Behavioural interventions for Attention Deficit Hyperactivity Disorder

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1 Behavioural interventions for Attention Deficit Hyperactivity Disorder Dr David Daley Professor of Psychological Intervention and Behaviour Change Division of Psychiatry & Applied Psychology, School of Medicine University of Nottingham

2 ADHD ADHD is a neuro-developmental disorder with symptoms frequently occurring in early childhood (Sonuga-barke & Halprin 2010) ADHD is one of the most common psychiatric disorders in childhood (Wichstrom et al 2012) The most common reason for referral to child mental health services (Goodman et al 2000) ADHD is as common in preschoolers as in schoolaged children with prevalence rates ranging between 2 and 5% (Lavigne et al 2009)

3 Impairment Impairment in ADHD is very common (Greenhill et al 2008) Impairments in relationships with parents, siblings and peers (Wehmeier et al 2010; Gardner & Gerdes 2015) Social and pre-academic skills (Daley & Birchwood 2010) Neuropsychological functioning (Sonuga-Barke,Dalen, Daley & Remington 2003)

4 The costs of untreated ADHD Daley, Jacobsen, Lange, Sorensen,& Walldorf, J. (2015). Explored the private and social costs of untreated ADHD in adulthood. Using the Danish National Registers they compared costs for Adults with a diagnosis of ADHD in adults but not in childhood and compared them to the costs for their same sex sibling

5 Yearly cost differences for public costs between ADHD adults and their siblings in euros Negative values represent a greater cost to individuals with ADHD

6 Yearly cost differences for public costs between ADHD adults and their siblings in euros Negative values represent a greater cost to individuals with ADHD

7 Yearly cost differences for private costs between ADHD adults and their siblings in euros Negative values represent a greater cost to individuals with ADHD

8 The cost of ADHD in Adulthood Total cost difference 13, 608 euros

9 Overview of the presentation The need for intervention Why behavioural interventions should be effective The evidence base for behavioural intervention Service delivery challenges Conclusions

10 ADHD and genetics How tall we are is almost entirely determined by our genes Yet during the 20th century, the population got much taller due to better nutrition (environment!)

11 Environment Just because ADHD is mostly due to genetics does not mean that changing the child s environment cannot have a dramatic impact Parents play a key role in determining the earlier environment that children and adolescents experience Teachers and peers also have a role in determining the later environment that ADHD children and adolescents experience

12 The role of the parent Parents exert a substantial influence and play a major role in their child s social environment. We need interventions which help parents to gain the correct skills not only to feel better about themselves (although that is important) But to modify their child s environment in order to change the developmental trajectory of ADHD

13 Executive functioning Executive functioning consists of higher cognitive processes such as: Planning: Can t organise themselves Working memory: Lower storage capacity Inhibitory control: Can t stop themselves from acting ADHD children have poor Executive functioning

14 The importance of reward

15 Motivation and Default Mode Network Liddle et al (2011) default mode network (DMN) activity in ADHD and control children was explored during a a go-no-go task in an fmri scanner under low and high motivational conditions. When ADHD children were off medication and motivational conditions were low, DMN activation was lower in this group compared with controls When motivational incentives were high, the groups did not differ with respect to DMN activation Liddle EB et al. J Child Psychol Psychiatry 2011;52:

16 Cognitive control and social reinforcement Kohls et al (2009) ADHD and control children performed the go-no-go task using non-social (money) and social (positive facial expressions) Both rewards improved inhibition in both groups ADHD children displayed a particularly high response to social reward compared with controls. Cognitive control in ADHD children can be improved by social reinforcement Kohls G et al. Dev Sci 2009;12:

17 Social Reinforcement

18 ADHD as a motivational style CHOICE DELAY AVERSION NO CHOICE MINIMISE DELAY MAXIMISE NON TEMPORAL STIMULATION IMPULSIVENESS INATTENTION OVER-ACTIVITY

19 Delay Aversion

20 Temporal Processing Children with ADHD display difficulties with time discrimination and reproduction and often underestimate periods of time (Toplak, Dockstader, & Tannock, 2006), Problems understanding time reduce with reinforcement in children with ADHD (Van Meel, Oosterlaan, Heslenfeld, & Sergeant, 2005).

21 The importance of understanding time

22 Interim summary We would like to get parents to Help to enhance executive functioning Increase their use of praise and reinforcement Increase tolerance for delay Help their children to understand time

23 But it is not just about neuropsychology Other factors are also important: Parent child interaction Parental emotional relationships Neural plasticity

24 Mediating role of positive parenting Mediating variable: Positive parenting Independent variable: Intervention status (0.224) Outcome variable: Change in Conners scores P < 0.05 P < 0.01 Jones K, Daley D, Hutchings J, Whitaker C (in press).

25 Does parental expressed emotion moderate genetic effects in ADHD? Sonuga-Barke et al (2008) examined the influence of expressed emotion (EE) on ADHD in a genomewide association scan study EE moderated the effects of genes on ADHD severity and comorbid conduct disorder, implicating both novel and established candidate genes Sonuga-Barke EJ et al. Am J Med Genet B Neuropsychiatr Genet 2008;147B:

26 A Window of opportunity We need to intervene while the parent-child relationship is still intact (Tarver, Daley & Sayal 2014) Earlier intervention is also supported by neural plasticity, where the task is much easier in younger children (Halprin et al 2010). The answer is environmental modification and parents hold the key

27 Interim summary We would like to get parents to Help to enhance executive functioning increase their use of praise and reinforcement, Increase tolerance for delay Help their children to understand time Enhance parent-child relationships Enhance emotional relationships Work with neural plasticity For ADHD we need interventions that are able to provide this.

28 Meta-analysis of Behavioural interventions for ADHD Daley, Van der Oord, Ferrin, Danckaerts, Doepfner, Cortese & Songua-Barke (in press) meta-analysis on non-pharmacological interventions for ADHD The analysis on children aged 3-18 focused on two key informants i) MPROX Person most proximal to the delivery of treatment ii)pblind Person most probably blind Daley, D., Van der Oord, S., Ferrin, M., Danckaerts, M., Doepfner, M., Cortese, S., Sonuga-barke E.J.S. & European ADHD Guidelines Group. (2014). Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains. Journal of the American Academy of Child & Adolescent Psychiatry, 53(8),

29 Child Outcomes SMD ADHD Conduct Problems Academic Social Skills MPROX PBLIND Low Meds

30 Parental Outcomes Positive Parenting Negative Parenting Mental Health MPROX PBLIND Low Meds Parental Self Concept

31 Child Outcomes SMD preschool ADHD Conduct Problems Academic Social Skills MPROX PBLIND Low Meds

32 Parental Outcomes SMD preschool Positive Parenting Negative Parenting Mental Health MPROX PBLIND Low Meds Parental Self Concept

33 Service Delivery Challenges for us all Mode of delivery Generic v s specialised treatment Dose rate Implementation Fidelity Moderators of outcome

34 Mode of Delivery Group v s individual treatment In the Uk group based treatment is recommend. The majority of parents have a preference for individual treatment ( Wymmbs et al 2015). Recent findings as yet unpublished from the UK indicate that individual behavioural treatment is more cost effective than group based treatment

35 Generic v s specialised treatment Abikoff et al (2015) Specialised behavioural treatment was not more effective than generic behavioural treatment. However if using generic behavioural treatment Ensure any psychoeducation is appropriate for ADHD. Ensure that strategies are modified for ADHD, ie time out is a double punishment for children with ADHD. If using a group format (and I don t recommend it!) don t mix the groups with parents of children with Autism or conduct Problems

36 Number of sessions Dose (ie number of sessions) varies considerably across behavioural treatments NFPP 8 sessions IY 22 Sessions. PMTO up to 40 sessions. We know very little about the relationship between dose and outcome. Interventions with higher dose do not appear to deliver better outcomes but are probably much more expensive to deliver and more taxing for the parents.

37 This is behavioural treatment not psychotherapy! Dose Response How many sessions do you think parents need, want and are able to tolerate? Don t be a Duracell Bunny!

38 Implementation Fidelity Implementation Fidelity the ability to deliver an intervention as intended is important. Fidelity impacts on treatment outcome for conduct problems (Eames et al 2007; 2008) Choose interventions which have a very clear training process Offer accreditation for the training your receive Offer access to local supervision

39 Moderators of outcome There are very clear moderators of outcome for behavioural interventions for ADHD. Parental ADHD is the most obviously one (Sonuga- Barke, Daley & Thompson 2002) Parental depression, child pragmatic speech are other potential moderators of outcome. Choose an intervention which helps you as a therapist to understand how you should modify intervention content or delivery to reduce the impact of this potential moderators on outcome

40 What are the clinical implications? What treatment benefits should we expect from behavioural interventions? What are the important issues to consider when delivering behavioural interventions? What are the important treatment indications and contraindications?

41 Summary Think carefully about what intervention provides as a treatment for ADHD. Consider the impact of Number of sessions Cost Fidelity Moderators of the likely success of the intervention for specific sub-groups.

42 What are the clinical implications? We have a duty of care to provide the most evidence based interventions in Denmark for ADHD. While parental preference is important we must first follow the evidence base, as preference sometimes leads us to incorrect choices If I gave you a choice of cancer treatments which one would you choose Counselling which might make you feel much better about your illness Chemotherapy which would make you feel absolutely rotten but is an excellent evidenced based intervention that kills cancer cells

43 Thank you Questions

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