Download No Slide Title

ATTENTION DEFICIT
HYPERACTIVITY DISORDER
Dr Wendy Vogel
Child and Adolescent Psychiatrist
Head, Division of Child & Adolescent Psychiatry,
Red Cross War Memorial Children’s Hospital
and University of Cape Town
OVERVIEW
•
•
•
•
•
History of ADHD
Update on DSM V
Assessment & Management of ADHD
Oppositional Defiant Disorder
When to refer
HISTORY OF ADHD
• 1798:Sir Alexander Crichton
 Attention and its diseases: A distraction of
attention does not have to be pathological; can
be “born with a person”
 Can also be caused by new disease and
generally diminished with age
 Hyperactivity not described
• 1809-1894: Heinrich Hoffmann
 Impulsive insanity/defective inhibition
Sir George Still (1868-1941)
•
•
•
•
•
Scientific starting point of history of ADHD
Motor agitation
Attention problems
Difficulty controlling impulses
Deficit of moral control (stigma)
• MBD
History of ADHD
1934: Kramer & Pollnow:
• Hyperkinetic disease of infancy
1937: Bradley:
• first Rx of ADHD with benzedrine
1944: Panizzoni
• methylphenidate (ritalin)
• Is the most effective and widely used
medication
DSM
• DSM-II Hyperkinetic reaction
of childhood
Overactivity, restlessness,
distractibility,short attention span,
especially in young children; the
behavior usually diminishes by
adolescence” (1968)
• DSM-III (1980)
Attention deficit
disorder: with/out
hyperactivity
• DSM
111R,(1987)IV,(1994)
IVR (2000)
DSM V
(2013)
Attention deficit
hyperactivity disorder
PREVALENCE:
•
•
•
•
3-10% children & adolescents
2 -5 % adult population
Universal among human population
USA: 2 – 20% UK: 3-9% ( 50% increase)
• M:F 3-4:1
WHY ?
AETIOLOGY
'
'
'
'
Very strong biological contributions
Genetic / hereditary (genes DAT1, DRD4 etc)
Peri-natal problems (prem & low birth weight)
In utero exposure to tobacco smoke
UPDATE ON DSM V:
Neurodevelopmental disorders:
• ADHD
• ASD
• Communication Disorders
• Intellectual Disability
• Specific learning disability
• Motor disorders (Tics, stereotypical
movement & DCD)
UPDATE ON DSM V:
• Several symptoms in each setting
• Symptoms present prior to age 12 years
(cf 7)
• Can diagnose with comorbid ASD
• Lower threshold for adults/adolescents
• (5cf 6)
• Specifiers
ADHD – DSM V
•
•
•
•
Symptoms for at least 6 months
Inconsistent with developmental level
Negative impact on social, school/work
Symptoms are not solely a manifestation
of oppositional behaviour,
defiance,hostility or failure to understand
tasks ( ie LD)
• Present before aged 12 years
HYPERACTIVITY/IMPULSIVITY
•
•
•
•
•
Fidgets,squirms
Leaves seat
Runs or climbs
Unable to play quietly
On the go/driven by a
motor
• Talks excessively
• Blurts out answers
• Difficulty waiting turn
• Interrupts
• Impaired response
inhibition, impulse control
or the capacity to delay
gratification
• inability to stop and think
before acting/doing
INATTENTION
(6 or more (5))
• Fails to give close
attention/careless
• Can’t sustain
attention
• Does not listen
• Cannot follow
through/tasks
incomplete
• Difficulty organising
tasks
• Avoids mental effort
• Often loses things
• Easily distracted
• Forgetful
OTHER BEHAVIOURS SEEN
•
•
•
•
•
•
Insatiability
Social clumsiness
Poor co-ordination
Disorganisation
Forgetting to do things or poor working memory
Delayed development of internal language and rule
following
• Difficulties with regulation of emotions, motivation
and arousal
• Diminished problem solving ability and flexibility
Changes in ADHD symptoms from
childhood to adulthood
Preschool
years
Primary
school years
Adolescence
Adulthood
Inattention
Short play
Incomplete
activities
Not listening
Brief activities
Changes
activity
Forgetful,
disorganised
distracted
Less
persistence
Lack of focus
on details
Poor planning
Incomplete
details
Forget appts
Lack of
foresight
Overactivity
whirlwind
Restless
hyperactive
fidgety
Subjective
feelings of
restlessness
Impulsivity
Does not
listen
No sense of
danger
Acts out of
turn
Interrupts
Intrusive
thoughtless
Poor self
control
Reckless risk
taking
Accidents
Impatience
Premature
decision
making
SPECIFIERS:
• Combined
(hyperactive,impulsive & inattentive)
• Predominantly inattentive
(inattention but not hyperactive/impulsive)
• Predominantly hyperactive/impulsive
(no inattention)
ADHD in females
•
•
•
•
•
•
•
Underdiagnosed & misdiagnosed (mood)
High levels of inattention
Less disruptive & low levels of hyperactivity
? Less severe form
Hormonal changes in adolescence (oest)
Greater risk of substance abuse
Respond well to medication & behaviour
intervention
• Environmental demands increase may become
more obvious
ASSESSMENT
• Paed/child psych/GP/HCP with expertise in ADHD
• Full developmental, medical (CARDIAC HISTORY)
and psycho-social history
• Assessment of needs
• CO-EXISTING CONDITIONS,
• School information
• Psychometric assessments (exclude a LD)
• Rating scales (SNAP) www.adhd.net
• Meet DSM V or ICD 10 criteria and moderate impairment
in more than 1 setting
• SPEAK TO THE CHILD !
• Assess the parents
STROOP TEST
(selective attention)
• Measures attention. It takes advantage of our ability to
read words more quickly and automatically than naming
colors.
• Cognitive mechanism in this task is directed/selected
attention: one has to manage one’s attention, inhibit or
stop one response in order to say or do something else.
PHYSICAL EXAM
• Exercise syncope, breathlessness and
cardiac symptoms
• H.R and B.P.
• Family hx of cardiac disease: CVS exam
• ECG if fam hx of serious cardiac disease
or sudden death
• Weight and height
• Risk assessment for substance
misuse/drug diversion
DIAGNOSIS MADE:
WHAT NEXT?
ADHD
alone
31%
Oppositional
Defiant
Disorder
40%
Anxiety ?ASD
Tics
11%
Mood
Disorders
Disorder
4%
34%
Conduct
Disorder
14%
•
Swedish study
• 85% of children with ADHD had 1 or
more co-morbid disorders
• 67% had at least 2 co-morbid disorders
•
•
LEARNING DISABILITIES
AUTISM
ESSENCE
(Early symptomatic syndromes eliciting neurodevelopmental
examinations)
Co existence of disorders (including ADHD,
ODD, Tic disorder, DCD, ASD)
& sharing of symptoms across disorders is
the rule
(C.Gillberg.Research in Developmental Disabilities 31 (2010) 1543-1551)
ESSENCE
(Early symptomatic syndromes eliciting neurodevelopmental
examinations)
• Impairing child symptoms (3-5 years)
•
•
•
•
•
•
•
•
•
General development
Communication & language
Social interrelatedness
Motor co-ordination
Attention
Activity
Behaviour
Mood
Sleep
 Major problems in 1 domain indicate major problems in
the same or overlapping domains many years later
 EARLY INTERVENTION
TREATMENT:
• PHARMACOLOGY
Stimulants
Non-stimulants
• NON-PHARMACOLOGY
Psychosocial management
Dietary interventions
Psychological interventions
Psycho-social management:
•
•
•
•
•
•
•
•
Psycho-education: parent/child/school
Develop therapeutic alliance
Promote consistent parenting
Parent-child relational work
Address parents’ ADHD etc
Behavioural intervention (+ve reinforcement etc)
Group therapy (social skills
O.T. and S.A.L.T.
PSYCHOLOGICAL
TREATMENT
• Cognitive training
 Attention and working memory training
• Behavioural interventions
 Parent training
 Parent-child training
 Parent-child plus teacher training
 CBT with child
DIETARY TREATMENT:
• Restricted elimination diets
 Need better evidence
• Artificial food colour exclusions
 Larger Rx effect (if food sensitivities)
• Free fatty acid supplementation (EPA/DHA)
 Small reduction in ADHD symptoms ?clinical
significance
DIETARY TREATMENT:
• NICE: general advice that a healthy balanced diet and
exercise should be recommended for all with ADHD
• CAUTIONS about lack of concrete evidence:
• It discourages removal of artificial food colourants and
additives from the diet
• If link seen need a food diary and dietician referral
• Opposes fatty acid supplementation
MEDICATION:
Stimulant:
Non stimulant:
Methylphenidate
SHORTACTING/IMMEDIATE
RELEASE
Ritalin (3-4 hours)
INTERMEDIATE RELEASE
Ritalin LA (8 hours)
LONG ACTING/MODIFIED
RELEASE
Concerta XL (12 hours)
• atomoxetine,
• extended-release
guanfacine ER
clonidine ER
Relative stimulant contraindications
–
–
–
–
–
–
–
–
–
–
–
Psychotic disorders
Severe Tourette’s ? No longer
MAOI (> 2/52 washout)
Active substance abuse (pt or family)
Unstable seizure disorder
Structural cardiac defects
Unstable HPT
Unstable cardiovascular disorder
Hx of S/E on stimulants
Pregnancy
Child < 3years
NON-STIMULANT MEDS
Atomoxetine (licensed)
• a selective noradrenaline reuptake inhibitor (SNRI)
• may cause a secondary increase in dopamine levels
• ADHD with comorbid anxiety disorders
• history of substance misuse (diversion)
• Compared to stimulants, slower onset of action but can
be taken once daily.
• Starting dose is 0,5mg/kg/day to 1,2mg/kg/day maximum
2,1mg/kg/day
NON STIMULANT MEDICATION:
• Clonidine and guanfacine are alpha-2
agonists with demonstrated efficacy in the
treatment of ADHD.
• Guanfacine is more selective than
clonidine causing fewer adverse effects
such as somnolence.
• Can also be used for patients with
comorbid tic disorders in which its efficacy
seems to be higher.
NEW MEDICATIONS:
• Lisdexamphetamine is an inactive
component (prodrug) that is gradually
converted into an active form of dextroamphetamine in the body.
• Due to its gradual conversion, effect of
Lisdexamphetamine is prolonged − up to
13 hours − thus not needing repeated
doses during the day.
CHOICE OF MEDICATION:
• Methylphenidate, (dexamphetamine), atomoxetine are
recommended within their licensed indications
• Choice of Rx based on
– Co-morbid conditions (eg tics/epilepsy)
– Tolerability, adverse effects
– Convenience of dosing ( compliance/schools)
– Potential for diversion
– Patient/ parent preference
• If >1 Rx suitable, prescribe Rx with lowest cost
Side-Effects Rating Scale
Name:
………………………………………………………….
Date:
……………………..
Person completing this form: ………………………………………………………………
Behaviour
No Problem
Serious Problems
Difficulty getting off to sleep
0
1
2
3
4
5
6
7
8
9
10
Difficulty in staying asleep
0
1
2
3
4
5
6
7
8
9
10
Nightmares
0
1
2
3
4
5
6
7
8
9
10
Loss of appetite
0
1
2
3
4
5
6
7
8
9
10
Stomach aches
0
1
2
3
4
5
6
7
8
9
10
Headaches
0
1
2
3
4
5
6
7
8
9
10
Tics
0
1
2
3
4
5
6
7
8
9
10
Nervous movements
0
1
2
3
4
5
6
7
8
9
10
Feeling dizzy
0
1
2
3
4
5
6
7
8
9
10
Feeling sick
0
1
2
3
4
5
6
7
8
9
10
Feeling drowsy
0
1
2
3
4
5
6
7
8
9
10
Feeling irritable
0
1
2
3
4
5
6
7
8
9
10
Feeing unhappy
0
1
2
3
4
5
6
7
8
9
10
Crying a lot
0
1
2
3
4
5
6
7
8
9
10
Loss of interest in others
0
1
2
3
4
5
6
7
8
9
10
Day dreaming
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
How easy is he/she to
manage
Any other different behaviour:
Side effects:
• Loss of appetite & LOW. Measure weight before Rx then
every 3-4 months. Plot
• Growth delay Measure height before Rx then every 3-4
months (ref endocrinologist)
• Insomnia: gather information before Rx
• CVS side effects Monitor BP pulse every 3-6months
• Hepatotoxicity, increase in hepatic enzymes,
bilirubin and jaundice (Atomoxetine)
• emergent suicidal behaviors
Sleep disturbance:
• Sleep diary
• Polysomnography if suspect sleep breathing
disorder episodic nocturnal phenomena, limb
movements
• Monitor
• Stop medication
• Add small dose if rebound
• Add melatonin
• Change stimulant
579 children with ADHD (c.t.)
Age 7 to 9,9 years
14 months Rx
Behaviour
Medication
MTA STUDY
Medication
Plus
behaviour
Community
Care
(Arch Gen Psych Vol 56, Dec 99)
RESULTS (1): M.T.A. STUDY
All 4 groups showed decreased
symptoms with significant differences
in degrees of change.
For most ADHD symptoms:
Combined Rx and medication Mx best
with no significant difference between
them.
(Arch Gen Psych Vol 56, Dec 99)
RESULTS (2): M.T.A. STUDY
• Oppositional/Aggressive symptoms
• Internalising symptoms
• Social Skills
• Parent-child relations
• Reading achievement
Combined Rx superior to Med Rx, B.T. &
C.C.
Arch Gen Psych Vol 56, Dec 99)
MTA
After 14 months, the MTA became an
uncontrolled naturalistic study: children were
allowed any treatment and followed up even
if treatment was abandoned.
MTA STUDY
• 3,6,8 years after enrolment there were no
significant group differences although the initial
improvement was maintained.
• Participants still taking medication by 6 and 8
years performed no better than their nonmedicated counterparts despite a 41% increase
in the average total daily dose.
“The sobering results of the MTA
suggest that maintaining a good
treatment response probably requires
a sustained effort that takes into
account long-term academic and
behavioral problems commonly
associated with ADHD and adapts to
the demands of adolescence.
Medication may continue to be helpful
for some teenagers, but their needs
should be re-evaluated periodically. A
child’s initial clinical presentation,
including symptom severity, behavior
problems, social skills and family
resources, may predict how they will
function as teens more so than the
type of treatment they receive. “
“ADHD is not just an issue of temperament or the
teacher’s need to maintain order in the
classroom. ADHD is a real disorder with
significant morbidity which places children at risk
for the development of antisocial disorders,
substance abuse, academic
underachievement,mood disorders…”
Newcorn (CNS Spectrum Vol. 5,6 June,2000)
OPPOSITIONAL DEFIANT DISORDER
(DSM V: Disruptive,Impulse-control, and Conduct
disorders)
• Angry/Irritable Mood
 Often angry & resentful
 Often touchy or easily annoyed
 Often loses temper
• Argumentative/defiant behaviour




Often argues with adults
Often deliberately annoys or irritates
Often blames others for his mistakes
Often actively defies or refuses to comply
• Vindictiveness
 Often spiteful & vindictive
DIFFERENTIAL DIAGNOSES
•
•
•
•
Anxiety disorders such as phobias or OCD
Autism
Sensory sensitivities
Depression
• Bullying
• Failure at school due to LD
RISK FACTORS:
•
•
•
•
•
•
•
•
Genetic
Neurobiological markers(H.R./Cortisol)
Age of onset
Temperament
Peer influences
Callous & unemotional traits
Neighbourhoods
Family factors & influences
TREATMENT
•
•
•
•
•
Parent Management training
The Incredible Years (Webster-stratton)
Play, praise, rewards, limit setting
Triple P
Proud2bme (Cape Town)
• Rx triggers/aetiology
GOALS OF TREATMENT:
For parents:
• Improve positive parenting skills
• Enhance problem solving conflict resolution &
communication
For the child:
• Develop effective communication,problem solving and
anger management
For the family
• Family counselling & support to deal with the stresses in
their relationships and home environment
In the classroom
• teacher to provide social skills, problem solving
• Promote compliance
NEW MEDICATIONS:
No medication for Rx of ODD
NEW medications:
Alpha 2 receptor agonists:
• Guanfacine and clonidine
• G is relatively more selective for alpha 2 A
agonists
• Controlled release Guanfacine ER may be
useful for ADHD and ODD
• Clonidine: used off label for ADHD and ODD
HELPFUL HINTS
•
•
•
•
•
•
Always look for co-morbidity
Treat co-morbidity (school,OT,SALT)
Girls are mis/underdiagnosed
Review need for ongoing Rx
ODD may be something else
SPEAK TO THE CHILD!
When to refer to psychiatry
•
•
•
•
If unsure of diagnosis
Parents requesting 2nd opinion
< 6years;
Complex diagnosis (ADHD with tics/ OCD/
non-responding depression)
• GP: max 1mg/kg/d methylphenidate
• Poor response to treatment
BOOKS
Nice guidleines
REFERENCES:
•
•
•
•
•
MTA Cooperative group A 14 month randomised clinical trial of treatment strategies
for ADHD. Arch Gen Psychiatry 56: 1073-1086
NICE: Methylphenidate, Atomoxetine and dexamphetamine for ADHD in children and
adolescents.2006
SIGN GUIDELINES
Taylor et al European Clinical guidelines for hyperkinetic disorder ( First upgrade) Eu.
Child Adolesc Psychiatry (Suppl 1) 13:1-30
Practice Parameters for the Assessment and treatment of ADHDD JAACAP
1997/2002