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ATTENTION DEFICIT HYPERACTIVITY DISORDER

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. OVERVIEW. History of ADHD Update on DSM V Assessment & Management of ADHD

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ATTENTION DEFICIT HYPERACTIVITY DISORDER

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  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 • 1809-1894: Heinrich Hoffmann • Impulsive insanity/defective inhibition

  4. 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

  5. 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

  6. DSM • DSM-II Hyperkinetic reaction of childhood Overactivity, restlessness, distractibility,shortattention 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)

  7. 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 ?

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

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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. Changes in ADHD symptoms from childhood to adulthood

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

  17. 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

  18. 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

  19. 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.

  20. PHYSICAL EXAM • Exercise syncope, breathlessness and cardiac symptoms • H.R and B.P. • Family hx of cardiac disease: CVS exam • ECG if famhx of serious cardiac disease or sudden death • Weight and height • Risk assessment for substance misuse/drug diversion

  21. DIAGNOSIS MADE:WHAT NEXT?

  22. Oppositional Defiant Disorder 40% ?ASD Tics 11% ADHD alone 31% MoodDisorders4% Anxiety Disorder 34% Conduct Disorder 14% • 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

  23. 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)

  24. 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

  25. TREATMENT: • PHARMACOLOGY • Stimulants • Non-stimulants • NON-PHARMACOLOGY • Psychosocial management • Dietary interventions • Psychological interventions

  26. 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.

  27. PSYCHOLOGICAL TREATMENT • Cognitive training • Attention and working memory training • Behavioural interventions • Parent training • Parent-child training • Parent-child plus teacher training • CBT with child

  28. 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

  29. 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

  30. MEDICATION: Stimulant: Non stimulant: atomoxetine, extended-release guanfacineER clonidine ER Methylphenidate SHORT-ACTING/IMMEDIATE RELEASE Ritalin (3-4 hours) INTERMEDIATE RELEASE Ritalin LA (8 hours) LONG ACTING/MODIFIED RELEASE ConcertaXL (12 hours)

  31. 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

  32. 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

  33. NON STIMULANT MEDICATION: • Clonidine and guanfacine are alpha-2 agonists with demonstrated efficacy in the treatment of ADHD. • Guanfacineis 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.

  34. 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.

  35. 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

  36. 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

  37. 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

  38. 579 children with ADHD (c.t.) • Age 7 to 9,9 years • 14 months Rx Behaviour Medication Medication Plus behaviour Community Care MTA STUDY (Arch Gen Psych Vol 56, Dec 99)

  39. 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)

  40. 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)

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

  42. 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.

  43. “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. “

  44. “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)

  45. 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

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