THE CHALLENGE OF ADHD IN THE PRESCHOOLER

Transcription

1 THE CHALLENGE OF ADHD IN THE PRESCHOOLER Paediatric Refresher Course 2011 Vineyard Hotel Prof A. Venter Department of Paediatrics and Child Health University of the Free State Departement Sentrum Department Centre UNIVERSITEIT VAN DIE VRYSTAAT UNIVERSITY OF THE FREE 1 STATE YUNIVESITHI YA FREISTATA Tel (051) info@ufs.ac.za

2 General considerations: 1. Preschool-onset of ADHD systems are well documented, often more severe 2. Symptoms persist well into adolescence 3. Co-morbidities are common -ODD and aggression 70% -Communication disorders >20% -Anxiety disorders >14% 4. Often suspended from pre-school or daycare settings Murray, Increased risk of physical injury 2 Schwebel, Speltz, Jones, 2002

3 There are two main challenges: a.issues regarding diagnosis b.issues regarding management 3

4 Issues regarding diagnosis 4

5 Diagnosis seldom reached at first visit! -often need a multi- disciplinary team. 5

6 ADHD in the preschooler: 1. Prevalence estimates range from 2.8% - 6.3% 2. Accurate diagnosis can be difficult 3. Assessment should include consideration of other causes of behavioral dysregulation: Domestic violence a. Family context Child abuse 6 Disturbed patters of attachment

7 ADHD in the preschooler: b. Anxiety processes c. Medical problems Developmental delay d. Developmental issues Sensory deficits Language disorders Brain injury 4. DSM-IV criteria (or ICD-10) still valid 7 Angold, Erkanli, Egger, Keenan, Wakschlag, 2000.

8 Clinical presentation of ADHD in Preschool years 1. Motor restlessness (always on the go) 2. Aggressive (physical) 3. Spills things 4. Insatiable curiosity 5. Fearless may endanger self or others 6. Low levels of compliance 8

9 Clinical presentation of ADHD in Preschool years 6. Vigorous, destructive play 7. Demanding, argumentative 8. Noisy 9. Interrupts others 10. Excessive temper tantrums Du Paul et al,

10 Dilemma: Pre-school (3.5-4 years) children have -shorter attention span -more impulsive behavior -poor self-regulation in formal settings Diagnosis further complicated by temperament and transient symptoms 40% of normal developing preschoolers may present with symptoms of ADHD Lack of appropriate measurement tools 10 Davis, Williams, 2011

11 Early risk factors for ADHD: 1. Family history of ADHD and psychiatric disorders 2. Pregnancy factors (smoking, substance abuse) 3. Poor infant health (prematurity, VLBW, asphyxia) 4. Social: Single parent, low education level 5. Early walking, late talking 6. Eczema Schmitt, 11 Buske-Kirshbaum, Roenner, 2010

12 Early risk factors for ADHD: (continue) 7. Fractious infant 8. Infantile colic 9. Sensory integration deficits 10.Demanding disposition 11.Life threating activities 12.Severe aggression 13.Sleep problems O Callaghan, Al Manm, O Callaghan et al,

13 Recommendations: 1. Essential to distinguish ADHD symptoms form normal developmental variation 2. Assessment should be undertaken thoroughly by experienced paediatricians or child psychiatrists 3. Utilize multiple informants 4. Diagnosis requires evidence of moderate to severe impairment across settings 5. May require a developmental assessment such as the Griffiths Mental Developmental Scales 13

14 Issues regarding treatment: 14

15 General considerations: 1. Multimodal therapy always the approach 2. Medication not to be used as first-line 3. Elimination and restriction diets not supported 15

16 Parent training: 1. Teaches parents to manage children s behaviour by manipulating antecedents (rules, instructions) and consequences (rewards, time-out) 2. Parents, who may have ADHD themselves, may find it impossible to provide a structured environment 3. Classroom behavioral interventions some short term benefits 16 Davis & Williams, 2011

17 The PATS Study (2001) 17

18 The PATS Study (2001): Diagnosis: Tools - Conners Parent and Teacher Rating Scales (Hyperactive/Impulsive) - Diagnostic Interview Schedule for Children - IV - Semi structured diagnostic interview Family demographics Physical examination Kollins, Greenhill, Swanson et al,

19 Inclusion criteria: - Age 36-65months - IQ > 70 (Differential Abilities Scale/Vinelands) - Participation in school-type program at least 2 half-days/week (at least 8 same-aged peers) - Living with primary caretaker for at least 6 months - Systolic and diastolic blood pressure <95 th centile 19

20 Exclusion criteria: - Children or parents who could not understand or follow instructions - Previous adverse events or evidence of a much improved response on MPH - Use of any psychotropic medication in past 30 days - History of Tourette s or Tics - Major medical conditions 20

21 Exclusion criteria (continue): - Adjustment disorders, autism, psychosis, suicidality or other psychiatric disorder that required medication - Evidence of physical, sexual or emotional abuse - Living with anyone who abuses stimulants or cocaine - History of bipolar disorder in both biological parents 21

22 PATS Study Phase 1 Screening Enrollment [ ] Phase 2 [ ] Parent training Phase 3 Baseline Phase 4 [ ] Open label safety lead in 10 weeks Community Parent Education Model Cunningham et al, 2000, weeks Clinical Global Impression Improvement Scale (CGI-I, Guy, 1976) < 30% reduction 1 week MPH 1.25mg bd 7.5mg tds in one week 22

23 PATS Study (continue): Phase 5 [ ] Crossover titration 5 weeks Randomized to receive 1.25, 2.5, 5, 7.5mg or placebo tds (10mg 2 weeks trial) Most clinical benefit No benefit out Phase 6 [114 77] 4 weeks Parallel Phase Effective dose or placebo Placebo responders Phase 7 [40 95] Open label maintenance 10 month in dosage with deterioration Phase 8 [29 8] 6 weeks Placebo vs. MPH Discontinuation 23

24 Side-effects: 1. More side-effects than older children 2. Includes: -decreased appetite/weight loss -nightmares -feeling sad/unhappy -withdrawn socially -trouble sleeping 24

25 Outcomes: 1. MPH-IR (2.5, 5, 7.5mg tds) produced significant reduction in ADHD symptoms in preschoolers over placebo 2. Effect sizes were smaller ( ) than those cited for school-aged children 3. 30% reported moderate to severe adverse events: -emotional outbursts, difficulty falling asleep, repetitive behaviours/thoughts/appetite decrease and irritability 4. 5 children had one-time pulse and blood pressure elevations that were transient 25

26 Outcomes: 5. 11% discontinued because of drug-attributed adverse event 6. Genetic studies inconclusive 7. Concerns about growth (20% less than expected height gain and 55% less than expected weight gain) -NB Sample was significantly larger than average Greenhill, Kollins, Abikoff et al 2006 Wigal, Greenhill, Chiang et al 2006 McGough, McCraclan, Swanson et al

27 Implications: 1. MPH is effective and relatively safe in preschool children 2. Start with small doses 2.5mg tds 3. Optimal dose mg/day 4. Higher rate of MPH discontinuation due to AE s. 5. Side-effects range different from school-aged children 6. Best responses in children with ADHD only, or ODD. (No response in those with >3 comorbidities) 27

28 Non-stimulants: year olds treated with atomoxetine in an open-label study in combination with parent education 2. Significant reduction in ADHD symptoms at dose 1.25 mg/kg 3. Adverse events included mood lability, decreased appetite, weight loss Kratochvil, Vaughan, Mayfield-Jorgensen et al,

29 Medication: 1. Consider when there has been a poor response to behavioural psychotherapy and ADHD symptoms have a severe impact on the child and their family/carers 2. Should be managed in a tertiary setting 3. Start with Ritalin IR trial and monitor closely 4. Extended-release forms of stimulants not routinely used 5. Effectivity and side-effects of non-stimulants not yet fully investigated in pre-schooler 6. Role of Risperidone no studies 29

30 Questions: 1. Long-acting stimulants their role and sideeffects 2. Long term outcomes of children treated early 3. Non-stimulant use in <5 years 4. The cost and resources for parental education 5. Evidence-based ADHD care for preschoolers in real world settings 6. The effects on brain-plasticity? Positive or negative 30

31 Personal view 1. Do not diagnose too quickly 2. Consider parental training and behaviour modification 3. Start medication when there is i. Severe sleep disorder ii. Severe aggression iii. Family is falling apart iv. Interferes with development v. Expelled from nursery school 4. From age 4 - start with Ritalin IR 5mg 5. Under 4 or in severe cases start Risperdal 0.125mg-0.25mg nocte and titrate up (not evidence based) 31