1	Medications and Psychosocial Treatments for ADHD Thomas E. Brown, PhD Associate Director, Yale Clinic for Attention and Related Disorders Department of Psychiatry Yale Medical School
2	A Chemical Problem ADHD is fundamentally a chemical problem Most effective treatment is to change the chemistry with medication Unless the problematic chemistry is changed, other interventions are not likely to be very effective
3	How do ADHD Impairments of EF Usually Respond to Medication? This wide range of cognitive impairments responds to medication treatment in 70-90% of cases in children, adolescents and adults Symptom improvement varies from modest to very dramatic Adverse effects are usually transient, not significant
4	Safety of ADHD Medications American Medical Assn. Report “More than 170 studies involving >6,000 children using stimulant medications for ADHD…up to 90% will respond to at least 1 stimulant without major adverse events if drug titration is done carefully “ Adverse effects from stimulants are generally mild, short-lived, & responsive to dosing or timing adjustments” (Goldman, et. al., 1998, pp 1103-1104)
5	MTA Study of ADHD Tx 579 children (7-9 years) ADHD Combined Type 14 months duration (10 yr f/u) Six sites
6	MTA Groups 1. Med Mgmt: tailored dose design TID dosing, monthly monitoring 2. Behav Tx: 8 wk summer prog, pt training child tx, schl aide, tchr consults, daily rpts. 3. Combined Med Mgmt + Behav Tx 4. Com Care: evals, 67% on meds, BID
7	MTA Results 1. Med Mgmnt, Comb Tx >Beh Tx, ComCare 2. Combined Tx = Med Mgmt for ADHD Sx 3. Comb Tx slightly better for assoc probs 4. Med Mgmt better than ComCare meds
8	MTA Study “Excellent Response” to Tx % of Ss scoring average of <1 (“just a little”) on SNAP-IV for Inattn, Hyper/Impulsive, Opp/Defiant 25% Community Care 34% Behavioral Treatment only 56% Medication Mgmt only 68% Combination Tx (Swanson, et. al., 2001)
9	Patients’ Fears of Medications for ADHD Change personality “zombie”? Slow growth? Start tics? Lose appetite? Sleep? Later drug or alcohol problems? Dependence on meds for lifetime? Being labeled, attribution problems? Reactions of family, teachers, peers?
10	Substance Abuse Associated With ADHD Risk of developing SUD over lifetime is 52% for adults with ADHD vs 27% In ADHD, substance-use disorders onset earlier, last longer, & remit more slowly If ADHD is appropriately treated with stimulant medications in childhood and adolescence, risk of SUD reduced 84% Wilens, Farone, Biederman, et al, Pediatrics, 2003)
11	Controversial Treatments for ADHD Dietary restrictions (food dyes, sugar) Diet supplements: anti-oxidants, algae optometric vision training EEG neuro-feedback No scientific evidence for the safety or effectiveness of these treatments for ADHD
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13	Stimulant Medications Amphetamine - dextroamphetamine (Dexedrine): 4-6 hours d, l amphetamine (Adderall): 4-6 hours Extended release (Adderall-XR) 8-10 hours Methylphenidate Ritalin: 4 hours Concerta: triphasic, 10-12 hours Metadate CD: biphasic, 8 hrs Focalin (d -isomer) 4 hours Ritalin-LA (biphasic) 6-8 hours
14	Stimulant Medications for ADHD Demonstrated safe and effective Often do not follow mg/kg Effective dose not based on age, wt or severity of sx Require titration and monitoring to “fine tune” to: - individual sensitivity - time frames for schedule and tasks
15	Stimulant Medications: Optimal Doses for ADHD For children aged 7 to 9 years in MTA study Dose of MPH- (TID for 7 day week) 29% Low (15 mg/day) 33% Moderate (16-34 mg/day) 38% High (35-60 mg/day Weight group, anxiety disorder dx or ODD dx had no significant effect on optimal dose (Greenhill, et al, 2001)
16	Stimulant Medications Adjustment of Dose Among 256 ADHD boys given meds in MTA 77% responded to carefully-titrated MPH 88% still on MPH 13 months later 61% needed dose adjustments w/in 13 mos. [increase (62%) decrease (31%) switch 7%] 90% responded well to MPH or to Dex, if dosage adjustments were made prn (Vitiello, et al, 2001)
17	ADHD Response to Stimulants
18	Time Frames and Rebound
19	Advantages of Extended-Release Formulations of Stimulants Provides sustained medication levels throughout the day Smoother: minimizes ups and downs during day No midday dose required, eliminating trips to the school nurse, doses during workday Reduces stigma Enhances patient compliance May reduce illicit diversion and abuse
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21	Extended-Release Beaded Capsules-Biphasic Release (Metadate-CD, Focalin-XR, Ritalin-LA)
22	Management Strategies for: Severe Decrease In appetite Monitor weight Administer with or after meals Give high-calorie snacks Consider medication holidays Eat in reverse Headache/Stomachache, Irritability/Moodiness, or OCD Symptoms Decrease dose Switch to another stimulant Switch to 2nd line agent
23	Management Strategies for: Delayed Sleep Latency Sleep Hygiene/Bedtime rituals Change to shorter acting stimulant Consider adjunctive treatment (e.g., clonidine) Relaxation training Irritability Evaluate when it occurs Peak (too high dose) Wear off (? rebound) Change dose Assess for comorbidity Consider adjunctive therapy
24	Non-Stimulant options for ADHD Specific noradrenergic agent -Strattera (atomoxetine) (approved for ADHD) Antidepressants (not approved for ADHD) -Wellbutrin (buproprion) -Pamelor (nortriptyline) -Norpramin (desipramine) Alpha-2 Agonists (not approved for ADHD) -Catapres (clonidine) -Tenex (guanfacine)
25	Atomoxetine (Strattera) Approved for ADHD for all ages Not a schedule II medication Must be taken daily 4-6 weeks before full effect Effects may last into next day Side effects: nausea, somnolence May also alleviate anxiety sx
26	Types of non-pharmacological treatments Psychoeducation about ADHD and its treatment to address prejudices/fears 2. Cognitive-behavioral treatments to modify maladaptive attitudes 3. Remedial instruction/coaching to modify deficits or maladaptive behaviors
27	Non-Pharmacological Treatments are important to ADHD treatment ADHD/ADD results from impairment brain chemistry and medication is most effective treatment BUT medication is not effective if not taken cannot fully alleviate some symptoms pills cannot teach skills
28	Home Interventions for ADD/LD School Problems daily parental reading with child daily parental help with organization/study early computer training and use supplementary audio or videos remedial tutoring avoid micro-managing homework for teens protect non-academic strengths
29	Parent Training for Management of ADHD Behavior Problems positive attending rewards for appropriate behavior planned ignoring transition management target behaviors & point systems use of “time out” & “response cost” (Cunningham, 1998; Teeter, 1998)
30	Improving Interactions of ADHD Teens and Their Parents recognize aims & limits of parental control facilitate appropriate independence seeking maintain adequate structure & supervision establish & enforce “bottom line” rules negotiate all “non-bottom line” issues use consequences wisely to influence focus on positives, practice forgiveness (A.Robin, 1998, C.Dendy, 1995)
31	School Accommodations for ADD/LD Daily check of assignments & organization preferential seating reduced volume of work weekly/daily progress reports alternative test delivery (oral/written) extended time for tests (as needed) (S.Rief, 2005, C.Dendy, 2000)
32	Cognitive Behavioral Treatments for: Defensive attitudes about self & others: “Everyone expects too much from me.” “I may seem smart, but I’m really stupid.” “High goals just bring disappointment.” “It’s not worth trying; the world is unfair.” “I’m just destined to be a loser.”
33	Remedial instruction or Coaching for: Skill deficiencies that persist Study skills and academic deficits Organization of ideas and stuff Priority setting & time management Budgeting income and spending Monitoring self in conversations
34	Interventions to Provide Therapy & Support relevant articles, books and websites support groups: CHADD, ADDA on-site support: for patient, teachers psychotherapy- individual, conjoint parent support/training mgmnt skills crisis intervention “realistic hope” vs. “optimism”
35	Levels of Care for ADHD tailor to pt & family needs Comprehensive assessment for ADHD, comorbid disorders, and context Family Education re: ADHD and its tx PE, “fine-tuning” of meds, monitoring Parent support & behavior mgmnt training Accommodations/Interventions in school Psychotherapy: individual, family