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