Psychological treatments in ADHD ExplanationSupport Behaviour therapy Cognitive therapies Counselling about medication Eric Taylor: King’s College London.
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Psychological treatments in ADHD
Psychological treatments in ADHD
ExplanationExplanationSupport Support
Behaviour therapyBehaviour therapyCognitive therapiesCognitive therapies
Counselling about medicationCounselling about medication
Eric Taylor: King’s College London Institute of Psychiatry
No competing interests; acknowledgements to NICE Guidelines Development Group
What is it like to have ADHD?What is it like to have ADHD?
““My thoughts are in a muddle”My thoughts are in a muddle” (usually only after treatment shows the difference)(usually only after treatment shows the difference)
““I get into trouble a lot, I don’t know why”I get into trouble a lot, I don’t know why” ““Other kids pick on me”Other kids pick on me” ““Ive got a bad temper”, “I cant concentrate”, “Ive Ive got a bad temper”, “I cant concentrate”, “Ive
got ADHD” got ADHD” (usually repeating what they have been told)(usually repeating what they have been told)
What do patients ask for?What do patients ask for?
Understanding by othersUnderstanding by others Knowledge of futureKnowledge of future Stop the bullyingStop the bullying Appreciation of the positiveAppreciation of the positive Time to talk with doctorTime to talk with doctor
Which one is most similar?Which one is most similar?
Which one is most similar?Which one is most similar?
1 2 3
4 5 6
Which one is most similar?Which one is most similar?
Choosing the immediate reward
?
1 p
2 p30 sec
Choosing the immediate reward
?
1 p
2 p30 sec
?
?
1 p 1 p 1 p
? ?
?
1 p 1 p 1 p
? ?
2 p
?
Post - reward delay
?
1 p 1 p
?
2 p
?
30 sec
Education should be widespreadEducation should be widespread
ChildrenChildren ParentsParents GrandparentsGrandparents SiblingsSiblings ClassmatesClassmates TeachersTeachers And increasingly for adult patients …And increasingly for adult patients …
Spouses, partners, employersSpouses, partners, employers
Key messagesKey messages
A real and potentially disabling conditionA real and potentially disabling condition Consider as a chronic disorderConsider as a chronic disorder Families, peers and teachers can help ++Families, peers and teachers can help ++ Many affected people make good adult Many affected people make good adult
adjustmentadjustment Medication helps but does not cureMedication helps but does not cure
Shaping the EnvironmentShaping the Environment
Longitudinal evidence from Newham studiesLongitudinal evidence from Newham studies All 7-year-old boys (3,215) identified from All 7-year-old boys (3,215) identified from
school rolls and health recordsschool rolls and health records Parent & teacher Rutter scales for 2,462Parent & teacher Rutter scales for 2,462 Stratified behaviorally into HA, Def, Inatt, Stratified behaviorally into HA, Def, Inatt,
Mixed & ControlMixed & Control Random selection of 50 in each groupRandom selection of 50 in each group Detailed interviews & tests: Detailed interviews & tests:
91%compliance91%compliance
Taylor, Sandberg, Thorley, Giles (1991) Maudsley Monograph No. 33
Outcome measuresOutcome measures
Parental interview ratingsParental interview ratings Psychiatric interview with youthsPsychiatric interview with youths Cognitive testingCognitive testing Home Office records of offendingHome Office records of offending School recordsSchool records Case conference diagnosisCase conference diagnosis
88% follow-up 10 years later; nonresponders similar to responders
Hyperactivity & conduct disorder
Age 7
Age 17
HA CDMixed
HA Mixed CD
Hyperactivity & conduct disorder
Age 7
Age 17
HA CDMixed
HA
Hostile parental EE
Not part of a peer group
Hyperactivity & conduct disorder
Age 7
Age 17
HA CDMixed
Age 27
Basic handling framework for parents – before specific therapyBasic handling framework for parents – before specific therapy Appropriate expectationsAppropriate expectations Positive attending to childPositive attending to child Effective communicationEffective communication
Obtain attention; simple instructionObtain attention; simple instruction Listen; figure out meaning of outburstsListen; figure out meaning of outbursts
Structuring the child’s dayStructuring the child’s day Rule-governed atmosphereRule-governed atmosphere Talking with teacherTalking with teacher KEEPING CALMKEEPING CALM
Specific approaches: Behaviour TherapySpecific approaches: Behaviour Therapy
Principles of behavioural treatmentPrinciples of behavioural treatment Identify specific problemsIdentify specific problems Analyse contingencies; Analyse contingencies; reward & response cost reward & response cost
rather than extinctionrather than extinction Enhance adult attending Enhance adult attending Teach effective instructionTeach effective instruction Token economy + response cost (frequent) Token economy + response cost (frequent)
or time-out + rapid novel rewardsor time-out + rapid novel rewards Include self- managementInclude self- management
Principles of behavioural treatmentPrinciples of behavioural treatment Identify specific problemsIdentify specific problems Analyse contingencies; Analyse contingencies; reward & response cost reward & response cost
rather than extinctionrather than extinction Enhance adult attending Enhance adult attending Teach effective instructionTeach effective instruction Token economy + response cost (frequent) Token economy + response cost (frequent)
or time-out + or time-out + rapid novel rewardsrapid novel rewards Include self- managementInclude self- management
Interventions in the classroomInterventions in the classroom
Proximity to teacherProximity to teacher Managed transitionsManaged transitions Pacing & letting off energyPacing & letting off energy Classroom aideClassroom aide
operant conditioningoperant conditioning peer advicepeer advice
Rule governmentRule government Clarity of goal & speed of feedbackClarity of goal & speed of feedback Understanding disorder (eg projects)Understanding disorder (eg projects) Monitoring medicationMonitoring medication
Some common-sense procedures – avoiding distractors and short-chunk learning – don’t yet have trial evidence
Learning social skills in peer groupLearning social skills in peer group
Listen to othersListen to others Join play graduallyJoin play gradually Learn the rulesLearn the rules
Avoid intrusiveness and excessive demandsAvoid intrusiveness and excessive demands
Figure out why others reactFigure out why others react Control angerControl anger Learn how to refuse kindlyLearn how to refuse kindly
Especially drugsEspecially drugs
But do behavioural treatments work?
I. The MTA study
But do behavioural treatments work?
I. The MTA study
Study
Treatments
Basel
ine,
7-9
.9 y
rs
8 Yea
rs
6 Yea
rs
36 M
os, 1
0-14
yrs
24 M
os, 9
-12
yrs
14 M
os, 8
-12
yrs
10 Y
ears
LNCG (n=289) added here
36 Month Findings on Substance Use
Molina et al
Assessment Points
Baseline EarlyTreatment
(3 m)
Mid-Treatment
(9 m)
End ofTreatment
(14 m)
FirstFollow-up
(24 m)
SecondFollow-up
(36 m)
14-m Treatment
Phase
10-m Follow-up
Phase
22-m Follow-up
Phase
0 362414
Month
RecruitmentScreeningDiagnosis
RANDOM
ASSIGNMENT
579 Subjects7 to 9 yrs old
ADHD-Combined
MedMgt144 Subjects
Beh144 Subjects
Comb 145 Subjects
CC 146 Subjects
Observation 1 LNCG Group
Pre-Baseline
Observation 2 LNCG Group
Jensen et al, 2007Intent-to-treat (ITT) Analysis Jensen et al, 2007Intent-to-treat (ITT) Analysis
Randomized Clinical Trial at 14-month assessment: Transition to Naturalistic Follow-up at the 24-month & 36-month Assessment
MTA Group, 1999a,b
MTA Group, 2004a,b
Towards consensus in clinical practice
Stage Example
Recommendations “Seek underlying causes before prescribing”
Guidelines “Assess learning difficulties, family history, peer relations, stress history”
Protocols “100% of referred cases are evaluated by child psychiatrist giving individual interview”
Towards clinical guidelines
Review Trial results Expert Review
Metaanalysis
Draft of
recommendations
Critique Clinical Literature
RefereeExpert panel
Recommendations
Modulation Acceptability
Cost
Subgroups
Users
Purchasers
Field trial
Guidelines
Modification Local factors Providers
+ purchasers Protocols
Stage Information Source Result
Organisation of NICE processOrganisation of NICE process
Professional teamProfessional team Systematic reviewersSystematic reviewers Health economistsHealth economists SecretariatSecretariat ImplementersImplementers
PanelPanel PsychiatryPsychiatry PaediatricsPaediatrics Primary carePrimary care EducationEducation UsersUsers
Commissioned projectCommissioned project
CarersCarers
Key recommendations from NICEKey recommendations from NICE
ADHD should be recognised and referredADHD should be recognised and referred Comprehensive specialist assessment; impairment req’dComprehensive specialist assessment; impairment req’d
Trusts to set up lead groupTrusts to set up lead group Adult services to be developedAdult services to be developed First choice usually group parent trainingFirst choice usually group parent training Severe cases go straight to medicationSevere cases go straight to medication First choice medication usually MPHFirst choice medication usually MPH Shared care expectedShared care expected
Table 5. Databases searched and inclusion/exclusion criteria for clinical evidence
Electronic databases CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO
Date searched Database inception to 18.12.08
Study design RCT
Patient population Children diagnosed with ADHD
Interventions Any non-pharmacological intervention used to treat ADHD symptoms and/or associated behavioural problems
Outcomes ADHD symptoms*; conduct problems*; social skills*; emotional outcomes*; self-efficacy*; reading; mathematics; leaving study early due to any reason, non-response to treatment.
*Separate outcomes for teacher, parent, self, and independent ratings.
Systematic literature review
Marking and combining studiesMarking and combining studiesCore ADHD symptoms at end of treatment
(teacher-rated)SMD -0.25 (-0.56 to 0.07)Quality: HighK = 4, N = 163
Core ADHD symptoms at end of treatment (parent-rated)
SMD -0.57 (-1.00 to -0.14)Quality: ModerateK = 5, N = 288
Conduct at end of treatment (teacher-rated) SMD -0.12 (-0.61 to 0.38)Quality: ModerateK = 3, N = 63
Conduct at end of treatment (parent-rated) SMD -0.54 (-1.05 to -0.04)Quality: ModerateK = 5, N = 231
Social skills at end of treatment (teacher-rated) SMD -0.40 (-1.33 to 0.54)Quality: ModerateK = 1, N = 18
Social skills at end of treatment (parent-rated) SMD -0.59 (-1.80 to 0.61)Quality: LowK = 2, N = 138
Social skills at end of treatment (child-rated) SMD -0.23 (-0.61 to 0.15)Quality: HighK = 1, N = 120
Emotional outcomes at end of treatment (teacher-rated)
SMD -0.20 (-1.12 to 0.73)Quality: ModerateK = 1, N = 18
Emotional outcomes end of treatment (parent-rated)
SMD -0.36 (-0.73 to 0.01)Quality: HighK = 2, N = 112
Self efficacy at end of treatment (child-rated) SMD -0.03 (-0.48 to 0.42) Quality: High K = 3, N = 78
Psychological interventionsPsychological interventions
TypeType DeliveryDelivery Costed as:Costed as:
Parent trainingParent training GroupGroup
IndividualIndividual
Group + childGroup + child
10 sessions10 sessions
10 sessions10 sessions
CognitiveCognitive IndividualIndividual n/a [no effect]n/a [no effect]
EducationalEducational Class informationClass information
ScreeningScreening
Delivery to teacherDelivery to teacher
n/an/a
Modelling health economic costsModelling health economic costs
Booster sessions
No treatmentNo response
Response
Parent training
No treatment
No treatment
No treatmentResponse
No response
Children with ADHD
Figure 3. Schematic diagram of the structure of the economic model
Selecting studies with “response rate” outcome measures (to allow QALY)Selecting studies with “response rate” outcome measures (to allow QALY)
Table 8. Characteristics of the studies examining parent-based therapies for children with ADHD included in the guideline systematic literature review
Study Intervention examined Mode of delivery
Medication status
BOR2002 Enhanced and standard positive parenting programme
Individual
None
HOATH2002 Enhanced positive parenting programme Group Some
PFIFFNER1997 Social skills training with parent generalisation Group Some
SONUGA-BARKE2001
Parent training Individual
None
Table 9. Input parameters utilised in the base-case economic analysis of parent training versus no treatment for children with ADHD
Input parameter value
Source - comments
Response ratesParent trainingNo treatment
0.522
0.206
Meta-analysis of BOR2002, HOATH2002, and SONUGA-BARKE2001; analysis based on intention-to-treat
Utility scoresResponderNon-responder
0.837
0.773
Coghill et al., 2004; scores based on EQ-5D; questionnaires filled in by parents of children with ADHD in the UK
Parent training cost10 x 1 hour group sessions with
clinical psychologist1 extra hour training and
preparationTotal intervention costTotal cost per family, assuming
10 families in each group3 x 0.5 hour individual booster
sessions for respondersTotal cost for responders
over 1 year
£660
£29
£689
£69
£99
£168
Curtis & Netten, 2006; clinical psychologist cost per hour: £29; cost per hour of client contact: £66; qualification costs excluded
Cost-effectiveness calculationCost-effectiveness calculation
Table 10. Cost-effectiveness of parent training versus no treatment in children with ADHD - results of the base-case analysis over 1 year
Intervention
Total QALYs / child
Total cost / child ICER
Parent training
0.803 £168 Parent training versus no treatment: £6,608/QALYNo
treatment0.785 0
Sensitivity analyses for differing assumptions
Economic conclusionEconomic conclusion
According to this analysis, and after assuming an 80% uptake of such programmes, the group clinic-based programme resulted in a cost per responder of £10,060 and £1,006 at a 5% and 50% success (response) rate, respectively; and a cost per QALY of £12,575 and £3,144 at a 5% and 20% improvement in HRQoL, respectively.
Clinical conclusionsClinical conclusions
The results of the economic analysis indicate that group-based parent training programmes (or CBT for children of school age) are likely to be cost-effective for children with ADHD, if the mode of delivery of such programmes does not affect their clinical effectiveness. Individual parent training is unlikely to be a cost-effective option
Specific approaches: cognitive therapySpecific approaches: cognitive therapy
Effective for coexistent anxiety/ depressionEffective for coexistent anxiety/ depressionFor Core ADHD symptoms, little effectFor Core ADHD symptoms, little effect::
Learning to Learning to STOP AND THINKSTOP AND THINK Recognising and managing angerRecognising and managing anger
Teaching others to be self-controlledTeaching others to be self-controlledTolerating waitingTolerating waiting
So far, trial evidence suggests no effect on core ADHD. What are we doing wrong?
Perhaps teaching cognitive control is hard because there are many routes into impaired control/ impulsiveness
Perhaps teaching cognitive control is hard because there are many routes into impaired control/ impulsiveness
GONOGOGONOGO STOPSTOP
press press inhibitinhibit
Selective inhibition of a Selective inhibition of a motor response/response motor response/response selectionselection
ISI: 1.6spress inhibit
Withholding of a planned motor response
REVERSALREVERSAL
press inhibit
Successful inhibition in normal adultsSuccessful inhibition in normal adults
Rubia et al., 1999, NeuroImage.
STOP SUCCESSFUL (-unsuccessful)STOP SUCCESSFUL (-unsuccessful)
ADHD: 0
L
RC
DIFFERENCEIFC
UNSUCCESSFULL STOPUNSUCCESSFULL STOPC > ADHD
LR
Rubia et al., AJP, 2004, in press.
SWITCH TASKSWITCH TASK
Modification of Meiran Switch task: Cognitive flexibility. Switching between two dimensions.
SWITCH (- repeat)SWITCH (- repeat)C
ADHD: 0
LEFTRIGHT
DIFFERENCE
Entering adult lifeEntering adult life
Counselling – what to expect?Counselling – what to expect? Learning coping skillsLearning coping skills Making autonomous decisionsMaking autonomous decisions Becoming intelligent users of treatmentBecoming intelligent users of treatment
Stresses of growing up with ADHDStresses of growing up with ADHD
Ideas of selfIdeas of self Coping with treatmentCoping with treatment Biological determinismBiological determinism Stigma and incomprehensionStigma and incomprehension Different impact at different life stagesDifferent impact at different life stages
ADHD: Outcome for diagnosed children ADHD: Outcome for diagnosed children
0
5
10
15
20
25
30
35
40
45
age 14 age 18 age 22
% s
till
sho
win
g di
sord
erPercentage with ADHD
Median values for all follow-up studies from childhood
Types of RemissionTypes of Remission Syndromatic remissionSyndromatic remission
Loss of full diagnostic statusLoss of full diagnostic status
Symptomatic remissionSymptomatic remission Loss of subthreshold diagnostic statusLoss of subthreshold diagnostic status
Functional remissionFunctional remission Loss of subthreshold diagnostic status with functional Loss of subthreshold diagnostic status with functional
recoveryrecovery
Keck PE Jr, et al. Am J Psychiatry. 1998;155(5):646-652.
Age-Specific Prevalence of Remission: DSM-III-R ADHDAge-Specific Prevalence of Remission: DSM-III-R ADHD
% R
emitt
ing
Dia
gnos
is
Age (Years)<6 6-8 9-11 12-14 15-17 18-20
0
10
20
30
40
50
60
70
80
90
100
SyndromaticSymptomaticFunctional
Keck PE Jr, et al. Am J Psychiatry. 1998;155(5):646-652.
Impulsiveness as a failureImpulsiveness as a failure
The charge of the light brigade: impulsiveness and inattention in Captain Nolan, rigidity in others
Impulsiveness as a strengthImpulsiveness as a strength
“That adventurer”
Impulsiveness as a mixtureImpulsiveness as a mixture
Genius and failure
Changes in adolescenceChanges in adolescence
Brain maturing:Brain maturing: Synaptic cull, cerebellar growth, fibre tracts, frontal Synaptic cull, cerebellar growth, fibre tracts, frontal
receptorsreceptors
Endocrine:Endocrine: Mixed effects of testosterone & early pubertyMixed effects of testosterone & early puberty
Physical:Physical: Sexual attractiveness & interestSexual attractiveness & interest
Cognitive:Cognitive: Abstract conceptual; hypothetical probabilitiesAbstract conceptual; hypothetical probabilities
Entering adult lifeEntering adult life
New demandsNew demands Study: self-regulated, more Study: self-regulated, more
difficult?difficult? Work: regularity, Work: regularity,
submitting to rules, submitting to rules, unreasonable peopleunreasonable people
Friends: more demandingFriends: more demanding Partners: sharingPartners: sharing Drugs & alcoholDrugs & alcohol Budgeting, negotiatingBudgeting, negotiating
New chancesNew chances Self-pacingSelf-pacing Choose own nicheChoose own niche Avoid hated situations?Avoid hated situations? Find helpersFind helpers Use skillsUse skills Brain maturingBrain maturing
ImpactImpact
Self-organisationSelf-organisation Finding things/ remembering appts/ budget/ Finding things/ remembering appts/ budget/
neatnessneatness
TimingTiming On time for work/meet deadlines/ pay billsOn time for work/meet deadlines/ pay bills
ThinkingThinking Muddled/ Distracted/ “Whirling”/ IncompleteMuddled/ Distracted/ “Whirling”/ Incomplete
Impulse controlImpulse control Negotiating/ Using drugs/ Mood stabilityNegotiating/ Using drugs/ Mood stability
Coping often by: prosthesis; delegation; “buddies”; job choice
ImpactImpact
Forensic: vulnerable/witness/competenceForensic: vulnerable/witness/competence Employment; accident-prone; strengths Employment; accident-prone; strengths Parenting problems affect the childrenParenting problems affect the children
What influences operate?What influences operate? Antisocial: abusive/modelling/disciplineAntisocial: abusive/modelling/discipline Cognitive: unfocussed/impoverishedCognitive: unfocussed/impoverished Conative: reward history/predictabilityConative: reward history/predictability Physical: fetal/perinatal/nutritional/injuryPhysical: fetal/perinatal/nutritional/injury
Adherence and attitudesAdherence and attitudes Tom is 15. Professional parents. White British.Tom is 15. Professional parents. White British. Mixed neuropsychiatric presentation:Mixed neuropsychiatric presentation:
Presented at age 10 with history of impulsive overactivity throughout Presented at age 10 with history of impulsive overactivity throughout his life; asked to leave nursery; multiple suspensions from primary his life; asked to leave nursery; multiple suspensions from primary school and three changes of school (all mainstream) due to mother’s school and three changes of school (all mainstream) due to mother’s perception of school failing himperception of school failing him
Reading age then was 7; WISC IQ 106; noncompliant with tasks seen Reading age then was 7; WISC IQ 106; noncompliant with tasks seen as difficultas difficult
Increasingly unpopular; steals to give to other kidsIncreasingly unpopular; steals to give to other kids Violent to his younger sister, not otherwiseViolent to his younger sister, not otherwise
Treated with Concerta (in spite of tics appearing); good response, Treated with Concerta (in spite of tics appearing); good response, maintained in mainstream with facilitator, friendless.maintained in mainstream with facilitator, friendless.
Problems nowProblems now
Age 14 increasing cannabis use; agreed to Age 14 increasing cannabis use; agreed to continue Concerta (54 mg daily) none the less; continue Concerta (54 mg daily) none the less; off medication at weekends and holidays; off medication at weekends and holidays; discussions in motivational interviewing format.discussions in motivational interviewing format.
Age 15 behaviour at school deteriorated. Age 15 behaviour at school deteriorated. Concerta increased; clonidine added; not helpful; Concerta increased; clonidine added; not helpful; admitted not taking medicinesadmitted not taking medicines
Wont accept a self-monitored trial; “dunno” and Wont accept a self-monitored trial; “dunno” and “don’t like it” on his objections.“don’t like it” on his objections.
Patients taking stimulants (General Practice Research Database)Patients taking stimulants (General Practice Research Database)
30
7 6 5 6
211
66
20 13
73
25 1936
241
42
0
50
100
150
200
250
300
16 17 18 19 20 to 21
Age, years
Nu
mb
er
of
pa
tie
nts
Female Male Total
Common reasons for nonadherenceCommon reasons for nonadherence ForgetForget StigmaStigma Not real selfNot real self Losing funny sideLosing funny side Adverse effectsAdverse effects
Physical; sex; tension; feared brain damagePhysical; sex; tension; feared brain damage Incompatible with misused substancesIncompatible with misused substances
InconvenienceInconvenience Don’t need itDon’t need it Up to meUp to me No pointNo point
Attitudes of young people to stimulantsAttitudes of young people to stimulants
Harpur (2006, PhD thesis Southampton)Harpur (2006, PhD thesis Southampton) Predominantly positivePredominantly positive ““Adherence” is complex – individually chosen regimes, Adherence” is complex – individually chosen regimes,
often by parents (Singh, 2006, Am J Med Ethics: often by parents (Singh, 2006, Am J Med Ethics: “authenticity”) – adherence to what?“authenticity”) – adherence to what?
Ferrin (2007, MSc, London)Ferrin (2007, MSc, London) Questionnaire from Childrens Health Beliefs model: locus Questionnaire from Childrens Health Beliefs model: locus
of control, self-esteem, general beliefs on medicine, of control, self-esteem, general beliefs on medicine, knowledgeknowledge perceived threat and benefit perceived threat and benefit doctor-patient relationship doctor-patient relationship
Outcome and adherenceOutcome and adherence
Simpson et al BMJ 2006 333 15Simpson et al BMJ 2006 333 15 Metaanalysis: good adherence in about 50%; Metaanalysis: good adherence in about 50%;
predicts good outcome, predicts good outcome, even for placeboeven for placebo. . (“healthy adherer”)(“healthy adherer”)
Charach et al J Amer Acad CAP 43 559Charach et al J Amer Acad CAP 43 559 Adherence to stimulants over 5 years predicts Adherence to stimulants over 5 years predicts
good outcome, is predicted by youth, severity good outcome, is predicted by youth, severity of ADHD, no ODDof ADHD, no ODD
Attitudes of young people to stimulantsAttitudes of young people to stimulants
Project commissioned from LSE (Singh)Project commissioned from LSE (Singh) Qualitative interviewingQualitative interviewing Attitudes predominantly positiveAttitudes predominantly positive Negative aspects acknowledgedNegative aspects acknowledged
InconvenientInconvenient Stigmatising for someStigmatising for some Sleep/appetite problemsSleep/appetite problems
Better for some activities, worse for othersBetter for some activities, worse for others
What do patients ask for?What do patients ask for?
Understanding by othersUnderstanding by others Safe treatmentSafe treatment Knowledge of futureKnowledge of future Stop the bullyingStop the bullying Appreciation of the positiveAppreciation of the positive Time to talk with doctorTime to talk with doctor
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