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Working with difficult children: Recent advances in ADHD. Eric Taylor King’s College London Institute of Psychiatry.

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working with difficult children recent advances in adhd

Working with difficult children: Recent advances in ADHD

Eric Taylor

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.

lessons from research
Lessons from research
  • It’s not their fault
  • Psychological treatments work
  • Medicines help the worst affected
  • Increasing range of medicines
slide3

More ‘diagnoses’ for child troubles

Born mad or made bad? Crime and the child

BBC to apologise for child drug program

conflicts in understanding adhd
Genetic influences 80%;

Frontal, striatal, cerebellar parts of brain are small

Same structures underactivate

Psychological deficits

Great differences over time

Great differences in prevalence between countries

Emotional & behavioural problems

Performance variable

Conflicts in understanding ADHD*

Persistent and pervasive abnormalities in : Attention (distractible, forgetful, disorganised); Activity (restless, fidgety) and Impulsiveness (acting without thinking)

where does adhd come from twin studies show high heritability
Where does ADHD come from?Twin studies show high heritability

DZ

MZ

Twin

correlations

Median heritability (13 studies) 0.82 (0.52-0.98)

search for high risk alleles
Search for high-risk alleles

7 (vs 2-5 or 8) copies of 48 bp VNTR on 11p.15.5

  • DRD4
    • metaanalysis p< .00000001
    • Odds ratio (averaged): 1.32
  • DAT1
    • metaanalysis p<.0001
    • Odds ratio (averaged): 1.13

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

slide7

Geographical variations in the number of repeats of the variable 48-bp sequence in DRD4

Chang et al

genome scan identifies a spot on chr 16 cadherin 13
Genome scan identifies a spot on Chr 16: Cadherin 13
  • Cadherins mediate cell adhesion and play a fundamental role in normal development. They participate in the maintenance of proper cell-cell contacts
  • CDH13 also implicated in substance misuse:

Nicotine dependence

Substance dependence

  • Plays a role in cell adhesion, cell-cell contacts and cell-migration
what is inherited
What is inherited?
  • Not ADHD: genetic influences on continuum*
  • Not a unitary trait: influences vary with context
  • Dispositions to react:
    • gene-environment interactions and correlations
      • early physical environmental associations
      • parenting influences on development
      • MAOA multiplies effects of violence, DRD4.7/DAT10 of smoking

*(with possible exception at highest level of severity & possible latent classes)

probable environmental associations
Probable environmental associations

Pregnancy

  • nicotine, alcohol, anticonvulsants, cocaine
  • lead, mercury; thyroid, immune rejection
  • stress; infections; toxaemia;APH

Perinatal

  • low birth weight, O.C.s, perinatal care, [season of birth]

Infancy

  • attachment problems, neglect, injury
  • socioeconomic adversity, nutrition

Childhood

  • Course influenced by exclusion, hostility, injury, school
slide12

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?

prevalence of disorder
Prevalence of disorder

ADHD /1000

Real prevalence

Administrative prevalence from local surveys; HKD in approx 105,000 nationally

prevalence of disorder1
Prevalence of disorder

Same survey method in Hong Kong and East London

is it a social problem
Is it a Social Problem?
  • Does society determine the presence of ADHD?
    • No, shared environment plays little part
  • Does society alter the rate?
    • Only small differences between societies
    • Little increase over time
  • Does society determine what is recognised?
    • Yes, substantial cultural differences
interventions in the classroom
Interventions in the classroom
  • Proximity to teacher
  • Managed transitions
  • Pacing & letting off energy
  • Classroom aide
    • operant conditioning
    • peer advice
  • Rule government
  • Clarity of goal & speed of feedback
  • Understanding disorder (eg projects)
  • Monitoring medication

Some common-sense procedures – avoiding distractors and short-chunk learning – don’t yet have trial evidence

specific treatments
Specific treatments
  • Psychological therapies:Parent training, behaviour mod, social skills
  • Licensed drugs:Methylphenidate, dexamfetamine, atomoxetine
  • Unlicensed drugs:Trial evidence:pemoline, imipramine, clonidine, bupropion, “Adderall”, modafinil, guanfacineAnecdotal: moclobemide, risperidone, sertraline
  • Diet: eliminations and supplements

Include non-specific interventions - education, support, advice

a range of presentations xavier
A range of presentations: Xavier

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.

a complex disorder multiply caused
A complex disorder, multiply caused

Not just bad parents: Medication of child reduces parental EE

  • Not just complications:
  • In never-medicated adults:
  • Recent findings of low dopamine and DAT
  • Recent findings of persisting hypoactivation

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)

a range of presentations matteo
A range of presentations: Matteo

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.

a complex disorder multiply caused1
A complex disorder, multiply caused

Inattention creates an increasingly unstimulating environment

principles of psychological treatment
Principles of psychological treatment
  • Identify specific problems
  • Analyse contingencies
  • Enhance adult attending
  • Teach effective instruction
  • Token economy + response cost (frequent) or time-out + rapid novel rewards
  • Include self- management
a school based trial
A school-based trial

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)

learning social skills in peer group
Learning social skills in peer group

Listen to others

Join play gradually

Learn the rules

Avoid intrusiveness and excessive demands

Figure out why others react

Control anger

Learn how to refuse kindly

Especially drugs

but do behavioural treatments work metaanalysis
But do behavioural treatments work? Metaanalysis

Pelham & Fabiano (2008) review:

Behavioural parent training

Behavioural classroom management

Intensive intervention in recreational settings

Journal of Clinical Child and Adolescent Psychiatry 37 184

cost effectiveness calculation
Cost-effectiveness calculation

Sensitivity analyses for differing assumptions

economic conclusion
Economic conclusion

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.

clinical conclusions
Clinical conclusions

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

slide34

Month

36

0

14

24

10-m

Follow-up

Phase

22-m

Follow-up

Phase

14-m

Treatment

Phase

R

A

N

D

O

M

A

S

S

I

G

N

M

E

N

T

MedMgt

144 Subjects

Recruitment

Screening

Diagnosis

Beh

144 Subjects

579 Subjects

7 to 9 yrs old

ADHD-Combined

Comb

145 Subjects

CC

146 Subjects

End of

Treatment

(14 m)

First

Follow-up

(24 m)

Second

Follow-up

(36 m)

Early

Treatment

(3 m)

Mid-

Treatment

(9 m)

Baseline

Pre-Baseline

Observation 2 LNCG Group

Observation 1 LNCG Group

Assessment Points

comparing therapies conclusions from mta study
Comparing Therapies:Conclusions from MTA Study
  • Medication is more powerful than behavioural treatment at 14 months
  • Research treatment better than routine
  • Many advantages in adding medicationto behavioural treatment; few in adding behavioural treatment to medication
comparing therapies mta timeline
Comparing therapies:MTA Timeline

8 Years

6 Years

24 Mos, 9-12 yrs

36 Mos, 10-14 yrs

14 Mos, 8-12 yrs

Baseline, 7-9.9 yrs

10 Years

Study

Treatments

36 Month Findings on Substance Use

Molina et al

Randomisation ends

jensen et al 2007 intent to treat itt analysis
Jensen et al, 2007Intent-to-treat (ITT) Analysis

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

equifinality of interventions how should clinical services react
Equifinality of Interventions: How Should Clinical Services React?
  • Results underestimate treatment effects?
  • Treatments lack long-term benefit?
  • Extra benefits of intensive therapy fade?
  • Self-selection makes good outcomes
subtyping
Subtyping

ANXIETY / DEPRESSION

IMP

1/4

SCHOOL

HOME

HKD

HYP

3/5

INAT

6/9

IMPAIRMENT

adhd versus hkd
ADHD versus HKD

ANXIETY / DEPRESSION

IMP

1/4

SCHOOL

HOME

HKD

HYP

3/5

INAT

6/9

IMPAIRMENT

economic modelling
Economic modelling

Continue

£

QoL

Methylphenidate

Parent training

Methylphenidate

Parent training

Continue

severe cases
Severe cases

Continue

Methylphenidate

Parent training

Methylphenidate

Relative effect of medication to behavioural interventions greater in hyperkinetic subtype

Parent training

Continue

treatment decisions
Treatment decisions
  • Severe, pervasive, disabling?
  • Problems at home?
  • Problems at school?
  • Persistent after treatment?
  • Comorbid problems?

Home CBT

?

Liaison

+ self-instruction

Medication

key recommendations from nice
Key recommendations from NICE
  • ADHD should be recognised and referred
  • Comprehensive specialist assessment; impairment req’d
  • Trusts to set up lead group
  • Adult services to be developed
  • First choice usually group parent training
  • Severe cases go straight to medication
  • First choice medication usually MPH
  • Shared care expected
drugs or behaviour therapy conclusions so far
Drugs or behaviour therapy?Conclusions so far
  • Both are effective
  • Both are cost-effective
  • Medication hazards:
      • Growth suppression (manageable)
      • Hypertension (avoidable with monitoring)
      • Unknown risks to CVS
  • ADHD is heterogeneous in severity and course
specific approaches cognitive therapy

Specific approaches: cognitive therapy

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

Tolerating waiting

So far, trial evidence suggests no effect on core ADHD. What are we doing wrong?

slide50

Perhaps teaching cognitive control is hard because there are many routes into impaired control/ impulsiveness

varieties of inattention
Attention domains

Executive function

Alerting

Sustaining vigilance

Resisting distraction

Altering focus

Allocating resource

Modify responsiveness

Varieties of “inattention”

Planning

Reaction time,

Continuous performance tests

CPT with distractors

Central-incidental learning

Dual task

“Inhibition”, preparedness, Sternberg, cognitive energetics

a sustained attention deficit
A sustained attention deficit?

Number of errors are high and responses slow throughout the test

eg Sergeant et al 1990

slowing the presentation rate
Slowing the presentation rate

Van der Meere et al 1995

a preparation deficit
A preparation deficit?

RT

Warning

Signal

Response

Sonuga Barke et al 1993

gonogo stop
GONOGO STOP
  • press inhibit
  • Selective inhibition of a motor response/response selection

press inhibit

ISI: 1.6s

Withholding of a planned motor

response

REVERSAL

press

inhibit

switch task
SWITCH TASK

Modification of Meiran Switch task: Cognitive flexibility. Switching between two dimensions.

delay of gratification
Delay of gratification

Useful clinical test in preschool children; needs to be subtler for older children (Mischel).

post reward delay
Post - reward delay

1 p

1 p

30 sec

?

?

?

2 p

Experiments by Edmund Sonuga-Barke

delay aversion v inhibition
Delay aversion v inhibition
  • Evidence for both; inhibitory failure in more severe cases
  • Combination of both predicts behavior much more strongly than either alone (Solanto et al)
  • Inhibition (5-choice serial RT; 5HT2A,C) and preference for delayed reward (5HT2C,B)show double dissociation with 5-HT receptor (Talpos et al)
time scales of reward effects
Time scales of reward effects

Response to reward

Anticipation Effects

Choice between alternatives

Expectation

Previous reward history

Reinforcement schedules

Pairing

Rapid change of activity

rewarded cpt
REWARDED CPT

8

8

7

7

X

6

6

5

5

4

4

3

3

2

2

1

1

  • FMRI: respond to “X” and “O”. ISI: 900ms
specific dysfunctions in cd vs adhd
Specific dysfunctions in CD vs ADHD

Sustained Attention

Reward

reward problems presented in psychopathology
‘Reward’ Problems presented in psychopathology
  • Misbehaviour (“oppositional/conduct disorders”)
  • Anhedonia
  • Misery
  • Addiction
  • Hunger for novelty/sensation/reward/dopamine
  • Apparently dysfunctional choices (risky or punished activities)
  • Insensitivity to reward schedules
clinicians use of reward mechanisms
Clinicians use of reward mechanisms
  • Parent Training
    • Clarity, consistency, speed
  • Premack principle
  • Reward schedules
    • enuresis training
    • reward frequency before training
  • Reward novelty
  • [Density, predictability, reward/punishment ratios]
clinicians use of punishment mechanisms
Clinicians’ use of punishment mechanisms
  • Reduction of naturalistic punishment
  • Response cost
  • (Time-out)
    • Conceptualised as extinction
what is it like to be inattentive impulsive
What is it like to be inattentive/ impulsive?
  • “My thoughts are in a muddle”
    • (usually only after treatment shows the difference)
  • “I get into trouble a lot, I don’t know why”
  • “Other kids pick on me”
  • “Ive got a bad temper”, “I cant concentrate”, “Ive got ADHD”

(usually repeating what they have been told)

conclusions
Conclusions
  • There are several testable cognitive dysfunctions
      • Response organisation, switching, reward, timing
  • They are found in several presentations
      • Attention deficit, impulsiveness, irritability
  • Useful for individual analysis, not diagnosis
      • But most tests are unstandardised
  • Could help to guide teaching
  • Treatment does not usually depend on cause
      • Consider behaviour modification and medication
research knowledge on adhd
Research knowledge on ADHD
  • Common, persistent, risk for mental health
  • Neurobiology becoming clearer
      • Low dopamine levels in striatum (PET)
      • Frontostriatal (& other) brain changes (MRI)
      • Genetic and environmental causes
        • Allelic variants associated, esp genes in dopamine system
  • Effective treatments
      • Stimulants, atomoxetine, behaviour therapy
      • Efficacy is not related to cause