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Multimodal Treatment of Hyperactivity Disorders

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?.

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Multimodal Treatment of Hyperactivity Disorders

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  1. Multimodal Treatment of Hyperactivity Disorders Professor Peter Hill London

  2. Multimodal treatment Total treatment of the whole child

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

  4. 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

  5. In this clinic In the last 100 cases seen in 2002 18 were confirmed as ADHD only 37 were ADHD and something else 45 looked like ADHD but were not

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

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

  8. Co-morbidity for developmental disorders dyslexia ADHD n=48 8 7 19 10 23 dyspraxia 26 Kaplan B et al 1998

  9. 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

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

  11. 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”)

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

  13. 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

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

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

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

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

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

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

  20. 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

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

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

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

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

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

  26. Medication 1. 2w 6w 9w 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

  27. 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

  28. 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, 2.5-5 Can add promethazine/diphenhydramine/clonidine/trazodone/melatonin as evening dose

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

  30. 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

  31. 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

  32. 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

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

  34. 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)

  35. 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

  36. 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 - amultimodal or total treatment approach

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