ADHD - An Interview with Professor Michael Kohn

Professor Kohn is considered one of the experts on ADHD in Australia.  
ADHD is the most commonly diagnosed childhood disorder, affecting about 7% of 4-9 year old children and nearly 10% of 10-14 year olds.  And if that fact is not enough to trouble you, did you know that the total social and economic cost of ADHD in Australia in 2019 was $20.42 billion!!!! This included financial costs of $12.83 billion and wellbeing losses of $7.59 billion. 

Dr Kohn is Area Director for Adolescent and Young Adult Services in Western Sydney, and is a founding Director of the Centre for Research into Adolescent’S Health (CRASH) where he has developed a clinical research program in developmental paediatrics and neuroscience. Dr Kohn has published over 140 peer reviewed scientific articles and 10 book chapters.

Dr Kohn was a committee member for the NHMRC ADHD Treatment Guidelines in 2010-2012. He is a reviewer for a range of scientific journals, Industry and the NHMRC.  Dr Kohn has been Chair of ADHD Australia since 2015.

Transcript

Dr. Anne Chalfant: Welcome to the Annie's Center podcast. My name is Dr. Anne Chalfant. Today we're talking about Attention Deficit Hyperactivity Disorder, or ADHD.

This morning, I interviewed Professor Michael Kohn on this topic. He is considered one of Australia's leading experts on ADHD. I'm really excited to be able to share that interview with you today. Before I get to that, though, I just want to give this brief introduction to the issue of ADHD. Why are we even talking about it? In my mind, there's three reasons why it's important to focus on ADHD. First, it's the most commonly diagnosed childhood disorder. Did you know that about 7% of four to nine-year-old children have ADHD? Almost 10% of 10 to 14-year-olds are diagnosed with ADHD. They're large numbers. Did you know that the social and economic costs last year of ADHD in Australia was $20.42 billion? Now that's a grim statistic. That included financial costs of $12.83 billion, well-being losses of $7.59 billion, and $10.19 billion in productivity losses. I'm talking about B for billion. Again, these are staggering figures.

The second reason is this issue of the social and economic costs. In our schools, for example, one-quarter of the students who actually have ADHD have been suspended for behavior difficulties associated with their disability. 40% of those suspensions are occurring in the first three years that a child is in primary school. 40% of those individuals who are suspended who have ADHD are in years as young as kindergarten. I can't believe that we are suspending children from kindergarten due to behavior difficulties associated with a disability. I think that's a shocking statistic.

The third reason is the amount of negative press that ADHD seems to attract. Whether it's arguments over, over-diagnosis, or under-diagnosis. Whether it's debates around whether or not we should be medicating children. Whether it's discussions in society or in the media about, whether ADHD has become a convenient diagnosis for what really is just naughty behavior, or a convenient excuse for adults for what really is just misconduct or bad conduct. ADHD certainly seems to have become the disorder that we love to hate, and we have ignored it. It's no longer recognized as a disability within the education system because it attracts no funding in terms of education support. In the NDIA, or the National Disability Insurance Agency in Australia, it gets no recognition. There's no funded support for ADHD through the NDIA, or its scheme, the NDIS. In our Pharmaceutical Benefits Scheme, or PBS, medication for ADHD for adults is also ignored.

How is it that we're in this situation, where a disorder that people genuinely have, where they really need support, a disorder that is costing the community so much money per year, is being ignored in this way. It's for this reason that I wanted to speak to Professor Michael Kohn on this topic.

A little about Professor Kohn. He's a clinical professor and pediatrician, with a special interest in treatment outcome research in developmental disorders, neuroscience, and nutritional disorders. Professor Kohn is area director of Adolescent and Young Adult Services in Western Sydney. He's the founding director of the Center for Research into Adolescence Health, or CRASH, C-R-A-S-H. He developed a clinical research program there, in Developmental Pediatrics and Neuroscience. Dr. Kohn has published over 140 peer-reviewed scientific articles, and 10 book chapters. He is a committee member of the NHMRC, which is the National Health and Medical Research Council, ADHD Treatment Guidelines. He is a reviewer for a range of scientific journals, industry, and the NHMRC. Dr. Kohn has been Chair of ADHD Australia since 2015. As I said, he is an expert in this area, and it was a great honor to interview him today. Let's listen to that interview now, and see what kind of information he can share with us about ADHD, and how he can shine a light on this topic.

Dr. Kohn, thank you for agreeing to share some insights on ADHD this morning. Now, I feel like it's one of those really important neurodevelopmental disorders, not just because the prevalence is so high, but it seems to be so, despite our modern understanding and great research and building of awareness within the clinical and the health professional world, very much understood and overlooked in some ways. I wanted to speak with you this morning, I suppose, given your expertise and your length of time working in this field.

Michael, where do you think we're at, first of all, in understanding what exactly might and might not cause ADHD?

Professor Michael Kohn: I think we're in a watershed moment, Annie. I think where we've come from is that we've had classic descriptions of behavior. That's been really confusing in some ways because the cause for the behavior has had some contention. Also, it's been ascribed to different kind of reasons like bad parenting, a bad person, a dumb person. There's been hugely negative connotations in terms of where we've been, how we've tried to categorize, how we've tried to describe a group of people whose brain are not efficiently solving challenges. Now, what we've got is a neuroscience that is telling us how the brain of an individual person is working to solve problems. The first time, we are really able to see the differences, and we're able to understand that there is biology, not just a society responsible for ADHD.

Dr. Anne: Yes, okay. In terms of looking at the biology, what do we think at the moment, what's the thinking around what some of the causal factors might be?

Professor Michael: What underlies the biology is less clear. We've just, at the moment, got a macro view. We've just got the ability to see how someone with ADHD, how their organ, their brain works differently to solve problems, and that this difference means that they're less efficient in some areas, in the areas of organization and planning. It may also mean that they're less efficient in processing skills that are so important such as language.

Dr. Anne: In terms of assessment then I suppose moving on from that, or jumping ahead to that a little bit. As a clinical psychologist, we would use rating scales, we'd interview parents, we'd interview school teachers, we'd look for presence of those difficulties or challenges across different settings in order to be thorough. From what you're saying, is there more need to be doing more in terms of neuroimaging and those sorts of studies to be more clear about diagnosis so that there's less murkiness around misdiagnosis, or possibly over diagnosis, what do you think?

Professor Michael: Anne, I think that there's two important issues to distinguish from what you've just said. First is the ability to make a diagnosis, but making a diagnosis doesn't actually help a person necessarily. I think part of the diagnostic process has to understand why the inefficiency is here, why the ADHDness is there. If we can package that, then we can tailor it for the individual how best to give them support. I think this objective rating of behavior, those scales that you're mentioning, they're really good to categorize someone, but we need to go further, and I think we can at the moment to best assist them to manage their ADHDness.

Dr. Anne: Sure, and so things like looking at their functioning and planning for support and treatment around that. Michael, what is the current prevalence? I presume it differs depending on age groups or clusters.

Professor Michael: This is, again, a really interesting observation if you step back.

Professor Michael: We know that in terms of the brain, there is groupings, 5% to 10% of people, whose brains naturally across our population will function in a deviant, in a not the majority way, and to [inaudible 00:10:16], let's look at left-handedness. Consistently across generations, there's been the way that someone's brain has worked to operationalize their motor system that is predominantly left-handed, that 5% to 10% group. The vast majority are right-handed. I think in terms of how a person's brain develops in terms of the development of cognitive skills, the efficiency to solve challenges, not just in the classroom, but in the playground, in a whole way that the brain operates, there's 5% to 10% of the population who are less efficient. That is the group that we are clearly identifying as having ADHD.

Again, the rule for them is, it's not just that they've got the ADHD illness, the vast majority of people where we see this ADHDness, they've got other kinds of co-occurring inefficiencies. As I said, it could be regulating your mood, or it could be using language. There's a range of ways in which the brain is operating inefficiently, which is [unintelligible 00:11:22] by having ADHD.

Dr Anne Yes, and then the subsequent, I suppose, challenges that we see, as you said, difficulties with language, and with mood regulation in a classroom environment. The huge challenge that poses, and I know that the numbers in terms of costs, not just the financial costs, but looking at children who are suspended from school or moved schools, because they're not being, I suppose, adequately supported within certain environments and the difficulties that poses for those that they have associated with learning difficulties must be huge.

Professor Michael: This is quite a political slant at the moment, how you view ADHD because of the NDIs. I couldn't agree more. What you said is that people with ADHD have a disability in terms of competitiveness with their same-age peers, in education, in work and in relationships, in a range of ways, and that it is lifelong. Why isn't it support for the people that are in this group that had this disability that's associated with having ADHD? Why are they able to be supported?

Dr Anne Just on that, I suppose, looking historically, Michael, my understanding is that a long, long ago, ADHD was a diagnosis that was given, for example, some funding or some support to raise concrete resources allocated within, for instance, the education system in the same way now that other neurodevelopmental disorders are like autism. Certainly thinking about things like the NDI as well, why do you think it is that it's lost that recognition as you indicated? I certainly see that myself, these are kids and adults are genuinely struggling and really need that support so that it doesn't cost further for them emotionally and personally, but also more broadly. We're thinking about resources and allocation of scarce health resources, for the country and for the economy. Why has there been that shift over time?

Professor Michael: Yes, Anne, and again, agreeing with you wholeheartedly. The clinicians, the families, those people with ADHD, their view has not changed. Someone's view has changed, and they are the decision-makers in terms of how the health system is managed. I think they are the people that need to be accountable to explain why they made the change and why they continue to resist support for young people and adults too in various ways with ADHD. Again, please, it isn't just the young people. I'm particularly concerned that ADHD is now well-recognized to a [unintelligible 00:14:30] adult life. I'm seeking for ADHD medications, or the first-line treatments for ADHD is not available through our PBS, our system subsidy for adults. [crosstalk] needs to change.

Dr Anne Absolutely. That's mind-blowing for me to hear that from you, Dr. Kohn. I had no idea that that was the case, and I can't imagine, for individuals that's depression or anxiety or things like that, I can't imagine them not being able to access medication is a line of treatment that they would so need and why that would be so different than someone who has adults ADHD that is really mind-blowing.

What can we do then, do you think, as a society or as a culture, or in certain aspects of how we're working to shed them more positive attention on ADHD and raise the profile in such a way that the needs can be better-understood then, but perhaps better recognized?

Professor Michael: I think, again, if I could go back to my example of left-handedness, this was definitely something that was seen in our society not even more than two generations ago as something that had to be stamped out. Even the name that was given to left handedness, sinister being left and dexterous being right. In our society, in a range of subtle and overt this, we look to try and change left-handed people to become right-handed people.

Now fast forward to 2020, we are really celebrating the diversity, but also inclusiveness and taking advantage of left-handed people. I can think of no better example than the selection of the Australian cricket team when we go back to playing cricket, there'll be definitely people who can ball and bat left-handed who have advantages and are included in our team. I think we need to get better at accommodating. We just need to recognize that people's brains aren't or created equal in some areas where we've got-- we select out for the classroom. We make it more difficult for ADHD people to thrive. What we need to do is to just to recognize that it's just a difference.

We need to accommodate it in areas where they're under stress, but equally well, what we need to do is to recognize it's not just a deficit, having ADHD, there are significant advantages in creativity, in entrepreneurship, in our whole range of ways. Our society really thrives because of the input from people who have ADHD. Looking at the tech industry, in Google, how the whole working environment has been restructured there to harness the energy and creativity from people with ADHD and not to have this 9:00 to 5:00, this regimentation which makes their difficulties in coping with society problematic.

Dr Anne It sounds like it's a combination of hopefully a shift in our view, but at the same time as more strengths-based approach as well, trying to harness peoples strengths and seeing the positives, as you put it, the creativity and the other strengths and capabilities of people with ADHD and harnessing those.

Michael, if we look at treatment, just to turn our attention to that now, what is the evidence telling us at the moment about best practices treatment for ADHD?

Professor Michael: Again, the worst best for a person with ADHD, may not thoroughly be what's best for ADHD in general. I think it's important to recognize that there is a spectrum of inefficiency. There are definitely strengths and difficulties for each individual person, a little magnifying them. I think a personalized approach is still the key where those support around not just the behaviors, but some of the learning language or emotional regulation difficulties.

Dr Anne That makes perfect sense. You're looking at the individual profile of a person with ADHD and designing treatment planning around their individual strengths and challenges, as opposed to saying, "Oh, well, you have ADHD. Here's the general path for you of action." Which I think sounds very similar to what's historically perhaps been some of the pitfalls with other neurodevelopmental disorders, for instance, or autism, while you have autism, do X, Y, and Z, as opposed to looking at the individual's particular profile and planning around that, is that what I'm hearing you say?

Professor Michael: Absolutely. If we take autism and we want to regulate the behaviors, we're missing the important opportunities, some of the drivers for the ADHD behavior to improve socialization and communication. In ADHD, what we have seen in a number of large studies is that there's definitely the use for the psycho-social, educational strategies in combination with pharmacological strategies. For ADHD, we've got a particular pharmacological approach which is highly effective in regulating the behaviors and overcoming a lot of the cognitive disability. Those studies, such as the NTA study, are getting on to be about 20 years old now, but not [inaudible 00:20:30] What it clearly shows it that if you fit into that category of ADHD, you will benefit most by having support around medication as part of your treatment at least in early year or so.

Dr. Anne: It's very interesting in terms of the timing of it, it sounds like that's very important.

Professor Michael: Yes, absolutely. It is complex, it's multifactorial, and I think that's why you need to have trained physicians, doctors and psychology working together to be able to optimize the approach for someone with ADHD.

Dr. Anne: Yes, and I think on that point, I couldn't agree with you more. Do you think then that we need to tighten up, in some way, the psycho-social interventions that are available? I'm just thinking it's similar to other neuro-development disorders. It seems like every possible intervention known to mankind can be used to at different times. I know several years ago when the NHMRC were looking at guidelines around ADHD, one of the concerns I believe that was raised was about just the variants of the psycho-social therapies and treatments. What's your thoughts, Michael, in terms of what you see is in the evidence, and I suppose anecdotally has been effective and perhaps less effective?

Professor Michael: Thank you, Anne. I have just two ideas to answer your question, but the first to explain it is that, I was on that NHMRC committee in 2011, and so I thought that that document at that time that the NHMRC produced not just the recommendations, but looking at the various kinds of ADHD treatments, and so a separate document from the NHMRC was looked at evidence-based for a range of treatments, as well as mainstream treatments. It's very clear that there isn't an evidence-based to support them. However, I think, again, when we're looking at the individual, you need to ask yourself three questions. One, is this likely to help? Is this going to do my child or me harm, and can I afford the time and money? I think, again, there isn't a mortgage on what is going to be helpful by any profession, doctors, psychologists and what else. I think as responsible parents, if you can answer those three questions, then it's worthwhile giving it a go for your young person or for yourself.

Dr. Anne: That's a great guideline I think for families that would be listening to this podcast, the sense of is this likely to help my individual child and their specific circumstances? You've talked about that idea of the individual profile of the person, and then the cost in term of your own personal time and resources. Yes, that's a great set of questions, I think that families really value from listening to this. Thank you, Dr. Kohn.

Then can I just ask you about some of the digital therapies that seem to be coming out of the US specifically? Recently, my understanding is that the food and drug authority in the States officially recognized a digital therapy, particularly a game as something that could be prescribed for someone with ADHD as a way of strengthening and targeting neuropathways. Is that something that you think might eventually occur here?

Professor Michael: Yes, look, it's occurring ever since psychology started to look at ADHD. What we're talking about now is actually a form of brain training, and we know that the brain is the organ involved in ADHD, we know that the brain is plastic, in other words, that it is able to respond and change in function with experience. Then it becomes, well, in this 2020 age, what kind of experiences can we manufacture to train the brain to perform in ways that we would see as being better, as optimal? These digital brain-training strategies are being developed at the rate of [unintelligible 00:25:08] There is an evidence-based, there are ways in which companies developing them have piloted and have researched them, have produced data, core administrations such as the FDA have looked at it and found them convincing, and found them helpful, so they've registered them. I think they're going to continue to evolve as a new kid on the block for ADHD treatment.

Dr. Anne: Yes, and hopefully again that's another good option then depending on the individual profile of the child or adolescent or adult with that challenge.

Professor Michael: [unintelligible 00:25:43] yes. The three questions apply, but I think, again, the dependency, the vulnerability, a preoccupation that someone with ADHD has for these digital strategies needs to be treated cautiously. It can be a help, but it can also be a distraction. Again, that's where care needs to be made in deciding you do that and to whom you might introduce these strategies.

Dr. Anne: Yes. Going back to the education system, Dr. Kohn, what's your view on things that might need to shift in the education system to give better support to children at school with ADHD? Again, I think I absolutely find it mindblowing statistics around the number of suspensions of children with ADHD from kindergarten to year two. Suspending children in kindergarten just seems to me incredible at any stage. What do you think is needed there? Is it that we need better training for teachers earlier on in their own training pathways? Is it more broad than that in terms of the shift in our recognition and understanding that what you're talking about earlier about recognizing strengths and the individuality of the child? What do you think needs to change?

Professor Michael: That's right. This is going to be an answer, all of the above-

Dr. Anne: [laughter]

Professor Michael: [inaudible 00:27:15] earlier when a child is suspended from education. I think we need to look at it from all of those perspectives. This is an area that ADHD Australia has been very strongly committed to. This is a national consumer organization that's looking to advocate and have support through the society for accommodation for young people and adults with ADHD. Again, most recently, ADHD Australia supported an organization of parents called PAAA. They did a survey in New South Wales schools of what's actually happening for those with ADHD, and it was definitely concerning in the extreme how there's a failure at the moment to accommodate and to support young people with ADHD within our system without reaching to a punitive approach. This is what we're saying right throughout today's podcast, is we need to understand and accommodate. You don't change by punishment, you change by education and by developing strategies to improve efficiency of how the brain is working, and we need to be able to find a way of moving more towards that from clearly what PAAA has shown us where we are today, and education of teachers, as well as families and skimming of young people are definitely the forefront of where we need to go.

Dr. Anne: It strikes me that that would just be, thinking about broader child development, that that would just be a good way to be interacting with kids in general whether or not they have ADHD and or possibly other learning issues. I can think of my own clients who do have ADHD, and when they've been in an environment where almost in one sense there's the expectations they have been raised or they've been inspired to do better and given the support to progress, they've actually thrived. As I suppose I'm suggesting for children, in general, I think when you encourage them, when you see positive in them and when you expect in a way more of them, they tend to rise to the occasion than if you cast them aside or write them off as being a challenge that's as if all hope is lost. No, I think your suggestion resonates very strongly with my own anecdotal, I suppose experience clinically.

Professor Michael: Yes, a lovely study. I think there are definitely universal strategies to help those with ADHD, and any of the young people struggling in the classroom environment. A lovely study from the 1950s. What you don't learn from history, you repeat what the psychologists who came into the classroom had to look at is the performance of young people. They wanted to see whether that correlated with the IQ, with the intelligence of the students. They found there was a trend, but it wasn't nearly as strong as the discrimination of performance on what the teacher thought about the student.

What the teachers view and how the teacher presented work interacted with the student was the most important discriminator of how that student did in that classroom rather than just IQ. I think that's such an important lesson going forward.

Dr. Anne: Yes. I couldn't agree with you more. Absolutely. In terms of going forward, and maybe speaking about you more personally, and your work that you have done over the years to be an advocate for people with ADHD through your work and through the organizations that you belong to, and it's a sensitive on preparing of guidelines in many, many different avenues and aspects, what aspect of your own work, Dr. Kohn, in this field, would you like people to be most aware of?

Professor Michael: I think there's the need to shine light and not make heat. I think everybody has got their own bias, their own prejudice, their own intellect. I think we would do the best by just challenging each other to produce data, to look at it in a cold way, and to look for ways that we can identify how we can strategize, how we can accommodate people where their brains are not working efficiently.

Dr. Anne: I love that line, shine light and not make heat. That's a great summary. Where to next then? What do you feel most hopeful about in the next 5 to 10 years in this field, whether it's research or clinical practice?

Professor Michael: Look, thank you. I am hopeful. I am hopeful because I see a number of small fires being lit over these last couple of years that are going to be able to burn brightly. I see through the auspice of the federal government that there's been funding to develop a professional group around Australia that brings together all of those involved in ADHD care. Most recently, that's been extended to a community group, so there'll be some funding for strategies to bring the community's ideas together.

I think that combination will enable arising a very big wrong. I think they will be able to, then the government policy will be able to be inclusive of people with ADHD and support them in ways which will make a paradigm change rather than at the moment then being excluded and discriminated against.

Dr. Anne: That sounds very hopeful indeed, and what a massive shift that would be, I think in the right direction. Dr. Kohn, thank you so much for the vast work you've done in this area, and also for shedding light today on the needs of people with ADHD and important issues that you've raised around assessment, around treatments, and that general comment that I think has come through the podcast, as a theme, the need for really looking at individual circumstances and profiles and making decisions, sensible decisions based on the individual strengths and weaknesses or challenges of that person and their functioning.

I really am very, very grateful for your time. I have great respect for you. I'm very honored that you've been able to get some time this morning. Thank you very much.

Professor Michael: Thank you for the opportunity.

Dr. Anne: Well, I hope you found that interview as informative and helpful as I did as both a clinician and a parent. I really liked the practical three-step question process that professor Kohn outlined for families considering treatment options to ADHD. To review those parent questions again, they were, one, is the treatment likely to be helpful? Two, could it cause my child or family any harm? Three, what are the costs to us in terms of time and money? What a great guide and a quick and easy process for parents to consider when they're looking at treatments for their child.

I'm going to include links to four excellent sites for ADHD in our show notes. These links will cover resources, information around assessment and treatment guidelines, and some current information around this idea of the digital therapeutic approach to ADHD, which is a new look at treatment for ADHD using digital technology. As always, please leave comments in the show notes, and rating. Thanks for listening and have a great week.

Announcement: The Annie's Center podcast with brought to you by Annie Center Proprietary Limited. Please visit anniecente.com and subscribe to receive the latest updates and digital downloads from Dr. Anne Chalfant.

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