Attention-Deficit/Hyperactivity Disorder (ADHD)

1. Attention-Deficit/Hyperactivity Disorder (ADHD) Andrea Chronis-Tuscano, Ph.D. Associate Professor of Psychology Director, Maryland ADHD Program University of Maryland

2. Maryland ADHD Program Mission • To conduct clinical research that advances our knowledge about the assessment and treatment of ADHD • To provide comprehensive, evidence-based assessment and treatment of ADHD and associated problems to children and their families • To train the next generation of clinical psychologists in evidence-based assessment and treatment practices • To educate parents, schools, health professionals and the community about evidence-based assessment and treatment for ADHD

3. Overview • Definition & Features • Etiological Factors • Evidence-Based Assessment & Treatment • Professional Practice Parameters

4. Prevalence & Impact • Prevalence rate of 6-10% • More prevalent in males than females • Male:female ratio is 3:1 in epidemiological samples • Ranges from 3:1 - 9:1 in clinical samples • 50% of children referred to mental health clinics are referred for ADHD-related problems • Annual societal cost of illness for ADHD estimated to be between $36 - 52 billion $12,005 -- $17,458 annually per individual • www.cdc.gov

5. Definition & Features

6. DSM-IV Diagnostic Criteria • Inattention Symptoms (at least 6 symptoms required) • Fails to give close attention to details or makes careless mistakes in schoolwork, work, etc. • Difficulty sustaining attention • Does not seem to listen when spoken to directly • Does not follow through on instructions and fails to finish schoolwork, chores, etc. • Difficulty organizing tasks and activities • Avoids tasks requiring sustained mental effort • Loses things necessary for tasks or activities • Easily distracted by extraneous stimuli • Forgetful in daily activities APA, 2000

7. ADHD Diagnostic Criteria (cont.) • Hyperactivity-Impulsivity Symptoms (at least 6 symptoms required) • Difficulty playing or engaging in activities quietly • Always "on the go" or acts as if "driven by a motor” • Talks excessively • Blurts out answers • Difficulty waiting in lines or awaiting turn • Interrupts or intrudes on others • Runs about or climbs inappropriately • Fidgets with hands or feet or squirms in seat • Leaves seat in classroom or in other situations in which remaining seated is expected APA, 2000

8. ADHD Diagnostic Criteria (cont.) • Symptoms present before age 7 • Clinically significant impairment in social or academic/occupational functioning • Some symptoms that cause impairment are present in 2 or more settings (e.g., school/work, home, recreational settings) • Not due to another disorder (e.g., Autism, Mood Disorder, Anxiety Disorder) APA, 2000

9. Subtypes • Combined Type • Clinical levels of both inattention and hyperactivity/impulsivity • Most common subtype • Predominantly Inattentive Subtype • Clinical levels of inattention only • Often not identified until middle school • Sluggish cognitive tempo • Predominantly Hyperactive/Impulsive Subtype • Clinical levels of hyperactivity/impulsivity only • More common among very young children prior to school entry

10. Controversial Issues with DSM-IV Criteria • Developmentally insensitive • Symptoms based on field trials conducted with elementary school aged boys (Lahey et al., 1994) • Categorical (not continuous) view • Requirement of onset before age 7 arbitrary • Requirement of 6 months duration too brief • Requirement that symptoms be demonstrated across 2 settings

11. Associated Problems • Peer problems • Inattentive symptoms  ignored • Hyperactive/impulsive symptoms  actively rejected • Not deficient in social reasoning/understanding, but rather the execution of appropriate social behavior • Family dysfunction/parental issues • No clear causal relationship between family problems and ADHD • Family problems can impact the severity and developmental course/outcomes of ADHD • Self-esteem • Inflated: Positive illusory bias (Hoza) • Low self esteem associated with comorbid depression

12. Developmental Course • ADHD is persistent across lifespan in most cases • Methodological issues impact estimates of persistence • ADHD severity, psychiatric comorbidity, and parental psychopathology predict persistence (Biederman et al., 2011) • Inattention remains stable; hyperactivity declines with age • DSM-IV criteria may not capture adolescent/adult manifestations of impulsivity • Adult outcomes including psychiatric comorbidity • When ADHD co-occurs with conduct disorder, chronic criminality and serious substance use can result • When ADHD co-occurs with depression, risk of suicide

13. Etiological Factors

14. Etiological Factors • Average heritability of .80 - .85 • Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions • Dysfunction in prefrontal lobes • Involved in inhibition, executive functions • Genes involved in dopamine regulation • Dopamine transporter (DAT1) gene implicated • 7 repeat of dopamine receptor gene (DRD4) implicated • Gene x environment interactions • Possible differences in size of brain structures • Prefrontal cortex, Corpus callosum, caudate nucleus • Abnormal brain activation during attention & inhibition tasks Kieling, Gondaves. Tannock. & Castellanos. 2008; Mick &. Faraone, 2008

15. Brain Structure & Function • Differences in brain maturation, structure, function (particularly abnormalities in frontostriatal circuitry): • Prefrontal cortex • Basal ganglia • Cerebellum • These areas of the brain are associated with executive function abilities: • Attention, spatial working memory, and short-term memory • Response inhibition and set shifting

16. Neurotransmitters • Neurotransmitter differences, particularly in levels of: • Dopamine • Norepinephrine • Epinephrine • Serotonin • Dopamine has been associated with approach and pleasure-seeking behaviors • Norepinephrine plays a role in emotional/behavioral regulation

17. Executive Functioning Deficits • Cognitive processes which activate, integrate, and manage other brain functions • Examples: • Cognitive: working memory, planning, use of organizational strategies • Language: verbal fluency, communication • Motor: response inhibition, motor coordination • Emotional: self-regulation of emotion, frustration tolerance • But… • EF deficits overlap with ADHD symptoms • EF deficits are not unique to ADHD • Not all children with ADHD have EF deficits

18. Barkley’s Theory “ADHD is not a problem with knowing what to do; it is a problem of doing what you know.” -Barkley, 2006 • Behavioral disinhibitionis the basis of executive functioning deficits in ADHD • A performance, rather than knowledge, deficit

19. A Possible Developmental Pathway for ADHD From Mash & Wolfe, 2007

20. Evidence-Based Assessment & Treatment of ADHD

21. Evidence-Based Assessment • Teacher- and parent-completed questionnaires • Structured clinical interview with parent(s) • IQ/Achievement testing to screen for learning disabilities (50% comorbidity) • Behavioral observations at home and school • No medical screen, cognitive test, or brain imaging technique can detect ADHD • Children with ADHD can focus long enough to watch TV, play videogames or sit still at the doctor’s office. Pelham, Fabiano & Massetti, 2005

22. Well-Established ADHD Treatments • Stimulant Medications • Behavioral Interventions • Behavioral parent training • Behavioral classroom management • Intensive summer treatment programs Pelham & Fabiano, 2008

23. Medication: Stimulants • Most well-researched, effective, and commonly used medication treatment for ADHD. • Methylphenidate (Ritalin, Concerta, andMetadate) • Dextroamphetamine (Adderall) • These medications reduce ADHD symptoms by: • Blocking the reuptake of norepinephrine (NOR)and dopamine (DOP) and facilitating their release  Enhances NOR and DOP availability in in certain brain regions: PFC and basal ganglia

24. Stimulant Medications • Research has shown that stimulants: • Are highly effective in reducing ADHD symptoms in the short term • Decrease disruption in the classroom • Increase academic productivity and on-task behavior • Improve teacher ratings of behavior • Different formulations work best for different children • Common side effects: insomnia, decreased appetite • Strattera (atomoxetine) • A non-stimulant alternative that works well for some children • Has not been studied as long or as intensively as the stimulants • Smaller effect size relative to the stimulants

25. Limitations of Stimulant Treatment • Individual differences in response • Not all children respond (approximately 80%) • Limited impact on domains of functional impairment • Primary reason for treatment seeking • Does not normalize behavior • Family problems beyond the scope of medication • No long-term effects established • Long-term use rare • Limited parent/teacher satisfaction • Some families are not willing to try medication

26. How do we identify evidence-based, non-pharmacological treatments?

27. “Evidence-based treatment” implies that studies have been conducted with the following features: • Careful specification of the target population • Diagnostic, demographic, recruitment, selection • Random assignment to conditions • Comparison could be to placebo but ideally to established tx • Use of treatment manuals • Ensures reliability of administration and facilitates replication • Multiple outcome measures with blind raters • Statistically significant differences between the tx and comparison group at post-tx • Replication, ideally by independent researchers Chambless et al., 1996; Silverman & Hinshaw, 2008

28. Well-Established Non-Pharmacological Treatments • Behavioral parent training • 33 well-conducted studies • Behavioral classroom management • 45 well-conducted studies Pelham, Wheeler & Chronis, 1998; Pelham & Fabiano, 2008

29. Behavioral Treatment Components • Psychoeducation about ADHD • Structure/routines • Clear rules/expectations • Attending/rewards • Planned ignoring • Effective commands • Time out/loss of privileges • Point/token systems • Daily school-home report card • Intensive summer treatment programs

30. Behavioral Treatment Considerations • Need to address cross-situational impairments • Poor generalization from treatment setting to real-world • Implement treatments in all settings in which child shows impairment • School behavior • 504 Plan/Individualized Education Plan (IEP) • Academic interventions needed in addition to behavioral interventions (Raggi & Chronis, 2006) • Environmental contingencies must be delivered consistently, which is difficult to maintain • Parental psychopathology can interfere with implementation

31. Multi-Modal Treatment Study for ADHD (MTA) • 6 sites • 579 Children, 7-9 y/o • ADHD, Combined Type • Assigned to 14 months of: • Med management • Intensive Behavior Therapy • Combined treatment • Treatment as Usual in the Community (TAU) • 2/3 received medication MTA Cooperative Group, 1999

32. Overall Results • All groups showed reductions in ADHD sx over time • On primary outcome measure (ADHD sx), medication alone and combined tx did better than behavioral tx alone and tx as usual (TAU) in the community • On many measures, combined tx was not significantly better than medication alone • Only combined tx was better than TAU on oppositional symptoms, aggression, depression/anxiety symptoms, social skills, parent-child relationship, and reading achievement • Higher medication doses were needed in the medication only group relative to the combined treatment group MTA Cooperative Group, 1999

33. Combined Treatment was superior in terms of: • Parent and teacher satisfaction with treatment • Normalization of child behavior • Improvements in functional outcomes • Family interactions • Peer relationships • Academic functioning Connors et al., 2001; Hinshaw et al., 2000; Pelham et al., 2004; Swanson et al., 2001; Wells et al., 2006

34. MTA 6-8 Year Follow-Up • Original treatment assignment not associated with any of the 24 outcomes 6-8 yrs later • ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes • Children with the best initial tx response and most favorable clinical presentation at baseline fared best over time • Children with behavioral and sociodemographic advantage, with the best response to any tx, had the best long-term prognosis • As a group, children with combined-type ADHD exhibit significant impairment in adolescence (on 9 of 21 measures) • This suggests a need for sustained treatment over the long term Molina et al., 2009

35. Practice Parameters

36. American Medical Association (AMA) • “encourages the use of individualized therapeutic approaches…which may include pharmacotherapy, psychoeducation, behavioral therapy, school-based and other environmental interventions, and psychotherapy, as indicated by clinical circumstances and family preferences.” (p.1106)” • American Academy of Pediatrics (AAP) • “the clinician should recommend medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong)” (p. 1037)

37. American Academy of Child & Adolescent Psychiatry (AACAP) • Treatment “may consist of pharmacological and/or behavior therapy” but that “pharmacological intervention for ADHD is more effective than a behavioral treatment alone” and that “behavioral intervention alone might be recommended as an initial treatment if the patient’s ADHD symptoms are mild with minimal impairment…or parents reject medication” (p.902)…”if a child has a robust response and shows normative functioning…then psychopharmacological treatment alone is satisfactory” (p. 912)… • If the child does not show a robust response to all FDA-approved medications, the clinician should “consider behavior therapy and/or the use of medications not approved by the FDA for treatment of ADHD” (p.907)

38. Summary • ADHD is a highly prevalent, brain-based disorder which is associated with lifelong impairment in functioning • Environmental factors can contribute to the expression, severity, course, and comorbid conditions • Long-term developmental outcomes for individuals with ADHD can include serious substance abuse, chronic criminality, depression and suicide • Stimulant medications and behavior therapy are currently the only established evidence-based treatments for ADHD • Combined behavioral-pharmacological treatment has the greatest impact on functional outcomes, is preferred by parents and teachers, and is most likely to result in normalization of behavior