Presentation on theme: "Attention-Deficit/Hyperactivity Disorder (ADHD)"— Presentation transcript:
1Attention-Deficit/Hyperactivity Disorder (ADHD) Andrea Chronis-Tuscano, Ph.D.Associate Professor of PsychologyDirector, Maryland ADHD ProgramUniversity of Maryland
2Maryland ADHD Program Mission To conduct clinical research that advances our knowledge about the assessment and treatment of ADHDTo provide comprehensive, evidence-based assessment and treatment of ADHD and associated problems to children and their familiesTo train the next generation of clinical psychologists in evidence-based assessment and treatment practicesTo educate parents, schools, health professionals and the community about evidence-based assessment and treatment for ADHD
3Overview Definition & Features Etiological Factors Evidence-Based Assessment & TreatmentProfessional Practice Parameters
4Prevalence & Impact Prevalence rate of 6-10% More prevalent in males than femalesMale:female ratio is 3:1 in epidemiological samplesRanges from 3:1 - 9:1 in clinical samples50% of children referred to mental health clinics are referred for ADHD-related problemsAnnual societal cost of illness for ADHD estimated to be between $ billion $12, $17,458 annually per individual
6DSM-IV Diagnostic Criteria Inattention Symptoms (at least 6 symptoms required)Fails to give close attention to details or makes careless mistakes in schoolwork, work, etc.Difficulty sustaining attentionDoes not seem to listen when spoken to directlyDoes not follow through on instructions and fails to finish schoolwork, chores, etc.Difficulty organizing tasks and activitiesAvoids tasks requiring sustained mental effortLoses things necessary for tasks or activitiesEasily distracted by extraneous stimuliForgetful in daily activitiesPrimary deficit in ADHD is sustained attention, particularly for repetitive, structured, and uninteresting tasks. Attention problems may be in alerting and preparing for the task from the outset, as well as, the ability to sustain attention. Variety of “attention deficits” – attentional capacity, selective attention (DISTRACTABILITY), and sustained attention.APA, 2000
7ADHD Diagnostic Criteria (cont.) Hyperactivity-Impulsivity Symptoms (at least 6 symptoms required)Difficulty playing or engaging in activities quietlyAlways "on the go" or acts as if "driven by a motor”Talks excessivelyBlurts out answersDifficulty waiting in lines or awaiting turnInterrupts or intrudes on othersRuns about or climbs inappropriatelyFidgets with hands or feet or squirms in seatLeaves seat in classroom or in other situations in which remaining seated is expectedSome have suggested that both hyperactivity and impulsivity part of a more fundamental deficit in behavioral regulation. Hyperactive-impulsive behavior is activity that is excessively intense, inappropriate, and NOT GOAL DIRECTED.Impulsivity – difficulty stopping ongoing behavior, difficulty awaiting turn, inability to resist immediate gratification (DELAY AVERSION), and interrupting others’ conversationsAPA, 2000
8ADHD Diagnostic Criteria (cont.) Symptoms present before age 7Clinically significant impairment in social or academic/occupational functioningSome symptoms that cause impairment are present in 2 or more settings (e.g., school/work, home, recreational settings)Not due to another disorder (e.g., Autism, Mood Disorder, Anxiety Disorder)APA, 2000
9Subtypes Combined Type Predominantly Inattentive Subtype Clinical levels of both inattention and hyperactivity/impulsivityMost common subtypePredominantly Inattentive SubtypeClinical levels of inattention onlyOften not identified until middle schoolSluggish cognitive tempoPredominantly Hyperactive/Impulsive SubtypeClinical levels of hyperactivity/impulsivity onlyMore common among very young children prior to school entryPredominately inattentive type – frequently described as drowsy, confused, “in a fog”. May be comorbid with learning disorders, slow processing speed, difficulties with information retrieval, anxiety, and mood disorder. Some debate as to whether this should be thought of as a separate disorder.
10Controversial Issues with DSM-IV Criteria Developmentally insensitiveSymptoms based on field trials conducted with elementary school aged boys (Lahey et al., 1994)Categorical (not continuous) viewRequirement of onset before age 7 arbitraryRequirement of 6 months duration too briefRequirement that symptoms be demonstrated across 2 settings
11Associated Problems Peer problems Family dysfunction/parental issues Inattentive symptoms ignoredHyperactive/impulsive symptoms actively rejectedNot deficient in social reasoning/understanding, but rather the execution of appropriate social behaviorFamily dysfunction/parental issuesNo clear causal relationship between family problems and ADHDFamily problems can impact the severity and developmental course/outcomes of ADHDSelf-esteemInflated: Positive illusory bias (Hoza)Low self esteem associated with comorbid depressionThere are some other problems that are associated with (but not caused by ADHD). Also, every child with ADHD is different and may have any combination of these difficulties or none of them. As I just mentioned, they may have difficulties making and keeping friends. This is particularly important as peer relationships are an important predictor of relationships with adults. Children with poor peer relationships are more likely to have poor relationships as adults. Children with ADHD often come from families where there is more stress or parents may have ADHD themselves. Due to the impairment caused by their symptoms, children with ADHD often don’t feel very good about themselves. I work part-time at Children’s National Medical Center and just last week I heard a child being tested in the room next door to where I was testing a child. This child was yelling, “I can’t do it. I always fail.” These thoughts are not uncommon in children with ADHD. Fifty percent of children with ADHD also have oppositional or aggressive difficulties. They may be arguing with adults often or misinterpreting something a peer does as hostile and impulsively hitting them when they feel threatened.
12Developmental Course ADHD is persistent across lifespan in most cases Methodological issues impact estimates of persistenceADHD severity, psychiatric comorbidity, and parental psychopathology predict persistence (Biederman et al., 2011)Inattention remains stable; hyperactivity declines with ageDSM-IV criteria may not capture adolescent/adult manifestations of impulsivityAdult outcomes including psychiatric comorbidityWhen ADHD co-occurs with conduct disorder, chronic criminality and serious substance use can resultWhen ADHD co-occurs with depression, risk of suicideProbable that ADHD is present at birth, but difficult to identify in infancy; hyperactivity-impulsivity usually appears first. Onset often in preschool years, but usually by school age. Deficits in attention increase as school demands increase. In early school years oppositional and socially aggressive behaviors often develop.Most children still have ADHD as teens, although hyperactive-impulsive behaviors decrease. Problems often continue into adulthood – those adults with ADHD may experience a great deal of boredom, work difficulties, impaired social relations, depression, low self-concept, and substance abuseBetter outcomes for youth with less severe symptoms, support, supervision, and access to resources
14Etiological Factors Average heritability of .80 - .85 Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditionsDysfunction in prefrontal lobesInvolved in inhibition, executive functionsGenes involved in dopamine regulationDopamine transporter (DAT1) gene implicated7 repeat of dopamine receptor gene (DRD4) implicatedGene x environment interactionsPossible differences in size of brain structuresPrefrontal cortex, Corpus callosum, caudate nucleusAbnormal brain activation during attention & inhibition tasksKieling, Gondaves. Tannock. & Castellanos. 2008; Mick &. Faraone, 2008
15Brain Structure & Function Differences in brain maturation, structure, function (particularly abnormalities in frontostriatal circuitry):Prefrontal cortexBasal gangliaCerebellumThese areas of the brain are associated with executive function abilities:Attention, spatial working memory, and short-term memoryResponse inhibition and set shiftingSpecific brain findings (neuro-imaging studies):--Neuro-imaging studies suggest the importance of the frontostriatal region of the brain in ADHD and the pathways connecting this region with the limbic system (via the striatum) and the cerebellum.--Children with ADHD have smaller right prefrontal cortex, structural abnormalities in areas of the basal ganglia (e.g., caudate nucleus), smaller total and right cerebral volumes, smaller cerebellum, and delay in brain maturation in the prefrontal cortex (children with ADHD lag 2-3 years behind children without ADHD in development of the PFC).Attention = the ability to focus or filter information, including attentional alerting and sustained attention.Memory = the ability to hold information in mind (spatial refers to how things are ordered in space relative to one another), which depends on attention.Response inhibition = the ability to interrupt a response during dynamic moment-to-moment behavior (i.e., maintaining focused behavior requires continually suppressing alternate behaviors that may be activated by context). *Most well-studied executive function skill in ADHD. Set shifting = The ability to shift one’s mental focus within a task such as sorting by color vs. sorting by number (i.e., task switching).**Note that spatial working memory and response inhibition are the most researched, and have moderate to large effect sizes (i.e., differences between ADHD kids and non-ADHD kids in spatial working memory and response inhibition are moderate to large).
16NeurotransmittersNeurotransmitter differences, particularly in levels of:DopamineNorepinephrineEpinephrineSerotoninDopamine has been associated with approach and pleasure-seeking behaviorsNorepinephrine plays a role in emotional/behavioral regulationMost research evidence suggests deficiencies in the availability of dopamine and norepinephrine among children with ADHD relative to comparison children, although epinephrine and serotonin have also been implicated.
17Executive Functioning Deficits Cognitive processes which activate, integrate, and manage other brain functionsExamples:Cognitive: working memory, planning, use of organizational strategiesLanguage: verbal fluency, communicationMotor: response inhibition, motor coordinationEmotional: self-regulation of emotion, frustration toleranceBut…EF deficits overlap with ADHD symptomsEF deficits are not unique to ADHDNot all children with ADHD have EF deficits
18Barkley’s Theory“ADHD is not a problem with knowing what to do; it is a problem of doing what you know.”-Barkley, 2006Behavioral disinhibition is the basis of executive functioning deficits in ADHDA performance, rather than knowledge, deficit
19A Possible Developmental Pathway for ADHD From Mash & Wolfe, 2007
21Evidence-Based Assessment Teacher- and parent-completed questionnairesStructured clinical interview with parent(s)IQ/Achievement testing to screen for learning disabilities (50% comorbidity)Behavioral observations at home and schoolNo medical screen, cognitive test, or brain imaging technique can detect ADHDChildren with ADHD can focus long enough to watch TV, play videogames or sit still at the doctor’s office.How do children get assessed for ADHD? Well, when they present to a professional, they should receive a comprehensive, evidence-based assessment. scales are often used to compare children to the norm. A clinical interview with parents is another way to clarify particular concerns that a parent may have or to follow-up on information gathered on these questionnaires. Also, many children with low IQs or learning disabilities have difficulty achieving at grade level, so IQ/Achievement testing is often part of a comprehensive assessment for ADHD. ADHD and learning disabilities co-occur frequently, so many children with ADHD have disorder of written expression or a math LD. Finally, behavioral observations are a very useful clinical tool in that we can see how a child performs in a one-on-one very structured situation with a lot of consistent praise and direct commands as well as the parent-child and teacher-child interaction.Pelham, Fabiano & Massetti, 2005
23Medication: Stimulants Most well-researched, effective, and commonly used medication treatment for ADHD.Methylphenidate (Ritalin, Concerta, and Metadate)Dextroamphetamine (Adderall)These medications reduce ADHD symptoms by:Blocking the reuptake of norepinephrine (NOR) and dopamine (DOP) and facilitating their release Enhances NOR and DOP availability in in certain brain regions: PFC and basal gangliaStimulants work by increasing norepinephrine and dopamine actions by blocking their reuptake and facilitating their release.This leads to enhancement of norepinephrine and dopamine in certain brain regions including the prefrontal cortex and basal ganglia.
24Stimulant Medications Research has shown that stimulants:Are highly effective in reducing ADHD symptoms in the short termDecrease disruption in the classroomIncrease academic productivity and on-task behaviorImprove teacher ratings of behaviorDifferent formulations work best for different childrenCommon side effects: insomnia, decreased appetiteStrattera (atomoxetine)A non-stimulant alternative that works well for some childrenHas not been studied as long or as intensively as the stimulantsSmaller effect size relative to the stimulants
25Limitations of Stimulant Treatment Individual differences in responseNot all children respond (approximately 80%)Limited impact on domains of functional impairmentPrimary reason for treatment seekingDoes not normalize behaviorFamily problems beyond the scope of medicationNo long-term effects establishedLong-term use rareLimited parent/teacher satisfactionSome families are not willing to try medication
26How do we identify evidence-based, non-pharmacological treatments?
27“Evidence-based treatment” implies that studies have been conducted with the following features: Careful specification of the target populationDiagnostic, demographic, recruitment, selectionRandom assignment to conditionsComparison could be to placebo but ideally to established txUse of treatment manualsEnsures reliability of administration and facilitates replicationMultiple outcome measures with blind ratersStatistically significant differences between the tx and comparison group at post-txReplication, ideally by independent researchersChambless et al., 1996; Silverman & Hinshaw, 2008
29Behavioral Treatment Components Psychoeducation about ADHDStructure/routinesClear rules/expectationsAttending/rewardsPlanned ignoringEffective commandsTime out/loss of privilegesPoint/token systemsDaily school-home report cardIntensive summer treatment programs
30Behavioral Treatment Considerations Need to address cross-situational impairmentsPoor generalization from treatment setting to real-worldImplement treatments in all settings in which child shows impairmentSchool behavior504 Plan/Individualized Education Plan (IEP)Academic interventions needed in addition to behavioral interventions (Raggi & Chronis, 2006)Environmental contingencies must be delivered consistently, which is difficult to maintainParental psychopathology can interfere with implementation
31Multi-Modal Treatment Study for ADHD (MTA) 6 sites579 Children, 7-9 y/oADHD, Combined TypeAssigned to 14 months of:Med managementIntensive Behavior TherapyCombined treatmentTreatment as Usual in the Community (TAU)2/3 received medicationMTA Cooperative Group, 1999
32Overall Results All groups showed reductions in ADHD sx over time On primary outcome measure (ADHD sx), medication alone and combined tx did better than behavioral tx alone and tx as usual (TAU) in the communityOn many measures, combined tx was not significantly better than medication aloneOnly combined tx was better than TAU on oppositional symptoms, aggression, depression/anxiety symptoms, social skills, parent-child relationship, and reading achievementHigher medication doses were needed in the medication only group relative to the combined treatment groupMTA Cooperative Group, 1999
33Combined Treatment was superior in terms of: Parent and teacher satisfaction with treatmentNormalization of child behaviorImprovements in functional outcomesFamily interactionsPeer relationshipsAcademic functioningConnors et al., 2001; Hinshaw et al., 2000; Pelham et al., 2004; Swanson et al., 2001; Wells et al., 2006
34MTA 6-8 Year Follow-UpOriginal treatment assignment not associated with any of the 24 outcomes 6-8 yrs laterADHD symptom trajectory in the first 3 years predicted 55% of the outcomesChildren with the best initial tx response and most favorable clinical presentation at baseline fared best over timeChildren with behavioral and sociodemographic advantage, with the best response to any tx, had the best long-term prognosisAs a group, children with combined-type ADHD exhibit significant impairment in adolescence (on 9 of 21 measures)This suggests a need for sustained treatment over the long termMolina et al., 2009
36American Medical Association (AMA) “encourages the use of individualized therapeutic approaches…which may include pharmacotherapy, psychoeducation, behavioral therapy, school-based and other environmental interventions, and psychotherapy, as indicated by clinical circumstances and family preferences.” (p.1106)”American Academy of Pediatrics (AAP)“the clinician should recommend medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong)” (p. 1037)
37American Academy of Child & Adolescent Psychiatry (AACAP) Treatment “may consist of pharmacological and/or behavior therapy” but that “pharmacological intervention for ADHD is more effective than a behavioral treatment alone” and that “behavioral intervention alone might be recommended as an initial treatment if the patient’s ADHD symptoms are mild with minimal impairment…or parents reject medication” (p.902)…”if a child has a robust response and shows normative functioning…then psychopharmacological treatment alone is satisfactory” (p. 912)…If the child does not show a robust response to all FDA-approved medications, the clinician should “consider behavior therapy and/or the use of medications not approved by the FDA for treatment of ADHD” (p.907)
38SummaryADHD is a highly prevalent, brain-based disorder which is associated with lifelong impairment in functioningEnvironmental factors can contribute to the expression, severity, course, and comorbid conditionsLong-term developmental outcomes for individuals with ADHD can include serious substance abuse, chronic criminality, depression and suicideStimulant medications and behavior therapy are currently the only established evidence-based treatments for ADHDCombined behavioral-pharmacological treatment has the greatest impact on functional outcomes, is preferred by parents and teachers, and is most likely to result in normalization of behavior