Drugs in ADHD(Attention Deficit Hyperactivity Disorder)

Dr. Samir H DalwaiMD, DCH, FCPS, DNB, LLB

Developmental & Behavioral Pediatrician,President, Indian Academy of Pediatrics-Mumbai,

Chairperson, IAP Chapter of Developmental Pediatrics,Founder Director, New Horizons Group.

Politically correct means of

communication about kids with ADHD!

Politically correct means of

communication about kids with ADHD!

Jose S Perez’s interpretation of

how we wish it could be!

Opening Comments

1. ADHD is a syndrome with a constellation of symptoms

2. Core features are Hyperactivity, Impulsivity, Inattention….

and also INCONSISTANCY*.

3. Pervasive across many life functions, especially concerned with learning and achievement, classically called

“ executive functioning”

(*New Horizons Child Development Centre)

Opening Comments

4. Associated with many co-morbidities/co-exiting conditions

5. Requires multi-dimensional treatment approach which would include pharmacotherapy

6. Only a persistent and sustained goal oriented programme over a specified period of time with proper compliance along with adherence to medication is required for maximum benefit.

ADHD

Core features Core Features PLUS Co-morbidities= Clinical/Functional Features

Pharmacotherapy Behaviour therapy + Pharmacotherapy

Aim of Management

• The TARGET is to enable the child to function appropriately and independently at home, in school and in society.

• Co-morbid/ co-existing conditions must be addressed and treated concurrently with ADHD

New Horizons Child Development Centre Data

1301

547

422

128

0

200

400

600

800

1000

1200

1400

2009-2012 2013-2015

Num

ber o

f chi

ldre

n

Children with ADHD in 2009-12 (TISS_NHCDC Study) & 2013-2015; and mean age [2013-15 data analysis is ongoing]

Total childrenChildren with ADHD

32.4%

23.4%

6.9 years

7.1 years

25

21

6 5

17

4

8

42 1 1 1 1 2 1

0

5

10

15

20

25

30

Num

ber o

f chi

ldre

n, o

ut o

f 128

child

ren

with

ADH

DADHD and co-morbidities , Data: 2013-2015

(n = 128 total children with ADHD,99 children or 77.3% had co-morbidities)

Number of children

Recommendations for Management

• Recommendations for treatment of children and adolescents with ADHD vary depending on the patient’s age.

• Combination of behavioural therapy and pharmacotherapy to be used

Pediatrics 2011;128: 000

If target behaviors do not improve with the above and

the child’s function continues to be impaired, add

First line of Intervention

ADHD

Preschool (4- 6 years)

BehaviourTherapy

Pharmacotherapy(Methylphenidate)

School (>6 years)

Pharmacotherapy

Behaviour Therapy

Types of Drugs• Stimulants

methylphenidate

• Non-stimulants atomoxetineclonidineguanfacine

• Alpha-2 adrenergic agonists

• Anti- depressants

Multimodal Treatment Study of Children with ADHD (MTA) (NIH: US based)

• Largest independent trial examining the effects on ADHD symptoms and long-term outcomes of different ADHD treatments including:

A. Intensive behavioural intervention

B. Medication

C. These two treatments combined, or

D. Routine community care

Multimodal Treatment Study of Children withADHD (MTA) (NIH: US based)

• Primary analyses- outcomes in this study were

– not significantly different for pharmacological treatment alone versus combined treatment after correction for multiple tests,

– but the combined group allowed as good a result with significantly lower dose of medication (methylphenidate)

• Secondary analyses-

– combined treatment was significantly better than pharmacological treatment alone

1. Initial advantage of medication wore off after 3 years of pharmacotherapy.

2. Children who had been assigned to intensive behavioural treatment were more likely to begin taking medication;

while those who had been taking medication were more likely to stop.

3. Among children originally in the behavioural treatment group, the incidence of high medication use increased from 14 to 45 percent.

Multimodal Treatment Study of Children with ADHD (MTA) (NIH: US based)

• Poor understanding on the part of patients (they presume ADHD is an academic problem as medication is not given on holidays and weekends)

• Expecting ‘CURE’. Failure to understand that treatment is protective-both now and for future adverse consequence- not curative

• Side-effects

• Multiple doses

Expert Rev Pharmacoeconomics Outcomes Res. 2013;13(6):791-815.

Summary of prospective studies examining adherence to ADHD medications in children, adolescents and adults.

Summary of prospective studies examining adherence to ADHD medications in children, adolescents and adults.

Problems with ADHD drugs• SIDE EFFECTS• ABUSE• MISUSE•In a United States survey of middle-class adolescents and young adults, 11% surveyed reported that they sold their stimulant medication and 22% had misused it. •A Canadian survey of high school children from the Atlantic provinces revealed that 26% of adolescents report having diverted their ADHD medications one or more times

And hence.. Management should involve..

A • Behavioural intervention

B • Pharmacotherapy

C • Educational measures

D • Combination of above

ENSURE COMPLIANCE

Timely review of goals set

Individualised as per

strengths and challenges

Scientific

Goal specific (should

change with time as child

improves

The 6 step model of New Horizons Developmental Program

• 1. Assessment by Developmental

Pediatrician

Developmental Pediatrician and Assisting Doctors

• 2. Individual Assessment

across Departments

Clinical Psychology, OT, PT,

Speech Therapy, Remedial Education • 3.Collaborative

Integrated Report and Diagnosis

Team Discussion

• 4. New Horizons Developmental Program (NHDP) with Time-bound Goals

Developmental Pediatrician

with Team and Parent

• 5. Individual Intervention Sessions across Departments,

• Documented and Monitored through daily logs, weekly reports and monthly review of Management Information System (MIS)

Team with Developmental Pediatrician with Centre Head, Clinical Coordinator

and Clinical Director

• 6. Reassessments and revised NHDP.

Developmental Pediatrician

with Team and Parent

MTA study results

New Horizons CDC data•Total no of children evaluated: 281

•Data available: 68

•Time frame of retrospective analysis :2015

•No. of children with ADHD: 13

•No. of children compliant to a 6 month programme: 13 (100%)

•No. of children compliant to a 1 year programme: 4 (30%)

Social factors

• India is home to 38 million children 0-9 years of age with one or more neurodevelopmental disorders (Silbeberg, 2014 and Census, 2011).

• Yet, only 2-3% of children with disabilities have access to education.

• Rehabilitation Council of India (RCI) estimated that 30 million children with disabilities need education. RCI aims to educate 10% of these children by 2020.

Key Messages

1. Consider ADHD to be a constellation of issues; the functional resolution of each of which is the ultimate aim of the physician.

2. The devil is in the detail; ensure each area has a target and a strategy.

3. Each strategy needs tactics; delivered via multiple stakeholders over a period of time.

4. This requires a Documented Program at the outset which will enumerate the script and the role of each player, lead the way till its conclusion; the New Horizons Developmental Program (NHDP) is one such indigenously developed program.

Thank You!

IAP Mumbai, IAP Navi Mumbai, IAP

CHAPTER OF DEVELOPMENTAL PEDIATRICS

National Conference of Developmental Pediatrics NCDP-EMBICON 2016Mumbai - 1, 2 October 2016

www.ncdp-embicon2016.comTheme: Integrating Developmental Pediatrics into Office Practice