Multimodal Treatment of Hyperactivity Disorders Professor Peter Hill London

Multimodal treatment Total treatment of the whole child

Two initial diagnostic issues Differential diagnosis Is this actually ADHD or something else? Co-morbidity What else is going on as well as ADHD?

In my hyper-specialist clinic at Great Ormond Street Hospital for Children, London Cases of ADHD referred for re-evaluation from all over the UK by other specialist child psychiatrists

In this clinic In the last 100 cases seen in were confirmed as ADHD only 37 were ADHD and something else 45 looked like ADHD but were not

Of these 45 (Looked like ADHD but on detailed examination, did not meet diagnostic criteria for it) 10 autistic spectrum/PDD 8anxiety 5attachment disorder 4global learning disability (IQ<50) 4conduct disorder only 3Tourettes syndrome

Of these 45 (continued) 3developmental language disorder 3primary sleep problem 2impaired auditory memory only 2episodic hyperactivity - Kleine-Levin syndrome -cyclothymic mood disturbance 1frontal lobe damage

Co-morbidity for developmental disorders ADHD n=48 dyspraxia dyslexia Kaplan B et al 1998

Co-morbidity for other disorders 40-70% have conduct or oppositional- defiant disorder 30-40% have anxiety disorders up to 30% eventually show mood disorder Increased rates of –tic disorders –drug misuse

Associated issues Family stress and breakdown Educational underachievement Low self-esteem Relationship failure ADHD in other family members

In other words Full clinical assessment absolutely necessary –For differential diagnosis –For assessment of co-morbid conditions –To recognize impairment and associated problems (the burden of ADHD)

Also necessary To establish a baseline of clinical features and impairments so that treatment can be evaluated

Protocol approach To ensure thoroughness Should be possible to audit - to examine what went on in each case Intended for first contact with specialist service

Boxes are ticked when task is completed Not there for data entry

Assessment 1. Baseline –presenting complaints –ADHD symptoms –academic achievement –social relationships –parental attitudes

Assessment 2. Sources Parental interview Parental questionnaire Child interview Teacher questionnaire Teacher report

Assessment 3. Coverage Current symptom review Developmental history Family history Medical history Medication history

Assessment 4. Physical assessment Growth chart Head circumference Hearing Co-ordination

Assessment 5. Psychometric assessment Verbal (BPVS, WISC, BAS) Non-verbal (Matrices, WISC, BAS) Reading

Assessment 6. Check co-morbidity Antisocial behaviour problem Emotional disorder Tic disorder Pervasive developmental disorder Specific scholastic skills problem Motor planning problem Self-esteem problem

Treatment practice Fulfil basic criteria for medication? Few foods diet Establish basic parental and classroom handling practices. Provide information. Medication protocol no yes

Treatment practice 1 Information to parents Information to child Letter to school Letter to GP and school doctor

Best treatment practice 2. Basic handling practices Appropriate expectations Positive parental attending Effective communication of rules Contingency management

Conditions for stimulant medication Diagnosis recorded Parents accept School will co-operate Normal heart and blood pressure Seizure-free or stable epilepsy Not Tourettes syndrome (?) Growth satisfactory No household member with substance misuse or eating disorder

Basic principle of medication protocol Titration of dose against symptom relief academic and social achievement side-effects

Medication 1. b Rating scale to parents Rating scale to teacher Side-effects list to parents Collect at or just before 2-3 weeks after baseline rating (b) 4-6 weeks ditto 6-9 weeks ditto Times will vary according to school term b=baseline 2w6w9w

Medication 2. Methylphenidate 5, 5, 5 for 2-3 weeks Methylphenidate 10, 10, 5 for 2-3 weeks Methylphenidate 15, 15, 5-10 for 2-3 weeks Can add promethazine/clonidine/trazodone/ melatonin as evening dose

Medication 3. If no response to methylphenidate Continue fortnightly questionnaires and review Dexamphetamine 2.5, 2.5, 2.5 Dexamphetamine 5, 5, 2.5 Dexamphetamine 7.5, 7.5, Can add promethazine/diphenhydramine/clonidine/trazodo ne/melatonin as evening dose

Medication 4. If no response to dexamphetamine Continue fortnightly questionnaires and review Imipramine 25 / day (single or divided) Imipramine 50 / day

Medication 5. If response, continue, reviewing personally no less frequently than 6 monthly with growth chart Discontinue medication at 12 monthly intervals to test requirement If no response, consult tertiary centre

Combinations Protocol uses psychological treatment for all, provided through parents (makes assumption that this is justified though MTA results question this) diet only if medication not acceptable

But What if diet not acceptable? –Can use cognitive-behavioural approach more intensively What about school? –Needs active liaison and agreed management strategies for classroom and playground behaviour for academic performance for self-esteem

What else? Use of both CBT for associated emotional and behavioural problems (MTA re- analysis) Taking the long view (American Academy of paediatrics guidance)

Examining the effect of medication (mainly MPH) on non-core psychological features Does not alter locus of control (Horn et al 1991) Improves parent-child and child-child interactions (Schachar et al 1987; Whalen et al 1989)) May increase self-esteem (atomoxetine: Swenson et al 2001) Reduces aggression (Taylor et al 1987) Increases academic performance (Pelham et al 2002)

Hard work? Full assessment of child Multiple baseline interventions Full involvement of family Inter-agency liaison, especially school Probably an argument for - Specialist clinics - Two levels of specialist service

Worthwhile? For child and family now For adulthood –Note that most of the poor outcomes in adult life are because of co-morbid disorder, educational failure, relationship failure and occupational failure Need therefore to take broadest possible view of treatment effectiveness - a multimodal or total treatment approach