Optimising the Management of ADHD Dr Khalid Karim University of Leicester Leicestershire Partnership Trust
Declaration Have previously presented talks and workshops for Shire Janssen Lilly Flynn I have not received any other funding This talk is a reflection of the available literature and personal opinion
Real title Is it actually possible to optimise ADHD treatment? Or a typical NHS fantasy Is it possible to quantify improvement? Use of rating scales
Aim To think about what we mean by optimising treatment of ADHD in practice Consider the various factors which affect this possibility Explore the various options when addressing this problem
Optimising Treatment Optimising make the best or most effective use of (a situation or resource) Google to make something as good as possible Cambridge Dictionary Treatment (Google) the manner in which someone behaves towards or deals with someone or something care given to a patient for an illness or injury
Optimising Treatment Why is it so difficult? Should we be trying to do this? Is there any way to do this? Would we know when we have got there? Who are we doing it for?
Who are we treating? The child/young person/adult with ADHD The parents/carers/others The education provision Social care provision Healthcare/justice system/employers
Who are we treating? There may be conflicting views on what are the issues Symptoms may change over time/developmental The child/young person will develop their own view/ independence May not want to take treatment/see the point What goals do we set with these different interest groups? Clinicians?
Clinician issues What pressure are services under so is optimisation even possible? Referral numbers Staff availability Clinical training and understanding Clinic time Service design Availability of treatment options (vary enormously) Psycho-education Behavioural management Pharmacological
What are we treating to get optimisation? Attention/concentration Impulsivity Hyperactivity Executive functioning Emotional volatility Anxiety Self-esteem Motor function difficulties Autistic tendencies Substance misuse Tics
What are we treating? The observed presentation Tends to dominate situations The inner cognitive presentation Behaviours are only a marker of these thoughts and feelings Risk profile
Why should we try to optimise treatments? Shaw et al (2012) Systemic review- improvements in many areas but some better than others compared with untreated ADHD- not necessarily optimised Still limited evidence Fredriksen et al (2013) Stimulant medication and atomoxetine generally well tolerated Fairly short studies, limited longer-term evidence Negative outcomes with untreated ADHD Multiple outcomes
Pragmatic approach Treatment in contemporary practice adopts SMART solutions Particularly being measurable Dundee ADHD care pathway (Coghill 2015) Clinical feedback, ADHD-RS-IV,SNAP-IV, SKAMP, CGAS I would argue that ADHD is more complex Limitations of instruments If we treat one thing something else changes Unpredictable outcomes least worse option Balance of outcome/side effects/compliance/engagement
ADHD is not a constant Optimisation of a moving target Child growth Child cognitive development Changes in the brain-up to 25yrs Inconsistency of symptoms on daily basis Effects of sleep, hunger, fatigue Effects of anxiety etc, etc.
What could we try? Feel free to come up with any suggestions NICE guidelines 2008 (updated 2016) Moderate Parent education Group parenting/cbt or individual CBT/social skills Then medication Severe Medication first Group/individual interventions Considerably affected by the resources available: TIME/staff/funding
What could we try? Executive Functioning Increasingly important in adolescence/adulthood Measurable- BRIEF Limited evidence of effectiveness of cognitive training (Rapport et al 2013) Medication-some limited evidence/?higher doses Sleep Significant data on sleep problems in ADHD Brief sleep intervention (Hiscock 2015)most on ADHD treatment Worse sleep on stimulant medication (Kidwell et al 2015) Use of melatonin for sleep issues
What could we try? Do behavioural interventions help? Literature is a little conflicting Daley et al (2014) meta-analysis No effect on core symptoms Effect on parenting and conduct behaviour Anxiety problems Sciberras, et al (2014) Occur in up to 40% children with ADHD Aetiology unclear but does affect presentation and treatment Focus on emotional dysregulation
Medication Remains controversial for many Fairly good evidence Short acting methylphenidate/dexamphetamine Longer acting methylphenidate (Equasym XL, Concerta XL, Medikinet XL Lisdexamfetamine (Elvanse) Atomoxetine (Stattera) Guanfacine (Intuniv) prolonged release Non-standard unlicensed treatments Imipramine, Clonidine
Optimising medication Significant evidence medication effective Longer-term effectiveness? Limited comparative data Farone (2010) compared stimulants Hanwella (2011) atomoxetine vs stimulants Guanfacine (intuniv) limited available data Effectiveness vs side-effects Analogy to OCD treatment (medication and therapy)
In Practice Essential to develop a comprehensive understanding of ADHD, there are limited training opportunities however. Essential to develop a good therapeutic relationship with the child and carers Consider with non-medical staff with some adolescents Consider what is the actual understanding of ADHD as child grows Profile changes, less hyperactivity, independence skills, ASD symptoms Warn in advance of the need to chop and change Careful with expectations
In Practice Decide on goals of treatment and tailor options to this Let family/young person decide on option (if possible) Assess for a number of changes Behaviour Attention Executive functioning Emotional changes Versus side-effects for medication Multidisciplinary group Training in ADHD, medication, CBT(anxiety)Sleep
In practice The treatment level is dependent on feedback from the child, family and school Fairly low threshold for medication/changing medication Examples of practice High levels of methylphenidate trialled on Lisdexamfetamine Longer acting stimulants for older children Emotional volatile-24 hour treatments Changing treatments for tics, appetite, sleep Medication differences in holidays/weekends/daily
Some complexities ADHD and ASD ADHD and Tics ADHD and epilepsy Presentations according to gender
Summary There appears to be no easy way to optimise medication Many different competing factors Understanding ADHD and the treatments appears to be a sensible option TIME is a critical element Questions?
References Shaw, M., Hodgkins, P., Caci, H., Young, S., Kahle, J., Woods, A.G. and Arnold, L.E., 2012. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC medicine, 10(1), p.99. Fredriksen, M., Halmøy, A., Faraone, S.V. and Haavik, J., 2013. Long-term efficacy and safety of treatment with stimulants and atomoxetine in adult ADHD: a review of controlled and naturalistic studies. European Neuropsychopharmacology, 23(6), pp.508-527. Rittel, H.W. and Webber, M.M., 1973. 2.3 planning problems are wicked. Polity, 4, pp.155-169. Attention deficit hyperactivity disorder: diagnosis and management NICE 2016 https://www.nice.org.uk/guidance/cg72 Rapport, M.D., Orban, S.A., Kofler, M.J. and Friedman, L.M., 2013. Do programs designed to train working memory, other executive functions, and attention benefit children with ADHD? A meta-analytic review of cognitive, academic, and behavioral outcomes. Clinical psychology review, 33(8), pp.1237-1252. Hiscock, H., Sciberras, E., Mensah, F., Gerner, B., Efron, D., Khano, S. and Oberklaid, F., 2015. Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. bmj, 350, p.h68. Kidwell, K.M., Van Dyk, T.R., Lundahl, A. and Nelson, T.D., 2015. Stimulant medications and sleep for youth with ADHD: a metaanalysis. Pediatrics, pp.peds-2015. Daley, D., Van der Oord, S., Ferrin, M., Danckaerts, M., Doepfner, M., Cortese, S., Sonuga-Barke, E.J. and European ADHD Guidelines Group, 2014. Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains. Journal of the American Academy of Child & Adolescent Psychiatry, 53(8), pp.835-847.
References Cortese, S., Holtmann, M., Banaschewski, T., Buitelaar, J., Coghill, D., Danckaerts, M., Dittmann, R.W., Graham, J., Taylor, E. and Sergeant, J., 2013. Practitioner review: current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents. Journal of Child Psychology and Psychiatry, 54(3), pp.227-246. Faraone, S.V. and Buitelaar, J., 2010. Comparing the efficacy of stimulants for ADHD in children and adolescents using meta-analysis. European child & adolescent psychiatry, 19(4), pp.353-364. Hanwella, R., Senanayake, M. and de Silva, V., 2011. Comparative efficacy and acceptability of methylphenidate and atomoxetine in treatment of attention deficit hyperactivity disorder in children and adolescents: a meta-analysis. BMC psychiatry, 11(1), p.176. Coghill, D. and Seth, S., 2015. Effective management of attention-deficit/hyperactivity disorder (ADHD) through structured re-assessment: the Dundee ADHD Clinical Care Pathway. Child and adolescent psychiatry and mental health, 9(1), p.52. Sciberras, E., Lycett, K., Efron, D., Mensah, F., Gerner, B. and Hiscock, H., 2014. Anxiety in children with attention-deficit/hyperactivity disorder. Pediatrics, 133(5), pp.801-808.