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Treatment%20of%20Attention%20Deficit%20Hyperactivity%20Disorder

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Title: Treatment%20of%20Attention%20Deficit%20Hyperactivity%20Disorder


1
Treatment of Attention Deficit Hyperactivity
Disorder
  • James H. Johnson, Ph.D., ABPP
  • University of Florida

2
Treatment of ADHD Basic Assumptions
  • ADHD is a chronic disorder and should be managed
    as such!
  • Elements of Chronic-condition care
  • Educating parents and child regarding the
    condition
  • Developing individual treatment plans
  • Helping coordinate multiple services
  • Encouraging parents to have contact with parents
    of other children with chronic conditions.
  • American Academy of Pediatrics (2005)

3
Treatment of ADHD Basic Assumptions
  • Treatment of ADHD will be based on a
    comprehensive assessment of the childs
  • core symptoms
  • comorbid conditions.
  • areas of impairment
  • Assessment to rule out mimics.
  • Physical exam
  • Evidence-based assessment measures (See Pelham,
    et al, 2005)

4
Treatment of ADHD Basic Assumptions
  • Treatments should take into account core
    symptoms
  • hyperactive/impulsive behavior
  • attention difficulties
  • The choice of treatment for core symptoms should
    be evidence-based (Pelham, et al 2008).
  • In choosing treatments - consideration should be
    given to treatment effectiveness and potential
    for side effects, considered within a
    risk/benefit framework.

5
Treatment of ADHD Basic Assumptions
  • Treatment should address areas of impairment.
  • These areas can include
  • academic impairment
  • social impairment
  • Impairments in adaptive behavior
  • impairments in family functioning.
  • DSM IV places a relatively greater emphasis on
    core symptoms compared to impairment
  • This may be a misplaced emphasis (Pelham, et al.
    2005)

6
Treatment of ADHD Basic Assumptions
  • DSM IV symptoms are not especially good
    predictors of long-term outcome
  • Symptoms are not usually the major reason for
    referral for treatment
  • In contrast, areas of impairment that are
    commonly seen in children with ADHD (academic,
    social, and family functioning are
  • predictive of negative long-term outcomes
  • are common reasons for referral
  • and can be thought of as target behaviors to be
    modified to improve current and long term
    functioning
  • Pelham, et al (2005)

7
Treatment of ADHD Basic Assumptions
  • Treatment plans should address relevant diagnosed
    comorbid conditions and co-occurring difficulties
  • In some instances comorbid conditions may be more
    closely related to long term negative outcomes
    than ADHD itself (e.g. Conduct Disorder)
  • Comorbid conditions may contribute to various
    types of impairment over and beyond ADHD core
    symptoms.
  • Multimodal treatments addressing core symptoms
    and comorbidities may be required to address the
    full range of factors that contributing to
    impairment.

8
Evidence-base for Treatments of ADHD
  • The assumption that treatments of children with
    ADHD should be evidence-based raises the question
    of
  • what treatments,
  • for what difficulties
  • are supported by empirical research?
  • These questions have been addressed by a summary
    of evidence-based treatments for ADHD undertaken
    by the American Academy of Pediatrics (2006).
  • This review was based on information provided by
    three major sources.

9
Evidence-base for Treatments of ADHD McMaster
Review
  • The first source was a review by the McMaster
    University Evidence-based practice Center.
  • Focused on studies of grade school children
    treated for gt 12 weeks.
  • Emphasis was on the efficacy (and safety) of
    pharmacological interventions with ADHD
  • The efficacy of single versus combined treatments
    of children with ADHD.
  • Stimulant drugs examined included methylphenidate
    (MPH), dexadrine (DEX) and pemoline (PEM -
    Cylert) as well as trycyclic antidepressants.

10
Evidence-base for Treatments of ADHD McMaster
Review
  • Review included 92 empirical articles reflecting
    78 investigations from a pool of 2,405 citations
    compiled from traditional databases.
  • Two reviewers independently rated articles to
    determine the quality of the methodology.
  • Studies were included in the evidence-based
    review if they were
  • randomized controlled trial studies
  • involved human subjects
  • published as a full report which included
    participants with ADHD.

11
Evidence-base for Treatments of ADHD McMaster
Findings
  • Drug-to-Drug Comparisons
  • Stimulant drug comparisons documented few, if
    any, overall differences between MPH, DEX, and
    PEM (Cylert)
  • Studies comparing different formulations of the
    same drugs found no significant effects.
  • Combined Interventions
  • MPH dexadrine, caffeine, desipramine (a TCA) or
    haloperidol and a single medication
  • behavior or cognitive therapy stimulant
    medication compared to single treatment
  • No evidence that non-pharmacological
    interventions alone (behavioral intervention)
    performed as well as the non-pharmacological
    intervention plus stimulant medication.

12
Evidence-base for Treatments of ADHD McMaster
Findings
  • Adverse Effects
  • Across studies the most frequent examples of
    adverse effects were appetite suppression, sleep
    disturbances, headaches, motor tics, abdominal
    pain, irritability , nausea, and fatigue.
  • Many of thee effects were mild, of short
    duration, and responsive to dosing or timing
    adjustments.
  • There were few if any differences in adverse
    effects across stimulants (MPH, DEX, PEM).

13
Evidence-base for Treatments of ADHD McMaster
Findings
  • Conclusions from this review
  • Stimulant medication significantly out performs
    non-pharmacologic interventions in controlling
    the core symptoms of ADHD.
  • There was insufficient information to conclude
  • whether drug combinations outperform stimulant
    medications alone, or
  • that non-pharmacologic interventions adds to drug
    treatment effects.

14
Evidence-base for Treatments of ADHD Canadian
Coordinating Office for Health Technology
Assessment (1998)
  • A second source of evidence-based research was
    reviewed by the Canadian Coordinating Office for
    Health Technology Assessment (1998)
  • Reviewed empirical evidence from 195 treatment
    studies of ADHD published after 1980
  • Studies were RCTs involving parallel group
    designs or within-subject crossover designs with
    participants randomly assigned, and involving
    children 18 or younger.
  • The review provided findings regarding
  • the efficacy of MPH in treating symptoms of ADHD
    and
  • the efficacy of combined interventions.

15
Evidence-base for Treatments of ADHD Canadian
Coordinating Office for Health Technology
Assessment (1998)
  • Review concluded that
  • Evidence consistently supports the efficacy of
    drug therapy in managing core symptoms of ADHD
  • No clear differences between MPH, DEX, and PEM.
  • Psychological/behavioral treatments without
    medication treatment were not efficacious in
    managing core symptoms of ADHD.
  • Combined therapy did not out perform medication
    alone, at least with core symptoms.
  • Finding were inconsistent with regard to the
    value of combining psychological/behavioral
    therapies with medications - as compared to drug
    therapies alone.

16
The Multimodal Treatment Study Background
  • Until fairly recently there were no well
    controlled long-term treatment studies in the
    area of ADHD.
  • There were many double-blind/placebo controlled
    studies, designed to assess the effects of
    various stimulant medications.
  • Results of these studies most often supported the
    use of these medications.
  • However, these studies were typically short
    duration studies.

17
The Multimodal Treatment Study Background
  • While such studies often provided support for the
    effectiveness of stimulant medications in
    treating ADHD, they provided little information
    regarding their long term effectiveness.
  • Likewise, there were few well-controlled studies
    on the relative effectiveness of different
    approaches to treatment of children with ADHD.
  • Little information was available regarding the
    long-term effectiveness of combined treatment
    approaches (e.g., stimulants and psychosocial
    interventions) in ADHD treatment.

18
The Multimodal Treatment Study Background
  • Late 1990s, NIMH sponsored a large multi-site,
    14 - month, investigation of the treatment of
    ADHD.
  • Multimodal Treatment Study of Children with ADHD
    ("MTA)
  • 18 nationally recognized authorities in ADHD.
  • At different university medical centers and
    hospitals
  • Goal To evaluate the effectiveness of leading
    treatments for ADHD notably stimulant drug and
    behavioral treatment.

19
Multimodal Treatment Study Background
  • Research sites included
  • New York State Psychiatric Institute at Columbia
    University, New York, N.Y.
  • Mount Sinai Medical Center, New York, N.Y.
  • Duke University Medical Center, Durham, N.C.
  • University of Pittsburgh, Pittsburgh, PA.
  • Long Island Jewish Medical Center, New Hyde Park,
    N.Y.
  • Montreal Children's Hospital, Montreal, Canada
  • University of California at Berkeley, CA.
  • University of California at Irvine, CA.

20
Multimodal Treatment Study Subject Recruitment
  • Only children determined to have Combined Type
    ADHD were included in the MTA study.
  • Children diagnosed with the hyperactive/impulsive
    subtype and inattentive subtype were excluded
  • This decision was made because the combined type
    is the most frequently diagnosed type of ADHD.
  • All in all, the study included 579 children ages
    7 to 9.9 years
  •  Approximately 20 were female and approximately
    the same percentage was African American.

21
The Multimodal Treatment Study Overview
  • After participants were identified, were
    determined to have meet study criteria,
    pre-treatment assessment measures were obtained,
    they were assigned at random to 1 of 4 treatment
    conditions.
  • medication alone
  • psychosocial/behavioral treatment alone
  • Combined treatment or
  • routine community care.
  • Fourteen months later, the participants were
    again assessed so that the impact of the
    different treatments could be evaluated.

22
The Multimodal Treatment Study Assessment
Measures
  • Primary ADHD symptoms - ratings provided by
    parents and teachers
  • Aggressive and oppositional behavior - ratings
    provided by parents, teachers, and classroom
    observers
  • Internalizing symptoms (e.g. anxiety and sadness)
    - ratings provided by parents, teachers, and
    children
  • Social skills - ratings provided by parents,
    teachers, and children
  • Parent-child relations - rated by parent
  • Academic achievement - assessed by standardized
    tests

23
The Multimodal Treatment Study Overview
  • The MTA Study was designed to answer three basic
    questions regarding the treatment of ADHD 
  • How do long-term treatments with medication and
    psychosocial (behavioral) interventions compare
    with one another?
  • Are there additional benefits of combining these
    two treatments in treating individual children?
  • What is the effectiveness of systematic,
    carefully delivered treatments vs. the way these
    treatments are usually applied in routine
    community care?

24
MTA Medication Alone Group
  • Children assigned to the Medication Management
    condition received drug treatment only.
  • Treatment 28-day, double-blind
    placebo-controlled trial in which the effects of
    4 different doses of short-acting methylphenidate
    were evaluated.
  • The doses tested were 5, 10, 15, and 20 mg.
  • Children received a full dose at breakfast and
    lunch, and a half-dose in the afternoon.
  • Parent and teacher ratings of children's behavior
    on each dose were compared by a team of
    experienced clinicians, and the best dose for
    each child was selected by consensus.

25
MTA Medication Alone Group
  • In this double-blind placebo-controlled trial,
    the child was administered actual medication on
    some days and a placebo during other days.
  • Neither the child, the teacher, nor the parent
    knew when the real medication was being received
    and when placebo was being given.
  • This was designed to insure that parent and
    teacher ratings of the child's behavior were not
    biased by the knowledge that the child was on
    medication.

26
MTA Medication Alone Group
  • If children did not show a response to
    methylphenidate in the initial trial, alternate
    medications were tested (non-double-blind
    procedures) in the following order until a
    satisfactory medication/dose was found
  • dextroamphetamine (the generic version of
    dexedrine),
  • pemoline (the generic version of Cylert), and
  • imipramine (a tricyclic antidepressant).

27
MTA Medication Alone Group
  • A total of 289 participants were initially
    assigned to receive medication in either the
    medication only condition or the combined
    condition.
  • A total of 256 (88.6) successfully completed
    this initial titration period used to select an
    effective medication.
  • In the case of the remaining children, parents
    either
  • refused to try their child on medication,
  • there were intolerable side effects, or
  • parents could not cooperate with the careful
    titration procedures.

28
MTA Medication Alone Group
  • An adequate response with at least one of the
    doses of methylphenidate was obtained for about
    69 of the children completing the initial
    medication trial - they began treatment on this
    dose.
  • Twenty-six children  who did not respond to
    methylphenidate were found to do well on
    dextroamphetamine and began on this medication.
  • A final 32 did not begin on any medication
    because they had such a strong placebo response
    that no clear benefits of medication could be
    demonstrated.

29
MTA Medication Alone Group
  • Monthly visits were scheduled during which time
    the provider for the child reviewed information
    about the child's behavior over the past month
    that had been provided by parent and teacher.
  • After reviewing this information, any needed
    dosage adjustments were made using predetermined
    guidelines.
  • Adjustments that involved increases or decreases
    of more than 10 mg/dose needed to be approved by
    a cross-site panel of experts.

30
MTA Medication Alone Group
  • At the end of the study, some 14 months later,
    approximately 74 of participants in the
    medication or combined treatment groups were
    being successfully maintained on methylphenidate.
  • 10 were being successfully maintained on
    dextroamphetamine.
  • 1 were being successfully maintained on Cylert.
  • Only two children were on any other type of
    medication.

31
MTA Medication Alone Group
  • Side effects were monitored monthly for all
    children who were on medication.
  • Over 85 of the sample reported either no or mild
    side effects.

32
MTA Medication Alone Group
  • It is important to note how different this
    approach to pharmacological treatment was from
    what often occurs in community treatment.
  • The primary differences are
  • the use of a double-blind trial to establish the
    best initial dose and type of medication for each
    child and,
  • regular follow-up visits to evaluate ongoing
    medication effectiveness based on parent and
    teacher reports
  • systematic adjustments made as needed.

33
MTA Medication Alone Group
  • Almost all children were effectively managed on
    one of the standard stimulants.
  • None required a combination of medications to
    effectively manage their ADHD symptoms.
  • This suggests that combination of mediations is
    rarely needed to treat ADHD, if a careful
    procedure is used to test out the different types
    of stimulants that are available. 

34
MTA Behavioral Treatment
  • Behavioral treatment included 1) parent training,
    2) child-focused treatment, and a 3)school-based
    intervention program.
  • Parent training involved a total of 27 group
    sessions and 8 individual sessions per family.
  • The focus was on teaching parents specific
    behavioral strategies to deal with the challenges
    that children with ADHD often present.

35
MTA Behavioral Treatment
  • The Child-focused Treatment was a summer
    treatment program that children attended for 8
    weeks, 5 days a week, during the summer.
  • This program employed intensive behavioral
    interventions that were administered by
    counselors/aides who were supervised by the
    therapists conducting the parent training.
  • The basic model was one in which children were
    able to earn various rewards based on their
    ability to follow well-defined rules and meet
    certain behavioral expectations.
  • Social skills training and specialized academic
    instruction was also provided.

36
MTA Behavioral Treatment
  • The School-based Treatment had 2 components
  • 10 to 16 sessions of biweekly teacher
    consultation focused on classroom behavior
    management strategies, and 12 weeks of a
    part-time aide who worked directly in the
    classroom with the child.
  • During the school year, a Daily Report Card was
    used to link the child's behavior at school to
    consequences at home.
  • The Daily Report Card was a 1-page
    teacher-completed rating of the child's success
    on specific behaviors.
  • This was brought home daily by the child to be
    reviewed by parents with rewards for a successful
    day provided as indicated.

37
MTA Behavioral Treatment
  • Consistent with what occurs in actual clinical
    practice, the family and child's involvement in
    behavioral treatment was gradually tapered over
    the 14 month period (Note BT stopped but meds
    not implications for findings??)
  • In most cases, contact had been reduced to once
    monthly or stopped altogether by the end of this
    period.
  • It can be noted that the behavioral treatment
    received here, reflects state-of-the-art practice
    that would be difficult for most children to get.
  • Thus, one would assume that the benefits of
    behavioral treatment seen here would likely be
    much greater than which would typically be
    obtained.

38
MTA Combined Treatment
  • Children in the combined treatment group received
    all of the treatments received by children in the
    Medication and Behavioral Treatment conditions.
  • Consistent with prior studies, by the end of the
    study, children in the combined group were being
    maintained on lower daily doses of
    methylphenidate than children who received
    medication alone.
  • Here, average doses were 31.2 mg/day for the
    Combined group and 37.7 mg/day for the Medication
    Only group.

39
MTA Community Treatment
  • As it would clearly be unethical to assign
    children with ADHD to a no-treatment control
    group for 14 months, some children were randomly
    assigned to a group that received "community
    care".
  • In this condition, following the child's
    diagnosis of ADHD, parents were provided with a
    list of community mental health resources and
    made whatever treatment arrangements they
    preferred for their child.

40
MTA Community Treatment
  • Most of the 97 children in this group (over 2/3)
    received medication from their own provider
    sometime during the 14 months.
  • Several things are interesting about the
    medication these children received compared to
    children who received medication as part of the
    study.
  • Community care children received less medication.
  • For those treated with methylphenidate, the
    average daily dose was 22.6 mg/day compared to
    the average daily doses of 31.2 mg and 37.7 mg
    for children in the other groups receiving
    medication.
  • Community care children received an average of
    2.3 doses per day compared to 3 times/day dosing
    for children in the study groups.

41
MTA Community Treatment
  • None of the children receiving medication in the
    study groups were maintained on clonidine or a
    combination of medications
  • 4 children seen by community physicians were
    treated with clonidine and 10 children received
    more than one medication.
  • Thus, physicians in the community were in some
    ways more conservative in their use of
    medication, using lower doses of methylphenidate.
  • But less conservative, being more likely to use
    medications other than the stimulants for
    treating ADHD.

42
MTA Research Questions
  • As noted earlier, the MTA study was designed to
    address 3 fundamental questions about ADHD
    treatment
  • How do long-term medication and behavioral
    treatments compare with one another in treatment
    effectiveness in children with ADHD?
  • Are there additional benefits when these two
    treatments are used together?
  • What is the effectiveness of systematic,
    carefully delivered treatments vs. routine
    community care in the management of ADHD?

43
MTA Overall Findings
  • Children in all groups (i.e. medication only,
    behavioral treatment only, combined treatment,
    and treatment in the community) showed
    significant reductions in their level of symptoms
    over time in most areas.
  • Even though some treatments were superior to
    others in certain domains, even children
    receiving the "least effective" treatment showed
    improvements.
  • Thus, these data should not be interpreted in a
    framework of "what worked" and "what did not
    work".
  • Rather, it is a matter of what was the most
    effective among treatments that showed positive
    effects.

44
Long-term Medication vs Behavioral Treatment
  • For both parent and teacher ratings of ADHD core
    symptoms, medication management alone was clearly
    superior to behavioral treatment alone.
  • Medication management and behavioral treatment
    did not typically differ significantly on other
    outcome measures.
  • While medication was found to be superior to
    behavioral treatment in managing core symptoms,
    these findings did not hold for other problems
    such as oppositional behavior, peer relations,
    internalizing behavior and academic achievement.

45
Combined vs Single Treatments
  • Combined Treatment Medication Management
    treatment did not differ significantly on any of
    the 6 domains assessed in this study.
  • This suggests that for most children with ADHD,
    adding behavioral intervention on top of
    well-conducted medication management is not
    likely to yield substantial incremental gains. 

46
Combined vs Single Treatments
  • However, when one looks at the rank ordering on
    different outcomes for children in the different
    groups, children in the combined treatment group
    did best on 12 of 19 outcome measures.
  • Those in the Medication Management group were
    best on only 4.
  • In addition, when the individual outcome measures
    were combined into composite measures, or when
    children's outcomes were grouped into Excellent
    Response vs. Less Dramatic Response
    categories,  children receiving combined
    treatment did modestly, but significantly,
    better.

47
Combined vs Single Treatments
  • Compared to Behavioral Treatment alone, Combined
    Treatment was found to be superior
  • on parent and teacher ratings of ADHD core
    symptoms,
  • on parent ratings of aggressive/oppositional
    behavior,
  • on parent ratings of children's internalizing
    symptoms,
  • and on results of the standardized reading
    assessment.
  • Thus, adding medication to the treatment of a
    child already receiving behavioral intervention
    is likely to yield additional benefits for most
    children.

48
MTA Treatments vs Community Care
  • Both Combined Treatment and Medication Treatment
    were superior to community care for parent and
    teacher reports of ADHD core symptoms,
  • Behavioral treatment was not.
  • In general, parents and teachers tended to report
    a decline of approximately 50 in inattentive and
    hyperactive/impulsive symptoms for children in
    the medication and combined treatment groups.
  • For children receiving community care, the
    declines reported were in the 25 range.
  • These were comparable to those reported for
    children receiving behavioral treatment.

49
MTA Treatments vs Community Care
  • In the non-ADHD domains, with children displaying
    oppositional behavior, internalizing symptoms,
    social skills deficits and reading problems,
    Combined Treatment was always superior to
    Community Based Treatment.
  • Here there were particularly dramatic differences
    in parent reports of oppositional and aggressive
    behavior.

50
MTA Treatments vs Community Care
  • These data indicate that, although children
    treated in the community made modest gains, those
    receiving medication treatment in the MTA study
    (either alone or in combination with behavioral
    treatment) did significantly better.
  • This was especially true for children receiving
    the combined treatments.

51
MTA Follow Up Analyses
  • The MTA research group also considered whether
    the effects of the different treatments may have
    varied depending on child characteristics.
  • Thus, they also looked at whether similar results
    were obtained
  • for boys vs. girls
  • for children with and without an additional
    diagnosis of either Oppositional Defiant Disorder
    (ODD) or Conduct Disorder (CD)
  • for children with and without a co-occurring
    Anxiety Disorder

52
MTA Follow Up Analyses
  • In general, there were no substantial differences
    in the effectiveness of the different treatments
    depending on these variables.
  • Similar treatment results were found for boys and
    girls and for children with and without a
    co-occurring behavior disorder.
  • There was some indication, however, that for
    children with a co-occurring anxiety disorder,
    behavioral intervention alone was as effective as
    both medication management and the combined
    treatment.

53
MTA Follow Up Analyses
  • It is also worth noting, however, that children
    with anxiety disorders, who received medication
    only, did not have a poorer response to
    medication than other children with ADHD.
  • Thus, findings from previous studies suggesting
    that children with ADHD and an anxiety disorder
    do not do as well on stimulant medication are
    contradicted by these results.

54
Impact of Treatment Adherence
  • In a final set of follow up analyses, the
    researchers also analyzed the results according
    to how children and parents were able to adhere
    to the prescribed treatments.
  • Here, children assigned to the Medication
    Management condition were divided into 2 groups
    depending on whether or not medication treatment
    was implemented as recommended and
  • Whether the family attended at least 80 of the
    scheduled follow-up visits where the effects of
    the medication could be monitored.

55
Impact of Treatment Adherence
  • For behavioral treatment, children were divided
    into 2 groups depending on whether or not
  • parents attended at least 75 of the scheduled
    parent group meetings,
  • the child attended at least 75 of the summer
    treatment program, and
  • whether the child and paraprofessional working
    with the child in the classroom were both present
    for 75 of the intended days.
  • If any one of these 3 conditions were not met,
    the behavioral treatment was not considered to
    have been implemented as intended.

56
Impact of Treatment Adherence
  • For the Combined Treatment group, families had to
    adhere to the guidelines for both Medication
    Management and Behavioral Treatment to be placed
    in the "as intended" group.
  • Otherwise, they were placed in a group that was
    judged to not have adhered to treatment as
    recommended

57
Adherence to Treatment Recommendations
  • One major item of interest is the percentage of
    families in the 3 MTA treatment conditions that
    were able/willing to adhere to treatment
    recommendations.
  • Acceptance/attendance was higher for the
    Medication Management treatment (78 of families
    completing treatment as intended) than in
    Behavioral Treatment (63) or Combined Treatment
    (61) groups.
  • Here it is noteworthy that, even when state of
    the art behavioral treatment is provided to
    families FREE, almost 40 of families were unable
    and/or unwilling to fully take advantage of it.

58
Treatment Adherence and Outcome
  • Regarding treatment adherence and child outcome,
    significant effects were found only for the
    Medication Management group.
  • Outcomes were significantly better for children
    where the recommended medication management
    procedure was followed more closely.
  • For the Behavioral and Combined Treatment
    conditions, outcome was not found to be related
    to degree of adherence.

59
Treatment Adherence and Outcome
  • Here, it has been suggested that the absence of
    an effect of adherence for the Combined Treatment
    group was likely due to the fact that parents and
    children failed to comply with the Behavioral
    treatment procedure.
  • And, that these children likely did as well as
    the "adherers" because of the benefits they
    derived from the medication.

60
Treatment of ADHD
  • Stimulant Medications
  • Other Medications
  • Psychosocial Treatments
  • Summer Treatment Programs
  • Educational Accommodations

61
Commonly Used Stimulant Medications
  • Ritalin
  • Concerta
  • Dexadrine
  • Adderall
  • Cylert (no longer prescribed)
  • Between 70 and 80 of children with ADHD respond
    positively to stimulant drugs.
  • Stimulant drugs represent an empirically
    supported treatment for core symptoms of ADHD.

62
New Approaches to ADHD Drug Delivery
  • The FDA has recently approved the Daytrana patch
  • This is a skin patch for the treatment of ADHD
    which was developed to help in the administration
    of ADHD drugs to children who find it hard to
    take pills or tablets.
  • The patch is a once-daily treatment for children
    6-12.
  • It delivers the active ingredient of Ritalin
    (methylphenidate) via the skin.
  • It is placed on the skin (hip) early in the
    morning and removed nine hours later.
  • It is applied, alternately, on the left and right
    sides of the hip (e.g. Monday - left, Tuesday -
    right, etc.)
  • The dosage comes in four strengths

63
NEW ADHD Medication Designed to Last All Day
  • Shire Pharmaceuticals has recently (2007)
    released Vyvanse, a new stimulant drug formulated
    as a once-daily medication.
  • Designed to last for up to 12 hours (after school
    coverage).
  • The medication has been shown to provide
    consistent ADHD symptom control throughout the
    day based upon parent reports in the morning
    (approximately 10am), afternoon (approximately
    2pm), and early evening (approximately 6pm).
  • Useful in controlling symptoms in the after
    school hours, to help child attend to homework
    and facilitate appropriate social behavior.

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Side Effects of Stimulants
  • Common side effects can include loss of
    appetite, weight loss, sleeping problems,
    irritability,
  • restlessness, stomachache, headache, rapid heart
    rate, elevated blood pressure, sudden
    deterioration of behavior
  • symptoms of depression with sadness, crying, and
    withdrawn behavior.
  • intensification of tics (muscle twitches of the
    face and other parts of the body), possible
    Tourettes and growth suppression.

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Side Effects (Cont.)
  • While side effects are always a possibility they
    are often
  • Transient in nature
  • The result of inappropriate medication levels
  • If one medication results in side effects,
    another might be used without side effects.
  • Sometimes other medications are used to minimize
    side effects.
  • Good clinical judgment by the clinician may help
    to minimize side effects.

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Some Examples of Non-Stimulants in ADHD Treatment
  • Non Stimulant ADHD Medication
  • Straterra - a norepinephrine reuptake inhibitor-
    selectively blocks the reuptake of
    norepinephrine, which increases its availability
  • Other Non Stimulant Drugs
  • Anti-depressants (e.g., Tofranil, Wellbutrin)
  • Anti-hypertensives (Clonidine)

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Psychosocial Treatments
  • Parent Training
  • Social Skills Training
  • Cognitive Behavioral Treatments.
  • Psychotherapy for comorbid conditions
  • Summer Treatment Program

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Summer Treatment Program
  • For 5-14 years old children's behavioral,
    emotional, and learning problems.
  • This program is composed of a set of
    evidence-based treatments incorporated into an
    8-week therapeutic summer day camp setting.
  • Group and tailored individual treatment plans are
    implemented by trained paraprofessionals under
    the supervision of experienced senior staff
    members.
  • Group sessions consist of 15 children paired with
    4 clinical staff members for the duration of the
    day, encouraging development of group interaction
    and friendships.
  • Group activities include two hours in behavioral
    modification sessions conducted by developmental
    specialists.
  • Sessions focus on treatment of problem behaviors
    in a classroom context, and may include
    individualized and computer-assisted instruction,
    as well.
  • The remainder of each day consists of
    recreationally-based, age-appropriate games and
    group activities, with implementation of a
    variety of integrated treatment components.

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Summer Treatment Programs
  • Goals
  • Development of the child's problem solving and
    social skills, and social awareness to enable
    him/her to get along better with other children
  • Improvement of the child's learning skills and
    academic performance
  • Development of the child's abilities to follow
    instructions, to complete tasks, and to comply
    with adults' requests
  • Improvement of the child's self-esteem by
    developing competencies such as in interpersonal,
    recreational, academic, and other task-related
    areas
  • Instruction of parents in how to develop,
    reinforce, and maintain these positive changes
  • If appropriate, evaluation of the effects of
    medication on the child's academic and social
    functioning in a natural setting

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Summer Treatment Program
  • Treatment Includes
  • individually adapted reward and response-cost
    programs
  • training in group problem solving, social , and
    contracting skills
  • instruction in overcoming learning deficits
  • strategies for improving concentration, task
    completion, and self concept
  • time out, and a daily feedback system
  • Treatment plans and strategies are continuously
    monitored and modified as necessary.

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Summer Treatment Programs
  • Research suggests that children who participate
    in summer treatment programs typically make gains
    in a wide range of areas
  • Such treatment programs appear to -
  • improve children's relationships with peers,
  • their interactions with adults,
  • their academic functioning,
  • and their level of self-esteem.

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Educational Interventions
  • Special Education Services for existing learning
    disabilities.
  • Classroom accommodations (504 Plans).
  • Classroom behavior modification programs.
  • School-Home Behavior Report Card

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Treatment Concluding Comments
  • In treating ADHD it is essential to treat the
    full range of difficulties that impact on child
    and family functioning.
  • Treatment of ADDH will often need to be
    multimodal in nature.
  • Findings from the Multimodal Treatment Study
    suggest that
  • Stimulant medication is effective in reducing
    core symptoms
  • Psychosocial treatments are of value in
    addressing associated comorbidities.

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