from abc to adhd -...
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From ABC to ADHDFrom ABC to ADHD
Eric Tridas, MD
A il 3 & 4 2009April 3 & 4, 2009The Hawai’i Branch of the
International Dyslexia Association
The Developmental WebDevelopment
al ProfileEducational & Developmental
Academic–OccupationalBehavioral–Emotional
Social Interaction
Behavioral Profile
Behavioral & Cognitive
Soc a te act oHealth
Health Medical
Environment EnvironmentalEnvironment Environmental
Developmental WebDevelopmental Web
Contributing Factors to Clinical Presentationto Clinical Presentation
Developmental Profile
PROCESSING
VISUAL
AUDITORY
TACTILE-KINESTHETICINPUT
E N LTA
NEU
S
CO
GN
ITIV
E
ATTE
NTI
ON
ENTI
AL/
SIM
U
RAT
ESHORT TERM
WORKING
LONG TERM
SEQ
U
OUTPUTORAL
WRITTENWRITTEN
Visual Perceptual Problems• IMAGINEHOWCONFUSINGITWOULDBEIFEVERYT
HINGYOUREADLOOKEDLIKETHIS!• ORI FTH EWOR DSBE GINA NDEN DI NPLAC• ORI FTH EWOR DSBE GINA NDEN DI NPLAC
ESTH ATDON’NTM AKES ENSET OY OU?• TAHW FI EHT SRETTEL EREW DESREVER, or
OUT FO ODREROUT FO ODRER• w re o n al pa
T oset aelv e g e.ge ds m c er hh d t
Language Processing
• Phonology• SemanticsSemantics• Morphology
S t• Syntax• Discourse• Metalinguistics• PragmaticsPragmatics
Tactile-kinesthetic Processing
• Impacts Fine Motor Function– Progresses in a proximal-distal fashion– Affected by:
• Sense of body position or movement• Visual spatial processingp p g• Verbal-motor integration• Motor planning • Motor sequential memoryq y• Monitoring• Tone• CoordinationCoordination
Memory
• Short Term• Active workingActive working• Long Term
Short Term Memory
• Holds information for a few seconds• Limited storage capacityLimited storage capacity • Depends on:
V l– Volume– Modality
Vi l A dit T til Ki th ti• Visual, Auditory, Tactile - Kinesthetic– Attention
Working Memory
• Intermediate duration• Holding an idea in mind while developing, g p g
elaborating, clarifying, using it– Recalling answers while thinking of the question– Complex math problems– Reading (summarizing/comparing while decoding
S l ti l hil b i h t– Selecting color while remembering what you are drawing
Working Memory
• Factors affecting it:– AttentionAttention– Rate– VolumeVolume– Automaticity of skill
Long Term Memory
• Unlimited storage capacity• Long durationLong duration• Retrieval affected by:
R l f ti l– Relevancy of stimulus– Frequency of use
St t f i ti ( lid ti )– Strategy for memorization (consolidation)
Output
• Oral– Casual– Benefits from tone, gestures, etc.
• Written– Very formal– Depends on fine motor / graphomotor
function• Motor sequences, pencil grip, spatial
organizationorganization
Fine Motor Function
• Progresses in a proximal-distal fashion• Affected by:
– Sense of body position or movement– Visual spatial processing
Verbal motor integration– Verbal-motor integration– Motor planning – Motor sequential memory– Monitoring– Tone
Coordination– Coordination
Behavioral Profile
ANXIETY
DEPRESSIONINTERNALIZING
OPPOSITIONAL-DEFIANT
ANXIETY
CONDUCTATTENTIONEXTERNALIZING
AUTISMATYPICAL
SCHIZOPHRENIA
Medical Factors
CHRONIC HEALTH PROBLEMS
ASSOCIATED HEALTH
IATROGENIC HEALTH
PROBLEMS
IATROGENIC HEALTH PROBLEMS
Environmental Factors
PARENTING PARENTS
TEMPERAMENT
STRESSORS
PEERS house
PHYSICAL FACILITY TEACHERSCURRICULUM DEMANDS
TEMPERAMENT
CURRICULUM DEMANDS
Developmental WebDevelopmental Web
Management
Educational ManagementEducational Therapy
Speech & Language Therapy
Occupational Therapy
REMEDIATION Weakness
CIRCUMVENTION StrengthsCIRCUMVENTION Strengths
Volume
Rate
Technology
Complexity
Psychological Management
ADULT FOCUSED Behavioral Therapy
CHILD FOCUSED Cognitive Therapy
Medical Management
MEDICATIONMEDICATION
SURGERY
Environmental Management
HOMEHOME
SCHOOL
DyslexiaDyslexia
Etiology
Phonological ProcessingPhonological Processing
Phonology
• Phoneme: – Building block of words
S ll t it f h– Smallest unit of speech– There are 40 - 52 phonemes in the English language – Are put together to form wordsAre put together to form words
• Words can be broken down into their elemental sounds allowing us to decipher words
• Deficits in phonology strongly correlate with reading problems
Phonologic System
• Processing and production of speech sounds
• Earliest language system to develop• It is natural does not have to be taught• It is natural – does not have to be taught• It is the foundation of language
Phonological Processing Deficits
Phonological R idPhonologicalAwareness
RapidNaming
PhonologicalMemory
Fluency
• The ability to read text– Quickly– Accurately– With good understanding
• The hallmark of a good reader• Is the bridge between decoding and g g
comprehension• It is acquired word-by-wordq y
Dyslexia Etiology
• Language problem specific to the Phonologic Module– Functional part of the brain where
• Sounds of language (phonemes) are put together to form wordstogether to form words
• Words are broken down into their elemental sounds (phonemes)
• Discriminates words from noise– Learning to read is not a natural biological
processprocess
Dyslexia: Neurobiology
S
Phoneme Processing
Speech
Visual Word - Fluency
Typical Readers Dyslexic Readers
Typical Readers: ypElision versus Repetition
left right
Eden et al., 2004
Dyslexia: Neurobiology
Control
Eden et al. Nature 1996 Dyslexic
Reading: NeurobiologyReading: NeurobiologyPhonological processing
Phoneme Processing
catcattæk
Reading: NeurobiologyReading: NeurobiologyVisual - Fluency
Visual Word - Fluency
catcat
Reading Disability
(D x F) + C = Reading
D = DecodinggF = FluencyC = Comprehensionp
M. Joshi; IDA National Conference November 2004
Reading Disability
GeneralGeneral Intelligence
Vocabulary
Text DecodingFluency
Word Identification
Reasoning
= Meaning
g
Concept Formation
Early IdentificationEarly Identification
What to look for
Early Signs of Dyslexia
• By age of onset:– Delay in speakingDelay in speaking– Difficulty in pronunciation– Insensitivity to rhymeInsensitivity to rhyme– Poor word retrieval or word finding– Naming the letters and their sounds– Naming the letters and their sounds
Early Signs of Dyslexia
• Infants and toddlers– Delay in speakingDelay in speaking
• First word by 1 year• Phrases by 18 - 24 months• Parents may ascribe it to family history
– Speech delay and dyslexia are familial
Early Signs of Dyslexia
• Preschool years– Difficulty in pronunciationDifficulty in pronunciation
• No “baby talk” by 5 or 6 years of age• Typical problems:
– What to listen for» Omission of initial sounds: lephant for elephant,
chi-en for chicken» Inverting sounds: aminal for animal
Early Signs of Dyslexia
• Preschool years– Insensitivity to rhymeInsensitivity to rhyme
• Unable to recite nursery rhymes– Children that remember nursery rhymes tend to be
d dgood readers
• Unable to differentiate between similar and different words
– Can not focus on parts of the words» What rhymes with: food, talk
Early Signs of Dyslexia
• Poor word retrieval or word finding– Talking around a word (circumlocution)Talking around a word (circumlocution)– Uses words like “stuff” or “things”
Early Signs of Dyslexia
• Naming the letters and their sounds– Before entering Kindergarten
• Knows the names of upper and lower case letters
– Before entering 1st grade• Knows the names and sounds of letters• Knows the names and sounds of letters• Alphabetic principle
– Sequence of letters = number and sequence of soundsM t h b i i d f d• Matches beginning sounds of words
• Pronounces beginning sounds of words• Counts phonemes in small words
Early Signs of Dyslexia
• Typical development– 4 – 6 y/o aware that words come apart4 6 y/o aware that words come apart– 6 y/o 70% can count phonemes in small words
• Early signs of dyslexia• Early signs of dyslexia– After 1 year of reading instruction (end of 1st
grade) can’t separate sounds of spoken wordgrade) can t separate sounds of spoken word
Common Signs of Dyslexia
• Problems with:– Phoneme segmentationPhoneme segmentation– Phoneme deletion– Specific word retrieval (i e tornado forSpecific word retrieval (i.e. tornado for
volcano, prostitute for prosecute)– Rapid word retrievalRapid word retrieval
History Screening: Infancy
Y N• Single words by 1 yr ■ ■Single words by 1 yr ■ ■• Phrases by 2 yrs ■ ■
F il hi t f l• Family history of language or reading problems ■ ■
History Screening: PreschoolEnd of K – 4 Y N• Omission of sounds ■ ■
– Eliminates initial sounds (i.e., lephant for elephant)
• Inverts sounds ■ ■( i l f i l)(aminal for animal)
• Insensitivity to rhyme ■ ■– Can’t memorize nursery rhymes
C ’t t ll if d h– Can’t tell if words rhyme• Does not know lower case alphabet ■ ■
History Screening: Kindergarten
By the end of year CAN NOT: Y N• Name upper and lower caseName upper and lower case
alphabet ■ ■• Name most letter sounds ■ ■Name most letter sounds ■ ■• Match beginning sounds to words ■ ■• Pronounce beginning sounds of• Pronounce beginning sounds of
words ■ ■
History Screening: 1st Grade
By the end of year CAN NOT: Y N• Can separate and / or countCan separate and / or count
sounds in a word ■ ■Fi d th i ht d• Find the right words ■ ■
Screening Test: End of 1st Grade
• Alphabetic principle P F– Names beginning letters of words ■ ■Names beginning letters of words ■ ■– Names beginning sounds of words ■ ■– Names ending letters of words ■ ■Names ending letters of words ■ ■– Names ending sounds of words ■ ■– Can tell # of sounds in a word ■ ■– Can tell # of sounds in a word ■ ■
Screening Test: K.5 and 1st Grade
• Rhyming P F– Say a word that rhymes withSay a word that rhymes with
• Food ■ ■• Walk ■ ■
– Can recite a rhyme ■ ■
History Screening: Infancy
Y N• Single words by 1 yr ■ ■Single words by 1 yr ■ ■• Phrases by 2 yrs ■ ■
F il hi t f l• Family history of language or reading problems ■ ■
History Screening: PreschoolEnd of K – 4 Y N• Omission of sounds ■ ■
Eli i t i iti l d– Eliminates initial sounds(i.e., -lephant for elephant, chi-en for chicken)
• Inverts sounds ■ ■(aminal for animal)
• Insensitivity to rhyme ■ ■– Can’t tell if words rhyme
• Does not know lower case alphabet ■ ■
History Screening: Kindergarten
By the end of year CAN NOT: Y N• Name upper and lower caseName upper and lower case
alphabet ■ ■• Name most letter sounds ■ ■Name most letter sounds ■ ■• Match beginning sounds to words ■ ■• Pronounce beginning sounds of• Pronounce beginning sounds of
words ■ ■
History Screening: 1st Grade
By the end of year CAN NOT: Y N• Can separate and / or countCan separate and / or count
sounds in a word ■ ■Fi d th i ht d• Find the right words ■ ■
Screening Test: End of 1st Grade
• Alphabetic principle P F– Reads the words accurately ○ ○Reads the words accurately– Names beginning letters of words ○ ○– Names beginning sounds of words ○ ○Names beginning sounds of words ○ ○– Names ending letters of words ○ ○– Names ending sounds of words ○ ○– Names ending sounds of words ○ ○– Can tell # of sounds in a word ○ ○
Screening Test: K.5 and 1st Grade
• Rhyming P F– Say a word that rhymes withSay a word that rhymes with
• Food ○ ○• Walk ○ ○
InterventionIntervention
What to do about it.
Research Based Reading Instruction• Essential Components
– Phonemic awareness• Recognize, remember and manipulate individual soundsg p
– Phonics and word recognition• Sound – symbol relationship, word meaning
– Reading Fluency• Read with sufficient speed an accuracy to support
comprehension – Vocabulary development
• Individual word meanings• Individual word meanings– Reading comprehension
• Verbal reasoning, background knowledge, comprehension strategiesg
Reading Instruction
• Other components– Basic writing skillsBasic writing skills
• Compose English with accuracy, fluency and clarity of expression
– Comprehending and using language• The ability to listen and understand the
i f h t i imeaning of what someone is saying
Effective Reading Instruction• Explicit
– Clearly and directly explained not left to discovery• Systematic
– The speech sounds, spelling patterns, sentence structures, text genre and language conventions
• CumulativeC ti l i kill b ild th– Continual review one skill builds on another
• Multisensory• Sequential and Incremental
M bl t– Manageable steps• Data driven
– Emphasis, speed of instruction and support are determined by student's progressstudent s progress
Dyslexia: Management
• Critical to start before 3rd grade• It is almost impossible to remediateIt is almost impossible to remediate
after 4th grade
l iEarly Intervention IS Urgent•10TH %ile 5th Grade reader
•50,000 words/year
•50TH %ile 5th grade reader•600,000 words/year
•Average students receive approximately 10 TIMES as
h ti imuch practice in a year
Anderson, Wilson & Fielding 1998
Dyslexia: Pre-testing Post-testing
yManagement
Dyslexia-specific brain activation profile becomes normal following successful remedialsuccessful remedial training
Simos, Fletcher, et al. Neurology,2002
What About Attention?What About Attention?
ADHD: What it is and what is not!What it is and what is not!
H ki ti R ti
ADHD: Historical TimelineHyperkinetic Reaction of Childhood (DSM-II)
Attention Deficit Hyperactivity Minimal Brain Damage Disorder (DSM-III-R)
1960 19801968 1987 19941930193019021902
Minimal Brain Dysfunction
1960 19801968 1987 19941930193019021902
y
Attention Deficit Disorder + or -Hyperactivity (DSM-III)
ADHD-like syndromefirst described
Attention Deficit/Hyperactivity Disorder (DSMAttention Deficit/Hyperactivity Disorder (DSM--IV)IV)
Diagnostic Criteria for ADHD: gDSM-IV• Persistent symptoms of inattention and/or impulsivity and
hyperactivity
• Onset of symptoms before age 7
• Impairment in 2 or more settings (eg, school, work, home)p g ( g, , , )
• Evidence of clinically significant impairment in social, academic, or occupational functioning, p g
• Symptoms not a result of other disorders
Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.
DSM-IV Diagnostic Criteria gSymptoms for ADHD
• Inattention (>6)I l
– Is disorganizedA id /di lik t k– Is careless
– Has difficulty sustaining attention
– Avoids/dislikes tasks requiring sustained mental effortg
in activity– Does not listen
– Loses important items– Is easily distracted
– Does not follow through with tasks
y– Is forgetful in daily
activities
Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.
DSM-IV Diagnostic Criteria gSymptoms for ADHD (cont’d)
• Impulsivity— Blurts out answers
Cannot wait turn
• Hyperactivity (>6)– Squirms and fidgets
Cannot stay seated — Cannot wait turn— Intrudes/interrupts others
– Cannot stay seated– Runs/climbs excessively– Cannot play/work quietly– Is on the go/driven
by a motor– Talks excessively
Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.
ADHD: DSM-IV Subtypes
• ADHD Combined Type– Criteria are met for both inattention and C te a a e et o bot atte t o a d
impulsivity/hyperactivity (> 6 of each)• ADHD Inattentive Type
– Criteria met for inattention but not for impulsivity/hyperactivity (> 6)
• ADHD Hyperactive-Impulsive Type– Criteria met for impulsivity/hyperactivity but not for p y yp y
inattention(> 6)
ADHD C bid C di iADHD: Comorbid Conditions60
55
50
4540%
40
35
30
25
20
(%)
30–35%
20–25% 15–25%
15–20% 20% 19%20
15
10
5
0
15%
Oppositionaldefiantdisorder1
Anxietydisorders3
Learningdifficulties2
Mooddisorders2
Conductdisorder3
Smoking4 Substanceusedisorder5
Languagedisorder2
1MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1076–1086.2Barkley R. Attention-deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment, 2nd ed. New York: Guilford Press, 1993.3Biederman J, et al. Am J Psychiatry 1991; 148:565–577.4Milberger S, et al. J Am Acad Child Adolesc Psychiatry 1997;36:37–44.5Biederman J, et al. J Am Acad Child Adolesc Psychiatry 1997;36:21–29.
C biditI C With ADHDComorbidity Is Common With ADHDComorbidity Is Common With ADHD
ADHD
CONDUCT (10%) Oppositional
Di d (40 50%)Oppositional
ADHD Disorder (40-50%)ADHDpp
Disorder (40-50%)
AnxietyDisorderAnxietyDisorder
Conduct (10%)
(35%)MoodDisorder(5-25%)
(35%)MoodDisorder(5-25%)ADHD Only (50%)ADHD Only (50%)
EtiologyEtiology
A Variety of Functional & StructuralA Variety of Functional & StructuralA Variety of Functional & StructuralA Variety of Functional & StructuralDifferences Appear in the ADHD BrainDifferences Appear in the ADHD Brain
Normal Controls ADHD
y = +21 mm y = +21 mm1 x 10-2 1 x 10-2y = +21 mm y 21 mm1 x 10
1 x 10-3 1 x 10-3
MGH-NMR Center & Harvard- MIT CITP Reprinted by permission of Elsevier Science from Anterior cingulate
cortex dysfunction in ADHD revealed by fMRI
and the Counting
Stroop , by Bush G, Frazier JA, Rauch SL, et al.,
MGH-NMR Center & Harvard- MIT CITP Reprinted by permission of Elsevier Science from Anterior cingulate cortex dysfunction in ADHD revealed by fMRI and the Counting Stroop , by Bush G, Frazier JA,RauchSL, et al., Biological Psychiatry 45(12), Copyright 1999 by the Society of Biological Psychiatry.
Twin Studies Show ADHDTwin Studies Show ADHD Is a Genetic Disorder
HeightBreast cancer Asthma Schizophrenia
Levy, 1997Nadder, 1998
Hudziak, 2000
Gjone, 1996Silberg, 1996
Sherman, 1997y,
Edelbrock, 1992Schmitz, 1995Thapar, 1995
Willerman, 1973Goodman, 1989
Gillis, 1992
Faraone. J Am Acad Child Adolesc Psychiatry. 2000;39:1455-1457. Hemminki. Mutat Res. 2001;25:11-21.Palmer. Eur Resp J. 2001;17:696-702.
Average genetic contribution of ADHD based on twin studies0 0.2 0.4 0.6 0.8 1
ADHD Mean
Impairment Caused by ADHDImpairment Caused by ADHD
How does it present?Impact on quality of lifeImpact on quality of life
ImpairmentAcademic
Behavioral/EmotionalBehavioral/EmotionalSocialization
M di lMedical
Impairment• ADHD is a disorder of performance, not
skill• ADHD disrupts executive function• ADHD creates problems with self• ADHD creates problems with self-
regulationADHD i h lth i k• ADHD increases health risks
Impairment• ACADEMIC
– Production vs. KnowledgeProduction vs. Knowledge• BEHAVIOR - EMOTIONAL
Spacey/Over Reactive vs Defiant– Spacey/Over-Reactive vs. Defiant• SOCIALIZATION
I ti bl M li i– Insatiable vs. Malicious• MEDICAL
– Cigarette smoking, Car accidents, SUD
ADHD: Impairment over time
Academiclimitations
RelationshipsOccupational/vocational
ADHD Low self-esteem
Legaldifficulties
Smoking andInjuriesMotor vehicle
accidentsSmoking and
substance abuse
ADHD: Impact on FamilyParents of children with ADHD experience higher levels of:
• Stress• Self-blameSelf blame• Social isolation• Depression• Depression• Marital discord
Mash and Johnston. J Clin Child Psychol. 1990;19:313.Murphy and Barkley. Am J Orthopsychiatry. 1996;66:93.
ADHD : AdultsADHD : Adults Performance Limitations• Despite similar educational levels and IQ
scores, non-medicated adults with ADHD display:– Significantly more academic difficulty in school
(25% repeat a grade)
– Lower levels of occupational advancement
Faraone S, et al. Biol Psychiatry. 2000;48:9-20.Biederman, et al. Am J Psychiatry. 1993;150:1792-1798.
ADHD Affects Socialization• Children are stigmatized by their behavior
– Disruptive behavior• Troublemakers
–Immaturity and impulsivenessCenter of attention• Troublemakers
• Bad sportsmanship• Excessive talking• Cannot sit still
U f d t i t th
•Center of attention•Breaks the rules•Blurting out answers
•Peer rejection• Unfocused, not responsive to others• Impulsive aggression
• Adolescents continue to demonstrate social problems
• Poor participation in group activities• Few friends
AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S.Barkley RA. J Am Acad Child Adolesc Psychiatry. 1991;30:752-761.
• Vulnerable to antisocial groups, drug abuse
Increased Traffic Violations and Motor Vehicle A id i Ad l d Ad l i hAccidents in Adolescents and Adults with ADHD
7080
90ADHD n=25 Control n=23P=0.004 P=0.07
506070
ects
(%) P=0.07
P=0.01
203040
subj
e
01020
Traffic Speeding Drunk License Driver-causedTraffic violations
Speeding violations
Drunk driving
License suspended
Driver-caused accidents
Barkley RA, et al. Pediatrics. 1996;98:1089-1095.
Increased Smoking with ADHDAdult patients with ADHD
50% 48.5%
40 8%
mok
ers
30%
40%
ADHDG l
40.8%
29% n=71
urre
nt s
m
20%
30%
*P<0.01
General population
25.8%
Cu
10%
Pomerleau, et al. J Subst Abuse. 1995;7:373-378.
*Smokers Quit ratio0%
Earlier Initiation of Smoking with ADHDSmoking with ADHD
0.6
0.5
lity ADHD n=128
C t l 1096- to 17-year-old boys0.4
0.3g pr
obab
il Control n=109
0.2
0 1
Smok
ing
0.1
00 2 4 6 8 10 12 14 16 18 20 22 24
P<0.003Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44.
Age
Untreated ADHD Is Associated WithUntreated ADHD Is Associated With Higher Risk of Substance Abuse
P=0.001use
(%)
use
(%)
P 0.001
P=0.001 P=0.001
subs
tanc
e
stan
ce a
bu
hist
ory
of s
nce
of s
ubs
Life
time
h
Prev
alen
Biederman J, et al. Biol Psychiatry. 1998;44:269-273.Biederman J, et al. Pediatrics. 1999;104:e20-e25.
Adolescent & Adult Outcome• Symptoms Persist in 50-65%• Associated Problems
– Conduct– EmotionalEmotional– Socialization– Education– Education– Employment
Satisfactory Outcome in 60 70%• Satisfactory Outcome in 60-70%
Management of ADHDManagement of ADHD
Good Management of ADHDgInvolves MultimodalTherapy
Multimodal Therapy
MedicationMedication Psychosocial TherapyPsychosocial TherapyStimulantsStimulants Parent TrainingParent TrainingAntidepressantsAntidepressants Child-Focused Treatment Child-Focused Treatment Alternatives SNRI’s School-Based InterventionSchool-Based Intervention
Normalization in Many AreasNormalization in Many Areas
MTA St d Obj ti d D iMTA Study Objective and DesignMTA Study Objective and DesignMTA Study Objective and Design
Objective:Objective:•• To compare the long-term efficacy ofTo compare the long-term efficacy of pharmacotherapy, behavioral
therapy, and combination therapy in the treatment of ADHD therapy, and combination therapy in the treatment of ADHD Protocol:Protocol:•• Population: 579 children with ADHD combined type, aged 7-9.9 yearsPopulation: 579 children with ADHD combined type, aged 7-9.9 years•• In a 4-group parallel design, children randomly assigned to:In a 4-group parallel design, children randomly assigned to:
–– Medication alone (primarily methylphenidate)Medication alone (primarily methylphenidate)–– Behavioral therapy aloneBehavioral therapy alone–– Combination of medication and behavioral treatmentCombination of medication and behavioral treatment–– Routine community care (medication and behavioral treatment)Routine community care (medication and behavioral treatment)
•• Duration of study treatment: 14 monthsDuration of study treatment: 14 months
The MTA Cooperative Group. Arch Gen Psychiatry. 1999;56:1073-1086.
MTA Study: Treatment Outcome: yTeacher-Rated InattentionCC3
3314-Month Outcomes14-Month Outcomes
Teacher-rated Inattention (MTA Group, 1999)Teacher-rated Inattention (MTA Group, 1999)2.52.5
Community Control22
´´
Behavior Modification
Medical Management11
1.51.5 ´
Combination TherapyComb, Med Mgt > Beh, CC
00
0.50.5
The MTA Cooperative Group. Arch Gen Psychiatry. 1999;56:1073-1086.
Assessment Point (Days)Assessment Point (Days)00
100100
200200
300300
400400
00
Long-term Outcomes of Therapies forLong term Outcomes of Therapies for ADHD in the MTA Study
Hyperactive Impulsive Symptoms(Teacher Reports)
70
(%)
65 60%
40
50
60
14 m
onth
s (
55
45
56%60%
45%
36%
20
30
40
vem
ent a
t 1 35
25
15
36%
0
10
Medication Combination Behavioral Community based
Impr
ov 15
5
Medicationmanagement
Combinationtherapy
Behavioraltreatment
Community-basedtreatment
The Developmental WebDevelopmental Profile
Educational & Developmental
Academic – OccupationalBehavioral – Emotional
Social Interaction
Behavioral Profile
Behavioral & Cognitive
Health
Health Medical
Environment EnvironmentalEnvironment Environmental
American Academy of Pediatrics: G id li f th T t t f ADHDGuidelines for the Treatment of ADHD
• Establish a treatment program that recognizes ADHD as a chronic condition
• Specify appropriate target outcomes to guide management• Prescribe stimulant medication and/or behavior therapy to• Prescribe stimulant medication and/or behavior therapy to
improve target outcomes in children with ADHD• If the treatment program has not met target outcomes,
evaluate:– Original diagnosis– Use of all appropriate treatments– Adherence to the treatment plan
Presence of coexisting conditions– Presence of coexisting conditions• Using information from parents, teachers, and the child,
follow-up to evaluate target outcomes and adverse effects
AAP. Pediatrics. 2001;108:1033-1044.
Types of Medications Used InTypes of Medications Used In Managing ADHD
ADHD
STIMULANTS SNRI’s
Amphetamines Atomoxetinemethylphenidate
dextroamphetamine Mixed AmphetaminesImmediate Release
PulseOROS
Transdermal
d-methylphenidate
Immediate ReleaseImmediate Release
PulseImmediate Release
Pulse
Immediate ReleasePulse
lisdexamfetamine
Dopamine
Norepinephrine
R t kReuptake pumps
Medication
Receptors
Dopamine
Norepinephrine
R t kReuptake pumps
Medication
Receptors
Proposed Effect of Stimulants
Increase Dopamine Production
AmphetaminesAmphetamines
MethylphenidateAtomoxetine
Decreases Dopamine ReuptakeDecreases Dopamine Reuptake
Medications: Clinical Impact• Increase control of attention• Increase impulse controlIncrease impulse control• Decrease activity
D di ti b h i• Decrease disruptive behavior• Improve handwriting (in 50%)
Medications: Clinical Impact• Academic • Increase Production
• Behavior • Increase ComplianceDecrease Disruption
• Socialization
Decrease Disruption
• Increase Awareness
Stimulant Medications• Side Effects
– Insomnia (50-60%)– Anorexia (50-60%)– Irritability (30%)– Headache– Stomachache– Nausea– Tics
Atomoxetine: Side Effects
• Anorexia• Dizziness - SleepinessDizziness Sleepiness• Dyspepsia
D titi• Dermatitis• Constipation• Mood Swings• Transient elevation of liver enzymesTransient elevation of liver enzymes• Increased suicidality
Medications: Duration of Action
• Short Acting: 4 hours• Intermediate Acting: 6 – 8 hoursIntermediate Acting: 6 8 hours• Long Acting: 8 – 12 hours
24 h24 hours
Medications• Short-Acting • Ritalin, Dexedrine, DextroStat,
Focalin Methylin (Tablet, Chewable & Liquid)
• Intermediate-Acting • Ritalin SR, Metadate ER, Adderall, Ritalin LA, Metadate-CD Methylin ER Focalin XR
• Long-Acting
CD, Methylin ER, Focalin XR
• Dexedrine Spansules, Cylert, Adderall-XR Concerta
• 24 hours
Adderall-XR, Concerta, Daytrana, Vyvanse
• Strattera
®MPH OROS (Concerta®)tr
atio
n m
L)
IR MPH 10 mg tid (n=15)CONCERTA® 36 mg qd (n=15)
12
16
20
Con
cent
(ng/
m
4
8
Time (h)0 2 4 6 8 10 12
0
MedicineCompartment
#1
MedicineCompartment
#2
PushCompartment
MedicineCompartment
#1Outer Coat of Medicine
MPH SODAS™ (Ritalin® LA)MPH SODAS (Ritalin LA)Pulse Release
SODAS™ is a trademark of Elan Corporation, Plc
Pulse Delivery System (SODASPulse Delivery System (SODAS, Difucaps)
15
20
entra
tion
0
5
10
Con
ce
20 4 6 8 10 12 14 160
Time (h)
Mixed Amphetamine SaltsMixed Amphetamine Salts (Adderall XR® )Formulation Study
® ®
25
30Adderall® 10 mg BID
Adderall XR® 20 mg QD
Bioequivalence of Adderall XR® 20 mg QD to Adderall® 10 mg BID
ne
20
25Dextroamphetamine
mph
etam
inen
trat
ion
L)
10
15
D-a
nd L
-am
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Con
ce(n
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L
0
5LevoamphetamineM
ean
DPl
as
Tulloch et al. Pharmacotherapy 2002;22:1405.
0 4 8 12 16 20 24 28 32 36 40 44 48 52Time (h)
Daytrana DOT Matrix™y OTransdermal Technology
• Methylphenidate is mixed with adhesive
DOT Matrix is a trademark of Noven Pharmaceuticals, Inc.
Pharmacokinetics with DaytranaC f
50
10 mg Daytrana 20 mg Daytrana 30 mg Daytrana
Mean Plasma Concentration of d-methylphenidate
Mean Plasma d-MPH Conc
30
40
50
d MPH Conc (ng/mL)
0
10
20
0 1 2 3 4 5 6 7 8 9 10 11 12Time post-dose (hr)
Patch Patch d
Lower limit of quantification 0.25 ng/mL.
Pierce et al. Poster presented at the AACAP Annual Meeting. Toronto. October 20, 2005.
applied removed
Application and Removal/Disposal
• Holding the patch down, the rest of the liner should be removed slowly and theremoved slowly and the exposed half should be pressed against the skinTh h h ld b d• The patch should be pressed down with the palm of the hand for 30 seconds
• Upon removal, the patch should be folded in half, with sticky sides together, and y g ,discarded immediately in toilet or lidded container
™Vyvanse™
• Is a pro-drug – Inactive until the body breaks it downInactive until the body breaks it down
• Combines an amphetamine and an amino acidamino acid– Dextroamphetamine and lysine
It lasts12+ hrs• It lasts12+ hrs• Not affected by GI transit time or pH
Atomoxetine (Strattera™) o o e e (S e )Efficacy
Behavioral ManagementBehavioral Management
What to do at Home
Core Principles for Behavior pManagement
• Immediacy of Consequences• Frequency of Consequences• Saliency of Consequences• Frequent Changes in Rewards
A t D ’t Y k• Act, Don’t Yack• Positives Before Negatives• Anticipate ProblemsAnticipate Problems• Pick Your Fights - Prioritize• Expect Variabilityp y• Practice Forgiveness
It is not your faultIt is not your fault…
But it is your problem