1. Management of ADHD
Dr Sushil Kumar S V, MB BS, MD (psychiatry) (USA), MHA (USA), FIPS
Assistant Professor
Department of Psychiatry
SS Institute of Medical Sciences and Research Center, Davangere,
Karnataka, INDIA
3. Introduction
Prevalence
ICMR Study - 1.6% (Srinath et al., 2005)
Preschoolers- 12.2% (Suvarna & Kamath, 2009)
Western- 2.4-19.8%
DSM 5
7 to 12 years
Comorbid with ASD
4. Normal variants
Attention span and sitting tolerance increases with
age of child.
Age
Task at hand
Individual Vs Joint activity Vs Group
Temper tantrum 2 vs 9 year
6. School age: Inattention > Hyperactivity
Difficulty focusing
Losing things
Forgetfulness
Poor Organizing
7. Adolescents- Inattention, Executive dysfunction, social
skills
Incomplete assignments and projects
Academic under-performance
Conflicts with peers, teachers and parents
Poor planning, organizing skills
Adler 2015
8. Gender differences
Boys: Girls: 4:1 to 5:1 Adults 1:1
Referral bias
Girl children- predominant Inattention
Severity and high rates of comorbidity
9. Assessment
What complaints mean?
“My child is hyper” – hyperactivity or tantrums
“He never listens to me”- inattention or defiance
Primary informant
Age of the child
Externalizing /Internalizing disorders
Multiple informants- multiple setting
Home
School
Social
Parental factors- psychopathology, parenting, marital discord, etc.
10. Comorbidity is the rule
ADHD
IDD
ASD ELD
SLD
THIS OR THAT / THIS AND THAT
14. Atomoxetine
NE Reuptake Inhibitor, Non-stimulant medication
Metaanalysis of 9 placebo controlled studies in children
and adolescents concluded that it was superior to placebo;
NNT 3.43
Acute response- 81%, long term response-78%
Sx reduction is gradual
Minimal improvement by week 4.
Remission 12-14 weeks
Newcorn JH, 2009; Dickson RA 2011
15. Methylphenidate
Increases NE and Dopamine by blocking their reuptake
Stimulants are highly efficacious
In double-blind, placebo-controlled trials in children, 65% to
75% of subjects with ADHD have been determined to be
clinical responders
Effect size - 1.0, one of the largest effects for any
psychotropic medication
SR- convenient, improve adherence and reduce stigma
16. Atomoxetine Vs MPH
Meta-analysis - 9 RCTs comparing
methylphenidate(0.8-1.12 mg/kg) and
atomoxetine(1.28-1.56 mg/kg.), with a total of 2762
participants Hanwella et al., 2011
No significant difference in efficacy and acceptability
OROS-SR methylphenidate is more effective than
Atomoxetine and may be considered as first line
Open/double blind, excluded comorbidities, 3-10 week
17. Indian study
RCT – ADHD + ODD
Methylphenidate (dose 0.2-1 mg/kg/day) or
Atomoxetine (dose 0.5-1.2 mg/kg/day) for 8 weeks.
80% of Methylphenidate group and 64.3% of
Atomoxetine group ceased to fulfill the criteria for
ODD by 8 weeks.
(Garg 2015)
18. Evidence
No demographic or clinical predictors of response to ATMX
~ 75% of responders to Methylphenidate will also respond
to Atomoxetine.
~ 50% of non-responders to MPH will respond to
Atomoxetine therapy Suyash P 2008
Partial responders to ATMX - adjunct MPH(OROS/SR)-
40% reduction symptom scores. Wilens
TE et al., 2009
Adolescents might benefit more from atomoxetine
treatment than children with regard to improvement in the
domains of Risk Avoidance and Achievement. Wehmeier
PM, 2010
19. Atomoxetine or MPH
MPH- for ADHD without significant comorbidity/
comorbid CD
MPH or Atomoxetine when Tics, Tourette’s syndrome,
Anxiety disorder (NICE 2005)
ATMX- first line- Substance abuse, Anxiety, Tics.
(AACAP, 2007)
20. Clonidine
Alpha 2 adrenergic agonists
FDA approved ER Clonidine for monotherapy as well
as adjunctive therapy for 6-17 years
IR- Cost effective
Comorbid Tic, Seizure disorder, Sleep disturbance
Major concern- sedative side effects
MPH+ Clonidine – Cardiac adverse events
21. Recent Updates
185 RCTs; 12,245 children, avg: 75 days
Improve some of the core symptoms of ADHD,
general behaviour and quality of life
Does not increase the risk of serious harms over six
months
MPH- is associated with adverse events - designing
high quality trials is challenging
Placebo Vs Nocebo trials
(Cochrane database on MPH, Nov 2015)
22. Non-pharmacological
Interventions
An overarching synthesis of the four reviews-
suggested
ADHD psycho-education
Relationship-building skills (Moore et al 2015)
Systematic reviews of quantitative and qualitative
research (Richardson et al., 2015)
beneficial effects of school based interventions
What works for whom and in which context
23. Parent training &
Social skills training
Cochrane database 2011 – 5 RCT
Parent training may have a positive effect
It may also reduce parental stress and enhance
parental confidence.
Data concerning ADHD-specific behaviour are
ambiguous.
Evidence from this review is not strong enough to
form a basis for clinical practice guidelines.
Little evidence to support or refute social skills
training for adolescents with ADHD.
24. 24 week naturalistic follow up
study
Psychoeducation and contingency management principles
63.5% were on monotherapy; 25.4% - Combination of
medication
11.1% -medication was deferred
Risperidone was used in a small number to treat
aggressive, disruptive and stereotyped behaviours.
The response rate >25% reduction in ADHD-RS was
67.4% at 12 weeks and 97.4% at 24 weeks.
Severity of illness and comorbid ODD predicted poorer
short term outcome
(Preeti Jacob DM Thesis 2014)
26. Case Vignette 1
3 year old child
presenting with hyperactivity
Constantly on the go
Throws Tantrums and bangs his head when demands
not met
No H/O seizures, starring spells or any other medical
comorbidity
27. History
1. Development- Normal motor, social and non-verbal
communication (pointing, pretend play)
Language delay – started talking by 2 and says 4-5
meaningful words
2. ABC- Tantrums- Demands not met; when he is unable
to communicate his needs, lasts for less than 5 minutes
3. Sleep- occasional disturbance
4. Impulsive
Pose danger
Needs constant monitoring
29. Non-pharmacological VS Pharmacological
Age
Severity-impulsivity, dysregulation, sleep disturbance
Parents preference
Trial of 8 weeks
Rationale: 50% of preschoolers do not continue to have the
diagnosis
Duration of pharmacological interventions once initiated
30. 1. Psychoeducation
2. Structure the day- after school hours
3. Attention enhancing tasks
4. Tantrum Mx
5. Speech and Language intervention
33. Big square to divided complex patterns
Use of self instructions
34. Prescriptive:
Week 1: 5 min, week 2: 7 min, etc
Variety of activities- child to choose
Alternate sitting and physical activity
Why, how long, what if does not work
PATS: low dose MPH
Children with sleep disturbance or wt/ht is less
Trial of low dose of Clonidine after baseline cardiac
evaluation
Tab. Clonidine 100 mcg 0—0 ---¼ x 4 days
¼---0---¼ or 0—0—1/2
Refer to a specialist
35. Case Vignette 2
9 year old female child
c/o not listening to parents and being argumentative
gradually worsening over the years
Easily distracted even for activities of interest such as
drawing– attention span 10-15 minutes
Child reports she has difficulty with spelling
ADHD, ODD and SLD
38. Parental Interventions
Simple, clear, brief instruction
DO commands
“switch off the TV” Vs “stop watching TV”
Catch the child being good and appreciate
Spend Quality time with the child
To be firm without being angry
Set clear limits and enforce
39. Negotiating to incorporate child’s wishes if reasonable
Use “if…then….”statements rather than bribing
“If you finish your homework then you will be allowed to
watch TV”
“I will give you this and you promise me that you will behave
better”
Planning ahead to avoid potential situations
marriage party or shopping mall
Star-charting of child’s specified behaviors for contingency
management
40.
41. School Based Intervention
Ask the child and family- School report/ Letter to school
Thank and appreciate them
1. Seating the child in first row
2. Frequent one-one attention
3. To support and encourage
Buddy support
To involve child – distributing books, cleaning the board,
etc.
Feedback following medication trial
Non-classroom – lunch-hour, PT, etc.
42. Case Vignette 3
14 year old Adolescent on Methylphenidate for past 5
years
Family reports his hyperactivity is better however have
concerns over his tendency for physical aggression
Child unwilling to take medication
Current severity
Comorbidities- DBD, Mood, Substance abuse
Growth chart- Weight and Height
43. Child’s subjective report on attention span and
academic performance
Executive functions- Planning, Organizing, Decision
making, problem solving
Risk taking behaviors, substance use
Engaging the adolescent; “Ferrari”
Addressing concerns over ht and wt; Maintaining at
minimum effective dose.
Anger management Techniques
