What is the
most commonly
diagnosed
behavioral disorder of
childhood?
ADHD
3 to 5% of U. S. school-age children meet criteria for ADHD
On average 3.5 times as many boys as girls.
May have early difficult temperament.
Diagnostic criteria designed for young children. Also used for older ones.
Either Inattention
or
Hyperactivity
or
Both
Careless mistakes
Problems with sustained attention
Doesn’t listen to speaker
Hates and avoids schoolwork and other difficult tasks
Forgets, loses pencils, has difficulty organizing tasks
Easily distracted
Fidgets, squirms, leaves seat, runs and climbs excessively
“Motor driven”
Talks excessively
Behaviors must
begin before
1
age 7 years
and in more
than 1 setting
Critics say it is over-used for perfectly normal but active boys
Drug treatment questioned
Most mental health professionals say that extreme ADHD is a disorder and should be
treated.
Still unknown (NIMH), so no strategies for prevention of ADHD
Stimulant drugs such as Ritalin, Concerta, Adderall found to produce better impulse
control in most children.
Only short-term improvement in school performance.
Side effects may be bothersome or medically serious
Stimulants popular for unauthorized use
Long term effects remain untested.
Direct targeting, measurement, and manipulation of target ADHD behaviors
Positive reinforcement of appropriate behavior
Response cost, fines, loss of positive reinforcement for misbehavior
Cognitive self-control skill instruction
Training parents to apply behavioral techniques
Training school personnel to apply behavioral techniques
Multimodal Intervention – try meds, behavior therapy, in combination
The most used are stimulants:
Methylphenidate (Ritalin*, Concerta**)
Dextroamphetamine (Dexedrine)
Amphetamine plus dextroamphetamine (Adderall; Addrall XR)
*90% of the world’s Ritalin is consumed in the U.S.
**The FDA has issued a warning of slightly elevated suicide risk for users of this drug
Other Alternatives:
2
Selective norepinephrine reuptake inhibitor. Strattera (atomoxetine (HCL)
Antidepressants
SSRIs (Prozac, Paxil or Paroxetine*, Luvox, Zoloft)
Tricyclics (Desipramine, Imipramine or Tofranil)
Antihypertensives (Cloridine)
***Warning against use with juveniles in Britain because effectiveness unknown and small increased
suicide risk
Rarely Used:
Anticonvulsants
Antipsychotics
!
"#
$%%&
NOTE:
Average cost to bring a new drug to market = $900 million (including promotion
costs). These costs are rising rapidly.
In clinical trials, a new drug must be safer and more effective than existing drugs.
A drug that has moved into first-stage human clinical trials has about an 8% chance
of reaching market.
American Academy of Pediatrics guidelines for treatment of ADHD
ADHD is a chronic condition requiring sustained monitoring
Goals should be individual, based on child’s social and academic problems
M.D. or other practitioner should recommend appropriate, research-based
stimulant medication and/or behavior therapy
'
(
) *
If unsuccessful, re-evaluate diagnosis, treatment alternatives, co-occurring
problems
Periodic, systematic follow-up required on success, adverse effects
Conclusion: Treatments improve functioning of most children with ADHD
Stimulant drugs. Use increased many times over since 1987, especially in low-income
families.
Number of treatment visits per child decreased, while number of prescriptions increased.
Monitoring questionable.
!
)
"
Appetite suppression
Insomnia (treated with sleeping medications)
3
Irritability, depressed mood
At higher doses, impairs logical thinking
Headaches, jittery feelings
Most side effects are mild and temporary, but some children have intense, serious effects, such as
seizures or psychotic behavior.
"
Parents, teachers, and most children pleased with increased attention, reduced
impulsivity, and lower activity level in c. 75% of cases.
May also reduce aggression and noncompliant, oppositional behavior.
“Normalizes” behavior in about 50% of children, others continue poor social skills.
"
(
) *
Only a small improvement in academic achievement and not in long term. Academic
achievement necessary to prevent retention in grade and 30% chance of not
graduating from high school.
25% of children do not benefit or get worse from stimulants for ADHD.
Stimulant drugs do appear to help most children with ADHD to control their
impulsivity, inattention, and hyperactivity, but at some cost.
Experts recommend closer monitoring of children receiving these medications than
most actually receive.
These medications may control symptoms, but do not teach children the skills
needed for good academic work and good social relationships.
Principles are simple and treatment is individualized.
BT is clearly directed at teaching needed skills and can be delivered by trained parents,
teachers, and child as well as by therapist.
Large number of research demonstrations of effectiveness of BT in improving children’s
classroom behavior, academic performance, and success in school.
Long term effects not established, but probably eroded over time.
+
Shaping new skills using prompting and positive reinforcement.
May need to begin with teaching sitting in chair and attending to work.
For convenience, points used immediately and later exchanged for reinforcer.
+
(
) *
In classrooms, a timer programmed to sound at random intervals and child given praise and
points if on-task.
Self-regulation training. Child trained to record own points and weaned from timer to longer
periods of self-control.
"
Demonstrated effective in teaching new skills and controlling inappropriate behavior
in single-subject and group research studies.
Improvement may be limited to training situation and trainer’s presence.
Improvements may fade when new behavior not reinforced.
4
"
(
) *
More difficult and time-consuming to administer than pills, though therapy has no
medication side effects.
Therapists and helpers must be carefully trained and supervised or treatment may
not be effective.
Training child in self-control boosts self-confidence.
Dependence on pills for control makes the child feel powerless.
'
,
Stimulants are useful for controlling inattention, overactivity and impulsivity.
Behavior Therapy is useful in teaching children appropriate classroom behavior,
learning skills, and social skills.
Neither type of treatment has a proven long-term benefit.
Continued monitoring and booster treatment may be required for years.
Little is known about the causes of ADHD, so prevention is challenging.
Early detection and treatment can help stop the condition from progressing.
Untreated severe ADHD can lead to academic failure, drop out, and low-paying jobs
as adults as compared with other family members. Also antisocial behavior.
ADHD
• Attention-Deficit/Hyperactivity Disorder is one of the commonest and most
controversial diagnoses of children
Symptoms are marked difficulty in concentrating on uninteresting tasks and
abundant, but undirected energy, fidgeting, and moving about.
For diagnosis, either attention deficit or hyperactivity may predominate or both may
be present.
Other symptoms include social problems with peers and aggressive behaviors.
School work is frequently poor, learning problems are common.
Over 3 times as many boys as girls have ADHD.
Causes are unknown, making prevention impossible.
Treatment is mostly stimulant drugs, with minor use of other types of medication.
Behavior therapy is useful in controlling symptoms and teaching appropriate
behaviors.
Multimodal treatment using drugs and therapy is advised.
5