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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
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