Childhood ADHD in general practice: lookalikes, two settings, and when not to start a stimulant

Paediatrician (name not stated)

Otter Speaker 2. Teaching table for BMOs / GPs. He said New South Wales changes had thrown the room “in the deep ocean,” and that they would have to learn fast. He mentioned running a clinic in Emerald because there is no paediatrician there. The Otter file does not name him.

Room

Rotating 20-minute stations. Host (Speaker 1) rang a bell between tables. Real cases from the previous two weeks — “nothing fabricated.”

Why this table, and the seven-year-old

He chose ADHD because of the New South Wales changes, and because “now you guys have been thrown in.” Learn fast. Questions welcome. Cases from the last two weeks — not constructed teaching slides.

Seven-year-old boy, referred for possible inattentive ADHD. That was the parents’ concern. Mum has ADHD. The child “is not focusing, very, very poor, cannot receive any information.”

Then the rest of the history, which is the point of the table: anxiety from an early age. Co-sleeps with Mum. Separation tantrums that were “completely out of ordinary.” Screens four to five hours. Sleep problems as well.

ADHD, autism, anxiety, sleep — pick the problem

The room said autism first. He agreed you should always ask, even when it is not the presenting complaint.

“Every person attending your clinic [with] behaviour issues, trust me, they all want ASD as a diagnosis.” If they have severe ADHD and need a lot of help, the label can unlock access. “Nothing wrong with that. This is how the political system works.” Still: in this boy, you have inattentive symptoms and anxiety. What questions actually separate ASD?

Sleep came next. Someone noted that ADHD treatment is the same class of medicine as narcolepsy treatment — so sometimes the child is just not sleeping. Lack of sleep also feeds anxiety. One behavioural difficulty is “a cascade.” Food, social, sleep, school: you are mapping a pattern, not ticking a box.

“Mum says he really struggles socially” does not immediately mean autism. You have to dig.

The park question

DSM-5 autism, as he used it at the table: social-communication difficulties and repetitive / obsessive behaviour are the two essential criteria (sensory on top). Mum has already said social struggle. His favourite question:

Does he make friends easily, and then the friends walk away — or, if you take him to a park where ten children are playing, does he go in, or stay aloof in the corner?

• Always shy, never indicated, goes further into the corner when he sees the group → look harder at ASD.
• Easy to go there, but friendships do not stick → more the ADHD pattern.

A colleague added an ASD landmark: socially awkward, no sense of other people’s space, can approach a stranger, treats people as objects that serve a purpose. “I can’t read your feelings… if I’m not interested in that topic, I don’t care about you.”

Two settings, before school, and impairment

He loves this case because one child has walked you through ADHD symptoms, autism symptoms, and anxiety. That is what ADHD is in clinic — not “learning difficulties, inattention, can I have medication, Conners high, Vanderbilt high.”

GPs are the first point of contact. You may do a Vanderbilt, take a history, and in some pathways start medication. His order:

1. Do we have enough symptoms?
2. Did this start before school? DSM-5 says by age 12. He always looks for something evident in daycare or preschool. “He was absolutely fine till grade three, and then suddenly” is a red flag, not a typical ADHD story.
3. Two settings. If it is only home, worry about home. If it is only school — is the school after funding, can the school cope, is the teacher inexperienced?
4. Impairment. That is the gate that matters most.

Thought experiment he ran: school confirming, parents confirming, As and Bs, no phone calls from school, “he’s an angel,” no social difficulty, just “very hyperactive” at home. The room: it does not meet the last DSM criterion — significant functional impairment.

“Masking,” home dynamics, and the Emerald nurse

Someone asked about the angel-at-school, unravels-at-home child — “they need to release.” The allied-health language for that, he said, is masking. Girls more than boys; trying to fit in.

He is a scientist about it. Has anyone looked at the evidence for the mechanism? He could not find it. Lots of hypothesising. His take, which he labelled not evidence-based and controversial: if you can do well at school, there is no reason you cannot do well at home. That takes him into home dynamics. Has the dog died? Grandparents? Relationship? Who is heavy-handed? What are the strategies when it happens? Work hours, how many days Dad is away? “99% of the time it will be hidden there. 1% of the time it’s a true problem.”

Last week: ten-year-old. Mum is a nurse. He runs a clinic in Emerald because there is no paediatrician. She has recently been diagnosed with ADHD herself and is strongly convinced the child has it. Long-standing trauma and anxiety. He told her, as a clinician to a clinician: I do not see ADHD in what you have told me. Treat anxiety first, then come back. She agreed. Fluoxetine (Otter: “sudden fluxity”) — behaviour improved at school. Still a struggle at home to do work. Academically great, good social circle. Third appointment: she still feels he has ADHD. Conners: school, no ADHD concerns; very high anxiety. He is not convinced. She made a complaint. A colleague: she is anchored; she is not listening. He suggested a psychologist. Her response: “I don’t believe in them.”

Psychologists, Vanderbilt, Conners

Seven-year-old boy, psychologist weekly for six months, no difference. The psychologist even goes to school. The boy likes her, plays with her, is appropriate with her — so rapport is not the missing piece.

His question to parents: how much time has the psychologist actually spent with you? He only counts someone as a paediatric psychologist if they spend at least half, preferably more, of the time with the parents and less with the child. You cannot change a seven-year-old by telling him he is doing it wrong. You can change an adult’s approach. A colleague: the child spends one hour with psychology and the whole day with Mum — better to get Mum.

Are GPs expected to sit through 50-page psychologist reports? Someone joked: upload it to AI and summarise. His practical answer now that they have been “thrown in”:

Autism levels as politics

Does the questionnaire assign level 1, 2, or 3? He thinks levels are “more political than anything else.” Level 3, for him: non-verbal, stimming, cannot do anything. Between level 1 and 2 he treats them as level 2, because if you do the hard work of diagnosing autism and then cannot get them help, what was the point?

Which level-1 autistic child, in his view, does not need a psychologist, an OT, or extra school support? If they need none of those, why attach a lifelong label? NDIS (Otter: “India”) does not support level 1.

Stimulants: echo, juice, dose, Intuniv, melatonin

Adult psychiatrists asking for echo: he will not put a finger into adulthood. In children, that used to be practice 20 years ago. Now, even a child with stable congenital heart disease — they do not bother cardiology, because they know the medicines are safe, unless something makes him worry a lesion was missed.

Dexamphetamine (Otter: “duramide”): a GP still using it, never saw problems. Evolving medicine; experience and judgement sit beside the textbook.

The capsule that stopped working

Seven-year-old, ADHD, 20 milligrams, long-acting capsules, good response, everyone happy — then the medicine became completely ineffective. He was taking it. Used to take it in water. Recently they started mixing it. Acidic medium can make it ineffective. “90% of my patients do that” without a problem; in this case, back to water and it worked. Keep it in mind.

Priapism after a year

Both parents doctors. ADHD, anti-anxiety, sleep medicine, everything working — then three absences from school and an erection “24/7.” Change it. He had been on the medicine a year; then the school letter. Sudden side-effects after a long stretch still count.

Sleep, dose, Intuniv

Stimulant in the morning, cannot sleep at night, so a second medicine is added — “instead of starting one child, they end up with another child.” His read: most of the time the child is on a higher dose than required. Pull it back. Genuine non-sleepers exist; he put that at about 10%.

A 20-kilogram child: textbooks one milligram per kilogram, so 20 milligrams. He starts at five milligrams, up by five each week, with a clear instruction: if ten works, do not go to 15.

Intuniv (guanfacine) on its own, for pure ADHD: “useless.” Two add-on jobs:

• Fifteen milligrams of stimulant working but not enough; twenty causes massive side-effects — stay on 15 and add Intuniv to piggyback the stimulant.
• Academics and work finished, everyone happy, but emotional regulation still not there.

A parent in the room: Intuniv 1 milligram has worked for her daughter for a year — he said that is a different situation, other benefits. Clonidine: he has not used it in five years, maybe one in a thousand. Melatonin: if he is in sleep trouble, “99% melatonin has taken me out of trouble.” Safe at six months to a year in his use; jury not out for years and years. Someone muttered they will find out in a few years. He still worries about taking it “for pennies” (long-term).

Has the proportion of ADHD and ASD gone up? Any general paediatrician, he said: 60 to 70% of the load is related. He has one filter that changed the scenario for him: anyone who needs to be seen yesterday comes through — and the recording ends as the bell goes.

Take-home messages for clinic

1. Lookalikes first. Anxiety, sleep, screens, co-sleeping, autism. The seven-year-old referred for inattentive ADHD had all of them.
2. The park question splits “struggles socially.” Corner = look at ASD. Joins then loses friends = more ADHD.
3. Onset before school (he looks in daycare/preschool). Sudden from grade three is not his ADHD story.
4. Two settings. Parent-only Conners is not collateral. Only-home or only-school each has a different worry.
5. Impairment is the medication gate. High scores, As and Bs, angel at school: diagnosis maybe, stimulant no. About 60% in his clinic do not need medicine after a proper history.
6. Do not outsource “masking.” He could not find mechanistic evidence. Ask about home before you medicate the after-school explosion.
7. Paediatric psychology means the parents. More than half the time with Mum and Dad. A seven-year-old does not change because you told him he is wrong.
8. Vanderbilt: six of nine inattention, six of nine hyperactivity, scored 2–3. Still only a screen.
9. Children and echo: he no longer routinely involves cardiology, even with stable congenital heart disease, unless something was missed. He would not comment on adults.
10. Capsule in juice can blank a long-acting stimulant. Try water.
11. Start low. Five milligrams weekly in his 20 kg example. If ten works, stop. Sleep problems: drop the dose before you add a night drug. Intuniv to piggyback a ceiling dose, or for leftover emotional dysregulation — not as solo ADHD treatment. Melatonin for sleep, in his hands, almost always; he is not casual about years of it.

Dr Kotha · Gold Coast · paediatric-adhd.drkotha.com