attention deficit hyperactivity disorder rachel j. valleley, ph.d. assistant professor, pediatrics...
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Attention Deficit Hyperactivity Disorder
Rachel J. Valleley, Ph.D.Assistant Professor, Pediatrics
Munroe-Meyer Institute, UNMC
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Current Conceptualization
Attention-Deficit Hyperactivity Disorder (ADHD)
DSM-IV, 1994
Three subtypes: Predominantly Inattentive Predominantly Hyperactive/Impulsive Combined
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Adolescent and Adult Outcomes
Chronic disorder lasting into adulthood 1/3: Tolerable outcome
mild problems - adapt to difficulties
1/3: Moderately poor outcome
variety of problems such as school, vocational, adjustment difficulties, interpersonal problems, underachievement,
problems with alcohol
1/3: Poor outcome severe dysfunction including repeated criminal activity, alcoholism and drug use.
Pittsburgh ADHD Longitudinal Study, Molina and Pelham
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Cause of ADHD
No one cause identified.
Not caused by Diet (i.e. food additives, sugar) Poor parenting
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Prevalence of ADHD
Standard estimate: 3%-5%
More recently: 12%(Fabiano & Pelham, 2001)
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Attention-Deficit Hyperactivity Disorder
Diagnosis:
Who has ADHD?
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Formal Diagnostic CriteriaDSM-IV, 1994
Criterion A:
Six or more symptoms from one or both of these lists:
Inattentive Type Hyperactive/Impulsive Type
…have been present for at least 6 months.
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Symptom Lists
Inattentive Type fails to attend to details, makes careless
mistakes difficulty sustaining attention in play or
work does not listen when spoken to does not follow through difficulty organizing tasks avoids task requiring sustained mental
effort loses things needed distracted by extraneous stimuli often forgetful
Hyper/Impulsive Type often fidgets hands/feet or squirms often leaves seat when sitting is expected runs about or climbs excessively difficulty playing or engaging in leisure
activities quietly often “on the go”/ “driven by motor” talks excessively blurts out answers before questions completed difficulty awaiting turn interrupts or intrudes on others
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Formal Diagnostic CriteriaDSM-IV, 1994
Criterion B:
Some of the symptoms were present before the age of seven years.
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Formal Diagnostic CriteriaDSM-IV, 1994
Criterion C:
Some impairment from the symptoms is present in two or more settings (e.g., home, and school or work).
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Formal Diagnostic CriteriaDSM-IV, 1994
Criterion D:
There is evidence of clinically significant impairment in social, academic, or occupational functioning.
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Formal Diagnostic CriteriaDSM-IV, 1994
Criterion E:
The identified symptoms are not better accounted for by another mental disorder.
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Other Common Causes of Attention & Hyperactivity Symptoms Oppositional Behavior Learning difficulties Depression/anxiety Drug/alcohol use Physical illness Adjustment
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Associated Problems
Oppositional Defiant Disorder: 35 - 65% Learning Disability: 25 - 30%
and variable academic quality Poor social skills, peer relationships
Often overlooked! Difficulties in family functioning
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Attention-Deficit Hyperactivity Disorder
Assessment:
All that wiggles is not ADHD
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Comprehensive Diagnosis for ADHD
There is no single test or laboratory measure which can reliably detect ADHD.
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Comprehensive Diagnosis for ADHD
Information gained by qualified clinician: From family
o standardized, norm-referenced ratingso detailed history
From schoolo standardized, norm-referenced ratingso academic historyo in-class observations
From cliniciano observations
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Parent Behavior Rating Scales
Conner’s: quick and dirty screening for ADHD and ODD
CBCL/BASC: screen for a variety of problems Eyberg: screen for most common behaviors
that drive parent crazy ADHD-IV: screens for hyperactivity/impulsivity
and inattention symptoms Disruptive Behavior Disorder: screens for
ODD & CD Narrative summary to assess for impairment
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Teacher Behavior Rating Scales
Conner’s: quick and dirty screening for ADHD and ODD
CBCL/BASC: screen for a variety of problems ADHD-IV: screens for hyperactivity/impulsivity
and inattention symptoms Disruptive Behavior Disorder: screens for
ODD & CD Narrative summary to assess for impairment
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Youth Behavior Rating Forms
If appropriate: CBCL to screen for a variety of problems Reynold’s Adolescent Depression Scale Reynold’s Child Manifest Anxiety Scale Childhood Depression Inventory
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When to refer?
Screening measure indicates elevation in Hyperactivity/Impulsivity and/or Inattention symptoms
Unclear if other explanation for symptoms Don’t have time for comprehensive evaluation
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What to expect if referred to me
Meet for initial appointment to determine if evaluation is warranted (screening measure already completed is helpful)
Conduct comprehensive evaluation Present treatment options based upon
diagnosis Send back to physician if want medication
and/or need verification of diagnosis for school
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Treating ADHD
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What we know works:
Drug TherapyBehavior TherapyCombined Behavioral/Drug Treatments
APA Task Force on Evidence-Based Treatments, JCCAP, Pelham, Wheeler, & Chronis, 1998
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What we know DOESN’T work:
Play therapy Individual or family counseling (without
altering the environment) Social skills/self-monitoring/organizational
planning. Dietary management Megavitamin therapy Sensory integration therapy/chiropractics Biofeedback
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Medications for ADHD
Ritalin
Adderall
Cylert
Dexedrin
Strattera
Concerta
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What Medications Can Do
Manage symptoms Decrease activity level Decrease impulsivity Increase attention or “focus”
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What Medications Can Do
Improve associated features Decrease “defiance” Decrease aggression Suppress negative social skills
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What Medications Can’t Do
Teach new, appropriate behaviorsCompliance/rule-following
Self-management Teach content previously missed
Academic work
Social skills “Cure” ADHD
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Stimulant Medications: Considerations Effective for 70-75% Higher doses associated with more side effects Positive effects are lost when drug discontinued
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Stimulant Medications:Contraindications Under six years of age High anxiety level Thought disorder History of tics or Tourette’s Syndrome Risk of drug abuse Unacceptably high levels of negative side effects
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Limitations to Medication Treatment
Rarely sufficient to bring a child into normal range of functioning. Works only as long as taken. Not effective for all children. Doesn’t affect several variables (e.g., academic skills, family
problems). Poor compliance with long-term use. Parents not satisfied with medication alone. Removes incentives to work on other treatments. Lack of long-term evidence for effects. Potentially problematic side-effects.
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Behavior Therapy for ADHD
Components Highly Structured Immediate Feedback
reinforcer or reward for appropriate behavior
punishment for inappropriate behavior Salient/Meaningful Feedback
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Common Behavior Interventions
Daily Behavior Report Card Token Economy Parent Training
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Daily Behavior Report Cards
Daily note is sent between home & school regarding child’s behavior
Target behaviors monitored throughout the day Performance on note determines consequences at
home and/or school
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Daily Behavior Report Cards
Academic Behaviors Working on assignments Completing homework Handing in assignments All work up to date On time for class
Social Behaviors Remained in seat Talked in turn Respectful behavior Got along with peers Following instructions Hands to self
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Sample School-Home Note
Classes Turned in work Work turned in at least 80% accurate
Teacher Initials
Math Yes No Yes No
Reading Yes No Yes No
Spelling Yes No Yes No
Social Studies Yes No Yes No
Science Yes No Yes No
Homework:
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Daily Behavior Report Card
Benefits Keeps communication open between child’s
environment Helps monitor whether behavior is changing Can monitor impact of medication Takes very minimal adult time Helps child get lots of positive feedback
throughout the day
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Token Economies
Arbitrary token (e.g., poker chip) given for demonstrating appropriate behavior
Tokens lost for inappropriate behavior Tokens exchanged for reinforcers
This type of intervention becomes highly individualized based upon behaviors targeted, what is reinforcing to the child, and in what settings it is used
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Parent Training
Increase positive interactions for appropriate behavior Child-Directed Interaction Role of Attention Access to Tangibles
Decrease negative behaviors Time-out (up around 8 years) Job card grounding (around 8 and older)
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Limitations of Behavioral Interventions Often not sufficient to bring a child into the
normal range of functioning. Must be broad in scope to affect important
familial variables. Lack of evidence for long-term effects. Difficult to get parents and teachers to do
over a long period of time. Costly compared to medications.
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Which to employ?
The NIMH Multimodal Treatment Study Largest NIMH-funded study of child mental
health concern 579 children at multiple sites Group comparisons including:
Community Treatment Psychosocial Treatment Only Medication Only Combination of BT and Meds
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Which to employ?
Summary of Findings All four groups improved with time. Combined > Behavior on all measures. Combined > Medicine on most measures of
impairment but not symptoms. Combined and sometimes Medicine > CC. Combined produced more normalization at
lower doses than Medicine; was more preferred by parents.
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Which to employ?
Med Mgmt Combined Behavioral
Declined/Drop Out
12% 4% 0%
Worse/Unchanged
6% 6% 5%
Slight Improved
22% 11% 22%
Improved 38% 37% 43%
Much Improved
22% 41% 30%
Change in Presenting Problem
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Which to employ?
Med Mgmt Combined Behavioral
Declined/Drop Out
12% 4% 0%
Dissatisfied 5% 3% 3%
Neutral 2% 2% 4%
Slightly Satisfied
23% 11% 19%
Satisfied 41% 38% 47%
Much Improved
17% 42% 27%
Satisfaction with Child’s Progress
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Which to employ?
Med Mgmt Combined Behavioral
Declined/Drop Out
12% 4% 0%
Dissatisfied 3% 2% 1%
Neutral 6% 4% 1%
Slightly Satisfied
5% 3% 4%
Satisfied 40% 18% 31%
Much Improved
34% 70% 64%
Overall Satisfaction with Treatment
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MTA Notes: The Combined Approach
Excellent Responder Analysis
% meeting Snap Parent/Teacher
“Normalization Criteria”
14 mos 24 mos
CC 25% 27%
Beh 34% 32%
Med 56% 38%
Combined 68% 48%
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When to refer?
Medication is not being enough to bring into normal functioning
Side effects too great for medication Parents want alternative treatment to
medication Co-occurring problems (ODD, CD, Anxiety,
Depression)
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Questions
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