Post on 10-Jul-2020
Children and Adolescents with
ADHD
Long-term randomized controlled
study
Dr.Nezla S. Duric
Child and Adolescent Psychiatrist /PhD
Children and Adolescents with ADHD
3 steps
qEEG
NEUROFEEDBACK
ADHD
ADHD Deficit of Self-Regulation
– ADHD-”problems “being secondary to inhibited impulse control
and lack of self-regulation
– Leads to a lack of development of other specific and important
psychological processes
– Also includes emotional dysregulation (Barkley)
ADHD patients do not lack knowledge or specific skills, but the ability
to coordinate / use these appropriately
ADHD Etiology
"The cause has been attributed to biofactors.
The outcome has to do with how the child
meets the environment and
how the environment meets the child"
Professor Eric Taylor at the Institute of Psychiatry, Kings College in London
Characteristics of ADHD
Lifelong Perspective
Pre-school Adolescent Adult
School-age College-age
Behaviour problems
Social skills
Self esteem
Psychiatric comorbidity
School performance
Smoking/abuse
Risk behaviour
Social skills
Self esteem
Psychiatric comorbidity
Academic performance
Occupational status
Psychiatric comorbidity
Smoking/abuse
Criminality
Risk behaviour
Social skills
Self esteem
Behaviour problems
Learning difficulties
Social skills
Self esteem
Academic performance
Relationships
Social skills
Self esteem
Halmøy et al, Journal of Attention Disorders, 2009
ADHD patho-physiology
• Cortical maturation
• Cortical rhytme
• Arousal level
Brain activity: Delta (0,1-4 Hz) Theta (4-7 Hz) Alpha (8-11 Hz) Beta(12-30 Hz) Gamma (over 30 Hz)
Cortical maturation and EEG
EEG - ADHD
Brain activity: Delta (0,1-4 Hz) Theta (4-7 Hz) Alpha (8-11 Hz) Beta(12-30 Hz) Gamma (over 30 Hz)
Increased levels of Theta and / or reduced levels of
Beta or Alpha brain activity in persons with ADHD
(Snyder, 2006); elevated Theta/beta ratio in resting
EEG (Barry 2003);reduced CNV (Banaschewski,2007)
The international 10-20-System of
electrode/sensor positions (Neuroscience for Kids, Erich H. Chudler)
Self-Regulation – Arousal Curve
Arousal
Performance
Optimum
Self-
regulation-
processes
ADHD and Treatment
PharmacologicalTreatment
PsychostimulantsNon-
psychostimulants
Neurofeedback
BehaviouralTreatments
Alternative Treatments
Non-pharmacological
Treatment
ADHD and Treatment
PharmacologicalTreatment
PsychostimulantsNon-
psychostimulants
Neurofeedback
BehaviouralTreatments
Alternative Treatments
Non-pharmacological
Treatment
ADHD and Treatment - Alternatives
PharmacologicalTreatment
PsychostimulantsNon-
psychostimulants
Neurofeedback
BehaviouralTreatments
Alternative Treatments
Non-pharmacological
Treatment
Neurofeedback
• Training of self-regulation
of brain activity
• Application:
neurophysiological
dysfunction and
enhacement of self-
regulation ability
• Feedback: visual, auditory,
tactile
Heinrich, H., H. Gevensleben, and U. Strehl, Annotation: neurofeedback - train your brain to train behaviour. J
Child Psychol Psychiatry, 2007.
ADHD and NF games
The Juggler
Children and Adolescents with ADHD
• UNIQUE STUDY DESIGN
• CLINICAL STUDY
• LARGE SAMPLE SIZE
• RANDOMIZATION
• CONTROL GROUP
• THREE ARMED GROUPS
• LONG-TERM STUDY
Aims of the Study
Part I
ADHD
• Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms.
• Explore primary health care’s ability to identify ADHD symptoms.
• Describe children and adolescents with ADHD regarding clinical characteristics.
Part II
ADHD and Treatment
• Evaluate the effect of NF treatment on ADHD core symptoms using self-report, parent`s, and teacher`s reports.
• Compare NF treatment for ADHD children and adolescents with standard medical treatment and combined treatment.
Part I
Characteristics of ADHD
• Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms.
• Explore primary healthcare ability to identify ADHD symptoms.
Aims of the Study
Part I
ADHD
• Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms.
• Explore primary health care’s ability to identify ADHD symptoms.
• Describe children and adolescents with ADHD regarding clinical characteristics.
Part II
ADHD and Treatment
• Evaluate the effect of NF treatment on ADHD core symptoms using self-report, parent`s, and teacher`s reports.
• Compare NF treatment for ADHD children and adolescents with standard medical treatment and multimodal treatment.
Part I
Characteristics of ADHD
• Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms.
• Explore primary health care’s ability to identify ADHD symptoms.
Aims of the Study
Part I
ADHD
• Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms.
• Explore primary health care’s ability to identify ADHD symptoms.
• Describe children and adolescents with ADHD regarding clinical characteristics.
Part III
qEEG in ADHD
• Define qEEG changes -Biomarkers
• Define qEEG changes _ Treatment
predictors
• Exploare correlation between
behavioral and qEEG parametars
Participants Part I: Characteristics of ADHD
Population Referredn = 494
ADHD Referredn = 187 (38 %)
ADHDn = 96 (51 %)
Other Diagnosis
Referred
n = 397 (62 %)
non ADHDn = 91
PHC*
CAMHC**
* Primary Health Care
** Child Adolescents Mental Health Clinic,
The Fonna Health Trust, Haugesund
Participants Part II/III: Treatment and qEEG
ADHD Invited Participants: 243(of 285)
Randomized: 130 (54 %)
Medication44 (34 %)
Neurofeedback +
Medication44 (34 %)
Neurofeedback42 (32 %)
Refused Participation: 113 (46 %)
Completed Follow up: 91 (70 %)
Medication31 (24 %)
Neurofeedback +
Medication30 (23 %)
Neurofeedback30 (23 %)
Drop out: 39 (30 %)
T1
T2
Pa
rt I
• ADHD multimodal clinical assessment
• Anamnesis
• Clinical examination (blood, EEG, EKG)
• Psychiatric observation
• ICD-10 interview
• Cognitive evaluation
Pa
rt II
+II
I
• Neurofeedback Treatment
• Pharmacological Treatment
• Parent report: Barkley Parent Scale
• Teacher report: Barkley Teacher Scale
• Self-report: SRQ
• qEEG
ADHD Treatment
Methods
ADHD Treatment in the study
Neurofeedback
• Lubar Theta/Beta – SMR protocol
• 30 sessions : 11-13 weeks
Stimulant Medication
Multimodal treatment
24
T 0 T 1 T 2 T 3
BaselineTreatment
Time perspective
Follow-up
Follow-up
0 10 20 30 40 50 60 70 80 90
Aberrancy in family relations
Inadequate parents attendance
Institution
Foster family
Mother educ. (<=9 years)
Father educ. (<=9 years)
Aberrancy in parents relations
CW support
SPS support
Two or more siblings
Job active mother
Job active father
red: p<0.05 Percent
ADHD
No ADHD
• 5. referred child has ADHD• Half of ADHD children live with
both biological parents• Twice ADHD children in forster
family• 5. ADHD children in institution
Results Part I:
Characteristics of ADHD referred population (N=187)
0 10 20 30 40 50 60 70 80 90
Aberrancy in family relations
Inadequate parents attendance
Institution
Foster family
Mother educ. (<=9 years)
Father educ. (<=9 years)
Aberrancy in parents relations
CW support
SPS support
Two or more siblings
Job active mother
Job active father
red: p<0.05 Percent
ADHD
No ADHD
• 5. referred child has ADHD• Half of ADHD children live
with both biological parents
• Twice ADHD children in forsterfamily
• 5. ADHD children in institution
Results Part I:
Characteristics of ADHD referred population (N=187)
Average referral age 10,5 år; 82% boys
Results Part I:
Characteristics of ADHD referred population (N=187)
Clinical examination:
• Increased risk of low birth weight
• increased TSH
• Somatic co-morbid conditions
Characteristics of ADHD population
ADHD
Combined
74%
ADHD
Hyperactive-Impulsive 22%
ADHD Inattentive 4%
4%
Characteristics of ADHD population
«Social Dysfunctioning»
Sex
ADHD/nonADHD
Low IQ
Primary Health Care
Primary health care services's ability to identify ADHD symptoms
1/3 of all referredchildren were
referred for ADHD
1/2 of ADHD referred childrenwere diagnozed
with ADHD
1/5 of ADHD referred children
were not diagnozed at all
Participants Part I: Characteristics of ADHD
Population Referredn = 494
ADHD Referredn = 187 (38 %)
ADHDn = 96 (51 %)
Other Diagnosis
Referred
n = 397 (62 %)
no ADHDn = 91
PHC*
CAMHC**
* Primary Health Care
** Child Adolescents Mental Health Clinic,
The Fonna Health Trust, Haugesund
none ADHD
34 none diagnose
Primary Health Care
• The sensitivity was 51% (96/187) regarding primary
health care`s ability to recognize ADHD.
• The specificity was 100% (0/494)
• Need for specific screening programs and diagnostic
guidelines for primary health care
Results Part II:
Treatment Response based on reports
one week later
Pre-post Change(within the groups)
Treatment Effect(between the groups)
Attention HyperactivityTotal score
Attention HyperactivityTotal score
Parents p < 0,001 p < 0,001 p < 0,001 p = 0,098 p = 0,101 p = 0,173
Teachers p < 0,001 p = 0,209 p < 0,001 p < 0,001 p = 0,425 p = 0,656
Children/ Adolescents
p < 0,001 p < 0,001 p = 0,322 p = 0,009
* Adjusted models did not show any effect (power)
Results Part II:
Correlation Children, Parent`s and Teacher`s
reports
Results Part II:
Treatment Response based on reports
LONG TERM
• Effectiveness Patterns towards TreatmentMedication
Neurofeedback
Neurofeedback + Medication
Follow up after treatment
0 3 98
10
12
14
16
18
20
22Attention
Barkley - teacher
0 3 94
6
8
10
12
14
16Hyperactivity
0 3 916
18
20
22
24
26
28
30
32
34Total score
0 3 98
10
12
14
16
18
20Attention
Barkley - parents
0 3 96
8
10
12
14
16
18
20
22Hyperactivity
0 3 915
20
25
30
35
40Total score
0 3 93.5
4
4.5
5
5.5
6
6.5
7
7.5
8Attention
Self report - child
time (months)
0 3 93
4
5
6
7
8
9Hyperactivity
time (months)
0 3 93
4
5
6
7
8
9
10School performance
time (months)
Results Part II:
Treatment Response based on reports
LONG TERM
New evidence for the long-term efficacy of
multimodal treatment:
• stimulant medication
• NF
Conclusion: Part I
Referral
Environment of
ADHD children
• High ADHD referral in late
school age
• Low diagnostic identification
=> “ADHD-guidelines” for Primary
Health Care needed
• Single parent / foster families
• Low parents education
• Child welfare
• Social dysfunction
• Low IQ
• High co-morbitity
Conclusion: Part I
Referral
Environment of
ADHD children
• High ADHD referral in late
school age
• Low diagnostic identification
=> “ADHD-guidelines” for Primary
Health Care needed
• Single parent / foster families
• Low parents education
• Child welfare
• Social dysfunction
• Low IQ
• High co-morbitity
Conclusion: Part II
Pre-post changes Treatment effect
• Significant improvement of
ADHD core symptoms
regadless treatment type
• Different focus from raters
• Neurofeedback is promising
reported shortly after
treatment
• Combined treatment makes
no superior efficacy
Conclusion: Part II
Pre-post changes Treatment effect
• Significant improvement of
ADHD core symptoms regadless
treatment type
• Different focus from raters
• Neurofeedback is promising
reported shortly after
treatment
• Multimodal treatment
makes superior efficacy in
long-term follow up
Part III Qeeg
• Frequences
• RatioBiomarkers
• The brain's electrical profile under different tasks
Predictors
Future perspectives
– Follow up over time
– qEEG analyses
Papers
1. Duric N.S., Elgen I.
Characteristics of Norwegian children suffering from ADHD symptoms: ADHD and primary
health care. Psychiatry Research. 2011, 188 (2011) 402-405. (Number of citations: 4)
2. Duric N.S., Elgen I.
Norwegian Children and Adolescents with ADHD – A Retrospective Clinical Study: Subtypes
and Comorbid Conditions and Aspects of Cognitive Performance and Social Skills. Adolescent
Psychiatry, 2011, Vol. 1, No. 4. (Number of citations: 3)
3. Duric N.S., Assmuss J., Gundersen D., Elgen I.
Neurofeedback for the treatment of children and adolescents with ADHD:
a randomized and controlled clinical trial using parental reports. BMC Psychiatry, 2012, Vol.12,
No. 1; 107. (Number of citations: 12)
4. Duric N.S., Assmuss J.,Elgen I.
NF treatment of children and adolescents with ADHD: Self-reported evaluation. Child and
Adolescent Psychiatry and Mental Health, December 2013.
I have ADSL,What s differencewith ADHD ?
It goes faster with ADHD
Thank you