Management of ADHD

Dr Sushil Kumar S V, MB BS, MD (psychiatry) (USA), MHA (USA), FIPS Assistant Professor

Department of PsychiatrySS Institute of Medical Sciences and Research Center, Davangere,

Karnataka, INDIA

Overview Introduction Recent Updates Case Vignettes

Preschooler School age Adolescent

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

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

Developmental differences

Preschoolers- Hyperactivity> Inattention Gross motor hyperactivity- running, climbing

Difficulty remaining quiet

Non-compliant

School age: Inattention > Hyperactivity Difficulty focusing

Losing things

Forgetfulness

Poor Organizing

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

Gender differences

Boys: Girls: 4:1 to 5:1 Adults 1:1 Referral bias Girl children- predominant Inattention Severity and high rates of comorbidity

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.

Comorbidity is the rule

ADHD

IDD

ASD ELD

SLD

THIS OR THAT / THIS AND THAT

ADHDDMDD

Depression

BPAD

ODD/CDAnxiety Disorder

TIC/Tourette

THIS OR THAT / THIS AND THAT

Comprehensive assessment

Multimodal assessment Interview- Child and Parent Observation Teachers Report Individual testing Rating Scale- ADHD RS, CONNERS SF

Evidence & Recent updates

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

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

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

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)

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

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)

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

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)

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

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 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)

Case VignettesWhat can be offered in clinical practice?

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

History1. Development- Normal motor, social and non-verbal communication (pointing, pretend play) Language delay – started talking by 2 and says 4-5

meaningful words2. ABC- Tantrums- Demands not met; when he is unable to communicate his needs, lasts for less than 5 minutes

3. Sleep- occasional disturbance4. Impulsive

Pose danger Needs constant monitoring

Assessment CONNERS SF- 16 Speech and Language Assessment MCHAT/ CARS VSMS

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

1. Psychoeducation2. Structure the day- after school hours3. Attention enhancing tasks

4. Tantrum Mx5. Speech and Language intervention

Attention Enhancing Tasks Sustained attention

Beading Grain/ vegetable sorting Colour cancellation

Impulsivity Matching pictures Mazes – preschool activity books

Sitting tolerance Colouring, finger painting Clay modeling- fine motor skills Story sessions- puppets

Targeting games (Uma Hirsave)

Progressively complex Different shapes, sizes & colour Sequencing, patterns

Big square to divided complex patterns Use of self instructions

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

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

Assessment ADHD RS - Inattentive subtype Comorbidities - SLD- evaluation Baseline Ht/ wt Appetite/ sleep Affordability and availability Parents preference Tab. Atomoxetine 10 mg 1—0—0 x 7 days

18 mg 1—0—0

Non-pharmacological interventions

1. Parent Management Training

2. Organizing the after-school hours3. Attention Enhancing tasks- tracing, sketching,

puzzles, etc4. Star Chart5. School based interventions

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

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

School Based Intervention

Ask the child and family- School report/ Letter to school Thank and appreciate them

1. Seating the child in first row2. Frequent one-one attention3. 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.

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

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

Thank you…..