ATTENTION DEFICIT HYPERACTIVITY DISORDER

Dr Wendy VogelChild and Adolescent PsychiatristHead, 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 infancy1937: Bradley:• first Rx of ADHD with benzedrine1944: Panizzoni • methylphenidate (ritalin)• Is the most effective and widely used

medication

DSM• 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 hyperactivity • DSM 111R,(1987)IV,

(1994) IVR (2000)

Attention deficit hyperactivity disorder

DSM V(2013)

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 activitiesNot listening

Brief activitiesChanges activityForgetful, disorganiseddistracted

Less persistenceLack of focus on detailsPoor planning

Incomplete detailsForget apptsLack of foresight

Overactivity whirlwind Restlesshyperactive

fidgety Subjective feelings of restlessness

Impulsivity Does not listenNo sense of danger

Acts out of turnInterrupts Intrusivethoughtless

Poor self controlReckless risk taking

AccidentsImpatiencePremature 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?

Oppositional Defiant

Disorder40%

?ASD

Tics11%

Conduct Disorder14%

MoodDisorders

4%

ADHD alone31%

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

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:

• PHARMACOLOGYStimulantsNon-stimulants• NON-PHARMACOLOGYPsychosocial managementDietary interventionsPsychological 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:

MethylphenidateSHORT-ACTING/IMMEDIATE RELEASE Ritalin (3-4 hours)INTERMEDIATE RELEASE Ritalin LA (8 hours)LONG ACTING/MODIFIED RELEASEConcerta XL (12 hours)

Non stimulant:• 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 MEDSAtomoxetine (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 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.

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:

• 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 years14 months Rx

Behaviour MedicationPlusbehaviour

Medication CommunityCare

MTA STUDY (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 achievementCombined Rx superior to Med Rx, B.T. &

C.C. Arch Gen Psych Vol 56, Dec 99)

MTA

After 14 months, the MTA became anuncontrolled 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 non-medicated 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 &

communicationFor the child:• Develop effective communication,problem solving and

anger managementFor the family• Family counselling & support to deal with the stresses in

their relationships and home environmentIn the classroom• teacher to provide social skills, problem solving• Promote compliance

NEW MEDICATIONS:

No medication for Rx of ODDNEW 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