Principles of Management of ADHD

Principles of Management of ADHD include psychotherapy and pharmacological threatment.

Behavioural Therapy

Behavioural Therapy is the only psychotherapy intervention viable for management of ADHD patients. They serve to alter the social and physical environment to modify ADHD patient’s behaviour. Models of behavioural therapy include:

A. Parent Behaviour Training

Parents are trained to implement specific techniques based on behavioural principles when interacting with child. Parent training sessions are given weekly and usually include homework sessions to give parents the opportunity to learn reward systems and strategies for providing consequences to shape behaviour.

Topics for learning include:

1. Overview of ADHD, social learning theory and behaviour management principles.

2. Establish daily report cards and checklist for rewarding bahaviour

3. Attend to appropriate behaviour and ignoring minor, inappropriate behaviour

4. Effective reprimands and commands

5. Establish and enforcing rules

6. Time-out procedures

7. Incorporating reward and response cost with home point system

8. Enforcing contingencies and planning ahead for misbehaviour outside home setting

9. Problem-solving techniques

10. Generalisation and maintenance of program post-therapy

B. Psychosocial Therapy

Psychosocial Therapy allows trained therapist to speak with child and family members about handling behviours and emotions to improve social skills.

C. School-based Programs

Special education services are offered in school settings to create and individualized education program (IEP) to increase school success

Pharmacological Modality in Treatment of ADHD

Stimulants and non-stimulants can be given and has shown success in reducing the symptoms of ADHD.

Alternative treatments such as nutrition and exercises could improve ADHD conditions, however there has been lacking of evidence to suggest a direct benefit (Larzelere et al 2010)

Stimulants

Methylphenidate Formulations – Concert, Quillivant XR

Methylphenidate HCl blocks reuptake of norepinephrine and dopamine in presynaptic neuron to increase their availability into extraneuronal space. It is available in IR, SR, LA, XR, OROS and MTS form.

The common side effects include insomnia, decreased appetite, weight loss, depression, anxiety, increased blood pressure and pulse rate, skin irritation

Extended release liquid formulation has been approved by FDA. Liquid XR could avoid the medication compliance challenges of solid form. The onset of treatment is 45 minutes and duration of action is 12 hours. It is also safe and well tolerable and adverse effects were consistent with known effects of methylphenidate.

Amphetamine Formulations – Dextroamphetamine sulphate, Vyvanse (prodrug)

LDX (Vyvanse) is a prodrug stimulant approved for management of ADHD symptoms. LDX is hydrolysed by endogenous enzymes into L-lysine and D-amphetamine. Swanson et al noted LDX was effective in reducing ADHD symptoms compared to placebo.

Efficacy was demonstrated between 2-12 hours post-dose. It is also well tolerable and safe for usage.

Common side effects include insomnia, decreased appetite, weight loss, depression, anxiety, increased blood pressure and pulse rate. It is also known to inhibit MAO and CYP2D6. Drug elimination is influenced by urinary pH and flow rates.

Non-Stimulants

Selective Norepinephrine Reuptake Inhibitor – Atomoxetine (Strattera)

Atomoxetine could increase concentration of NE and dopamine by acting on presynaptic norepinephrine  transporter in prefrontal cortex

Common side effects include GI upset, nausea, sedation, insomnia, agitation. CYP2D6 inhibitors may increase atomoxetine SS concentrations.

Α2-Adrenergic Agonist - Clonidine (Kapvay), Guanfancine

Clonidine and Guanfacine are also non-stimulant treatments of ADHD. The extended release forms are approved by FDA for ADHD.

Side effects are low blood pressure (hypotension), low heart rate (bradycardia), constipation, dry mouth, increased appetitie, hypersomnolence, sedation. Guanfancine is less sedating than clonidine as it is thought that the side effect of guanfancine diminishes over time (Faraone et al 2010). Care should be taken for guanfacine not to be taken with fatty meals as it may cause increase in exposure.

If withdrawal is indicated, gradual dose reductions are recommended to reduce withdrawal symptoms such as rebound hypertension and lightheadedness.

Monitoring Side Effects of Treatment

1. Inquiry by open-ended questions, spontaneous patient reporting. Structured interview is also possible but there are weakness in terms of biasness.

2. Commonly observed side effects include appetite suppression, headache, insomnia, irritability, abdominal pain

3. ECG prior to treatment initiation + regular blood pressure and auscultation examintion as there are risk of sudden cardiac death secondary to cardiac abnormalities and cardiovascular effects of drugs. Thorough family history of cardiac events should also be taken.

4. Consider drug holidays or dose alteration if there are significant side effects.

Assessment of Neurocognitive Domains

There are 6 Neurocognitive Domains:
Acronym: MAPLES
1. Learning and Memory
2. Complex Attention
5. Perceptual Motor
4. Language
2. Executive Function
6. Social Cognition

Learning and Memory Domain
Immediate Memory Span is the ability to repeat a list of words or digits. It is also sometimes subsumed under working memory in executive function. Usually tested in mini mental state examination by listing 3 mutually exclusive items and asking patients to recall them.

Recent Memory assesses the process of encoding new information. Various subsets of recent memory include:
- Free Recall as the ability to recall as many words, diagrams or elements in a story as possible
- Cued Recall as the ability to recall with semantic cues
- Recognition Memory as even more obvious cues such as "did you see this picture"
- Semantic Memory as the memory for facts
- Autobiographical Memory as the memory for personal events or people
- Implicit Learning as the procedural and unconscious learning of skills

Complex Attention Domain
Sustained Attention is the maintenance of attention over time

Selective Attention is the maintenance of attention despite competing stimuli or distractors

Divided Attention is the ability to attend to 2 tasks within the same period


Perceptual Motor Domain
Visual Perception tests line bisection tasks to detect visual defect or attentionl neglect

Visuoconstructional assessment assesses the assembly of items under hand-eye coordination

Perceptual Motor integrates perception with purposeful movement

Praxis is the integrity of learned movements

Gnosis is the perceptual integrity of awareness and recognition

Language Domain
Expressive language consists of confrontational naming (identification), fluency and phonemic

Grammar and Syntax is assessed by comparing the frequency of errors and normal slips of the tongue

Receptive language consists of comprehension, performance of actions according to verbal command

Executive Function Domain
Planning is the ability to find a solution or interpret something

Decision Making as the performance of tasks that assesses the process of deciding in the face of competing alternatives

Working Memory is the ability to hold information for brief period and to manipulate it

Feedback and Error Utilisation is the abilithy to benefit from feedback to infer rules for solving a problem

Overriding Habits/Inhibition is the ability to choose a more complex and effortful solution to be correct

Mental and Cognitive Flexibility is the ability to shift between 2 concepts, tasks or response rules

Social Cognition
Emotional Recognition is the identification of emotion in images of faces representing a variety of both positive and negative emotions

Theory of Mind is the ability to consider another person's mental state (such as thoughts, desires and intentions) or experience