD, the frontal part of the brain tends to present with a further delay than in children of the same age. And same thing with adolescents. So you have this kind of delayed of maturation. So this part of the brain, the frontal part of the brain, remains slightly immature. This is the one of the reasons that we think that the executive function, and I'm gonna go more into details, is not as effective as in children of the same age who don't have ADHD. Now, as we said, the target of the medication, and because this part of the brain is responsible for us for the four symptoms that I mentioned, which was inattention, concentration, hyperactivity, and impulsivity. The executive function is a slightly wider and broader umbrella of symptomatology, of things that we do, the executive function. So the executive function is exactly the task of the executive board. This is what the executive board is there to do. And this is task initiation. So starting something, and you can see in ADHD the symptoms of procrastination. So start task initiation leads if there is a problem with there with procrastination. Goal-oriented persistence, the ability to stick onto a task when it's started, the ability to work of working memory, managing things at the same time, and this is, you know, for example, following instruction, following complex instruction, that part of working memory, yeah, and the part of inhibition of impulses. I'd like to do that, but I'm stopping myself. This is just a very quick idea of alongside with organization, for example, and planning and time management. Organization, planning, and time management. These are very complex executions that our brain does. They are under the umbrella of the executive team in the perfrontal part of the brain. And we know that a lot of children with ADHD have difficulties in these domains, in this executive function domain. So you do not hear exactly attention concerns. They are they're not just that. You see, it's a much broader uh concept. Now, our medication specifically target the core symptoms of ADHD and by proxy, but only by proxy, the executive function problems. So the broader, we know that the medication are more effective to treat the core symptoms of ADHD, inattention, concentration, impulsivity, hyperactivity, more uh you know, more effective than the executive function as a whole. So you might have kids that respond well to the medication in terms of their inattention and concentration, but they might respond not as well in terms of their executive function, procrastination, for example, or disorganization. So a smaller percentage of children that are treated with ADHD medication will respond to for their executive function, but still there is a response to the executive function, and this is where medication needs to have bodies alongside with them. And these bodies are executive function training, our diet, our exercise, our sleep. They need to have bodies ready to work. Because actually, I would say the 50% or in my clinical experience, 50 or 60% medication only will be quite disappointing to treat the vast executive function. Instead, 70 to 80 percent at the first go, you treat the core symptom of ADHD. So very effective to treat the core symptom of ADHD, a little bit less effective to treat the executive dysfunctions, and that's where you need your buddies with you.

Emotional Dysregulation And Control

Dr Olivia 18:00

I like that idea of buddies to get that whole picture. And that's where the magic happens, is when you have the medication and the buddies all together, and then these children can really fly. And you know, a lot of the things that you've brought up there are a lot of the requirements that they have in school or in home as they grow up, as they're expected to do more in life, it becomes more difficult.

SPEAKER_03 18:24

Exactly. Exactly, exactly.

Dr Olivia 18:27

One of the things, one of the symptoms that you you haven't touched upon is emotional dysregulation as well, um, which I think is, you know, I know it's not in the DSM diagnostic criteria, but it is a real issue, I think, for most parents with children, including myself, um, as uh one of the hardest things to cope with. Um, how does that work with the medications and how does the medication support or not support that?

SPEAKER_03 18:54

I think there is a specific reason for it not to be in the DSM, given that it's quite a broader symptom and is actually I would consider the emotional dysregulation being part and not just being part of the ADHD. I'm gonna go give you a little bit more of an explanation. As we said, the frontal part of the brain is the responsible, is the executive board, the gate, etc. The emotional regulation comes, our emotional regulation, our emotions come from a deeper part of the brain, which is more the limbic system. So our limbic system is regulated. Imagine this is a more core, is an older part of our brain versus the new cortex, the new part of the brain, which is exactly the frontal cortex.

Dr Olivia 19:38

It's kind of our fight or flight place, isn't it?

SPEAKER_03 19:40

Exactly. The frontal cortex has some bearing and some domination and some control over the limbic system. So we control our emotion. The executive fingers tend to control the emotion. This is why an emotion comes out and the executive board says, ah, just a second, just keep it there for a moment. Just just keep it, keep it, keep it, leave it, keep it there for a second. And that and that kind of filter, that it filters the limbic system a little bit. Like, just a second, just wait a second, please. I understand you need to say something. I already understand your emotion is just wait a second. Um, that doesn't work as well. And this control can be a bit dysregulated. The emotional dysregulation comes very much from an active limbic system and a less controlling executive board. You have, you know, you imagine this executive board that is controlling a lot of, you know, a lot of other boards or a lot of other, you know, operations that occur in the brain. These operations are a little bit unruly. They're on strike, so very often they're on strike. So the executive board loses control of this part, of this part of the brain, and then you have your emotional dysregulation that comes out. It's not internalized, it's not inside. This is why sometimes ADHD is called externalizing uh disorder. Because it comes out, you see it, you're seeing behaviors, you're seeing emotions. They come out and unable to be controlled. This is your emotional dysregulation, in a very nutshell, in a very simplistic way. Uh, there are other aspects of emotions that, for example, are involved in ADHD. For example, what is now known as uh sensitivity rejection dysphoria. So the fact that some children is mainly adults, might feel so extremely um sensitive to any perceive of rejection. They feel this emotional dysregulation every time they feel rejected. Is this a core part of the brain? Is it a learned mechanism? Is this something that we don't know at this point? But you know, emotions is very involved in ADHD. Not every child and not every adult with ADHD will have emotional dysregulation. But we know that a good percentage have emotional dysregulation. Now, the medication, the moment you get the board in control, the board's very good in control. You can imagine that some of this emotional dysregulation would be under control. Because the board gets hold and gets control of the unruly department of emotion. The department of emotion is very unruly, is on strike, and it gets better control of it.

Starting Treatment And Titration Strategy

Dr Olivia 22:11

Yeah. I love the way you to kind of it's created a picture in my mind. So it's kind of a knock-on effect, in a way, of that control, that it then does help to regulate a bit more that. And that's why there's also breakthroughs as well. There's you're not gonna uh get rid of that at all. Um to now look at when people, when kids start medications, you talked about the stimulants and the non-stimulants. Most children are started on stimulants. How does that go? And can we talk a little bit about dosing, a little bit about onboarding? I know from my personal experience, I've and I my daughter's been on both a stimulant and then switched to a non-stimulant. There is an onboarding period, and it can be challenging. And um, I it got worse kind of before it got better, was would be the way I would describe it in both cases, both for the stimulant and non-stimulant. But I think it's important that parents realize as well that it's not just, oh, you're gonna take this and it's gonna be fine. And then how, if you could talk a little bit about how different children need different dosages and how kind of to conceptualize for parents what that journey is gonna look like if they do decide to put their children on a medication.

SPEAKER_03 23:26

Again, if you if you if if I can again use an example of the coffee and tea, you can ask a child age eight or seven or or nine to prepare some tea, some instant tea or some instant coffee, and they will be able to do it. So for me to tell you about the medication, it will tell me 10 minutes, and every person could be the potentially knowing about the ADHD medication, even an eighty, nine-year-old kid can know about it. Everybody can make a coffee or can make a tea. But to make a good coffee and to make a good tea, this is where the expertise comes into play. And this is where, although this medication is very easy to conceptualize, for medication, two stimulants and two non-stimulants, easy job. It is actually a very complex job. How to select, how to initiate, how to titrate up, or when and when and how to switch. So these are complex in that a lot of experience is necessary. Now, patience, which is something that ADHD kids or their family don't have, is highly necessary at this stage. So we need to be extremely patient. There are different approaches to the medication treatment. I will share your mind. There is a different type of approach that is called forced titration, which means that you start a medication, you bring it up, bring it up, bring it up until you hit side effects, and then, you know, and then you bring it down a notch. So you bring to the maximal effective dose, you know, at every week or at every two weeks. I do not engage into this type of approach. It's called forced titration, is a is a known. My approach, my approach is start very low, bring it up very slowly. Even if we have an exam that I appreciate that, but if we do things slowly, if we do things you know calmly, we can get it exactly right. My idea is the minimal effective dose is to get really what I want, but with a minimal dose.

Dr Olivia 25:27

I like your method. I think the other method sounds a bit uh because I but we'll talk about later, but but the less that you need the better. But do you notice it's a your your rationale to me makes sense?

SPEAKER_03 25:40

To to be, I mean, the reason the rationale of a force titrature method is that with methylphinidate, you have a linear response to treatment. Now I'm gonna go a little bit more complex, so linear response to treatment, which means that the higher the dose, the higher the response. And this is a straight curve. If you put dose on your x-axis and you put response on your y-axis, you have a good linear response. So the higher, the more response. But in this axis, there is no side effects. The higher you go, the more risk of side effects you get. Yeah. Other medications, such as atomoxidine or internive, or to a certain degree, even uh dexamphetamine after 50 milligrams, don't have a linear response. They have more curvy type of response. And for example, internive, you tend to have the bigger response at a lower dose, and then the curves tend to plateau, for example. But you have a steep curve to begin, then the curve tends to flatten out. Same thing with atomoxidin. So the curves are not the same, and this is why it's complex. So, and this is why force titration can work well with uh with methylphenidate, but not with other medication when you have a different type of curve. But again, I take to take into consideration the potential side effects, the experience of the patient and their family. If you burn anyone's finger, it's harder than to return to it. So I prefer no finger burnt. So I prefer to cook the coffee right and not to scald any any any any any fingers and to scorch any finger. So I think let's prepare the coffee right. That is not too acid and it's not too hot and it's just right. So this is the idea of starting low and building up slowly. Methylphinidate is our first-line medication, as by nice guidelines. Why? Why is it methylphinidate? It is because it's been found to have the best response and the least side effects in combination. So they're the least like to create side effects at a very good response. Kind of the sweet spot medication. It will not work for everyone, though, as I said. Some people like tea and coffee the same way, but some other people are very finicky. They only like Arabic beans, coffee. And there's some people will respond to methylphinate, approximately 70%, but not every kid will respond to methylphinidate. If you don't respond to that, then you have the other options of maybe another stimulant. And maybe you try, then it doesn't work. Maybe you try the non-stimulants. Or combine the medication, you get a response of approximately 90% once you so very high response rate.

Working Partnership With Your Clinician

Dr Olivia 28:15

Very high response rate. And so with what advice would you give parents when they start on treatment, um, working with their clinician? Like what type of things should they look for? What kind of side effects should they look for? When should they contact their clinician? Um it's a partnership job.

SPEAKER_03 28:36

It's work in progress and it's partnership job. Who are the partners of this job? It is the clinician, it is the parent, it is the child. Let's not forget. So it is a three-way partnership. Everybody needs to be involved. So the clinician needs to put their expertise and they need to present to the parents a menu of options. The guidelines should be respected, but in some cases, the guideline needs to be not respected because there are some certain reasons for it. This is the discussion, this is the informed consent that needs to be obtained and discussed together on the table with the parent, but also with the child according to their age. So the most important factor for the medication to work, you know what it is? Is the medication needs to be taken. If the medication is not taken, it's not going to be work. It might be surprising, but actually that's the case. That's the biggest factor of non-working of the medication, is medication is not taken because the dog is getting it or because the plant is getting it. So if the child is not on board, or you know, or the child has an adolescence, so even more not on board, potentially, we've lost the we lost the the aspect of adherence to the medication and compliance to the therapeutic plan. So everybody needs to be on board. Oh sorry, the biggest factor for compliance, so for the medication being adhered, so the patients and the parents adhere to the medication is that the the patients need to have a good subjective experience, a good experience with that. So asking, how are you feeling with it? Asking, do you feel is working? Asking, have you got headaches? How is your sleep? How's your appetite? So, and and for the clinician to experience, you might experience a bit of a headache, you might experience a bit of a sleep problem, you might experience a bit of appetite. So, but in general, this symptom will be tolerated and you will grow tolerant to it. It means that the symptom will diminish over time. So having this open discussion is paramount. It is paramount for then the patients, okay, I'm expecting these side effects. If it happens, I'm not going to be dismayed or I'm not going to be, I know what it is, I know what's going to happen. The parents know it, they take monitor and then refer back to the uh to the clinician. Sometimes we enter a battle, a bit not a battle, but a discussion with parents because of course uh uh you know reviews means money being seen, the clinician, and uh, and the clinician wants to see the patients, and that kind of the problem. At the beginning of treatment, it is essential to keep a tight leash, a tight partnership with the clinician. Why? It's because in this phase, to get the medication right and to get the dose right, this dialogue needs to be an ongoing dialogue. How was your sleep? How was your appetite? What about trying a little bit more? What about trying a bit less? This titration, in general, in my experience, once you get the medication right, it will be right for a long time. So at that point, that's why the connection with the clinician is okay every six months. Um, but that's why in the child, and you say six months only, and I would say the child grows. The child grows and the brain grows. And this is why this adjustment might need it, might be needed with uh with developing age.

Puberty, Hormones, And Re‑Challenge

Dr Olivia 31:56

And I mean, you know, also as kids get older and hormones come into play, does that also impact kind of how their brains are working, how the medication works as kids go through that kind of teenage era?

SPEAKER_03 32:11

Absolutely. And to be honest, I'll give you a little bit of my experience. If something doesn't work when you are prepuberous before your puberty, it might be sometimes worth rechalling after puberty. Um, and I've really seen, for example, in kids that presented with terrible irritability or methylphenidate, and that's why we had to ditch all the stimulants. We went on the non-stimulants before they were puffed puberty. The medication works well. They are at this point 14, 15, they're entering more GCSCs exams, they need a sharper focus, their non-stimulant doesn't give the same sharp. And they say, What do we do, doctor? Because we try the methylfinidate, they made my child so irritable. I would say, I think this is time for a rechallenge. So, to the point that hormones can change the brain to the point to make something that was not working before working, or sometimes make something that is working not working. So the the puberty is a very important time, and again, we need to be very watchful around that time.

Dr Olivia 33:17

And it's a very important time for school as well, and to have that attention, it's actually one of the key key times. Now, there's a lot of research out there on the stimulants, and there's a lot of, you know, you can read a lot on it. There's not as much, at least in my experience, on the non-stimulants. Are they both as effective in terms of things? Or is one kind of a little bit less effective?

Effect Sizes: What The Numbers Say

SPEAKER_03 33:39

In numbers. No, they're not. In big numbers, if I take a population of 100,000 children, I would say for certain that the measure of effectiveness of a medication called effect size, the effect size is larger for stimulant medication. Effect size, a large effect size is everything above the number of one. In methylphandate is 1.2 and even 1.5 for dexamphetamine. So they are large effect size. So it works with a vast majority of people. The effect size of the guanfacine and the atomoxin are in the region of the 0.5 to 0.7. So they are they have a lower effect size. So you might say, well, therefore they're rubbish, right? And I would say in individual level, we talked about population level. I'm talking about 100,000 children, but in individual level means your child, in your child, in your you know, adolescent, well, it's a it's a game of numbers, yes. But if that atomoxilin works, it really works. And you might, that child, you know, your child might be the one that actually responds to atomoxidin, does not respond instead to methylphenidate to the similar medication, for example. So at an individual level, um you have more likelihood to respond if the first medication is a methylphenidate over if it is atomoxidin. But your child might respond much better to be atomoxidine, or their ADHD presentation might be much better controlled by, let's say, a guanfacine over at least the examphetamine, so over an L-Vance, because your child presents some OCD behavior, because your child presents some anxiety, because your child presents more emotional ability, because of this specific reason, the fit would be better with a non-simulant versus a stimulant, for example.

Dr Olivia 35:38

That's brilliant. And that brings me up to my next topic that I wanted to discuss with you. So when we have different things going on, so when you have autism and ADHD, um, I have a lot of um moms getting in touch with me about how sometimes they feel like, okay, the ADHD medicine might be really working really well, but then the autism seems like it becomes more predominant and more difficult. And the getting it right, like the kind of personalized dosaging that you were talking about there and getting it right for the individual child becomes more complex. I'd love to pick apart both autism and ADHD, but also anxiety and ADHD. And um, with the autism, also look at pathological demand avoidance as well and how that kind of ties into it. I know that's a lot, but you know, when there are more things going on, as there often are with our children, how do you, you know, how do you look at the medication situation?

ADHD With Autism: Different Responses

SPEAKER_03 36:28

Look, I'll again, I think it's very appropriate to distinguish comorbidities in general and comorbidity with autism. Comorbidity means when ADHD comes with something else. So the AUDHD, so the autism and ADHD, that kind of we start to believe as clinicians, even as researchers, a group of researchers, believe that it's a condition itself. There is ADHD, there is autism, and then there is ADHD plus autism as a condition itself. Um the AUDHD, in fact, respond to the medication not as a pure ADHD, or sort of the person with just ADHD. Um and we've seen in response to treatment and we've seen in potential risk of side effects. In my experience, autism modifies not only the response to the medication, but makes the brain much more sensitive to side effects. So that mechanism of starting low and building it very slowly becomes even more relevant when it comes to AST in commodity with ADHD. The biggest potential risky side effects is irritability. The children in general, normal, normal developing children, you know, non-autistic children, don't normally have this as a major side effect. Instead, children with autism and treated with stimulant medication have irritability as a major, most important side effect that would hop out. So while only one in 1.8 in 100 kids would stop methylphinidate because they have intolerable side effects. 20% of kids with autism would stop medication because of intolerable side effects. Wow, that's a huge difference. It's a big difference, it's tenfold bigger. So one in five will stop medication because of the methylphinidate because of intolerable side effects. And the response rate we said is 70% to the first line, which is methylphenidate. In kids with autism, it's 50% of the response rate. So it changes the dynamic. It doesn't mean that ADHD is not treatable within the autistic within the autistic population, is absolutely not true, because it's very treatable. But we need to be careful that we have different numbers we're dealing with, with different numbers of response and different numbers of side effects. So, and sometimes this is where the non-stimulant medication that have been a little bit like you know our second, you know, second best in the ADHD children, they can become our besties in ASD kids with ADHD. Because we know that there are studies, uh Ms. Skahill and Hartkend Kampf in the Netherlands, they have studied actually the non-stimulant atomoxin and the guanfacene have a nice and important role to play within children with autism, for example, with less side effects, better sometimes emotional regulation control, better impulsivity control. So I would say that that balance sometimes slightly changes versus stimulant versus non-stimulants in the autistic population.

unknown 39:24

Yeah.

Dr Olivia 39:24

It's interesting. So would you start, would you start? Sorry, it's interrupt you there, would you start on a non-stimulant then versus a stimulant, or do you still start with a stimulant in that population?

SPEAKER_03 39:34

It really depends. It really, really depends uh on the child, on the presentation of the child. Uh and uh if a child presents with uh, you know, as a high functioning autism, although we don't use that terms anymore, but a very high functioning gotism with demands specifically on attention and concentration, I would still prefer to try a stimulant and keep it short trial. If it doesn't work, if you've got like irritability, I ditch it in a second, the medication. But I would try that first and then go to non-stimulants as a second liner. With highly complex kids, they're already coming with a plethora of other conditions, for example, much more, maybe lower level of IQ, maybe more complex presentation, maybe epilepsy, maybe some a lot of ritualized behavior, a lot of anxiety, a lot of PDA. Then I might opt for a non-stimulant strategy. We need to be very to have very valid reasons if we are deviating from guidelines. And the guidelines do not distinguish autistic children versus non-autistic children when it comes to ADHD. But the experience differentiates the both. So with a good partnership with the family, we might decide on to start on something different.

Dr Olivia 40:46

Yeah, that's interesting. And it makes sense then from that irritability standpoint that if you do have a child that's presenting with a PDA profile, and then they go on to a stimulant which increases the irritability, which would probably make worse the PDA kind of profile as well, based on that.

Anxiety, OCD, Tics, And PDA Considerations

SPEAKER_03 41:02

In some, I mean, no, you never, again, only in 15 to 20 percent would you have increased in irritability. In other kids, absolutely not whatsoever you would have it. But um, but if this is the case, if if you have a family that's already so burnt out because the child has been so irritable, and yet they're coming already to you that like exhausted because of the irritability, because of the PDA, this is the main thing. Yeah, you need to be very careful. I was saying, do I take the risk? I mean, do you do we want the risk of trying or potentially burning the finger thing, isn't it? Exactly. And the the finger might be so burned that I prefer than you know going from coffee to tea and not even starting the coffee.

Dr Olivia 41:40

Yeah, that makes sense. So it comes back to really that communication between you and your clinician and the child, getting that kind of real history of what's going on. And it is it is very much, even though there's only those four medications we talked about within those two categories, it is very personalized. And you really have to look at a really good history of where the family and the child is at and what conditions and comorbidities they have.

SPEAKER_03 42:05

Absolutely. And again, let's not forget that as we said, there are the other comorbidities. There is the depression and there are OCD, there is ticks and tourette. There are other comorbidities that can come along with uh with the with ADHD. And again, we know unfortunately that ADHD rarely comes on its own. The majority of cases ADHD comes with something else in a lifetime presentation. And again, in some cases with autism, some other present with some level of anxiety, some other with low mood, etc. So the vanilla plane ADHD is a matter of a 40% only of ADHD, is vanilla plane ADHD. Often comes with something else. And we need to be very attentive because it might not occur at the very time when we see the child, because the child might be seven and just had ADHD, but they might accumulate some anxiety, for example, at the age of 12 or 13 because of their ADHD, maybe because the ADHD was not properly treated or not treated at all. So we need to consider this comorbidities. We know the best thing is always to treat the ADHD. We know for certain that we must treat the ADHD. Um, and again, I'm not talking treating just pharmacologically, sometimes even non-pharmacologically only, but we need to do address, address the ADHD in order for us to diminish the risk of comorbidities. So the ADHD should be treated. Again, medication or non-medication, that's completely a preference of the families and the presentation, depending on the presentation, but should be treated, should be addressed. And then the comorbidity, we make at least an easier job for the comorbidities. So if you have anxiety and depression and comorbidity, so by treating the ADHD, you make the treatment of anxiety and depression easier in a certain way. And then you just treat it the anxiety and the depression in their own right, with CBT as a first line or psychotherapy as a first line, and an extreme situation pharmacologically treating it. I am very reluctant and I'm very Slow into treat. I'm very fast in a certain way to treat ADHD with medication because I do believe I've seen the effect. And you know, I wouldn't say every child, but I'm quite, I'm quite kind of boisterous when it comes to treating ADHD itself. I'm very, very, very cautious when it comes to pharmacological treatment of the other conditions of anxiety, depression. So where my first line is definitely the psychological treatment. And in some cases, medication have a role, but you know, a definitely secondary role to play.

Dr Olivia 44:32

And is that partially based on the kind of good side effect profile and also the amount body of evidence that you have of ADHD versus some of the side effect profiles with the anxiety and the depressing depression medications? That the risk benefits is for sure.

SPEAKER_03 44:50

And also, I mean, we're talking in this situation of ADHD plus something else, so not just depression on its own or anxiety. And I we also know that by treating the ADHD, you help to unpack and to try to, therefore, to diminish the risk of developing anxiety and depression, and you make also the anxiety and depression more treatable. For example, if I just say that the most important treatment for anxiety and depression is cognitive behavioral therapy or any form of psychotherapies or talking therapy, and you're very distractable and inattentive, you would assume that if you have ADHD and is untreated and I'm sending you to CBT, you might struggle to really make the most of that talking therapy. You know? If I give you good attention, good concentration, good focus, you might make much more of that CBT therapy, of that psychotherapy. So again, in virtue of treating the ADHD, you might the other treatment more effective just in virtue because you can take them better.

Dr Olivia 45:48

That makes sense. That does make a lot of sense. Um and what about OCD and ticks and Tourette's? Does that have any particular differentiation that you would like to discuss?

Side Effects: What To Watch And When

SPEAKER_03 45:59

We've seen, we've I've seen there is a sometimes there is a triad situation. So you have kids with OCD, ADHD and ticks. Uh it's it's it's a known triad, and we have some kids with ADHD and ticks or ADHD and OCD. Um it's more complex uh in because some of our medication might trigger, they don't normally cause, might trigger uh OCD thoughts or a movement, so a tick. So we need to be very careful in the treatment of the ADHD, not to trip over to the uh exaggerating or accentuating the OCD or the ticks. Um, for example, if you give a lot of focus, sometimes you can give hyperfocus and an obsession in an OCD situation. So this is where the balance is very important to try to avoid um to trigger sometimes any obsession. To be honest, a lot of medication can trick can trigger it, even atomoxin in some cases. The only one that I found that not triggering an obsessive thought is the guanfocine. Completely like I have not had any case where guanfocine was triggering thoughts. I had cases where all stimulants and even atomoxin in some OCD were triggering obsessive thoughts. So you really need to navigate very carefully there to find a medication that does not triggers either the ticks or the OCD, and then you need to treat the OCD and the TICS.

Dr Olivia 47:21

Okay. That's super interesting, and it's, you know, uh it's it's been incredibly insightful. Is there anything we didn't talk about side effects too much with the stimulants? Um, so maybe touch upon that and then I'm gonna open it up for questions. But um, is there anything else you feel like that we should discuss that we haven't maybe discussed this evening?

SPEAKER_03 47:39

Well, I definitely think the side effect profile is essential. As I said, the rule of thumb is that the majority of side effects are mild, and those mild side effects tend to disappear, to peter off in time. So I suggest patience with some sort of side effects. I suggest no patience with other types of side effects. Irritability in a narcissistic child, no patience. Forget about it, ditch it. When it comes to a slight delay in sleep onset, I would say just be a bit more patient there. Let's try. Or a bit of a reduction of appetite. A child has got a massive R fit, massive problem with uh, you know, with eating, the moment I see the appetite dropping, I ditch it. Do you see? It depends on the patients you are talking to. Um, so side effects in general tend to be physical and again short-lived. With stimulants, it's the typical one is delay of sleep onset. It takes longer to fall asleep, uh, diminishing of appetite, headaches. These are the most typical side effects. Then you have a bit of a heartburn, or these are a bit of a dry mouth, a bit of dry eyes. These tend to be the really the most common. Then you have some psychological side effects, feeling a bit buzzy, uh, or feeling too quiet. You know, the child sometimes says, I'm feeling too quiet up here. I don't really like, I'm less spontaneous, less funny. My key, my friends don't like me as much because I'm less impulsive, I'm not the joker anymore. Uh, in the class, uh, some kids would develop a little bit of anxiety or a little bit of irritability, as I said. So you need to explore that. With the non-stimulants, it's a little bit different. With atomoxidine, um, nausea is the most common side effects. Um, and because crazy sometimes has a heartburn. Um, and sometimes the mood can go low, extremely rare, but is a glow is a warning about suicidal ideation, extremely rare, extremely, extremely rare, but we need to be warning the families.

Dr Olivia 49:38

Interesting, actually, with with my daughter with with Adamoxetine, she had some darkish thoughts, but it they went away, you know, like her mood dropped, but we we you know, we we tried it and I said, let's just and and explain what's going on. Like you, you, you, you talked about earlier. And I just said, I think that's part of the medication. Let's see how it goes. If it doesn't, you know, not check in with her, and then you know, it's completely disappeared now, they're gone. Exactly.

SPEAKER_03 50:02

The adjustments. So sometimes the body just needs to adjust to it. But is it important to inquiry about, to ask about, and to make sure that the child and the family are aware about this potential risk.

Dr Olivia 50:12

And that they they they can normalize it and that the child can then know what's going on, even with the not the lack of appetite, even you know, that this is this is what's going on. We need to tempt you with something that you want to eat. And the timing, I think, with the appetite is also important too, depending on when you're taking the dose.

SPEAKER_03 50:28

Exactly. I mean, with the stimulants, you really play with the stimulants, what time? I mean, do you have a bigger breakfast? You know, do you catch up for lunch or do you catch up for dinner? And with uh the non-stimulus, for example, atomoxin, if you've got a massive gastric reflux, I mean, you can bring it at nighttime, or you can split the dose during the day. These are things that you can do with atomoxidine. And guanfacene, the biggest side effects is sonolence, so tiredness. Um, and with the problem with the guanfacine, the medication cannot be stopped abruptly. It's very important to tell the family. You don't need to not stop abruptly, especially if you're a higher dose, because you can have a rebound in hypertension. So the risk is more lowering the blood pressure, especially if it's hot. Um, so the medication lowers the blood pressure. So you need to be careful. If you're already a person that tends to faint, maybe the medication is not right for you because it would lower a little bit your blood pressure. So these are the they all have different side effect profile. It's very important to have to discuss with the clinician. It's important to read also on the leaflet uh the potential side effects, but not panicking about it and discussing if you have got any concern with a clinician.

Dr Olivia 51:26

Yeah, exactly. And you know what? You've you said to me before, talk to your kids because they really they they will tell you exactly how they're feeling on the medication. They really are the best person to get in contact with.

SPEAKER_03 51:37

Absolutely, absolutely, absolutely.

Dr Olivia 51:40

Well, excellent. Thank you so much. It's been so informative as always. And I'm now gonna open up for questions. And I also have a couple of questions that people have sent in. Some of them we've actually already addressed, but you never know if people are gonna ask a question or not, but I'm putting it out there. So if there's anyone out there who has a question, please turn on your camera and your microphone now. Otherwise, I will ask some of the questions that have been sent in advance. May do you want to speak, please?

SPEAKER_02 52:08

Hello, that was so useful. Thank you. Um, my question is in relation to my son who is 12 years old, has tried both um stimulants and um atomoxetin, and I'm thinking about whether we should try guanthosine, but he's in chronic burnout and has been for well over a year. He's autistic ADHD. Um so I'm curious to know whether whether it's whether what what impact autistic burnout or ADHD burnout has on trialling medication.

Closing Notes & Resources

SPEAKER_03 52:43

Thank you for your question. Okay, I need to make give a disclaimer that I cannot comment specifically for any child, etc., because I I don't know the story in great detail. And the point is like just to say that exactly, and I say the disclaimer not just because I don't want to be sued, but I'm just saying the disclaimer on the fact that um the complexity of ADHD, it looks like so simple, right? For medication, the complexity is to such a level of details that you need hours to collect all the information that will generate, therefore, a flowchart of decision points, because it's so important. In general, I was a child with autism and autism burnout, which is a very important point, which is the feeling of almost physical exhaustion, physical exhaustion of depletion of even of the neurotransmitters within the brain. You're just so tired and your adrenal system has come to an exhaustion. So it's a combination of brain and adrenal system to get to the exhaustion. This is the autistic burnout, the constant masking, the constant negotiation with a world that is difficult to decipher, to understand, and to abide to certain rules when you actually your body and your brain works in a different way. So it really leads to exhaustion. And ADHD makes it even harder to deal with the exhaustion because it uh it brings executive dysfunction, it brings more impulsivity, it brings more hyperactivity. So it is even harder to deal with that. So um I would say again, of the four options, it is important to leave no rock unturned. I would say three options have been tried. Uh the consideration of the fourth option, it is a it is it is it is a sensible option to consider. Skahil in uh uh in the mid in the mid um, so I think 2010, 2015, 2016, had a good study about guanfacene in uh children with ADHD and ASD. So in TNIV, guanfacine, there was a study, a good randomized control trial, a big study in the States, um, that found guanfacin was effective in children with ASD. Was not only effective, was quite well effective, and actually quite well tolerated. I find that guanfacin, it is um it is definitely one of my favorite medications when it comes from to AUDHD, because it has, I would say, is one of the biggest properties of emotional regulation. Um, and given that calmness, I mean there was some study even in rejection uh sensitivity, so in that this the rejection sensitivity dysphoria, because the guanaphasine has this effect because it uses different pathways, it actually is a postsynaptic uh alpha 2 agonist. So it's a very, very different than the reuptake inhibitors, which are the other medications. All the others are reaptake inhibitors, dopamine or adrenaline or both. So this is a very different type of medication, acts directly onto instead of acting on the gatekeeper, acts on the gate. So this doesn't wake up the gatekeeper, it just opens and closes the gate directly. So it's very different. So it just works downstream than instead of upstream. Um, so it's kind of your electric gate instead of giving the coffee to the gatekeepers. Um, this is a completely different mechanism of action. So for me, if I tried everything else, well, this is medication with a completely different mechanism of action that I think is worth considering.

SPEAKER_02 56:04

Thank you. That's really helpful. Thank you.

SPEAKER_00 56:07

Thank you for listening, Send Parenting Tribe. I think Dr. Giorli has really explained the intricacies of ADHD medication. I've included in the show notes a link to his clinic as well, and I'd like to wish all of you a great week ahead.