Working with difficult children: Recent advances in ADHD Eric Taylor Eric Taylor King’s College London Institute of King’s College London Institute of Psychiatry Psychiatry There are many ways in which children can be ‘difficult’: ADHD is just one. Behaviour is dysregulated : inattention, executive dysfunction, altered response to reward, poor time perception, and response disorganisation can all be involved. Assessment can guide
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Working with difficult children: Recent advances in ADHD Eric Taylor King’s College London Institute of Psychiatry There are many ways in which children.
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Working with difficult children: Recent advances in ADHD
Working with difficult children: Recent advances in ADHD
Eric TaylorEric Taylor
King’s College London Institute of PsychiatryKing’s College London Institute of Psychiatry
There are many ways in which children can be ‘difficult’: ADHD is just one. Behaviour is dysregulated : inattention, executive
dysfunction, altered response to reward, poor time perception, and response disorganisation can all be involved. Assessment can guide
education, help counselling, and lead to treating ADHD.
Lessons from researchLessons from research
It’s not their faultIt’s not their fault Psychological treatments workPsychological treatments work Medicines help the worst affectedMedicines help the worst affected Increasing range of medicinesIncreasing range of medicines
More ‘diagnoses’ for child troubles
BBC to apologise for child drug program
Born mad or made bad? Crime and
the child
Conflicts in understanding ADHD*Conflicts in understanding ADHD* Genetic influences 80%;Genetic influences 80%; Frontal, striatal, Frontal, striatal,
cerebellar parts of brain cerebellar parts of brain are smallare small
Same structures Same structures underactivateunderactivate
Psychological deficitsPsychological deficits
Great differences over Great differences over timetime
Great differences in Great differences in prevalence between prevalence between countriescountries
Persistent and pervasive abnormalities in : Attention (distractible, forgetful, disorganised); Activity (restless, fidgety) and Impulsiveness
(acting without thinking)
Where does ADHD come from?Twin studies show high heritabilityWhere does ADHD come from?Twin studies show high heritability
Twin
correlations
DZ MZ
Median heritability (13 studies) 0.82 (0.52-0.98)
Search for high-risk allelesSearch for high-risk alleles DRD4DRD4
metaanalysis p< .00000001metaanalysis p< .00000001 Odds ratio (averaged): 1.32Odds ratio (averaged): 1.32
DAT1DAT1 metaanalysis p<.0001metaanalysis p<.0001 Odds ratio (averaged): 1.13Odds ratio (averaged): 1.13
8 candidate genes well established to be associated with ADHD:
mostly affecting dopamine or serotonin neurotransmission
7 (vs 2-5 or 8) copies of 48 bp VNTR on 11p.15.5
9 vs 10 copies of 40 bp VNTR on 5p15.3
Geographical variations in the number of repeats of the variable 48-bp sequence in DRD4
Chang et al
Genome scan identifies a spot on Chr 16: Cadherin 13Genome scan identifies a spot on Chr 16: Cadherin 13
Cadherins mediate cell adhesion and play a fundamental role Cadherins mediate cell adhesion and play a fundamental role in normal development. They participate in the maintenance in normal development. They participate in the maintenance of proper cell-cell contactsof proper cell-cell contacts
CDH13 also implicated in substance misuse:CDH13 also implicated in substance misuse:
Nicotine dependenceNicotine dependence
Substance dependenceSubstance dependence
Plays a role in cell adhesion, cell-cell contacts and cell-Plays a role in cell adhesion, cell-cell contacts and cell-migrationmigration
What is inherited?What is inherited?
NotNot ADHD: ADHD: genetic influences on continuum*genetic influences on continuum* NotNot a unitary trait: influences vary with context a unitary trait: influences vary with context Dispositions to react:Dispositions to react:
gene-environment interactions and correlationsgene-environment interactions and correlations early physical environmental associationsearly physical environmental associations parenting influences on developmentparenting influences on development MAOA multiplies effects of violence, DRD4.7/DAT10 of MAOA multiplies effects of violence, DRD4.7/DAT10 of
smokingsmoking
*(with possible exception at highest level of severity & possible latent classes)
But, if ADHD is so neurological, how come it varies so much in different places? Isn’t it really a social disorder? What about the rise of television and the decline of the family?
Prevalence of disorderPrevalence of disorder
Administrative prevalence from local surveys; HKD in approx 105,000 nationally
0
10
20
30
40
50
Nu
mb
ers
pe
r 1
00
0
US'80 UK'80 US'98 UK'99
Admin prevalence Hyperkinetic disorder
ADHD /1000
Real prevalence
Prevalence of disorderPrevalence of disorder
Same survey method in Hong Kong and East London
0
10
20
30
40
50
60
70
Nu
mb
ers
pe
r 1
00
0
HKratings
UKdiag
HK ratings UK ratings HK diag UK diag
Is it a Social Problem?Is it a Social Problem?Is it a Social Problem?Is it a Social Problem?
Does society determine the presence of ADHD?Does society determine the presence of ADHD? No, shared environment plays little partNo, shared environment plays little part
Does society alter the rate?Does society alter the rate? Only small differences between societiesOnly small differences between societies Little increase over timeLittle increase over time
Does society determine what is recognised?Does society determine what is recognised? Yes, substantial cultural differencesYes, substantial cultural differences
Patterson - OSLC
Is it a Treatable Problem?
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
Diet: Diet: eliminations and supplementseliminations and supplements
Include non-specific interventions - education, support, advice
Xavier, aged 11, has been out of the control of his parents after an episode of meningoencephalitis at age 4. He is dangerously aggressive to his sister and younger brother and has been excluded from a special unit at school. He sets fires, steals from shops, and puffs cannabis with a group of older boys.He can’t concentrate in class, is very forgetful and disorganised; and teachers have believed that this comes from a chaotic home background.
A range of presentations: XavierA range of presentations: Xavier
A complex disorder, multiply causedA complex disorder, multiply caused
Not just genetic: The Environmental Risk Longitudinal Twin Study interviewed the mothers of 565 five-year-old monozygotic (MZ) twin pairs : the twin receiving more maternal negativity and less warmth had more antisocial behavior problems. (Moffitt et al 2008)
Not just bad parents: Medication of child reduces parental EE
Not just complications:Not just complications:In never-medicated adults:In never-medicated adults:Recent findings of low Recent findings of low dopamine and DATdopamine and DATRecent findings of Recent findings of persisting hypoactivationpersisting hypoactivation
A range of presentations: MatteoA range of presentations: Matteo
Matteo is regarded by his parents as a charming 8-year-old who has recovered from injury but is now encountering bullying. His teachers, however, refer him to the clinic with a very different story: he does not listen to them, he does not concentrate as he should, he has low academic self-esteem and big tempers when frustrated, he is inclined to lose his way, he is clumsy and his handwriting is terrible.
He was popular when he started at school, but now is teased a great deal. His teachers are frustrated because in individual sessions he shows good understanding and creativeness.
A complex disorder, multiply causedA complex disorder, multiply caused
Inattention creates an increasingly unstimulating environment
Effect sizes on ADHD scalesEffect sizes on ADHD scales
Year 2 behaviour in schools receiving an Information Booklet was improved (ES = 0.26)Pupil attitudes to school and reading were improved (ES = 0.17)No effect of screening programme.
Cost of booklet £2.55
(similar booklet in Taylor E (ed) People with Hyperactivity. CDM 171; MacKeith Press)
Learning social skills in peer groupLearning social skills in peer group
Listen to others Join play gradually Learn the rules
Avoid intrusiveness and excessive demands
Figure out why others react Control anger Learn how to refuse kindly
Especially drugs
But do behavioural treatments work? Metaanalysis
But do behavioural treatments work? Metaanalysis
Pelham & Fabiano (2008) review: Behavioural parent training Behavioural classroom management Intensive intervention in recreational settings
Journal of Clinical Child and Adolescent Psychiatry 37 184
Table 5. Databases searched and inclusion/exclusion criteria for clinical evidence
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.
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
SSRS Total Social Skills (Parent)SSRS Total Social Skills (Parent)
Economic modellingEconomic modelling
Methylphenidate
Parent training
Continue
MethylphenidateParent training
Continue
QoL £
Severe casesSevere cases
Methylphenidate
Parent training
Continue
MethylphenidateParent training
Continue
Relative effect of medication to behavioural interventions greater in hyperkinetic subtype
Treatment decisionsTreatment decisions
Severe, pervasive, disabling?
Problems at home? Problems at school?
Persistent after treatment?
Comorbid problems?
Home CBT
Liaison+ self-instruction
Medication
?
Key recommendations from NICEKey recommendations from NICE
ADHD should be recognised and referred Comprehensive specialist assessment; impairment req’d
Trusts to set up lead group Adult services to be developed First choice usually group parent training Severe cases go straight to medication First choice medication usually MPH Shared care expected
Drugs or behaviour therapy?Conclusions so farDrugs or behaviour therapy?Conclusions so far Both are effective Both are cost-effective Medication hazards:
Growth suppression (manageable) Hypertension (avoidable with monitoring) Unknown risks to CVS
ADHD is heterogeneous in severity and course
Specific approaches: cognitive therapySpecific approaches: cognitive therapy
Effective for coexistent anxiety/ depressionFor Core ADHD symptoms, little effect:
Learning to STOP AND THINK Recognising and managing anger
Teaching others to be self-controlledTolerating 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
Varieties of “inattention”Varieties of “inattention”
Clinicians’ use of punishment mechanismsClinicians’ use of punishment mechanisms Reduction of naturalistic punishment Response cost (Time-out)
Conceptualised as extinction
What is it like to be inattentive/ impulsive?What is it like to be inattentive/ impulsive?
““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)
ConclusionsConclusions
There are several testable cognitive dysfunctionsThere are several testable cognitive dysfunctions Response organisation, switching, reward, timingResponse organisation, switching, reward, timing
They are found in several presentationsThey are found in several presentations Attention deficit, impulsiveness, irritabilityAttention deficit, impulsiveness, irritability
Useful for individual analysis, not diagnosisUseful for individual analysis, not diagnosis But most tests are unstandardisedBut most tests are unstandardised
Could help to guide teaching Could help to guide teaching Treatment does not usually depend on causeTreatment does not usually depend on cause
Consider behaviour modification and medicationConsider behaviour modification and medication
Research knowledge on ADHDResearch knowledge on ADHD
Common, persistent, risk for mental health Neurobiology becoming clearer
Low dopamine levels in striatum (PET) Frontostriatal (& other) brain changes (MRI) Genetic and environmental causes
• Allelic variants associated, esp genes in dopamine system
Effective treatments Stimulants, atomoxetine, behaviour therapy Efficacy is not related to cause