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ATTENTION DEFICIT HYPERACTIVITY DISORDER Dr Wendy Vogel Child and Adolescent Psychiatrist Head, Division of Child & Adolescent Psychiatry, Red Cross War.

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Presentation on theme: "ATTENTION DEFICIT HYPERACTIVITY DISORDER Dr Wendy Vogel Child and Adolescent Psychiatrist Head, Division of Child & Adolescent Psychiatry, Red Cross War."— Presentation transcript:

1 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

2 OVERVIEW History of ADHD Update on DSM V Assessment & Management of ADHD Oppositional Defiant Disorder When to refer

3 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 : Heinrich Hoffmann  Impulsive insanity/defective inhibition

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6 Sir George Still ( ) Scientific starting point of history of ADHD Motor agitation Attention problems Difficulty controlling impulses Deficit of moral control (stigma) MBD

7 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

8 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) Attention deficit hyperactivity disorder DSM V (2013)

9 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 ?

10 AETIOLOGY ' Very strong biological contributions ' Genetic / hereditary (genes DAT1, DRD4 etc) ' Peri-natal problems (prem & low birth weight) ' In utero exposure to tobacco smoke

11 UPDATE ON DSM V: Neurodevelopmental disorders: ADHD ASD Communication Disorders Intellectual Disability Specific learning disability Motor disorders (Tics, stereotypical movement & DCD)

12 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

13 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

14 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

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16 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

17 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

18 Changes in ADHD symptoms from childhood to adulthood Preschool years Primary school years AdolescenceAdulthood InattentionShort 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 OveractivitywhirlwindRestless hyperactive fidgetySubjective feelings of restlessness ImpulsivityDoes not listen No sense of danger Acts out of turn Interrupts Intrusive thoughtless Poor self control Reckless risk taking Accidents Impatience Premature decision making

19 SPECIFIERS: Combined (hyperactive,impulsive & inattentive) Predominantly inattentive (inattention but not hyperactive/impulsive) Predominantly hyperactive/impulsive (no inattention)

20 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

21 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) Meet DSM V or ICD 10 criteria and moderate impairment in more than 1 setting SPEAK TO THE CHILD ! Assess the parents

22 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.

23 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

24 DIAGNOSIS MADE: WHAT NEXT?

25 Oppositional Defiant Disorder 40% ?ASD Tics 11% Conduct Disorder 14% Mood Disorders 4% ADHD alone 31% Anxiety Disorder 34% 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

26 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) )

27 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

28 TREATMENT: PHARMACOLOGY Stimulants Non-stimulants NON-PHARMACOLOGY Psychosocial management Dietary interventions Psychological interventions

29 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.

30 PSYCHOLOGICAL TREATMENT Cognitive training  Attention and working memory training Behavioural interventions  Parent training  Parent-child training  Parent-child plus teacher training  CBT with child

31 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

32 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

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34 MEDICATION: Stimulant: Methylphenidate SHORT- ACTING/IMMEDIATE RELEASE Ritalin (3-4 hours) INTERMEDIATE RELEASE Ritalin LA (8 hours) LONG ACTING/MODIFIED RELEASE Concerta XL (12 hours) Non stimulant: atomoxetine, extended-release guanfacine ER clonidine ER

35 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

36 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

37 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.

38 NEW 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.

39 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

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41 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

42 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

43 579 children with ADHD (c.t.) Age 7 to 9,9 years 14 months Rx BehaviourMedication Plus behaviour MedicationCommunity Care MTA STUDY (Arch Gen Psych Vol 56, Dec 99)

44 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)

45 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)

46 MTA After 14 months, the MTA became an uncontrolled naturalistic study: children were allowed any treatment and followed up even if treatment was abandoned.

47 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 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. “

49 “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)

50 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

51 DIFFERENTIAL DIAGNOSES Anxiety disorders such as phobias or OCD Autism Sensory sensitivities Depression Bullying Failure at school due to LD

52 RISK FACTORS: Genetic Neurobiological markers(H.R./Cortisol) Age of onset Temperament Peer influences Callous & unemotional traits Neighbourhoods Family factors & influences

53 TREATMENT Parent Management training The Incredible Years (Webster-stratton) Play, praise, rewards, limit setting Triple P Proud2bme (Cape Town) Rx triggers/aetiology

54 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

55 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

56 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!

57 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

58 BOOKS

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60 Nice guidleines

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62 REFERENCES: 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.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

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