ATTENTION

DEFICIT/
HYPERACTIVITY
DISORDER

EVIDENCE BASED
NEUROLOGICAL
TREATMENTS

EDPS 658

Lindsay Birchall

PRESENTATION OVERVIEW
What is ADHD
-Symptoms
DSM-V
The neurology of ADHD
Empirically Based Neurological Interventions
-Medications
-Early Interventions
-Behaviour Modification
-Cognitive Behaviour Therapy
-Psychoeducational & Environmental
Modifications
Lifespan-Outcomes
Questions

QUESTIONS

Text Box

What are the symptoms of

ADHD?

ATTENTION DEFICIT/HYPERACTIVITY
DISORDER DSM-V (APA, 2013)
A. A persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with
functioning or development, as characterized by
Inattention and/or Hyperactivity and Impulsivity:
-Exclusion Opposition, defiance or hostility, not
due to lack of understanding
-Older adults (17 yrs+) 5 symptoms required
B. Symptoms present prior to 12 years of age
C. Present in 2 or more settings
D. Evidence of reduced functioning
E. Exclusive Factors: Schizophrenia or another
psychiatric disorder (e.g. anxiety, mood disorder)

ADHD
DSM-V CONTD
(APA, 2013)

Specify:
Type- 314.01 (F90.2) Combined Presentation
314.00 (F90.0) Predominantly Inattentive
314.01 (F90.1) Predominantly
Hyperactive/Impulsive
-Partial Remission
-Severity (mild, moderate, severe)

THINGS TO NOTE
DIAGNOSTIC

SUBJECTIVITY (OFTEN,

ON THE GO, SEVERITY, DISORGANIZED, WEARING

OTHERS OUT WITH THEIR ACTIVITY, LOSES THINGS,
FORGETFUL)

GENETICS/ENVIRONMENT
EXECUTIVE FUNCTIONING

GENDER

2:1
CULTURE
PREVALENCE
CHILDREN 5%
ADULTS - 2.5%

AttentionDeficit/Hyperactivity
Disorder (ADHD) is a
common, long-lasting,
treatable childhood
psychiatric
Disorder (Curatolo, DAgati
& Moavero, 2010)

CO-MORBIDITIES AND TREATMENT

DSM-V (APA, 2013)
ODD-50%-combined
type
ODD-25%-inattentive
CD-25%-combined
Disruptive Mood
Dysregulation
Disorder
SLD
Anxiety
Major Depressive
Disorders

Intermittent Explosive Disorder

Substance Use Disorder

Personality disorders (e.g. anti-social)

OCD
Tics
ASD

THEORETICAL MODELS ADHD

Beck, David & Rostain, 2006

THE NEUROLOGY OF ADHD

NEUROLOGICAL FEATURES - ADHD

Brain Volume 3-5% smaller

(CURATOLO ET AL., 2010; PARKER, 2013; Seidman, Valera, and

Makris, 2005)

NEUROLOGICAL FEATURES - ADHD

Prefrontal Cortex structure/function/volume
(Pasini & DAgati, 2009; Emond, Joyal & Poissant, 2009; Makris et al., 2008).

NEUROLOGICAL FEATURES - ADHD

Basal ganglia & Cerebellum
structure/function/volume
(Pasini & DAgati, 2009; Emond, Joyal & Poissant, 2009; Castellanos, 2002)

NEUROLOGICAL FEATURES - ADHD

Brain Maturation Delay -Grey Matter &

Prefrontal Cortex (Shaw et al, 2007, Shaw at al, 2006)

NEUROLOGICAL FEATURES - ADHD

White Matter Myelenation - DTI studies

(DAgati, Casarelli, Pitzianti & Pasini, ND)

NEUROTRANSMITTERS
Who Remembers?

TREATMENT MEDICATIONS

ADHD-NEUROTRANSMITTERS & MEDICATION

Dopamine
Impulse Control

Serotonin Depression

Norepinephrine
Attention/Distractibili
ty

HOW MEDICATIONS WORK NEUROTRANSMITTERS

STIMULANT-METHYLPHENIDATE
(CURATOLO ET AL., 2010; PARKER, 2013)

Trade

How it works

Concerta
Methylin
Ritalin
Equasym
XL

-Blocks DA transporter
-Amplifies DA response
duration
-Disinhibits D2
Receptor
-Inhibits NE re-uptake

Name

Application

-Immediate
Release
-Osmotic
Release
-Extended
Release
-Long-acting
-Transdermal
Side Effects:
patch
Decreased appetite, insomnia, abdominal
pain, nervousness, irritability, weight
gain, headache, dizziness, affective
symptoms, nausea, vomiting, short term
increase in heart rate and blood pressure

Efficacy (MetaAnalysis)
.92
.90
.85
.96
N/A

STIMULANT DEXTROAMPHETAMINE
(CURATOLO ET AL., 2010; PARKER, 2013)

Trade Name

How it works

Application

Efficacy
(Meta-

Analysis)
Dexadrine,
Dextrostat
ProCentra

-Increases release -Immediate

of DA and NE into Release
synaptic cleft
-Extended
-Decreases reRelease
uptake into
-Prodrug
presynaptic
neuron
Side Effects:
Decreased appetite,
insomnia,
-Inhibits
palpitations, tremor,
headache, dizziness,
catabolism
dry mouth, weight loss, abdominal
symptoms, irritability, abdominal pain

1.24
1.13
1.52

STIMULANT-LISDEXAMFETAMINE
(CHAPLAN & HAYWARD, 2008; PARKER, 2013; VYVANCE.COM)

Trade Name

How it works

Application

Efficacy?

Vyvance

-Amino acid
attached to
methylphenidat
e inactive

Extended
Release (long
duration of
action)

-reduce ADHD
behaviour
severity by 80%
compared to
68% with
methylphenidat
e and 10-14%
for the placebo

Side Effects:
Dry Mouth, decreased appetite,
insomnia, anxiety, irritability, nausea,
vomiting, weight loss, upper stomach
pain, diarrhea, dizziness *slows growth
in children and adolescence

STIMULANT MIXED
AMPHETAMINE SALTS (CURATOLO ET AL., 2010;
PARKER, 2013)

Trade

How it works

Application

Name
Adderall

-Increases release
of DA and NE into
synaptic cleft,
decreases reuptake into
presynaptic
Side Effects: neuron, inhibits
Decreased appetite,
agitation,
catabolism
insomnia, headache

Efficacy
(Meta

Analysis)
-Immediate
Release
-Extended
release

1.34
0.77

Tolerance

Addiction

Stages

NON-STIMULANTS- ATOMOXETINE
(PARKER ET AL., 2013; CURATOLO ET AL., 2010; STRATERRA.COM)

Trade

How it Works

Application

Name
Straterra

Efficacy
(Meta-

Analysis)
-Selectively
inhibits synaptic
DA re-uptake
-increase in
dopamine and
norepinephrine

-Immediate
Release
-up to two
weeks for
effects

.63

Side Effects:
*Suicidal Thoughts or actions*
Constipation, dry mouth, nausea, decreased appetite,
dizziness, sexual side effects, abdominal pain and
problems passing urine

NON-STIMULANTS GUANFACINE

(CURATOLO ET AL., 2010; PARKER, 2013; WANG ET AL., 2007; SALLEE, LYNE,
WIGAL & MCGOUGH, 2009; SALLEE ET AL., 2009)

Trade
Name

How it works

Application

Efficacy
(Meta

Analysis)
Tenex

Intuniv

-Selective alpha2A
adrenergic receptor
agonist

Immediate
Release

N/A

Extended
Release

.80

Side Effects:
Upper abdominal pain, decreased appetite, vomiting,
irritability, fatigue, dry mouth, constipation, long term
increase in blood pressure

CONSIDERATIONS
Comprehensive Treatment
-Medications
-Behaviour
-Educational
-CBT
-Comorbidities

CONSIDERATIONS
Tracking

Progress
Young children (under 6)
Behaviour first
Strong Evidence
Stimulants & Non-Stimulants

(Curatolo et al., 2010; Biederman & Spencer, 2008; Parker,

2013)

EARLY INTERVENTIONS CRITICAL

(Halperin, Bdard & Curchack-Lichtin,

2012)

a) No intervention
b) Small impact of early
intervention
c) Larger impact of early
intervention

(Halperin, Bdard &

Curchack-Lichtin, 2012)

EARLY INTERVENTIONS-PREVENTION?
COGNITIVE REHABILITATION?
(HALPERIN, BDARD & CURCHACK-LICHTIN, 2012)

The goal is to reduce the likelihood

of the emergence and/or persistence
of ADHD from its earliest
manifestations by facilitating brain
growth to alter its adverse long-term
trajectory (p. 532)
Plasticity
Comorbidities
Academic failure
Behaviour Patterns
Parent-Child Relationships
Window of Opportunity

EVIDENCE BASED PARENT FOCUSED

EARLY INTERVENTIONS
(Halperin, Bdard & Curchack-Lichtin, 2012)

The
2008)

Incredible Years

Tripple

(Jones, Daley, Hutchings, Bywater & Eames,

P
Head Start
Revised New Forest Parenting Program
(NFPP) (Sonuga-Barke, Daley, Thompson & Laver-Bradbury, 2001; Thompson et al.,
(Bor, Sanders & Markie-Dadds, 2002)

(Parker, 2013; Hamperlin et al., 2012)

2009)

Relationship Based Promote Parent

Capacity
Behavioural Focus Positive Supports

EARLY INTERVENTION
NEUROCOGNITIVE (HAMPERLIN ET AL., 2012)
Training Executive, Attention and Motor Skills
(TEAMS).
Executive Training of Attention and
Metacognition (ETAM)

Parent Capacity Behavioural Focus

Positive Supports
Practice, practice, practice
Be Direct Break Skills Down
Teach One Skills at a Time

GENERAL STRATEGIES EARLY

INTERVENTION
Build Rapport
Clear Behavioural
Expectations
Consistent Behavioural
Expectations
Consistent Follow
Through
Immediate
Consequences (+/-)
Visual supports
Positive Practice

Use of rewards/reinforcementCelebrate
achievements!

Limited use of consequences

Break Skills Down

Teach Skills until Mastery-One thing at a

time

Have Patience

Play Therapy

BEHAVIOUR MODIFICATION PRINCIPLES

CLASSROOM - PARENTS

BEHAVIOUR MODIFICATION
PRINCIPLES
(CHRONIS ET AL., 2006)

Targeting specific behaviors

Using praise
Planned Ignoring
Timeout
Positive attention
Rewards to increase positive behaviors
Non-physical discipline strategies

BEHAVIOUR INTERVENTIONS MY
EXPERIENCE PRE-K
Immediate feedback (+/-)
Positive practice
Visual Schedules
Provide Opportunities for control A or B choices
Teach appropriate avoidance (e.g. all done, break)
Clear and consistent behavioural expectations and follow through
Reduced negative feedback no punishment
Token Economy/Reinforcement
Persistence Training
Frustration Tolerance Programming
Emotional Regulation (e.g. 5 point scale)
Coping Skills/Relaxation
Visuals (e.g. stop, think, do)
Teaching Interactions
Focus on the process (praise for effort)
Behavioural Consequence Mapping
Practice, Practice, Practice

COGNITIVE BEHAVIOURAL
INTERVENTIONS

WHAT IS COGNITIVE BEHAVIOURAL

THERAPY?
Therapeutic approach
Active Participation from the individual
Problem Focused-Addresses dysfunctional
emotions, maladaptive behaviors and cognitive
processes
Uses systematic goal-oriented procedures
Assumes behaviours can be controlled through
rational thought
Therapist assists individual in developing and
implementing specific strategies to improve
behaviours.

Text Box
What types of skills would you teach
using CBT?

COGNITIVE BEHAVIOUR THERAPY

(PSYCHOEDUCATION)
(KNOUSE & SAFREN, 2010; TOPLAK, CONNORS, SHUSTER, BOJANA
KNEZEVIC & PARKS, 2007)

Problem solving
Self regulation
Self Monitoring
Attention
Impulse Control
Social Skills
Memory
EF (e.g. organization)
Stress Management
Motivation
Self-Esteem

Communication
Initiation

Conflict Resolution

Cognitive Restructuring (e.g. talk therapy unhealthy belief systems)

Cognitive Flexibility
Anger Management

Anxiety

Depression

Cognitive Behavioural Model (Knouse & Safren,

2010)

CBT - EVIDENCE

(HAPERLIN, BEDARD & CURCHACK-LICHTIN, 2012; KNOUSE & SAFREN, 2010;

TOPLAK, ET AL., 2007)

Developmentally Appropriate!!!
Evidence Emerging (playing catch up)
General increase in behaviours targeted
(pre-post measures) small to large effect sizes
Some difficulty with generalization
Some reported long term effects on ADHD symptom
Some caution the overuse of metacognition as a strategy due
to attention and Executive Function difficulties
Some reported long term increases in academic success
All reported better results when CBT was paired with
behaviour modification for children and adolescents
(Transition from extrinsic rewards internalized cognitive,
self-regulated habits).

CBT - THINKING- APPROACHES/STRATEGIES

(HAPERLIN, BEDARD & CURCHACK-LICHTIN, 2012; KNOUSE & SAFREN, 2010; TOPLAK, ET AL., 2007)

Talk Therapy (how beliefs influence actions)

Metacognitive Strategies
Mindfulness Meditation Training
Roleplaying Exercises
Cognitive Remediation Programs
Dialectical Behaviour Therapy
Self-report/Assessment/Monitoring
Homework
Token Economy
Learn to Break Skills Down
Work on one skill at a time
Behavioural Techniques (e.g. Social Reinforcement)
Group Therapy (CBT-Metacognitive, Mindfullness)

PSYCHOEDUCATIONAL &
ENVIRONMENTAL
MODIFICATION
STRATEGIES

PSYCHOEDUCATIONAL &
ENVIRONMENTAL MODIFICATION
STRATEGIES
(KNOUSE & SAFREN, 2010; TOPLAK, ET AL., 2007)

Organization/Planning
Motivation
Listening
Scheduling
Time Management
Problem Solving
Managing Procrastination
Breaks (movement or otherwise)
Desk Placement
Self-Help Book of Strategies
Breaking Down Tasks
Visual/Auditory Reminders

APPS (APPLICATIONS )
SOCIAL MEDIA
POP CULTURE

LIFESPAN CONSIDERATIONS

LIFESPAN
The research has not yet delivered evidence
that the long-term outcome is being improved,
(Taylor, 2009, p.130)
Stimulants: Little is known about the long-term
effects of stimulants on the functional organisation of
the developing brain, (Curatolo, 2010, p.82).
Absence of Intervention poor outcomes
Best Outcome = Early Intervention + Evidence Based
Interventions (ongoing)

INDIVIDUALIZED
TREATMENT APPROACH

TAKE HOME
Build on a persons strengths!!!!!
Medications + Behavioural Modification + CBT =
Gold Standard
Psychoeducational Supports and Environmental
Modifications
Evidence Based Interventions
Tailored to the Individual
Parents Involved
Multidisciplinary Team
Technology

Questions?

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Biederman, J., Spencer, T., J. (2008). Psychopharmacological interventions. Child Adolesc
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Big Think, How ADHD Effects your Brain, retrieved from: https://
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Bor ,W., Sanders, M., R., Markie-Dadds, C. (2002) The effects of the Triple P Positive Parenting
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