Treatment of ADHD

Question 1

stats on increase of ADHD

Answer 1

Over the last two decades, Attention Deficit Hyperactivity Disorder has taken the title of being the most commonly diagnosed disorder in school-aged children. During the 1990’s, the rate of kids seeing physicians for stimulant pharmacotherapy for ADHD increased fivefold (Mayes et al., 2008).

Question 2

why is it important to treat ADHD early and accurately

Answer 2

age 3, severity of ADHD is the most significant indicator of chronicity of the disorder into middle childhood (Sonuga-Barke, et al., 2006).

Research on older children suggests that early onset may be associated with poorer outcome, e.g., greater cognitive and language deficits, higher rates of psychiatric comorbidity and greater social and academic impairments (Taylor, 1999).
Thus, it is important to accurately detect and treat ADHD in this population in order to minimise the impact of the disorder on the child’s life,

Question 3

state the different methods for treating ADHD

Answer 3

Pharmacotherapy;
stimulant and non stimulant

non-pharmalogical

parent training

CBT

SST

Question 4

general info on stimulants

Answer 4

Stimulants commonly used and often considered most effective at reducing core symptoms

Question 5

why do stimulants work

Answer 5

Stimulant medications increase dopamine and norepinepherine neurotransmitters in the brain and also increase blood flow to the brain. ADHD children feel the need to self-stimulate however stimulants reduce this need.

Question 6

name two types of stimulant and their shelf names

Answer 6

Amphetamine- Adderal

Methylphenidate e.g. Ritalin

Question 7

support for Amphetamine

Answer 7

Gillberg et al., 1997- Support- Amphetamine- Adderal was clearly superior to placebo in reducing inattention, hyperactivity, and other disruptive behavior problems and tended to lead to improved results on the Wechsler Intelligence Scale for Children—Revised

Question 8

support for methlyphenidate

Answer 8

Prins et al., 2007- Both methylphenidate and psychosocial treatments are effective in reducing ADHD symptoms. However, psychosocial treatment yields smaller effects than both other treatment conditions.

Question 9

support for overall stimulants

Answer 9

Meta-analysis by Jadad et al., 1999- Six studies compared drugs with nondrug interventions and showed consistently that stimulants, particularly MPH, may be more effective than nonpharmacological interventions.

Question 10

what are issues with stimulants

Answer 10

heart problems

abuse

Question 11

support for heart problems and stimulants

Answer 11

Mick et al., 2013- found that subjects randomized to CNS stimulant treatment demonstrated a statistically significant increased resting heart rate [+5.7 bpm (3.6, 7.8), p<0.001] and systolic blood pressure findings [+2.0 mmHg (0.8, 3.2), p=0.005] compared with subjects randomized to placebo

Question 12

support for abuse in stimulants

Answer 12

Faraone et al., 2007- 2 in 10 youths with ADHD misuse their medication.

Thomas et al., 2011 studied abuse in college students- The most frequently endorsed misuse items were used too much(36%), self-reported misuse (19%), and intentionally used with alcohol or other drugs (19%).
Misusers of prescribed stimulant medication were more likely to report cigarette smoking,binge drinking, illicit use of cocaine, and screen positive on the Drug Abuse Screening test (
Conclusion: There is a strong relationship between misuse of prescribed stimulants for ADHD and substance use behaviors, as well as other deleterious behaviors such as diversion. These findings suggest the need for close screening, assessment, and therapeutic monitoring of medication use in the college population.

Question 13

general issues with stimulants

Answer 13

Side effects wide array: insomnia, mood disturbances, headaches, loss of appetite, lethargy (Roberts et al., 2009)

Question 14

why use non stimulants?

Answer 14

Why use? Despite the well-established efficacy and safety of stimulants for ADHD2, alternative medications are still needed for several reasons. About 10–30 % of children and adults with ADHD may not respond to stimulants or may be unable to tolerate potential adverse events such as decreased appetite, sleep disturbances, mood lability, and exacerbation of comorbid tic disorders- (Barkley 1977; Barkley et al., 1990

Question 15

give eg. of non stimulants

Answer 15

tricyclic antidepressants and atomoxetine

Question 16

what is atomoxetine

Answer 16

s a highly selective inhibitor of the presynaptic noradrenaline transporter.

Question 17

support for efficacy of atomoxetine

Answer 17

Outcomes on psychosocial measures, including functional and quality-of-life measures, such as the Child Health Questionnaire (CHQ), a parent-rated health outcome scale that measures physical and psychosocial well-being, provide evidence that the improvements in ADHD symptoms associated with atomoxetine are associated with better family and social functioning during acute therapy [Michelson et al., 2001] and long-term (24-month) treatment [Perwien et al., 2003] and, thus, are clinically significant.

Question 18

saftey pros of atomxetine

Answer 18

The safety and tolerability of atomoxetine have been evaluated in several clinical trials and the available data do not suggest any serious safety concerns. Atomoxetine has generally been well tolerated [Michelson et al., 2001, 2002, 2003]. Overall drug discontinuation rates were low in both groups (atomoxetine, 2.3 %; placebo, 1.2 %).
Cardiovascular effects of atomoxetine (subtle increases in both heart rate and blood pressure) appear not to be clinically significant [Belle et al., 2002].
Hypersensitivity reactions appear to be rare [Belle et al., 2002].

Unlike stimulants, available data on atomoxetine does not show any potential for abuse. The safety profile and/or efficacy of atomoxetine appear to be favourable compared with other non-stimulant medications tried in ADHD

Question 19

cons of atomoxetine

Answer 19

Like stimulants, atomoxetine may be associated with a brief period of decreased appetite and weight loss upon initiation (14.1 % vs. 5.8 % placebo) [179]. Controlled long-term studies are not yet available to confirm these findings.
Other side effects of atomoxetine include dry mouth, insomnia, constipation, vomiting, dizziness, fatigue, nausea, dyspepsia and mood swings. In addition, urinary retention and sexual dysfunction have been observed in adult patients. Most of these adverse effects diminish over the first months of treatment.

Question 20

how studies are TCAs

Answer 20

) would rank second in terms of number of controlled studies-

tricyclic antidepressants have the most evidence for the treatment of ADHD in the non-stimulant category.

Question 21

give e.g. of TCAs

Answer 21

e.g. DESIPRAMINE

Question 22

support for desipramine

Answer 22

Desipramine significantly superior to placebo in a double-blind, placebo controlled trial. The effect size was found to be similar to stimulants. patients showed a significant reduction in depressive symptoms compared with patients who received placebo- Biederman 1989

Out of 33 studies (21 controlled, 12 open) evaluating in children and adolescents (n=1139), and adults (n=78), 91 percent reported improvement in ADHD symptoms- Spencer et al., 1997

Question 23

what are health issues of TCAs

Answer 23

TCA overdose is a significant cause of fatal drug poisoning. The severe morbidity and mortality associated with these drugs is well documented due to their cardiovascular and neurological toxicity. Additionally, it is a serious problem in the pediatric population due to their inherent toxicity- Kou et al., 2005
Cause cardiovascular toxicity manifested by ECG abnormalities, arrhythmias and hypotension.- Thomas et al., 2005

Question 24

issue with efficacy between TCA and stimulants

Answer 24

Furthermore, their efficacy in treating symptoms of ADHD is considered to be lower than that of the psychostimulants (Pliszka, 1987; Biederman et al., 1989; Jadad and Atkins, 1998).

Question 25

common reasons not to medicate

Answer 25

Roberts et al., 2009 proposed common reasons:
The cost of the medication is too much for the family to afford, the child does not respond to the medication, the side effects are outweighing the improvements of the medication and parents not accepting pharmacological treatment

Question 26

backgorund to non-pharmacological treatment

Answer 26

In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) published ADHD Clinical Guidelines in early 2009. These firmly endorsed the use of non-pharmacological treatments by stating that drug treatments for children, young people and adults with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions

Question 27

methods of non-drug treatment

Answer 27

Parent training

CBT

Structured skills training

Question 28

what is considered actually best for treatment of ADHD and support for this

Answer 28

Ramsay et al., 2006 pharmacotherapy and psychotherapy- Results indicate that combined treatment is associated with significant improvements on all clinical measures.

Ideally, a biopsychosocial approach should be used in the treatment of ADHD to obtain and maintain successful treatment.- Bundur et al., 2005

Question 29

what does parent training aim to do

Answer 29

• Aims to teach parents to: learn how to identify and manipulate the background and consequences of a child’s behaviour, target and monitor problematic behaviours, reward prosocial behaviours through praise, positive attention and tangible rewards and decrease unwanted behaviours through planned ignoring, time-out and other similar non-physical disciplinary techniques.

Question 30

what does parent training address

Answer 30

• Addresses the issue of parenting problems directly by working with parents to enable them to modify and enhance their parenting skills in order to improve parent-child relationship (Pelham et al., 1998)

Question 31

parent training types in preschool children

Answer 31

Triple P

Incredible Years program

Question 32

support for triple P program

Answer 32

Bor et al. 2002

One study evaluated the effects of two versions of the Triple P programme (standard vs. enhanced) versus a waitlist condition on 87 preschoolers who presented with both hyperactive/inattentive and disruptive behaviours (Bor et al., 2002).Results revealed that both versions of the Triple P programme brought about clinically reliably reductions in disruptive behaviours and hyperactive/inattentive difficulties in comparison to the waitlist group. These improvements were maintained for over a year. Parental competence was also found to improve following the intervention in comparison to the waitlist group

Question 33

efficacy of incredible years program

Answer 33

(Daley et al., 2007, 2008).

The Incredible Years programme has also been found to be effective for preschool children presenting with early onset symptoms of both ADHD and conduct disorders. Recent research revealed that parents of the children who received the treatment reported lower levels of inattention and hyperactive/ impulsive symptoms in comparison to parentswhose children were in the control condition

Additionally, 52% of the treatment group in comparison to 21% of the control group demonstrated clinically reliable improvements following the intervention.
These improvements were maintained, as 57% of the children in the treatment group were found to be below the level of clinical concern on at a subsequent follow-up 18 months later (Daley et al., 2008)

Question 34

support for parent training in schoolage children

Answer 34

Daly et al., 2007- shown its efficacy by demonstrating its ability to reduce ADHD symptoms, improve parenting skills and decrease levels of family distress.

A large evidence base exists for the use of behavioural parent training interventions for school-age children with ADHD, oppositional defiant disorder (ODD) and conduct disorders (Pelham et al., 1998; Brestan &Eyberg, 1998).

Question 35

variability of effectiveness of parental training

Answer 35

Degree of variability of its success depending on number of factors.
• AGE- may be better for younger children with problems more related to compliance, rule-following, defiance and aggression (Kazdin & Weisz, 2003; Van den Hoofdakker et al., 1993).
• Less beneficial for ADHD children whose parents demonstrate ADHD symptoms (Harvey et al., 2003; Songuga-Barke et al., 2006)

Question 36

problems with parental training

Answer 36

• some parents dislike name parental training and deem that it is a term that implies fault of them in some way and that they lack parenting skills or are bad parents.
• Requires active parents who are involved and are willing to follow through the treatment
• Issues with any parent strategy, may not be useful past young childhood.

Question 37

conclusions of parental trainnig

Answer 37

Although most of these programmes have been developed for the treatment of conduct prob-lems as opposed to ADHD, it appears that parent training programmes are beneficial in the treatment of ADHD by helping parents become more competent at dealing with their child’s behavioural problems.–> this may be more useful in young age as issues in Attention may not be as visible as children are more watched and controlled by parents however may lead to treatment being less effective as the child becomes more independent.

Question 38

intro to CBT

Answer 38

CBT is a less common but potentially highly underrated method of treatment

Question 39

how is CBT treatment relevant to those suffering from ADHD

Answer 39

CBT is relevant for adults with ADHD in two ways. First, in recent years, CBT programs have been developed specifically for adults with ADHD. Some of these programs aim to help adults overcome their difficulties in everyday executive functions that are needed to effectively manage time, organize and plan in the short term and the long term. Other programs focus on emotional self-regulation, impulse control and stress management.

Additionally, it has been well established that adults with ADHD are more likely than adults in the general population to suffer from co-existing anxiety and depressive disorders. A large national study found 51% of adults with ADHD suffered from co-morbid anxiety and 32% suffered from co-morbid depression. Thus, treatments that incorporate CBT for these disorders may be quite helpful to many adults with ADHD, even though they are not designed specifically to address the symptoms and impairment associated with ADHD.

Question 40

support for CBT

Answer 40

Safren et al., 2005 compared CBT plus medication to a medication only group. CBT group demonstrated significantly greater improvements on scores of ADHD symptoms and also anxiety scores.
Rostain and Ramsey (2006) reported that a combined medication + CBT treatment. Seventy per cent of the participants in the combination treatment group showed moderate to significant improvements in ADHD symptoms. Furthermore, participants reported significant improvement in depression, anxiety and hopelessness score

Question 41

support for CBT in children

Answer 41

Durlak et al., 1991- meta-analysis concluded that CBT intervention may be helpful for children with behavioural and social mal-adjustment.
Froelich et al., 2002 controlled study showed that CBT may be helpful for the treatment of core symptoms in ADHD.

Question 42

recomendations as to when to stop parental therapy

Answer 42

NICE clinical guideline suggests up to 12-13 as treatment method.

Question 43

what are issues with CBT

Answer 43

CBT may only be effective when provided in combination with medication
RCT used controls receiving support with parents receiving psychoeducation and ADHD children who were not on medication and received CBT. Results showed that children in CBT group improved on parent ratings of hyperactivity and self-esteem however the children did not improve on parent or teacher ratings of inattention or impulsivity. (Roberts et al., 1991)

Question 44

what does clinical expererience say regarding the effect of CBT and medication

Answer 44

Clinical experience suggests that they have different effects: Whereas medication helps to control the core symptoms of distractibility, short attention span and impulsivity, CBT is more effective at increasing the habits and skills needed for executive self-management and may also serve to improve emotional and interpersonal self-regulation.

Question 45

overall conclusions of CBT

Answer 45

Overall: may be especially useful in treating ADHD patients with co-morbid symptoms of anxiety/ depression

Question 46

support for structured skills training

Answer 46

Preliminary studies of a structured skills-training programme based on the principles of Dialectic Behavioural Therapy have demonstrated improvements in severity of ADHD symptoms, depressive symptoms and personal health status (Hesslinger et al., 2002; Philipsen et al., 2007).
Furthermore, in the study by Philipsen et al. (2007), individuals who were also taking medication did not demonstrate any additional benefits compared with those who weren’t. Further controlled trials are required to confirm these encouraging initial findings

Question 47

what does structured skills training link to

Answer 47

Conduct disorder skills treatment