Attention Deficit Hyperactivity Disorder

Rachel J. Valleley, Ph.D.Assistant Professor, Pediatrics

Munroe-Meyer Institute, UNMC

Current Conceptualization

Attention-Deficit Hyperactivity Disorder (ADHD)

DSM-IV, 1994

Three subtypes: Predominantly Inattentive Predominantly Hyperactive/Impulsive Combined

Adolescent and Adult Outcomes

Chronic disorder lasting into adulthood 1/3: Tolerable outcome

mild problems - adapt to difficulties

1/3: Moderately poor outcome

variety of problems such as school, vocational, adjustment difficulties, interpersonal problems, underachievement,

problems with alcohol

1/3: Poor outcome severe dysfunction including repeated criminal activity, alcoholism and drug use.

Pittsburgh ADHD Longitudinal Study, Molina and Pelham

Cause of ADHD

No one cause identified.

Not caused by Diet (i.e. food additives, sugar) Poor parenting

Prevalence of ADHD

Standard estimate: 3%-5%

More recently: 12%(Fabiano & Pelham, 2001)

Attention-Deficit Hyperactivity Disorder

Diagnosis:

Who has ADHD?

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion A:

Six or more symptoms from one or both of these lists:

Inattentive Type Hyperactive/Impulsive Type

…have been present for at least 6 months.

Symptom Lists

Inattentive Type fails to attend to details, makes careless

mistakes difficulty sustaining attention in play or

work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental

effort loses things needed distracted by extraneous stimuli often forgetful

Hyper/Impulsive Type often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure

activities quietly often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion B:

Some of the symptoms were present before the age of seven years.

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion C:

Some impairment from the symptoms is present in two or more settings (e.g., home, and school or work).

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion D:

There is evidence of clinically significant impairment in social, academic, or occupational functioning.

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion E:

The identified symptoms are not better accounted for by another mental disorder.

Other Common Causes of Attention & Hyperactivity Symptoms Oppositional Behavior Learning difficulties Depression/anxiety Drug/alcohol use Physical illness Adjustment

Associated Problems

Oppositional Defiant Disorder: 35 - 65% Learning Disability: 25 - 30%

and variable academic quality Poor social skills, peer relationships

Often overlooked! Difficulties in family functioning

Attention-Deficit Hyperactivity Disorder

Assessment:

All that wiggles is not ADHD

Comprehensive Diagnosis for ADHD

There is no single test or laboratory measure which can reliably detect ADHD.

Comprehensive Diagnosis for ADHD

Information gained by qualified clinician: From family

o standardized, norm-referenced ratingso detailed history

From schoolo standardized, norm-referenced ratingso academic historyo in-class observations

From cliniciano observations

Parent Behavior Rating Scales

Conner’s: quick and dirty screening for ADHD and ODD

CBCL/BASC: screen for a variety of problems Eyberg: screen for most common behaviors

that drive parent crazy ADHD-IV: screens for hyperactivity/impulsivity

and inattention symptoms Disruptive Behavior Disorder: screens for

ODD & CD Narrative summary to assess for impairment

Teacher Behavior Rating Scales

Conner’s: quick and dirty screening for ADHD and ODD

CBCL/BASC: screen for a variety of problems ADHD-IV: screens for hyperactivity/impulsivity

and inattention symptoms Disruptive Behavior Disorder: screens for

ODD & CD Narrative summary to assess for impairment

Youth Behavior Rating Forms

If appropriate: CBCL to screen for a variety of problems Reynold’s Adolescent Depression Scale Reynold’s Child Manifest Anxiety Scale Childhood Depression Inventory

When to refer?

Screening measure indicates elevation in Hyperactivity/Impulsivity and/or Inattention symptoms

Unclear if other explanation for symptoms Don’t have time for comprehensive evaluation

What to expect if referred to me

Meet for initial appointment to determine if evaluation is warranted (screening measure already completed is helpful)

Conduct comprehensive evaluation Present treatment options based upon

diagnosis Send back to physician if want medication

and/or need verification of diagnosis for school

Treating ADHD

What we know works:

Drug TherapyBehavior TherapyCombined Behavioral/Drug Treatments

APA Task Force on Evidence-Based Treatments, JCCAP, Pelham, Wheeler, & Chronis, 1998

What we know DOESN’T work:

Play therapy Individual or family counseling (without

altering the environment) Social skills/self-monitoring/organizational

planning. Dietary management Megavitamin therapy Sensory integration therapy/chiropractics Biofeedback

Medications for ADHD

Ritalin

Adderall

Cylert

Dexedrin

Strattera

Concerta

What Medications Can Do

Manage symptoms Decrease activity level Decrease impulsivity Increase attention or “focus”

What Medications Can Do

Improve associated features Decrease “defiance” Decrease aggression Suppress negative social skills

What Medications Can’t Do

Teach new, appropriate behaviorsCompliance/rule-following

Self-management Teach content previously missed

Academic work

Social skills “Cure” ADHD

Stimulant Medications: Considerations Effective for 70-75% Higher doses associated with more side effects Positive effects are lost when drug discontinued

Stimulant Medications:Contraindications Under six years of age High anxiety level Thought disorder History of tics or Tourette’s Syndrome Risk of drug abuse Unacceptably high levels of negative side effects

Limitations to Medication Treatment

Rarely sufficient to bring a child into normal range of functioning. Works only as long as taken. Not effective for all children. Doesn’t affect several variables (e.g., academic skills, family

problems). Poor compliance with long-term use. Parents not satisfied with medication alone. Removes incentives to work on other treatments. Lack of long-term evidence for effects. Potentially problematic side-effects.

Behavior Therapy for ADHD

Components Highly Structured Immediate Feedback

reinforcer or reward for appropriate behavior

punishment for inappropriate behavior Salient/Meaningful Feedback

Common Behavior Interventions

Daily Behavior Report Card Token Economy Parent Training

Daily Behavior Report Cards

Daily note is sent between home & school regarding child’s behavior

Target behaviors monitored throughout the day Performance on note determines consequences at

home and/or school

Daily Behavior Report Cards

Academic Behaviors Working on assignments Completing homework Handing in assignments All work up to date On time for class

Social Behaviors Remained in seat Talked in turn Respectful behavior Got along with peers Following instructions Hands to self

Sample School-Home Note

Classes Turned in work Work turned in at least 80% accurate

Teacher Initials

Math Yes No Yes No

Reading Yes No Yes No

Spelling Yes No Yes No

Social Studies Yes No Yes No

Science Yes No Yes No

Homework:

Daily Behavior Report Card

Benefits Keeps communication open between child’s

environment Helps monitor whether behavior is changing Can monitor impact of medication Takes very minimal adult time Helps child get lots of positive feedback

throughout the day

Token Economies

Arbitrary token (e.g., poker chip) given for demonstrating appropriate behavior

Tokens lost for inappropriate behavior Tokens exchanged for reinforcers

This type of intervention becomes highly individualized based upon behaviors targeted, what is reinforcing to the child, and in what settings it is used

Parent Training

Increase positive interactions for appropriate behavior Child-Directed Interaction Role of Attention Access to Tangibles

Decrease negative behaviors Time-out (up around 8 years) Job card grounding (around 8 and older)

Limitations of Behavioral Interventions Often not sufficient to bring a child into the

normal range of functioning. Must be broad in scope to affect important

familial variables. Lack of evidence for long-term effects. Difficult to get parents and teachers to do

over a long period of time. Costly compared to medications.

Which to employ?

The NIMH Multimodal Treatment Study Largest NIMH-funded study of child mental

health concern 579 children at multiple sites Group comparisons including:

Community Treatment Psychosocial Treatment Only Medication Only Combination of BT and Meds

Which to employ?

Summary of Findings All four groups improved with time. Combined > Behavior on all measures. Combined > Medicine on most measures of

impairment but not symptoms. Combined and sometimes Medicine > CC. Combined produced more normalization at

lower doses than Medicine; was more preferred by parents.

Which to employ?

Med Mgmt Combined Behavioral

Declined/Drop Out

12% 4% 0%

Worse/Unchanged

6% 6% 5%

Slight Improved

22% 11% 22%

Improved 38% 37% 43%

Much Improved

22% 41% 30%

Change in Presenting Problem

Which to employ?

Med Mgmt Combined Behavioral

Declined/Drop Out

12% 4% 0%

Dissatisfied 5% 3% 3%

Neutral 2% 2% 4%

Slightly Satisfied

23% 11% 19%

Satisfied 41% 38% 47%

Much Improved

17% 42% 27%

Satisfaction with Child’s Progress

Which to employ?

Med Mgmt Combined Behavioral

Declined/Drop Out

12% 4% 0%

Dissatisfied 3% 2% 1%

Neutral 6% 4% 1%

Slightly Satisfied

5% 3% 4%

Satisfied 40% 18% 31%

Much Improved

34% 70% 64%

Overall Satisfaction with Treatment

MTA Notes: The Combined Approach

Excellent Responder Analysis

% meeting Snap Parent/Teacher

“Normalization Criteria”

14 mos 24 mos

CC 25% 27%

Beh 34% 32%

Med 56% 38%

Combined 68% 48%

When to refer?

Medication is not being enough to bring into normal functioning

Side effects too great for medication Parents want alternative treatment to

medication Co-occurring problems (ODD, CD, Anxiety,

Depression)

Questions

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