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Attention-Deficit/Hyperactivity Disorder (ADHD). Andrea Chronis-Tuscano, Ph.D. Associate Professor of Psychology Director, Maryland ADHD Program University of Maryland. Maryland ADHD Program Mission.

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Attention-Deficit/Hyperactivity Disorder (ADHD)

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Attention-Deficit/Hyperactivity Disorder (ADHD)

Andrea Chronis-Tuscano, Ph.D.

Associate Professor of Psychology

Director, Maryland ADHD Program

University of Maryland


Maryland ADHD Program Mission

  • To conduct clinical research that advances our knowledge about the assessment and treatment of ADHD

  • To provide comprehensive, evidence-based assessment and treatment of ADHD and associated problems to children and their families

  • To train the next generation of clinical psychologists in evidence-based assessment and treatment practices

  • To educate parents, schools, health professionals and the community about evidence-based assessment and treatment for ADHD


Overview

  • Definition & Features

  • Etiological Factors

  • Evidence-Based Assessment & Treatment

  • Professional Practice Parameters


Prevalence & Impact

  • Prevalence rate of 6-10%

  • More prevalent in males than females

    • Male:female ratio is 3:1 in epidemiological samples

    • Ranges from 3:1 - 9:1 in clinical samples

  • 50% of children referred to mental health clinics are referred for ADHD-related problems

    • Annual societal cost of illness for ADHD estimated to be between $36 - 52 billion $12,005 -- $17,458 annually per individual

  • www.cdc.gov


Definition & Features


DSM-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 attention

    • Does not seem to listen when spoken to directly

    • Does not follow through on instructions and fails to finish schoolwork, chores, etc.

    • Difficulty organizing tasks and activities

    • Avoids tasks requiring sustained mental effort

    • Loses things necessary for tasks or activities

    • Easily distracted by extraneous stimuli

    • Forgetful in daily activities

APA, 2000


ADHD Diagnostic Criteria (cont.)

  • Hyperactivity-Impulsivity Symptoms (at least 6 symptoms required)

    • Difficulty playing or engaging in activities quietly

    • Always "on the go" or acts as if "driven by a motor”

    • Talks excessively

    • Blurts out answers

    • Difficulty waiting in lines or awaiting turn

    • Interrupts or intrudes on others

    • Runs about or climbs inappropriately

    • Fidgets with hands or feet or squirms in seat

    • Leaves seat in classroom or in other situations in which remaining seated is expected

APA, 2000


ADHD Diagnostic Criteria (cont.)

  • Symptoms present before age 7

  • Clinically significant impairment in social or academic/occupational functioning

  • Some 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


Subtypes

  • Combined Type

    • Clinical levels of both inattention and hyperactivity/impulsivity

    • Most common subtype

  • Predominantly Inattentive Subtype

    • Clinical levels of inattention only

    • Often not identified until middle school

    • Sluggish cognitive tempo

  • Predominantly Hyperactive/Impulsive Subtype

    • Clinical levels of hyperactivity/impulsivity only

    • More common among very young children prior to school entry


Controversial Issues with DSM-IV Criteria

  • Developmentally insensitive

    • Symptoms based on field trials conducted with elementary school aged boys (Lahey et al., 1994)

  • Categorical (not continuous) view

  • Requirement of onset before age 7 arbitrary

  • Requirement of 6 months duration too brief

  • Requirement that symptoms be demonstrated across 2 settings


Associated Problems

  • Peer problems

    • Inattentive symptoms  ignored

    • Hyperactive/impulsive symptoms  actively rejected

    • Not deficient in social reasoning/understanding, but rather the execution of appropriate social behavior

  • Family dysfunction/parental issues

    • No clear causal relationship between family problems and ADHD

    • Family problems can impact the severity and developmental course/outcomes of ADHD

  • Self-esteem

    • Inflated: Positive illusory bias (Hoza)

    • Low self esteem associated with comorbid depression


Developmental Course

  • ADHD is persistent across lifespan in most cases

    • Methodological issues impact estimates of persistence

    • ADHD severity, psychiatric comorbidity, and parental psychopathology predict persistence (Biederman et al., 2011)

  • Inattention remains stable; hyperactivity declines with age

    • DSM-IV criteria may not capture adolescent/adult manifestations of impulsivity

  • Adult outcomes including psychiatric comorbidity

    • When ADHD co-occurs with conduct disorder, chronic criminality and serious substance use can result

    • When ADHD co-occurs with depression, risk of suicide


Etiological Factors


Etiological Factors

  • Average heritability of .80 - .85

    • Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions

  • Dysfunction in prefrontal lobes

    • Involved in inhibition, executive functions

  • Genes involved in dopamine regulation

    • Dopamine transporter (DAT1) gene implicated

    • 7 repeat of dopamine receptor gene (DRD4) implicated

    • Gene x environment interactions

  • Possible differences in size of brain structures

    • Prefrontal cortex, Corpus callosum, caudate nucleus

  • Abnormal brain activation during attention & inhibition tasks

Kieling, Gondaves. Tannock. & Castellanos. 2008; Mick &. Faraone, 2008


Brain Structure & Function

  • Differences in brain maturation, structure, function (particularly abnormalities in frontostriatal circuitry):

    • Prefrontal cortex

    • Basal ganglia

    • Cerebellum

  • These areas of the brain are associated with executive function abilities:

    • Attention, spatial working memory, and short-term memory

    • Response inhibition and set shifting


  • Neurotransmitters

    • Neurotransmitter differences, particularly in levels of:

      • Dopamine

      • Norepinephrine

      • Epinephrine

      • Serotonin

    • Dopamine has been associated with approach and pleasure-seeking behaviors

    • Norepinephrine plays a role in emotional/behavioral regulation


    Executive Functioning Deficits

    • Cognitive processes which activate, integrate, and manage other brain functions

    • Examples:

      • Cognitive: working memory, planning, use of organizational strategies

      • Language: verbal fluency, communication

      • Motor: response inhibition, motor coordination

      • Emotional: self-regulation of emotion, frustration tolerance

    • But…

      • EF deficits overlap with ADHD symptoms

      • EF deficits are not unique to ADHD

      • Not all children with ADHD have EF deficits


    Barkley’s Theory

    “ADHD is not a problem with knowing what to do; it is a problem of doing what you know.”

    -Barkley, 2006

    • Behavioral disinhibitionis the basis of executive functioning deficits in ADHD

    • A performance, rather than knowledge, deficit


    A Possible Developmental Pathway for ADHD

    From Mash & Wolfe, 2007


    Evidence-Based Assessment & Treatment of ADHD


    Evidence-Based Assessment

    • Teacher- and parent-completed questionnaires

    • Structured clinical interview with parent(s)

    • IQ/Achievement testing to screen for learning disabilities (50% comorbidity)

    • Behavioral observations at home and school

    • No medical screen, cognitive test, or brain imaging technique can detect ADHD

    • Children with ADHD can focus long enough to watch TV, play videogames or sit still at the doctor’s office.

    Pelham, Fabiano & Massetti, 2005


    Well-Established ADHD Treatments

    • Stimulant Medications

    • Behavioral Interventions

      • Behavioral parent training

      • Behavioral classroom management

      • Intensive summer treatment programs

    Pelham & Fabiano, 2008


    Medication: Stimulants

    • Most well-researched, effective, and commonly used medication treatment for ADHD.

      • Methylphenidate (Ritalin, Concerta, andMetadate)

      • 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 ganglia


    Stimulant Medications

    • Research has shown that stimulants:

      • Are highly effective in reducing ADHD symptoms in the short term

      • Decrease disruption in the classroom

      • Increase academic productivity and on-task behavior

      • Improve teacher ratings of behavior

    • Different formulations work best for different children

    • Common side effects: insomnia, decreased appetite

    • Strattera (atomoxetine)

      • A non-stimulant alternative that works well for some children

      • Has not been studied as long or as intensively as the stimulants

      • Smaller effect size relative to the stimulants


    Limitations of Stimulant Treatment

    • Individual differences in response

      • Not all children respond (approximately 80%)

    • Limited impact on domains of functional impairment

      • Primary reason for treatment seeking

    • Does not normalize behavior

    • Family problems beyond the scope of medication

    • No long-term effects established

    • Long-term use rare

    • Limited parent/teacher satisfaction

    • Some families are not willing to try medication


    How do we identify evidence-based, non-pharmacological treatments?


    “Evidence-based treatment” implies that studies have been conducted with the following features:

    • Careful specification of the target population

      • Diagnostic, demographic, recruitment, selection

    • Random assignment to conditions

      • Comparison could be to placebo but ideally to established tx

    • Use of treatment manuals

      • Ensures reliability of administration and facilitates replication

    • Multiple outcome measures with blind raters

    • Statistically significant differences between the tx and comparison group at post-tx

    • Replication, ideally by independent researchers

    Chambless et al., 1996; Silverman & Hinshaw, 2008


    Well-Established Non-Pharmacological Treatments

    • Behavioral parent training

      • 33 well-conducted studies

    • Behavioral classroom management

      • 45 well-conducted studies

    Pelham, Wheeler & Chronis, 1998; Pelham & Fabiano, 2008


    Behavioral Treatment Components

    • Psychoeducation about ADHD

    • Structure/routines

    • Clear rules/expectations

    • Attending/rewards

    • Planned ignoring

    • Effective commands

    • Time out/loss of privileges

    • Point/token systems

    • Daily school-home report card

    • Intensive summer treatment programs


    Behavioral Treatment Considerations

    • Need to address cross-situational impairments

      • Poor generalization from treatment setting to real-world

      • Implement treatments in all settings in which child shows impairment

    • School behavior

      • 504 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 maintain

      • Parental psychopathology can interfere with implementation


    Multi-Modal Treatment Study for ADHD (MTA)

    • 6 sites

    • 579 Children, 7-9 y/o

    • ADHD, Combined Type

    • Assigned to 14 months of:

      • Med management

      • Intensive Behavior Therapy

      • Combined treatment

      • Treatment as Usual in the Community (TAU)

        • 2/3 received medication

    MTA Cooperative Group, 1999


    Overall 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 community

    • On many measures, combined tx was not significantly better than medication alone

    • Only combined tx was better than TAU on oppositional symptoms, aggression, depression/anxiety symptoms, social skills, parent-child relationship, and reading achievement

    • Higher medication doses were needed in the medication only group relative to the combined treatment group

    MTA Cooperative Group, 1999


    Combined Treatment was superior in terms of:

    • Parent and teacher satisfaction with treatment

    • Normalization of child behavior

    • Improvements in functional outcomes

      • Family interactions

      • Peer relationships

      • Academic functioning

    Connors et al., 2001; Hinshaw et al., 2000; Pelham et al., 2004; Swanson et al., 2001; Wells et al., 2006


    MTA 6-8 Year Follow-Up

    • Original treatment assignment not associated with any of the 24 outcomes 6-8 yrs later

    • ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes

      • Children with the best initial tx response and most favorable clinical presentation at baseline fared best over time

      • Children with behavioral and sociodemographic advantage, with the best response to any tx, had the best long-term prognosis

    • As 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 term

    Molina et al., 2009


    Practice Parameters


    • American 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)


    • American 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)


    Summary

    • ADHD is a highly prevalent, brain-based disorder which is associated with lifelong impairment in functioning

    • Environmental factors can contribute to the expression, severity, course, and comorbid conditions

    • Long-term developmental outcomes for individuals with ADHD can include serious substance abuse, chronic criminality, depression and suicide

    • Stimulant medications and behavior therapy are currently the only established evidence-based treatments for ADHD

    • Combined 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


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