Download Attention-Deficit / Hyperactivity Disorder

Attention-Deficit /
Hyperactivity Disorder
Ross Andelman, M.D.
Contra Costa Children’s Mental Health
CCRMC Noon Lecture Series
September 8th 2009
ADHD Diagnosis
“A persistent pattern of inattention
and/or hyperactivity-impulsivity that is
more frequent and severe than is
typically observed in individuals at
comparable level of development.”
DSM IV, APA 1994
ADHD: Current Perspective
Highly prevalent in community studies
Extremely prevalent in clinical samples
Developmental disorder
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Presents in childhood (before age 7)
Persists into adolescence and into adulthood
Neurobiological disorder
Disorder of executive function
Spectrum ‘heterogeneous’ disorder
Highly inheritable
Responsive to appropriate treatment
ADHD Etiology
-Genetics
Up to 92% concordance in monozygotic twins
Heritability - .75 (twin studies)
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Comparable to schizophrenia
Panic - .48; Height - .92
Siblings - 26-50% in full; 9% in half
First degree family members – 20-25%
Dopamine transporter gene (DAT1), chr 5
Dopamine receptor D4 (DRD4*7), chr 11
ADHD: D/O of Executive Fxn
Shifting from one mindset to another flexibility
Organization - anticipating needs & problems
Planning - goal setting
Working memory (short-term) - receiving,
storing, retrieving information
Separating affect from cognition - detaching
emotions from reason
Inhibiting and regulating verbal and motoric
action - jumping to conclusions too quickly,
difficulty waiting in line in an appropriate
fashion
ADHD, DSM IV Diagnosis
6 of 9 Sxs of inattention and/or
6 of 9 Sxs of hyperactivity-impulsivity
Sxs present for more than 6 months
Presence of some Sxs before age 7
Impairment in 2 or more settings
Clear evidence of significant social, academic,
or occupation impairment
Symptoms not secondary to other Dx
ADHD, DSM IV
–Inattentive Symptoms
Fails to give close attention; makes careless
mistakes
Has difficulty sustaining attention
Does not seem to be listening when spoken to
Does not follow through; fails to finish tasks
Difficulty organizing tasks
Avoids tasks requiring sustained mental effort
Often loses things
Easily distracted by extraneous stimuli
Forgetful in daily activities
ADHD, DSM IV
-Hyperactivity-Impulsivity Symptoms
Fidgets or squirms
Unable to stay in seat
Runs and climbs excessively
Difficulty playing quietly
On the go (driven by a motor)
Talks excessively
Blurts out answers
Difficulty waiting turn
Interrupts or intrudes on others
ADHD, Presentation
-Preschool
Hyperactivity the rule
Frequent temper tantrums
Impulsive aggression toward peers
Fearlessness with frequent injuries
Noncompliance with preschool rules & decorum
Demanding and argumentative with parents
Sleep disturbance
Delays in motor-language development
ADHD, Presentation
-Elementary Age
Difficulty, especially with challenging work
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Homework disorganized, messy, with careless errors
Easily distracted, unable to sustain attention
Difficulty forming & keeping peer relationships
Denny Cantwell's 'lack of social savoir-faire'
Perceived as poorly controlled, disrespectful,
disruptive, class clown, immature, bad
Impulsivity and noncompliance now result in
trips to the principal's office
ADHD, Presentation
-Adolescence
From 'on the go' to fidgety and restless
School performance inconsistent
If not yet diagnosed, likely to be intelligent
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Poor organization & poor follow through
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Persistent high risk behavior
Bike and auto accidents
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Drug and alcohol use
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Lack of social skills now impacts on both
same-sex and opposite-sex relationships
ADHD, Presentation
-Adults
Failure to meet educational and career goals
Poor organization, time management, and Procrastination
Interpersonal instability at home and at work
Poor social skills 'grown up‘
Short fuse, irritability
Inability to maintain long-term relationships
May still be restless or fidgety
May be drawn to high risk activities &
substance abuse
May have legal problems
May have low self-esteem
ADHD - Assessment
Diagnostic Bottom Line
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Diagnostic interviews with parents & child or
adult +/- spouse/ co-worker
Rating scales – e.g. SNAP, Vanderbilt,
Conners, & Adult ADHD checklists
Frills and Extras
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Observation of behavior in natural contexts
Medical and / or neurological evaluation
Cognitive, psycholinguistic, and psychoeducational testing
ADHD, Initial Assessment
-Goals
Determine presence of core symptoms (Sxs)
Rule out alternate explanations for symptoms
Assess for co-morbid conditions
Obtain baseline ratings of symptom severity
and functional impairment
Educate family about disorder
Dispel myths and normalize condition
ADHD, Initial Assessment
-Interview and History
Symptom & impairment history
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How long / how bad / where / when
Family’s understanding of problem
What has helped? What has not?
Past mental health history
Birth, development, and medical history
Social and educational history
Family and home environment
Family psychiatric history
Individual and family strengths and resources
ADHD, Treatment
-Goals
Reduce core symptoms of ADHD
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Establish individual target symptoms
Improve functioning in all areas of
impairment
Assess for and attend to co-occurring
conditions
Minimize adverse effects of therapy
ADHD, Treatment
Treatment is Multimodal!
Psycho-Education
Psycho-Pharmacology
Psycho-Social
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Educational Interventions
Parent Training and Support
Social Skills Training
Recreational Mainstreaming
Individual and Group Psychotherapies
ADHD
Psychopharmacology
ADHD, Treatment
-Psychopharmacology
Symptoms likely to respond to medication
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Inattention
Impulsivity
Hyperactivity
Non-compliance with authority
Impulsive aggression
Social deficits
Academic performance
ADHD, Treatment
-Psychopharmacology
ADHD, Treatment
-Psychopharmacology
 Psychostimulants
MPH, dextroamphetamine, mixed amphetamines
>200 double-blind random controlled trials (RCTs)
Typical investigations of efficacy usually quite brief
 Other medications found effective in RCTs
Tricyclic Antidepressants (>18 trials)
Atomoxetine
Buproprion
alpha-2 agonists
 Promising, efficacy not yet fully established
Venlafaxine, Nicotine, modafinil, donepezil
ADHD, Psychopharmacology
-? Adverse effects of stimulants
Weight loss; Sleep disturbance;
Mood lability
? Risk of sudden death
? Induce tics
? Height suppression
? Dependence
? Drug abuse
ADHD, Psychopharmacology
-Stimulants
The Andelman (Cantwell-UCLA) Algorithm
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Trial of one of the long-acting formulations,
titrating dose weekly, and monitoring benefits
and side effects through parent and child
interviews, and teacher serial checklists
 Concerta 18mg – 36 mg – 54 mg qAM;
 Metadate CD 20mg – 40 mg - 60mg qAM;
 Dexadrine Spansule 10 mg – 20 mg - 30mg qAM;
 Adderall XR 10 mg – 20 mg -30mg qAM
 Vyvance 20mg – 30 mg – 40 mg – 50 mg qAM
ADHD, Psychopharmacology
-Beyond Stimulants
Atomoxetine (Strattera)
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Initiate 0.5mg/kg/D qAM or 10mg
Titrate alt weekly to 1.2mg/kg or 80mg Max
Bupropion (Wellbutrin [SR])
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Initiate 3mg/kg/D qAM to TID [BID for SR]
Titrate weekly to 7mg/kg/D or 400mg Max
Clonidine (Catapres) or Guanfacine (Tenex)
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Initiate 0.05mg qHS (.5mg Guanfacine)
Titrate weekly to .05mg TID (.5mg Guanfacine),
then to .1mg TID Max (1mg TID Guanfacine)
ADHD, Treatment
-Psychosocial interventions
• Behavioral parent support & training
•
Bibliotherapy / Organizational support
• Behavioral classroom interventions
• Social skills group therapy
• Individual psychotherapy
•
Unfortunately not all that useful
ADHD, Treatment
-Parent training
ADHD, Psychosocial Treatment
-Parent Training
Normalize hygiene – food and sleep
Consistency in expectations / discipline
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Positive reinforcement
Homework & Chores
Provide structure and predictability
Modeling good organizational skills
Home-school-clinician communication
Exercise & relaxation
ADHD, Psychosocial Treatment
-Parent Training –Behavioral Mod
 Positive attending
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Catch the child doing good: Be specific!
 Contingency contracting
 Identifying “target behaviors”
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Establishing behavioral baseline
Ignoring low-level negative behaviors
 Creating positive reward systems
 Selected use of “punishment”
 Shaping, cueing, modeling
Parent Training
-Creating positive rewards
Parent Training
-Creating positive rewards
-Parent Training
Selective ignoring
ADHD, Psychosocial Treatment
-School-based interventions
ADHD, Psychosocial Treatment
- Self Discipline (Adult)
Normalize hygiene
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Food and sleep
Exercise & relaxation
Structure and predictability
Developing good organizational skills
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Attention to schedule, deadlines, & priorities
ADHD, Treatment
-Psycho-Education: Bibliotherapy
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Driven to Distraction: Recognizing and Coping with Attention
Deficit Disorder from Childhood through Adulthood,
Hallowell and Ratey, 1995.
Attention Deficit Hyperactivity Disorder: What Every Parent
Wants To Know, Wodrich, 1994.
ADHD 102: Practical Strategies for Reducing the Deficit,
Frank and Smith, 2001.
Getting a Grip on ADD: A Kids Guide to Understanding and
Coping With Attention Disorders,
Frank and Smith, 1994.
I Would If I Could : a Teenagers Guide ADHD Hyperactivity,
Gordon, 1992.
ADHD Treatment
QUESTIONS?