Andrea Chronis-Tuscano, Ph.D.Associate Professor of PsychologyDirector, Maryland ADHD Program

University of Maryland

Attention-Deficit/Hyperactivity Disorder (ADHD)

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

Overview Definition & FeaturesEtiological FactorsEvidence-Based Assessment &

TreatmentProfessional Practice Parameters

Prevalence & ImpactPrevalence 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 samples50% of children referred to mental health

clinics are referred for ADHD-related problemsAnnual societal cost of illness for ADHD

estimated to be between $36 - 52 billion $12,005 -- $17,458 annually per individual

www.cdc.gov

Definition & Features

DSM-IV Diagnostic CriteriaInattention 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

directlyDoes 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.)Hyperactivity-Impulsivity Symptoms (at least 6

symptoms required)Difficulty playing or engaging in activities quietlyAlways "on the go" or acts as if "driven by a

motor”Talks excessivelyBlurts 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 seatLeaves seat in classroom or in other situations in

which remaining seated is expected

APA, 2000

ADHD Diagnostic Criteria (cont.)Symptoms present before age 7Clinically significant impairment in social

or academic/occupational functioningSome 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

SubtypesCombined Type

Clinical levels of both inattention and hyperactivity/impulsivity

Most common subtypePredominantly Inattentive Subtype

Clinical levels of inattention onlyOften not identified until middle schoolSluggish cognitive tempo

Predominantly Hyperactive/Impulsive SubtypeClinical levels of hyperactivity/impulsivity onlyMore common among very young children prior to

school entry

Controversial Issues with DSM-IV Criteria

Developmentally insensitiveSymptoms based on field trials conducted

with elementary school aged boys (Lahey et al., 1994)

Categorical (not continuous) viewRequirement of onset before age 7

arbitraryRequirement of 6 months duration too

briefRequirement that symptoms be

demonstrated across 2 settings

Associated ProblemsPeer problems

Inattentive symptoms ignoredHyperactive/impulsive symptoms actively rejectedNot deficient in social reasoning/understanding, but

rather the execution of appropriate social behavior

Family dysfunction/parental issuesNo clear causal relationship between family problems

and ADHDFamily problems can impact the severity and

developmental course/outcomes of ADHD

Self-esteemInflated: Positive illusory bias (Hoza)Low self esteem associated with comorbid

depression

Developmental CourseADHD is persistent across lifespan in most cases

Methodological issues impact estimates of persistenceADHD severity, psychiatric comorbidity, and parental

psychopathology predict persistence (Biederman et al., 2011)

Inattention remains stable; hyperactivity declines with ageDSM-IV criteria may not capture adolescent/adult

manifestations of impulsivity

Adult outcomes including psychiatric comorbidityWhen ADHD co-occurs with conduct disorder, chronic

criminality and serious substance use can resultWhen ADHD co-occurs with depression, risk of suicide

Etiological Factors

Etiological FactorsAverage heritability of .80 - .85

Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions

Dysfunction in prefrontal lobesInvolved in inhibition, executive functions

Genes involved in dopamine regulationDopamine transporter (DAT1) gene implicated7 repeat of dopamine receptor gene (DRD4)

implicatedGene 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 & FunctionDifferences in brain maturation,

structure, function (particularly abnormalities in frontostriatal circuitry):

Prefrontal cortexBasal gangliaCerebellum

These areas of the brain are associated with executive function abilities:

Attention, spatial working memory, and short-term memory

Response inhibition and set shifting

NeurotransmittersNeurotransmitter differences,

particularly in levels of:DopamineNorepinephrineEpinephrineSerotonin

Dopamine has been associated with approach and pleasure-seeking behaviors

Norepinephrine plays a role in emotional/behavioral regulation

Executive Functioning DeficitsCognitive processes which activate, integrate,

and manage other brain functions

Examples:Cognitive: working memory, planning, use of

organizational strategiesLanguage: verbal fluency, communicationMotor: response inhibition, motor coordination Emotional: self-regulation of emotion, frustration

tolerance

But…EF deficits overlap with ADHD symptomsEF deficits are not unique to ADHDNot all children with ADHD have EF deficits

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 disinhibition is the basis of executive functioning deficits in ADHD

A performance, rather than knowledge, deficit

From Mash & Wolfe, 2007

A Possible Developmental Pathway for ADHD

Evidence-Based Assessment & Treatment of ADHD

Evidence-Based Assessment

Teacher- and parent-completed questionnairesStructured 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

Stimulant Medications

Behavioral InterventionsBehavioral parent trainingBehavioral classroom managementIntensive summer treatment programs

Pelham & Fabiano, 2008

Medication: StimulantsMost well-researched, effective, and commonly

used medication treatment for ADHD.Methylphenidate (Ritalin, Concerta, and Metadate)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 MedicationsResearch has shown that stimulants:

Are highly effective in reducing ADHD symptoms in the short term

Decrease disruption in the classroomIncrease academic productivity and on-task behaviorImprove 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

childrenHas not been studied as long or as intensively as the

stimulantsSmaller effect size relative to the stimulants

Limitations of Stimulant TreatmentIndividual differences in response

Not all children respond (approximately 80%)Limited impact on domains of functional

impairmentPrimary reason for treatment seeking

Does not normalize behaviorFamily problems beyond the scope of

medicationNo long-term effects establishedLong-term use rare Limited parent/teacher satisfactionSome families are not willing to try

medication

How do we identify evidence-based, non-pharmacological treatments?

“Evidence-based treatment” implies that studies have been conducted with the following features:

Careful specification of the target populationDiagnostic, demographic, recruitment, selection

Random assignment to conditionsComparison could be to placebo but ideally to

established txUse of treatment manuals

Ensures reliability of administration and facilitates replication

Multiple outcome measures with blind ratersStatistically significant differences between

the tx and comparison group at post-tx Replication, ideally by independent

researchersChambless et al., 1996; Silverman & Hinshaw, 2008

Well-Established Non-Pharmacological TreatmentsBehavioral parent training

33 well-conducted studies

Behavioral classroom management45 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 ConsiderationsNeed to address cross-situational impairments

Poor generalization from treatment setting to real-world

Implement treatments in all settings in which child shows impairment

School behavior504 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 maintainParental psychopathology can interfere with

implementation

Multi-Modal Treatment Study for ADHD (MTA)6 sites579 Children, 7-9 y/oADHD, Combined TypeAssigned to 14 months of:

Med management Intensive Behavior Therapy Combined treatmentTreatment as Usual in the Community

(TAU)2/3 received medication

MTA Cooperative Group, 1999

Overall ResultsAll groups showed reductions in ADHD sx over timeOn 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:Parent and teacher satisfaction with

treatmentNormalization of child behaviorImprovements in functional outcomes

Family interactionsPeer relationshipsAcademic 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-UpOriginal treatment assignment not associated with any

of the 24 outcomes 6-8 yrs laterADHD symptom trajectory in the first 3 years predicted

55% of the outcomesChildren with the best initial tx response and most favorable

clinical presentation at baseline fared best over timeChildren 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

Practice Parameters

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)

Summary 1. ADHD is a highly prevalent, brain-based disorder which

is associated with lifelong impairment in functioning2. Environmental factors can contribute to the

expression, severity, course, and comorbid conditions3. Long-term developmental outcomes for individuals

with ADHD can include serious substance abuse, chronic criminality, depression and suicide

4. Stimulant medications and behavior therapy are currently the only established evidence-based treatments for ADHD

5. 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