Child Study Center Grand Rounds 02.16.2021

Transcript

• 00:00Thank you Andreas for that lovely
• 00:02introduction to the introduction and
• 00:05for inviting me to introduce Michael.
• 00:07It's actually very special 'cause
• 00:09Michael's given me a lot of introductions,
• 00:11and so it's cool that I'm getting to
• 00:14return the favor for this grand rounds.
• 00:17So I think most of you are
• 00:20probably familiar with Michaels.
• 00:22You know basic baseball stats here
• 00:24that he got his bachelors in biology
• 00:27from University of Pennsylvania
• 00:29and then he came to Yale.
• 00:31So he did his medical training here
• 00:33at Yale and then decided to stick
• 00:36around to join the inaugural class
• 00:39of the Solemate Integrated Program.
• 00:41I had to include this picture,
• 00:43which is one of my favourites.
• 00:45I think Anna Stevens sent this
• 00:47out on a chat program and I just
• 00:50grabbed it right up 'cause I think
• 00:52this is the first four years of the
• 00:54Soul Net program in a very faded,
• 00:57appropriately faded photo.
• 00:58So you can probably recognize
• 00:59a lot of the folks on here.
• 01:01A lot of successful people and a lot
• 01:04of really kind people in this photo,
• 01:06and you can see a sort of self satisfied
• 01:10Michael Block right in the middle.
• 01:12So he finished the program in 2010
• 01:15and along the way got a Masters in
• 01:18Epidemiology which has served him very
• 01:20well and probably is part of the work
• 01:22he's going to present to you today.
• 01:26And after all this time at Yale,
• 01:28he thought I still have more work to do
• 01:31here and so he joined the faculty and
• 01:33has been here for the last 10 years.
• 01:36He's touched a lot of different programs
• 01:38and impacted this center in many ways,
• 01:41but one of them is really transforming
• 01:43his own little corner of the 2nd
• 01:45floor in the Child Study Center
• 01:47into the shrine to Mets baseball.
• 01:49You know,
• 01:50I hope someday that the Mets
• 01:52return the favor for his loyalty,
• 01:54but I don't know if this will be the year.
• 01:59And this is the part where I think you
• 02:01know we highlight some of the wonderful
• 02:04accomplishments and it's hard to do
• 02:06because Michael has done so very many
• 02:09things at the Child study center.
• 02:11So he's the Co director of the Tick
• 02:13in OC D program with Tom Fernandez.
• 02:16He's my Co director with the pediatric
• 02:19treatment Resistant Depression
• 02:20program that we started in late 2019.
• 02:22He's the Co director of the
• 02:24T32 program with Mike Crowley.
• 02:26You can see he's a Co director of
• 02:28many things which I think highlights
• 02:30how well he works with the faculty
• 02:33and the trainees here.
• 02:34He's also the associate director
• 02:36of the Albert J Solnit program,
• 02:38so really coming full circle from
• 02:40being a member of the first class
• 02:42to now shaping the future.
• 02:44He was also the inpatient Chiefs
• 02:46of the Clinical Neuroscience
• 02:48Research Unit up until 2018,
• 02:49so you can see these are very
• 02:52prestigious programs both within
• 02:53and outside the Child Study Center,
• 02:55and I think it's not a coincidence
• 02:58that Michael's fingerprints
• 03:00are on these programs and that
• 03:02they've been so very successful.
• 03:04Of course, what we're talking about
• 03:06here today is some of his research,
• 03:08and he's been very impactful
• 03:10with his clinical trial.
• 03:11An meta analytic work,
• 03:12I think he's one of the only
• 03:14speakers where I had to ask him what
• 03:17exactly are you presenting today?
• 03:19I mean, most people I know what
• 03:21they're going to talk about,
• 03:23but he's an expert in so many areas.
• 03:26Publishing really important work
• 03:27and depression, anxiety, OCD,
• 03:28trichotillomania tic disorders,
• 03:2980 HD and then not only in child psychiatry,
• 03:32but also publishing across the lifespan.
• 03:35I think it's hard to overstate
• 03:37how important his work has been,
• 03:39not just to child psychiatry,
• 03:41but to psychiatry at large.
• 03:43If you like to put numbers
• 03:45to stuff like this,
• 03:46he's got an h-index of 62.
• 03:48This is a graph looking at the
• 03:51h-index of Nobel Prize winners
• 03:52after they've won the Nobel Prize,
• 03:55so presumably have done some very impactful
• 03:57work that's been widely disseminated,
• 03:59and you can see each index of 62.
• 04:02It's pretty darn good.
• 04:04Very influential in the field.
• 04:06He's on the editorial board of
• 04:08all these important journals,
• 04:10so I think it's fair to say that he's
• 04:13really a modern Renaissance person
• 04:15here at the Child Study Center.
• 04:18And finally,
• 04:18you might worry that having you
• 04:20know all of these titles and
• 04:22doing all of this important work,
• 04:24you know that that might go
• 04:26to his head that he would be,
• 04:28you know,
• 04:29not approachable or too busy or
• 04:31or any of those things.
• 04:33And I think you know my favorite thing.
• 04:35Working with Michael both as a
• 04:37mentee and now as a partner is just
• 04:39how caring he is for his patients.
• 04:42And for trainees that they always come first.
• 04:44And you know,
• 04:45it's nice to publish papers and get.
• 04:48Prizes.
• 04:48He's got plenty of papers
• 04:50and plenty of prizes,
• 04:51but I don't think he ever loses
• 04:53sight of the fact that the
• 04:55purpose of this work is really
• 04:56to impact the the kids and the
• 04:59families that we see every day.
• 05:00So I'm really excited to hear what
• 05:02he's going to talk about today,
• 05:04which is using meta analysis to guide
• 05:07the assessment and treatment of ADHD.
• 05:09Go Michael.
• 05:14Unmute myself, thank you
• 05:15for the kind introduction.
• 05:16I'm gonna do my own introduction of
• 05:18myself and I may need to borrow your
• 05:20slides for my introduction next time,
• 05:22'cause I think you did a
• 05:23better job then I'll do it.
• 05:25I'm introducing myself. I guess.
• 05:30First thing to say is I need to get the.
• 05:33Sorry, let's get it working OK.
• 05:40OK, can people see the slides?
• 05:43Someone says not yet,
• 05:44but while you do that, Michael,
• 05:46I just want to add one word to
• 05:48the introduction of
• 05:49the introduction and that
• 05:50is that your partner in crime is part of.
• 05:53He's certainly worth giving a thumbs up,
• 05:56so Angie in the House so anyway.
• 05:59Back to you Michael, can you see the slides?
• 06:03Yep OK good OK let me.
• 06:06OK, so yes, the first thing we get through
• 06:09his disclosures and we run a bunch of
• 06:12clinical trials that are partially funded by.
• 06:16Industry, none of these really involve ADHD.
• 06:19I haven't really done any
• 06:21clinical trials in ADHD,
• 06:22so I don't think any of the
• 06:25particular disclosures are relevant.
• 06:28I think Jenny gave a really good
• 06:30kind of introduction on what I do.
• 06:32I think the first thing to say is
• 06:34what I do with the Child study
• 06:36Center is that I have a fairly busy
• 06:38outpatient practice and all the
• 06:40disorders that you talked about earlier
• 06:42in the in the Child study Center.
• 06:45I involved in the only training
• 06:48program in the T 32 and then just run
• 06:50a lab involved in clinical trials
• 06:53and meta analysis research and all
• 06:56these things really intersect in both
• 06:58the research and care of patients,
• 07:01and I guess the real thing I want
• 07:04people to get out of this lecture
• 07:06more so than any particulars about
• 07:0980 HD pharmacology or 80 HD treatment
• 07:12is just that the experiences with
• 07:14the patients and the trainees.
• 07:16Really affects the research and
• 07:18then the research also affects the
• 07:21care of the patients and hopefully
• 07:23the education of the trainees and
• 07:25that it's sort of a circle.
• 07:27I guess I would also say that I'm a
• 07:29father of three kids and and I picked up
• 07:32two dogs in the family during the pandemic,
• 07:35so I apologize if they make any noise
• 07:38and I I guess I also should think Angie,
• 07:41for if it's quiet you should think energy
• 07:43could she'll be responsible for that,
• 07:45will hope it continues along.
• 07:47And
• 07:48then just again, the main
• 07:50purpose of this talk is to
• 07:52discuss that utility of clinical research
• 07:54and meta analysis and improving the
• 07:56care of patients and then also to just
• 07:58demonstrate how clinical exposure and
• 08:00teaching actually informs the research.
• 08:02And I'll be talking through that today.
• 08:06Really, where we're going?
• 08:07I guess there are three main points
• 08:09and I'm going to kind of have 3A2 cases
• 08:12that involve really three aspects of
• 08:14research that we've done in the lab.
• 08:16The block lab over the last few years
• 08:19really to demonstrate three things.
• 08:21The first one I want to demonstrate
• 08:23to people is that your risk of being
• 08:25diagnosed and treated with 80HD is
• 08:27related to your astrological form.
• 08:29That's the first thing I intend
• 08:31to prove to people.
• 08:32The second one is just to talk about common.
• 08:36Understanding of the treatments of
• 08:37the efficacy of common treatments for
• 08:40ADHD and also examine the effects of
• 08:42particularly doses of psychostimulants
• 08:43on the efficacy of medications for
• 08:46ADHD and the last thing I really want
• 08:48to talk about is just the important of
• 08:51race and racism and racial bias in the
• 08:54treatment of ADHD and other psychiatric
• 08:56conditions that we've also been doing.
• 08:59Research in the training program in
• 09:01the lab on this and I think doing
• 09:04an evidence based presentation on.
• 09:0680 HD ADHD pharmacology and and
• 09:08trying to psychiatry in general.
• 09:10It's also important to highlight
• 09:12these findings.
• 09:15So the first part of this
• 09:16talk will just be about.
• 09:20The risk of ADHD and its Association with
• 09:23birth date and this is research
• 09:26that's done primarily by a couple of.
• 09:29Trainees in lab. Jose Flores, who's now
• 09:32in his addiction fellowship here at Yale,
• 09:34soon hopefully to be involved in
• 09:37a child Psychiatry fellowship.
• 09:38And Victor, who's visiting scholar
• 09:40here in the Child Study Center.
• 09:42Ann, if you're looking at 80 HD
• 09:45as hopefully all of you know,
• 09:47being involved in the Child study center,
• 09:49ADHD is really associated with
• 09:51three core symptoms in extension
• 09:53and then hyperactivity impulsive
• 09:55ITI to get the diagnosis.
• 09:56You have to have an age of onset prior to.
• 10:00Well and you have to have
• 10:02symptoms in multiple settings
• 10:04and it needs to cause impairment.
• 10:06Other things that you may or may not
• 10:10know about 80 HD is that it's if you
• 10:13look at twin and molecular studies,
• 10:15it's as heritable or more
• 10:17heritable than any psyche.
• 10:19And then other psychiatric
• 10:21conditions that are currently around.
• 10:23It's has a similar heritability
• 10:25in twin studies to autism,
• 10:27schizophrenia,
• 10:27bipolar disorder,
• 10:28and in both twin and molecular studies.
• 10:30It has a much greater heritability
• 10:33estimate than things like.
• 10:35Depression and anxiety disorders.
• 10:37It also really has a pretty
• 10:40clear neuroscience.
• 10:41Neural biological mark marker of
• 10:448080 where it's really delayed
• 10:47development of the prefrontal cortex
• 10:50that's important in modulating
• 10:53cognitive control processes like.
• 10:56Attention and motor planning.
• 10:58So it's a disorder that has clear
• 11:01heritability and also has a clear
• 11:04neurological signal associated with it.
• 11:09I'm now going to convince you
• 11:12that it's associated with
• 11:13astrological sign and birth date,
• 11:15so I'm generally using my kids as
• 11:17examples of these things rather than
• 11:20the patients I'm singing clinic
• 11:22just 'cause it's easier for me
• 11:24to keep track of their names and
• 11:26not commit any HIPAA violations.
• 11:28So this patient I'm actually
• 11:30going to talk about would fit well
• 11:32with one of my sons, Paul,
• 11:34but also is actually very germane to.
• 11:38Patient Amalia was seeing a fairly
• 11:41recently in the clinic that I I
• 11:43took over when she left for Brown.
• 11:45So Paul is in now eight years old.
• 11:48He's in second grade.
• 11:50His plans are to have his own YouTube
• 11:53channel where he's going to be a star.
• 11:56Hasn't quite figured out what he's
• 11:58gonna do on his YouTube channel yet.
• 12:00He likes legos.
• 12:01He likes racing Matchbox cars
• 12:03watching and playing Minecraft videos.
• 12:05He likes cooking that can be really kind
• 12:08of disastrous thing if unsupervised.
• 12:10And he likes unboxing present,
• 12:12so I think if he had his say,
• 12:14and what is YouTube channel would be he
• 12:17would unbox presents that someone gave them.
• 12:20Another thing to say about Sam and
• 12:23Paul is that they're Twins and.
• 12:27And. And they were actually born.
• 12:33December 13th, 2012.
• 12:35And this is actually a picture of
• 12:38when the boys were in Phyllis Bodel,
• 12:40so when they were in kindergarten here
• 12:43and had a wonderful experience here.
• 12:46But Paul's experience in kindergarten
• 12:48at Bodel was at least initially
• 12:50quite rocky for him when he,
• 12:53when he started out kindergarten here,
• 12:55he kind of not really stay on the
• 12:58rug in class and he and he not be
• 13:02happy to go in every day and he said.
• 13:06You know the this is much harder
• 13:08for me than the other kids.
• 13:10The other kids are are smarter than me.
• 13:13They are able to do things I can't
• 13:15and he said this when he was starting
• 13:18kindergarten.
• 13:19Ann and I think this was probably
• 13:21an accurate perception of.
• 13:23So, uh, this initial kindergarten experience.
• 13:25If Odell, that he was behind the other kids.
• 13:30So one important thing to know about
• 13:33kindergarten in school in Connecticut is
• 13:35that it has a January 1st cut off date.
• 13:39So all the kids that are born.
• 13:43Set the cutoff for going into
• 13:45the next rate is January 1st,
• 13:47so we actually did a meta analysis.
• 13:50Looking at whether this sort of.
• 13:53Being behind in kindergarten,
• 13:55I was very interested in how
• 13:57this affected kids academically,
• 13:59'cause I was very interested for my own kids,
• 14:02but also that just the effect was so
• 14:05obviously large in in the Twins lives
• 14:08and so we actually did a meta analysis.
• 14:11Jose, Victor and I and Adam and a bunch
• 14:15of other people looking at 14 studies
• 14:17that looked at the Association between
• 14:20birth date and and diagnosis of 80 HD.
• 14:23The studies involved over 3,000,000 children
• 14:26involving nine different countries,
• 14:27and we stratified the studies based on when
• 14:31the cut off for school was in the area.
• 14:34So this is a graph looking at the
• 14:37odds of being diagnosed or treated
• 14:40for 80 HD as a function of when your
• 14:43birth month was and this was for
• 14:46studies that had a January 1st cut
• 14:48off like Connecticut and you can see
• 14:51that the lowest odds ratio occurs in.
• 14:54For the kids born in January and then
• 14:56there's a fairly steady increase
• 14:58up until the end of the year.
• 15:00And with the largest odds ratio being
• 15:02in October, November and December.
• 15:04If you look separately at schools,
• 15:08that locations which had a September
• 15:101st cut off for an end of August cut
• 15:14off for for going into kindergarten.
• 15:18You saw a a different relationship
• 15:20with birthday that the
• 15:22highest the highest rate of diagnosis of
• 15:26diagnosis and treatment for ADHD was in
• 15:29July and August and lowest
• 15:31was right after the school cut
• 15:34off in September and October. And
• 15:38if you overlay the two time periods and put
• 15:41the cut off in a common place, you get a
• 15:45fairly similar trends where kids
• 15:47are at much lower risk when they
• 15:50are relatively old for their grade
• 15:52and are at a much higher risk of
• 15:55getting diagnosed for ADHD if they're
• 15:57young for their their school age.
• 16:00And this is in another way of looking
• 16:03at a comparing the odds of being
• 16:06diagnosed or treated for ADHD.
• 16:09In the 120 days before the school
• 16:11cut off versus 120 days after the
• 16:14school cut off and at least your
• 16:17odds of being diagnosed or treated
• 16:19for ADHD was about 40% higher.
• 16:22If you were born right before the school,
• 16:25cut off as opposed to afterwards an you
• 16:28can actually take this data and look
• 16:31at changing when the actual cut off
• 16:34time is and you see that if you only
• 16:37look at the 30 days before and after.
• 16:41So the school cut off.
• 16:43The kids are at about a 50% increased
• 16:46risk of being diagnosed and or treated
• 16:50for ADHD if they are born in the month
• 16:54before the school cut off as opposed
• 16:57to the month after this welcome.
• 17:00So it has a pretty profound effect.
• 17:03Anne Anne this really?
• 17:06Has a really profound implications
• 17:08for a number of things.
• 17:09So the first thing is the bottom
• 17:12line is that the month of birth is
• 17:15strongly associated with the risk of
• 17:17being diagnosed and treated for ADHD.
• 17:19It's related to the school entrance
• 17:22cut off date for the location.
• 17:24It seems like the effect decreases
• 17:26with increasing age and the effect
• 17:28is quite substantial.
• 17:29Really.
• 17:30A 50% increased risk of being
• 17:32born in December in Connecticut
• 17:34as of four supposed to be.
• 17:37Being born in January and this really
• 17:39probably has pretty important impacts,
• 17:42especially for studies in early childhood
• 17:45that look at ADHD risk that it's not
• 17:48only your risk of ADHD compared to your
• 17:52actual Chronicle chronological age,
• 17:54but it's probably equally or more
• 17:57important the your risk of ADHD
• 18:00compared to what your expected age is,
• 18:03what your grade in school is.
• 18:06It also has implications for both
• 18:08public policy in early education.
• 18:10I mean with Paul,
• 18:11he's doing great.
• 18:13He's now eight years old in the second grade,
• 18:16which probably gave away what
• 18:18we did with Paul,
• 18:19which is we had him repeat kid in
• 18:22kindergarten when he went into spring Glen,
• 18:24but but this has a significant
• 18:26financial implications,
• 18:27and we're we're we're quite privileged
• 18:29to have the economic ability to
• 18:31have our kids repeat kindergarten.
• 18:33My estimate when we were doing the
• 18:36finances for making this decision
• 18:38was it was going to cost us about.
• 18:40$32,000 for the year to hold the
• 18:43Twins back a year in school for the
• 18:45both of them so that most families
• 18:48don't have $32,000 to spend on this.
• 18:51And I think that really made
• 18:53me think a lot about this.
• 19:00Moving on to the assessment
• 19:03and treatment of ADHD.
• 19:05We're treating kids with ADHD in the clinic.
• 19:08I think the one thing that I really
• 19:10want people to take home is the
• 19:13importance of using rating scales that
• 19:15rating scales given to the caregivers,
• 19:17and the teachers are much more
• 19:20sensitive to change than just
• 19:22sort of asking how kids are doing.
• 19:24And I think people a lot of times in
• 19:27judging improvement in 80 HD don't really
• 19:30recognize how much better kids can get.
• 19:32And it's not just having them be
• 19:35significantly improved, its to.
• 19:36The goal should be.
• 19:38Permission and the nice thing about
• 19:40these rating scales for ADHD is
• 19:43that they are freely available,
• 19:45so I'm I'm a big fan of the ADHD rating
• 19:48scale for which is publicly available
• 19:51on lines and 18 question survey given
• 19:54to parents or teachers that scores ADHD
• 19:57symptoms from never happening to very off.
• 20:00Thing,
• 20:01and it's freely available online.
• 20:03Here's a web link to it.
• 20:05Ascentia Lee.
• 20:06The kids that come in for ADHD in the clinic.
• 20:10This is what they give them or similar
• 20:13things like this snap or the Vanderbilt
• 20:17in terms of treating families with
• 20:19children with ADHD in the clinic.
• 20:22Really,
• 20:22Psychoeducation is the first things
• 20:25involved in treating these kids
• 20:27racking just helping them recognize
• 20:29the important symptoms and.
• 20:31Cognitive common impairments
• 20:32associated with ADHD.
• 20:34Obviously the typical stuff like inattention,
• 20:36hyperactivity,
• 20:37and impulsive ITI,
• 20:38but the other things that are really
• 20:41important to talk about with families is
• 20:44just the organizational difficulties.
• 20:46Many of these kids have also the common
• 20:50comorbidities that are associated with ADHD.
• 20:53You could call them
• 20:54oppositional defiant disorder,
• 20:56conduct disorder,
• 20:57but I would say that there it's really.
• 21:01Kind of the main problems are aggression,
• 21:03irritability and emotional
• 21:04abilities is sort of, if we're not.
• 21:06If we're going to get into common
• 21:08language and just understanding
• 21:09these things and treating them,
• 21:11the other thing really to talk
• 21:13about with families, just.
• 21:15Will talk about the people very often.
• 21:18Focus on the risks of what the medications
• 21:22are on the treatments for ADHD,
• 21:25but I think it's also important
• 21:28to recognize what the risks are.
• 21:30Not treating ADHD properly and that
• 21:33ADHD is associated with significant
• 21:35impairment impairment in in school,
• 21:38poor school performance,
• 21:39increased risk of dot dropout,
• 21:41and and suspension.
• 21:43It's associated with social impairments,
• 21:45difficulties with friendships
• 21:47and recreational activities.
• 21:49It's associated with the problems
• 21:51went in familial relationships,
• 21:53so also associated with a lot of
• 21:56safety issues that so children
• 21:58with ADHD and and going on to
• 22:01adulthood with 88 fear associated
• 22:03with increased risk of accidents.
• 22:06Whether it's physical accidents in childhood
• 22:08or traffic accidents and adulthood,
• 22:10increased risk of substance
• 22:12abuse and other risky behaviors,
• 22:14most of these things actually improved
• 22:17significantly with successful treatments.
• 22:21Behavioral treatments are also important
• 22:24that children with ADHD establishing
• 22:26clearer routines encourageing
• 22:28structure in their daily set schedule,
• 22:31setting, clear expectations,
• 22:32possibly setting up a reward system
• 22:35for good behavior, avoiding harsh
• 22:37punishment as much as possible,
• 22:40promoting exercise, sleep,
• 22:41hygiene, good nutrition,
• 22:43and then promoting things to strengthen
• 22:46the parent child relationship.
• 22:49There are also a lot of things you can
• 22:52do in school to help kids with ADHD,
• 22:55so there are a lot of
• 22:56things listed on this slide,
• 22:58but essentially having the kids sit
• 23:00in a place in the classroom where
• 23:02they're free from distractions,
• 23:04breaking up the big assignments
• 23:05into smaller pieces and then also
• 23:07writing down in organizing things
• 23:09for kids as much as possible,
• 23:11and then probably the last thing again,
• 23:13is having a reward system in
• 23:16school with a behavioral plan that
• 23:18praises them for good behavior.
• 23:20So when looking at the other six commonly
• 23:24used treatment for ADHD is medication,
• 23:27so I really if you look at all the big
• 23:32NIH clinical trials in psychiatry.
• 23:37MTA,
• 23:37so the multimodal treatment study of
• 23:40ADHD was the first one that was done
• 23:43and I think was the one that got a
• 23:46lot of the trials funded for other
• 23:49disorders looking at practical clinical
• 23:51trials about treatment and the MTA study.
• 23:54The design was quite simple,
• 23:56involved 580 kids 7 to 10 years
• 23:58old with combined type ADHD.
• 24:00They were randomized to 14 months so
• 24:03it's incredibly long randomized trial.
• 24:05They were either randomized
• 24:07to medication management.
• 24:08Behavioral treatment in this behavioral
• 24:10treatment arm was really probably
• 24:12behavioral treatment on steroids
• 24:13compared to what we what the best thing
• 24:16I can possibly offer a kid in the clinic.
• 24:1935 sessions of parent management
• 24:20training an 8 week child focused
• 24:23summer camp in ADHD where the kids
• 24:25would go if they were in the study
• 24:28and then there was a school based
• 24:30intervention where they work with
• 24:31the teachers in the profession.
• 24:33Paraprofessional,
• 24:33the same counselors kind of did
• 24:36all these treatments in the study.
• 24:37You had the combination treatment
• 24:39of both the medication management.
• 24:42And the behavioral therapy and
• 24:44then 'cause they couldn't use
• 24:46placebo controls for 14 months.
• 24:48They had a community care condition
• 24:51where patients were randomized to
• 24:53treatment in the community where they
• 24:55would most of the patients got medications.
• 24:58Actually similar medications to the ones
• 25:01used in the medication management condition.
• 25:05And the primary result of
• 25:07the clinical trial was this,
• 25:09essentially,
• 25:09what mattered in MTA over the 14 months
• 25:12of treatment was whether you were in
• 25:16the medication management condition.
• 25:18So the medication management condition
• 25:20and the combined Freeman condition
• 25:22did statistically equivalent,
• 25:23which was significantly better than
• 25:26the behavioral treatment alone or the
• 25:28Community care for core ADHD symptoms.
• 25:31And it's important to note
• 25:33that the medication management.
• 25:35That the combined treatment so
• 25:37that the addition of behavioral
• 25:38therapy didn't significantly improve
• 25:40outcome to the medications alone,
• 25:43at least in the core ADHD symptoms
• 25:45it did for some of the comorbid
• 25:48behavioral disorders and anxiety,
• 25:50but there was no St statistically
• 25:53significance there.
• 25:54So the bottom line is that medications
• 25:56are even over a fairly long period of
• 26:00time are the most effective treatment
• 26:02we have for the core symptoms of ADHD.
• 26:06And we really in terms of psychopharmacology,
• 26:09we really have two types of medications,
• 26:12methylphenidate derivatives
• 26:12and amphetamine derivatives,
• 26:14to the psychostimulant medications.
• 26:15And there is a huge
• 26:17variety of medications now,
• 26:19but they all essentially work on
• 26:21these two active ingredients.
• 26:23Just the pharmacokinetics of the number
• 26:26of times you need to take him a day
• 26:29when they're in your system differs.
• 26:32And then there are none.
• 26:34Psychostimulant medications
• 26:35like atomoxetine bupropion.
• 26:36A2 agonist like 115 in funding.
• 26:39An if you look at the efficacy
• 26:42of ADHD medications,
• 26:43really the message is quite
• 26:45simple so the so this is a network
• 26:48meta analysis that looked at the
• 26:51comparative efficacy of treatments
• 26:52and the bottom line was that the
• 26:55stimulants worked much better,
• 26:57so this is looking at response rates that
• 27:00the response rates compared to placebo
• 27:03were much higher for stimulants
• 27:05for methylphenidate amphetamine
• 27:06derivatives compared to any of the
• 27:08non stimulant ADHD medication.
• 27:10So the. So the response rate was
• 27:13about 40 to 50% worse for non
• 27:17stimulant medications compared to
• 27:18stimulant medications for ADHD.
• 27:22It's also important to say that
• 27:24the stimulants work much faster,
• 27:26so you can see the effects
• 27:28of stimulants within a week,
• 27:30whereas most of the non stimulant ADHD
• 27:33medications take a couple months before
• 27:35you see the full efficacy of them.
• 27:38So then the next thing we looked at,
• 27:41and this was done with Jose and Victor again,
• 27:45and also a now a PhD student at that
• 27:48time of Louisa Medical student from
• 27:51Brazil looking at does dosing affect the
• 27:54efficacies of stimulants for childhood ADHD?
• 27:58And I'm going to talk about a girl.
• 28:02I will call her Rachel rub.
• 28:04This is not will use Rachel loosely.
• 28:06So Rachel when she presented to the
• 28:09clinic was a 9 year old girl who was in
• 28:123rd grade carrying a diagnosis of ADHD.
• 28:15She was actually referred to the thread,
• 28:17so seedy clinic 'cause she had
• 28:19some skin picking symptoms.
• 28:21But the big issues was she was at least
• 28:23two grades behind for math and reading
• 28:26and she was getting getting frequently
• 28:28in trouble for school for issues
• 28:31with hyperactivity and impulsive ITI.
• 28:33And when I met her for initially
• 28:35for the evaluation,
• 28:37this is back in the time where
• 28:39we actually saw people in person.
• 28:41She really couldn't even sit for
• 28:43half the 60 minute interview.
• 28:45I plan to do with the family and she
• 28:48was on 10 milligrams of Adderall
• 28:50and she was eventually referred.
• 28:51Because was the Adderall making
• 28:53the skin picking worse?
• 28:54That was a fairly similar.
• 28:57People question to the answer.
• 28:59The first answer is probably their case.
• 29:01Report level data that the stimulants
• 29:03can be associated with skin picking,
• 29:05but there isn't any data from
• 29:07controlled studies, and even if it was,
• 29:10making the skin picking worse,
• 29:11the issues in fool falling behind
• 29:13in the behavioral issues were much
• 29:16more significant and so the basic
• 29:18clinical question is are higher doses
• 29:20of stimulants more effective for ADHD
• 29:22and would they affect the care of this child?
• 29:27So the thing
• 29:28I didn't talk about in the
• 29:30MTA study when it's revisited,
• 29:32is why was the medication management
• 29:34condition more effective than
• 29:36the Community care condition?
• 29:38Actually, in this graph,
• 29:39we stratify the community care conditions
• 29:42by whether or not they were medicated
• 29:46in the medicated Community care.
• 29:48Kids did significantly better
• 29:50than the unmedicated ones,
• 29:51but they did significantly worse
• 29:53than the kids in the medication
• 29:56management condition and.
• 29:58These kids were started
• 29:59on the same medications.
• 30:00So about 86% of them were on
• 30:03methylphenidate and almost every other
• 30:05kid was on an amphetamine derivative.
• 30:08And the big difference was probably
• 30:11one thought to be one of those
• 30:14that the kids in the in medication
• 30:17management condition on average
• 30:19received most of methylphenidate.
• 30:21That was about 40% higher than those
• 30:24in the Community care condition.
• 30:27It was 37.1 milligrams per day
• 30:30of short acting methylphenidate,
• 30:31versus a little under 23. So we actually
• 30:37looked at this in a large meta analysis,
• 30:41so we took all randomized
• 30:43placebo controlled studies of
• 30:45stimulants for childhood ADHD.
• 30:4725 studies involving 70
• 30:49treatment arms over 5000 kids. We
• 30:52excluded trials that wouldn't really be
• 30:55clinically relevant.
• 30:56Crossover trials trials which had
• 30:58the participants selected for
• 31:00a particular dose of methylphenidate
• 31:03or doing well on stimulants.
• 31:06The median length of the
• 31:07trial was four weeks and we
• 31:09really looked at two things.
• 31:12Wait, what was the dose response
• 31:13relationship in in 80 HD medications in
• 31:16general and then versus methylphenidate
• 31:19amphetamine derivatives and also the
• 31:21differences in fixed inflexible dose
• 31:23trials and just so people get the
• 31:25difference between fixed those trials,
• 31:27inflexible those trials.
• 31:28A fixed dose trial is a trial
• 31:31where the patient is assigned to a
• 31:34particular dose of the medication
• 31:36and they can either take that meta
• 31:39dose of the medicine or drop out.
• 31:41So they they have side effects,
• 31:43they still have to stay on
• 31:45that dose of the medicine,
• 31:46whereas in a flexible dose
• 31:48trial you can adjust the dose of
• 31:50medications related to side effects.
• 31:51So if you're on a particular dose
• 31:53of stimulants, inflexible dose trial,
• 31:55you could go down on the dose,
• 31:57whereas in if you were fixed those trial,
• 31:59you could either continue on
• 32:00that dose or drop out.
• 32:02That's the big difference
• 32:03between the two trial designs.
• 32:06And if you're looking at efficacy,
• 32:08the improvement in ADHD symptoms,
• 32:10the first important point is
• 32:13if you look at medications.
• 32:15Overall, as you increase the
• 32:17dose of of stimulant medications,
• 32:19and so these are in methylphenidate
• 32:23equivalents and a basic ways.
• 32:25Generally the Adderall derivatives have
• 32:28twice the potency of methylphenidate,
• 32:30so 60 milligrams of methylphenidate people
• 32:32to 30 milligrams of Adderall derivatives.
• 32:35Essentially,
• 32:35there was a overall in the studies.
• 32:38You saw a fairly substantial benefit
• 32:41of increasing the dose of stimulants.
• 32:43Really throughout the dose range,
• 32:46but particularly up to 30 milligrams.
• 32:48And when you looked at the
• 32:51flicks fixed versus flexible,
• 32:52those studies,
• 32:53if you looked at the fixed those studies.
• 32:57Where children had to take
• 32:59the dose they were assigned.
• 33:02It seemed like the dose response
• 33:04relationship was was fairly substantial,
• 33:07up to about 20 or 30 milliequivalents and
• 33:11then really leveled off at a dose after
• 33:153030 milligram milliliter equivalent.
• 33:18So essentially,
• 33:19if you were on a dose of methylphenidate
• 33:21up and you were increasing,
• 33:23it is generally always made.
• 33:25It sends up to 30 milligrams.
• 33:27If you could adjust the dose and
• 33:29if you went higher on the dose and
• 33:31you couldn't have just said it was
• 33:34a relatively neutral proposition.
• 33:35Whereas if you look at the
• 33:37flexible dose studies in orange,
• 33:39there is
• 33:40a fairly linear relationship between the dose
• 33:42and the efficacy of the medication.
• 33:44That is even going up to the
• 33:47higher doses were better.
• 33:48Uh, when you were able to adjust
• 33:50the dose down due to tolerability?
• 33:56In terms of side effect,
• 33:58dropouts, not surprisingly.
• 34:01There you are.
• 34:02Higher rates of side effects,
• 34:04dropouts with psychostimulant medications.
• 34:06As you got to a higher dose,
• 34:09the effects were great greater,
• 34:10so the dropouts due to side effects were
• 34:14hiring the fix those studies is compared
• 34:16to the flexibel those studies and.
• 34:20And the and the risk of side effects
• 34:23and the relationship between dose
• 34:25and dropouts to the side effects was
• 34:28fairly similar between methylphenidate
• 34:31and amphetamine derivatives.
• 34:33And if you looked at acceptability
• 34:35across all the studies,
• 34:37the the likelihood of all cause
• 34:40dropouts of people leaving the
• 34:42study was actually lower the higher
• 34:44you got on stimulant medication.
• 34:46So subjects were less likely
• 34:48to drop out of these studies.
• 34:51The higher dose
• 34:52of stimulant medications
• 34:53you put them on, and.
• 34:56And not surprisingly,
• 34:58this was a greater effect, inflexible.
• 35:00Those studies where you could
• 35:03decrease the dose of the
• 35:05medication due to side effects.
• 35:07And again, there was not much
• 35:10difference between methylphenidate
• 35:11and amphetamine derivatives
• 35:12in terms of these outcomes.
• 35:17So the bottom line is, well, when
• 35:20you can pause or just a dose of
• 35:23stimulants to the side effects
• 35:25similar to flexible dosing trials,
• 35:28and almost always makes sense to
• 35:30try at least try titrating up to
• 35:33higher doses of stimulants that it's
• 35:36associated with the greater treatment
• 35:38efficacy and its associated with the.
• 35:41Actually, greater,
• 35:42better acceptability among patients
• 35:43and medications work better,
• 35:45and this outweighs any side effects.
• 35:47They have an when you have
• 35:50side effects in these trials,
• 35:52either clinically or in
• 35:53actual clinical trials,
• 35:55you can quickly adjust the
• 35:57dose down so it so it leads
• 35:59to less dropouts and and this.
• 36:05Again, really backs up the findings
• 36:07of the original MTA study, and then I
• 36:11think it's really important clinically,
• 36:13so I put a graph up from actually a
• 36:16article that was published in the
• 36:19Orange Journal this past month,
• 36:21and this was a study that looked at treating
• 36:24kids with ADHD and comorbid aggression,
• 36:27and essentially kids were put in this study.
• 36:30If they had both,
• 36:32significant if they had qualified
• 36:34for diagnosis of ADHD. And
• 36:36then had a significant aggressive symptoms,
• 36:38as judged by a threshold an aggression,
• 36:41rating skill and all the kids were.
• 36:44Initially optimized on stimulant
• 36:46medication so they were put on
• 36:49stimulant medication and then if they
• 36:51did not respond to stimulant medication
• 36:54then they were randomized to
• 36:56receive either Depa Co Risperdal
• 36:58and placebo and they had about.
• 37:02150 kids that started
• 37:04this study and 63% of them when the
• 37:08dose of the stimulant was optimized
• 37:11for ADHD no longer met the aggression
• 37:14criteria of being in the trial.
• 37:17So essentially it seems like
• 37:19Risperdal and Deppe coat.
• 37:23Seem like they were a
• 37:24little better than placebo,
• 37:25though not statistically significant
• 37:27'cause they lost most of their
• 37:28sample in the open phase.
• 37:32But most of the kids who were really
• 37:35being enrolled in this trial for
• 37:38aggression, who had comorbid ADHD
• 37:40symptoms actually optimizing
• 37:41the stimulant led to substantial
• 37:44improvement in these patients.
• 37:45An really, at least as a clinician,
• 37:49makes me wonder how
• 37:50many kids are created with
• 37:53this load open the stimulant
• 37:55plus Risperdal or Deppe code
• 37:57and and whether we should.
• 37:59We should really be optimizing
• 38:01the dose of stimulants first.
• 38:06So Rachel's story continued. So Rachel's roll
• 38:10call her was. Was increased
• 38:14to a dose of Concerta. 54
• 38:16milligrams in the clinic.
• 38:19We switched her from Adderall to
• 38:21Concerta, just 'cause the
• 38:23pharmacokinetics made more sense.
• 38:25Is now advancing school.
• 38:28She's on grade levels.
• 38:30She's excelling in school made honor,
• 38:33roll, receiving excellent behavioral
• 38:35out valuations from school or ADHD.
• 38:38Symptoms are now minimum minimal. The mom
• 38:43came in to see me last
• 38:46week. It wasn't last week was a
• 38:48couple weeks ago in the clinic and
• 38:51and I see her every month just
• 38:53to kind of manage the medications
• 38:56and the real Rachel in the clinic.
• 38:59Mom said since rate rachels
• 39:01ADHD is improved in school,
• 39:03no one's pushing her like they should.
• 39:06She's not being challenged and they're
• 39:08letting her off easy on his assignments,
• 39:11keeping in place educational.
• 39:12Supports if they probably shouldn't.
• 39:15I hate to bring up race,
• 39:17but is she being treated
• 39:19differently because she's black?
• 39:21So Rachel in real clinic life is
• 39:24a black patient with ADHD and.
• 39:27This question really kind
• 39:29of stopped me in my tracks,
• 39:32'cause I think the answer is clearly yes.
• 39:36It's quite possible she's being
• 39:39treated differently with her
• 39:41ADHD in school and both in the
• 39:45clinic because of her her race.
• 39:48And that's the basic clinical question,
• 39:50and if you look at the literature on 80
• 39:53E, this was a study published in Pediatrics
• 39:56that involved in nationally represented
• 39:58sample of over 17,000 kids with 88.
• 40:00The fall to 8th grade an looked at
• 40:04outcomes were essentially diagnosis
• 40:06or assessment for ADHD and whether
• 40:09they were taking medications or not.
• 40:11And if you were black or Hispanic,
• 40:15you are much less likely
• 40:17to be diagnosed with ADHD.
• 40:19And if you looked among.
• 40:23Black and Hispanic children in school.
• 40:26The kids who did have ADHD at 5th grade
• 40:29were much less likely to be receiving
• 40:32pharmacological treatment
• 40:34for ADHD. So again, this
• 40:37the pharmacological treatment is is
• 40:39again the most effective treatment
• 40:40we know about for ADHD symptoms,
• 40:42and it's clear it's quite a bit less.
• 40:45I have also done some work in
• 40:48the past, I guess looking at
• 40:50the MTA cohort. So again, this
• 40:52these were the, you know,
• 40:54the kids with ADHD that were in the
• 40:57big NIH DOT study comparing behavioral
• 40:59treatments to stimulants over 14 months,
• 41:01and we looked at they actually filed
• 41:03these kids up to adulthood now.
• 41:06But we looked at the eight year follow
• 41:09up data and looked at really did a
• 41:12bunch of analysis looking at data
• 41:14driven predictors of the likelihood
• 41:16of receiving school discipline.
• 41:18So being suspended or expelled
• 41:20from school in the Co work and what
• 41:23in kids with ADHD predicts who's
• 41:25going to get suspended
• 41:26or expelled from school.
• 41:28And if you look at this cohort and
• 41:31essentially our main philosophies
• 41:33in these data driven approaches is
• 41:35throw everything at the kitchens.
• 41:38Except the kitchen sink at them
• 41:40and then see what comes out
• 41:43as being important and the best
• 41:46predictor of in this cohort.
• 41:48So kids who actually receive the
• 41:51evidence base the similar pharmacological
• 41:54treatments and behavioral treatments
• 41:56for ADHD. If you identified his black,
• 41:59you were 62% more likely to have been
• 42:03received school discipline. So over
• 42:05the eight year follow up, period.
• 42:09And and this is an Ann, I
• 42:11think at the time when I did this,
• 42:14when we publish this about five years ago,
• 42:17this was astonishing to me.
• 42:18I will say it's not astonishing to
• 42:21me anymore, but it was amazing to me.
• 42:24That raised was a better predictor
• 42:26of receiving significant different
• 42:27discipline in school than your
• 42:29initial response to medications.
• 42:30How bad your ADHD symptoms were,
• 42:33what your gender was, when you had,
• 42:36whether you had any comorbid diagnosis.
• 42:39At initial baseline.
• 42:40So basically everything.
• 42:41I felt like I was trained to
• 42:43look at as a psychiatrist.
• 42:46With less important than race and
• 42:50looking at really school disciplines
• 42:52and outcomes and and and then
• 42:55the other issue is our racial. The.
• 43:02You are racial implicit associations are
• 43:04are are how we treat patients of different
• 43:08races important in the in the diagnosis
• 43:11and treatment of different conditions.
• 43:14And although this is not
• 43:16directly related to ADHD,
• 43:18this was something that came out of.
• 43:21This study came out of a discussion
• 43:24with Malia, who I think from
• 43:26the audience today, and Jerome,
• 43:29who's now an assistant professor at Penn.
• 43:32Some also recently got his K award,
• 43:35and it's doing really well and it
• 43:38was just really came out of the
• 43:41observation of when we're talking
• 43:43that mostly the adult clinics,
• 43:45but also the child clinics.
• 43:47If you looked at the patients
• 43:50we treated in the OCD clinic,
• 43:52we rarely ever treated a black
• 43:55patient in that clinic,
• 43:56and if you looked at the patients
• 43:59we were treating for schizophrenia,
• 44:01they were primarily by PAC individuals.
• 44:04That was just something that's
• 44:06been striking in my training
• 44:07and my observation that yell,
• 44:09and I think it's true to some
• 44:11extent in the in the general clinics
• 44:13and the specialty clinics too.
• 44:15But I would say little less so in children.
• 44:20So we wanted to know like what's
• 44:23what's driving this effect?
• 44:25What's causing this?
• 44:26And the first important thing to note
• 44:29is that there are definitely racial
• 44:32diagnostic treatment disparities in track in
• 44:34psychiatry. So prior studies have
• 44:37suggested that individuals black
• 44:39individuals are three to five times
• 44:41more likely to be diagnosed with
• 44:43schizophrenia compared to white patients,
• 44:45despite evidence suggesting a
• 44:47similar prevalence across racial
• 44:49groups. So we wanted to examine
• 44:51implicit associations or attitudes.
• 44:53Uh, basically appraisals that are made
• 44:56automatically and unconsciously and may
• 44:59contribute to health care disparity and
• 45:02prior research is really conceptualized.
• 45:05Implicit bias ease as a
• 45:07form of indirect racism,
• 45:09and really we had two study
• 45:13questions and this trial do
• 45:15psychiatrist and trainees have
• 45:17racial implicit associations were
• 45:19related to psychiatric diagnosis,
• 45:21treatment and compliance an.
• 45:24And what Democrats demographic factors
• 45:26predict racial implicit associations of any.
• 45:28And so I don't know how many
• 45:31of you have taken the.
• 45:35You can look on Project
• 45:37Implicit's website and
• 45:38take any one of a number of them. There
• 45:41will also and show you another
• 45:43study you can do at the end
• 45:45looking at child mental health,
• 45:47but essentially these tasks. You care.
• 45:52Black and white faces with different words.
• 45:55So in the first Test you were pairing
• 45:58them with mood disorders and psychosis.
• 46:02The second task, compliance versus
• 46:04noncompliance, and the third test.
• 46:06We look at pharmacological outcomes,
• 46:08antidepressants and
• 46:09anti said antipsychotic medications.
• 46:11This involved around 300
• 46:13psychiatrists and medical
• 46:14students. Quite diverse,
• 46:16sample only a little.
• 46:18Over half of them were
• 46:21identified as white.
• 46:22Very good stratification of
• 46:24different training levels.
• 46:25Lots of medical students and roses.
• 46:27In the mean outcome was D scores,
• 46:31so the strength
• 46:32of Association between how fast
• 46:34and how many errors you made when
• 46:37comparing black versus white faces
• 46:39and the categories of words in this
• 46:43case can find versus non compliant
• 46:45psychotic versus mood disorder and
• 46:48antipsychotics versus antidepressants.
• 46:50And basically, participants who
• 46:53categorised white faces more
• 46:55quickly and with fewer errors
• 46:58when their parents have.
• 47:02Greater implicit pro
• 47:04white anti black bias so.
• 47:09Associating whitefaces with compliance.
• 47:12Or the other outcomes and this is
• 47:16just a way of looking at the histogram
• 47:19of the outcome and so we went when
• 47:23we looked at this in the sample,
• 47:25I think the first thing was it was striking,
• 47:29but not particularly surprising was
• 47:31that most psychiatric providers
• 47:33associated faces of black
• 47:35individuals with psychosis
• 47:36noncompliance an antipsychotic words.
• 47:38And for any of these three outcomes, about
• 47:4140% of the sample had.
• 47:43Moderate are greater.
• 47:46Association of Black faces with.
• 47:51With psychosis or the OR the other outcomes,
• 47:53and if you looked in the other direction,
• 47:56so the. It was about 5%, so they
• 47:59were, so they are eight
• 48:01times more likely to have.
• 48:04Associations of these providers of
• 48:06black individuals with psychosis
• 48:08noncompliance and antipsychotics.
• 48:09Then we looked at the
• 48:11characteristics of our sample,
• 48:13and we looked at two things.
• 48:16Provider race and the Big Thing was that.
• 48:21Black providers did not show this same
• 48:25implicit bias as other populations,
• 48:27and then the other big thing was it seemed
• 48:31like your amount of implicit bias got
• 48:34worse as you increased level of training,
• 48:38and this was true for psychosis
• 48:40and antipsychotic medication words,
• 48:42but not necessarily,
• 48:44but was not true of compliance,
• 48:47so it seems almost like it's possible that
• 48:50these implicit biases get trained into.
• 48:53Your potential medical
• 48:55education was really striking, so the
• 48:58conclusions that psychiatrist and
• 49:00trainees have racial implicit biases
• 49:02related to psychiatric diagnosis,
• 49:04treatment, and compliance.
• 49:06Clinician race and training seem
• 49:08like they're predictive of these
• 49:11racial implicit bias ease.
• 49:13We have additional data
• 49:14that Victor is writing up at
• 49:17the moment, suggesting that
• 49:19greater Self reported childhood
• 49:21exposure to black intervention.
• 49:23Individuals is actually associated
• 49:25with decreasing racial implicit bias
• 49:28even after controlling for race.
• 49:31And then I think it's important.
• 49:34I'm also emphasized that although
• 49:36we just looked it implicit,
• 49:38bias in these studies that there are
• 49:41additional factors that I wish we
• 49:44looked at more in this study that
• 49:46are really important than that we're
• 49:49including in future studies that
• 49:51explicit racism import is important.
• 49:53Also, structural, systemic, race,
• 49:55racism are also really important factors.
• 49:58And then negative mental health care
• 50:01outcomes experienced by many black patients.
• 50:04If you're looking at what the
• 50:07application is, I think the first thing
• 50:10is just education education about racism and
• 50:13racial implicit bias is imperative to
• 50:16reducing racism and psychiatric care
• 50:18that it seems like racial diversity
• 50:21and psychiatric providers may mitigate
• 50:23some of these effects of implicit bias.
• 50:26And then I think the thing we're working
• 50:29on now is, are there similar racial,
• 50:32implicit, and explicit biases
• 50:34among. Child, mental health
• 50:36providers and then hopefully doing
• 50:38teachers and school workers.
• 50:42And then the next step for
• 50:45research is just really developing
• 50:47interventions and curriculums that
• 50:48reduce racism and implicit bias.
• 50:50Then I think another important
• 50:52thing is just measuring the
• 50:54efficacy of these interventions.
• 50:56So I think there going to be a lot of
• 50:59interventions that are coming along,
• 51:02but it would be really great to
• 51:05have better measures of racism,
• 51:07explicit racism and implicit racism.
• 51:09Look at how well this actually
• 51:11improved outcomes within provided.
• 51:13Within systems and then the
• 51:15last thing is to look at kids.
• 51:19And so here is the.
• 51:22Applied for the current study we're doing.
• 51:25Looking at external Ising behaviors
• 51:27and and racing kids and just trying
• 51:30to get a similar sample in child
• 51:32psychiatric providers and other mental
• 51:35health professionals to look at whether
• 51:37they're similar biases in that population.
• 51:42Alright,
• 51:42take home points 80.
• 51:44HD causes significant impairments for
• 51:46kids and adults pharmacotherapies
• 51:48most effective treatment for core
• 51:51ADHD symptoms across the lifespan.
• 51:53Higher doses of stimulant medications
• 51:56have greater efficacy and there actually
• 51:59associated with improved acceptability.
• 52:02They mitigate about against
• 52:04many poor outcomes in children,
• 52:06and then I think it's important
• 52:09in any evidence based presentation
• 52:11about treatment of ADHD in kids.
• 52:14Just to mention that there is racial
• 52:17in equities are really profound factor
• 52:20and in the current care and outcome
• 52:23over Dalton with ADHD and then this
• 52:26goes along side of any research.
• 52:29Optimizing stimulant medications
• 52:30is also to improve the outcomes.
• 52:33Of all of our patients with ADHD.
• 52:36Spectar, particularly the black ones,
• 52:38and so thank you,
• 52:40I will leave it open for questions.
• 52:55There were two questions in the chat.
• 53:01Any of the chatters want to?
• 53:06Ask your question, I think. Justin.
• 53:11Jose, did you raise your hand? Go for it.
• 53:15Thank you doctor black.
• 53:17Great talk. I had a question
• 53:19specifically about the testing for ADHD.
• 53:21I do know that I don't know
• 53:24if you're familiar with Robert
• 53:26Williams and how he showed that
• 53:28some of the IQ tests were also,
• 53:31you know, they scored differently
• 53:32for Caucasian or white patients
• 53:34versus black children in particular.
• 53:37Have you seen anything like
• 53:39that with the ADHD testing like
• 53:41the Vanderbilt or. They the the
• 53:44ADHD four that you know that it
• 53:46also shows any racial bias. So
• 53:49I'm I'm by no means an expert in this.
• 53:52I sort of came about it in a data
• 53:56driven way after blocker muted.
• 53:59You did know you're good, you're good, OK?
• 54:05I think there's a lot of complexities too.
• 54:11The diagnosis and treatment of
• 54:13ADHD by race and ethnicity,
• 54:15and I don't think it's a simple story.
• 54:17I think they're probably different cut
• 54:19points on assessments and informants.
• 54:21It affects the outcome.
• 54:23I don't know the literature that well.
• 54:25I would also say it's I think I've
• 54:28it's a great under simplification
• 54:31of what I've said regarding.
• 54:33I think it would be too much of
• 54:36a take home message just to say.
• 54:39You know Bipac children or underdiagnosed
• 54:41or treated for ADHD that clearly the
• 54:44assessment and treatment of in all this
• 54:47is going to be much more complex than that.
• 54:50I also really worried about the proper
• 54:54assessment of comorbid disorders.
• 54:57You know I,
• 54:58I just worry that this is more of a
• 55:00circle surrogate for less mental health care,
• 55:03psychiatric care in general,
• 55:04and that it's not only that the kids
• 55:06are being left diagnosed with ADHD,
• 55:08but that we're also missing
• 55:10other other factors.
• 55:11And and I think that was one
• 55:13thing that was really hard.
• 55:14And, you know,
• 55:16I completely ducked the question
• 55:18of how I'm going to deal with
• 55:20this in the family other than.
• 55:22Affirming that the Moms concern
• 55:24is probably well validated.
• 55:28But I don't know. I think there's a lot
• 55:33of research to be done in the area,
• 55:35and what I can say is it's probably
• 55:37a fairly large effect and I I don't.
• 55:40I don't pretend to understand how it all
• 55:42works and how it should be measured,
• 55:44but I think that's something that our our
• 55:46field and really needs to start focusing on,
• 55:49'cause at least in the data driven
• 55:51approaches, it's as important is how well
• 55:53you respond to stimulants, which, again,
• 55:55stimulants work better than any other
• 55:57medication I know of for any condition.