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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

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
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
  • Definition & Features
  • Etiological Factors
  • Evidence-Based Assessment & Treatment
  • Professional Practice Parameters
prevalence impact
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
dsm iv diagnostic criteria
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
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 cont8
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

  • 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
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
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
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 factors14
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
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
  • 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
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
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
evidence based assessment
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
Well-Established ADHD Treatments
  • Stimulant Medications
  • Behavioral Interventions
    • Behavioral parent training
    • Behavioral classroom management
    • Intensive summer treatment programs

Pelham & Fabiano, 2008

medication stimulants
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
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
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
evidence based treatment implies that studies have been conducted with the following features
“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
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
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
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
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
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
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


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)
  • 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