Post on 07-May-2015
description
Fiona McNicholasFiona McNicholas
Professor Child & Adolescent Psychiatry, UCDProfessor Child & Adolescent Psychiatry, UCDConsultant Lucena Clinic, Rathgar & Our Lady’s Consultant Lucena Clinic, Rathgar & Our Lady’s
Children’s Hospital, CrumlinChildren’s Hospital, Crumlin
Understanding and managing ADHD in Understanding and managing ADHD in children and adolescentschildren and adolescents
Parent Talk HADD in association with Lucena Foundation
20th September 2011
A Blitz…A Blitz…
HistoryHistory Diagnostic CriteriaDiagnostic Criteria AssessmentAssessment Treatment Treatment
Heinrich Hoffmann
German psychiatrist’s children’s book (1846)
First translated into English by Mark Twain
19501950 19801980 1968 19701968 1970 19871987 1994199419371937
Minimal Minimal Brain Brain
Damage/ Damage/ dysfunctiondysfunction Attention Attention
Deficit/Hyperactivity Deficit/Hyperactivity Disorder (Disorder (DSM-III-RDSM-III-R))
ADHD (ADHD (DSM-IVDSM-IV))
Hyperactive Hyperactive Child SyndromeChild Syndrome
Development of ADHD as a clinical entityDevelopment of ADHD as a clinical entity
1930193019021902
11stst Clinical Clinical Description Description
by Stillby Still
2010
DSM V?GenderAge/ onset
STROOP TEST
Hyperkinetic ReactionHyperkinetic Reactionof Childhood (of Childhood (DSM-IIDSM-II))
ADD ± HA (ADD ± HA (DSM-IIIDSM-III))
Adult ADHD StudiedAdult ADHD Studied
V. Douglas
19501950 198019801968 19701968 1970 1994199419371937
Efficacy of Efficacy of Amphetamine Amphetamine
(Bradley)(Bradley)
Development of treatments in ADHDDevelopment of treatments in ADHD
1930193019021902
Antipsychotics
1954 1st published study on MPH
1962-1993250 reviews3000 articles on stimulant effects
1966 161 RCT
Long acting medsRitalin LAConcertaAtomoxetineEquasym
2011
Newer DrugsGuanfacine
InattentionInattention HyperactivityHyperactivity
ImpulsivityImpulsivity
ADHDADHD
Diagnostic criteriaDiagnostic criteria(ICD/DSM)(ICD/DSM)
Over activity Over activity InattentionInattention Impulsivity Impulsivity Symptoms before age Symptoms before age
7 (6 ICD) 7 (6 ICD) Pervasive across Pervasive across
situation situation Cause impairment of Cause impairment of
social or educational social or educational functioning.functioning.
Not due to Autistic Not due to Autistic spectrum disorders, spectrum disorders, Psychotic or other Psychotic or other mental disorder mental disorder (anxiety, depression)(anxiety, depression)
Symptoms suggestive of Symptoms suggestive of InattentionInattention
• Forgetful in daily activitiesForgetful in daily activities• Loses things necessary for tasksLoses things necessary for tasks• Difficulty organising tasks/activitiesDifficulty organising tasks/activities• Does not seem to listen when spoken to directlyDoes not seem to listen when spoken to directly• Does not follow through on instructions and fails to finish Does not follow through on instructions and fails to finish
school work, chores or duties (not due to oppositional school work, chores or duties (not due to oppositional behaviour or failure to understand)behaviour or failure to understand)
• Fails to give close attention to details or makes careless Fails to give close attention to details or makes careless errors in schoolwork, or other activitieserrors in schoolwork, or other activities
• Difficulty sustaining attention in tasks or play activitiesDifficulty sustaining attention in tasks or play activities• Avoids, dislikes or reluctant to engage in tasks that Avoids, dislikes or reluctant to engage in tasks that
require sustained mental effortrequire sustained mental effort• Easily distracted by extraneous stimuliEasily distracted by extraneous stimuli
Symptoms suggestive of Symptoms suggestive of Hyperactivity/ImpulsivityHyperactivity/Impulsivity
Fidgets with hands or feet or Fidgets with hands or feet or squirms in chairsquirms in chair
Leaves seat in classroom or Leaves seat in classroom or other in which sitting is other in which sitting is expectedexpected
Runs about, climbs Runs about, climbs excessively in situations in excessively in situations in which it is inappropriate which it is inappropriate (restless)(restless)
Difficulty playing in activities Difficulty playing in activities quietlyquietly
‘‘On the go’ or ‘driven by a On the go’ or ‘driven by a motor’motor’
Talks excessivelyTalks excessively Blurts out answersBlurts out answers Difficulty awaiting turnDifficulty awaiting turn Interrupts or intrudes on Interrupts or intrudes on
othersothersA continuum-
STROOPSTROOP-read the words-read the words
(Skill)(Skill)
RED YELLOW GREEN BLUEGREEN RED BLUE YELLOWBLUE GREEN YELLOW REDYELLOW RED GREEN BLUERED YELLOW GREEN BLUEGREEN RED BLUE YELLOW
STROOPSTROOP-name the colour of the -name the colour of the
wordswords(Attention)(Attention)
RED YELLOW GREEN BLUE
GREEN RED BLUE YELLOW
BLUE GREEN YELLOW RED
YELLOW RED GREEN BLUE
RED YELLOW GREEN BLUE
GREEN RED BLUE YELLOW
RED YELLOW GREE BLUERED YELLOW GREE BLUE
GREEN RED BLUE YELLOWGREEN RED BLUE YELLOW
BLUE GREEN YELLOW REDBLUE GREEN YELLOW RED
YELLOW RED GREEN BLUEYELLOW RED GREEN BLUE
RED YELLOW GREEN BLUERED YELLOW GREEN BLUE
GREEN RED BLUE YELLOWGREEN RED BLUE YELLOW
RED YELLOW GREEN BLUE
GREEN RED BLUE YELLOW
BLUE GREEN YELLOW RED
YELLOW RED GREEN BLUE
RED YELLOW GREEN BLUE
GREEN RED BLUE YELLOW
Videos, television, computers, playing.
Skill but very little concentration required
Homework, math, schoolwork. Sustained attention requiredNeed to inhibit pre-potent response to label colours
Skill versus Attention and InhibitionSkill versus Attention and Inhibition
Skill RequiredSkill Required Sustained Attention RequiredSustained Attention Required
How common is ADHD?How common is ADHD? 3-5% children, 2% adults3-5% children, 2% adults
30-50% of children referred to child psychiatry clinics have 30-50% of children referred to child psychiatry clinics have ADHDADHD
More common in boys than girls 4:1- clinical referralsMore common in boys than girls 4:1- clinical referrals• 2.5:1 community2.5:1 community
Persists in 30-50% of patients into adolescence and Persists in 30-50% of patients into adolescence and adulthood (symptom profile may change)adulthood (symptom profile may change)
Ireland: Using 1-5% prevalence ratesIreland: Using 1-5% prevalence rates 0-14yrs 864,449 0-14yrs 864,449 (2006 Census)(2006 Census) 8,6448,644 – 43,000 <15yrs with ADHD – 43,000 <15yrs with ADHD
Associated school problemsAssociated school problems
Language impairment 15-75%Language impairment 15-75%
Learning Disability 15-40%Learning Disability 15-40%
Low Self esteemLow Self esteem
Poor social skillsPoor social skills
Labeled ‘trouble maker’Labeled ‘trouble maker’
Associated Family problemsAssociated Family problems
Poor relationship Poor relationship with parents with parents • often secondary often secondary
and improves with and improves with appropriate appropriate interventionintervention
Family History Family History ADHDADHD
Co-morbid Disorders Co-morbid Disorders
Oppositional Defiant
Disorder40%
Tics11%
Conduct Disorder14%
ADHD alone31%
Anxiety Disorder
34%
Mood Disorders 4% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096
Cause -hypothesisCause -hypothesis
Abnormal Dopamine signalling in Abnormal Dopamine signalling in the frontal cortex (executive the frontal cortex (executive functioning)functioning)
Deficiency of Noradrenaline in Deficiency of Noradrenaline in the reticular activating system the reticular activating system (RAS)(RAS)
the area of the brain the area of the brain responsible for balancing responsible for balancing other systems involved in other systems involved in learning, self-control, learning, self-control, inhibition and motivationinhibition and motivation
MGH-NMR Center & Harvard-MIT CITP. Bush, et al. Biol Psychiatry 1999;45:1542.
1 x 10-3
1 x 10-2
1 x 10-3
y = +21 mm y = +21 mm
Normal control ADHD
Anterior Cingulate Cortex
Frontal StriatalInsular network
• fMRI : Adult ADHD show decreased blood flow to the anterior cingulate and increased flow in the frontal striatum
• PET: Adults with ADHD show decreased cerebral metabolism compared with controls
Neuroimaging and ADHDNeuroimaging and ADHDStroop testStroop test
1 x 10-2
Assessment: History & ObservationsAssessment: History & Observations
Symptoms of ADHDSymptoms of ADHD• HomeHome• SchoolSchool• After school activitiesAfter school activities
Co-morbidityCo-morbidity• LDLD• MotorMotor• ODD/CDODD/CD• Other child psychiatric Other child psychiatric
disordersdisorders
Perpetuating factorsPerpetuating factors• FamilyFamily• TemperamentTemperament• EnvironmentEnvironment
InformantsInformants• ParentsParents• ChildChild• Teacher, Coach, play Teacher, Coach, play
school, clubs etcschool, clubs etc
TestsTests• Physical examination Physical examination
Rating scalesRating scales• Formal assessments Formal assessments
NEPS, SALT, OT, NEPS, SALT, OT, hearing, visionhearing, vision
04/11/2304/11/23Med Stu Teaching Pack Med Stu Teaching Pack
2020
Adults with A.D.H.D.Adults with A.D.H.D.
Clinical picture includes Clinical picture includes • inattention, impulsivity, disorganisation, inattention, impulsivity, disorganisation,
work/college and social problems, work/college and social problems, interpersonal problems which can lead to interpersonal problems which can lead to isolation, isolation,
Poor self esteem secondary to the Poor self esteem secondary to the experience of previous failureexperience of previous failure
Shifting focus of attention is often Shifting focus of attention is often problematic for patients with ADHDproblematic for patients with ADHD
04/11/2304/11/23Med Stu Teaching Pack Med Stu Teaching Pack
2121
Added items for AdultsAdded items for Adults Executive function Executive function Self regulationSelf regulation Self organisationSelf organisation PrioritisationPrioritisation Awareness of timeAwareness of time PlanningPlanning Memory FunctioningMemory Functioning
Consequences: UntreatedConsequences: Untreated
Features persist into adolescence (80%) & Features persist into adolescence (80%) & adulthood (65%)adulthood (65%)
Cantwell ’85 Cantwell ’85 • Developmental delay 30%Developmental delay 30%• Continual display 40%Continual display 40%• Developmental decay 30%Developmental decay 30%
ADHD is a specific risk factor forADHD is a specific risk factor for Conduct Disorder-overall 58% chance Conduct Disorder-overall 58% chance High rate of High rate of Drug/alcohol misuseDrug/alcohol misuse
0% 10% 20% 30% 40% 50% 60%
Fired from job
Incarcerated
Arrested
Serious car accident
Accident prone
Substance abuse
STD
Teen pregnancy
< high school
Repeat a grade
Subjects (%)
ADHD
Normal
Functional Impairment in Patients with ADHD Functional Impairment in Patients with ADHD Compared to Those WithoutCompared to Those Without
35%
40%16%
50%
30%
53%
52%
Biederman et al. Am J Psych 1995.
Treatment Treatment
Treatment OptionsTreatment Options
EssentialEssential• Diagnostic Report- sharing information with parents, Diagnostic Report- sharing information with parents,
school and GPschool and GP• Psycho-education (Support Groups)Psycho-education (Support Groups)• MedicationMedication• Treat any co-morbid conditionTreat any co-morbid condition• Parent ManagementParent Management
Additional: Additional: • Behavioural TreatmentBehavioural Treatment
Individual Cognitive-behavioural therapyIndividual Cognitive-behavioural therapy• Family TherapyFamily Therapy• Group work- social skillsGroup work- social skills
Medication-what works?Medication-what works?
Stimulants Stimulants • Most researched area in pediatricsMost researched area in pediatrics
>155 RCTs w >5,600 children for stimulants (Spencer et al, 96)>155 RCTs w >5,600 children for stimulants (Spencer et al, 96)
• Response rate:Response rate: 70% will respond to a stimulant70% will respond to a stimulant 85-90% to one of the 3 stimulants85-90% to one of the 3 stimulants Non-Adherence rates 20-65% Non-Adherence rates 20-65%
• Choice:Choice: MethylphenidateMethylphenidate DexamphetamineDexamphetamine Short or longer actingShort or longer acting
• Concerta/Ritalin LA/EquasymConcerta/Ritalin LA/Equasym• AtomoxetineAtomoxetine
Stimulants raise dopamine levelsStimulants raise dopamine levels
Stimulants raise dopamine levelsStimulants raise dopamine levelsMPH/ AmphetaminesMPH/ Amphetamines
Noradrenergic agents Noradrenergic agents can reduce arousalcan reduce arousalClonidine / GuanfacineClonidine / GuanfacineTCAs, venlafaxine, TCAs, venlafaxine, bupropion bupropion Atomoxetine (Raises Atomoxetine (Raises fromtal DOPA also by inh fromtal DOPA also by inh NA transporter)NA transporter)
‘‘Self Medication’Self Medication’ Risk of smoking in ADHDRisk of smoking in ADHD
• Nicotine an indirect DOPA agonistNicotine an indirect DOPA agonist• Nicotine positive effects on Nicotine positive effects on concentration concentration• + Trials of usefulness in ADHD – nicotine patch+ Trials of usefulness in ADHD – nicotine patch
Stimulant AbuseStimulant Abuse risk of misuse (both alcohol and drugs)risk of misuse (both alcohol and drugs)
Rate ADHD treated < controls < ADHD untreatedRate ADHD treated < controls < ADHD untreated Suggestion to be maintained need CBTSuggestion to be maintained need CBT
• Drug users don’t get a high from stimulantsDrug users don’t get a high from stimulants• Diversion may be a riskDiversion may be a risk
• Wilens et al, Pediatrics meta analysis 2003Wilens et al, Pediatrics meta analysis 2003
Possible treatments..Possible treatments..
Omega 3 Fatty acidsOmega 3 Fatty acids• Positive cognitive & Positive cognitive &
behavioural effects behavioural effects after 3months in DCDafter 3months in DCD
• Richardson et alRichardson et al Peds 2005Peds 2005
• Other subsequent Other subsequent studies negativestudies negative
Transcranial stimulationTranscranial stimulation
NeurofeedbackNeurofeedback
General Behaviour ManagementGeneral Behaviour Management
WHAT WORKS IN BEHAVIOURAL WHAT WORKS IN BEHAVIOURAL THERAPY?THERAPY?
Parent training is generally regarded as the most effective Parent training is generally regarded as the most effective behavioural therapybehavioural therapy
Parent training combined with medication management Parent training combined with medication management increases parent acceptability of medicationincreases parent acceptability of medication
School-based treatment is more effective than individual School-based treatment is more effective than individual strategies, however benefits are only seen during strategies, however benefits are only seen during treatment programmes and are not generalisedtreatment programmes and are not generalised
Individual treatment approaches have not been shown to Individual treatment approaches have not been shown to be effective be effective
Behavioural Treatment-for younger childrenBehavioural Treatment-for younger children
Identify problem situations and the precipitating Identify problem situations and the precipitating factorsfactors
Specific strategies Specific strategies – Reward / Cost system – Reward / Cost system
– – Time outTime out – Social reinforcement – Social reinforcement – Behaviour modelling – Behaviour modelling
Parent–child interactionsParent–child interactions• Enhance positive and limit negative interactionsEnhance positive and limit negative interactions
Kendall Therapist Manual 1992Kendall Therapist Manual 1992
Problem solving steps:Problem solving steps:
• Using 5 fingersUsing 5 fingers• Model sequence- Model sequence-
say out loud, then say out loud, then child repeats, then child repeats, then fadingfading
• Positive self Positive self coping statementscoping statements
• Use for homework Use for homework as well as as well as behaviour /social behaviour /social problemsproblems
1.1. What is my problem/task?What is my problem/task?
2.2. Look at all the Look at all the options/possibilitiesoptions/possibilities
3.3. Focus in-concentrate hard Focus in-concentrate hard and select oneand select one
4.4. Review progress or revise Review progress or revise decisiondecision
5.5. Praise yourselfPraise yourself
Consider your own feelings..Consider your own feelings..
Do what you can.. Do what you can.. ‘ACT’‘ACT’
God grant me serenity God grant me serenity • to accept the things that I to accept the things that I
cannot change, cannot change, • courage to change the things courage to change the things
that I can that I can • and wisdom to know the and wisdom to know the
difference. difference.
• Serenity Prayer St. Francis of Serenity Prayer St. Francis of AssisiAssisi
Hurt
Tired
Annoyed
Defeated
Angry
Rejected
Sad
And your perceptions...
It is how you interpret it…It is how you interpret it…
GuidelinesGuidelines
Web sites 1. http://www.chadd.org – Children & Adults with ADHD - Videos of a variety of well-known figures talking about ADHD, as well as
individual cases & families talking about their experiences. Directed towards parents/adults a little more than children. http://www.chadd.org/Content/CHADD/EspeciallyForPress/CHADD_Video.htm
2. http://www.nimh.nih.gov/media/video/adhd.shtml - Educational video by ADHD researchers talking about symptoms & treatment. Aimed at parents. Some audio features as well.
3. http://www.incadds.ie/ - does not have any videos on the site itself. Has links to a lot of useful ADHD sites. Appears to be the main site for info & support on ADHD in Ireland according to ADHD Europe (http://www.adhdeurope.eu/home.html).
4. http://www.hadd.ie/home.htm - the other site listed on the ADHD Europe website. It offers membership to the site & has a range of videos on ADHD to be rented for a small fee. Videos cannot be viewed on the website itself, and cannot be rented by non-members.
HADD
Web ToolkitsSimple road maps to help parents/carers, children and teachers find the right tools at the right timeDiscussion guides to structure discussions at critical points in the child’s schoolingDownloadable tools to help provide a consistent approach to supporting a child, and work in effective partnership.
http://www.adhdandyou.ie
• 5 section headings (green)• Section content shown in blue• Detailed content shown in accompanying Word doc
Resources Resources
DBT TherapyCBT
Collaborative Problem Solving
www.sosprograms.comwww.sosprograms.com
The EndThe End
Medical Costs Are Greater in Children With ADHDMedical Costs Are Greater in Children With ADHD
Leibson CL, et al. JAMA. 2001;285:60-66.9 year FU of >4000 children
26%
41%
81%
18%
33%
74%
0
10
20
30
40
50
60
70
80
90
Inpatient hospitaladmission
Outpatienthospitaladmission
Emergencyadmission
ADHD (n=309) Non-ADHD (n=3810)
P<0.001
P<0.006
P<0.005
$4306
$1944
$0
$500
$1000
$1500
$2000
$2500
$3000
$3500
$4000
$4500
ADHD Non-ADHD
Overall medical costs
1987 to 1995
% t
ota
l co
ho
rt
Med
ical
co
st o
ver
9 ye
ars
(199
5 n
atio
nal
avg
. do
llars
)
N=4119
P<0.001
Action of StimulantsAction of Stimulants Dopamine:Dopamine:
• Releases DOPA and Blocks re-uptake via the DOPA Releases DOPA and Blocks re-uptake via the DOPA transportertransporter
• Reduces DOPA transporter density Reduces DOPA transporter density • Leads to increased dopamine at nerve endingsLeads to increased dopamine at nerve endings
Noradrenaline:Noradrenaline:• Increase levels of NA in the RASIncrease levels of NA in the RAS
Behavioural effect:Behavioural effect:• 75% will show normalising levels of inattention, 75% will show normalising levels of inattention,
hyperactivity and impulsivityhyperactivity and impulsivity• Improvement in academic output (70%) and accuracy Improvement in academic output (70%) and accuracy
(50%)(50%)
v v Storagevesicle
DA Transporter
Cytoplasmic DA
Methylphenidate blocks
reuptake
Presynaptic NeuronePresynaptic Neurone
SynapseSynapseWilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513.
Amphetamine blocks
reuptake
Amphetamine blocks
Mechanism of Action of StimulantsMechanism of Action of Stimulants
Once a day preparationsOnce a day preparations *Concerta (OROS) *Concerta (OROS) 22% and 78%22% and 78% Metadate ERMetadate ER 30% and 70%30% and 70% BiphentinBiphentin 40% and 60%40% and 60% FocalinERFocalinER 50% and 50%50% and 50% *RitalinLA*RitalinLA 50% and 50%50% and 50% AdderallXRAdderallXR 50% and 50%50% and 50% MedikinetMedikinet 50% and 50%50% and 50% Methylphenidate Patch (Daytrana)Methylphenidate Patch (Daytrana) Single doseSingle dose *Strattera*Strattera QD doseQD dose LisdexamfetamineLisdexamfetamine (Vyvanse)(Vyvanse) QD doseQD dose Guanfacine Extended ReleaseGuanfacine Extended Release QD doseQD dose
Release Mechanisms Different and Patented* Available in Ireland
Side effectsSide effects• Common:Common:
GI-Nausea, Anorexia, PainGI-Nausea, Anorexia, Pain• Concerns re height & weight Concerns re height & weight • FU over 2 yrs slightly less weight gain (0.72kg) and less height gain FU over 2 yrs slightly less weight gain (0.72kg) and less height gain
(0.67 cm) than expected (Gadow et al, 99)(0.67 cm) than expected (Gadow et al, 99) HeadacheHeadache InsomniaInsomnia Irritability or sadnessIrritability or sadness
• Less common:Less common: Mild increase in HR or BP (10 beats -clinically NS)Mild increase in HR or BP (10 beats -clinically NS) Rebound effectRebound effect Psychosis rarePsychosis rare Cardiovascular risk if pre-existing diseaseCardiovascular risk if pre-existing disease AggressionAggression
• MPH Fewer s/e than dexamphetamine (Conners,71)MPH Fewer s/e than dexamphetamine (Conners,71)