Trea%ng ADHD. Primary Empirically Based Treatments: ü Psychos%mulants. ü Behavioral/Con%ngency Management. ü Parent Training

Transcription

1 Trea%ng ADHD Primary Empirically Based Treatments: ü Psychos%mulants ü Behavioral/Con%ngency Management ü Parent Training

2 DSM-IV CLINICAL MODEL OF ADHD Biological Influences, e.g., genetics NEUROBIOLOGICAL SUBSTRATE CORE FEATURES: CORE INATTENTION FEATURE: WORKING HYPERACTIVITY MEMORY IMPULSIVITY Pharmacological Treatment Behavioral Interventions ENVIRONMENTAL/ COGNITIVE DEMANDS SECONDARY INATTENTION FEATURES: Academic HYPERACTIVITY Underachievement Social IMPULSIVITY Skill Deficits Poor Organizational Skills Classroom Deportment Cognitive Abilities

3 Training

4 Mr. A&en)on The A&en)on Training System Inventor: M.D. Rapport, Ph.D. Manufactured by Gordon Systems Inc. P.O. Box 746, DeWi&, NY 13214

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9 Psychos%mulants Psychos%mulants were discovered serendipitously by an astute physician no%ng improved concentra%on and reduced motor ac%vity in children administered Benzedrine who suffered postpneumoencephalography headaches. Pneumoencephalography is an obsolete medical procedure used during the early 20 th century that involved draining most of the cerebrospinal fluid from around the brain and replacing it with air, oxygen, or helium to enhance x- ray imaging. Contemporary parent and classroom con%ngency management (behavioral) therapies, in contrast, were appropriated from the widespread applica%on of operant condi%oning principles used to improve the func%oning of individuals with moderate to profound developmental and/or intellectual disabili%es beginning in the 1960s (for a historical review, see Bijou, 1966).

10 PROGRAMATIC RESEARCH Psychopharmacological Studies with ADHD: Effects on Behavior and Cognition: u Rapport et al., 1985 u Rapport et al., 1986 u Rapport et al., 1987 u Rapport et al., 1988 u Rapport et al., 1988 u Rapport et al., 1989 u Rapport et al., 1991 u Rapport et al., 1995 u Rapport et al., 1996 Theoretical Studies: u Rate Dependency, 1986 u Complex Reinforcement Schedules, 1988 u Delay of Gratification, 1986 u Law of Initial Values - Cardiovascular, 1988 u Contribution of Body Mass, 1989; 1997 u Serum Cholesterol, 1995 u Prediction Models of Response, 1997 u Conceptual Model of ADHD, 2000

11 METABOLISM OF METHYLPHENIDATE O C O CH 3 CH RAPIDLY ABSORBED H N + H SUBJECT TO SIGNIFICANT FIRST PASS ELIMINATION Ü BIOAVAILABILITY OF 19-21% NO ACCUMULATION, MINIMUM BINDING TO PLASMA ALBUMIN T 1/2 = 2.5 TO 4 HOURS [4-6 for SR preps]

12 Psychos%mulants such as methylphenidate (MPH) act primarily as dopamine and norepinephrine reuptake inhibitors, and to a lesser extent, as direct agonists that s%mulate the release of dopamine and norepinephrine into the synapse. The well- documented finding that both processes promote the availability of these neurotransmi@ers in cor%cal- subcor%cal pathways involving the frontal/pre- frontal cortex, temporal lobe, and basal ganglia is of par%cular relevance for the treatment of ADHD (cf. Dickstein, Bannon, Castellanos, & Milham, 2006, for a meta- analy%c review). These anatomical structures play a cri%cal role in suppor%ng execu%ve func%ons (EF), an umbrella term for higher- order cogni%ve processes such as working memory, set shihing, and inhibitory control that enable goal directed behavior and novel problem solving (Garon, Bryson, & Smith, 2008; Miyake et al., 2000).

13 PHARMACOTHERAPY OF ADHD p PRIMARY BEHAVIORAL EFFECTS: REDUCTIONS: u REDUCED GROSS MOTOR ACTIVITY u REDUCED IMPULSIVITY u REDUCED INATTENTIVENESS u REDUCED NON- COMPLIANCE u REDUCED AGGRESSIVENESS IMPROVEMENTS: u IMPROVE SOCIAL FUNCTIONING u IMPROVED PEER RELATIONSHIPS u IMPROVED ABILITY TO MODULATE THE INTENSITY OF THEIR BEHAVIOR u IMPROVED COMMUNICATION WITH OTHERS u IMPROVED RESPONSIVENESS TO OTHERS WITH FEWER NEGATIVE INTERACTIONS u IMPROVED PARENT- CHILD INTERACTIONS

14 PHARMACOTHERAPY OF ADHD p PRIMARY COGNITIVE EFFECTS OF PSYCHOSTIMULANT: u ACADEMIC ASSIGNMENTS COMPLETED u ACADEMIC ASSIGNMENTS CORRECT u IMPROVED VIGILANCE u REDUCED COGNITIVE IMPULSIVITY - IMPROVED REFLECTIVENESS u REACTION TIME - IMPROVED & LESS VARIABLE u IMPROVED SHORT- TERM MEMORY- moderate u IMPROVED LEARNING OF VERBAL AND NONVERBAL INFORMATION- moderate u IMPROVED USE OF STUDY TIME NEARLY ALL EFFECTS ARE DOSE- DEPENDENT

15 u COMMON TREATMENT EMERGENT EFFECTS - PSYCHOSTIMULANTS COMMON: Ü APPETITE (ANOREXIA) AND WEIGHT LOSS Ü SLEEP DISTURBANCE (INITIAL INSOMNIA) IF LATE AFTERNOON DOSE IS ADMINISTERED. Ü IRRITABILITY Ü MILD NAUSEA OR STOMACH UPSET Ü COGNITIVE CONSTRICTION Ü OVERFOCUSED STATES (USUALLY SEEN AT HIGHER DOSAGES) UNCOMMON (UNUSUAL) Ü HEADACHES Ü REBOUND EFFECTS (ESP. NOTED WITH DEXEDRINE) Ü MOODINESS Ü INCREASED TALKATIVENESS Ü SUPPRESSION OF ADAPTIVE BEHAVIOR AND MOOD/AFFECT (USUALLY SEEN AT HIGH DOSAGE RANGE) Ü BRIEF PSYCHOSIS Ü AGITATION PHARMACOTHERAPY OF ADHD

16 ZONES OF PEAK ENHANCEMENT COGNITIVE SOCIAL EMERGENT PERFORMANCE EMERGENT SYMPTOMS P OPTIMAL COGNITIVE ZONE 0.5 OPTIMAL BEHAVIORAL ZONE 1.0 INCREASING DOSAGE

17 DOSE RESPONSE CURVES FOR LEARNING AND TEACHER RATED BEHAVIOR (ACTRS) 72 LEARNING ACTRS PERCENT CORRECT TEACHER RATINGS PL DOSE (MPH)

18 90 80 ON- TASK ACADEMIC EFFICIENCY TEACHER RATING 5 PERCENT ACTRS Baseline PL 5- mg 10- mg 15- mg 20- mg Rapport, Denney, DuPaul, & Gardner (1994). J AM. ACAD. CHILD ADOLESC. PSYCHIATRY

19 NO CHANGE SIGN IMPROVED NORMALIZED IMPROVED OR NORMALIZED 94% % 76% 78% PERCENT OF SAMPLE % 47% 50% 53% 16% ADHD N = 76 NC N = % 3% ATTENTION AES ACTRS Rapport, Denney, DuPaul, & Gardner (1994). J AM. ACAD. CHILD ADOLESC. PSYCHIATRY 7%

20 ASSESSING PHARMACOLOGICAL RESPONSE IN CHILDREN WITH ADHD TARGET BEHAVIORS SOCIAL COGNITIVE/ ACADEMIC DON T FOGET THE DEAD MAN RULE!

21 DEAD MAN RULE IF A DECEASED INDIVIDUAL CAN PERFORM THE BEHAVIOR OR MEET THE CRITERIA, IT IS GENERALLY NOT AN APPROPRIATE TARGET FOR TITRATION RESTLESS OF OVERACTIVE EXCITABLE, IMPULSIVE DISTURBS OTHER CHILDREN SHORT ATTENTION SPAN CONSTANTLY FIDGETING EASILY DISTRACTED EASILY FRUSTRATED CRIES OFTEN AND EASILY MOOD CHANGES QUICKLY TEMPER OUTBURSTS, EXPLOSIVE

22 Summary of Rx Effec%veness When administered in their most potent forms and carefully monitored, psychos%mulant medica%on alone and combined with intensive, packaged behavioral treatment is associated with large magnitude reduc%ons in and hyperac%vity/impulsivity symptoms (ES range = 1.53 to 1.89) for up to 24 months (Van der Oord, Prins, Oosterlaan, & Emmelkamp, 2008); Psychosocial interven%ons used alone are associated with more moderate (ES range =.31 to.87) benefits (Abikoff et al., 2004; Lee, Niew, Yang, Chen, & Lin, 2012; Van der Oord et al., 2008). These impressive reduc%ons in core behavioral symptoms, however, are unaccompanied by significant or sustained improvements in ecologically valid academic and learning outcomes such as quiz and test grades, overall grade point averages, grade reten%ons, high school gradua%on rates, and standardized achievement test scores (Barkley, Fischer, Smallish, & Fletcher, 2006; Molina et al., 2009; Van der Oord et al., 2008) highligh%ng the weak linkage between ADHD behavioral symptom expression and func%onal impairment (Gordon et al., 2006; Pelham et al., 2005). In addi%on, no study to date has demonstrated sustained maintenance of medica%on- related behavioral changes beyond a 24- month %me frame (Jensen et al., 2007; Molina et al., 2009).

23 Types of Individual Responders

24 ACTRS LINEAR RESPONDER [70%] PERCENTAGE = ATTENTION = AES = TEACHER RATING BASE PL 5- MG 10- MG 15- MG 20- MG MEDICATION CONDITION

25 ACTRS THRESHOLD RESPONDER [13%] = ATTENTION = AES = TEACHER RATING 0 5 PERCENTAGE BASE PL 5- MG 10- MG 15- MG 20- MG MEDICATION CONDITION

26 ACTRS QUADRATIC RESPONDER [8%] 0 5 PERCENTAGE = ATTENTION = AES = TEACHER RATING BASE PL 5- MG 10- MG 15- MG 20- MG MEDICATION CONDITION 20 25

27 MOST FREQUENTLY ADKED QUESTIONS BY PARENTS p ARE PSYCHOSTIMULANTS ADDICTIVE? p WILL PSYCHOSTIMULANTS STUNT MY CHILD S GROWTH? p SHOULD I GIVE MY CHILD MEDICATION WHEN HE OR SHE IS ILL? p WILL PSYCHOSTIMULANTS MAKE MY CHILD A ZOMBIE OR CHANGE HIS OR HER PERSONALITY? p WILL MY CHILD NEED A HIGHER DOSE WHEN HE OR SHE IS OLDER OR WEIGHS MORE? p MORAL ISSUE: DRUGS ARE BAD [EYEGLASSES] p WILL TAKING PSYCHOSTIMULANTS AS A CHILD MAKE MY CHILD MORE LIKELY TO USE ILLEGAL DRUGS AS AN ADOLESCENT? p SHOULD I NOT GIVE MY CHILD THE MEDICATION ONCE IN A WHILE AND SEE IF THE TEACHER CAN TELL THE DIFFERENCE? p HOW LONG WILL MY CHILD NEED TO TAKE MEDICATION?