Presentation on theme: "ATTENTION DEFICIT HYPERACTIVITY DISORDER"— Presentation transcript:
1ATTENTION DEFICIT HYPERACTIVITY DISORDER Dr Wendy VogelChild and Adolescent PsychiatristHead, Division of Child & Adolescent Psychiatry,Red Cross War Memorial Children’s Hospitaland University of Cape Town
2OVERVIEW History of ADHD Update on DSM V Assessment & Management of ADHDOppositional Defiant DisorderWhen to refer
3HISTORY 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 ageHyperactivity not described: Heinrich HoffmannImpulsive insanity/defective inhibition
6Sir George Still ( )Scientific starting point of history of ADHDMotor agitationAttention problemsDifficulty controlling impulsesDeficit of moral control (stigma)MBD
7History of ADHD 1934: Kramer & Pollnow: Hyperkinetic disease of infancy1937: Bradley:first Rx of ADHD with benzedrine1944: Panizzonimethylphenidate (ritalin)Is the most effective and widely used medication
8DSM DSM-III (1980) Attention deficit disorder: with/out hyperactivity DSM-II Hyperkinetic reaction of childhoodOveractivity, restlessness, distractibility,short attention span, especially in young children; the behavior usually diminishes by adolescence” (1968)DSM-III (1980)Attention deficit disorder: with/out hyperactivityDSM 111R,(1987)IV,(1994) IVR (2000)Attention deficit hyperactivity disorderDSM V(2013)
9PREVALENCE: 3-10% children & adolescents 2 -5 % adult population Universal among human populationUSA: 2 – 20% UK: 3-9% ( 50% increase)M:F 3-4:1WHY ?
11UPDATE ON DSM V: Neurodevelopmental disorders: ADHD ASD Communication DisordersIntellectual DisabilitySpecific learning disabilityMotor disorders (Tics, stereotypical movement & DCD)
12UPDATE ON DSM V: Several symptoms in each setting Symptoms present prior to age 12 years (cf 7)Can diagnose with comorbid ASDLower threshold for adults/adolescents(5cf 6)Specifiers
13ADHD – DSM V Symptoms for at least 6 months Inconsistent with developmental levelNegative impact on social, school/workSymptoms are not solely a manifestation of oppositional behaviour, defiance,hostility or failure to understand tasks ( ie LD)Present before aged 12 years
14HYPERACTIVITY/IMPULSIVITY Difficulty waiting turnInterruptsImpaired response inhibition, impulse control or the capacity to delay gratificationinability to stop and think before acting/doingFidgets,squirmsLeaves seatRuns or climbsUnable to play quietlyOn the go/driven by a motorTalks excessivelyBlurts out answers
16INATTENTION (6 or more (5)) Fails to give close attention/carelessCan’t sustain attentionDoes not listenCannot follow through/tasks incompleteDifficulty organising tasksAvoids mental effortOften loses thingsEasily distractedForgetful
17OTHER BEHAVIOURS SEEN Insatiability Social clumsiness Poor co-ordinationDisorganisationForgetting to do things or poor working memoryDelayed development of internal language and rule followingDifficulties with regulation of emotions, motivation and arousalDiminished problem solving ability and flexibility
18Changes in ADHD symptoms from childhood to adulthood Preschool yearsPrimary school yearsAdolescenceAdulthoodInattentionShort playIncomplete activitiesNot listeningBrief activitiesChanges activityForgetful, disorganiseddistractedLess persistenceLack of focus on detailsPoor planningIncomplete detailsForget apptsLack of foresightOveractivitywhirlwindRestlesshyperactivefidgetySubjective feelings of restlessnessImpulsivityDoes not listenNo sense of dangerActs out of turnInterruptsIntrusivethoughtlessPoor self controlReckless risk takingAccidentsImpatiencePremature decision making
19SPECIFIERS: Combined (hyperactive,impulsive & inattentive) Predominantly inattentive(inattention but not hyperactive/impulsive)Predominantly hyperactive/impulsive(no inattention)
20ADHD in females Underdiagnosed & misdiagnosed (mood) High levels of inattentionLess disruptive & low levels of hyperactivity? Less severe formHormonal changes in adolescence (oest)Greater risk of substance abuseRespond well to medication & behaviour interventionEnvironmental demands increase may become more obvious
21ASSESSMENT Paed/child psych/GP/HCP with expertise in ADHD Full developmental, medical (CARDIAC HISTORY)and psycho-social historyAssessment of needsCO-EXISTING CONDITIONS,School informationPsychometric assessments (exclude a LD)Rating scales (SNAP)Meet DSM V or ICD 10 criteria and moderate impairment in more than 1 settingSPEAK TO THE CHILD !Assess the parents
22STROOP 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.
23PHYSICAL EXAM Exercise syncope, breathlessness and cardiac symptoms H.R and B.P.Family hx of cardiac disease: CVS examECG if fam hx of serious cardiac disease or sudden deathWeight and heightRisk assessment for substance misuse/drug diversion
25OppositionalDefiantDisorder40%?ASDTics11%Conduct14%Mood Disorders 4%ADHDalone31%Anxiety34%Swedish study85% of children with ADHD had 1 or more co-morbid disorders67% had at least 2 co-morbid disordersLEARNING DISABILITIESAUTISM
26ESSENCE (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) )
27ESSENCE (Early symptomatic syndromes eliciting neurodevelopmental examinations) Impairing child symptoms (3-5 years)General developmentCommunication & languageSocial interrelatednessMotor co-ordinationAttentionActivityBehaviourMoodSleepMajor problems in 1 domain indicate major problems in the same or overlapping domains many years laterEARLY INTERVENTION
32DIETARY TREATMENT:NICE: general advice that a healthy balanced diet and exercise should be recommended for all with ADHDCAUTIONS about lack of concrete evidence:It discourages removal of artificial food colourants and additives from the dietIf link seen need a food diary and dietician referralOpposes fatty acid supplementation
34MEDICATION: Stimulant: Non stimulant: atomoxetine, Methylphenidate SHORT-ACTING/IMMEDIATE RELEASE Ritalin (3-4 hours) INTERMEDIATE RELEASE Ritalin LA (8 hours) LONG ACTING/MODIFIED RELEASE Concerta XL (12 hours)atomoxetine,extended-release guanfacine ERclonidine ER
35Relative stimulant contraindications Psychotic disordersSevere Tourette’s ? No longerMAOI (> 2/52 washout)Active substance abuse (pt or family)Unstable seizure disorderStructural cardiac defectsUnstable HPTUnstable cardiovascular disorderHx of S/E on stimulantsPregnancyChild < 3years
36NON-STIMULANT MEDS Atomoxetine (licensed) a selective noradrenaline reuptake inhibitor (SNRI)may cause a secondary increase in dopamine levelsADHD with comorbid anxiety disordershistory 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
37NON 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.
38NEW MEDICATIONS:Lisdexamphetamine is an inactive component (prodrug) that is gradually converted into an active form of dextro-amphetamine 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.
39CHOICE OF MEDICATION:Methylphenidate, (dexamphetamine), atomoxetine are recommended within their licensed indicationsChoice of Rx based onCo-morbid conditions (eg tics/epilepsy)Tolerability, adverse effectsConvenience of dosing ( compliance/schools)Potential for diversionPatient/ parent preferenceIf >1 Rx suitable, prescribe Rx with lowest cost
41Side effects:Loss of appetite & LOW. Measure weight before Rx then every 3-4 months. PlotGrowth delay Measure height before Rx then every 3-4 months (ref endocrinologist)Insomnia: gather information before RxCVS side effects Monitor BP pulse every 3-6monthsHepatotoxicity, increase in hepatic enzymes,bilirubin and jaundice (Atomoxetine)emergent suicidal behaviors
42Sleep disturbance: Sleep diary Polysomnography if suspect sleep breathing disorder episodic nocturnal phenomena, limb movementsMonitorStop medicationAdd small dose if reboundAdd melatoninChange stimulant
43MTA STUDY 579 children with ADHD (c.t.) Age 7 to 9,9 years 14 months RxBehaviourMedicationMedicationPlusbehaviourCommunityCareMTA STUDY(Arch Gen Psych Vol 56, Dec 99)
44RESULTS (1): M.T.A. STUDYAll 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)
45RESULTS (2): M.T.A. STUDY Oppositional/Aggressive symptoms Internalising symptomsSocial SkillsParent-child relationsReading achievementCombined Rx superior to Med Rx, B.T. & C.C.Arch Gen Psych Vol 56, Dec 99)
46MTAAfter 14 months, the MTA became an uncontrolled naturalistic study: children were allowed any treatment and followed up even if treatment was abandoned.
47MTA STUDY3,6,8 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 non-medicated counterparts despite a 41% increase in the average total daily dose.
48“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. “
49Newcorn (CNS Spectrum Vol. 5,6 June,2000) “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)
50OPPOSITIONAL DEFIANT DISORDER (DSM V: Disruptive,Impulse-control, and Conduct disorders) Angry/Irritable MoodOften angry & resentfulOften touchy or easily annoyedOften loses temperArgumentative/defiant behaviourOften argues with adultsOften deliberately annoys or irritatesOften blames others for his mistakesOften actively defies or refuses to complyVindictivenessOften spiteful & vindictive
51DIFFERENTIAL DIAGNOSES Anxiety disorders such as phobias or OCDAutismSensory sensitivitiesDepressionBullyingFailure at school due to LD
52RISK FACTORS: Genetic Neurobiological markers(H.R./Cortisol) Age of onsetTemperamentPeer influencesCallous & unemotional traitsNeighbourhoodsFamily factors & influences
53TREATMENT Rx triggers/aetiology Parent Management training The Incredible Years (Webster-stratton)Play, praise, rewards, limit settingTriple PProud2bme (Cape Town)Rx triggers/aetiology
54GOALS OF TREATMENT: For parents: Improve positive parenting skills Enhance problem solving conflict resolution & communicationFor the child:Develop effective communication,problem solving and anger managementFor the familyFamily counselling & support to deal with the stresses in their relationships and home environmentIn the classroomteacher to provide social skills, problem solvingPromote compliance
55NEW MEDICATIONS: No medication for Rx of ODD NEW medications: Alpha 2 receptor agonists:Guanfacine and clonidineG is relatively more selective for alpha 2 A agonistsControlled release Guanfacine ER may be useful for ADHD and ODDClonidine: used off label for ADHD and ODD
56HELPFUL HINTS Always look for co-morbidity Treat co-morbidity (school,OT,SALT)Girls are mis/underdiagnosedReview need for ongoing RxODD may be something elseSPEAK TO THE CHILD!
57When to refer to psychiatry If unsure of diagnosisParents requesting 2nd opinion< 6years;Complex diagnosis (ADHD with tics/ OCD/ non-responding depression)GP: max 1mg/kg/d methylphenidatePoor response to treatment
62REFERENCES:MTA Cooperative group A 14 month randomised clinical trial of treatment strategies for ADHD. Arch Gen Psychiatry 56:NICE: Methylphenidate, Atomoxetine and dexamphetamine for ADHD in children and adolescents.2006SIGN GUIDELINESTaylor et al European Clinical guidelines for hyperkinetic disorder ( First upgrade) Eu. Child Adolesc Psychiatry (Suppl 1) 13:1-30Practice Parameters for the Assessment and treatment of ADHDD JAACAP 1997/2002