1 Managing ADHD: Counseling and MedicationRussell A. Barkley, Ph.D. Professor, Department of Psychiatry Medical University of South Carolina Charleston, SC ©Copyright by Russell A. Barkley, Ph.D., 2004

2 Major Treatment ApproachesI. Evaluation (Diagnosis) II. Education (Counseling) III. Medication IV. Accommodations at home in school in the community Maturation (accounts for 3-4x more change than psychosocial treatments)

3 Counseling Parents and ClientsReview ADHD: Nature, Causes, Course, and Treatments (Proven and Unproved) Discuss ADHD as a Chronic Handicapping Condition (I.e. diabetes) Alert Them to Potential Grief Reaction Present the “Parents are Shepherds” Model Change Expectations (30% rule <24 yr) Modify Settings: Points of Performance Encourage Acceptance & Advocacy Encourage routine aerobic exercising

4 Unproved/Disproved TherapiesElimination Diets – removal of sugar, additives, etc. (Weak evidence) Megavitamins, Anti-oxidants, Minerals (No compelling proof or disproved) Sensory Integration Training (disproved) Chiropractic Skull Manipulation (no proof) Play Therapy, Psycho-therapy (disproved) Biofeedback (EMG or EEG) (experimental) 2 randomized trials found no convincing effects Self-Control (Cognitive) Therapies (in clinic) Social Skills Therapies (in clinic) Better for Inattentive (SCT) Type and Anxious Cases

5 Empirically Proven TreatmentsParent Education About ADHD Psychopharmacology Stimulants (e.g., Ritalin, Adderall, etc.) & Atomoxetine (Strattera) Other Noradrenergic Medications (e.g.,Wellbutrin) Tricyclic Anti-depressants (e.g., desipramine) Anti-hypertensives (e.g., Catapres, Tenex) Parent Training in Child Management Children (<11 yrs., 65-75% respond) Adolescents (25-30% show reliable change) Family Therapy for Teens: Problem-Solving, Communication Training (30% show change) Best to combine it with BMT to reduce drop outs

6 Empirically Proven TreatmentTeacher Education About ADHD Teacher Training in Classroom Behavior Management Special Education Services (IDEA, 504) Regular Physical Exercise Residential Treatment (5-8%) Parent/Family Services (25+%) Parent/Client Support Groups (CHADD, ADDA, Independents)

7 Why Do Family Therapies Decline in Effectiveness with Child’s Age?Parents are crucially important to the feeding, clothing, protection, and loving support of their children But the 3 Laws of Behavior Genetics show limits to this: All behavioral traits are heritable – affected by our genes Family and parenting effects contribute less than genes to all of our traits – the influence of parenting is often negligible Unique events (mainly those outside the home) are more important in shaping children’s psychological development than is parenting or family environment How these influences change with age: Parental influences diminish steeply with age Genetic influences increase with age Unique events increase their influence with age Bottom line – You don’t get to design your children or their fates

8 If the Parent has ADHD Consider medication for that parentHave non-ADHD parent handle school homework Alternate nights – each parent takes turns managing the ADHD child every other night Let non-ADHD parent handle deadlines and ADHD parent can make up for it by taking on tasks that are not time sensitive Put yourself in time-out (a quiet room) if you are feeling overwhelmed by your child Discuss major disciplinary actions with your partner before implementing them

9 Why Medicate? Stimulant medications and Strattera are the most effective treatments we have available for ADHD with the largest evidence base Their safety is incredibly well established They improve percent of clinical cases, normalizing 50-60% of such cases They are convenient to administer, with the least effort required relative to other non-medical treatments, especially the once daily delivery systems They can be used for years, even into adulthood They can are active in community settings where no caregivers may be present to provide active treatment (unsupervised activities, driving alone or with friends, free time in schools, bus rides, etc.)

10 Medications Most well-studied drugs in psychiatry Stimulants ResponseUsed 40+ yrs; 350+ studies; thousands of cases Stimulants Response Methylphenidate %+ Ritalin IR, SR, LA, Metadate CD, Concerta, Focalin IR & XR Adderall & XR (d-, l-amphetamines) 76%+ Dexedrine (d-amphetamine) %+ Cylert (pemoline)(discontinue use) %+ Trying all stimulants %+ ? Preschool Response Rate (few studies) 4-5 year olds <50%? 2-3 year olds <30%? Greater side effects than 6+ year olds

11 Key Points: The trend in recent years has been toward special formulations to make longer-acting stimulants because psychostimulants generally have a short duration of action. Methylphenidate and d-amphetamine are short-acting stimulants with peak clinical effect seen between 1 and 2 hours after administration; the effect lasts between 2 and 5 hours. Short-acting formulations require multiple daily doses. The mixture of different amphetamine salts extends the duration of action up to a maximum of 7 hours because of the differing kinetic profile of the two stereoisomers of amphetamine. Sustained release formulations extend the drug effect about 6 to 8 hours thereby reducing the number of daily doses of stimulants to one or two doses. Lengthening duration of action affects not only potential for efficacy but could also affect the potential for side effects. References: Physician’s Desk Reference, 2002.

12 Concerta: A New Delivery SystemConcerta uses OROS technology to create an osmotic pump Activated by water absorption in the stomach and intestinal track Pressure delivers a continuous flow of liquid methylphenidate Lasts hours Same effects and side effects as regular methylphenidate

13 Stimulants: Behavioral EffectsIncreased Concentration & Persistence Decreased Impulsivity & Hyperactivity Increased Work Productivity (~Accuracy) Better Emotional Control Decreased Aggression & Defiance/ODD/CD Improved Compliance & Rule Following Better Working Memory & Internalized Language Improved Handwriting & Motor Coordination Improved Self-esteem Decreased Punishment from Others Improved Peer Acceptance & Interactions Better Awareness of Game in Sports

14 Stimulants: Side EffectsLargely benign; <5% discontinue due to adverse events All are dose responsive Insomnia & Loss of Appetite (50%+) Headaches & Stomach Aches (20-40%) Irritable, Prone to Crying (<10%) Nervous Habits & Mannerisms (<10%) Tics (<3%) & Tourette’s (Rare) Mild Weight Loss (mean = 1-4 lbs.; transient) Small Effects on Height over 1st year (about 1 cm)

15 Side effects - stimulantsIncreased Heart Rate (3-10 bpm), Pressure ( mmHg) Monitor higher risk African-American males <3% stimulant psychosis No discernible long-term adverse consequences to date Pemoline – requires frequent monitoring of liver enzymes

16 Stimulants: Common MythsAddictive When Used as Prescribed No, must be inhaled or injected These drugs are over-prescribed 1-2 % on medication vs. 3-7% prevalence Creates Aggressive, Assaultive Behavior No, decreases aggression & antisocial actions Increased Risk of Seizures (No) Only at very, very high doses Cause Tourette’s Syndrome (No) can increase tics in 30%; decrease it in 35%

17 More Myths About StimulantsGreater Risk of Later Substance Abuse No, 12 studies find no such result; a few also found decreased risk if continued through teens Doesn’t Improve Academic Achievement Not if you mean academic knowledge Improves work productivity Improves classroom conduct and rule-following Improves peer interactions at school Can result in improved grades Results in reduced punishment

18 Stimulants: Suggested PracticesTake time to explain medication to parents Always give parents a drug fact sheet Or Dr. Tim Wilens book on medications Use parent/teacher ratings during titration Start – once daily delivery system - Concerta, Medadate CD or Adderall XR Start – lowest dose (low-slow-go approach) Increase dose weekly Upper limit is determined by response titrate upward until side effects or a positive response is obtained

19 Stimulants: Suggested PracticeUse late day dosing as needed (35%+ will) If no response, try another stimulant or other delivery system or switch to Strattera Body weight is not so important to dosing Use medication on weekends as needed Consider use in summer as needed Always start school year back on meds. Use October for trial off meds. (2-5 days) Get parent and teacher ratings (Oct.) Use as many years as needed

20 Strattera (atomoxetine)Exclusive noradrenergic reuptake inhibitor Unscheduled (not Schedule II); no abuse potential Approved in US January 2003 by FDA; tested in more than 5,000 cases worldwide Used with more than 2 million patients to date Effective for kids, teens, and adults with ADHD Equal efficacy with methylphenidate for new, medication naïve cases; slightly lower success rates in children previously on stimulants (effect sizes are s)omewhat smaller vs ) 75%+ positive response rate Sustained response demonstrated for up to 3 years Can be given once daily (in AM) or split (AM/PM)

21 More on Strattera Reduces ADHD, ODD, & aggressionReduces internalizing symptoms Increases in school productivity Improved peer social behavior Improved self-esteem Improved parent-child relations Improved dry nights among bed-wetters Better “morning after” behavior Less insomnia (7%) than methylphenidate (30-50%) Faster time to sleep onset No emotional blunting – restriction of range

22 Side Effects Sedation (in kids) (20%)Decreased appetite (14-22%); nausea (12%); Dizziness (6%) Increased blood pressure (2 mm/Hg diastolic, 3 mm HG systolic); Increase of 8 bpm pulse; Temporary weight loss (1-5 lbs) early in therapy – first year; no further loss thereafter Transient minor effect on height CYP2D6 genotype results in poor metabolizers with 2-3x blood levels of extensive metabolizers but no differences in tolerability or discontinuation due to adverse events

23 Strattera - Dosing Capsule sizes: 10, 18, 25, 40, 60 mgStarter sample bubble packs available in 18/25, 25/40, and 40/60 mg titration packs – Starting dose: 0.5 mg/kg, range up to 1.8 mg/kg (monitor blood levels beyond 1.8 mg/kg this) Therapeutic doses often achieved between 1.0 and 1.4 mg/kg; studies found no differences between 1.2 and 1.8 mg/kg but both better than 0.5 mg/kg Can be given once or twice daily Adult dosing mg daily dose

24 The Changing Landscape of Medical Management of ADHDPsychosocial Treatments + Accommodations Non-stimulants - atomoxetine Stimulants

25 Thinking About Strattera Barkley & Macias Clinical GuideUrgency of drug response Patient Characteristics Prior Responding to Stimulants Social Context of the Patient

26 When to Use Strattera: Patient CharacteristicsNo need for urgent drug response in severe cases Pre-existing bedtime or morning behavior problems New cases that are fussy eaters or pre-existing eating problems Adolescents or college students where concern is recreational misuse or diversion Prior history of drug dependence or abuse Comorbid tic disorders Comorbid anxiety/depression Comorbid enuresis

27 Issues Related to Stimulant UseOld cases unresponsive to stimulants Adverse responses to stimulants Significant sleep problems from stimulants Significant morning behavior problems from stimulants Significant appetite suppression from stimulants Significant blunting or constriction of normal affect from stimulants (withdrawn, automaton-like affect)

28 Social Context for PrescribingSubstance abuser in immediate family Parent resistance to use of scheduled medications (adverse publicity, abuse or diversion potential, extended family conflict) Patient resides in school dormitory or group living arrangement (diversion potential)

29 Other AntidepressantsNone are FDA approved for ADHD Tricyclic Antidepressants (Use is declining): Tofranil (Imipramine) Elavil (Amitriptyline) Norpramin (Desipramine) (Has most research) Other Noradrenergic Agents: Wellbutrin - bupropion (A few studies – significant positive effects; not as effective as stimulants) SSRIs – Selective Serotonin Reuptake Inhibitors Prozac (fluoxetine) - Not effective for ADHD

30 Tricyclic Antidepressants: Behavioral EffectsModest improvement in attention span Modest decrease in impulsivity Modest decreases in hyperactivity Better mood regulation, less irritable Decreased aggression, hot temper Little improvement in school performance Some improvement in social relations

31 TCA - Antidepressants - Side EffectsDry mouth, Constipation (often) Blurred vision (occasionally) Delayed urination (uncommon) Increased perspiring during exertion Slowing of cardiac conduction (rare) Tachycardia, Hypertension (rare) Increased heart rate, Heart block (very rare) Psychotic reactions, mania (very rare) Seizures (rare)

32 Antihypertensive Drugs: Clonidine and GuanfacineNot FDA approved for use with ADHD Consider as last choice agents; both require EKG monitoring; can be combined with stimulants May be most optimal for aggressive-explosive behavior and severe hyperactivity Both Alpha2 adrenergic agonists but may work in ADHD by affecting norepinephrine Both improve ADHD, ODD, & CD symptoms but not as effective as stimulants; guanfacine better for comorbid tic disorders Cause sedation (more for clonidine) and rebound hypertension; Clonidine may improve sleep problems associated with ADHD or stimulants

33 Why Use Psychosocial Treatment?Combination often results in greater effectiveness than single modality treatment Better prepares parents and teachers for managing the ADHD child when off medication or when non-ADHD behavioral problems exist Addresses comorbid disorders where medications may have little or no effects (LD, CD, MDD, anxiety disorders, etc.) Can result in lower doses of medications while achieving same level of effectiveness as do higher drug doses used alone May address specialty populations where parent or child skill deficits exist due to low socioeconomic status or educational inopportunity Enhances parent-teacher consumer acceptability of treatment

34 Treatment Approach IV: 18 Great Ideas for ManagementParents are Shepherds, Not Engineers Reduce Delays, Externalize Time Externalize Important Information Externalize Motivation (Think win/win) Externalize Problem-Solving Use Immediate Feedback Increase Frequency of Consequences Increase Accountability to Others Use More Salient & Artificial Rewards

35 More of the Great Ideas Change Rewards PeriodicallyTouch More, Talk Less Act, Don’t Yak Keep Your Sense of Humor Use Rewards Before Punishment Anticipate Problem Settings - Make A Plan Keep A Sense of Priorities Maintain a Disability Perspective Practice Forgiveness (Child, Self, Others)

36 Major Behavioral TacticsBalance the following two strategies Altering Antecedents – Get Proactive: Giving effective instructions Altering performance settings Point of performance prompts & cues Altering Consequences – Being Reactive Positive reinforcement (tokens, rewards, etc.) Punishment (time outs, grounding, fines, etc.) Changing schedules (increasing frequency and immediacy of consequences)

37 Parent Training 1. Review of ADHD 2. Explain the 4-factor model of ODD3. Improve parental attending skills 4. Improve attending to compliance and command effectiveness 5. Decrease disruption, increase independent play (Shaping with frequent reinforcement) 6. Establish a Home Token System 7. Improve Punishment Tactics Fines, time outs, and isolation to bedroom 8. Trouble-shooting Disciplinary Tactics 9. Managing Children in Public Places Transition planning 10. Helping at School: Daily Behavior Cards 11. Review of Skills - Future Problems 12. 1-month Booster Session

38 4-Factor Model of DefianceParental Personality Child defiance and social aggression Disrupted parenting Family Stressors Child Temperament (& ADHD)

39 Making Commands EffectiveHeavily Praise High Compliance Commands Initially Use Imperatives, Not Questions Go to Child, Touch, & Use Eye Contact Child Recites Request Make Complex Tasks Simpler Ones Make Chore Cards for Multi-Step Tasks List all steps involved in task on 3x5 file card Stipulate a time period on the card

40 More on Effective CommandsReduce Time Delays for Consequences Use Timers at Points of Performance Don’t Assign Multiple Tasks at Once Praise the Initiation of Compliance Reward Throughout the Task Child Evaluates Performance at End

41 Great Rules for Token Systems1. Use physical tokens for children <7 yrs 2. List as many rewards as possible (15+) 1/2 or more must be available daily Add bonus points for attitude 3. Make a list of daily/weekly jobs 4. Target social behavior (starts & stops) 5. Assign point values based on: Effort required in the task Amount of prior resistance to doing it 6. Use bigger values for older kids

42 Rules for Token Systems7. All money is earned via the token system 8. No credit: No tokens, no privileges 9. Give tokens prolifically; assign a daily quota 10. Introduce the program on a positive note 11. Award tokens for obeying 1st command 12. No fines for the initial week 13. Once fines begin, avoid punishment spirals (Fine twice, then time out or isolate) 14. Use bigger fines for antisocial acts 15. Keep a 2:1 ratio (rewards-to-fines)

43 Procedures for Time OutsFor Household Rules - Instant Time Out For immediate commands: Give Command (then use 5 count, backwards) Give Warning (repeat 5 count) (Raised voice) Then initiate time out Release from time out contingent on: Serving minimum period (1-2 min./yr.) Then becoming quiet Then consenting to command

44 Rules for Time Outs Afterwards, reward next good behaviorIf child escapes time out: Increasing length of time out does not work Consider using fines in token system Better yet, use bedroom for time out - Close and lock the door , as needed Use time outs for just 1or 2 types of problem behavior at a time

45 Managing Children in Public: Transition PlanningBefore entering public place, STOP! Review 2-3 rules child needs to obey Child repeats them back Establish an incentive or reward Establish the punishment to be used Bring something for the child to do Enter the place, then follow your plan Reward throughout the trip

46 Problem Solving Training -TeensRequires Behavior Management Training First ! Limited efficacy (<30% reliable change) Three Stages to Therapy: I. Training family members in problem solving steps (6-8 sessions, 2x/week) II. Coaching family members in positive communication skills (6-8 sessions) III. Helping parents and teen to reframe unreasonable beliefs (2-4 sessions) Taped practice sessions as homework

47 Stage I: Problem Solving6 Steps to effective problem solving: 1. Define the problem - write it down Keep family members on task 2. Generate list of all possible solutions No criticisms permitted 3. Briefly (!) critique each possibility (+ - 0) 4. Select the most agreeable option 5. Make this a behavior contract (All sign) 6. Establish penalties for breaking it

48 Stage II: Reversing Negative Communication StylesTypes of Negative Communication: - Blames/accuses Rigid/Defensive - Moralizing Mind Reading - Commands/Threats Monopolizing - Put Downs/Insults Over-generalizing - Exaggerating Outcomes - Sarcasm - Diversions, off task Tuning Out Therapy concentrates on alternative positive styles of communication

49 Stage III: Helping Families to Restructure Irrational BeliefsTeen: Ruination & Fairness Autonomy & Approval Double Standards Parents: Ruination & Perfectionism Blind Obedience & Malicious Intent