Multimodal Treatment of Hyperactivity Disorders

Professor Peter Hill

London

Multimodal treatment

Total treatment of the whole child

Two initial diagnostic issues

• Differential diagnosis

Is this actually ADHD or something else?

• Co-morbidity

What else is going on as well as ADHD?

In my hyper-specialist clinic at Great Ormond Street Hospital for

Children, London

Cases of ‘ADHD’ referred for re-evaluation from all over the UK by other specialist child psychiatrists

In this clinic

In the last 100 cases seen in 2002

18 were confirmed as ADHD only

37 were ADHD and something else

45 looked like ADHD but were not

Of these 45

(Looked like ADHD but on detailed examination, did not meet diagnostic criteria for it)

10 autistic spectrum/PDD 8 anxiety9 attachment disorder10 global learning disability (IQ<50)4 conduct disorder only3 Tourette’s syndrome

Of these 45(continued)

3 developmental language disorder3 primary sleep problem2 impaired auditory memory only2 episodic hyperactivity

-Kleine-Levin syndrome

-cyclothymic mood disturbance

1 frontal lobe damage

Co-morbidity for developmental disorders

8

19

26

10

23

7ADHDn=48

dyspraxia

dyslexia

Kaplan B et al 1998

Co-morbidity for other disorders

• 40-70% have conduct or oppositional-defiant disorder

• 30-40% have anxiety disorders

• up to 30% eventually show mood disorder

• Increased rates of– tic disorders– drug misuse

Associated issues

• Family stress and breakdown

• Educational underachievement

• Low self-esteem

• Relationship failure

• ADHD in other family members

In other words

• Full clinical assessment absolutely necessary – For differential diagnosis– For assessment of co-morbid conditions– To recognize impairment and associated

problems (“the burden of ADHD”)

Also necessary

• To establish a baseline of clinical features and impairments so that treatment can be evaluated

Protocol approach

• To ensure thoroughness

• Should be possible to audit - to examine what went on in each case

• Intended for first contact with specialist service

Boxes are ticked when task is completed

Not there for data entry

Assessment 1.

• Baseline – presenting complaints– ADHD symptoms– academic achievement– social relationships– parental attitudes

Assessment 2. Sources

• Parental interview

• Parental questionnaire

• Child interview

• Teacher questionnaire

• Teacher report

Assessment 3. Coverage

• Current symptom review

• Developmental history

• Family history

• Medical history

• Medication history

Assessment 4. Physical assessment

• Growth chart

• Head circumference

• Hearing

• Co-ordination

Assessment 5.Psychometric assessment

• Verbal (BPVS, WISC, BAS)

• Non-verbal (Matrices, WISC, BAS)

• Reading

Assessment 6. Check co-morbidity

• Antisocial behaviour problem

• Emotional disorder

• Tic disorder

• Pervasive developmental disorder

• Specific scholastic skills problem

• Motor planning problem

• Self-esteem problem

Treatment practice

Fulfil basic criteria for medication? Few foods diet

Establish basic parentaland classroom handlingpractices.

Provide information.

Medication protocol

no

yes

Treatment practice 1

• Information to parents

• Information to child

• Letter to school

• Letter to GP and school doctor

Best treatment practice 2. Basic handling practices

• Appropriate expectations

• Positive parental attending

• Effective communication of rules

• Contingency management

Conditions for stimulant medication

• Diagnosis recorded

• Parents accept

• School will co-operate

• Normal heart and blood pressure

• Seizure-free or stable epilepsy

• Not Tourette’s syndrome (?)

• Growth satisfactory

• No household member with substance

misuse or eating disorder

Basic principle of medication protocol

Titration of dose against

• symptom relief

• academic and social achievement

• side-effects

Medication 1. b• Rating scale to parents • Rating scale to teacher• Side-effects list to parents Collect at or just before • 2-3 weeks after baseline rating (b)• 4-6 weeks ditto• 6-9 weeks dittoTimes will vary according to school termb=baseline

2w 6w 9w

Medication 2.

• Methylphenidate 5, 5, 5 for 2-3 weeks

• Methylphenidate 10, 10, 5 for 2-3 weeks

• Methylphenidate 15, 15, 5-10 for 2-3 weeks

Can add promethazine/clonidine/trazodone/

melatonin as evening dose

Medication 3.

If no response to methylphenidateContinue fortnightly questionnaires and review

• Dexamphetamine 2.5, 2.5, 2.5• Dexamphetamine 5, 5, 2.5• Dexamphetamine 7.5, 7.5, 2.5-5

Can add promethazine/diphenhydramine/clonidine/trazodone/melatonin as evening dose

Medication 4.

If no response to dexamphetamineContinue fortnightly questionnaires and review

• Imipramine 25 / day (single or divided)

• Imipramine 50 / day

Medication 5.

• If response, continue, reviewing personally no less frequently than 6 monthly with growth chart

• Discontinue medication at 12 monthly intervals to test requirement

• If no response, consult tertiary centre

Combinations

Protocol uses

• psychological treatment for all, provided through parents (makes assumption that this is justified though MTA results question this)

• diet only if medication not acceptable

But

• What if diet not acceptable?– Can use cognitive-behavioural approach more

intensively

• What about school?– Needs active liaison and agreed management strategies

• for classroom and playground behaviour

• for academic performance

• for self-esteem

What else?

Use of both CBT for associated emotional and behavioural problems (MTA re-analysis)

Taking the long view (American Academy of paediatrics guidance)

Examining the effect of medication (mainly MPH) on

non-core psychological features• Does not alter locus of control (Horn et al 1991)• Improves parent-child and child-child interactions

(Schachar et al 1987; Whalen et al 1989))• May increase self-esteem (atomoxetine: Swenson

et al 2001)• Reduces aggression (Taylor et al 1987)• Increases academic performance (Pelham et al

2002)

Hard work?

• Full assessment of child• Multiple baseline interventions• Full involvement of family• Inter-agency liaison, especially school

Probably an argument for

- Specialist clinics

- Two levels of specialist service

Worthwhile?

• For child and family now• For adulthood

– Note that most of the poor outcomes in adult life are because of co-morbid disorder, educational failure, relationship failure and occupational failure

• Need therefore to take broadest possible view of treatment

effectiveness - a multimodal or total treatment approach