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So, hello, every everyone. I'm uh Teresa. I'm a doctor from Spain and I'm doing a clinical research fellowship at Imperial College London. So it will be great if you can uh if you have access to the chat and you can write. Uh yeah, your where are you attending the session from? And also uh what year of medical school are you in? Because yes, I'm curious and it will be great to know it. And uh so today we are going to speak about attention deficit hyperactive disorder or the hyperkinetic disorder. This is the first part of the session. So next week we are going to see the second part that is going to be focused on digital tools, the use of digital tools in psychiatry and particularly in A D H D at this is my research field. But today we're going to focus more on general considerations about A D H D. So we are going to speak about the definition and sub tights the epidemiology, etiology and risk factors. Um I want to explain a bit about the neuropathology of A D H D and we are going to to watch a video that explain it very clearly, then we are going to cover the symptoms, executive function comorbidities, the course of the disorder diagnosis treatment. And if we have time, um we can discuss a few cases and I want to suggest you some resources that are very useful for you, for patient's and for families. Um It's quite long. So if we don't have time to finish today, we will do it next week. Um Okay. So let's start by the definition of attention deficit hyperactive disorder. So, A D H D is a condition that affects people's behavior. And we're going to have three core symptoms that are inattention, hyperactivity and impulsivity. And um normally we can have uh patient's with symptoms from all of these categories, but we can also have patient's with symptoms from only one of the two categories. So, oh, sorry, the first category is the inattentiveness and the second category is impulsivity and hyperactivity. So, as I say, we can have patient's with symptoms from only one of the two categories. So for example, uh 2 to 3 out of 10 people with A D H D only have symptoms from the inattentiveness pattern. And this is also known as attention deficit disorder. And sometimes uh this goes under diagnosis as is less obvious that when we have a patient with motor agitation and this hyperactivity and impulsivity, impulsiveness component. Uh Sorry. So, uh to make the diagnosis, we need uh symptoms from one of the two categories of from both present more than six months and present in more than one context. So not only for example, at school, but also at home, and this is uh to rule out the possibility that this behavior is a reaction to a certain teacher or to parental control, then we also need to have a functional impairment. So uh moderate psychological um impairment problems at school problems with friends. And uh these symptoms have to be present before the age of 12 years old. In, in some some great area, say that before the age of six years old. But the D S M five and the I C D 11 said before the age of 12 years old. But what is clear is that these symptoms are going to be present in the early development of uh of our patient. Okay, I'm sorry. So um this is a table Samarasinghe a bit the symptoms from both categories. So in the upper activity and impulsivity, behavioral pattern, we can find Children that are unable to sit still, especially when Cadmus is expected. So in quiet places, in calm places, they are constantly fitting, creating um they are unable to concentrate on task with excessive physical movement and also excessive talking. So this um leads to interrupting conversation, they are unable to respect terms. Um Also we can find that they act without thinking and then um they make these unwise decisions, they are very impulsive and with little or no sense of danger. And then in the inattention category, we can find Children or uh or adults with short attention span, there is early distracted and they make these careless mistakes, for example, uh in homeworks or doing exams, uh they appear forget fel they lose things um enable to stick to tasks, especially when they are tedious and time consuming, for example, in homeworks and um they are unable to listen to follow instructions, they are constantly changing activities. So they start an activity and without finishing, they start another one and then another one and they have difficulties in organizes their task, schedule, sex, cetera. So um we are going to find some differences depending on the medical classification systems we look at, but they sit in the D S M five and the I C D 11. Uh we have three types of A D H D uh as I say before, they can be combined type when we have symptoms from both categories or predominantly inattentive type or predominantly a proactive impulsive type. If we look at the I C T 10 is when they described this disorder and they call this disorder hyperkinetic disorder. And according to this uh CD 10, we can make the diagnose when the symptoms are before the age of six years old. So now um I think you have access to the chat, but so it will be great if you can write what you think about this. So, what percentage of Children with a D H D do you think? Um, there are around the world in school ages? I would like to hear your thoughts. Yes. Assad. I think you raise your hand. I think it would be 5%. Perfect. Very good. Yeah, it's 5%. So around the world is more or less between 3 to 5%. So, yeah, that's correct. And then I check the number of Children in Ukraine that have a diagnosis of A D H D and they say it is between 50 100 sorry, 50,000 to 150,000. I have another question now. So um if you can guess how much more prevalent is in boys than in girls. Yeah, Assad, it should be a more of a four by one. Sorry. Which one? A option? A a okay. Thank you very much for repeat answering. So it's a but it's also be so it's going to depend on the sample we take for doing this analysis and also they criteria they use for, for, for doing this study. So if they, when they take um clinical samples, it's a 4 to 1. But when they take the general population, it's 2 to 1. So it is clear that we are going to see more voice in the clinic than girls. And this is sometimes because the attentional component is more frequent in girls. So as I said before, it's less obvious. So sometimes girls goes under diagnose and then the last question and the most difficult one. So I have to check the answer on the internet. But I think, yeah, it's curious. So, when do you think, um, is the first year when, uh, yeah, the first A D H D K s was described as a, uh, I think it's more recently. So I would go in 1994 1994. I think it's the recent very recently. Categorizing A D H D. Yeah. Yeah, that's true. So maybe it's 1994 when they describe a D H D as a D H D. But in 17 98 they were already describing Children with this behavior and we think they were speaking about A D H D. Okay. And I say this only to introduce this because I think it's quite curious in 80 50 for a doctor created this book here, the first picture and he described kids with a D H D as having impulsive insanity and effective inhibition. Then years after in the land set, this um a pediatrician published this paper in the land set and he was describing kids uh children's with motor agitation, attention problems, difficulty in controlling impulses and need for immediate for um he was no, the th kids and there are small consideration brothers and he called the disorder a deficit in moral control. So we can see that since uh earliest and uh since uh many years so you can use me. I think my internet is unstable. Yeah, we can hear it. It's a bit unstable but it's more or less okay. A message saying this. So um with that uh from Lee eighties Children being misinterpreted as having control over their symptoms and being responsible for the and today that this is not the case, this is a uh a neuro developmental disorder and we don't have to blame uh Children for these behavioral symptoms. And we need to psycho educate parents, teachers, patient's. So let's talk a bit about the etiology and the risk factors. Uh We don't know the exact cause of A D H D. But what we think is that is a combination between components. So between a genetic component with environmental perinatal neuro biological factors. So, in terms of the genetic component, it is clear that A D H D runs in the family, um and first degree relatives of patients with a T H D R 5 to 10 times more likely to develop a D H D themselves. Again, we haven't identified a single, an exact gene that leads to a D H D. But what we think is that um there is a combination of genie's that by themselves, they don't have a huge impact back together, they can lead to the, the condition. Um We have also studied prenatal factors. So as a potential uh a theology of the condition, again, in combination with other things there are some evidence associating 80 HD with sorry prematurity and low birth. We can read things. We can write some papers. Also speaking about um exposure to cigarettes, two drugs during the pregnancy, maternity, obesity, maternity pretension. So there are many hypotheticals but hypothesis by but they don't have a lot of consistent and in terms of the environmental factor, again, um we can read things um relating A D H D with exposure to pesticides, to toxins with nutritional surpluses. For example, um the additive coloring in a way, the additive colorings in food sugar and also uh nutritional deficits, magnesium, Eireann. But again, these results are not consistent. Then in terms of the neuro biological deficit, we are going to watch now a video that is very clear and you're going to understand it very easily. And then we can also read papers and yes, literally speaking about deprivation and family factors leading to A D H D. But there are no evidence to say that poor parenting, heart parenting or neglect sh in etcetera is going to lead to um A D H D. So what is clear is that these family factors are going to have an impact on the course and the outcome of the disorder. So we need to support parents um in this uh to to enhance the course and the the outcome. Um Sorry, I don't know why there is like a red thing here. Well, somebody else. Okay. Okay. No, worries. Um So in terms of the neuropathology, what we know that brains A D H D brands are different from the brains in the general population. So there is a delay in the cortical maturation. Here in the picture, you can see a study um that try to analyze the age um when A D H D kids and the general population, Children achieve the peak of thickness in their cortical um maturation. So in the general population, they reached this peak when they were aged 7.5 years old. And in the A D H D sample, they reached this peak when they turned 10 years old. So we can see that there is a delay in this cortical maturation. So the brain matters more slowly and then this was more significant in the prefrontal cortex. So the prefrontal cortex regulates attention, emotions and uh motor uh um sorry motor responses. So we expect this area to be impaired in Children with aidid's. There are also a lot of evidence and studies uh stating that there is a reduction in the total brain size, especially in the basal ganglia and the limbic areas that regulates emotions. So, um these um differences in the brain size are not significant when we compare adults with A D H D and adults in the general population. So we think that uh these Children with A D H D catch up in their brain size when they grow up, then we uh there are also at this regulation in the catecholaminergic uh system. So, dopamine and Nora Dren Elin uh played a part in this disorder, dopamine and or adrenaline uh contribute to maintaining alertness, increasing focus, sustaining thoughts, effort, and motivation. And the treatment we are going to use in these patient's increase the levels of document and nor adrenaline and has positive effects on the disorder. So that's why we think they play a part in the condition. And then we also find uh dysfunction in the frontal striatal circuit. This is the front astri little secret. Okay. I wanted to show you and this is a neuro pathway that links frontal lobe regions with the basal ganglia. This tree a tune and uh mediate motor, cognitive and behavioural um systems within the brain. So it's mediated by Kaba. That is a, it's another neurotransmitter is related again by catacholamines and plays a part in the executive function and inhibitory control. So we are going to to see these inhibitory control and executive function bert in kids with a D H D. Let's watch now the video that explained it very well. Okay. Uh enjoy deficit hyperactivity disorder or A D H D as it's commonly known affects about one in 20 young people around the world. He can have a major impact on life at home and school and with friends, symptoms of inattention impulsivity and hyperactivity can reduce a person's ability to control their actions and concentrate without getting distracted. Some people have expressed skepticism about the disorder but brain imaging has shown that symptoms of A D H D are associated with a series of abnormalities in the development and function of parts of the brain. Let's look first at the cortex, the brain surface layer in normal development, the cortex which plays key roles in memory, attention fought and language gradually increases in thickness before reaching a peak during teenage years. And the shadow A D H D, the cortex generally develops more slowly, particularly in frontal and temporal lobe regions, which are important for memory and can pay via typically the frontal cortex along with other major parts of the brain are smaller in Children with A D H D. But in those without these different parts of the brain do not operate in isolations but interact extensively to form networks, controlling functions such as language attention and movement. The activity of different networks increases and decreases to allow different functions to take place. For example, while you're watching this video activity and networks involved processing information will have typically increased. While activity and networks involved with mind wandering my ticket for decreased in a person with A D H D, the activity of these networks is impaired and connections with are disrupted. And when we look more communication between these networks, there is also disruption in the release of the chemicals dopamine and law driven, which are responsible for relaying messages between brain cells overall, when Children with A D H D carry out particular tasks, some networks are not switched on enough while others remain switched on. Too much research from around the world has shown widespread differences in the development and function of the brain. Yeah, while we can't yet use brain imaging to diagnose the disorder, the more we can learn about A D H D in the brain, the better we can understand the symptoms that Children with a D H D experience in everyday life. And the more we'll be able to do to support. Okay, I hope it's more or less clear now, the neuropathology. So uh now let's talk a bit about the symptoms. Um symptoms are going to change a bit depending on the age of our patient. Uh So in preschool Children, we are going to see um short sequences of play lasting less than three minutes. They do not listen, they do not have a sense of danger. And sometimes this is difficult to distinguish from a conduct disorder or oppositional disorder. Uh Then in primary school, we are going to see Children that spend less than 10 minutes in activities with this premature changes. So as I say before they start something without finishing, they start another thing there, forget fel distracted, restless, intrusive and disruptive, they act out of turn and sometimes they are real freaking rule breaking. Sorry. Then in the adolescence, we are going to see Children that has um less um uh yes, less attention that they appear so lasting less than 30 minutes, they do not focus and they have difficulties in planning. Um They do not focus in details of the task. So they have these mistakes during exams, homeworks. Um they fit getty reckless and also with poor self control. And then if the if the condition persisting adulthood that we are going to see adults that again, do not focus on details, they are restless, they are forgetful many times they forget appointments. Um they are inpatient inpatient and um they make these premature and unwise decisions due to this impulsive component. So I did 13 adulthood is associated with negative consequences. For example, there is an association with uh lower job performance, unemployment, lower academic performance. There are more likely to have accidents to get divorced, more pregnancy in teenagers due to these impulsiveness uh and also more associations with older uh psychiatric disorders. So that's why it's very important to detect the condition to treat it and to try to avoid it um in the adulthood. So I think it's also important because sometimes we tend to over diagnose uh to keep in mind that A D H D is not naughtiness, all naughtiness is not due to A D H D and then children's with A D H D can also be naughty and children's without A D H D sometimes can also have uh concentration difficulties. And this doesn't mean that they will get the diagnosis of A D H D uh in terms of the executive function, um sorry, where I have this, well, the, the executive function um is also impairing these kids with a D H D. We have already spoken about this. I think it's important to know what executive function means because when we read papers on or we here um sessions about a GST, we usually use this term. So this executive function help us to achieve our goals. And we're going to watch this second video here that explain it very clearly. And I think it's interesting to know what this means. Let's go. Thank you. Uh Instead of executive functioning in related D D D D and actually in the core functions or deficits in the disorder now can thin the executive functions as those capacities for self control that allow us it's just actual problem solving toward a goal. So it's goal directed, problem solving and goal directed persistence. Now, there are at least five of these executive functions that appeared to evolve. Dilation. Three's too just said man, good our disorder. The first of these is ability to inhibit your behavior to stop what you're doing in order to allow the other exact functions to be able to take over and got your behavior towards trip. The second is the ability to use visual imagery, often called non verbal working memory. Humans have the ability to hold images in mind about what they are proposing to do. And they use those images as mental maps to guide their behavior toward the intended target. And also to remember the sequence of steps that's necessary to accomplish that goal for that task. Out of this executive ability also comes our sense of hindsight, foresight and overall are subject sense of time. So we would expect all of these to be impaired by the disorder. And so they seem to be the third executive ability is the ability to talk to yourself in your mind as a form of self guidance from sunup to sundown. All of our waking moments include a voice in our head that we use, not just to converse with ourselves, but also to give ourselves instructions and even to question ourselves when we face the novel situation where this mine's voice is often called verbal working memory. And it's another form of self control. The humans used to guide behavior over time to accomplish goals. Now, the fourth executive ability is the ability to control our own emotions. And with that, our motivations, it is out of here that we get emotional self control, the ability to inhibit strong emotion that's being elicited by things around us and to moderate those emotions so that they're more in keeping with our long term welfare and our long term goals. And then finally, there is the ability to plan and problem solve. This executive function involves mental play, the ability to manipulate information in mind in order to discover novel combinations that might serve to overcome obstacles toward our goals and allow us to accomplish our cast and goals. As we aim our behavior toward the future. These five executive functions by adulthood serve as a set of mind tools, a veritable swiss army knife of mental faculties that allow people to regulate their own behavior over time for their own long term welfare. So the preferential context cortex is essential for this executive functioning and it's the cortex that was delayed in maturation. So it makes sense that we are going to see this executive functioning in pair. Okay. So no, now let's talk a bit about the comorbidities. So um the A D H D is going to be linked and associated with other psychiatric disorder. So the most common association is with oppositional and conduct problems. So these Children are going to be 10 times more likely to develop these disorders than the general population. There is also an association with other neuro developmental disorders such as a ST uh ticks, modern coordination problems, learning difficulties. Um Also another association is with anxiety and with depression, there are three and five times respectively, more likely to get these disorders, an association with substance abuse as uh they, they will have this again, impulsive component and sometimes they also use substance to try to control and to reduce their symptoms and um association with learning and communication problems and with the sleep disturbances, the course of the condition, the persistence is unclear, but it is commonly say that 15% of the patient's are going to have a full, full persistence, 40 to 60% a partial remission. And then around 30% of the Children are going to grow out of the condition and they will not require any treatment or any support when they are adults. Um the severity, it's link it linked with the persistence of the condition. So the more severe is the case, the more persistent is going to be some adults. Even if they still have an A D H D, they will be able to manage and to cope uh by adapting their careers and their home life. For example, instead of choosing a work where they have to spend eight hours before in front of the computer, they can choose work outdoor where they can move around etcetera. But on the contrary, we also have patient's with major problems and even being adults, they need require they need treatment to avoid again all of these negative consequences. Okay. So now in terms of the diagnosis, uh we are going to do an a specialist assessment. So here in the UK, the G P teachers, school nurses and uh maybe parents can make the referral and we are going to base the diagnosis on recognizing patterns of behavior. So we are going to do an assessment with parents and the uh the child, we're going to ask about the neuro developmental history. We are going, it's very useful to ask for reports from school and from other professionals. And then sometimes it's also very useful to do observation at school. And uh also to keep in mind to trust and to rely on one what parents tell us because sometimes we can see a child that is very calm in the consultation, but it can, can have a D H D. So yes, to, to trust and to listen what parents tell us, we can base it our clinical thinking on finical hypotheticals with the questioner or different questioners. So we are not going to make a diagnosis base it on the scoring we get from a questionnaire but it's a combination. So we have our clinical thinking, we have identified some patterns of behavior we have asked for uh reports, we have observed the child's behavior and then we can do questioners. For example, here we usually do the corners that we have. The long and the short version, the long version is very long and we ask teachers, parents and the patient, the the young person if they are over eight years old to complete it and it give us very detail and useful information. Um We also get like a graph with percentage. So it's very visual and it's, it's a very good one. But it's long, we can also use the A D H D rating scale. For the snap for the strength and difficulty questionnaire. So we have many of them, there are many others. And here I wanted to introduce as well the topic of digital tools. So now we can uh take profit of the technology and use these digital tools to get information from the patient. For example, for this assessment, uh we're going to speak about this next week. But for example, using or accessing the GPS in the mobile phone or data from the uh smart watches, we can know if a patient is moving a lot, having this model agitation, but we're going to speak more in detail about this next week. Um Here, I only wanted to show you like how the corners looks like. And the second one is the 80 S C rating scale for okay. So now let's talk about the treatment. So um our patient's with 80 80 are going to face difficulties across many different environments. So at school in the community at home, so we need to support them in all of these situations, we can do uh psychological interventions or use medication or both of them. So in terms of the psychological interventions is essential to deliver psychoeducation to teachers, to parents. So that so that they know the condition, they know how to manage it and to avoid these unfair punishments or to blame Children for their behavior. Also, when the young person grow up, we can explain to them the conditions so that they know what's happening and how to manage it. Uh Also, it's very useful to give some behavioral management strategies to teachers and parents. We are going to speak about these strategies in the next slides. And parents can find very useful the management training and support groups, especially when they have kids that have this behavioral component. We can try CVT socialist skills training and we need to build up their confidence because sometimes they have self poor esteem problems in uh making friends due to all of these symptoms. So these psychological interventions in general, they are effective. But the effect, the effect size is a smaller than the medication. So we can use these interventions when we have a patient that is too young to start medication or in milder cases or again, in combination with treatment in more moderate and severe cases. Uh the use of medication, we are going to speak uh in a few slides. And again, the digital tools we can use digital tools especially for psychological interventions. For example, um uh if we detect that a patient is uh getting very distressed, moving around, etcetera, then we can deliver a recommendation. For example, uh it will be good if you start doing mindfulness, exercise or breathing techniques, these kind of things. But again, we will see this uh in more detail next week. So now uh what time is it okay? Now, let's talk a bit about the strategies we can suggest these strategies to teachers and two parents. So having a D H D doesn't mean that Children can disobey or can have violent behaviors can is we're so there is a still need for boundaries and for discipline as with every other kid, um it's good to give simple instructions. So to stand up close to the the child, to look at their eyes and to give a very simple instruction and then to praise the child every time they do something that is required however small, it is, it can be useful to do a list of things to do. So that to writing a piece of paper, a small tax that they have to do. And then to place this list whenever wherever they can look at it very easily. For example, in the fridge in the door of their bedroom, then to break the task to a smaller time span. So instead of asking a child to spend one hour doing homework, we can ask them to uh stay 15 to 20 minutes, then to have a break, to move around, then to continue another 15 minutes. And this uh to give time and activities to expend their energy. So every child, even if they do not have a D H D, if they are under stimulated, they can get bored and then they can uh misbehave. And on the contrary, if they are over stimulated, they can get overwhelmed. And again, they can uh misbehave. So this is called the stimulus window. And in our patient's with a D H D, this window is going to be narrow. So they are going to get uh frustrated, overwhelming or bored more easily than a than children's in the general population. So we need to give them activities where to expand their energy but not too much. And then we can read sometimes recommendations to changing the diet or avoiding additives. So as I say before, when we were speaking about the risk factors and the theology, there are no evidence to link this um uh elements, diet additives with a D H D. So in general, we are not going to recommend parents and patient's to change their diet or avoid additives. Sometimes if we have, if there is a clear link between a certain element and the worsening of the symptoms. So for example, if parents said that when their child eats chocolate, he becomes more anxious, uh nervous, etcetera, maybe we can suggest to do a food diary or to try to reduce a bitty amount of this uh food or to try to avoid it or to deliver to refer this patient to a nutrition, nutrition. But in general, we are not going to ask to make these changes. Okay. So here there are some strategies that we can give to the teachers that I think are very, very useful and interesting to know. So first to make clear to the teacher that this is a neurological deficit. And it's not intentional again, to avoid these punishments and uh to blame them uh to create a routing so that the kids knows how to expect and they perform better when there are minimal choices. And so to guide them on how they have to do to place the child in a small classes in the quite area for independent work with a clear desk, sometimes with mechanical, let's for example, air plaques and also to see them where there is less destruction. So in the front of the classroom, close to the teacher, far from the door, will's bishop that we have child attention before giving the distance and the direction and then to check their understanding. So asking the child to repeat what you explain to him to give extra time uh to break the assignments into a small ones uh to leave the easiest exercise to the end of the exile. The task as the concentration is going to decrease and look at weight. The argument increments again, to use a positive language, press child, it was to allow for physical movements can ask the child to stand up and go to another class to bring something or yes, during the breaks, they can move around the class. We have to um tell teachers that they do not have to expect need to work. Because this child, these Children are going to have uh motoring maturity and then the handwriting is not going to be great and they are also impulsive, they are distrustful, they'll make these mistakes and then they are going to cross out words, etcetera. So sometimes it's good. Instead of doing great in exercise, they can use computer or make oral presentations and also to do visual and activity based work, we can use a behavioral system. Uh We can also do this in at home with parents so that the child can win stars or stickers if they do what is required or if they achieve a goal and then to keep a visual record so that they can look at it easily to limit the group a segments because they are going to get distracted with other kids. And this last point is very important. So to keep contact with uh the clinician in this case and with the parents. So I have uh some documents with a lot of these strategies to give to the to the teachers. Um I have to do a summary here, but if you are interested, I can send it to you. And in this is in this um documents, uh we have like this drawing. I think it's curious where we can suggest how to place the students depending on their symptoms and behavior in the classroom. I thought it was curious to see. And then um we have, we have already seen these psychological interventions and the next step is to try medication. Okay. So before starting medication, we will need to do a physical assessment. So we need to record the weight, the hay and the BP to monitor these during the treatment. Um We are not going to start medication if the patient is under five years old. So if they, if they are five or over, we can start and then we're going to do uh individually tailored uh Taylor India, this medication is going to reduce the symptoms. So it's going to reduce the the problems with the concentration is going to reduce the feet, getting the motor agitation. And this gives an opportunity and time to the child to learn and to train the new skills. We are training and we are teaching them. So we are going to see improvement in the educational outcomes and we are going to reduce the family and the school based problems. Uh in terms of medication, the best evidence is for the stimulant medication. So, um well, the medication is going to enhance the arrows, Elinda prefrontal context cortex. We have already speak about this more or less. It's going to improve the efficiency of information processing. So, inattention impulsivity, productivity and it's going to increase the levels of dopamine and or adrenally between the nurse ending in the prefrontal context. So in terms of medication, we have stimulants, the best evidence is for stimulants and the most common used, one is the methylphenidate. We also have the amphetamines in the stimulant category. And then we have the non stimulants. Uh We're going to quickly speak about the atomoxetine one fast included in. And there are others that I don't think we need to, to spend time on this. So the stimulant medication again, the most uh used one is the methylphenidate. The efficacy and the safety has been well established and we will have a clinical response in the 70% of the cases. We're going to start with low doses and we are going to increase in them until we get the benefits we are looking for. And we have different uh forms of uh deliver of giving this. So we have the short acting uh and the long acting or modified release depending on the child needs. We are going to use one or the other or in combination. And there are many, many brand names, medic in it. Retaliation drank Illini qua seem Concerta, some, maybe some of them brings you a bell and then this is according to the nice guidelines. But if we were going to start with methylphenidate and if in six weeks, weeks, there are no positive effects, then we can switch to lisdexamfetamine or the exam phetamine that are also stimulant medication. In adults, we can as a first choice select the lisdexamfetamine. So all of these stimulant medication has some common side effects that are nauseous, decreasing the appetite and then weight loss, insomnia, agitation. So, uh that's why we're going to monitor uh and to do regular checking on the, hey, the weight and in during summers, we can suggest and recommend our patient's to do drug holidays. So to not take the medication during summers. And um this can have some benefits, for example, um some people develop tolerance to the medication. So during this uh holidays, out of medication, we can reduce this tolerance, they can catch up in weight and we can also check if they still need medication or not. So, if during summer there are, can focus etcetera, maybe there is no more need of medication. Uh If we have more serious side effects such as tick psychotic symptoms, uh increasing the BP, um growth retardation, then we need to think that maybe something else else is happening at the same time. So we need to rule out other diagnosis comorbidities because these side effects are not common. Uh, sorry, I'm checking the chat. Okay. Um And then, uh we can use the non stimulant medication. We are going to use this kind of medication only when the stimulant medication is not available is not tolerated, it's not appropriate or we cannot use it. Okay. But this non stimulant medication has much more uh side effects and it's less effective. We can use the atomoxetine that is a selective neuro adrenaline reuptake inhibitor. So it's going to increase the neuro adrenaline and then the dopamine and it's good when we have a D H D associated with anxiety or substance misuse. And sometimes we can also use one fascinating cloNIDine that are alpha chew agonist. And there are useful if there is an association of a D H D with ticks or with uh conduct disorders, then it's it's a good treatment. There are others. But to be honest, I have never used these other treatments for Children with a D H D. So uh I don't have experience with this. Okay. Um I can send this to, to you guys. So here I have placed like a table submarine the treatment, the brand names, the dosage, etcetera and he will have another uh rising the recommendations for the treatment. And then I think it's important uh to keep this in mind and yes, to not forget these things. So A D H D is not, not in this is common across all cultures. It can be serious and if it's untreated, it can lead to unfair punishment, blaming this child, Children. And then this can worsen the behavior, it can persist into adulthood and then it can lead to these negative consequences with divorce accidents, unemployment. It's stigmatizing many times these patient's and families explain that they feel social exclusion and again, they feel blamed for these behaviors and it's treatable with evidence based treatment. So it's important for us to identify these, these patient's to support them, to give the correct treatment and to avoid all of these complications. Okay. It's uh well, I have prepared to very quick cases. Um So we can maybe go through this very quick because we don't have a lot of time. But um for example, uh I want you to think what you will ask if you have in your consultation. Uh nine years old girl who is referred by her G P due to anxiety and low mood. And when we ask a bit about the symptoms, we find uh again that she has anxiety and low mood, poor performance at school, low self esteem and problems with the sleep. What you think you would ask to this patient or, or the parents, you can write it in the chat. It's okay or I can. Yes, assad. Thank you very much for uh okay. The first thing we should about was was she always like this or this is new, these symptoms of these mood changes and new depending upon if it's chronic or not chronic. Perfect. Yeah. Ok. So these parents tell you that she has always been clumsy with a lot of accidents. Um She has always been having um this mind wondering when she's doing homework in the last year is higher expectations at school. The performance is slower and she's struggling a lot with this. What you can ask or what do you think? Ok. We could also ask like, is there any moment when she's not clumsy or whether she's been calm, very uh not anxious? So you might need to ask, what are those situation? Is it a situation? Is it a person who she is very quiet to it or attempted to because then we might differentiate but uh it's a situational of forcing of it. Yes. Ok, perfect. We can also ask maybe um about family history about yeah, parents or siblings with similar symptoms. Uh We can also ask about the novel developmental history if there are if there were some delays in the developmental story in the normal development and uh where else we can ask yes, you know about the delivery the pregnancy, these kind of things. Um So I wanted to show this case because it's we can have patients that are referred more focus like uh disorder. So explaining this anti itty, this low mood. But with these symptoms, if we start asking questions, we can see that the main problem can be an A D H D. So in this case, and more focus on attention deficit disorder and uh these kids when the expectations at school increase, they can fall behind her ears. And then of course, this can have an impact on their performance, on their self esteem, their mood uh can be ca mention this. And then uh here, for example, in this case, I will uh start maybe treatment, psychological interventions focus on the 80 HD instead of uh focusing the treatment for depression or or anxiety. So I hope this makes sense. And then we have time. No, no, so much. I wanted to present this case. This is a real case that I have in the clinic. So they referred a 16 years old ploy uh for an idea t assessment because he has difficulties in concentration. So the symptoms were low concentration, he get distracted very easily with low performance, with bad behavior at school, he was irritable and with the sleep. So um when we did the assessment, um he started explaining that these symptoms start before the pandemic or during the lockdown because it was very difficult to be focused on the online uh classes at school. And then it was super very difficult to go back to school and to start like the normal life again. And then um in this case, it was clear when you start asking all of this question during the assessment that the low concentration, the poorest sleep, the low performance where uh symptoms from depression and not from A D H D. So even if we have people refer for dhd, we need to do this assessment and to make the differential diagnosis between mood disorder society and of the common Beatem cancer. So I wanted also to suggest you some resources uh that are very good for you and also for patient's and uh parents. So from the Royal Collective Psychiatrist Web, you can find very useful information sheets to give to the parents. And then the uh when in the ninth, you can follow the instructions on how to deliver the street in the at this web resources and sugar group and work for his Children. So I think this is very useful and yeah, that's all very much. I hope it has been useful. And again, I hope next week you can also attend and we will uh we will review uh do a quick summary of what we have learned today. And then uh we will focus more on the digital tools part. Thank you, Assad for, for your interactions.