Working with difficult children: Recent advances in ADHD. Eric Taylor King’s College London Institute of Psychiatry.
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King’s College London Institute of Psychiatry
There are many ways in which children can be ‘difficult’: ADHD is just one. Behaviour is dysregulated : inattention, executive dysfunction, altered response to reward, poor time perception, and response disorganisation can all be involved. Assessment can guide education, help counselling, and lead to treating ADHD.
Born mad or made bad? Crime and the child
BBC to apologise for child drug program
Frontal, striatal, cerebellar parts of brain are small
Same structures underactivate
Great differences over time
Great differences in prevalence between countries
Emotional & behavioural problems
Performance variableConflicts in understanding ADHD*
Persistent and pervasive abnormalities in : Attention (distractible, forgetful, disorganised); Activity (restless, fidgety) and Impulsiveness (acting without thinking)
Median heritability (13 studies) 0.82 (0.52-0.98)
7 (vs 2-5 or 8) copies of 48 bp VNTR on 11p.15.5
9 vs 10 copies of 40 bp VNTR on 5p15.3
8 candidate genes well established to be associated with ADHD:
mostly affecting dopamine or serotonin neurotransmission
Geographical variations in the number of repeats of the variable 48-bp sequence in DRD4
Chang et al
*(with possible exception at highest level of severity & possible latent classes)
But, if ADHD is so neurological, how come it varies so much in different places? Isn’t it really a social disorder? What about the rise of television and the decline of the family?
Administrative prevalence from local surveys; HKD in approx 105,000 nationally
Same survey method in Hong Kong and East London
Is it a Treatable Problem? in different places? Isn’t it really a social disorder? What about the rise of television and the decline of the family?
Patterson - OSLC
Some common-sense procedures – avoiding distractors and short-chunk learning – don’t yet have trial evidence
Include non-specific interventions - education, support, advice
Xavier, aged 11, has been out of the control of his parents after an episode of meningoencephalitis at age 4. He is dangerously aggressive to his sister and younger brother and has been excluded from a special unit at school. He sets fires, steals from shops, and puffs cannabis with a group of older boys.
He can’t concentrate in class, is very forgetful and disorganised; and teachers have believed that this comes from a chaotic home background.
Not just bad parents: Medication of child reduces parental EE
Not just genetic: The Environmental Risk Longitudinal Twin Study interviewed the mothers of 565 five-year-old monozygotic (MZ) twin pairs : the twin receiving more maternal negativity and less warmth had more antisocial behavior problems. (Moffitt et al 2008)
Matteo is regarded by his parents as a charming 8-year-old who has recovered from injury but is now encountering bullying. His teachers, however, refer him to the clinic with a very different story: he does not listen to them, he does not concentrate as he should, he has low academic self-esteem and big tempers when frustrated, he is inclined to lose his way, he is clumsy and his handwriting is terrible.
He was popular when he started at school, but now is teased a great deal. His teachers are frustrated because in individual sessions he shows good understanding and creativeness.
Inattention creates an increasingly unstimulating environment
Tymms & Merrill (2009)
86 schools & 2,584 pupils in randomised trial
Year 2 behaviour in schools receiving an Information Booklet was improved (ES = 0.26)
Pupil attitudes to school and reading were improved (ES = 0.17)
No effect of screening programme.
Cost of booklet £2.55
(similar booklet in Taylor E (ed) People with Hyperactivity. CDM 171; MacKeith Press)
Listen to others
Join play gradually
Learn the rules
Avoid intrusiveness and excessive demands
Figure out why others react
Learn how to refuse kindly
Pelham & Fabiano (2008) review:
Behavioural parent training
Behavioural classroom management
Intensive intervention in recreational settings
Journal of Clinical Child and Adolescent Psychiatry 37 184
NICE approach: Systematic literature review in different places? Isn’t it really a social disorder? What about the rise of television and the decline of the family?
Sensitivity analyses for differing assumptions
According to this analysis, and after assuming an 80% uptake of such programmes,
the group clinic-based programme resulted in a cost per responder of £10,060 and £1,006 at a 5% and 50% success (response) rate, respectively; and a cost per QALY of £12,575 and £3,144 at a 5% and 20% improvement in HRQoL, respectively.
The results of the economic analysis indicate that group-based parent training programmes (or CBT for children of school age) are likely to be cost-effective for children with ADHD, if the mode of delivery of such programmes does not affect their clinical effectiveness. Individual parent training is unlikely to be a cost-effective option
Month in different places? Isn’t it really a social disorder? What about the rise of television and the decline of the family?
7 to 9 yrs old
Observation 2 LNCG Group
Observation 1 LNCG Group
24 Mos, 9-12 yrs
36 Mos, 10-14 yrs
14 Mos, 8-12 yrs
Baseline, 7-9.9 yrs
36 Month Findings on Substance Use
Molina et al
MTA Group, 1999a,b
MTA Group, 2004a,b
Randomized Clinical Trial at 14-month assessment: Transition to Naturalistic Follow-up at the 24-month & 36-month Assessment
ANXIETY / DEPRESSION
ANXIETY / DEPRESSION
Relative effect of medication to behavioural interventions greater in hyperkinetic subtype
Effective for coexistent anxiety/ depression
For Core ADHD symptoms, little effect:
Learning to STOP AND THINK
Recognising and managing anger
Teaching others to be self-controlled
So far, trial evidence suggests no effect on core ADHD. What are we doing wrong?
Attention domains many routes into impaired control/ impulsiveness
Modify responsivenessVarieties of “inattention”
Continuous performance tests
CPT with distractors
“Inhibition”, preparedness, Sternberg, cognitive energetics
Number of errors are high and responses slow throughout the test
eg Sergeant et al 1990
Van der Meere et al 1995
Sonuga Barke et al 1993
Withholding of a planned motor
Modification of Meiran Switch task: Cognitive flexibility. Switching between two dimensions.
Useful clinical test in preschool children; needs to be subtler for older children (Mischel).
Experiments by Edmund Sonuga-Barke
Reward & Social Influences many routes into impaired control/ impulsiveness
Response to reward
Choice between alternatives
Previous reward history
Rapid change of activity
(usually repeating what they have been told)