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Understanding and managing adhd in children and adolescents by Professor Fiona Mc Nicholas 21 september 2011adhd hadd sept pdf 20 9 2011
 

Understanding and managing adhd in children and adolescents by Professor Fiona Mc Nicholas 21 september 2011adhd hadd sept pdf 20 9 2011

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Presentation by Professor Fiona McNicholas Understanding and Managing ADHD in Children and Adolescents an HADD and Lucena Parent Evening 20 September 2011 as part of ADHD Awareness Week 2011

Presentation by Professor Fiona McNicholas Understanding and Managing ADHD in Children and Adolescents an HADD and Lucena Parent Evening 20 September 2011 as part of ADHD Awareness Week 2011

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Understanding and managing adhd in children and adolescents by Professor Fiona Mc Nicholas 21 september 2011adhd hadd sept pdf 20 9 2011 Understanding and managing adhd in children and adolescents by Professor Fiona Mc Nicholas 21 september 2011adhd hadd sept pdf 20 9 2011 Presentation Transcript

    • Fiona McNicholas
    • Professor Child & Adolescent Psychiatry, UCD
    • Consultant Lucena Clinic, Rathgar & Our Lady’s Children’s Hospital, Crumlin
    Understanding and managing ADHD in children and adolescents Parent Talk HADD in association with Lucena Foundation 20 th September 2011
  • A Blitz…
    • History
    • Diagnostic Criteria
    • Assessment
    • Treatment
    • Heinrich Hoffmann
    • German psychiatrist’s children’s book (1846)
    • First translated into English by Mark Twain
  • Development of ADHD as a clinical entity 1950 1980 1968 1970 1987 1994 1937 Minimal Brain Damage/ dysfunction Attention Deficit/Hyperactivity Disorder ( DSM-III-R ) ADHD ( DSM-IV ) Hyperactive Child Syndrome 1930 1902 1 st Clinical Description by Still 2010 DSM V? Gender Age/ onset STROOP TEST Hyperkinetic Reaction of Childhood ( DSM-II ) ADD ± HA ( DSM-III ) Adult ADHD Studied V. Douglas
  • Development of treatments in ADHD 1950 1980 1968 1970 1994 1937 Efficacy of Amphetamine (Bradley) 1930 1902 Antipsychotics 1954 1 st published study on MPH 1962-1993 250 reviews 3000 articles on stimulant effects 1966 161 RCT Long acting meds Ritalin LA Concerta Atomoxetine Equasym 2011 Newer Drugs Guanfacine
  • ADHD Inattention Hyperactivity Impulsivity
  • Diagnostic criteria (ICD/DSM)
    • Over activity
    • Inattention
    • Impulsivity
    • Symptoms before age 7 (6 ICD)
    • Pervasive across situation
    • Cause impairment of social or educational functioning.
    • Not due to Autistic spectrum disorders, Psychotic or other mental disorder (anxiety, depression)
  • Symptoms suggestive of Inattention
      • Forgetful in daily activities
      • Loses things necessary for tasks
      • Difficulty organising tasks/activities
      • Does not seem to listen when spoken to directly
      • Does not follow through on instructions and fails to finish school work, chores or duties (not due to oppositional behaviour or failure to understand)
      • Fails to give close attention to details or makes careless errors in schoolwork, or other activities
      • Difficulty sustaining attention in tasks or play activities
      • Avoids, dislikes or reluctant to engage in tasks that require sustained mental effort
      • Easily distracted by extraneous stimuli
  • Symptoms suggestive of Hyperactivity/Impulsivity
    • Fidgets with hands or feet or squirms in chair
    • Leaves seat in classroom or other in which sitting is expected
    • Runs about, climbs excessively in situations in which it is inappropriate (restless)
    • Difficulty playing in activities quietly
    • ‘ On the go’ or ‘driven by a motor’
    • Talks excessively
    • Blurts out answers
    • Difficulty awaiting turn
    • Interrupts or intrudes on others
    A continuum-
  • STROOP -read the words (Skill) RED YELLOW GREEN BLUE GREEN RED BLUE YELLOW BLUE GREEN YELLOW RED YELLOW RED GREEN BLUE RED YELLOW GREEN BLUE GREEN RED BLUE YELLOW
  • STROOP -name the colour of the words (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 BLUE
    • GREEN RED BLUE YELLOW
    • BLUE GREEN YELLOW RED
    • YELLOW RED GREEN BLUE
    • RED YELLOW GREEN BLUE
    • GREEN RED BLUE YELLOW
    Skill versus Attention and Inhibition 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 required Need to inhibit pre-potent response to label colours Skill Required Sustained Attention Required
  • How common is ADHD?
    • 3-5% children, 2% adults
    • 30-50% of children referred to child psychiatry clinics have ADHD
    • More common in boys than girls 4:1- clinical referrals
      • 2.5:1 community
    • Persists in 30-50% of patients into adolescence and adulthood (symptom profile may change)
    • Ireland: Using 1-5% prevalence rates
        • 0-14yrs 864,449 (2006 Census)
        • 8,644 – 43,000 <15yrs with ADHD
  • Associated school problems
    • Language impairment 15-75%
    • Learning Disability 15-40%
    • Low Self esteem
    • Poor social skills
    • Labeled ‘trouble maker’
  • Associated Family problems
    • Poor relationship with parents
      • often secondary and improves with appropriate intervention
    • Family History ADHD
  • Co-morbid Disorders Oppositional Defiant Disorder 40% Tics 11% Conduct Disorder 14% ADHD alone 31% Anxiety Disorder 34% Mood Disorders 4% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096
  • Cause -hypothesis
    • Abnormal Dopamine signalling in the frontal cortex (executive functioning)
    • Deficiency of Noradrenaline in the reticular activating system (RAS)
        • the area of the brain responsible for balancing other systems involved in learning, self-control, inhibition and motivation
  • Neuroimaging and ADHD Stroop test 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 Striatal Insular 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
    1 x 10- 2
  • Assessment: History & Observations
    • Symptoms of ADHD
      • Home
      • School
      • After school activities
    • Co-morbidity
      • LD
      • Motor
      • ODD/CD
      • Other child psychiatric disorders
    • Perpetuating factors
      • Family
      • Temperament
      • Environment
    • Informants
      • Parents
      • Child
      • Teacher, Coach, play school, clubs etc
    • Tests
      • Physical examination Rating scales
      • Formal assessments NEPS, SALT, OT, hearing, vision
    IF ME
  • Adults with A.D.H.D.
    • Clinical picture includes
      • inattention, impulsivity, disorganisation, work/college and social problems, interpersonal problems which can lead to isolation,
    • Poor self esteem secondary to the experience of previous failure
    • Shifting focus of attention is often problematic for patients with ADHD
    10/02/11 Med Stu Teaching Pack
  • Added items for Adults
    • Executive function
    • Self regulation
    • Self organisation
    • Prioritisation
    • Awareness of time
    • Planning
    • Memory Functioning
    10/02/11 Med Stu Teaching Pack
  • Consequences: Untreated
    • Features persist into adolescence (80%) & adulthood (65%)
    • Cantwell ’85
      • Developmental delay 30%
      • Continual display 40%
      • Developmental decay 30%
      • ADHD is a specific risk factor for
        • Conduct Disorder-overall 58% chance
        • High rate of Drug/alcohol misuse
  • Functional Impairment in Patients with ADHD Compared to Those Without 35% 40% 16% 50% 30% 53% 52% Biederman et al. Am J Psych 1995.
  • Facts
    • Significant adverse outcomes in ADHD
    • Less than half of those with ADHD receiving treatment
    • Treatments known to be effective for core ADHD symptoms:
      • Medication
      • Behavioural Therapy in addition to medication
      • Others ( family, group, social skills) unclear
    • International consensus statement on ADHD, (2002) Clin Child & Family Psychology Review, Vol 5, N0 2, 89-91
  • Treatment
  • Treatment Options
    • Essential
      • Diagnostic Report- sharing information with parents, school and GP
      • Psycho-education (Support Groups)
      • Medication
      • Treat any co-morbid condition
      • Parent Management
    • Additional:
      • Behavioural Treatment
        • Individual Cognitive-behavioural therapy
      • Family Therapy
      • Group work- social skills
  • Medication-what works?
    • Stimulants
      • Most researched area in pediatrics
        • >155 RCTs w >5,600 children for stimulants (Spencer et al, 96)
      • Response rate:
        • 70% will respond to a stimulant
        • 85-90% to one of the 3 stimulants
        • Non-Adherence rates 20-65%
      • Choice:
        • Methylphenidate
        • Dexamphetamine
        • Short or longer acting
          • Concerta/Ritalin LA/Equasym
          • Atomoxetine
  • Stimulants raise dopamine levels Stimulants raise dopamine levels MPH/ Amphetamines Noradrenergic agents can reduce arousal Clonidine / Guanfacine TCAs, venlafaxine, bupropion Atomoxetine (Raises fromtal DOPA also by inh NA transporter)
  • ‘ Self Medication’
    •  Risk of smoking in ADHD
      • Nicotine an indirect DOPA agonist
      • Nicotine positive effects on  concentration
      • + Trials of usefulness in ADHD – nicotine patch
    • Stimulant Abuse
      •  risk of misuse (both alcohol and drugs)
        • Rate ADHD treated < controls < ADHD untreated
        • Suggestion to be maintained need CBT
      • Drug users don’t get a high from stimulants
      • Diversion may be a risk
      • Wilens et al, Pediatrics meta analysis 2003
  • Possible treatments..
    • Omega 3 Fatty acids
      • Positive cognitive & behavioural effects after 3months in DCD
      • Richardson et al
        • Peds 2005
      • Other subsequent studies negative
      • Transcranial stimulation
      • Neurofeedback
  • General Behaviour Management
  • WHAT WORKS IN BEHAVIOURAL THERAPY?
    • Parent training is generally regarded as the most effective behavioural therapy
    • Parent training combined with medication management increases parent acceptability of medication
    • School-based treatment is more effective than individual strategies, however benefits are only seen during treatment programmes and are not generalised
    • Individual treatment approaches have not been shown to be effective
  • Behavioural Treatment-for younger children
    • Identify problem situations and the precipitating factors
    • Specific strategies – Reward / Cost system
    • – Time out – Social reinforcement – Behaviour modelling
    • Parent–child interactions
      • Enhance positive and limit negative interactions
  • Problem solving steps:
            • Using 5 fingers
            • Model sequence- say out loud, then child repeats, then fading
            • Positive self coping statements
            • Use for homework as well as behaviour /social problems
    • What is my problem/task?
    • Look at all the options/possibilities
    • Focus in-concentrate hard and select one
    • Review progress or revise decision
    • Praise yourself
    Kendall Therapist Manual 1992
  • Consider your own feelings..
    • Do what you can.. ‘ACT’
    • God grant me serenity
      • to accept the things that I cannot change,
      • courage to change the things that I can
      • and wisdom to know the difference.
      • Serenity Prayer St. Francis of Assisi
    Hurt Tired Annoyed Defeated Angry Rejected Sad And your perceptions...
  • It is how you interpret it…
  • Guidelines
  • 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 Toolkits Simple road maps to help parents/carers, children and teachers find the right tools at the right time Discussion guides to structure discussions at critical points in the child’s schooling Downloadable 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 DBT Therapy CBT Collaborative Problem Solving
      • www.sosprograms.com
  • The End
  • Medical 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 hospital admission Outpatient hospital admission Emergency admission 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 % total cohort Medical cost over 9 years (1995 national avg. dollars) N=4119 P <0.001
  • Action of Stimulants
    • Dopamine:
      • Releases DOPA and Blocks re-uptake via the DOPA transporter
      • Reduces DOPA transporter density
      • Leads to increased dopamine at nerve endings
    • Noradrenaline:
      • Increase levels of NA in the RAS
    • Behavioural effect:
      • 75% will show normalising levels of inattention, hyperactivity and impulsivity
      • Improvement in academic output (70%) and accuracy (50%)
  • Mechanism of Action of Stimulants v v Storage vesicle DA Transporter Cytoplasmic DA Methylphenidate blocks reuptake Presynaptic Neurone Synapse Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513. Amphetamine blocks reuptake Amphetamine blocks
  • Once a day preparations
    • *Concerta (OROS) 22% and 78%
    • Metadate ER 30% and 70%
    • Biphentin 40% and 60%
    • FocalinER 50% and 50%
    • *RitalinLA 50% and 50%
    • AdderallXR 50% and 50%
    • Medikinet 50% and 50%
    • Methylphenidate Patch (Daytrana) Single dose
    • *Strattera QD dose
    • Lisdexamfetamine (Vyvanse) QD dose
    • Guanfacine Extended Release QD dose
    Release Mechanisms Different and Patented * Available in Ireland
  • Side effects
      • Common:
        • GI-Nausea, Anorexia, Pain
          • Concerns re height & weight
          • FU over 2 yrs slightly less weight gain (0.72kg) and less height gain (0.67 cm) than expected (Gadow et al, 99)
        • Headache
        • Insomnia
        • Irritability or sadness
      • Less common:
        • Mild increase in HR or BP (10 beats -clinically NS)
        • Rebound effect
        • Psychosis rare
        • Cardiovascular risk if pre-existing disease
        • Aggression
      • MPH Fewer s/e than dexamphetamine (Conners,71)