Section 8 - Treatment for ADHD

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Lecturer: Simon Bignell

Section: 8 of 11

‘Autism, Asperger’s & ADHD’ (6PS055)

‘ADHD, Autism & Asperger’s’ (6PS077)

Treatment for ADHD

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Section: 8 of 11



Introduction to the Section• Clinical Symptoms.• Intervention Development.• Considerations for interventions

in ADHD.• Non-pharmacologic

Treatments.• MTA study.• Medication.

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Section: 8 of 11



Learning Outcomes of this SectionOn completion of the Section and with independent

study you should be able to:

1. Understand what are the common methods of treating Attention-Deficit/Hyperactivity Disorder.

2. Understand some of the issues surrounding behavioural and psycho-pharmaceutical interventions for Attention-Deficit/Hyperactivity Disorder.

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Section: 8 of 11



Attention-Deficit / Hyperactivity Disorder (ADHD)

• ADHD is: A disorder of behavioural inhibition and self-control.

• ADHD is not: A disorder of skills or knowledge.

• “ADHD is not a problem with a child’s knowing what to do; it is a problem with doing what the child knows.”

Barkley (2000).

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Section: 8 of 11



ADHD: Clinical Symptoms

Inattention• Inability to focus on an activity for longer than a

few minutes.• Careless mistakes.• Cannot carry out instructions.• Fails to finish work.• Forgets / misplaces things.• Easily distracted.

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Section: 8 of 11



Hyperactivity• Can’t sit still / fidgets / restless.• Always wants to touch things.• Talks excessively.• Cannot play quietly.• Distracts other children.


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Impulsivity• Does not think before

acting.• React immediately to a

situation.• Cannot wait his / her turn.


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Section: 8 of 11



Problems Associated With ADHD

• Conduct problems (e.g., Oppositional behaviour, lying, stealing, and fighting).

• Academic underachievement.

• Specific learning disabilities.

• Difficulties getting along with peers & teachers.

• High rates of disruptive behaviour.

• Family functioning at home.

• Low rates of engagement with academic instruction and materials.

• Inconsistent completion and accuracy on schoolwork.

• Poor performance on homework, tests, & assignments.

ADHD

School

Occupational statusSocial/financial

status

Peer relationships

Marital status

Traffic accidents

Drug abuse

Delinquency

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Section: 8 of 11



Problems With Currently Available Research Literature

• Limited data on school-based interventions in general.

• “One size fits all” approach is typical.• Emphasis on reduction of disruptive behaviour

rather than improvement in social behaviour or academic skills.

• Few studies of adolescents.• Focus on short-term outcomes & limited data on

generalisation of effects.

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Intervention Development

• All strategies do not fit all children.• Functional assessment.

– Which intervention for each child, problem, and situation.

– Identify.• Contingencies that maintain behaviour (ABC).• Situations/operations that set occasion for

problem behaviour.– Interviews, direct observation, manipulation of

situations.• Functional assessment = increase chances of

effective intervention.

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Intervention Development: Questions To Be Addressed

• What are the behavioural objectives?• What are the child’s strengths and weaknesses?• What are the optimum intervention strategies?• What additional resources are available to address the

child’s ADHD-related problems?• Must take into account:

– Severity of ADHD-related behaviours.– Presence of associated disorders.– Response to prior interventions.– Availability of community resources.

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Empirically Supported Treatment For ADHD

• Psychopharmacology.– Stimulants most widely researched and prescribed. E.g., CNS

stimulants such as Ritalin (methylphenidate). Also, Dexedrine, Adderall, Cylert.

– Antidepressants: Elavil, Tofranil, and Prozac.• Psychosocial/behavioural interventions.

– Applied at school and home.– Reinforcements, rewards, immediate consequences, and cues to

reinforce rules.• Combined treatment.

– Increased range of treatment targets.– Improves treatment acceptability.– Particularly helpful with comorbid externalising and internalising

disorders.

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Treatments That Are Commonly Used But Are Not Evidence-based For ADHD

• Traditional one-to-one therapy or counseling.• Cognitive therapy.• Office based "Play therapy”.• Elimination diets (Feingold Diet, etc.).• Biofeedback/neural therapy/attention (EEG) training.• Allergy treatments.• Chiropractics.• Perceptual or motor training/sensory integration training.• Treatment for balance problems.• Pet therapy (including Horse & Dolphin therapy).• Dietary supplements (megavitamins, blue-green algae).

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Non-pharmacologic Treatments

Behavioural Therapy.• Social skills: geared towards changing abnormal

behaviour.

• Contingency management: reward system reinforcing good behaviour.

• Psychotherapy: helps to build up feelings of self-worth. Important to also perform family therapy.

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Components of Effective, Comprehensive Treatment for ADHD• Parent training - use always.• School intervention - use

always.• Child intervention - use always.• Medication - use when needed.• (However, medication is

increasingly being used as a frontline strategy.)

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Parent training.– Behavioural approach.– Focus on parenting skills, child’s behaviour, and family relationships.– Parents learn skills and implement treatment with child, modifying

interventions as necessary.– Group-based, weekly sessions with therapist initially (8-16 sessions), then

contact faded.– Continued support and contact as long as necessary (e.g., 2 or 3 years

and/or when deterioration occurs).– Program for maintenance and relapse prevention.– Re-establish contact for major developmental transitions (e.g.,

Adolescence).– Can be offered in primary care, schools, churches, community centres.– By individuals with wide variety of training and is very cost effective.

Components Of Effective, Comprehensive Treatment For ADHD

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School intervention.– Behavioural approach - teachers are trained and implement

treatment with the child, modifying interventions as necessary.– Focus on classroom behaviour, academic performance, and peer

relationships.– Widely available in schools.– Teacher training: (1) in service training and follow up or (2)

consultant model - initial weekly sessions, then contact faded.– Continued support and contact for as long as necessary - typically

multiple years and/or if deterioration.– Program for maintenance and relapse prevention (e.g., School-

wide programs, train all school staff, including administrators; eventually train parent to implement and monitor).


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Child intervention.– Behavioural and developmental approach.– Focus on teaching academic, recreational, and social/behavioural

competencies, decreasing aggression, increasing compliance, developing close friendships, improving relationships with adults, and building self-efficacy.

– Paraprofessional implemented (for cost reasons).– Intensive treatments such as summer treatment programs (9 hours

daily for 8 weeks), and/or school-year, after-school, and Saturday (6 hours) sessions.

– Continued support and contact as long as necessary - multiple years or if deterioration occurs.

– Program for relapse prevention (e.g., Integrate with school and parent treatments - link all through home/school report card systems).


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Multimodal Treatment Study (MTA)• Comprehensive psychosocial and pharmacological

treatment for ADHD: the NIMH/USOE multimodal treatment study.

• Randomised clinical trial of four treatments:– Community comparison control (CC.).– Psychosocial alone (Beh.).– Pharmacological alone (Med Mgt.).– Combined psychosocial and pharmacological (Comb.).

• 576 subjects, three consecutive years across six sites.• 144 subjects per group overall; 24 per group per site.• Treatment for 14 months; follow-up for 10 months.

SNAP-ADHD (Parent/Teacher): Treatment Group Outcomes Across 24 Months (Lower Score Better).

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Multimodal Treatment Study (MTA)

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Summary of MTA results at 14 months.• All four groups improved dramatically with time.• Active med (study: 39 mg MPH/day) was superior to faded Beh on

ADHD symptom measures and some measures of impairment.• 75% of Beh group were maintained off medication.• Combined (31 mg MPH/day) was superior to Beh on all measures

and to med on most measures of impairment but not significantly on symptoms.

• Comb (and sometimes med) were superior to CC and Beh was equivalent (70% of CC medicated; 24 mg MPH/day).

• Combined produced more normalisation at lower doses (and lower rates of increase in dose) than med and was much preferred by parents.


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•Despite the evidence, there is controversy about which treatments should be used for ADHD.

•The MTA study has resulted in widespread agreement amongst psychiatric professionals, ADHD experts, pharmaceutical companies, media outlets, and advocacy groups that medication is the treatment of choice for ADHD.


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• MTA results reported in the professional community:– “…if one provides medication as the first line of treatment many

children will not require behavioural interventions.” (MTA cooperative group, archives of general psychiatry, 1999).

– “Multimodal treatment offers little advantage over medication.” (Greenhill, Abikoff & Newcorn, J. Amer. Acad. Child. Adolesc. Psychiat., 1999).

– “The MTA studies suggest that there’s very little benefit from any psychotherapeutic treatment.” (David Shaffer, cost and therapeutics, 2000.).

– “There is not a consensus…that a comprehensive approach to treatment for ADHD is multimodal…stimulant treatment is easily available in the community and behavioural treatment is not…” (Mina Dulcan, M.D., Editor, Journal of the American Academy of Child and Adolescent Psychiatry, 2002).


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• MTA results reported in the media:– “Medication makes the difference in ADHD kids:

monitoring medication is the key”.– “Psychosocial treatments of no benefit even when

used with medication”. (Clinical Psychiatry, Pediatric, Family Practice News).

– “Medication wins over behavioral treatments hands down…”. (Jensen/NY Times).

– “We are wasting tons of money on psychosocial [behavioural] treatments that don’t work…”. (Clinical Psychiatry, Pediatric, Family Practice News).


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Impact of MTA: Trends in Medication Use

Before MTA, Concerta, and Adderall XR.– Meds for school hours only-184 days per year.

– Modal total daily dose: 15-20 mg Methylphenidate (MPH); 10 mg Adderall.

– Weekends and summers medication free.

– Most children medicated 1-3 years.

– Lifetime dose: 5400 mg to 10,800 mg.

After MTA, Concerta, and Adderall XR.– Meds for school and home.

– Equivalent total daily doses: 36 mg Concerta; 20 mg Adderall.

– Weekends and summers medicated (so 365 days per year).

– Current recommendations (e.g., MTA): start early and medicate for all 12 school years.

– Lifetime dose: 14,600 mg/year X 12 =175,000 mg MPH.

Racemic amphetamine and Dextroamphetamine Methylphenidate (aka Ritalin)

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Psychopharmacology In ADHD

• ≥70-80% of children treated with stimulants have symptom reduction.

• Group data do not predict individual response – individual trials.

• Stimulants are prescribed for about 4% of school age children.

• Most well-researched intervention for ADHD.

• Brand names of drugs that contain methylphenidate include Ritalin® (Ritalina®, Rilatine®), Concerta® (a timed-release capsule), Metadate®, Methylin® and Rubifen®.

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• See: Scheffler RM, Hinshaw SP, Modrek S, Levine P. The global market for ADHD medication. Health Affairs. March/April 2007. 26(2).

• One in 25 American children and adolescents is taking drugs for ADHD.

• Global expenditures on ADHD medications rose nine-fold from less than $300 million in 1993 to $2.4 billion in 2003.

• In addition, more countries have begun to use the medications.

• “Given ADHD’s prevalence and the increasing use of these medications, the disorder is poised to become the world's leading childhood disorder treated with medication… with this in mind, we should clearly identify the benefits and risks of these pharmacologic treatments, and promote careful prescribing and monitoring practices.” (Scheffler et al, 2007).

• These findings challenge the widespread belief that ADHD is largely a US issue.


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Stimulant effects:• Improve -

– Sustained attention.– Response inhibition.– Persistence with tasks.– Compliance with instructions.– Academic productivity and accuracy.– Rates of skill acquisition.

• Reduce -– Excessive motor activity.– Disruptive behavior.– Rates of aggression.


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Stimulant side-effects:• Most frequent –

– Appetite reduction (50-60%).– Insomnia (50-60%).

• Less frequent -– Irritability (20-40%).– Headaches and Stomachaches (20-40%).

• Rare –– Motor and/or vocal tics.

• Perception of side effects varies across raters.• Long-term effects – Mild Weight Loss (A Few Pounds First 1-2 Years);

No effect on Skeletal Growth.


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Medication for ADHD: PROS.• Decrease in classroom disruption.• Improvement in teacher ratings of behaviour.• Improvement in compliance with adult requests and

commands.• Increase in on-task behaviour and academic productivity

and accuracy (but no long-term effect on academic achievement).

• Improvement in peer interactions.• Improvement in performance on laboratory measures of

attention, impulsivity, and learning.


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Medication for ADHD: CONS.• Rarely sufficient to bring a child to the normal range of

functioning.• Works only as long as medication taken.• Not effective for all children.• Does not affect several important variables (e.g., Academic

achievement, concurrent family problems, peer relationships).• Poor compliance in long-term use.• Parents are not satisfied with medication alone.• Removes incentive for parents and teachers/schools to work on

other treatments.• Uniform lack of evidence for beneficial long-term effects.• Potential serious adverse effects in growth and substance use

(data controversial).


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Conclusions• ADHD has enormous impact on school functioning.• Medication is most effective for changing behaviour, but

not necessarily for academic performance.• Studies have shown that norepinephrine and dopamine

are at the heart of ADHD’s problems.• Many drugs that increase the levels of these

neurotransmitters can be used to fight ADHD.• Individually tailored school-based interventions have

potential for building upon medication effects.• Must go beyond ‘one size fits all’.

Section 8 - Treatment for ADHD

Education

Transcript of Section 8 - Treatment for ADHD