Fiona McNicholasFiona McNicholas

Professor Child & Adolescent Psychiatry, UCDProfessor Child & Adolescent Psychiatry, UCDConsultant Lucena Clinic, Rathgar & Our Lady’s Consultant Lucena Clinic, Rathgar & Our Lady’s

Children’s Hospital, CrumlinChildren’s Hospital, Crumlin

Understanding and managing ADHD in Understanding and managing ADHD in children and adolescentschildren and adolescents

Parent Talk HADD in association with Lucena Foundation

20th September 2011

A Blitz…A Blitz…

HistoryHistory Diagnostic CriteriaDiagnostic Criteria AssessmentAssessment Treatment Treatment

Heinrich Hoffmann

German psychiatrist’s children’s book (1846)

First translated into English by Mark Twain

19501950 19801980 1968 19701968 1970 19871987 1994199419371937

Minimal Minimal Brain Brain

Damage/ Damage/ dysfunctiondysfunction Attention Attention

Deficit/Hyperactivity Deficit/Hyperactivity Disorder (Disorder (DSM-III-RDSM-III-R))

ADHD (ADHD (DSM-IVDSM-IV))

Hyperactive Hyperactive Child SyndromeChild Syndrome

Development of ADHD as a clinical entityDevelopment of ADHD as a clinical entity

1930193019021902

11stst Clinical Clinical Description Description

by Stillby Still

2010

DSM V?GenderAge/ onset

STROOP TEST

Hyperkinetic ReactionHyperkinetic Reactionof Childhood (of Childhood (DSM-IIDSM-II))

ADD ± HA (ADD ± HA (DSM-IIIDSM-III))

Adult ADHD StudiedAdult ADHD Studied

V. Douglas

19501950 198019801968 19701968 1970 1994199419371937

Efficacy of Efficacy of Amphetamine Amphetamine

(Bradley)(Bradley)

Development of treatments in ADHDDevelopment of treatments in ADHD

1930193019021902

Antipsychotics

1954 1st published study on MPH

1962-1993250 reviews3000 articles on stimulant effects

1966 161 RCT

Long acting medsRitalin LAConcertaAtomoxetineEquasym

2011

Newer DrugsGuanfacine

InattentionInattention HyperactivityHyperactivity

ImpulsivityImpulsivity

ADHDADHD

Diagnostic criteriaDiagnostic criteria(ICD/DSM)(ICD/DSM)

Over activity Over activity InattentionInattention Impulsivity Impulsivity Symptoms before age Symptoms before age

7 (6 ICD) 7 (6 ICD) Pervasive across Pervasive across

situation situation Cause impairment of Cause impairment of

social or educational social or educational functioning.functioning.

Not due to Autistic Not due to Autistic spectrum disorders, spectrum disorders, Psychotic or other Psychotic or other mental disorder mental disorder (anxiety, depression)(anxiety, depression)

Symptoms suggestive of Symptoms suggestive of InattentionInattention

• Forgetful in daily activitiesForgetful in daily activities• Loses things necessary for tasksLoses things necessary for tasks• Difficulty organising tasks/activitiesDifficulty organising tasks/activities• Does not seem to listen when spoken to directlyDoes not seem to listen when spoken to directly• Does not follow through on instructions and fails to finish Does not follow through on instructions and fails to finish

school work, chores or duties (not due to oppositional school work, chores or duties (not due to oppositional behaviour or failure to understand)behaviour or failure to understand)

• Fails to give close attention to details or makes careless Fails to give close attention to details or makes careless errors in schoolwork, or other activitieserrors in schoolwork, or other activities

• Difficulty sustaining attention in tasks or play activitiesDifficulty sustaining attention in tasks or play activities• Avoids, dislikes or reluctant to engage in tasks that Avoids, dislikes or reluctant to engage in tasks that

require sustained mental effortrequire sustained mental effort• Easily distracted by extraneous stimuliEasily distracted by extraneous stimuli

Symptoms suggestive of Symptoms suggestive of Hyperactivity/ImpulsivityHyperactivity/Impulsivity

Fidgets with hands or feet or Fidgets with hands or feet or squirms in chairsquirms in chair

Leaves seat in classroom or Leaves seat in classroom or other in which sitting is other in which sitting is expectedexpected

Runs about, climbs Runs about, climbs excessively in situations in excessively in situations in which it is inappropriate which it is inappropriate (restless)(restless)

Difficulty playing in activities Difficulty playing in activities quietlyquietly

‘‘On the go’ or ‘driven by a On the go’ or ‘driven by a motor’motor’

Talks excessivelyTalks excessively Blurts out answersBlurts out answers Difficulty awaiting turnDifficulty awaiting turn Interrupts or intrudes on Interrupts or intrudes on

othersothersA continuum-

STROOPSTROOP-read the words-read the words

(Skill)(Skill)

RED YELLOW GREEN BLUEGREEN RED BLUE YELLOWBLUE GREEN YELLOW REDYELLOW RED GREEN BLUERED YELLOW GREEN BLUEGREEN RED BLUE YELLOW

STROOPSTROOP-name the colour of the -name the colour of the

wordswords(Attention)(Attention)

RED YELLOW GREEN BLUE

GREEN RED BLUE YELLOW

BLUE GREEN YELLOW RED

YELLOW RED GREEN BLUE

RED YELLOW GREEN BLUE

GREEN RED BLUE YELLOW

RED YELLOW GREE BLUERED YELLOW GREE BLUE

GREEN RED BLUE YELLOWGREEN RED BLUE YELLOW

BLUE GREEN YELLOW REDBLUE GREEN YELLOW RED

YELLOW RED GREEN BLUEYELLOW RED GREEN BLUE

RED YELLOW GREEN BLUERED YELLOW GREEN BLUE

GREEN RED BLUE YELLOWGREEN RED BLUE YELLOW

RED YELLOW GREEN BLUE

GREEN RED BLUE YELLOW

BLUE GREEN YELLOW RED

YELLOW RED GREEN BLUE

RED YELLOW GREEN BLUE

GREEN RED BLUE YELLOW

Videos, television, computers, playing.

Skill but very little concentration required

Homework, math, schoolwork. Sustained attention requiredNeed to inhibit pre-potent response to label colours

Skill versus Attention and InhibitionSkill versus Attention and Inhibition

Skill RequiredSkill Required Sustained Attention RequiredSustained Attention Required

How common is ADHD?How common is ADHD? 3-5% children, 2% adults3-5% children, 2% adults

30-50% of children referred to child psychiatry clinics have 30-50% of children referred to child psychiatry clinics have ADHDADHD

More common in boys than girls 4:1- clinical referralsMore common in boys than girls 4:1- clinical referrals• 2.5:1 community2.5:1 community

Persists in 30-50% of patients into adolescence and Persists in 30-50% of patients into adolescence and adulthood (symptom profile may change)adulthood (symptom profile may change)

Ireland: Using 1-5% prevalence ratesIreland: Using 1-5% prevalence rates 0-14yrs 864,449 0-14yrs 864,449 (2006 Census)(2006 Census) 8,6448,644 – 43,000 <15yrs with ADHD – 43,000 <15yrs with ADHD

Associated school problemsAssociated school problems

Language impairment 15-75%Language impairment 15-75%

Learning Disability 15-40%Learning Disability 15-40%

Low Self esteemLow Self esteem

Poor social skillsPoor social skills

Labeled ‘trouble maker’Labeled ‘trouble maker’

Associated Family problemsAssociated Family problems

Poor relationship Poor relationship with parents with parents • often secondary often secondary

and improves with and improves with appropriate appropriate interventionintervention

Family History Family History ADHDADHD

Co-morbid Disorders Co-morbid Disorders

Oppositional Defiant

Disorder40%

Tics11%

Conduct Disorder14%

ADHD alone31%

Anxiety Disorder

34%

Mood Disorders 4% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096

Cause -hypothesisCause -hypothesis

Abnormal Dopamine signalling in Abnormal Dopamine signalling in the frontal cortex (executive the frontal cortex (executive functioning)functioning)

Deficiency of Noradrenaline in Deficiency of Noradrenaline in the reticular activating system the reticular activating system (RAS)(RAS)

the area of the brain the area of the brain responsible for balancing responsible for balancing other systems involved in other systems involved in learning, self-control, learning, self-control, inhibition and motivationinhibition and motivation

MGH-NMR Center & Harvard-MIT CITP. Bush, et al. Biol Psychiatry 1999;45:1542.

1 x 10-3

1 x 10-2

1 x 10-3

y = +21 mm y = +21 mm

Normal control ADHD

Anterior Cingulate Cortex

Frontal StriatalInsular network

• fMRI : Adult ADHD show decreased blood flow to the anterior cingulate and increased flow in the frontal striatum

• PET: Adults with ADHD show decreased cerebral metabolism compared with controls

Neuroimaging and ADHDNeuroimaging and ADHDStroop testStroop test

1 x 10-2

Assessment: History & ObservationsAssessment: History & Observations

Symptoms of ADHDSymptoms of ADHD• HomeHome• SchoolSchool• After school activitiesAfter school activities

Co-morbidityCo-morbidity• LDLD• MotorMotor• ODD/CDODD/CD• Other child psychiatric Other child psychiatric

disordersdisorders

Perpetuating factorsPerpetuating factors• FamilyFamily• TemperamentTemperament• EnvironmentEnvironment

InformantsInformants• ParentsParents• ChildChild• Teacher, Coach, play Teacher, Coach, play

school, clubs etcschool, clubs etc

TestsTests• Physical examination Physical examination

Rating scalesRating scales• Formal assessments Formal assessments

NEPS, SALT, OT, NEPS, SALT, OT, hearing, visionhearing, vision

04/11/2304/11/23Med Stu Teaching Pack Med Stu Teaching Pack

2020

Adults with A.D.H.D.Adults with A.D.H.D.

Clinical picture includes Clinical picture includes • inattention, impulsivity, disorganisation, inattention, impulsivity, disorganisation,

work/college and social problems, work/college and social problems, interpersonal problems which can lead to interpersonal problems which can lead to isolation, isolation,

Poor self esteem secondary to the Poor self esteem secondary to the experience of previous failureexperience of previous failure

Shifting focus of attention is often Shifting focus of attention is often problematic for patients with ADHDproblematic for patients with ADHD

04/11/2304/11/23Med Stu Teaching Pack Med Stu Teaching Pack

2121

Added items for AdultsAdded items for Adults Executive function Executive function Self regulationSelf regulation Self organisationSelf organisation PrioritisationPrioritisation Awareness of timeAwareness of time PlanningPlanning Memory FunctioningMemory Functioning

Consequences: UntreatedConsequences: Untreated

Features persist into adolescence (80%) & Features persist into adolescence (80%) & adulthood (65%)adulthood (65%)

Cantwell ’85 Cantwell ’85 • Developmental delay 30%Developmental delay 30%• Continual display 40%Continual display 40%• Developmental decay 30%Developmental decay 30%

ADHD is a specific risk factor forADHD is a specific risk factor for Conduct Disorder-overall 58% chance Conduct Disorder-overall 58% chance High rate of High rate of Drug/alcohol misuseDrug/alcohol misuse

0% 10% 20% 30% 40% 50% 60%

Fired from job

Incarcerated

Arrested

Serious car accident

Accident prone

Substance abuse

STD

Teen pregnancy

< high school

Repeat a grade

Subjects (%)

ADHD

Normal

Functional Impairment in Patients with ADHD Functional Impairment in Patients with ADHD Compared to Those WithoutCompared to Those Without

35%

40%16%

50%

30%

53%

52%

Biederman et al. Am J Psych 1995.

Treatment Treatment

Treatment OptionsTreatment Options

EssentialEssential• Diagnostic Report- sharing information with parents, Diagnostic Report- sharing information with parents,

school and GPschool and GP• Psycho-education (Support Groups)Psycho-education (Support Groups)• MedicationMedication• Treat any co-morbid conditionTreat any co-morbid condition• Parent ManagementParent Management

Additional: Additional: • Behavioural TreatmentBehavioural Treatment

Individual Cognitive-behavioural therapyIndividual Cognitive-behavioural therapy• Family TherapyFamily Therapy• Group work- social skillsGroup work- social skills

Medication-what works?Medication-what works?

Stimulants Stimulants • Most researched area in pediatricsMost researched area in pediatrics

>155 RCTs w >5,600 children for stimulants (Spencer et al, 96)>155 RCTs w >5,600 children for stimulants (Spencer et al, 96)

• Response rate:Response rate: 70% will respond to a stimulant70% will respond to a stimulant 85-90% to one of the 3 stimulants85-90% to one of the 3 stimulants Non-Adherence rates 20-65% Non-Adherence rates 20-65%

• Choice:Choice: MethylphenidateMethylphenidate DexamphetamineDexamphetamine Short or longer actingShort or longer acting

• Concerta/Ritalin LA/EquasymConcerta/Ritalin LA/Equasym• AtomoxetineAtomoxetine

Stimulants raise dopamine levelsStimulants raise dopamine levels

Stimulants raise dopamine levelsStimulants raise dopamine levelsMPH/ AmphetaminesMPH/ Amphetamines

Noradrenergic agents Noradrenergic agents can reduce arousalcan reduce arousalClonidine / GuanfacineClonidine / GuanfacineTCAs, venlafaxine, TCAs, venlafaxine, bupropion bupropion Atomoxetine (Raises Atomoxetine (Raises fromtal DOPA also by inh fromtal DOPA also by inh NA transporter)NA transporter)

‘‘Self Medication’Self Medication’ Risk of smoking in ADHDRisk of smoking in ADHD

• Nicotine an indirect DOPA agonistNicotine an indirect DOPA agonist• Nicotine positive effects on Nicotine positive effects on concentration concentration• + Trials of usefulness in ADHD – nicotine patch+ Trials of usefulness in ADHD – nicotine patch

Stimulant AbuseStimulant Abuse risk of misuse (both alcohol and drugs)risk of misuse (both alcohol and drugs)

Rate ADHD treated < controls < ADHD untreatedRate ADHD treated < controls < ADHD untreated Suggestion to be maintained need CBTSuggestion to be maintained need CBT

• Drug users don’t get a high from stimulantsDrug users don’t get a high from stimulants• Diversion may be a riskDiversion may be a risk

• Wilens et al, Pediatrics meta analysis 2003Wilens et al, Pediatrics meta analysis 2003

Possible treatments..Possible treatments..

Omega 3 Fatty acidsOmega 3 Fatty acids• Positive cognitive & Positive cognitive &

behavioural effects behavioural effects after 3months in DCDafter 3months in DCD

• Richardson et alRichardson et al Peds 2005Peds 2005

• Other subsequent Other subsequent studies negativestudies negative

Transcranial stimulationTranscranial stimulation

NeurofeedbackNeurofeedback

General Behaviour ManagementGeneral Behaviour Management

WHAT WORKS IN BEHAVIOURAL WHAT WORKS IN BEHAVIOURAL THERAPY?THERAPY?

Parent training is generally regarded as the most effective Parent training is generally regarded as the most effective behavioural therapybehavioural therapy

Parent training combined with medication management Parent training combined with medication management increases parent acceptability of medicationincreases parent acceptability of medication

School-based treatment is more effective than individual School-based treatment is more effective than individual strategies, however benefits are only seen during strategies, however benefits are only seen during treatment programmes and are not generalisedtreatment programmes and are not generalised

Individual treatment approaches have not been shown to Individual treatment approaches have not been shown to be effective be effective

Behavioural Treatment-for younger childrenBehavioural Treatment-for younger children

Identify problem situations and the precipitating Identify problem situations and the precipitating factorsfactors

Specific strategies Specific strategies – Reward / Cost system – Reward / Cost system

– – Time outTime out – Social reinforcement – Social reinforcement – Behaviour modelling – Behaviour modelling

Parent–child interactionsParent–child interactions• Enhance positive and limit negative interactionsEnhance positive and limit negative interactions

Kendall Therapist Manual 1992Kendall Therapist Manual 1992

Problem solving steps:Problem solving steps:

• Using 5 fingersUsing 5 fingers• Model sequence- Model sequence-

say out loud, then say out loud, then child repeats, then child repeats, then fadingfading

• Positive self Positive self coping statementscoping statements

• Use for homework Use for homework as well as as well as behaviour /social behaviour /social problemsproblems

1.1. What is my problem/task?What is my problem/task?

2.2. Look at all the Look at all the options/possibilitiesoptions/possibilities

3.3. Focus in-concentrate hard Focus in-concentrate hard and select oneand select one

4.4. Review progress or revise Review progress or revise decisiondecision

5.5. Praise yourselfPraise yourself

Consider your own feelings..Consider your own feelings..

Do what you can.. Do what you can.. ‘ACT’‘ACT’

God grant me serenity God grant me serenity • to accept the things that I to accept the things that I

cannot change, cannot change, • courage to change the things courage to change the things

that I can that I can • and wisdom to know the and wisdom to know the

difference. difference.

• Serenity Prayer St. Francis of Serenity Prayer St. Francis of AssisiAssisi

Hurt

Tired

Annoyed

Defeated

Angry

Rejected

Sad

And your perceptions...

It is how you interpret it…It is how you interpret it…

GuidelinesGuidelines

Web sites 1. http://www.chadd.org – Children & Adults with ADHD - Videos of a variety of well-known figures talking about ADHD, as well as

individual cases & families talking about their experiences. Directed towards parents/adults a little more than children. http://www.chadd.org/Content/CHADD/EspeciallyForPress/CHADD_Video.htm

2. http://www.nimh.nih.gov/media/video/adhd.shtml - Educational video by ADHD researchers talking about symptoms & treatment. Aimed at parents. Some audio features as well.

3. http://www.incadds.ie/ - does not have any videos on the site itself. Has links to a lot of useful ADHD sites. Appears to be the main site for info & support on ADHD in Ireland according to ADHD Europe (http://www.adhdeurope.eu/home.html).

4. http://www.hadd.ie/home.htm - the other site listed on the ADHD Europe website. It offers membership to the site & has a range of videos on ADHD to be rented for a small fee. Videos cannot be viewed on the website itself, and cannot be rented by non-members.

HADD

Web ToolkitsSimple road maps to help parents/carers, children and teachers find the right tools at the right timeDiscussion guides to structure discussions at critical points in the child’s schoolingDownloadable tools to help provide a consistent approach to supporting a child, and work in effective partnership.

http://www.adhdandyou.ie

• 5 section headings (green)• Section content shown in blue• Detailed content shown in accompanying Word doc

Resources Resources

DBT TherapyCBT

Collaborative Problem Solving

www.sosprograms.comwww.sosprograms.com

The EndThe End

Medical Costs Are Greater in Children With ADHDMedical Costs Are Greater in Children With ADHD

Leibson CL, et al. JAMA. 2001;285:60-66.9 year FU of >4000 children

26%

41%

81%

18%

33%

74%

0

10

20

30

40

50

60

70

80

90

Inpatient hospitaladmission

Outpatienthospitaladmission

Emergencyadmission

ADHD (n=309) Non-ADHD (n=3810)

P<0.001

P<0.006

P<0.005

$4306

$1944

$0

$500

$1000

$1500

$2000

$2500

$3000

$3500

$4000

$4500

ADHD Non-ADHD

Overall medical costs

1987 to 1995

% t

ota

l co

ho

rt

Med

ical

co

st o

ver

9 ye

ars

(199

5 n

atio

nal

avg

. do

llars

)

N=4119

P<0.001

Action of StimulantsAction of Stimulants Dopamine:Dopamine:

• Releases DOPA and Blocks re-uptake via the DOPA Releases DOPA and Blocks re-uptake via the DOPA transportertransporter

• Reduces DOPA transporter density Reduces DOPA transporter density • Leads to increased dopamine at nerve endingsLeads to increased dopamine at nerve endings

Noradrenaline:Noradrenaline:• Increase levels of NA in the RASIncrease levels of NA in the RAS

Behavioural effect:Behavioural effect:• 75% will show normalising levels of inattention, 75% will show normalising levels of inattention,

hyperactivity and impulsivityhyperactivity and impulsivity• Improvement in academic output (70%) and accuracy Improvement in academic output (70%) and accuracy

(50%)(50%)

v v Storagevesicle

DA Transporter

Cytoplasmic DA

Methylphenidate blocks

reuptake

Presynaptic NeuronePresynaptic Neurone

SynapseSynapseWilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513.

Amphetamine blocks

reuptake

Amphetamine blocks

Mechanism of Action of StimulantsMechanism of Action of Stimulants

Once a day preparationsOnce a day preparations *Concerta (OROS) *Concerta (OROS) 22% and 78%22% and 78% Metadate ERMetadate ER 30% and 70%30% and 70% BiphentinBiphentin 40% and 60%40% and 60% FocalinERFocalinER 50% and 50%50% and 50% *RitalinLA*RitalinLA 50% and 50%50% and 50% AdderallXRAdderallXR 50% and 50%50% and 50% MedikinetMedikinet 50% and 50%50% and 50% Methylphenidate Patch (Daytrana)Methylphenidate Patch (Daytrana) Single doseSingle dose *Strattera*Strattera QD doseQD dose LisdexamfetamineLisdexamfetamine (Vyvanse)(Vyvanse) QD doseQD dose Guanfacine Extended ReleaseGuanfacine Extended Release QD doseQD dose

Release Mechanisms Different and Patented* Available in Ireland

Side effectsSide effects• Common:Common:

GI-Nausea, Anorexia, PainGI-Nausea, Anorexia, Pain• Concerns re height & weight Concerns re height & weight • FU over 2 yrs slightly less weight gain (0.72kg) and less height gain FU over 2 yrs slightly less weight gain (0.72kg) and less height gain

(0.67 cm) than expected (Gadow et al, 99)(0.67 cm) than expected (Gadow et al, 99) HeadacheHeadache InsomniaInsomnia Irritability or sadnessIrritability or sadness

• Less common:Less common: Mild increase in HR or BP (10 beats -clinically NS)Mild increase in HR or BP (10 beats -clinically NS) Rebound effectRebound effect Psychosis rarePsychosis rare Cardiovascular risk if pre-existing diseaseCardiovascular risk if pre-existing disease AggressionAggression

• MPH Fewer s/e than dexamphetamine (Conners,71)MPH Fewer s/e than dexamphetamine (Conners,71)