1. Attention Deficit Hyperactivity Disorder Rachel J. Valleley, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute, UNMC

2. Current Conceptualization Attention-Deficit Hyperactivity Disorder (ADHD) DSM-IV, 1994 Three subtypes:  Predominantly Inattentive  Predominantly Hyperactive/Impulsive  Combined

3. 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

4. Cause of ADHD No one cause identified. Not caused by  Diet (i.e. food additives, sugar)  Poor parenting

5. Prevalence of ADHD Standard estimate: 3%-5% More recently:12% (Fabiano & Pelham, 2001)

6. Attention-Deficit Hyperactivity Disorder Diagnosis: Who has ADHD?

7. Formal Diagnostic Criteria DSM-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.

8. Symptom Lists Inattentive Type 3 fails to attend to details, makes careless mistakes 3 difficulty sustaining attention in play or work 3 does not listen when spoken to 3 does not follow through 3 difficulty organizing tasks 3 avoids task requiring sustained mental effort 3 loses things needed 3 distracted by extraneous stimuli 3 often forgetful Hyper/Impulsive Type 3 often fidgets hands/feet or squirms 3 often leaves seat when sitting is expected 3 runs about or climbs excessively 3 difficulty playing or engaging in leisure activities quietly 3 often “on the go”/ “driven by motor” 3 talks excessively 3 blurts out answers before questions completed 3 difficulty awaiting turn 3 interrupts or intrudes on others

9. Formal Diagnostic Criteria DSM-IV, 1994 Criterion B: Some of the symptoms were present before the age of seven years.

10. Formal Diagnostic Criteria DSM-IV, 1994 Criterion C: Some impairment from the symptoms is present in two or more settings (e.g., home, and school or work).

11. Formal Diagnostic Criteria DSM-IV, 1994 Criterion D: There is evidence of clinically significant impairment in social, academic, or occupational functioning.

12. Formal Diagnostic Criteria DSM-IV, 1994 Criterion E: The identified symptoms are not better accounted for by another mental disorder.

13. Other Common Causes of Attention & Hyperactivity Symptoms  Oppositional Behavior  Learning difficulties  Depression/anxiety  Drug/alcohol use  Physical illness  Adjustment

14. 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

15. Attention-Deficit Hyperactivity Disorder Assessment: All that wiggles is not ADHD

16. Comprehensive Diagnosis for ADHD There is no single test or laboratory measure which can reliably detect ADHD.

17. Comprehensive Diagnosis for ADHD Information gained by qualified clinician:  From family o standardized, norm-referenced ratings o detailed history  From school o standardized, norm-referenced ratings o academic history o in-class observations  From clinician o observations

18. 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

19. 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

20. 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

21. 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

22. 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

23. Treating ADHD

24. What we know works:  Drug Therapy  Behavior Therapy  Combined Behavioral/Drug Treatments APA Task Force on Evidence-Based Treatments, JCCAP, Pelham, Wheeler, & Chronis, 1998

25. 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

26. Medications for ADHD Ritalin Adderall Cylert Dexedrin Strattera Concerta

27. What Medications Can Do Manage symptoms 4 Decrease activity level 4 Decrease impulsivity 4 Increase attention or “focus”

28. What Medications Can Do Improve associated features 4 Decrease “defiance” 4 Decrease aggression 4 Suppress negative social skills

29. What Medications Can’t Do 4 Teach new, appropriate behaviors Compliance/rule-following Self-management 4 Teach content previously missed Academic work Social skills 4 “Cure” ADHD

30. Stimulant Medications: Considerations 4 Effective for 70-75% 4 Higher doses associated with more side effects 4 Positive effects are lost when drug discontinued

31. Stimulant Medications: Contraindications 4 Under six years of age 4 High anxiety level 4 Thought disorder 4 History of tics or Tourette’s Syndrome 4 Risk of drug abuse 4 Unacceptably high levels of negative side effects

32. 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.

33. Behavior Therapy for ADHD Components 4 Highly Structured 4 Immediate Feedback reinforcer or reward for appropriate behavior punishment for inappropriate behavior 4 Salient/Meaningful Feedback

34. Common Behavior Interventions Daily Behavior Report Card Token Economy Parent Training

35. Daily Behavior Report Cards 4 Daily note is sent between home & school regarding child’s behavior 4 Target behaviors monitored throughout the day 4 Performance on note determines consequences at home and/or school

36. Daily Behavior Report Cards Academic Behaviors 3 Working on assignments 3 Completing homework 3 Handing in assignments 3 All work up to date 3 On time for class Social Behaviors 3 Remained in seat 3 Talked in turn 3 Respectful behavior 3 Got along with peers 3 Following instructions 3 Hands to self

37. Sample School-Home Note ClassesTurned in workWork turned in at least 80% accurate Teacher Initials MathYes No ReadingYes No SpellingYes No Social StudiesYes No ScienceYes No Homework:

38. 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

39. 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

40. 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)

41. 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.

42. 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

43. 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.

44. Which to employ? Med MgmtCombinedBehavioral Declined/ Drop Out 12%4%0% Worse/ Unchanged 6% 5% Slight Improved 22%11%22% Improved 38%37%43% Much Improved 22%41%30% Change in Presenting Problem

45. Which to employ? Med MgmtCombinedBehavioral Declined/ Drop Out 12%4%0% Dissatisfied 5%3% Neutral 2% 4% Slightly Satisfied 23%11%19% Satisfied 41%38%47% Much Improved 17%42%27% Satisfaction with Child’s Progress

46. Which to employ? Med MgmtCombinedBehavioral 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

47. MTA Notes: The Combined Approach Excellent Responder Analysis % meeting Snap Parent/Teacher “Normalization Criteria” 14 mos24 mos CC25%27% Beh34%32% Med56%38% Combined68%48%

48. 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)

49. Questions ????????????