Transcript Externalizing Behavior Problems

Attention Deficit
Hyperactivity Disorder
Rachel J. Valleley, Ph.D.
Assistant Professor, Pediatrics
Munroe-Meyer Institute, UNMC
Current Conceptualization
Attention-Deficit Hyperactivity Disorder (ADHD)
DSM-IV, 1994
Three subtypes:
Predominantly Inattentive
 Predominantly Hyperactive/Impulsive
 Combined

Adolescent and Adult Outcomes
 Chronic disorder lasting into adulthood
 1/3: Tolerable outcome
mild problems - adapt to difficulties

1/3: Moderately poor outcome
variety of problems such as school, vocational, adjustment
difficulties, interpersonal problems, underachievement,
problems with alcohol

1/3: Poor outcome
severe dysfunction including repeated criminal activity,
alcoholism and drug use.
Pittsburgh ADHD Longitudinal Study, Molina and Pelham
Cause of ADHD
No one cause identified.
Not caused by
Diet (i.e. food additives, sugar)
 Poor parenting

Prevalence of ADHD
Standard estimate: 3%-5%
More recently:
12%
(Fabiano & Pelham, 2001)
Attention-Deficit Hyperactivity
Disorder
Diagnosis:
Who has ADHD?
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion A:
Six or more symptoms from one or both of these
lists:
 Inattentive Type
 Hyperactive/Impulsive Type
…have been present for at least 6 months.
Symptom Lists
Inattentive Type
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fails to attend to details, makes careless
mistakes
difficulty sustaining attention in play or
work
does not listen when spoken to
does not follow through
difficulty organizing tasks
avoids task requiring sustained mental
effort
loses things needed
distracted by extraneous stimuli
often forgetful
Hyper/Impulsive Type
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often fidgets hands/feet or squirms
often leaves seat when sitting is expected
runs about or climbs excessively
difficulty playing or engaging in leisure
activities quietly
often “on the go”/ “driven by motor”
talks excessively
blurts out answers before questions completed
difficulty awaiting turn
interrupts or intrudes on others
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion B:
Some of the symptoms were present before the age
of seven years.
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion C:
Some impairment from the symptoms is present in
two or more settings (e.g., home, and school or
work).
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion D:
There is evidence of clinically significant
impairment in social, academic, or occupational
functioning.
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion E:
The identified symptoms are not better accounted for
by another mental disorder.
Other Common Causes of Attention &
Hyperactivity Symptoms
 Oppositional Behavior
 Learning difficulties
 Depression/anxiety
 Drug/alcohol use
 Physical illness
 Adjustment
Associated Problems
 Oppositional Defiant Disorder: 35 - 65%
 Learning Disability: 25 - 30%
and variable academic quality
 Poor social skills, peer relationships

Often overlooked!
 Difficulties in family functioning
Attention-Deficit
Hyperactivity Disorder
Assessment:
All that wiggles is not ADHD
Comprehensive Diagnosis for ADHD
There is no single test or laboratory measure which
can reliably detect ADHD.
Comprehensive Diagnosis for ADHD
Information gained by qualified clinician:

From family
o standardized, norm-referenced ratings
o detailed history

From school
o standardized, norm-referenced ratings
o academic history
o in-class observations

From clinician
o
observations
Parent Behavior Rating Scales
 Conner’s: quick and dirty screening for ADHD
and ODD
 CBCL/BASC: screen for a variety of problems
 Eyberg: screen for most common behaviors
that drive parent crazy
 ADHD-IV: screens for hyperactivity/impulsivity
and inattention symptoms
 Disruptive Behavior Disorder: screens for
ODD & CD
 Narrative summary to assess for impairment
Teacher Behavior Rating Scales
 Conner’s: quick and dirty screening for ADHD
and ODD
 CBCL/BASC: screen for a variety of problems
 ADHD-IV: screens for hyperactivity/impulsivity
and inattention symptoms
 Disruptive Behavior Disorder: screens for
ODD & CD
 Narrative summary to assess for impairment
Youth Behavior Rating Forms
 If appropriate:
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CBCL to screen for a variety of problems
Reynold’s Adolescent Depression Scale
Reynold’s Child Manifest Anxiety Scale
Childhood Depression Inventory
When to refer?
 Screening measure indicates elevation in
Hyperactivity/Impulsivity and/or Inattention
symptoms
 Unclear if other explanation for symptoms
 Don’t have time for comprehensive evaluation
What to expect if referred to me
 Meet for initial appointment to determine if
evaluation is warranted (screening measure
already completed is helpful)
 Conduct comprehensive evaluation
 Present treatment options based upon
diagnosis
 Send back to physician if want medication
and/or need verification of diagnosis for
school
Treating ADHD
What we know works:
 Drug Therapy
 Behavior Therapy
 Combined Behavioral/Drug Treatments
APA Task Force on Evidence-Based Treatments, JCCAP, Pelham,
Wheeler, & Chronis, 1998
What we know DOESN’T work:
 Play therapy
 Individual or family counseling (without
altering the environment)
 Social skills/self-monitoring/organizational
planning.
 Dietary management
 Megavitamin therapy
 Sensory integration therapy/chiropractics
 Biofeedback
Medications for ADHD
Ritalin
Adderall
Cylert
Dexedrin
Strattera
Concerta
What Medications Can Do
Manage symptoms
 Decrease activity level
 Decrease impulsivity
 Increase attention or “focus”
What Medications Can Do
Improve associated features
 Decrease “defiance”
 Decrease aggression
 Suppress negative social skills
What Medications Can’t Do
 Teach new, appropriate behaviors
Compliance/rule-following
Self-management
 Teach content previously missed
Academic work
Social skills
 “Cure” ADHD
Stimulant Medications:
Considerations
 Effective for 70-75%
 Higher doses associated with more side effects
 Positive effects are lost when drug discontinued
Stimulant Medications:
Contraindications
 Under six years of age
 High anxiety level
 Thought disorder
 History of tics or Tourette’s Syndrome
 Risk of drug abuse
 Unacceptably high levels of negative side effects
Limitations to Medication Treatment
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Rarely sufficient to bring a child into normal range of functioning.
Works only as long as taken.
Not effective for all children.
Doesn’t affect several variables (e.g., academic skills, family
problems).
Poor compliance with long-term use.
Parents not satisfied with medication alone.
Removes incentives to work on other treatments.
Lack of long-term evidence for effects.
Potentially problematic side-effects.
Behavior Therapy for ADHD
Components
 Highly Structured
 Immediate Feedback
reinforcer or reward for appropriate behavior
punishment for inappropriate behavior
 Salient/Meaningful Feedback
Common Behavior Interventions
 Daily Behavior Report Card
 Token Economy
 Parent Training
Daily Behavior Report Cards
 Daily note is sent between home & school
regarding child’s behavior
 Target behaviors monitored throughout the day
 Performance on note determines consequences at
home and/or school
Daily Behavior Report Cards
Academic Behaviors
Social Behaviors
 Working on assignments
 Remained in seat
 Completing homework
 Talked in turn
 Handing in assignments
 Respectful behavior
 All work up to date
 Got along with peers
 On time for class
 Following instructions
 Hands to self
Sample School-Home Note
Classes
Turned in work
Work turned in at least
80% accurate
Math
Yes
No
Yes
No
Reading
Yes
No
Yes
No
Spelling
Yes
No
Yes
No
Social Studies
Yes
No
Yes
No
Science
Yes
No
Yes
No
Homework:
Teacher
Initials
Daily Behavior Report Card
 Benefits
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Keeps communication open between child’s
environment
Helps monitor whether behavior is changing
Can monitor impact of medication
Takes very minimal adult time
Helps child get lots of positive feedback
throughout the day
Token Economies
 Arbitrary token (e.g., poker chip) given for
demonstrating appropriate behavior
 Tokens lost for inappropriate behavior
 Tokens exchanged for reinforcers
 This type of intervention becomes highly
individualized based upon behaviors
targeted, what is reinforcing to the child, and
in what settings it is used
Parent Training
 Increase positive interactions for appropriate
behavior
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Child-Directed Interaction
Role of Attention
Access to Tangibles
 Decrease negative behaviors
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Time-out (up around 8 years)
Job card grounding (around 8 and older)
Limitations of Behavioral
Interventions
 Often not sufficient to bring a child into the
normal range of functioning.
 Must be broad in scope to affect important
familial variables.
 Lack of evidence for long-term effects.
 Difficult to get parents and teachers to do
over a long period of time.
 Costly compared to medications.
Which to employ?
 The NIMH Multimodal Treatment Study
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Largest NIMH-funded study of child mental
health concern
579 children at multiple sites
Group comparisons including:
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Community Treatment
Psychosocial Treatment Only
Medication Only
Combination of BT and Meds
Which to employ?
 Summary of Findings
 All four groups improved with time.
 Combined > Behavior on all measures.
 Combined > Medicine on most measures of
impairment but not symptoms.
 Combined and sometimes Medicine > CC.
 Combined produced more normalization at
lower doses than Medicine; was more
preferred by parents.
Which to employ?
Change in Presenting Problem
Med Mgmt
Combined
Behavioral
Declined/
Drop Out
Worse/
Unchanged
Slight
Improved
12%
4%
0%
6%
6%
5%
22%
11%
22%
Improved
38%
37%
43%
Much
Improved
22%
41%
30%
Which to employ?
Satisfaction with Child’s Progress
Med Mgmt
Combined
Behavioral
Declined/
Drop Out
Dissatisfied
12%
4%
0%
5%
3%
3%
Neutral
2%
2%
4%
Slightly
Satisfied
23%
11%
19%
Satisfied
41%
38%
47%
Much
Improved
17%
42%
27%
Which to employ?
Overall Satisfaction with Treatment
Med Mgmt
Combined
Behavioral
Declined/
Drop Out
Dissatisfied
12%
4%
0%
3%
2%
1%
Neutral
6%
4%
1%
Slightly
Satisfied
5%
3%
4%
Satisfied
40%
18%
31%
Much
Improved
34%
70%
64%
MTA Notes: The Combined Approach
Excellent Responder Analysis
% meeting Snap Parent/Teacher
“Normalization Criteria”
CC
Beh
Med
Combined
14 mos
25%
34%
56%
68%
24 mos
27%
32%
38%
48%
When to refer?
 Medication is not being enough to bring into
normal functioning
 Side effects too great for medication
 Parents want alternative treatment to
medication
 Co-occurring problems (ODD, CD, Anxiety,
Depression)
Questions
 ????????????