adhd powerpoint 1
TRANSCRIPT
Behavioral and Pharmacologic
Treatments of AD/HD
Behavioral and Pharmacologic
Treatments of AD/HD Paul P. Doghramji Jr.
March 30, 2009
Paul P. Doghramji Jr.March 30, 2009
Presentation OutlinePresentation Outline Definition and Diagnosis
Neurobiology
Prevalence and co-morbidities Pharmacologic treatments
Stimulants Non-stimulants
Non-pharmacologic Treatments CBT IPT Neurofeedback
Optimal treatment: Combination
Definition and Diagnosis Neurobiology
Prevalence and co-morbidities Pharmacologic treatments
Stimulants Non-stimulants
Non-pharmacologic Treatments CBT IPT Neurofeedback
Optimal treatment: Combination
Attention Deficit/Hyperactivity
Disorder
Attention Deficit/Hyperactivity
Disorder Neurobehavioral developmental disorder
Characterized by: Inattention Hyperactivity Impulsivity
Very often co-morbid with: Learning disabilities Psychiatric disorders
Neurobehavioral developmental disorder
Characterized by: Inattention Hyperactivity Impulsivity
Very often co-morbid with: Learning disabilities Psychiatric disorders
AD/HD Diagnosis (DSM-IV*)
AD/HD Diagnosis (DSM-IV*)
Persistent (>6 months) pattern of developmentally inappropriate inattention and/or hyperactivity-impulsivity
Symptom onset before age 7 Symptoms present in >2 settings (eg, home and school)
Interference with social, academic, or occupational functioning
Disorder not accounted for by another mental disorder
Persistent (>6 months) pattern of developmentally inappropriate inattention and/or hyperactivity-impulsivity
Symptom onset before age 7 Symptoms present in >2 settings (eg, home and school)
Interference with social, academic, or occupational functioning
Disorder not accounted for by another mental disorder
*American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000
Inattention Symptoms (DSM-IV)
Inattention Symptoms (DSM-IV)
1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Often has trouble organizing activities.6. Often avoids, dislikes, or doesn't want to do
things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
8. Is often easily distracted.9. Is often forgetful in daily activities.
1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Often has trouble organizing activities.6. Often avoids, dislikes, or doesn't want to do
things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
8. Is often easily distracted.9. Is often forgetful in daily activities.
Hyperactivity/Inpulsivity (DSM-IV)
Hyperactivity/Inpulsivity (DSM-IV)
Hyperactivity1. Often fidgets with hands or feet or squirms in seat.2. Often gets up from seat when remaining in seat is
expected.3. Often runs about or climbs when and where it is not
appropriate (adolescents or adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.Impulsivity1. Often blurts out answers before questions have been
finished.2. Often has trouble waiting one's turn.3. Often interrupts or intrudes on others (e.g., butts
into conversations or games).
Hyperactivity1. Often fidgets with hands or feet or squirms in seat.2. Often gets up from seat when remaining in seat is
expected.3. Often runs about or climbs when and where it is not
appropriate (adolescents or adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.Impulsivity1. Often blurts out answers before questions have been
finished.2. Often has trouble waiting one's turn.3. Often interrupts or intrudes on others (e.g., butts
into conversations or games).
Neurobiology of ADHDNeurobiology of ADHD
Specific etiology unknown but involves combination of genetic and acquired factorsUp to 90% heritability
Neuroimaging anomalies (structural/metabolic) in frontal cortex and basal gangliaPrefrontal cortex dysfunction fundamental to symptomatology
Biochemical abnormalities: possible alterations in dopamine and/or norepinephrine
Specific etiology unknown but involves combination of genetic and acquired factorsUp to 90% heritability
Neuroimaging anomalies (structural/metabolic) in frontal cortex and basal gangliaPrefrontal cortex dysfunction fundamental to symptomatology
Biochemical abnormalities: possible alterations in dopamine and/or norepinephrine
ADHD
Normal
Prevalence Prevalence
Affects 6% to 10% of school-aged children1-3 – Diagnosed in boys 3 times more than in girls2,3
Accounts for 30% to 50% of mental health referrals4
One of 10 most common pediatric concerns5
Resulted in over 10 million physician office visits in 2001
Up to 65% of children with ADHD continue to experience
the disorder into adulthood.
Affects 6% to 10% of school-aged children1-3 – Diagnosed in boys 3 times more than in girls2,3
Accounts for 30% to 50% of mental health referrals4
One of 10 most common pediatric concerns5
Resulted in over 10 million physician office visits in 2001
Up to 65% of children with ADHD continue to experience
the disorder into adulthood.
Co-morbiditiesCo-morbidities
87% have at least 1 and 56% have at least 2 additional psychiatric disorders
Common co-morbidities include Depression Anxiety Substance abuse disorder Insomnia Bipolar disorder Oppositional Defiance Disorder (ODD)
87% have at least 1 and 56% have at least 2 additional psychiatric disorders
Common co-morbidities include Depression Anxiety Substance abuse disorder Insomnia Bipolar disorder Oppositional Defiance Disorder (ODD)
ADHD: Drug TherapyADHD: Drug TherapyADHD: Drug TherapyADHD: Drug Therapy
StimulantsMethylphenidateD-amphetamine, mixed amphetamine salts
DextroamphetamineLisdexamphetamineModafinilDexmethylphenidate
StimulantsMethylphenidateD-amphetamine, mixed amphetamine salts
DextroamphetamineLisdexamphetamineModafinilDexmethylphenidate
Non-StimulantsAtomoxetineClonidineAntidepressants
Non-StimulantsAtomoxetineClonidineAntidepressants
ADHD: Drug TherapyADHD: Drug TherapyADHD: Drug TherapyADHD: Drug TherapyTraditional Stimulants Non-Stimulants
Advantages • Highly effective• Rapid onset of effect• Long term experience
• Schedule II• Rapid offset (“crash”)• Incompatibility with
various co-morbidities• Cardiovascular effects • Effect on growth (?)• Persistent insomnia,
appetite decrease• “Jitteriness”; blunting of
affect/creativity
• Non-scheduled• Compatibility with co-
morbidities
• Slow onset of effect• Cardiovascular
effects• Somnolence;
Gastrointestinal (GI) effects
Disadvantages
Effects of StimulantMedications on ADHD Symptoms in Various Settings
Effects of StimulantMedications on ADHD Symptoms in Various Settings
Classroom Decreased interrupting Decreased fidgeting and finger tapping Increased on-task behavior
Home Improved parent-child interactions Increased on-task behavior Improved compliance
Social settings Improved peer nomination rankings of social standing Increased attention span during sports activities
Laboratory Decreased response variability Decreased impulsivity in cognitive tasks Increased accuracy of performance Improved short-term memory Improved reaction time Improved math computation Improved problem-solving in games Increased sustained attention
Classroom Decreased interrupting Decreased fidgeting and finger tapping Increased on-task behavior
Home Improved parent-child interactions Increased on-task behavior Improved compliance
Social settings Improved peer nomination rankings of social standing Increased attention span during sports activities
Laboratory Decreased response variability Decreased impulsivity in cognitive tasks Increased accuracy of performance Improved short-term memory Improved reaction time Improved math computation Improved problem-solving in games Increased sustained attention
Behavioral Therapy Techniques
Behavioral Therapy Techniques
Technique Description Example
Positive reinforcement Rewards or privileges are provided contingent on the child’s behavior
Child completes an assignment and is permitted to play a computer game
Time out Access to positive reinforcement is removed when the child engages in unwanted or problem behavior
Child is required to sit for 5 minutes in the corner of the room after impulsively hitting a sibling
Response cost Rewards or privileges are withdrawn when the child engages in unwanted or problem behavior
Child loses the privilege of playing computer game after he/she fails to complete homework
Token economy Rewards and privileges are provided when the child engages in desired behavior s and are lost if not
Child ears stars for completing assignment or loses stars for getting out of his/her seat
Interpersonal Psychotherapy Interpersonal Psychotherapy
Commonly administered to adolescents with ADHD and depression
Second-line treatment when patient fails to comply with taking medication or medication is ineffective.
Treatment aids individuals with: Social skills/interaction Focus on work and organization Extensive substance abuse Bipolar disorder Depression
Commonly administered to adolescents with ADHD and depression
Second-line treatment when patient fails to comply with taking medication or medication is ineffective.
Treatment aids individuals with: Social skills/interaction Focus on work and organization Extensive substance abuse Bipolar disorder Depression
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy
Aims to influence dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure
Goal: help children identify the faulty thoughts and ideas that lead to the problematic behavior.
Holistic approach and involving doctors, teachers, parents and the patient in the therapeutic process
Once the negative symptoms have been stabilized, cognitive behavior therapy can be used to further increase positive behaviors, decrease negative behaviors and reduce other symptoms such as anxiety and depression.
Children and their parents are seen individually and together during different phases of treatment Adults experience group therapy sessions
Aims to influence dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure
Goal: help children identify the faulty thoughts and ideas that lead to the problematic behavior.
Holistic approach and involving doctors, teachers, parents and the patient in the therapeutic process
Once the negative symptoms have been stabilized, cognitive behavior therapy can be used to further increase positive behaviors, decrease negative behaviors and reduce other symptoms such as anxiety and depression.
Children and their parents are seen individually and together during different phases of treatment Adults experience group therapy sessions
CBT Difference in Various Ages
CBT Difference in Various Ages
Adults Highly effective in treating anxiety and depression Greater improvement of organization Immense minimization of self-esteem issues Techniques for reaching goals and self-improvement
Children: Learn/rehearse to consider choices before
problematic behavior begins (slow down) Self-control and calming techniques Use of structured feedback to monitor, correct,
and reward behavior Independent study skills to improve organization
and academic performance
Adults Highly effective in treating anxiety and depression Greater improvement of organization Immense minimization of self-esteem issues Techniques for reaching goals and self-improvement
Children: Learn/rehearse to consider choices before
problematic behavior begins (slow down) Self-control and calming techniques Use of structured feedback to monitor, correct,
and reward behavior Independent study skills to improve organization
and academic performance
NeurofeedbackNeurofeedback
A type of biofeedback that can be used to train ADHD children to change their brain wave patterns to be more like normal children
These patterns can be measured and recorded by an electroencephalogram (EEG)The EEG can be used to make a map of the persons mental function
Biofeedback is the use of instrumentation to mirror psychological and physiological processes of which the individual is not normally aware
Treatment results in significant reduction of AD/HD symptoms and behavior
A type of biofeedback that can be used to train ADHD children to change their brain wave patterns to be more like normal children
These patterns can be measured and recorded by an electroencephalogram (EEG)The EEG can be used to make a map of the persons mental function
Biofeedback is the use of instrumentation to mirror psychological and physiological processes of which the individual is not normally aware
Treatment results in significant reduction of AD/HD symptoms and behavior
How Neurofeedback Works!
How Neurofeedback Works!
When an ADHD child is given a task requiring attention, instead of increasing beta waves he increases theta waves
Over 40+ sessions, children gradually taught to inhibit theta production and increase beta usage
Improvements shown in cognition, AD/HD symptom reduction, and behavior
Symptomatic improvement similar to stimulants Neurofeedback improvement does not
disappear Stimulant improvement lasts X amount of hrs
When an ADHD child is given a task requiring attention, instead of increasing beta waves he increases theta waves
Over 40+ sessions, children gradually taught to inhibit theta production and increase beta usage
Improvements shown in cognition, AD/HD symptom reduction, and behavior
Symptomatic improvement similar to stimulants Neurofeedback improvement does not
disappear Stimulant improvement lasts X amount of hrs
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Problems With Neurofeedeback Problems With
Neurofeedeback Treatment lasts at least 40 sessions Treatments are expensive Treatment requires child motivation, boredom renders slightly ineffective
Age is a major factor Too young - child won’t do what is required
Adults and older - more difficult to make EEG changes and receive good results
Treatment doesn’t work for everyone; greater than 90% success rate
Treatment lasts at least 40 sessions Treatments are expensive Treatment requires child motivation, boredom renders slightly ineffective
Age is a major factor Too young - child won’t do what is required
Adults and older - more difficult to make EEG changes and receive good results
Treatment doesn’t work for everyone; greater than 90% success rate
NIH Multimodal Treatment Study
of ADHD in Children (MTA Study)
NIH Multimodal Treatment Study
of ADHD in Children (MTA Study)
Methods comparing 4 methods of intervention
medication management (MM) intensive behavioral treatment the 2 combined treatment by community providers
Results MM or combined treatment were significantly superior to
community and behavioral treatment after 14 months Parent satisfaction was highest for behavioral
interventions Behavioral modification in combination with MM may
reduce the need for higher doses of medication Behavior modification seen to be best for children with
co-morbidities, and/or whose families have limited financial resources
Methods comparing 4 methods of intervention
medication management (MM) intensive behavioral treatment the 2 combined treatment by community providers
Results MM or combined treatment were significantly superior to
community and behavioral treatment after 14 months Parent satisfaction was highest for behavioral
interventions Behavioral modification in combination with MM may
reduce the need for higher doses of medication Behavior modification seen to be best for children with
co-morbidities, and/or whose families have limited financial resources
ConculsionConculsion
ADHD is a common psychopathology in children and adults with much impairment and disability
Two forms of treatment include pharmacological and behavioral
The combination of management methods seem to be most effective
ADHD is a common psychopathology in children and adults with much impairment and disability
Two forms of treatment include pharmacological and behavioral
The combination of management methods seem to be most effective
References References 1. Castellanos et al. Arch Gen Psychiatry. 1996;53:607-616.
2. Castellanos et al. Arch Gen Psychiatry. 2001;58:289-295.
3. Cook et al. Am J Hum Genet. 1995;56:993-998.
4. LaHoste et al. Mol Psychiatry. 1996;1:121-124.
5. . Egan et al. Proc Natl Acad Sci U S A. 2001;98:6917-6922.
6. . Fossella et al. BMC Neurosci. 2002;3:14.
7. MTA Cooperative Group. Arch Gen Psychiatry. 1999;56:1073-1086.
8. Donnelly et al. Differential Diagnosis and Treatment of Adult ADHD and Neighboring Disorders. 2006; 13:1-4
9. Arnsten AFT. Fundamentals of attention-deficit/hyperactivity disorder; circuits and pathways, J Clin Psychiatry 2006; 67 (suppl 8):7-12
10. Biederman J, Lopez FA, Boellner SW et al. A randomized, double-blind, placebo controlled, parallel-group study of SLI381 (Adderall XR) in children with attention deficit/hyperactivity disorder. Pediatrics 2002; 110:258-66.
11. Grcevich SJ, Sea D, Mays D et al. Safety and efficacy of mixed amphetamine salts XR in adolescents with ADHD. Presented at the 31st Annual Meeting of the American Academy of Child and Adolescent Psychiatry (Oct 19-24,2004), Washington, DC, USA
12. J Am Acad Child Adolesc Psychiatry. 2002; 41:S26-49.15
1. Castellanos et al. Arch Gen Psychiatry. 1996;53:607-616.
2. Castellanos et al. Arch Gen Psychiatry. 2001;58:289-295.
3. Cook et al. Am J Hum Genet. 1995;56:993-998.
4. LaHoste et al. Mol Psychiatry. 1996;1:121-124.
5. . Egan et al. Proc Natl Acad Sci U S A. 2001;98:6917-6922.
6. . Fossella et al. BMC Neurosci. 2002;3:14.
7. MTA Cooperative Group. Arch Gen Psychiatry. 1999;56:1073-1086.
8. Donnelly et al. Differential Diagnosis and Treatment of Adult ADHD and Neighboring Disorders. 2006; 13:1-4
9. Arnsten AFT. Fundamentals of attention-deficit/hyperactivity disorder; circuits and pathways, J Clin Psychiatry 2006; 67 (suppl 8):7-12
10. Biederman J, Lopez FA, Boellner SW et al. A randomized, double-blind, placebo controlled, parallel-group study of SLI381 (Adderall XR) in children with attention deficit/hyperactivity disorder. Pediatrics 2002; 110:258-66.
11. Grcevich SJ, Sea D, Mays D et al. Safety and efficacy of mixed amphetamine salts XR in adolescents with ADHD. Presented at the 31st Annual Meeting of the American Academy of Child and Adolescent Psychiatry (Oct 19-24,2004), Washington, DC, USA
12. J Am Acad Child Adolesc Psychiatry. 2002; 41:S26-49.15