Psychological treatments in ADHD

Psychological treatments in ADHD

ExplanationExplanationSupport Support

Behaviour therapyBehaviour therapyCognitive therapiesCognitive therapies

Counselling about medicationCounselling about medication

Eric Taylor: King’s College London Institute of Psychiatry

No competing interests; acknowledgements to NICE Guidelines Development Group

What is it like to have ADHD?What is it like to have ADHD?

““My thoughts are in a muddle”My thoughts are in a muddle” (usually only after treatment shows the difference)(usually only after treatment shows the difference)

““I get into trouble a lot, I don’t know why”I get into trouble a lot, I don’t know why” ““Other kids pick on me”Other kids pick on me” ““Ive got a bad temper”, “I cant concentrate”, “Ive Ive got a bad temper”, “I cant concentrate”, “Ive

got ADHD” got ADHD” (usually repeating what they have been told)(usually repeating what they have been told)

What do patients ask for?What do patients ask for?

Understanding by othersUnderstanding by others Knowledge of futureKnowledge of future Stop the bullyingStop the bullying Appreciation of the positiveAppreciation of the positive Time to talk with doctorTime to talk with doctor

Which one is most similar?Which one is most similar?

Which one is most similar?Which one is most similar?

1 2 3

4 5 6

Which one is most similar?Which one is most similar?

Choosing the immediate reward

?

1 p

2 p30 sec

Choosing the immediate reward

?

1 p

2 p30 sec

?

?

1 p 1 p 1 p

? ?

?

1 p 1 p 1 p

? ?

2 p

?

Post - reward delay

?

1 p 1 p

?

2 p

?

30 sec

Education should be widespreadEducation should be widespread

ChildrenChildren ParentsParents GrandparentsGrandparents SiblingsSiblings ClassmatesClassmates TeachersTeachers And increasingly for adult patients …And increasingly for adult patients …

Spouses, partners, employersSpouses, partners, employers

Key messagesKey messages

A real and potentially disabling conditionA real and potentially disabling condition Consider as a chronic disorderConsider as a chronic disorder Families, peers and teachers can help ++Families, peers and teachers can help ++ Many affected people make good adult Many affected people make good adult

adjustmentadjustment Medication helps but does not cureMedication helps but does not cure

Shaping the EnvironmentShaping the Environment

Longitudinal evidence from Newham studiesLongitudinal evidence from Newham studies All 7-year-old boys (3,215) identified from All 7-year-old boys (3,215) identified from

school rolls and health recordsschool rolls and health records Parent & teacher Rutter scales for 2,462Parent & teacher Rutter scales for 2,462 Stratified behaviorally into HA, Def, Inatt, Stratified behaviorally into HA, Def, Inatt,

Mixed & ControlMixed & Control Random selection of 50 in each groupRandom selection of 50 in each group Detailed interviews & tests: Detailed interviews & tests:

91%compliance91%compliance

Taylor, Sandberg, Thorley, Giles (1991) Maudsley Monograph No. 33

Outcome measuresOutcome measures

Parental interview ratingsParental interview ratings Psychiatric interview with youthsPsychiatric interview with youths Cognitive testingCognitive testing Home Office records of offendingHome Office records of offending School recordsSchool records Case conference diagnosisCase conference diagnosis

88% follow-up 10 years later; nonresponders similar to responders

Hyperactivity & conduct disorder

Age 7

Age 17

HA CDMixed

HA Mixed CD

Hyperactivity & conduct disorder

Age 7

Age 17

HA CDMixed

HA

Hostile parental EE

Not part of a peer group

Hyperactivity & conduct disorder

Age 7

Age 17

HA CDMixed

Age 27

Basic handling framework for parents – before specific therapyBasic handling framework for parents – before specific therapy Appropriate expectationsAppropriate expectations Positive attending to childPositive attending to child Effective communicationEffective communication

Obtain attention; simple instructionObtain attention; simple instruction Listen; figure out meaning of outburstsListen; figure out meaning of outbursts

Structuring the child’s dayStructuring the child’s day Rule-governed atmosphereRule-governed atmosphere Talking with teacherTalking with teacher KEEPING CALMKEEPING CALM

Specific approaches: Behaviour TherapySpecific approaches: Behaviour Therapy

Principles of behavioural treatmentPrinciples of behavioural treatment Identify specific problemsIdentify specific problems Analyse contingencies; Analyse contingencies; reward & response cost reward & response cost

rather than extinctionrather than extinction Enhance adult attending Enhance adult attending Teach effective instructionTeach effective instruction Token economy + response cost (frequent) Token economy + response cost (frequent)

or time-out + rapid novel rewardsor time-out + rapid novel rewards Include self- managementInclude self- management

Principles of behavioural treatmentPrinciples of behavioural treatment Identify specific problemsIdentify specific problems Analyse contingencies; Analyse contingencies; reward & response cost reward & response cost

rather than extinctionrather than extinction Enhance adult attending Enhance adult attending Teach effective instructionTeach effective instruction Token economy + response cost (frequent) Token economy + response cost (frequent)

or time-out + or time-out + rapid novel rewardsrapid novel rewards Include self- managementInclude self- management

Interventions in the classroomInterventions in the classroom

Proximity to teacherProximity to teacher Managed transitionsManaged transitions Pacing & letting off energyPacing & letting off energy Classroom aideClassroom aide

operant conditioningoperant conditioning peer advicepeer advice

Rule governmentRule government Clarity of goal & speed of feedbackClarity of goal & speed of feedback Understanding disorder (eg projects)Understanding disorder (eg projects) Monitoring medicationMonitoring medication

Some common-sense procedures – avoiding distractors and short-chunk learning – don’t yet have trial evidence

Learning social skills in peer groupLearning social skills in peer group

Listen to othersListen to others Join play graduallyJoin play gradually Learn the rulesLearn the rules

Avoid intrusiveness and excessive demandsAvoid intrusiveness and excessive demands

Figure out why others reactFigure out why others react Control angerControl anger Learn how to refuse kindlyLearn how to refuse kindly

Especially drugsEspecially drugs

But do behavioural treatments work?

I. The MTA study

But do behavioural treatments work?

I. The MTA study

Study

Treatments

Basel

ine,

7-9

.9 y

rs

8 Yea

rs

6 Yea

rs

36 M

os, 1

0-14

yrs

24 M

os, 9

-12

yrs

14 M

os, 8

-12

yrs

10 Y

ears

LNCG (n=289) added here

36 Month Findings on Substance Use

Molina et al

Assessment Points

Baseline EarlyTreatment

(3 m)

Mid-Treatment

(9 m)

End ofTreatment

(14 m)

FirstFollow-up

(24 m)

SecondFollow-up

(36 m)

14-m Treatment

Phase

10-m Follow-up

Phase

22-m Follow-up

Phase

0 362414

Month

RecruitmentScreeningDiagnosis

RANDOM

ASSIGNMENT

579 Subjects7 to 9 yrs old

ADHD-Combined

MedMgt144 Subjects

Beh144 Subjects

Comb 145 Subjects

CC 146 Subjects

Observation 1 LNCG Group

Pre-Baseline

Observation 2 LNCG Group

Jensen et al, 2007Intent-to-treat (ITT) Analysis Jensen et al, 2007Intent-to-treat (ITT) Analysis

Randomized Clinical Trial at 14-month assessment: Transition to Naturalistic Follow-up at the 24-month & 36-month Assessment

MTA Group, 1999a,b

MTA Group, 2004a,b

Towards consensus in clinical practice

Stage Example

Recommendations “Seek underlying causes before prescribing”

Guidelines “Assess learning difficulties, family history, peer relations, stress history”

Protocols “100% of referred cases are evaluated by child psychiatrist giving individual interview”

Towards clinical guidelines

Review Trial results Expert Review

Metaanalysis

Draft of

recommendations

Critique Clinical Literature

RefereeExpert panel

Recommendations

Modulation Acceptability

Cost

Subgroups

Users

Purchasers

Field trial

Guidelines

Modification Local factors Providers

+ purchasers Protocols

Stage Information Source Result

Organisation of NICE processOrganisation of NICE process

Professional teamProfessional team Systematic reviewersSystematic reviewers Health economistsHealth economists SecretariatSecretariat ImplementersImplementers

PanelPanel PsychiatryPsychiatry PaediatricsPaediatrics Primary carePrimary care EducationEducation UsersUsers

Commissioned projectCommissioned project

CarersCarers

Key recommendations from NICEKey recommendations from NICE

ADHD should be recognised and referredADHD should be recognised and referred Comprehensive specialist assessment; impairment req’dComprehensive specialist assessment; impairment req’d

Trusts to set up lead groupTrusts to set up lead group Adult services to be developedAdult services to be developed First choice usually group parent trainingFirst choice usually group parent training Severe cases go straight to medicationSevere cases go straight to medication First choice medication usually MPHFirst choice medication usually MPH Shared care expectedShared care expected

Table 5. Databases searched and inclusion/exclusion criteria for clinical evidence

Electronic databases CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO

Date searched Database inception to 18.12.08

Study design RCT

Patient population Children diagnosed with ADHD

Interventions Any non-pharmacological intervention used to treat ADHD symptoms and/or associated behavioural problems

Outcomes ADHD symptoms*; conduct problems*; social skills*; emotional outcomes*; self-efficacy*; reading; mathematics; leaving study early due to any reason, non-response to treatment.

*Separate outcomes for teacher, parent, self, and independent ratings.

Systematic literature review

Marking and combining studiesMarking and combining studiesCore ADHD symptoms at end of treatment

(teacher-rated)SMD -0.25 (-0.56 to 0.07)Quality: HighK = 4, N = 163

Core ADHD symptoms at end of treatment (parent-rated)

SMD -0.57 (-1.00 to -0.14)Quality: ModerateK = 5, N = 288

Conduct at end of treatment (teacher-rated) SMD -0.12 (-0.61 to 0.38)Quality: ModerateK = 3, N = 63

Conduct at end of treatment (parent-rated) SMD -0.54 (-1.05 to -0.04)Quality: ModerateK = 5, N = 231

Social skills at end of treatment (teacher-rated) SMD -0.40 (-1.33 to 0.54)Quality: ModerateK = 1, N = 18

Social skills at end of treatment (parent-rated) SMD -0.59 (-1.80 to 0.61)Quality: LowK = 2, N = 138

Social skills at end of treatment (child-rated) SMD -0.23 (-0.61 to 0.15)Quality: HighK = 1, N = 120

Emotional outcomes at end of treatment (teacher-rated)

SMD -0.20 (-1.12 to 0.73)Quality: ModerateK = 1, N = 18

Emotional outcomes end of treatment (parent-rated)

SMD -0.36 (-0.73 to 0.01)Quality: HighK = 2, N = 112

Self efficacy at end of treatment (child-rated) SMD -0.03 (-0.48 to 0.42) Quality: High K = 3, N = 78

Psychological interventionsPsychological interventions

TypeType DeliveryDelivery Costed as:Costed as:

Parent trainingParent training GroupGroup

IndividualIndividual

Group + childGroup + child

10 sessions10 sessions

10 sessions10 sessions

CognitiveCognitive IndividualIndividual n/a [no effect]n/a [no effect]

EducationalEducational Class informationClass information

ScreeningScreening

Delivery to teacherDelivery to teacher

n/an/a

Modelling health economic costsModelling health economic costs

Booster sessions

No treatmentNo response

Response

Parent training

No treatment

No treatment

No treatmentResponse

No response

Children with ADHD

Figure 3. Schematic diagram of the structure of the economic model

Selecting studies with “response rate” outcome measures (to allow QALY)Selecting studies with “response rate” outcome measures (to allow QALY)

Table 8. Characteristics of the studies examining parent-based therapies for children with ADHD included in the guideline systematic literature review

Study Intervention examined Mode of delivery

Medication status

BOR2002 Enhanced and standard positive parenting programme

Individual

None

HOATH2002 Enhanced positive parenting programme Group Some

PFIFFNER1997 Social skills training with parent generalisation Group Some

SONUGA-BARKE2001

Parent training Individual

None

Table 9. Input parameters utilised in the base-case economic analysis of parent training versus no treatment for children with ADHD

Input parameter value

Source - comments

Response ratesParent trainingNo treatment

0.522

0.206

Meta-analysis of BOR2002, HOATH2002, and SONUGA-BARKE2001; analysis based on intention-to-treat

Utility scoresResponderNon-responder

0.837

0.773

Coghill et al., 2004; scores based on EQ-5D; questionnaires filled in by parents of children with ADHD in the UK

Parent training cost10 x 1 hour group sessions with

clinical psychologist1 extra hour training and

preparationTotal intervention costTotal cost per family, assuming

10 families in each group3 x 0.5 hour individual booster

sessions for respondersTotal cost for responders

over 1 year

£660

£29

£689

£69

£99

£168

Curtis & Netten, 2006; clinical psychologist cost per hour: £29; cost per hour of client contact: £66; qualification costs excluded

Cost-effectiveness calculationCost-effectiveness calculation

Table 10. Cost-effectiveness of parent training versus no treatment in children with ADHD - results of the base-case analysis over 1 year

Intervention

Total QALYs / child

Total cost / child ICER

Parent training

0.803 £168 Parent training versus no treatment: £6,608/QALYNo

treatment0.785 0

Sensitivity analyses for differing assumptions

Economic conclusionEconomic conclusion

According to this analysis, and after assuming an 80% uptake of such programmes, the group clinic-based programme resulted in a cost per responder of £10,060 and £1,006 at a 5% and 50% success (response) rate, respectively; and a cost per QALY of £12,575 and £3,144 at a 5% and 20% improvement in HRQoL, respectively.

Clinical conclusionsClinical conclusions

The results of the economic analysis indicate that group-based parent training programmes (or CBT for children of school age) are likely to be cost-effective for children with ADHD, if the mode of delivery of such programmes does not affect their clinical effectiveness. Individual parent training is unlikely to be a cost-effective option

Specific approaches: cognitive therapySpecific approaches: cognitive therapy

Effective for coexistent anxiety/ depressionEffective for coexistent anxiety/ depressionFor Core ADHD symptoms, little effectFor Core ADHD symptoms, little effect::

Learning to Learning to STOP AND THINKSTOP AND THINK Recognising and managing angerRecognising and managing anger

Teaching others to be self-controlledTeaching others to be self-controlledTolerating waitingTolerating waiting

So far, trial evidence suggests no effect on core ADHD. What are we doing wrong?

Perhaps teaching cognitive control is hard because there are many routes into impaired control/ impulsiveness

Perhaps teaching cognitive control is hard because there are many routes into impaired control/ impulsiveness

GONOGOGONOGO STOPSTOP

press press inhibitinhibit

Selective inhibition of a Selective inhibition of a motor response/response motor response/response selectionselection

ISI: 1.6spress inhibit

Withholding of a planned motor response

REVERSALREVERSAL

press inhibit

Successful inhibition in normal adultsSuccessful inhibition in normal adults

Rubia et al., 1999, NeuroImage.

STOP SUCCESSFUL (-unsuccessful)STOP SUCCESSFUL (-unsuccessful)

ADHD: 0

L

RC

DIFFERENCEIFC

UNSUCCESSFULL STOPUNSUCCESSFULL STOPC > ADHD

LR

Rubia et al., AJP, 2004, in press.

SWITCH TASKSWITCH TASK

Modification of Meiran Switch task: Cognitive flexibility. Switching between two dimensions.

SWITCH (- repeat)SWITCH (- repeat)C

ADHD: 0

LEFTRIGHT

DIFFERENCE

Entering adult lifeEntering adult life

Counselling – what to expect?Counselling – what to expect? Learning coping skillsLearning coping skills Making autonomous decisionsMaking autonomous decisions Becoming intelligent users of treatmentBecoming intelligent users of treatment

Stresses of growing up with ADHDStresses of growing up with ADHD

Ideas of selfIdeas of self Coping with treatmentCoping with treatment Biological determinismBiological determinism Stigma and incomprehensionStigma and incomprehension Different impact at different life stagesDifferent impact at different life stages

ADHD: Outcome for diagnosed children ADHD: Outcome for diagnosed children

0

5

10

15

20

25

30

35

40

45

age 14 age 18 age 22

% s

till

sho

win

g di

sord

erPercentage with ADHD

Median values for all follow-up studies from childhood

Types of RemissionTypes of Remission Syndromatic remissionSyndromatic remission

Loss of full diagnostic statusLoss of full diagnostic status

Symptomatic remissionSymptomatic remission Loss of subthreshold diagnostic statusLoss of subthreshold diagnostic status

Functional remissionFunctional remission Loss of subthreshold diagnostic status with functional Loss of subthreshold diagnostic status with functional

recoveryrecovery

Keck PE Jr, et al. Am J Psychiatry. 1998;155(5):646-652.

Age-Specific Prevalence of Remission: DSM-III-R ADHDAge-Specific Prevalence of Remission: DSM-III-R ADHD

% R

emitt

ing

Dia

gnos

is

Age (Years)<6 6-8 9-11 12-14 15-17 18-20

0

10

20

30

40

50

60

70

80

90

100

SyndromaticSymptomaticFunctional

Keck PE Jr, et al. Am J Psychiatry. 1998;155(5):646-652.

Impulsiveness as a failureImpulsiveness as a failure

The charge of the light brigade: impulsiveness and inattention in Captain Nolan, rigidity in others

Impulsiveness as a strengthImpulsiveness as a strength

“That adventurer”

Impulsiveness as a mixtureImpulsiveness as a mixture

Genius and failure

Changes in adolescenceChanges in adolescence

Brain maturing:Brain maturing: Synaptic cull, cerebellar growth, fibre tracts, frontal Synaptic cull, cerebellar growth, fibre tracts, frontal

receptorsreceptors

Endocrine:Endocrine: Mixed effects of testosterone & early pubertyMixed effects of testosterone & early puberty

Physical:Physical: Sexual attractiveness & interestSexual attractiveness & interest

Cognitive:Cognitive: Abstract conceptual; hypothetical probabilitiesAbstract conceptual; hypothetical probabilities

Entering adult lifeEntering adult life

New demandsNew demands Study: self-regulated, more Study: self-regulated, more

difficult?difficult? Work: regularity, Work: regularity,

submitting to rules, submitting to rules, unreasonable peopleunreasonable people

Friends: more demandingFriends: more demanding Partners: sharingPartners: sharing Drugs & alcoholDrugs & alcohol Budgeting, negotiatingBudgeting, negotiating

New chancesNew chances Self-pacingSelf-pacing Choose own nicheChoose own niche Avoid hated situations?Avoid hated situations? Find helpersFind helpers Use skillsUse skills Brain maturingBrain maturing

ImpactImpact

Self-organisationSelf-organisation Finding things/ remembering appts/ budget/ Finding things/ remembering appts/ budget/

neatnessneatness

TimingTiming On time for work/meet deadlines/ pay billsOn time for work/meet deadlines/ pay bills

ThinkingThinking Muddled/ Distracted/ “Whirling”/ IncompleteMuddled/ Distracted/ “Whirling”/ Incomplete

Impulse controlImpulse control Negotiating/ Using drugs/ Mood stabilityNegotiating/ Using drugs/ Mood stability

Coping often by: prosthesis; delegation; “buddies”; job choice

ImpactImpact

Forensic: vulnerable/witness/competenceForensic: vulnerable/witness/competence Employment; accident-prone; strengths Employment; accident-prone; strengths Parenting problems affect the childrenParenting problems affect the children

What influences operate?What influences operate? Antisocial: abusive/modelling/disciplineAntisocial: abusive/modelling/discipline Cognitive: unfocussed/impoverishedCognitive: unfocussed/impoverished Conative: reward history/predictabilityConative: reward history/predictability Physical: fetal/perinatal/nutritional/injuryPhysical: fetal/perinatal/nutritional/injury

Adherence and attitudesAdherence and attitudes Tom is 15. Professional parents. White British.Tom is 15. Professional parents. White British. Mixed neuropsychiatric presentation:Mixed neuropsychiatric presentation:

Presented at age 10 with history of impulsive overactivity throughout Presented at age 10 with history of impulsive overactivity throughout his life; asked to leave nursery; multiple suspensions from primary his life; asked to leave nursery; multiple suspensions from primary school and three changes of school (all mainstream) due to mother’s school and three changes of school (all mainstream) due to mother’s perception of school failing himperception of school failing him

Reading age then was 7; WISC IQ 106; noncompliant with tasks seen Reading age then was 7; WISC IQ 106; noncompliant with tasks seen as difficultas difficult

Increasingly unpopular; steals to give to other kidsIncreasingly unpopular; steals to give to other kids Violent to his younger sister, not otherwiseViolent to his younger sister, not otherwise

Treated with Concerta (in spite of tics appearing); good response, Treated with Concerta (in spite of tics appearing); good response, maintained in mainstream with facilitator, friendless.maintained in mainstream with facilitator, friendless.

Problems nowProblems now

Age 14 increasing cannabis use; agreed to Age 14 increasing cannabis use; agreed to continue Concerta (54 mg daily) none the less; continue Concerta (54 mg daily) none the less; off medication at weekends and holidays; off medication at weekends and holidays; discussions in motivational interviewing format.discussions in motivational interviewing format.

Age 15 behaviour at school deteriorated. Age 15 behaviour at school deteriorated. Concerta increased; clonidine added; not helpful; Concerta increased; clonidine added; not helpful; admitted not taking medicinesadmitted not taking medicines

Wont accept a self-monitored trial; “dunno” and Wont accept a self-monitored trial; “dunno” and “don’t like it” on his objections.“don’t like it” on his objections.

Patients taking stimulants (General Practice Research Database)Patients taking stimulants (General Practice Research Database)

30

7 6 5 6

211

66

20 13

73

25 1936

241

42

0

50

100

150

200

250

300

16 17 18 19 20 to 21

Age, years

Nu

mb

er

of

pa

tie

nts

Female Male Total

Common reasons for nonadherenceCommon reasons for nonadherence ForgetForget StigmaStigma Not real selfNot real self Losing funny sideLosing funny side Adverse effectsAdverse effects

Physical; sex; tension; feared brain damagePhysical; sex; tension; feared brain damage Incompatible with misused substancesIncompatible with misused substances

InconvenienceInconvenience Don’t need itDon’t need it Up to meUp to me No pointNo point

Attitudes of young people to stimulantsAttitudes of young people to stimulants

Harpur (2006, PhD thesis Southampton)Harpur (2006, PhD thesis Southampton) Predominantly positivePredominantly positive ““Adherence” is complex – individually chosen regimes, Adherence” is complex – individually chosen regimes,

often by parents (Singh, 2006, Am J Med Ethics: often by parents (Singh, 2006, Am J Med Ethics: “authenticity”) – adherence to what?“authenticity”) – adherence to what?

Ferrin (2007, MSc, London)Ferrin (2007, MSc, London) Questionnaire from Childrens Health Beliefs model: locus Questionnaire from Childrens Health Beliefs model: locus

of control, self-esteem, general beliefs on medicine, of control, self-esteem, general beliefs on medicine, knowledgeknowledge perceived threat and benefit perceived threat and benefit doctor-patient relationship doctor-patient relationship

Outcome and adherenceOutcome and adherence

Simpson et al BMJ 2006 333 15Simpson et al BMJ 2006 333 15 Metaanalysis: good adherence in about 50%; Metaanalysis: good adherence in about 50%;

predicts good outcome, predicts good outcome, even for placeboeven for placebo. . (“healthy adherer”)(“healthy adherer”)

Charach et al J Amer Acad CAP 43 559Charach et al J Amer Acad CAP 43 559 Adherence to stimulants over 5 years predicts Adherence to stimulants over 5 years predicts

good outcome, is predicted by youth, severity good outcome, is predicted by youth, severity of ADHD, no ODDof ADHD, no ODD

Attitudes of young people to stimulantsAttitudes of young people to stimulants

Project commissioned from LSE (Singh)Project commissioned from LSE (Singh) Qualitative interviewingQualitative interviewing Attitudes predominantly positiveAttitudes predominantly positive Negative aspects acknowledgedNegative aspects acknowledged

InconvenientInconvenient Stigmatising for someStigmatising for some Sleep/appetite problemsSleep/appetite problems

Better for some activities, worse for othersBetter for some activities, worse for others

What do patients ask for?What do patients ask for?

Understanding by othersUnderstanding by others Safe treatmentSafe treatment Knowledge of futureKnowledge of future Stop the bullyingStop the bullying Appreciation of the positiveAppreciation of the positive Time to talk with doctorTime to talk with doctor