Behavioral and

Pharmacologic Treatments
of AD/HD
Paul P. Doghramji Jr.
March 30, 2009
 Presentation Outline
 Definition and Diagnosis
 Neurobiology
 Prevalence and co-morbidities
 Pharmacologic treatments
 Stimulants
 Non-stimulants
 Non-pharmacologic Treatments
 CBT
 IPT
 Neurofeedback
 Optimal treatment: Combination
Attention Deficit/Hyperactivity
Disorder
 Neurobehavioral developmental disorder
 Characterized by:
 Inattention
 Hyperactivity
 Impulsivity
 Very often co-morbid with:
 Learning disabilities
 Psychiatric disorders
 AD/HD Diagnosis (DSM-IV*)
 Persistent (>6 months) pattern of
developmentally inappropriate inattention and/or
hyperactivity-impulsivity
 Symptom onset before age 7
 Symptoms present in >2 settings (eg, home and
school)
 Interference with social, academic, or
occupational functioning
 Disorder not accounted for by another mental
disorder
*American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Washington, DC, American Psychiatric Association, 2000
Inattention Symptoms (DSM-IV)
1. Often does not give close attention to details or makes
careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play
activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to
oppositional behavior or failure to understand instructions).
5. Often has trouble organizing activities.
6. Often avoids, dislikes, or doesn't want to do things that
take a lot of mental effort for a long period of time (such as
schoolwork or homework).
7. Often loses things needed for tasks and activities (e.g. toys,
school assignments, pencils, books, or tools).
8. Is often easily distracted.
9. Is often forgetful in daily activities.
 Hyperactivity/Inpulsivity (DSM-IV)
Hyperactivity
1. Often fidgets with hands or feet or squirms in seat.
2. Often gets up from seat when remaining in seat is expected.
3. Often runs about or climbs when and where it is not
appropriate (adolescents or adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.
Impulsivity
1. Often blurts out answers before questions have been finished.
2. Often has trouble waiting one's turn.
3. Often interrupts or intrudes on others (e.g., butts into
conversations or games).
 Neurobiology of ADHD
Specific etiology unknown but involves
combination of genetic and acquired
factors
 Up to 90% heritability
Neuroimaging anomalies
(structural/metabolic) in frontal cortex
and basal ganglia ADHD
 Prefrontal cortex dysfunction
fundamental to symptomatology
Biochemical abnormalities: possible
alterations in dopamine and/or
norepinephrine
Normal
 Prevalence
 Affects 6% to 10% of school-aged children1-3
– Diagnosed in boys 3 times more than in girls2,3
 Accounts for 30% to 50% of mental health
referrals4
 One of 10 most common pediatric concerns5
 Resulted in over 10 million physician office visits in
2001
 Up to 65% of children with ADHD continue to experience the
disorder into adulthood.
 Co-morbidities
 87% have at least 1 and 56% have at least 2
additional psychiatric disorders
 Common co-morbidities include
 Depression
 Anxiety
 Substance abuse disorder
 Insomnia
 Bipolar disorder
 Oppositional Defiance Disorder (ODD)
 ADHD: Drug Therapy
Stimulants Non-Stimulants
Methylphenidate Atomoxetine
D-amphetamine, Clonidine
mixed amphetamine
salts Antidepressants
Dextroamphetamine
Lisdexamphetamine
Modafinil
Dexmethylphenidate
 ADHD: Drug Therapy
Traditional Stimulants Non-Stimulants
Advantages • Highly effective • Non-scheduled
• Rapid onset of effect • Compatibility with co-
• Long term experience morbidities

• Schedule II • Slow onset of effect

Disadvantages • Rapid offset (“crash”) • Cardiovascular
• Incompatibility with effects
various co-morbidities • Somnolence;
• Cardiovascular effects Gastrointestinal (GI)
• Effect on growth (?) effects
• Persistent insomnia,
appetite decrease
• “Jitteriness”; blunting of
affect/creativity
 Effects of Stimulant
Medications on ADHD Symptoms in
Various Settings
 Classroom
 Decreased interrupting
 Decreased fidgeting and finger tapping
 Increased on-task behavior
 Home
 Improved parent-child interactions
 Increased on-task behavior
 Improved compliance
 Social settings
 Improved peer nomination rankings of social standing
 Increased attention span during sports activities
 Laboratory
 Decreased response variability
 Decreased impulsivity in cognitive tasks
 Increased accuracy of performance
 Improved short-term memory
 Improved reaction time
 Improved math computation
 Improved problem-solving in games
 Increased sustained attention
 Behavioral Therapy Techniques
Technique Description Example
Positive reinforcement Rewards or privileges Child completes an
are provided contingent assignment and is
on the child’s behavior permitted to play a
computer game
Time out Access to positive Child is required to sit for
reinforcement is 5 minutes in the corner
removed when the child of the room after
engages in unwanted or impulsively hitting a
problem behavior sibling
Response cost Rewards or privileges Child loses the privilege
are withdrawn when the of playing computer
child engages in game after he/she fails to
unwanted or problem complete homework
behavior
Token economy Rewards and privileges Child ears stars for
are provided when the completing assignment
child engages in desired or loses stars for getting
 Interpersonal Psychotherapy
 Commonly administered to adolescents with
ADHD and depression
 Second-line treatment when patient fails to
comply with taking medication or medication is
ineffective.
 Treatment aids individuals with:
 Social skills/interaction
 Focus on work and organization
 Extensive substance abuse
 Bipolar disorder
 Depression
Cognitive Behavioral Therapy
 Aims to influence dysfunctional emotions, behaviors and
cognitions through a goal-oriented, systematic procedure
 Goal: help children identify the faulty thoughts and ideas that
lead to the problematic behavior.
 Holistic approach and involving doctors, teachers, parents
and the patient in the therapeutic process
 Once the negative symptoms have been stabilized, cognitive
behavior therapy can be used to further increase positive
behaviors, decrease negative behaviors and reduce other
symptoms such as anxiety and depression.
 Children and their parents are seen individually and together
during different phases of treatment
 Adults experience group therapy sessions
 CBT Difference in Various
Ages
 Adults
 Highly effective in treating anxiety and depression
 Greater improvement of organization
 Immense minimization of self-esteem issues
 Techniques for reaching goals and self-improvement
 Children:
 Learn/rehearse to consider choices before problematic behavior
begins (slow down)
 Self-control and calming techniques
 Use of structured feedback to monitor, correct, and reward
behavior
 Independent study skills to improve organization and academic
performance
 Neurofeedback
 A type of biofeedback that can be used to train ADHD
children to change their brain wave patterns to be more
like normal children
 These patterns can be measured and recorded by an
electroencephalogram (EEG)
The EEG can be used to make a map of the persons
mental function
 Biofeedback is the use of instrumentation to mirror
psychological and physiological processes of which the
individual is not normally aware
 Treatment results in significant reduction of AD/HD
symptoms and behavior
 How Neurofeedback Works!
 When an ADHD child is given a task requiring
attention, instead of increasing beta waves he
increases theta waves
 Over 40+ sessions, children gradually taught to
inhibit theta production and increase beta usage
 Improvements shown in cognition, AD/HD
symptom reduction, and behavior
 Symptomatic improvement similar to stimulants
 Neurofeedback improvement does not
disappear
 Stimulant improvement lasts X amount of hrs
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 Problems With
Neurofeedeback
 Treatment lasts at least 40 sessions
 Treatments are expensive
 Treatment requires child motivation, boredom
renders slightly ineffective
 Age is a major factor
 Too young - child won’t do what is required
 Adults and older - more difficult to make EEG
changes and receive good results
 Treatment doesn’t work for everyone; greater
than 90% success rate
NIH Multimodal Treatment Study
of ADHD in Children (MTA Study)
 Methods comparing 4 methods of intervention
 medication management (MM)
 intensive behavioral treatment
 the 2 combined
 treatment by community providers

 Results
 MM or combined treatment were significantly superior to community
and behavioral treatment after 14 months
 Parent satisfaction was highest for behavioral interventions
 Behavioral modification in combination with MM may reduce the need
for higher doses of medication
 Behavior modification seen to be best for children with co-morbidities,
and/or whose families have limited financial resources
 Conculsion
 ADHD is a common psychopathology in
children and adults with much
impairment and disability
 Two forms of treatment include
pharmacological and behavioral
 The combination of management
methods seem to be most effective
 References
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3. Cook et al. Am J Hum Genet. 1995;56:993-998.
4. LaHoste et al. Mol Psychiatry. 1996;1:121-124.
5. . Egan et al. Proc Natl Acad Sci U S A. 2001;98:6917-6922.
6. . Fossella et al. BMC Neurosci. 2002;3:14.
7. MTA Cooperative Group. Arch Gen Psychiatry. 1999;56:1073-1086.
8. Donnelly et al. Differential Diagnosis and Treatment of Adult ADHD and Neighboring Disorders. 2006; 13:1-4
9. Arnsten AFT. Fundamentals of attention-deficit/hyperactivity disorder; circuits and pathways, J Clin Psychiatry
2006; 67 (suppl 8):7-12
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SLI381 (Adderall XR) in children with attention deficit/hyperactivity disorder. Pediatrics 2002; 110:258-66.
11. Grcevich SJ, Sea D, Mays D et al. Safety and efficacy of mixed amphetamine salts XR in adolescents with ADHD.
Presented at the 31st Annual Meeting of the American Academy of Child and Adolescent Psychiatry (Oct 19-
24,2004), Washington, DC, USA
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