The Current and future need for integrated Multi-Level Treatment
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The Current and future need for integrated Multi-Level Treatment

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Russell A. Barkley. ...

Russell A. Barkley.
Clinical Professor of Psychiatry Medical University of South Carolina, Charleston SC, and Research Professor, Departament of Psychiatry Suny Upstate Medical University Syracuse, NY.

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The Current and future need for integrated Multi-Level Treatment The Current and future need for integrated Multi-Level Treatment Document Transcript

  • 14/12/2008Impact of ADHD on Major Life Activities – The Current and Future Need for Integrated Multi-Level Treatment Multi- Russell A. Barkley, Ph.D. Clinical Professor of Psychiatry Medical University of South Carolina Charleston, SC and Research Professor, Department of Psychiatry SUNY Upstate Medical University Syracuse, NY ©Copyright by Russell A. Barkley, Ph.D., 2007 Email: russellbarkley@earthlink.net Website: russellbarkley.org Sources: Barkley, R. A. (2006). Attention d f kl ( ) deficit h hyperactivity disorder: a handbook for diagnosis and treatment d d h db k f d d (3rd ed.). New York: Guilford. Barkley R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford 1
  • 14/12/2008 ObjectivesTo review the impact of ADHD on majorlife activities outside of educational andoccupational settingsTo highlight recent results of the g gMilwaukee follow-up study concerning follow-outcomes at age 27To discuss the treatment implications ofthese findings h fi diTo illustrate the need for multidisciplinarytreatment and multi-agency involvement multi- 2
  • 14/12/2008 Motor Vehicle Driving RisksPoorer steering, slower braking reaction timeRated by self, others, and driving instructors as using fewersafe d i ing habits drivingMore likely to drive before legally licensedMore accidents (and more at faults) (2-3x risk) (2- % with 2+ crashes: 40 vs. 6 % with 3+ crashes: 26 vs 9More citations (Speeding - mean 4-5 vs. 1-2) 4- 1-Worse accidents ($4200-5000 vs $1600-2200) ($4200- $1600- (% having a crash with injuries: 60 vs 17%)More Suspensions/Revocations ( p / (Mean 2.2 vs 0.7)) (% suspended: 22-24 vs. 4-5%) 22- 4-Greater adverse impact of alcohol on driving 3
  • 14/12/2008 Sexual- Sexual-Reproductive RisksNo Higher Incidence of Sexual DisordersBegin Sexual Activity Earlier (15 vs 16 yrs.)More Lifetime Sexual Partners (13.6 vs. 5.4)M Lif ti S lP t % having more than 4 partners by early adulthood 60 vs. 28%More Partners in Prior Year (2.4 vs. 1.6)Less Time with Each PartnerMore casual sex (outside relationships)(37 vs. 19%)Less Likely to Employ ContraceptionGreater Teen Pregnancies (24-38 vs. 4-5%) (24- 4- 32% males, 68% femalesRatio for Number of Births by age 21(37:1) 54% Do Not Have Custody of OffspringBy age 2 51% have children vs. 13% for controls 27, % h h ld 3% f lHigher Risk for STDs (17 vs. 4%)Overall riskier sexual behavior 4
  • 14/12/2008 Antisocial Activities (age 21; Milwaukee Study) Self- Self-reports for lifetime occurrences Hyper Control Hyper ControlAntisocial Activities Mean Mean % %Stolen Property 18.6 5.1 85 64Stolen Money 6.0 2.3 50 36Disorderly Conduct 18.5 8.3 69 53Assaulted with Fists 13.8 4.1 74 52Assaulted with a 2.7 0.3 22 7WeaponCarries Concealed 15.1 4.9 38 11WeaponIllegal Drug Possession 234.5 130.6 51 42*Illegal DIll l Drug S l Sales 14.3 14 3 4.5 45 24 20*Breaking and Entering 2.1 0.5* 20 8Sets Fires 0.4 0.1* 15 6Runaway from home 3.9 2.0* 31 16 5
  • 14/12/2008Dimensions of Antisocial Acts Predatory: Mugs, fights, carries & uses weapons Related chiefly to CD Self- Self-sufficiency: Runs away, steals money, prostitution away money Associated with CD Drug- Drug-related: Possesses, uses, & sells drugs; steals Related to both CD and ADHD 6
  • 14/12/2008 Antisocial Activities (age 27) Lifetime Antisocial Acts 80 70 60 Percent of Group 50 f 40 H+ADHD 30 H-ADHD 20 Community 10 0 Stolen Breaking Assault - Assault - Carried Sold DisorderlyArrested Jailed Property + Fists WeaponsWeapons Drugs Entering Type of ActH+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments);H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome;Controls = Community control group 7
  • 14/12/2008 Antisocial Activities (lifetime) UMASS Study Criminal Activities 60 50 40Percent 30 ADHD Clinical 20 Community 10 0 Shoplifted Stolen Money Breaking/Entering Assault Sold Illegal Drugs Arrested Jailed Specific Crimes and Outcomes 8
  • 14/12/2008 Childhood Antisocial Activities (retrospectively recalled) Childhood Conduct Disorder Symptoms 45 40 35 30 25Pe rce nt 20 ADHD Clinical 15 Community 10 5 0 Bullied Fights Break-ins Stolen Violate Ran Away Truant Valuables Curfew Sym ptom 9
  • 14/12/2008 Judicial Costs of ADHD (by age 21) ADHD children followed to young adulthood are more than twice as likely to be arrested as control children (48% vs. 20%) Mean judicial costs have been estimated to be $8,814 per ADHD person vs. $341 per control. Regression modeling placed the total criminal costs at $37,830 per ADHD person having CD. CD. 45- 45-80% of teenagers in juvenile custody have ADHD 25- 25-40% of adult prisoners have ADHDData from the Milwaukee follow-up study as reported in the paper by follow- Secnik, Swensen, Buesching, Secnik, Swensen, Buesching, Barkley, Fischer, & Fletcher (submitted for publication). 10
  • 14/12/2008 Social ImpairmentsIncreased parent-child conflict & stress parent- Greater parental commands, hostility, reduced responsiveness, more lax yet harsh discipline More child noncompliance, hostility, disruption Poorer sense of competence in parental role Greater parenting stress and maternal depression Especially problematic for ODD/CD subgroupPeer Relationship Problems (50-70%+) ee e at o s p ob e s (50- 0% ) Less sharing, cooperation, turn-taking turn- Intrusive, angry; reduced empathy and guilt Most serious in ODD/CD subgroup More likely to be bullied and to be bullies in childhood More likely to be beaten up, mugged, or assaulted with a y p, gg , weapon by young adulthood 11
  • 14/12/2008 Social & LifestyleFewer close friends; shorter duration of relationsRated by p y parents as more socially impaired y pLower levels of marital satisfaction by bothproband and partnerGreater parenting stress in parental roleDifferences in leisure time use: Spend more time talking on phone, watching TV, S d lk h h playing videogames, and socializing Spend less time reading, getting adult education, and exercisingGreater money management problems Lower current savings, less saving for retirement, exceed credit card limits more often, buy on impulse more often, less debt repayment, low credit rating, greater risk of car repossessions and losing utilities 12
  • 14/12/2008 Money Problems (age 27; MKE) Money Problem Areas 80 70 60 P ercent of Group 50 f 40 H+ADHD 30 H-ADHD 20 Community 10 0 Managing Impulse Missed Missed Exceeded No Savings Poor Credit Money Buying Paying Paying Card Limit Rating Rent Card Problem TypeH+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments);H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome;Controls = Community control group 13
  • 14/12/2008 Health Risks and Concerns Skinner Health and Lifestyle Interview – MKE Study Health Concerns 90 80 70 60 oup Percent of Gro 50 H+ADHD 40 H-ADHD 30 Community 20 10 0 Eating Sleep Social Tobacco Drugs Emotional Spe cific He a lth Are aH+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments);H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome;Controls = Community control group 14
  • 14/12/2008 Medical and Health ConcernsGreater risk for accidental injuries, nonsurgical hospitalizations, ERutilization, and driving accidentsGreater medical and dental health problems More sick days off from work Greater workman’s compensation claims Poorer preventive dental care and more cavities as childrenGreater sleeping problemsHigher frequency of vague medical complaints Related to somatization and anxiety levels on SCL-90-R SCL-90-Greater likelihood of smoking, alcohol, and marijuana use and greaterfrequency of using these substances Conduct disorder increases risk for hard drug use (cocaine, heroine, methamphetamine, illegal use of prescription drugs, etc.)Growing risk of cardiovascular disease Greater body mass index (higher percent obese) Lower HDL cholesterol and higher Total/HDL ratio Higher atherosclerotic risk to coronary arteries Higher Framingham CHD risk percent over next 5 and 10 yearsPossibly greater risk for cancerShortened life expectancy as a consequence ???? 15
  • 14/12/2008 Areas for Future ResearchDetermine if outcomes are different for SCT typeFurther examine for sex differencesExtend findings past age 35Determine occupational costs (e.g., sick days,absenteeism, accidents on job, workman’scompensation claims, etc.) etc.)Study accident rates at home and communityExamine impact in more detail on child-rearing andE amine mo e child- ea ingmarriagesFurther evaluate growing risk for medical illnesses Somatization disorders cardiovascular disease cancer Obesity and eating disorders (females)Further evaluate risks for earlier mortality 16
  • 14/12/2008 Summation of ImpairmentsFollow-Follow-up studies provide convincing evidence that ADHD isassociated with impairment in many major life activities overdevelopment p Poor Educational Performance, Reduced Years of Education, Greater Risk for Learning Disabilities Increased Risk for Comorbid Psychiatric Disorders Lower Occupational Levels and Poorer Workplace Performance Higher Rates of Antisocial Activities, Crime, Arrests, and Incarcerations Greater Risks for Teen Pregnancy , STDs, and Earlier Parenthood Greater Driving Risks (Speeding, Crashes, Injuries Increased Health Risks for Obesity, Cardiovascular Disease and Cancer; Possibly Reduced Life ExpectancyThis Demonstrates a Great Need for Government,Educational, Health Care, Mental Health Care, and JudicialDepartments and Professionals to Work More CloselyTogether to Reduce Such Impairments and the Obvious Socialand Financial Burden They Create for Society 17
  • 14/12/2008 Managing Educational RisksEducating teachers and school administrators onADHD and associated academic risksTeacher training in classroom behavior managementT h t i i i l b h i tstrategiesImplement ADHD school liaisonEarly screening and identification of ADHD cases at schoolentryPre-Pre fP -referral assistance to regular classroom teachers on l i t t l l t hbehavior management tacticsPre-Pre-referral curriculum adjustmentsIf necessary, eventual referral for formal specialeducational servicesEarlier implementation of extended release medications asnecessaryVocational assessment and job skills training during highschool 18
  • 14/12/2008 Addressing Employment RisksEducate employers on nature of ADHD, workplaceimpact & risks, & workplace managementVocational assessment i high school for placementV i l in hi h h l f lin technical training classesCounseling teen/adult for ADHD-friendly jobs ADHD-Post-Post-high school technical training if no plans forcollege enrollment If college bound, consider community college as first stepMilitary enlistment if not going on to collegeMake reasonable workplace adjustments Similar to school behavior management tacticsMedication management across longer periods Extended release formulations; supplement with IR 19
  • 14/12/2008 Treating Child/Teen ODDBoth stimulants and atomoxetine reduce defiance whenit is comorbid with ADHD; not when ODD occurs alone Higher doses may be needed for comorbid casesImplement adjunctive parent training in behaviormanagement methods; but positive responding is age- age-related: 60- 60-75% successful for children f lf hild 25- 25-35% treatment response after 13+ yrs. of age May need to treat parent’s ADHD first to succeed May need to add problem-solving communication training of problem- teen and parents after age 14 yearsSeverely explosive anger may be a sign of childhoodBPD or SMD; may require use of atypical antipsychoticsor antihypertensives 20
  • 14/12/2008 Treatment of Antisocial RisksStimulants and atomoxetine reduce aggressive behavior andantisocial activities Stimulants can be titrated more rapidly if management need is urgent Higher doses often required in comorbid cases Stimulant effectiveness may deteriorate with duration of treatment (3+ yrs) in this subset of ADHD cases (MTA study)Parent and family interventions often required Problem- Problem-solving, communication training and parent BMT Multi- Multi-systemic therapy where available Treatment of parental depression and other psychiatric disorders Terminate deviant peer relationships Family relocation to better neighborhoods advisableIf psychopathy (callous-unemotional traits) is present there is limited (callous-or no response to behavior therapy alone – medication is necessaryfirst, then follow up with behavioral treatments*Avoid group treatment due to deviancy training by aggressive peerswho train less aggressive peers to become more aggressiveInvolvement of social service and juvenile justice agencies is highlylikely – educate them about ADHD with this CD comorbidityMood stabilizers, atypicals, or antihypertensives may be needed for atypicals,highly aggressive/explosive cases representing severe mood orbipolar disorders 21
  • 14/12/2008 Implications for Driving RisksEducate parents, teens, primary care physiciansand motor vehicle agencies on driving risksLonger learner’s permit periodGraduated licensing approachG d d li i h Daytime with adults, night-time with adults, alone, with peers, full night- independence (3-6 months at each stage, gradual independence) (3No (!) cell phone use/text messaging whiledrivingGreater supervision of vehicle use p Chart intended vehicle use Random spot checking on destinations Critical incident cameras in vehicle (DriveCam Inc., San Diego, CA), (DriveCam or GPS car monitoring devices (MobileTeen GPS, AIG Insurance (MobileTeen Co.).Behavior contracting for safe driving (Barkley Safe Driving Program, Compact Clinicals, Kansas City, MO; Clinicals, Maureen Synder’s book on ADHD and driving, addwarehouse.com) Synder s driving addwarehouse com)Medication management Extended release formulations with supplemental immediate release as neededAvoid alcohol use while driving 22
  • 14/12/2008 Implications for Risky Sexual ConductEducate parents, primary medical care providers,and appropriate social service agencies on ADHDand risks for teen pregnancy & STDsGreater parental supervision of teen social anddating activitiesDelay couples dating in favor of group y p g g pdating with multiple peersEducate teens on sex and risksDiscuss use of contraception with teens & parentsMedication management to reduce impulsiveconduct and increase self-control d d self- lf lHPV immunization for females with ADHD To reduce future risks for cervical cancer 23
  • 14/12/2008Implications for Health RisksEducate primary care providers andgovernment health agencies on ADHD andrelated health and lifestyle risksEncourage greater use of preventive medical& dental careProvide assistance with managing legalsubstances Smoking cessation programs Alcohol abuse treatments Substance abuse rehabilitation programsDiscuss with parents and ADHD teens/adultsthe growing cardiovascular and cancer riskswith ageEncourage b tt h lth maintenanceE better health i tpractices (better diet, routine physicalexercise) 24
  • 14/12/2008 ConclusionsADHD is associated with impairment in every major lifeactivity studied to dateADHD results in greater impairment, more domains of impairmentimpairment, and more sustained impairment than otheroutpatient psychiatric disordersThe impairments from ADHD are associated withsubstantial economic costs, greater burdens on society,and greater risk for early mortality g y yADHD is among the most treatable psychiatric ordevelopmental disabilities having more treatmentsavailable producing greater improvements in a higherpercentage of cases with higher rates of normalizationReducing these huge societal costs will require multi- g g q multi-disciplinary management and better integratedgovernment social services, health and mental healthcare, and educational services 25