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

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.

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)

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