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