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• Over the past decade, research has revealed • What did we learn from the MTA study ? some pretty sobering facts about outcomes for children with ADHD • 579 7-9 yo randomized to 4 treatments • We’ve spent a lot of time and money figuring out that many treatments don’t work as well • Treated for 14 mos, followed for 8 years • At 14 mos, M and B better than P and C • More global rather than specific intervention • B > M only for those with comorbidities • Parents and teachers working together • At 3 years, no difference between any • Initial trajectory remains important: • Students typically show their best (or worst) – ADHD persisted in 44% from childhood • Teachers have to focus on year-long goals, – Increased substance use (ODD), anxiety- • Students often need more repetition to solidify a skill than teachers can provide – Even teens with subthreshold ADHD had • Parents and teachers often differ on how much support a student needs with homework • Teachers are sometimes reluctant to be • Emotional lives and QOL in children and • We’re the adults, right ? We should be able to manage this. If something isn’t working, you must be to blame.
Stimulant vs non-stimulant – what does • Methylphenidate – Blocks the dopamine • Ritalin – Ritalin, Ritalin LA• Methylin – Methylin, Methylin ER • Concerta *• Daytrana * (patch, can be removed early)• Focalin – Focalin, Focalin XR (single, more • Amphetamine increases the release of both dopamine and norepinephrine – 4, 8, 12* • Dexedrine (4)• Dexedrine spansules (8)• Adderall – Adderall, Adderall XR• Vyvanse *• (Generic is called mixed salts of • Only one brand, Strattera; no generic • Blocks the norepinephrine transporter • Usually lasts about 8 hours, but may • Behaves like an antidepressant in some • Stimulants are very much alike, with the same completion, work production and accuracy, • About 30% of students will respond better to intrusive social behaviors, and some, but not • Some students will respond better to one • ? Executive function- yes if performance medication than another in the same category • Many students do not respond equally to • Side effects – appetite, insomnia, repetitive short- vs long-acting versions of the same • Mood – withdrawal, perseveration / • A stimulant may not maintain the same effect inflexibility, rebound, anxiety, irritability, • Lower rate of effectiveness for core ADHD • Less likely to cause withdrawal or increase • Use limited by lethargy• Theoretical risk for hypotension • More likely to cause lethargy, GI upset and • No studies longer than 6 weeks• Intuniv and Kapvay approved for use with • Similar or greater cardiovascular effects • Effective in 75% of children with ADHD • When not effective, it is usu. due to side – They are normed and standardized, and used in likelihood of effectiveness (IQ, neurologic – They are not terribly useful for judging meaningful outcomes such as academic progress, adaptive comorbidity, nutritional deficiency, ? prenatal • Children may respond differently to different • Rebound is identifiable- usually core ADHD • Children may respond differently to same medication in immediate-vs slow-release form • Sometimes, more gradual, insidious changes • Children may respond differently to brand vs over time, even after initial effectiveness • Irritability, depression, withdrawal, mood • Medication effects may change over time, • Strattera, Concerta, Vyvanse ? Long-acting ? • Almost no studies longer than 2 years • “Sitting still” does not equal “thinking” • Be specific about what you are seeing • “Calling out” does not equal impulsivity • Identify the specific child’s challenges if • Inattention is not the same as forgetting • What do you see in school that “grabs” • Increased focus does not necessarily mean it or “repels” a child’s ability to attend ? – Increased focus on internal thoughts, preferred topics, or inner imaginary world looks like • Students with ADHD often have social • Typically negative interactions happen • But you know the behaviors that make • These are not only “secondary” to their • Be specific with parents about what you • Students don’t generalize skills learned • Help to identify potential buddies or • Give the student a job with the same • Strategies for generalization of skills • Showcase the student’s strengths in the setting in which weaknesses are usually the focus • The quality of life for students with • Main concerns: social connectedness, similar degree as it is for those with a chronic medical illness, a brain injury, or • Parents have a higher rate of divorce • Chronic stress effects on mothers in • Be attentive to gradual or unexpected • Join with parents to be on “Team Doe” • It’s more important to be part of the • Be specific in articulating the skill and performance deficits- academics, social, • Identify subtle behaviors that provoke Bussing R et al Adolescent outcomes of childhood ADHD in a diverse community sample. JAACAP (2010) 49:6, 595-605 Molina BSG et al The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study JAACAP (2009) 48:5, 484-500 Murray DW et al A clinical review of outcomes of the multimodal treatment study of children with ADHD Curr Psychaitry Reports (2008) 10, 424-431 Storebo OJ et al Social skills training for ADHD in children 5-18 yrs Chochrane Database of Systematic Reviews (2011) 12:CD008223 Zwi M et al Parent training interventions for ADHD in children 5-18 yrs Chochrane Database of Systematic Reviews (2011) 12:CD003018


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