Transcript for episode 45

Demystifying ADHD and Medication with Dr. Giovanni Giaroli

Please excuse any errors as this transcript has been auto-generated.

Dr Olivia KesselHost00:08

Welcome to the Send Parenting Podcast. I'm your neurodiverse host, dr Olivia Kessel, 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. In this episode, and in honor of ADHD Awareness Month, we've invited Dr Giroli onto the podcast.

00:56

Dr Giroli is a consultant, child, adolescent and adult psychiatrist specializing in neurodevelopmental conditions such as ADHD, autism, ticks and Tourettes across the lifespan, from childhood to adulthood, and also other childhood conditions such as anxiety, depression, obsessive-compulsive disorder and bipolar disorder. In 2014, dr Giroli founded the Giroli Center, really due to the lack of services offered to children and young adults in the NHS and fueled by his frustration to ensure that patients and parents receive better services. Today, we'll be talking to him in great detail about the treatment of ADHD and anxiety from a pharmacological and medical viewpoint. He has an absolute wealth of knowledge and experience and is really able to explain the complexities of treatment options, both in ADHD and anxiety, in a way that is understandable. I would highly recommend listening to this podcast.

02:01

So welcome, dr Giroli, to the Send Parenting Podcast. I am really excited to have you on the podcast as a guest today to show us not only your passion for neurodiversity, but also your pharmacological or medical knowledge in terms of treatments for individuals with ADHD, anxiety, sleep disorders. There's so much information out there, both on social media and on the web, and a lot of misinformation, so I know there's a lot of confusion, and so I'm really looking forward to and I know my listeners will to kind of get your esteemed opinion so that then we're empowered to make our decisions as to whether or not we want to go down a pharmacological route with our children.

Dr Giovanni GiaroliGuest02:41

So welcome, thank you so much for having me.

Dr Olivia KesselHost02:44

I guess I'd like to kick it off maybe with telling us a little bit about your background and your passion and how it led you to forming the Giroli Center Right.

Dr Giovanni GiaroliGuest02:53

So by background I'm a physician, so I'm a medical doctor, trained in Italy and then trained in adult psychiatry in Verona, which was a WHO center. Then I moved to Australia where I pursue. My passions actually was children, so I specialized in childhood lessons psychiatry in Melbourne and then I came to the UK in 2007 as a consultant in an East London trust, and I worked as a childhood lessons psychiatrist ever since, and since the very beginning I developed a passion for neurodevelopmental conditions because they were so gratifying in not only in the diagnostic aspect, but extremely gratifying in the success. So it was wonderful to start to see my patients with ADHD flourishing after being diagnosed and then treated, flourishing from several settings not only school, but also home, friendship, etc. And so it is a type of job that gives you a lot of satisfaction when you see your patients really getting better and really start to thrive in life.

04:08

So I worked in the NHS for several years and then I started to struggle with the delay in offering service to our patients. I started to work in private practice, very much developing on my passion, which was neurodevelopmental conditions, and that's why I started. Actually, 2009 is when I started private practice, but I then went fully into private practice, made this big jump in 2014 to fully dedicate myself to private practice and to research, at the time with the UCL, and then I continued, and that's the rest is history.

Dr Olivia KesselHost04:51

Well, you know, it's amazing how you say that, because it does mirror what my experience has been with Alexandra and I've shared on this podcast that she's been actually diagnosed at your center with ADHD and put on medication at your center, and for me it's been like a light switch has been turned on and I noticed it at home in terms of how she's able to shower herself, get her bag ready. She's just a different child and it reminds me of when I've worked with Parkinson's patients and you give them to a dopa and they come back to life again. But I must say there's you know how does it work? How does this ADHD medicine have such an impact? And I know it has a differing impact in terms of some children respond, some children don't respond. It maybe has been overprescribed. I'd love to unpick some of that story with you.

Dr Giovanni GiaroliGuest05:41

Well, and you know the story comes with controversy. So that's interesting how the story comes with controversy, given this is not a visible condition. You know, medicating something that is not visible is always raised controversy, from philosophical controversy to financial controversy, to ethical controversies. You know well, I don't think there's ever been anyone who doubted the use of insulin in diabetes, for example. You know it's a real condition, so you can see the conditions, real because it exists, you see it's in the blood, you see the consequences and so insulin makes sense and then met, for me made sense and all the other medication for diabetes type one, type two, make all sense.

06:24

When the conditions are invisible, such as in psychiatry, medication can be controversial unless the patient is dangerous to society, that no one has any any problem in medicating someone who's dangerous to themselves or to others. But in condition where you'd not see this immediate danger and you know you can look at the depression, the very beginning and now neurodevelopmental condition, then children are involved you can imagine why treating something which is not visible is not immediately lethal, is not, doesn't put you at risk or doesn't put other immediately at risk, why treating it Is it, does it exist, does it not? And this is why the controversy about medicating something which is not visible, something which is not dangerous and we can talk about that and and, and and medicating children. So that's why I'd like to start even with a controversy before talking about them.

Dr Olivia KesselHost07:17

Yeah, no, it's it, it's so true. And diagnosis we might even have to take a step back even further because the diagnosis. I talked to a lot of parents. I had a parent I was talking to yesterday and she's like Olivia. We struggled till her child was 14 to get a diagnosis and prior to that they blamed her. They said it's your parenting, it's your discipline, it's your too gentle of a parent. You know, and it's not an uncommon story that it's, you know, it's just bad behavior. So I think we need to take a step back with, you know, actually even getting diagnosed with a condition.

Dr Giovanni GiaroliGuest07:47

Well, I do this job, so I do believe that this condition truly exists and actually we have now so many biological correlates to support that this diagnosis exists. We know that exists by just looking at it, but just phenomenologically, I'm observing, I think that you know, if you're a teacher and if you're a clinician, if you're a parent having a child with ADHD, you know that exists. I mean, you're not really have doubt that exists. But now we have so many strong correlates which are again biological, which is a brain structure, the brain development. You know how the development of certain areas of the brain is delayed in children with ADHD, how the thickness of the gray matter differs, how the connectome differs in patients with ADHD versus not.

08:34

We know genetically, we know polygenic risk scores.

08:38

We, you know, in big GWAS studies we now identify, you know, loci, where there is, you know, polymorphism and it increases the risk.

08:47

It's an aggregate so, and we know this is a highly inheritable condition with a heritability of 80%. So it is a true condition. Also, the Scandinavians done incredible research, looking at mega database and looking how, if this condition is untreated this is the scary bit, you know, when we say, oh, this is not a danger, so we don't worry about that, we shouldn't mediate something. But if we look at this database of the condition untreated longitudinally, so over time, we know that it increases the risk of failed marriages, it increases the risk of substance use disorder, it increases the risk of having an unsuccessful career at work, but moreover, it increases the risk of jail and increases the risk of mortality. Mortality per se, you know, and let alone just you know, not just because increase of road traffic accident, which is connected again with the condition when it's untreated. But these does got studies that show the increase of mortality is in aggregate if ADHD is untreated versus not untreated. I think we're very sombering data.

Dr Olivia KesselHost10:01

That's scary and you know that's just not known. It's just not known by you know the public, or or by parents, because you know it's. You know it is, as you say, a very scary thing to give your child a drug. But when you hear those that kind of data from large studies that have been over a long period of time, I think that's such an important thing to consider when you are looking at it. And I know you know we're gonna go over how it works. But it's also it's it's not necessarily a drug that you have to take for life. There's actually like a good period of time to take it where you actually can learn. Can you? Can you tell us a little bit about that?

Dr Giovanni GiaroliGuest10:37

Absolutely so. Again, when I say treatment, of course we consider medication as part of the treatment, not the treatment as a whole, because treatment I just let me spend two seconds about the other bit of the treatment because I mean psych education is itself Very therapeutic for the environment, the family, the school, the patient themselves. To understand the company, the condition, understand better, putting to play, to put in place Accommodation to school environment, accommodation, the home environment, this is essential as part of the treatment teaching the child how to create vicarious functions, to To kind of compensate their difficulties. This is paramount. You know executive function training, adhd coaching, this all thing can help.

11:22

Then we know there are the importance of sleep, the importance of exercise, the importance of nutrition. For example, we've seen that in some patients certain omega 3 can help. We know that in some patient exclusion of artificial coloring can help. So we know there are other things that we can do and now they are even developing. I mean we are running a trial. You know King's College is running a trial and we are a PIC center, so we are recruiting for them and they are actually exploring the possibility of Trajamminal nerve stimulation as a possibility of a non-pharmacological treatment. Actually this has been FDA approved as an alternative to medication In the states and now we are looking at the possibility of it being in Europe too. So there are things that we can do now or they are in developing as alternative to medication, but medication remains an important, very important Part of the treatment with I want to just say that's very specifically, very specifically, that ADHD treatment.

12:26

We have the biggest effects sizes in all psychiatry, meaning that these medication are the most effective medication in Psychiatric medications. You know, with FX size of 1.2, 1.3 for the stimulants, that we compared to approximately 0.5 for antidepressants. The higher the number, the more effective the medication. So these are effective as, or even more than asthma medication for the treatment of asthma. So we talk about highly effective medication.

Dr Olivia KesselHost12:57

Yeah, and you know I completely agree with you, being a medical doctor myself there's no point in just doing a drug therapy without having the wrap around holistic care, because they work together synergistically and you know the importance of having that ADHD coach the nutrition, making sure they have the right building blocks for dopamine. The sleep which is difficult ADHD and sleep are do not go hand in hand. And you know what it was. It was such a relief to understand why I was struggling with my daughter for the last 12 years Not being able to sleep. You know I remember mothers even saying, oh, my child sleeps tonight. I'm like, you know, when she was a baby and I was like, oh well, soon, soon It'll happen for her.

Dr Giovanni GiaroliGuest13:34

No, no, yeah, 70%, 70% of kids, 70% of kids with ADHD have a sleep problem.

Dr Olivia KesselHost13:43

Up to 70%, wow and you know what that is so Empowering as a mother, because you know you think like is there something wrong with me, is there something wrong with them? Why can't they just sleep through the night? Why can't they get to sleep? And you know, once you understand that no, this is part of their physiological condition, and then you can think about okay, what are the right things to put in place to help them to sleep.

Dr Giovanni GiaroliGuest14:06

Absolutely. And again, strategies are fundamental in the sleep, behavioral strategies are fundamental around the sleep. But again, sometimes there is a bit of a role for medication. Here I again this is a more marginal role, but again, the potential use of melatonin is the first step that there's been, now even licensed in the treatment for ADHD Could really have a bit of a role to play.

Dr Olivia KesselHost14:28

It's it's revolutionized my life, dr Garily. It has changed my life. We now have, you know, we, we have a bedtime routine. We always have the bedtime routine and that's really important, that that doesn't change, even if we're late, you know. So how we do the bedtime routine reading the book, getting into bed, all of that stays the same. But the addition of that melatonin in the evening, you know, 30 minutes before she goes to bed, and we have one that's, you know, helps her go to sleep and helps her stay asleep. She's actually sleeping the whole night in her bed and waking up At a good time and you know, at sometimes six o'clock in the morning where she'd always be waking up 435. So it's, it's been for me remarkable indeed, indeed, indeed, again.

Dr Giovanni GiaroliGuest15:07

That again I don't want to disappoint the willy-sand and of course we're gonna go into the bowel of the medication and understanding exactly what they do. But you know, forgive me if I give this kind of preamble before talking about the medication.

15:22

Because I really think it's very important because you know medication and not necessarily the panacea, they're a massive help, yeah, but I do not want to give the idea that the parents are so, okay, the medication, this is enough. No, all the rest, and especially if we're gonna talk, and we are gonna talk about what happens when the child grows, can we stop the medication, you know, can we take breaks from the medication? Indeed, if you're putting this car folding around, this scaffolding around, that comes from the psycheducation, the training etc. You really have, then the, the house that stands even without medication at certain points. So I think that's very important to put that holistically all together. But I'm very Please do fire up, you know, with your questions about the medication. I'm already yeah.

Dr Olivia KesselHost16:07

So first of all, how does the medication work, okay, and who does it work for and who doesn't it work for? Absolutely Okay.

Dr Giovanni GiaroliGuest16:12

Okay, this is a very interesting question.

16:16

So let's divide medication into major categories and I'm told today I'm going to only talk about the medications that are licensed in the UK by the BNF in the treatment of ADHD in children. So I just want to make very clear my topic. So we're going to talk about children and we're going to talk about medication that are licensed by the British National Formula in the UK, and also these are recommendation. I'm going to also follow the recommendation from the NICE guidelines. So this is the framework we're going to talk today about within so the medication divide in two categories. We have stimulant medications and non stimulant medication and within each categories we have two type of medication for each category. So for the non stimulant medication, we have atom oxidin, which is a noradrenaline reuptake inhibitor, and we'll go into the details of that. And then we have guanfacin, which is instead is a post-synaptic medication that works still on alpha 2A receptors, again in the noradrenaline type of route. Then we have the stimulants, and we have the methylphenidate as one stimulant and that is a dopamine and noradrenaline reuptake inhibitor. And then we have the dexamphetamine least dexamphetamine family. This is again a noradrenaline and dopamine reuptake inhibitor with some extra function within the cell. So, again for the listener, there are two main categories stimulants and non stimulants. The broad difference between these two categories is dopamine. So in the stimulants they increase the amount of dopamine available to connect with the receptor. So they increase the dopamine in the brain that does something. In the non stimulants the dopamine is not directly increased but they only work on noradrenaline. We will see that automoxin increases a little bit of dopamine, but in different type of ways. So but this is I think is important to categorize differently Dopamine medication and noradrenaline medication for the stimulants and noradrenaline medication for the non stimulants.

18:37

Why do we talk about stimulants in a child that is already highly stimulated? This is a very interesting concept. And we do talk about stimulants because they wake up neurons that otherwise are slightly sleepy in the brain. These are interneurons that connect the bits of the brain, especially in the prefrontal cortex, precuneus, cerebellum, etc. That are very important to wake up this region, that are hypoactive. So they're not very active. They don't fire that well in ADHD.

19:14

So you would expect an overactive brain. Actually it's a slightly sleepy brain in certain part of it. And then you have this default mode network, which is this background noise which is loud, loud, loud, loud, loud. So it's very hard to switch it off and that's why children tend to get distracted by this loud brain they have. But this loud brain with this higher default mode network that cannot be switched off, at the same time has sleepy part of the brain that we need to wake up. Hence the concept of stimulant medication. And the concept of non-stimulants is that they still wake up, but they do not touch dopamine. So these are the main categories. I hope this. Please tell me if it's not clear enough. Yeah, if I use jargon.

Dr Olivia KesselHost20:01

No, no, but I think it's really. It is clear and it explains why. Because, you know, classically people think of an ADHD person who's having too much energy. Too much is switched on, but the way you've just explained it has illustrated that there is an area in the brain that is not so turned on, that needs to be turned on to get those things like executive memory functioning, to get the attention that they are struggling with, absolutely absolutely yes.

Dr Giovanni GiaroliGuest20:26

And again, the main fuel for these neurons is neurodrylanine, dopamine. Hence we're talking about these two substances. Indeed, the stimulant medication, given this kind of double action, you know, on dopamine and neurodrylanine, are, on studies and also in experiences, slightly more powerful and more effective than a non-stimulant. Hence there are our first liners, and especially methylphenidate. According to NICE guidelines, it is our first liner. Why is it methylphenidate, our first liner? Because it is where the best ratio of effectiveness and side effects so we can obtain the maximum results with the least possible side effects.

21:14

Hence that medication is a gentle stimulant that can really capture up to 70, 75% of first treated responders, so 70% of the first time people treated. So drug naive patients treated, actually do respond, and then we can try several types of medication if the first doesn't work. Given again in this scenario, we have four medications to cover that. So we reach up to, in my clinical experience, 90, 95% of actually people treated with, you know, with different sequels. Again, 70% respond to the first go. But we can treat up to 90, 95% of people with ADHD.

Dr Olivia KesselHost22:02

Wow. So using those four types of drugs you can actually get a result in 99.5% of your clients 95% 95% in general.

Dr Giovanni GiaroliGuest22:11

Yeah, there is still a percentage, unfortunately, of patients that would not respond to anything, but it's a very small percentage.

Dr Olivia KesselHost22:18

And is there any benefit between going down the stimulant versus the non-stimulant route? Or is it just what the body is responding to? It's a total individual response.

Dr Giovanni GiaroliGuest22:27

So it's very much connected to the brain, how the brain responds to it, how well it binds the medication in its receptors and how well it's metabolically, your body gets rid of it. So some kids, for example, churn it very quickly and they get rid of it, and so they need to adjust the dose and some medication go too fast in the system so they need to change the medication. So, purely individual response and that's why we can switch between stimulants to non-stimulants and vice versa in order to cover this scenario. Moreover, the non-stimulant medication sometimes offers advantages when we have comorbidities, for example in children that are highly anxious, in children that have comorbid, for example, severe OCD, in children that have comorbid autism. Sometimes the non-stimulants come in a very gentle way and really feel nicely agape. For example, you know the TICS and Tourette. Not necessarily the stimulants are bad, bad, bad for TICS and Tourette, but sometimes the non-stimulants come with the advantage to even reducing, sometimes a little bit, the symptoms of TICS and Tourette, for example, the guanfacin.

Dr Olivia KesselHost23:42

That's super interesting. Yeah, so it's finding the right bespoke treatment for that child Indeed.

Dr Giovanni GiaroliGuest23:50

So this is a completely bespoke type of medicine and of course we start unless there are specific reasons completely with the guidelines with methylphenidate. But then from that point we can really become creative around the child's needs and after we see how the child responds to medication, to get the right medication for that specific child and the right dose for the child. It doesn't mean necessarily small child's small doses, so that's also another thing that's interesting. I've seen very thin children with high dose and very big teenagers on very small dose. So that really depends. I mean, there is a rule of thumb. Some medication really go prokilos, such as the non-stimulants, the stimulants in general. We had an idea of 0.5 to 2 milligram prokilo, but these are very, very indicative. As I mentioned, in clinical practice you see very teeny children only responding to high dose and vice versa. Some very big boys or girls in there are the less than responding actually to very low dose. So this is the individuality of the response to medication.

Dr Olivia KesselHost24:58

And then how does that go when a child starts, and when do children usually start medication, or when should they start medication? And then how does it changes there, you know, as their chemistry changes, as they go through their hormonal changes, how does that progress? And then when do you look at maybe going off it? So what's that journey look like?

Dr Giovanni GiaroliGuest25:16

rule of thumb. Of course every journey is different but the diagnosis itself doesn't have massive validity before the school age, which means that if we make a diagnosis at the age of four not necessarily has a validity or doesn't necessarily Stay true in time for two or three years. One is that a diagnosis made at the age of eight tend to be very valid, even in the longitudinal aspects of state through in time. So I would Be very, with a younger child, the more sure I want to be of the diagnosis and the younger the child, the more I want to be sure that the medic, that the ADHD is impacting on the thriving in the school environment, the home environment. I become a little bit more. You know, lacks with the use of medication, with age meaning that even if there is only one setting Involved, for example in a teenager, I think that's worth treating as worth medicating. Even is just one setting is affected, for example if school is highly affected or friendship is highly affected, make sense. But the youngest the child, I will want to see more setting involved. This is my personal opinion, my personal way approach. So I'm more. I need to be very careful, the younger the child, careful on the validity of the diagnosis and careful about the impact of the condition in several areas. And with the older age I don't get like more cavalier, is that's not what I'm saying, but I appreciate that an adolescent, my real, it might really matter a lot how social life is or close to exam school really matters. So I'm, you know. And so even independent of the severity of the pervasiveness of the condition, if the child is very affecting one area, you know, we can really consider medication Now. So we can start at any age. Well, from the age of six in general onwards, because medication tend to have the license sing apart from the victim is slightly younger, but I would say the rule of thumb six, seven, when they are in school, we can start medication. Yeah, and another very important point is that once you start medication, you need to be aware that Especially the younger you are, the more your brain develops. So we need to see the child frequently, you know, as as I can't, because the child develops, we want to make sure that we are current in our treatment, current to the child development. Do you see what I mean? So, and then every year, I think is a good story, every six months or every year is a good point to review the need of medication, to try maybe a period especially with stimulants it's easier to try period of the medication. How does it go? Do we still need it, do we need to adjust the dose, etc.

27:57

And then another very important key point is adolescence, where the brain develops even further. There is a massive spur of change during adolescence and some kids start to need more medication. Some kids needs less medication. Some some kids Don't need medication anymore, and this is a very important turning point. So we need to be very careful about around adolescence also, because there are other conditions that the child can accrue, which means that some kids can become a bit more anxious, some kids can become a bit more depressed.

28:27

We can be becoming aware of presence of other type of neuro difficulties. You know, for example, autism is a high functional disease spectrum disorder. We tend to diagnose them not the age of four or five, but we tend to diagnose the age of Ten, twelve and a little bit later with girls. So this is the time in which we come more aware of comorbidities and that's when we need to be very careful to adjust the medication according to the comorbidities. And then another very important point is post school, in between high school and university and then post universities. So if you really ask me what are the main crucial point, I would say adolescence after GCC is a levels after uni. These are very three crucial points to reassess. I mean the W H said very clearly that we are at a lesson under twenty five, so our brain develops up to twenty five. In our social brain, our social interaction, do develop until twenty five.

Dr Olivia KesselHost29:21

Yeah, you know, I just learned that the other day about how long it takes us to actually develop, and I think then how much pressure we put on kids at fifteen, sixteen, is probably misplaced a bit.

29:30

Indeed indeed but that that really clearly lays it, lays it out in terms of what that journey would look like or how it could take different twists and turns during that treatment pathway. And then I presume you know, then you try having a drug, taking them off the drug when they, when they're past those, those key points, and see how they function, how they do?

Dr Giovanni GiaroliGuest29:50

I mean I think I mistake sometimes from us, from physicians, is that we've all the patients responding so well to the medication. What changing? Which is fair enough, but I don't want to forget that a child is a medication. I always want to give a child, in crucial moment of their life, a chance to prove themselves how they manage without the medication. I wouldn't do it before a GCSE, you know I wouldn't do it before an A level, you know I wouldn't do in this very crucial moment of their life. But after this crucial moment, I think it's worse. I think it's worth, not worse. I think it's worth considering, considering how the child is managing with a lower dose of the medication.

30:31

Without the medication, of course, you would try to, only in certain moment. You should do it, but I think we should do it. We should remember let's not leave the child forever more on the medication until they get tired of it. Because this is the problem, and we know that children in the longitudinal studies, children, or adolescent or adult, eventually get tired of taking the medication. They stop taking the medication, you know. So why don't we instead let him get tired or bored, or annoyed, or had enough or fed up with that? Why don't we have a dialogue with the patients, with the family, to start to see points in which we say, okay, let's try to see at that point or that point how we manage with a lower dose or without man.

Dr Olivia KesselHost31:11

Yeah, and I think that's, you know, so important. You know, and it's interesting. It's making other questions pop up in my mind because you know, from my daughter and for some other kids who I know who are also on medication, when they have not been able to get their medication okay, and then they're experiencing life Back again where they're, they're not having that, that stimulation in the areas of the brain that we mentioned. They don't like it, you know.

31:34

So my daughter, this morning, because we had a A supply issue, she said to me is my mommy, I, you know, at school I noticed that they're running out of pills, so are you, and I mean she's 12. It obviously means something to her that she's. She doesn't remind me to get milk, she doesn't even remind me to get chocolate, but she's like, mommy, I don't want, I don't want to experience that. Then I, you know, you need to, you need to make sure we get medication, and I've. It's not the first time. I've heard that from other parents as well. So, and there's been some supply issues, I think sometimes. I saw something pop up on LinkedIn today in terms of supply issues.

Dr Giovanni GiaroliGuest32:04

The moment, october 23. So for the listener, the listening, the future. So maybe it's not a problem anymore. But in October 23 we are having major supply issues of the stimulant medication at the moment and certain dosage of even the atom oxen and start even in ground for sin. So it's a bit of a scary month to talk about medication if you are taking medication, if you're really working very well. Yes, there been some supply issue. That creates a lot of anxieties in the children in their families.

Dr Olivia KesselHost32:36

It's interesting because they they're having a webinar, I think, on LinkedIn about what you can do while you're waiting, so looking at that holistic health, looking at meditation, looking at how you can bridge that gap and I mean, I know I'm on HRT and that's also in short supply and I also feel that panic when it's when it's not available, because it does me so much good being on it. So, yeah, it's a, it's a. It's a weird world we live in, I think. Post.

Dr Giovanni GiaroliGuest33:00

And there are other things I want to say again for the patients that are listening very shortly after we recorded and there are experiencing supply issues. While the stimulants, you know it's safe to come off, the stimulants safe from a biological point of view, not safe from you know you still need to be very careful because your ADHD can come back and therefore you're a slimer risk when you cross the road and all that stuff. You know that we need to consider, you know. But also the non-stimular medication coming off abruptly in some cases can be a little bit dangerous. Special with the one for seeing if, special if you're a high dose. So you I suggested the listener that are on one for seeing a rathamoxidine to avoid any withdrawals or any rebound effect from stopping this medication. Sat that suddenly. I suggest to contact their clinicians sooner than later to make sure what to do in case there is a shortage of these very medication, because these are no medication that you can stop like that. You need really to cross state to come down slowly.

Dr Olivia KesselHost33:59

Do we know the reason why, or is that no, I?

Dr Giovanni GiaroliGuest34:02

don't personally know Manufacturer supply chain supply, manufacturer supply, but definitely I'm not aware of these are present in other countries. I'm not sure there is anything to do with that specific country or not. I'm not sure.

Dr Olivia KesselHost34:19

It's interesting and that's good advice for people who are out there and that if they're not on those particular ones, that actually you can stop and start. And I know lots of families who maybe don't use the drugs during holidays or don't use the drugs because of those reasons that you said. They don't struggle or it's not an issue for that parent to have the child, so they choose different times to take the drug and the child does fine on it.

Dr Giovanni GiaroliGuest34:42

Absolutely, but even with children with a stimulant medication methylphenidate or dexamphetamine formulation need to be careful if there is a lack of supply so they stop, stop his saving but then restarting on a very high dose after they've been offered a period of time that cannot be necessarily super safe either. So I would say there is a supply is to just contact their clinician and to really make sure there is a very specific and bespoke plan for the child in case there is a shortage of their medication anyway. So safer is to come off, yes, for those stimulant medication, apart from the ADHD creeping back. But then coming on is not necessarily. If you are on 54 milligrams of methylphenidate, then if you have two weeks off and you want to restart, it could be jolting restarting on such a high dose if you had a period of.

Dr Olivia KesselHost35:34

Yeah, yeah, and so I mean the message is loud and clear Get back with your physician, make sure that you have a good action plan and also talk to your pharmacy to make sure to see what the supply looks like, so that you know when to do it, because there's always a delay in getting appointments.

Dr Giovanni GiaroliGuest35:48

Absolutely it sounds good.

Dr Olivia KesselHost35:49

Get back in touch with your physician. It's easier said than done sometimes.

Dr Giovanni GiaroliGuest35:53

Absolutely, but this is a good time to send an email.

Dr Olivia KesselHost35:58

Excellent. Well, is there anything you think we haven't discussed in terms of ADHD?

Dr Giovanni GiaroliGuest36:02

before we move on to anxiety, I'd like to mention very quickly about this. Medication come with side effects so I want to be very careful, you know, to talk very briefly about the side effects and I would say that side effects tend to be quite low in term of risk of side effects and tend to be not severe enough to stop the medication. So these are quite safe medication as a whole. In general, in some kids, when there is a history of cardiac problem, we might ask to do an ECG or to get a cardiac assessment, just to be safe, to be very on the safe side, we tend to be very cautious as physicians because these medications are safe, but we want to make sure that we're using a healthy heart etc. And there are some side effects such as appetite suppression. There are some side effects as, for example, a sleep delay, onset and some other side effects such as headache or slightly increase in you know slightly hyperiderosis, so you sweat a bit more or you have a dry mouth.

36:54

So it's important to inform the child and the family about these side effects. Most of them are short lived, so most of them, once you adjust on the medication, they disappear. Some of them don't disappear and therefore it's important that you talk to your physician to make sure that you are OK to tolerate them, because if you are not OK, we should really consider a change of the medication. And another thing is very important Always ask my patients how do you feel on this medication?

37:19

If they don't feel good on the medication, if the medication doesn't sit well on them, what we call a negative subjective experience on this medication tends to be a predictor of poor compliance and actually predictor of actually eventually the child will refuse to take it. So always listen to the child, ask them how they feel on the medication, especially after they settle after a couple of weeks. How do you feel now on the medication? Does it make you feel anxious? Does it sit on you? Is it OK? Because if it's not, I tend to listen to the child quite a lot and then consider change of the dose or change of medication.

Dr Olivia KesselHost37:53

Yeah, no. And it's so important to listen to them because they will tell you the truth. That's the beauty of children they usually tell you exactly how they're feeling.

Dr Giovanni GiaroliGuest38:04

Absolutely.

Dr Olivia KesselHost38:05

Absolutely so. Now moving on to anxiety, and it's not such a clear cut picture in terms of anxiety, and I have had some parents inquire for me. Olivia, my son has autism. He's super, super anxious and I don't understand why my GP won't give him an anti-anxiety medication and I don't understand it. So I said this would be a great question to ask you while we were looking at ADHD, because it is a different kettle of fish in terms of anxiety. So can you extrapolate a bit on Again the treatment of anxiety in neurodiversity?

Dr Giovanni GiaroliGuest38:43

Exactly so, I think this is very important to frame the question and again, it will be an answer within the topic of neurodiversity. So I'm going to talk about anxiety and treatment of anxiety within the neurodiversity condition. So specifically, I'm going to talk about anxiety within ADHD and within autism. Yeah, so these are unfortunately common comorbid conditions, so they can occur with ADHD and they can occur in autism. In ADHD you tend to see a little bit more with an inattentive type of ADHD, a little bit more frequently in girls and a little bit more frequently in pre-adolescence adolescence. In autism, you really see across the board and sometimes you see anxiety manifested in autism as form of refusal of demand, avoidance or in terms of irritability and aggression. So it's interesting how these anxiety tend also to manifest themselves slightly differently, Slightly more in girls with ADHD, slightly more around puberty. This is just a rule of thumb in general with a theory across the board girls and boys and sometimes there's this manifestation of avoidance or irritability, et cetera. Yes, it's a different category of fish. So, in terms of treatment and pharmacological treatment, while you heard me so enthusiastic about pharmacological treatment and excitement about treatment connecting with ADHD, I am myself extremely cautious in the pharmacological treatment of these symptoms in general and specifically in these conditions, in ADHD and autism, I'm not denying pharmacological treatment whatsoever, but I make sure that alternative treatment are attempted, and attempted properly, first. So with autism, for example, cognitive behavioral therapy modified to the fact that the child has autism with the rigidity connected to the autism. So CBT per se doesn't necessarily work that well with autism, it needs to be modified to the condition. But again, or family therapy in both ADHD and AST and CBT purely for ADHD are definitely my to-go-first option big time and I would go a good go for this therapy first. Only if the patient is so still deteriorating, non-responding at all to this form of behavioral, cognitive type of intervention, we can consider medication.

41:12

These are in general SSRIs, so Selective Serotonin Reactake Inhibitors, so work on serotonin, a slightly different type of pathway In ADHD. If the child is treated, we need to be careful about interaction, drug interaction. I think it's very important which medication, for example atomoxidine and for example feroxidine. They don't go well together because one increases the plasma level of the other. So we need to be very careful about what medication we're using. And also, as a clinical observation, I noticed that when the child tend to be treated, the child with ADHD and very successfully responding on the ADHD medication, tend to curb a little bit the response when he's started to add an SSRI, so the responses can in some cases can be curved. I have patients with both and it works fantastically well, but in some cases you see a little bit of a curving of response.

42:09

The problem with these SSRIs is that it's a slightly longer commitment. You start normally six to 12 months, for the medication takes 34 weeks to have effect and we have sometimes side effects with this medication, not only the nose or the GI side effects that are unknown but also activations on the child gets restless and there is warning up to 25 that the use of SSRI can increase suicidal ideation, can cause suicidal ideation, and that is something again that we take extremely seriously. We tell every time we start this treatment to the patients and the child we want to a very collaborative approach and again, another thing to consider is that there are no license medication for the treatment of anxiety for under 18. So there is, you know, so all this treatment are more study based, but there is no specific license for the treatment of SSRI. So we need to be very careful when we do prescribe this medication. Start extremely low, go very slow. It's a paramount.

Dr Olivia KesselHost43:04

And it sounds like exhausting other routes.

Dr Giovanni GiaroliGuest43:07

first is a better 100% is the only way forward. I think the study medication to prematurely and having a very pharmacological attitude to the treatment of anxiety, I personally this is my personal view I think is the wrong attitude. I think we should really think about the anxiety, how to treat the context of anxiety and the environment, therefore the situation and the cognition and the response. And this you can only achieve that by family therapy or individual therapy first, and then the medication can be an adjunct treatment to these pre-existing form of psychological treatment.

Dr Olivia KesselHost43:44

And how long you know? How long is it before therapy works in your opinion, or does it differ so much from individual to individual that you can actually put a time line up?

Dr Giovanni GiaroliGuest43:54

You can put a time line because, I mean, sometimes you have individual response extremely well. There are aspects specific to the therapy and aspects that are non specific to the therapy, which means the therapeutic alliance, the feeling listened, the feeling heard, so. And then there are the aspects specific to that CBT or interpersonal or psychoanalytical etc. And we know that both play a role and some child just being in that context has been heard. Feeling heard, feeling they develop a connection with the therapist is extremely containing and therapeutic. Some other they require to put in place the techniques that they learn in the therapy and therefore it might take longer. You know six, 12, sometimes 18 sessions are needed.

Dr Olivia KesselHost44:37

Yeah. So it's good to have that in your mind as a parent, that you know to, to that you're in it for the long game, and to you know to really, because, no, you know, the risk of suicidal ideation is just. I mean, that's massive, it is there and it's a very rare event but it is a vent.

Dr Giovanni GiaroliGuest44:51

It tends to happen more in certain presentation not in every child you know when he uses or there is already preexisting depression, etc. There are some factors that tend to increase the potential risk. And is a remote risk, but it is a risk.

Dr Olivia KesselHost45:04

Yeah, you know, I think it's really great to hear you speak about the two different interventions for ADHD and for anxiety, because it it gives us a good picture of you as a physician that you're not just proponent of medicating, you are looking at this from a very scientific and knowledge base and experience base from all of the children that you've looked after all around the world it sounds like, from Italy to Australia to England so that that that, for me as a mother, gives validity and gives me security in what you've said. So thank you for that and I appreciate the time that you've given us today. Now I always ask my guests at the end of the podcast what would be and this is a difficult one in the subject your three top tips that you would say to parents. This is what you should take away with you.

Dr Giovanni GiaroliGuest45:54

Okay, so my first step is that do not over emphasize, nor under emphasize, the effect of a macological treatment in your child's journey, so I think we need to place it correctly, at the right level of importance.

Dr Olivia KesselHost46:12

I like that.

Dr Giovanni GiaroliGuest46:12

So that's my first take home message. The second message is that don't be impatient when you're treating these conditions. You are here for the long run. So if your physician start very prudently low and goes up slowly, don't be impatient. Start low and go slow. It's always a very effective mantra when it comes to psychopharmacology. And the third point is let your child speak about themselves. So, as you said, something very true before is that the child tend to be extremely honest, and I found exactly that in my experience. The child is the truth mouth, so if they tell true, they speak the truth. So listen to them. If they don't like something, listen to them. So this is an invitation for parents and for clinicians. Sometimes we are at fault of just looking at that parent. And so what is your child side effect? No, no, no, let's ask the child how do you feel on the medication? So really listening to the child.

Dr Olivia KesselHost47:25

I think those are three great tips for us to take away, as well as all the other knowledge you've imparted today. Thank you so much for coming on the show. It is much appreciated.

Dr Giovanni GiaroliGuest47:34

Thank you so much for having me. It's been a pleasure.

Dr Olivia KesselHost47:37

Thank you for listening. Send parenting tribe. I know that you are listening by the amount of downloads we received, but today only six kind souls have rated the show on their preferred podcast platform. I'm not asking this to get nice feedback although it is nice but it's really a way for the algorithm to know and to then present this podcast to more people. I know when I started my journey with my wonderfully wired child, I would have loved to know where I could tap into empowering experts. It's just one little click right below where you press play. Wishing you and your family a happy week ahead.