2. CREDITS
Attention-Deficit/Hyperactivity Disorder
(ADHD)
At the Leading Edge
Program Directors:
Emmett Francoeur, MD, FRCPC Samuel Chang, MD, FRCPC Grazyna Jackiewicz, MD, FRCPC
Associate Professor, Clinical Associate Assistant
McGill University Professor, University of Calgary Professor, Pediatrics, McMaster
Director, Child Development Director, Adolescent Substance University
Program, McGill University Abuse & Psychiatric Disorders Clinic Consulting Pediatrician in
Health Center Psychiatrist, Foothills Medical Developmental/Behavioural
Westmount, Quebec Centre Pediatrics, American Board Certified
Calgary, Alberta Chedoke Developmental/
Behavioural Clinic,
Hamilton, Ontario
Private Practice,
Niagara Falls, Ontario
5. ADHD is Most Likely Caused by a
Complex Interplay of Factors
Neuroanatomic
Genetic origins
Neurochemical
ADHD
Environmental
factors CNS insults
Swanson JM, et al. Mol Psychiatry. 1998;3(1):38-41. Swanson JM, et al. Lancet. 1998; 351(9100):429-33. Milberger S, et al. Biol Psychiatry. 1997;41(1):65-
75. Castellanos FX, et al. Arch Gen Psychiatry. 1996;53(7):607-16. 5
6. ADHD Impacts Domains of Function
Difficulty With:
Before
School After School Bedtime
School
• Waking up • Lower grades • Sports/Clubs • Bedtime prep
• Getting ready for • Lack of focus • Homework • Settling down
school • Disruptive • Risky behavior and falling asleep
• Struggling • Difficulty with and injuries
excessively friendships • Sitting through dinner
with parents
• Family interactions
Barkley RA, et al. J Am Acad Child Adolesc Psychiatry. 1990;29(4):546-57. Barkley RA. J Clin Psychiatry. 2002;63(Suppl 12):S10-5. DuPaul GJ, et al. J Am
Acad Child Adolesc Psychiatry. 2001;40(5):508-15. Greenhill LL. J Clin Psychiatry. 1998;59(Suppl 7):S31-41. Weiss G, et al. J Am Acad Child Psychiatry 6
1985;24(2):211-20.
7. ADHD Impacts Social Functioning
Problems
• Problems with the justice system
• Family conflicts
• Early and impulsive sexuality
+ ADHD • Tobacco and substance abuse
• Accidents and injuries
• Interpersonal difficulties
• School and professional difficulties
American Academy of Pediatrics. Pediatrics. 2000:105(5);1158-70. Barkley RA, et al. Clinical Child and Family Psychology Review. 2002;5(2):89-111.
Barkley RA. In: Barkely RA, ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition. New York; Guilford, 7
2006.
8. Evidence for Frontal Lobe Deficits
•Deficits on Executive Function Tests
•Less Frontal Electrical Activity (QEEG, EEG, EP)
•Reduced Blood Flow to Frontal and Striatal Regions
(SPECT; Altropane Uptake)
•Diminished Frontal and Striatal Metabolic Activity
(PET and fMRI)
•Smaller Frontal-Basal Ganglia-Cerebellar Areas (MRI)
8
10. Executive Functions Often
Impaired in ADHD
Executive Functions
Organizing Focusing, Regulating Managing Utilizing Monitoring
prioritizing, sustaining alertness, frustration working and self-
and focus, and sustaining And memory regulating
activating shifting effort, and modulating And action
to work focus to processing emotions accessing
tasks speed recall
1. 2. 3. 4. 5. 6.
Activation Focus Effort Emotion Memory Action
Brown TE. 2001. Manual for Attention Deficit Disorder Scales for Children and Adolescents. 10
11. Clinical Presentation of ADHD in
Adolescents
ADHD Symptoms in Adolescents
May have a sense of inner Procrastinates and displays
restlessness rather than hyperactivity disorganized school work with poor
follow-through
Fails to work independently Poor peer relationships
Poor self-esteem
Inability to delay gratification Specific learning disabilities
Behaviour not usually modified by Engages in ―risky‖ behaviour
reward or punishment (speeding, unprotected sex, substance
abuse)
Apparent disregard for own safety Difficulties or clashes with authority
(injuries and accidents)
Greenhill LL. J Clin Psych. 1998;59(Suppl 7):31-41.
11
12. Persistance of Disorder
•Symptoms decrease somewhat with age
•Adolescence: (Based on Parent reports)
•50% persistence to adolescence (1970-80s)
•70-80% in modern DSM studies (1990s onward)
•Young Adulthood (age 20-26) (Barkley et al. 2002)
•Depends on who you ask (self vs. parents)
•3-8% Full disorder (self-report using DSM III R
•46% Full disorder (parent reports using DSM III R)
•12% - Using 98th percentile (+2SDs; self-report)
•66% - Using 98th percentile (parent report)
•Parent reports have greater veracity—they correlate more highly with various domains
of major life activities than do self reports
•85-90% remain functionally impaired
Barkley RA. 2003. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment
12
13. Role of teachers
• Observer
• Reporter (report cards)
• Manager
• Parent liaison
• Health Care liaison
• Monitor
13
14. ADHD Management Goals
• Treat ADHD throughout the lifespan
• Treat symptoms throughout the full day in
multiple areas of a patient‘s daily life
No longer sufficient to treat during the school
day or work hours
• Develop collaboration between home and
school
Connor DF. In: Barkley RA, ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition. New
York; Guilford, 2006. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice 14
Guidelines, First Edition. Toronto, ON; CADDRA, 2006.
15. ADHD Management Strategies
• Psychoeducation
Give local resources, written material and web based
resources
• Psychosocial interventions
Classroom intervention, family counselling, support
groups
• Medications
Mainstay of treatment, single most effective
intervention, safe, effective and non addictive
Not for children less than 6 years old (certain
exceptions apply)
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
Toronto, ON; CADDRA, 2006. 15
16. MTA Study: Objective and Design
Objective: To compare the long-term efficacy of pharmacotherapy,
behavioral therapy, and combination therapy in the treatment of ADHD.
Medication management
(primarily methylphenidate)
579 Children
ADHD, Combined type
Age Range: 7-9.9 years Behavioral treatment
Randomly assigned
14-month study Combination treatment: medication
and behavioral therapy
Routine Community Care
MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-1086.
16
17. MTA RESULTS
A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. The MTA Cooperative Group
17
ARCH GEN PSYCHIATRY/VOL 56, DEC 1999
18. MTA Study: Conclusions
• Combined treatment and medication management were more
effective than behavioral treatment and community care in
reducing ADHD core symptoms:
Inattention
Hyperactive-impulsive behavior
• Patients in the combined treatment group experienced:
1. No significant difference in core ADHD symptoms vs. those in
the medication management group
2. Improvements in core ADHD symptoms at a lower dose than
patients in the medication management group
3. Modest advantages in non-ADHD symptoms and positive
functioning outcomes vs. patients in the medication
management group
MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-86.
18
19. Medication Selection Considerations
• Earlier medication response
• Desired duration of action
• Patient and parent preference of medication
• Age of patient
• Side effect profile
• Efficacy of response
• Cost
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
Toronto, ON; CADDRA, 2006. 19
25. ADHD Therapeutic Options
Two Main
Classes of Medication
Stimulant Non-stimulant
Methylphenidate
• Ritalin® Atomoxetine
• Concerta® • Strattera®
• Biphentin®
Amphetamines
• Dexedrine® Spansule
• Adderall® XR
• Vyvanse ®
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
Toronto, ON; CADDRA, 2006. 25
26. Mechanism of Action of ADHD
Medications
Stimulant Atomoxetine
Norepinephrine
Presynaptic neuron Presynaptic neuron
Dopamine
Norepinephrine
reuptake pump
Dopamine
reuptake pump
STM Stimulant
A Atomoxetine
Postsynaptic neuron Postsynaptic neuron
26
27. 1st Line Medications for ADHD Simple
(Children)
FIRST LINE AGENTS – Long-acting preparations
Brand Name Dosage Starting Titration Schedule Every 7 Maximum daily
(Generic) Form Dose days* (up to 40 kg child)
Product CADDRA Product CADDRA
Monograph Board Monograph Board
Adderall® XR 5, 10, 15, 20, 10 mg qam ↑5 -10mg ↑5 -10mg 30 mg 30 mg
(amphetamine mixed 25, 30 mg cap
salts)
Concerta® 18, 27, 36, 54 18 mg qam ↑18 mg ↑18 mg 54 mg 72 mg
(methylphenidate HCl) mg tab
Strattera® * 10, 18, 25, 40, 0.5 0.8 mg/kg/d at wk 3 Same Lesser of 1.4 mg/kg
(atomoxetine HCl) 60 mg cap mg/kg/d 1.2 mg/kg/d at wk 5 Same /day or 60 mg/day
Biphentin® 10, 15, 20, 30, 10-20 mg ↑ 10 mg ↑ 10 mg 60 mg 60 mg
(methylphenidate HCl) 40, 50, 60 mg qam
cap
Vyvanse ® 20, 30, 40, 50, 20-30 mg By clinical ↑ 10 mg 60 mg 60 mg
(lisdexamfetamine 60 qam discretion
Dimesylate) mg tab
*atomoxetine every 10 days; clinicians may opt to titrate every 14 days (practicality)
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines,
Third Edition. Toronto, ON; CADDRA, 2011. 27
28. 2nd Line / Adjunctive Medications for
ADHD Simple (Children)
SECOND LINE/ADJUNCTIVE AGENTS – Short-acting & moderate-acting preparations
Brand Name Dosage Starting Titration Schedule Maximum daily (up to
(Generic) Form Dose Every 7 days 40 kg child) CADDRA
Dexedrine® 5 mg tab 2.5 – 5 mg q ↑2.5 -5 mg 40 mg 20 mg
(dextro-amphetamine am and q noon (add q4pm dose)
sulphate)
Dexedrine® Spansule* 10, 15 mg 10 mg q am ↑10 mg 40 mg 30 mg
(dextro-amphetamine cap
sulphate)
PMS® or Ratio® - 5, 10, 20 mg 5 mg q am and ↑5 mg 60 mg 60 mg
methylphenidate tab q noon (add q4pm dose)
Ritalin® 10, 20 mg tab 5 mg b.i.d. to ↑5 - 10 mg 60 mg 60 mg
(methylphenidate HCl) t.i.d. (add q4pm dose)
Ritalin® SR† 20 mg tab 20 mg q am ↑20 mg 60 mg 60 mg
(methylphenidate HCl) (add p2pm dose)
*Dexedrine® Spansule may last 6-8 hours
†Ritalin® SR may help cover the noon period but clinical experience suggests an effect similar to short-acting preparations
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition.
Toronto, ON; CADDRA, 2011. 28
29. 3rd Line Medications for ADHD Simple
(Children)
THIRD LINE AGENTS - Off-label treatments for ADHD used in treatment failure
Titration Maximum daily
Brand Name Dosage Starting Schedule (up to 40 kg
(Generic) Form Dose Every 7 days child)
Apo®-imipramine* 10, 25, 50, 75 25 mg ↑25 mg 150 mg
mg tab
Wellbutrin® SR 100, 150 mg 100 mg qam Add 100 mg qhs 200 mg
(bupropion) tab
*Tofranil is not recommended due to inadequate dose forms. Sometimes imipramine is used if mood problems and
ADHD symptoms coexist. Imipramine is metabolized to desipramine which is an effective noradrenergic agonist.
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
Toronto, ON; CADDRA, 2006. 29
30. Benefits
• Attention Span
Reduced distractibility, improved concentration
Improved organizational skills
• Activity levels
Reduced restlessness, fidgeting, hyperactivity
• Impulse control
Improved patience
Reduced verbal and physical impulsive actions
Reduced frequency and intensity of emotional
reactivity 30
31. Adverse Effects
• Reduced appetite, potential weight loss
• Insomnia, difficulty to awaken in a.m., cycle
• Stomach aches
• Irritability
• Rebound; wear off of meds
• Less talkative, stares, ‗zombie‘
• Tics
• Skin picking
31
32. Diagnosis and Monitoring
The SNAP-IV Short Rating Scale
For each item, check the column that best describes this child: Not At Just A Quite Very
All Little A Bit Much
1. Often fails to give close attention to details or makes careless
mistakes in schoolwork or tasks ____ ____ ____ ____
2. Often has difficulty sustaining attention in tasks or play activities ____ ____ ____ ____
3. Often does not seem to listen when spoken to directly ____ ____ ____ ____
4. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties ____ ____ ____ ____
5. Often has difficulty organizing tasks and activities ____ ____ ____ ____
6. Often avoids, dislikes, or reluctantly engages in tasks requiring
sustained mental effort ____ ____ ____ ____
7. Often loses things necessary for activities (e.g. toys, school
assignments, pencils, or books) ____ ____ ____ ____
8. Often is distracted by extraneous stimuli ____ ____ ____ ____
9. Often is forgetful in daily activities
32
33. Diagnosis and Monitoring
For each item, check the column that best describes this child: Not At Just A Quite Very
All Little A Bit Much
10. Often fidgets with hands or feet or squirms in seat ____ ____ ____ ____
11. Often leaves seat in classroom or in other situations in which
remaining seated is expected ____ ____ ____ ____
12. Often runs about or climbs excessively in situations in which
it is inappropriate ____ ____ ____ ____
13. Often has difficulty playing or engaging in leisure activities quietly ____ ____ ____ ____
14. Often is ―on the go‖ or often acts as if ―driven by a motor‖ ____ ____ ____ ____
15. Often talks excessively ____ ____ ____ ____
16. Often blurts out answers before questions have been completed ____ ____ ____ ____
17. Often has difficulty awaiting turn ____ ____ ____ ____
18. Often interrupts or intrudes on other (e.g. butts into conversations/
games) ____ ____ ____ ____
33
34. Scoring
The 4-point response is scored 0 – 3 (Not at All= 0, Just A Little = 1, Quite A Bit = 2, and Very Much
= 3). Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the
specific subset (eg., Inattention) and dividing by the number of items in the subset (eg., 9). The
score for any subset is expressed as the Average Rating-Per-Item.
Rating Scales II: SNAP scoring Tentative 5% cutoffs
Teachers and Parents
ADHD-Inattentive (1-9) Mean Total
T 2.56 23
P 1.78 16
ADHD-Hyperactive/Impulsive (10-18)
T 1.78 16
P 1.44 13
34
36. Managing Medication Outcomes
Therapeutic Response
Good Poor
• Treat the side effects or • Reconsider diagnosis or switch to
reassure & observe if side another first line agent
effects persist • If diagnosis is correct, switch to a
• Slightly lower the dose second line agent
• Slightly lower the dose & High
supplement with short-acting
agent Adverse
• Switch to another first line Effects
agent
• Continue therapy • Reconsider diagnosis
• If diagnosis is correct, raise the
dose or switch to another agent Low
• Validate patient adherence
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
Toronto, ON; CADDRA 2006. 36
37. Resources
Support Groups
Look for support groups in your area on the CADDAC website (www.caddac.ca)
under Resources.
Websites
Canadian ADHD Resource Alliance (CADDRA) – www.caddra.ca
Centre for ADD/ADHD Advocacy, Canada (CADDAC) – www.caddac.ca
Attention Deficit Disorder Association (ADDA) - www.add.org
Answers to your questions about ADHD (Patricia O. Quinn, MD and Kathleen
Nadeau, PhD) - www.ADDvance.com
Online catalogue of ADHD resources – www.addwarehouse.com
Quebec-based Dr Annick Vincent's ADHD website - www.attentiondeficit-
info.com
Children and Adults with Attention Deficit Hyperactivity Disorder – www.chadd.org
Connecting doctors, parents and teachers – www.myadhd.com
Online planner - www.skoach.com
Totally ADD – www.totallyadd.com
37
38. GOALS
• Effectiveness
• Duration
• Minimal Adverse Effects
• Management of Adverse Effects
• Regular monitoring
• Individualized schedule
• Happy well functioning child/ adolescent
• The ‗Science of effectiveness‘ for teens
• Personal responsibility for one‘s own ADHD
38
39. ADHD Assessment Instruments/Tools
• The following websites contain various types
of ADHD testing tools:
www.neurotransmitter.net/adhdscales.html
www.massgeneral.org/schoolpsychiatry/screenin
gtools_table.asp
SNAP-IV: www.adhdcanada.com/pdfs/SNAP-
IVTeacherParetnRatingScale.pdf
Weiss Functional Impairment Scale:
http://www.caddra.ca/english/pdfs/Child_7.pdf
39
41. True or False?
1. The best way to arrive at the correct dose of stimulant medication is by
adjusting it to the weight of the child.
2. Structured classrooms are useful locations for observations about
ADHD features and responses to medication.
3. Three times daily medication administration is usually best because
fine adjustments can be made for each dose.
41
42. True or False?
1. The best way to arrive at the correct dose of stimulant medication is by
adjusting it to the weight of the child. FALSE
Clinical response of each individual child is the best indicator for adjusting
medication.
2. Well structured classrooms are useful locations for observations about
ADHD features and responses to medication. TRUE
Settings with looser structure allow enough variation in activities that many
features of ADHD may be far less noticeable.
3. Three times daily medication administration is usually best because
fine adjustments can be made for each dose. FALSE
Single long acting doses tend to work more smoothly for the child through
out the full day and have reduced potential for adverse effects.
42
43. Oppositional Defiant Disorder
• Review the DSM IV TR
• Primarily an environmentally determined
disorder
• Major predisposing factor—ADHD
• Can be confused with normal developmental
stage of development of autonomy—ages 2-3
43
44. The Non Compliance Cycle
Parent
commands
Other
Parent interactions
Repeats Compliance
command
Loop repeats
3 to 7 times
Compliance
Parent
threatens
Loop repeats
3 to 7 times
Compliance
Parent
Acquiescence
?
Aggression
Presentation by Barkley R. Original research, by Patterson G (?)
44
45. Three Pathways to Boys’ Problem
Behaviour and Delinquency.
AGE OF % BOYS
ONSET
Few
Late
VIOLENCE MOD. To
(rape, attack SERIOUS
Strong arm) DELINQUENCY
(fraud, burglary,
Serious theft)
PHYSICAL FIGHTING PROPERTY DAMAGE
(physical fighting, (vandalism, fire setting)
Gang fighting)
AUTHORITY
AVOIDANCE
MINOR AGGRESSION (truancy, MINOR COVERT BEHAVIOR
(bullying, annoying others) Running away, (shoplifting, frequent lying)
Staying out late)
OVERT PATHWAY COVERT PATHWAY)
DEFIANCE/ DISOBEDIENCE
Many
Early
STUBBORN BEHAVIOUR
AUTHORITY CONFLICT PATHWAY
(before age 12)
Loeber R &Hay. Three developmental pathways to serious disruptive behaviours.
45
46. The Benefits of Treatment? One Study
• Retrospective study of 25 adolescents age 15 at a Toronto residential
setting:
• Start of problems:
Age 4.7 years
First intervention age 6.48 years
Average number of CD symptoms: 5
• Age 16
15.6 Agencies
Average 8 months / agency
18.9 interventions
Average 7 months / intervention
Number of schools – 6.88
Average number of CD symptoms: 10.16
Shamsie J. Conference on Conduct Disorder, Vancouver BC 1990. Later literatrue noted in following article.
Shamsie J, Hamilton H, Sykes C. Can J Psychiatry 1996; 41:211-216. The Characteristics and Intervention Histories of Incarcerated and Conduct- 46
Disordered Youth
47. Managing
Disruptive Behavioral Disorders
1. Program Infrastucture
Cognitive Behavioral Approach
2. Assess and Manage
Token Economy
Therapeutic Classroom
3. Skill Building
Relaxation
Psycho-educational Anger Management
4. Classical Therapy (Blind Trials)
Social Skills
Medication Anxiety Management
Individual
Activity Based Unstructured Time
5. School Preparation ADL/ Recreation
Occupational/
Family
Behavioral Management
6. Child Computerized (CPT, Dominic)
Management Training
Group
Medication Observation
Parents – Mandatory
Report Cards
7. In the Cooperative Activity
Teachers .
Community
Child- Individual
SchoolVisits
Family Anxiety takers
Home - Social
8. Case Conferencing Work
Associated Care
School Visits
Parenting Schools
Community
Parents & Teachers–
Individual Parent
Community Child / 1 way mirror
Observe Agencies (Health, FCS, Others)
47
48. Adapted from: The Discipline Pyramid. From McMahon, Slough, and Conduct Problems Prevention 48
Research Group (1996). Copyright 1996 by Sage Publications, Inc.
Notas do Editor
QEEG - Quantitative ElectroencephalographyEP - Evoked PotentialsSPECT – Single Photon Emission Computed TomographyMRI - Magnetic Resonance ImagingAltropane – small molecule that binds with extremely high affinity and specificity to dopamine transporters