ADHD – a slide kit for clinicians

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1 ADHD – a slide kit for clinicians
TDAH: Trouble du déficit de l’attention/hyperactivité Dr Massat, Service de Psychiatrie Erasme ADHD – a slide kit for clinicians Educational intent: to illustrate the three core symptoms of ADHD - inattention, hyperactivity and impulsivity SPEAKERS’ NOTES Complicating comorbidity should be raised. Explain that the core symptoms will be covered in more detail in module 2. Additionally, supplement with the following case-studies (Julia, inattentive, and Joe, combined/ predominantly impulsive) if you wish. Julia, 14 years old, is being presented by both of her parents because her school performance is getting worse and she doesn’t feel like doing her homework or studying for school. Julia thinks that studying is not worth it, and classes and, especially, teachers are only getting on her nerves. Her parents bother her the whole day and she can’t please anybody at all. Her parents explain that she always had problems at school. Even in her first year at primary school it was obvious that Julia was day-dreaming, that she did not follow the teacher, and that she needed much more time than everybody else because she was always doing something different. Reading and writing were especially difficult for her right from the beginning. Her current teacher explains that she has always known Julia as a kind of dreamer. She seems to tire very quickly, and the latter parts of her written tests are full of careless mistakes - and not only in dictation. Julia used to be quite an open person who tried very hard to fulfil everybody’s expectations. Now, however, there is a growing realisation that Julia does not feel like trying anymore. Her attitude is worsening and she seems very unhappy. She complains that everybody always complains about her. She always resolves to concentrate more at home and at school, and to try to finish things, but she finds this very hard – other things are always coming into her mind. The problem is compounded because she’s always looking for things – she lives in absolute chaos and loses things all the time. In a recent test, Julia scored an average IQ. She does try very hard but gets distracted easily. She interrupts frequently, asking how much longer things will take, and seems focused on failure. Joe, 7 years old, charming and bright, has earned the reputation of ‘class clown’, mostly because he answers questions before the teacher has completed them. He can’t wait to get his ice-cream at school dinner, but, on one occasion, dropped it on another child’s head. Joe was a lot of fun in nursery school, but his teachers and friends are now annoyed by his stampeding habits and frequent interruptions. His mother describes him as ‘a bull in a china shop’ and finds it very hard to take him shopping. He is so unpredictable and impetuous that he often makes irrelevant comments to strangers. His teachers now find him a nuisance and, on two occasions, he has been excluded from school. He is losing friends and becoming increasingly miserable and lonely as a result. Impulsivité Hyperactivité Inattention Speakers’ notes ©Döpfner et al 2002 Case description Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Comorbidity Cost Implications

2 LES PRINCIPAUX SYMPTOMES Une définition en bref du TDAH
ADHD – a slide kit for clinicians Educational intent: to provide a definition of ADHD at the outset  SPEAKERS’ NOTES While shades of all three core features are present to varying degrees in all children, the key diagnostic qualifier is careful evaluation of what constitutes inappropriate behaviour leading to problems in social, scholastic, family and work environments. The test of inappropriateness rests on identifying symptoms that are maladaptive and inconsistent with developmental level. Niveau d’inattention et/ou d’hyperactivité-impusivité inapproprié pour le développement de l’enfant et présent avant l’âge de 7 ans. Speakers’ notes Case description Case description Core symtoms Core symtoms Emergence of a concept Classification Epidemiology Aetiology Comorbidity Cost Implications

3 LES PRINCIPAUX SYMPTOMES Définition en bref
ADHD – a slide kit for clinicians Educational intent: to inform of the preconditions for diagnosis of ADHD SPEAKERS’ NOTES Point out that the second criterion is difficult to judge. Leurs caractéristiques doivent être plus sévères que celles observées chez d´autres enfants du même niveau de développement doivent être présentes dans toutes les activités (par ex. famille, école) doivent créer de sérieux problèmes au quotidien évoluent avec l’âge et peuvent rester à vie Speakers’ notes Case description Case description Core symtoms Core symtoms Emergence of a concept Classification Epidemiology Aetiology Comorbidity Cost Implications

4 ADHD – a slide kit for clinicians
EMERGENCE D’UN CONCEPT a L’histoire de Fidgety Phil par Heinrich Hoffmann ADHD – a slide kit for clinicians Educational intent: to indicate that an inappropriate level of restlessness in some children had been recognised as early as 1846 SPEAKERS’ NOTES Heinrich Hoffman ( ) demonstrated the problem of the inappropriately restless child quite well in his 19th-century children's tale. He described Fidgety Phil in these terms: ‘won't sit still’ ‘wriggles’ ‘giggles’ ‘swings backwards and forwards and tilts up his chair’. contd… Full poem: “Let me see if he is able To sit still for once at the table.” Thus Papa bade Phil behave; And Mama looked very grave. But Fidgety Phil, He won't sit still; He wriggles, And giggles, And then, I declare, Swings backwards and forwards, And tilts up his chair, Just like any rocking horse — “Philip! I am getting cross!” See the naughty, restless child Growing still more rude and wild, Till his chair falls over quite. Philip screams with all his might, Catches at the cloth, but then That makes matters worse again. Down upon the ground they fall, Glasses, plates, knives, forks and all. How Mama did fret and frown, When she saw them tumbling down! And Papa made such a face! Philip is in sad disgrace. Where is Philip? Where is he? Fairly cover'd up, you see! Cloth and all are lying on him; He has pull'd down all upon him! What a terrible to-do! Dishes, glasses, snapt in two! Here a knife, and there a fork! Philip, this is naughty work. Table all so bare, and ah! Poor Papa and poor Mama Look quite cross, and wonder how They shall make their dinner now. 1846 Speakers’ notes Case description Core symtoms Emergence of a concept Emergence of a concept Classification Epidemiology Aetiology Comorbidity Cost Implications

5  EMERGENCE D’UN CONCEPT
ADHD – a slide kit for clinicians Educational intent: to illustrate historical, medical and scientific progress towards the current concept of this disorder SPEAKERS’ NOTES Sir George Still (London) suggested an organic aetiology for disruptive behaviour in This paediatrician provided an early description of children who were neither mentally retarded nor brain-damaged, suffering from defective volition and inattention. He also identified a 3:1 male:female prevalence ratio. He stressed that inattention, hyperactivity and impulsivity played a major role and that the condition did not respond to punishment. Several other workers, however, believed in a thesis of brain damage. In 1932, Kramer and Pollnow from Berlin published about 45 cases of preschool children and young schoolchildren with a hyperkinetic disorder who showed the dimensions of inattention, hyperactivity and impulsivity. Their descriptions were named ‘Kramer-Pollnow syndrome’. In 1937, Bradley et al observed marked behavioural improvement in children receiving amphetamines. These studies refocused attention on earlier descriptions of a hyperactive-impulsive syndrome in children. In 1962, the Oxford Conference, an international study group on child neurology, criticised use of the term ‘minimal brain dysfunction’ to describe such children, while Bax and MacKeith suggested in 1963 to use this term for children with learning problems. The term stems from Strauss and Lehtinen (1947) who described brain damaged children as ‘disinhibited, perseverating and distractable’. The term MBD was still controversial in 1987 (Nichols). In 1965, the International Statistical Classification of Disease, 8th edition (ICD-8) named the disorder ‘hyperkinetic syndrome of childhood’. In 1968, the Diagnostic and Statistical Manual of Mental Disorders, 2nd edition (DSM-II) followed suit. In the 1970s, the Isle of Wight study by Rutter et al reported very low prevalences of HKD (ADHD was not measured). In 1978, a review of the literature suggested that cognitive rather than motor deficits explained the condition. In 1980, the 3rd edition of the DSM (DSM-III) revised its classification to ‘attention deficit disorder with or without hyperactivity’ (ADDH or ADD). In 1987, a revision (DSM-III-R) deleted the term ADD and postulated that overactivity and restlessness were key to the disorder. In 1994, the 4th edition of the DSM (DSM-IV) suggested that the disorder ‘ADHD’ consisted of three core symptoms – inattention, hyperactivity and impulsivity – and was manifest in one of three categories or subtypes: predominantly inattentive, predominantly hyperactive-impulsive or combined type. DSM-IV thus expanded the scope of the diagnosis and increased the number of children meeting the diagnostic criteria by about 24%. 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 George Still décrit des symptômes similaires au TDAH Kramer et Pollnow décrivent le trouble hyperkinétique Bradley utilise la benzédrine dans le trouble hyperkinétique Panizzon crée la méthylphénidate (MPH) Disfonction cérébrale minime (MBD) Clements et Peters introduisent le terme de déficit de l’attention Attention Deficit Disorder ± Hyperactivity (DSM-III) ADD/H± Attention Deficit Hyperactivity Disorder (DSM-IIIR) ADHD L’ICD-10 définit le trouble hyperkinétique HKD 1994 Critères de l’ADHD/ADD réactualisés dans le DSM-IV Speakers’ notes Case description Core symtoms Emergence of a concept Emergence of a concept Classification Epidemiology Aetiology Comorbidity Cost Implications

6 TABLEAU CLINIQUE Les symptômes principaux de l’ADHD/HKD Inattention a
ADHD – a slide kit for clinicians Educational intent: to begin to outline the symptom criteria for inattention and identify any differences in this respect between DSM-IV (ADHD) and ICD-10 (HKD) SPEAKERS’ NOTES Key: orange = ICD-10/ HKD (vs DSM-IV/ ADHD) The symptoms of inattentiveness as outlined by DSM-IV and ICD-10 (research diagnostic criteria) are almost identical. There are a few different wordings in ICD-10 that, in general, suggest a slightly higher level of severity/ impairment. contd… Souvent, ne parvient pas à prêter attention aux détails, ou fait des fautes d'étourderie dans les devoirs scolaires, le travail ou d'autres activités (A souvent du mal) (ne parvient pas) à soutenir son attention au travail ou dans les jeux Semble souvent ne pas écouter (ce qu’on lui dit) quand on lui parle personnellement Souvent, ne se conforme pas aux consignes et ne parvient pas à mener à terme ses devoirs scolaires, ses tâches domestiques ou ses obligations professionnelles (cela n'est pas dû à un comportement d'opposition, ni à une incapacité à comprendre les consignes) Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

7 TABLEAU CLINIQUE Les symptômes principaux de l’ADHD/HKD  Inattention
ADHD – a slide kit for clinicians Educational intent: to continue to outline the symptom criteria for inattention and identify any differences in this respect between DSM-IV (ADHD) and ICD-10 (HKD) SPEAKERS’ NOTES Key: orange = ICD-10/ HKD (vs DSM-IV/ ADHD) A souvent du mal à organiser ses travaux ou ses activités Souvent, évite, a en (forte) aversion, ou fait à contrecoeur les tâches qui nécessitent un effort mental soutenu (comme le travail scolaire ou les devoirs à la maison) Perd souvent les objets nécessaires à son travail ou à ses activités (p.ex., jouets, cahiers de devoirs, crayons, livres ou outils) Souvent, se laisse facilement distraire par des stimuli externes A des oublis fréquents dans la vie quotidienne Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

8 ADHD – a slide kit for clinicians
TABLEAU CLINIQUE Les symptômes principaux de l’ADHD/HKD Hyperactivité ADHD – a slide kit for clinicians Educational intent: to outline the symptom criteria for hyperactivity and identify any differences in this respect between DSM-IV (ADHD) and ICD-10 (HKD) SPEAKERS’ NOTES Key: orange = ICD-10/ HKD (vs DSM-IV/ ADHD) Again, there are only slight differences in the wording of DSM-IV and ICD-10. Remue souvent les mains ou les pieds, ou se tortille sur son siège Se lève souvent en classe ou dans d'autres situations où il est supposé rester assis Souvent, court ou grimpe partout, dans des situations où cela est inapproprié (chez les adolescents ou les adultes, ce symptômes peut se limiter à un sentiment subjectif d'impatience motrice) A souvent du mal à se tenir tranquille dans les jeux ou les activités de loisir Est souvent "sur la brèche" ou agit souvent comme s'il était "monté sur ressorts“. Montre un comportement persistant d’activité motrice excessive qui n’est pas modifiée dans l’essentiel par le contexte ou les demandes sociales Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

9 TABLEAU CLINIQUE Les symptômes principaux de l’ADHD/HKD Impulsivité
ADHD – a slide kit for clinicians Educational intent: to outline the symptom criteria for impulsivity and identify any differences in this respect between DSM-IV (ADHD) and ICD-10 (HKD) SPEAKERS’ NOTES Key: orange = ICD-10/ HKD (vs DSM-IV/ ADHD) Again, there are only slight differences in the wording of DSM-IV and ICD-10. Laisse souvent échapper la réponse à une question qui n'est pas encore entièrement posée A souvent du mal à attendre son tour lors de jeux ou de situations de groupes Interrompt souvent les autres ou impose sa présence (p. ex., fait irruption dans les conversions ou dans les jeux) parle souvent trop (sans réponse appropriée aux contraintes sociales) Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

10 ADHD – a slide kit for clinicians
TABLEAU CLINIQUE Les symptômes principaux de l’ADHD/HKD Critères de diagnostic – nombre de symptômes requis ADHD – a slide kit for clinicians Educational intent: to compare further the ICD-10 and DSM-IV classification systems SPEAKERS’ NOTES Symptom requirements DSM-IV (1994): predominantly inattentive ADHD must have > 6/9 symptoms of inattention present; predominantly hyperactive/ impulsive ADHD must have > 6/9 symptoms of hyperactivity/ impulsivity present; combined type ADHD must have > 6/9 symptoms of inattention and > 6/9 symptoms of hyperactivity/ impulsivity present. ICD-10 clinical descriptions (1992): ‘impaired attention and lack of persistent task involvement in combination with overactivity’ (no specific number of symptoms was required) ICD-10 research criteria (1994): there must be > 6/9 symptoms of inattention plus at least 3/ 5 symptoms of hyperactivity and 1/ 4 symptoms of impulsivity present. Impulsivity is a necessary symptom of HKD, but not ADHD Impairment/ pervasiveness requirements DSM-IV (1994): ‘some impairment from the symptoms [must be] present in two or more settings’ and ‘there must be clear evidence of clinically significant impairment in social, academic or occupational functioning’ ICD-10 clinical descriptions (1992): ‘impairment in attention and overactivity should both be present and evident in more than one situation’ ICD-10 research criteria (1994): ‘criteria should be met for more than a single situation, eg the combination of inattention and overactivity should be present both at home and at school or at both school and another setting where children are observed, such as a clinic’ and ‘the disturbance causes clinically significant distress or impairment in social, academic or occupational functioning’. DSM-IV requiert qu’au moins 6/9 symptômes soient présents autant pour le sous-type inattentif que pour le sous-type hyperactif/impulsif (pour un sous-type combiné il est requis une combinaison des deux) En comparaison au sous-type DSM-IV, les critères ICD-10 (critères de recherche) sont moins rigoureux en ce qui concerne le nombre de symptômes requis, mais plus rigoureux en ce qui concerne l’atteinte/la persistance. Les critères ICD et DSM ont été établis en pensant aux enfants Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

11 ADHD – a slide kit for clinicians
TABLEAU CLINIQUE Principaux symptômes Critères de diagnostic additionnels a ADHD – a slide kit for clinicians Educational intent: to begin to list the additional diagnostic criteria for ADHD  SPEAKERS’ NOTES This slide introduces the additional diagnostic criteria required by ICD-10 and DSM-IV. The additional criteria are essential in order to establish the diagnosis of ADHD as a disorder rather than assessing transient symptoms. There are minor differences, but both classification systems require: a duration of at least 6 months an age of onset ‘no later than 7 years’ (ICD-10) or ‘before 7 years’ (DSM-IV) pervasiveness of symptoms – ie ‘some impairment in two or more settings’ (DSM-IV) or ‘the criteria should be met for more than a single situation’ (ICD-10, the more stringent of the two). contd… Durée Les critères symptomatiques doivent avoir été rencontrés pendant les derniers six mois Age au début Quelques symptômes doivent avoir été présents avant l´âge de 6-7 ans. Persistance Les symptômes sont présents dans au moins 2 domaines (p.ex à l´école, au travail ou à la maison) Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

12 ADHD – a slide kit for clinicians
TABLEAU CLINIQUE Principaux symptômes  Critères de diagnostic additionnels ADHD – a slide kit for clinicians Educational intent: to continue to list the additional diagnostic criteria for ADHD  SPEAKERS’ NOTES This slide continues to show the additional diagnostic criteria required by ICD-10 and DSM-IV. The additional criteria are essential in order to establish the diagnosis of ADHD as a disorder rather than assessing transient symptoms. There are minor differences, but both classification systems require: impairment: a level of impairment or (in ICD-10) ‘clinically significant distress or impairment’ discrepancy: the child motor activity exceeds the upper limit of what is usual at this age for an otherwise normal child exclusion: ‘pervasive developmental disorder, schizophrenia, or other psychotic disorder are not better accounted for by another mental disorder (mood, anxiety, dissociative, personality disorder)’ (DSM-IV) or ‘does not meet the criteria for pervasive developmental disorder, manic or depressive episode, anxiety disorder’ (ICD-10). NB The DSM-IV wording ‘not better accounted for by another mental disorder’ may be more appropriate than the ICD-10 wording ‘does not meet the criteria for’, at least with respect to mood and anxiety disorders, on the basis that many studies (eg MTA) show the coexistence of ADHD and depression/ anxiety. Atteinte Les symptômes doivent avoir mené à une atteinte significative (sociale, académique ou professionnelle) Divergence Les symptômes sont excessifs par rapport à d’autres enfants du même age et du même QI Exclusion Les symptômes ne doivent pas être uniquement attribuables à d’autres troubles mentaux Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

13 ADHD – a slide kit for clinicians
TABLEAU CLINIQUE Principaux symptômes  Problèmes de diagnostic ADHD – a slide kit for clinicians Educational intent: to continue to remind that DSM-IV and ICD-10 criteria are not fully operational and that there is still a lot of scope for subjective interpretation of symptomatology and other diagnostic criteria SPEAKERS’ NOTES Behaviour dependent on context Interpreters should be aware that behaviour varies according to the demands of the environment. Age and gender The ADHD phenotype is well known and validated in 6–12-year-old boys of normal intelligence, but the phrasing and cut-off point may not be optimally adjusted for girls or other age groups. Variation du comportement dépendant du contexte Les critères sont les plus adéquats pour les garçons âgés de 6-12 ans avec une intelligence normale et moins adéquats pour les filles, les enfants préscolaires, les adolescents, les adultes et ceux atteints d’un retard mental Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

14 TABLEAU CLINIQUE Cours du trouble Psychopathologie du développement
ADHD – a slide kit for clinicians Educational intent: to describe the psychopathology of ADHD in toddlers SPEAKERS’ NOTES There may also be delays in language and motor milestones. NOURRISSONS/ ENFANTS EN BAS AGE (1-3 ans) Changement du tempérament, troubles régulatoires et adaptation sociale limitée dans le cadre de l’interaction parent/enfant Précurseur possible du TDAH Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

15 TABLEAU CLINIQUE Cours du trouble Psychopathologie du développement
ADHD – a slide kit for clinicians Educational intent: to describe the psychopathology of ADHD in preschool children SPEAKERS’ NOTES There may be an increased frequency of accidents and motor coordination difficulties. Differentiation from normal range of behaviour is difficult. Reliable and valid ADHD diagnostic instruments for this age group are still missing. The mentioned signs are suggested by the opinion of clinical experts and might be understood merely as risk factors rather than as diagnostic signs. ENFANTS PRESCOLAIRES (3-6 ans) Intensité et durée de jeu réduites Agitation motrice Problèmes associés et conséquences déficits du développement comportement de la défiance oppositionnelle problèmes d’adaptation sociale Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

16 TABLEAU CLINIQUE Cours du trouble Psychopathologie du développement
ADHD – a slide kit for clinicians Educational intent: to describe the psychopathology of ADHD in primary school children ENFANTS EN AGE SCOLAIRE (6-12 ans) Dissipation Agitation motrice Comportement impulsif et perturbateur Problèmes associés et implications troubles d’apprentissage spécifiques comportement agressif estime de soi-même réduite redoublement de classes rejet par les pairs atteinte des relations familiales Speakers’ notes ©EINAQ & ©ATC Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

17 TABLEAU CLINIQUE Cours du trouble Psychopathologie du développement
ADHD – a slide kit for clinicians Educational intent: to describe the psychopathology of ADHD in adolescents ADOLESCENTS (13-17 ans) Difficultés de planification et d´organisation Inattention persistante Réduction des agitations motrices Problèmes associés comportement agressif, peu sociable et délinquant Abus d´alcool et de drogues problèmes émotionnels accidents Speakers’ notes Clinical picture Clinical picture Assessment Differential diagnosis Conclusions

18 CLASSIFICATION ADHD/HKD
ADHD – a slide kit for clinicians Educational intent: to compare the DSM-IV and ICD-10 classification systems SPEAKERS’ NOTES The two major international classification systems (DSM-IV and ICD-10) have converged over time. Although their respective definitions of ADHD/ HKD are now much more similar, differences remain. ICD-10 only recognises the combined impairment of attention and overactivity/ impulsivity. DSM-IV recognises three subtypes on the basis of the degree of inattention and/ or hyperactivity/ impulsivity present. With the exception of the combined subtype, there may be present signs of other subtypes. ICD-10 recognises a separate categorical diagnosis of ‘hyperkinetic conduct disorder’ when the overall criteria for conduct disorder in addition to those of hyperkinetic disorder are met (DSM-IV would instead diagnose comorbid conduct disorder). The consequence of these differences is that ICD-10-defined cases are more severe and fewer in number (their prevalence is lower), and may be similar to the subgroup of more severe cases of ADHD-combined type according to DSM-IV. More details will be given in module 2. DIAGNOSTIC DSM-IV (ADHD) ADHD: sous-type combiné Inattention Hyperactivité/impulsivité + ADHD: sous-type où l`inattention prédomine Inattention ADHD: s.-type à hyperactivité/ impulsivité prédominantes Hyperactivité/impulsivité DIAGNOSTIC ICD-10 (HKD) Trouble de l’activité et de l’attention Inattention Hyper- activité Impulsivité + + Trouble de la conduite hyperkinétique Speakers’ notes Case description Core symtoms Emergence of a concept Classification Classification Epidemiology Aetiology Comorbidity Cost Implications

19 CLASSIFICATION du TDAH Répartition des sous-groupes selon le sexe
ADHD – a slide kit for clinicians Educational intent: to illustrate the three ADHD subtypes according to gender SPEAKERS’ NOTES The three ADHD subtypes are not equally common. The combined subtype is seen most often, while the hyperactive/ impulsive subtype may even be considered a questionable entity. In both boys and girls the combined subtype is most prevalent in clinics. There is a slightly higher proportion of girls presenting with the inattentive subtype in clinics. Epidemiological research indicates that the inattentive subtype predominates. Population clinique ç (N=140) (N=140) Speakers’ notes Biederman et al 2002 Case description Core symtoms Emergence of a concept Classification Classification Epidemiology Aetiology Comorbidity Cost Implications

20 EPIDEMIOLOGIE a Taux de prévalence
ADHD – a slide kit for clinicians Educational intent: to begin to discuss prevalence rates and their variation SPEAKERS’ NOTES The prevalence of HKD based on current ICD-10 criteria is about 1.5% (about 20% of DSM-IV ADHD). Factors influencing the prevalence rate include: classification system criteria type of instrument source and whether combined or retained separately age of assessment symptom count only or also assessment of degree of impairment sex ratio in study. Estimates of overall sex ratios in clinical populations range from 3:1 (boys to girls) to 6:1 (boys to girls), but it is 1:1 in general population-based studies. Les taux de prévalence dépendent des différences de la composition des échantillons des sources d´informations des instruments d`investigation utiliés La meilleure estimation basée sur les critères DSM-IV actuels, est une prévalence de 2-5% Speakers’ notes Case description Core symtoms Emergence of a concept Classification Epidemiology Epidemiology Aetiology Comorbidity Cost Implications

21 Pathologie génétique?

22 ETIOLOGIE Génétique comportemetale
Etudes familiales Bases génétiques De l’ADHD Etudes de jumeaux Génétique moléculaire Etudes d’adoption

23 ADHD – a slide kit for clinicians
Etudes familiales On examine le phénotype (ADHD) parmi les parents 1D, 2D d’un enfant ADHD (proband), parmi la fratrie (siblings) Méthode idéale: diagnostic en « double aveugle », et comparaison des fréquences avec la famille des contrôles Speakers’ notes

24 ADHD – a slide kit for clinicians
ADHD: études familiales ADHD chez les parents 1D d’enfants ADHD Plus ou moins 6 fois plus de chance de d’avoir un ADHD chez les parents 1D d’ADHD que chez les parents de sujets contrôles Speakers’ notes

25 ADHD – a slide kit for clinicians
ADHD: études familiales Montrent une agrégation du trouble dans les familles, argument insuffisant pour parler de « maladie génétique » Familles: partagent des gènes communs mais aussi certains facteurs environnementaux La transmission familiale peut aussi être induite par le partage des facteurs environnementaux Speakers’ notes

26 Etudes de jumeaux Distinguer l’influence génétique des facteurs environnementaux On postule que les jumeaux MZ ont  100% des gènes en commun et les DZ (50%) MZ et DZ partagent un environnement comparable ()

27 ADHD: études de jumeaux/ concordance

28 ADHD – a slide kit for clinicians
Etudes d’adoption ADHD – a slide kit for clinicians Parents adoptifs Parents biologiques L’idéal serait d’examiner l’ADHD chez les parents adoptifs et biologiques du même enfant… Permet une distinction entre la transmission génétique et environnementale Speakers’ notes

29 ADHD – a slide kit for clinicians
ADHD: études d’adoption (Sprich et al, 2000) Les parents biologiques d’enfants ADHD ont beaucoup plus de probabilité d’âtre atteint d’un ADHD que les parents adoptifs et que les contrôles. Idem pour la fratrie. Une étude d’adoption ( ven den Oord, 1994 a montré que les gènes contribuaient de façon très substantielle (47% de la variance) dans les troubles déficit d’attention chez les ADHD Les études fines qui où l’on a pu stratifier le phénotype selon une tendance plutôt implusive/hyperactive et déficit attentionnel montrent que la concordance est surtout importante pour le DA. Speakers’ notes

30 ADHD – a slide kit for clinicians
Héritabilité: mesure le degré pour lequel une pathologie est influencée par les facteurs génétiques: 0,68_0,8 (idem filles et garçons) Le fait que l’héritabilité ne soit ^pas égale à 1 montre l’intervention des facteurs environnementaux. Speakers’ notes

31 ADHD est une des pathologies psychiatriques la plus héritable

32 ADHD – a slide kit for clinicians
Hérédité à déterminisme complexe- Gènes de susceptibilité Modèle oligo(poly)génique- épistasie Effets modérés Pénétrance incomplète, phénocopies Hétérogénéité génétique Hétérogénéité phénotypique Certaines études ont néanmoins montré l’existence d’une transmission par un modèle monogénique de type mendélien. Speakers’ notes

33 Principe des études de linkage:
Recherche d’une liason génétique entre un marqueur moléculaire et une pathologie

34 Principe des études d’association
Comparaison des fréquences des allèles entre une population de patients et une population de sujets contrôles (sujets non apparentés) Résultat attendu: un excès significatif d’un allèle dans la population de patients

35 ADHD – a slide kit for clinicians
Hypothèses biologiques ADHD – a slide kit for clinicians Imagerie cérébrale Argument pharmacologique Methylphenidate Néanmoins, la résistance à l’hormone thyroidienne est retrouvée en faible proportion chez les sujets ADHD ( 1 cas/2500) Hypoactivité du système dopaminergique et noradrenergique Expérimentation animale HVA dans le LCR Après traitement MPD Speakers’ notes

36 DAT1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 DRD4 19 20 21 22 X Y

37 DAT: gène codant pour le transporteur dopaminergique Shéma synapse DAT

38 ADHD – a slide kit for clinicians
Gène DAT Modèle knockout de souris Suppression du gène DAT 3-4 études de population mais aussi de triades ont répliqué ce résultat Phénotype Hyperdopaminergique Hyperlocomotion spontanée Speakers’ notes

39 DRD4: gène codant pour le récepteur dopaminergique D4

40 Modèle comprenant les facteurs de risques incluant l’allèle DRD4 ( Mick et al, 2002)

41 ADHD – a slide kit for clinicians
Autres F génétiques Complications (grossesse et naissance,éclampsie) Causes neurologiques , toxiques PB familiaux facteurs nutritionnels? Les études contrôlées n’ont pas montré (ex pour la consommation excessive de sucres) un effet sur l’ADHD Speakers’ notes

42 ETIOLOGIE Facteurs biologiques acquis
ADHD – a slide kit for clinicians Educational intent: ADHD may also be acquired and/ or modulated by certain biological factors SPEAKERS’ NOTES There is a strong association between maternal lifestyle factors in pregnancy and ADHD risk. Nicotine exposure is most evident, but intrauterine alcohol exposure also seems to show a dose-response relationship. ADHD is the dominant psychopathological feature observed in children with fetal alcohol syndrome (although these children exhibit a wide array of psychopathology) and children suffering fetal alcohol effects (a minor variant of the syndrome with less severe dysmorphic features) also experience long-lasting attention deficit. Prenatal exposure to nicotine does not lead to a dysmorphic syndrome but it does lead to reduced birth weight. Prenatal and perinatal risk factors, most notably prematurity and low birth weight, correlate with ADHD, but the association is not exclusive. Food allergies pertain to a small minority of ADHD children and have led to the development of the so-called ‘oligogenic’ diet. However, this is very complicated, difficult to implement effectively and suitable only for a few selected cases (it may now even be discredited). The contribution of each biological factor is difficult to determine in any individual case. NB. Mothers who share ADHD-related genes with their offspring are more likely to smoke and drink alcohol while pregnant (passive gene-environment correlation). Exposition intra-utérine à l’alcool ou à la nicotine Prématurité extrême et faible poids natal Troubles cérébraux (par ex. encéphalite, traumatismes cérébraux) Allergies alimentaires Speakers’ notes Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Aetiology Comorbidity Cost Implications

43 ETIOLOGIE Neuroanatomie
ADHD – a slide kit for clinicians Educational intent: to introduce the neuroanatomical abnormalities associated with ADHD (according to age) SPEAKERS’ NOTES Magnetic resonance imaging (MRI) has revealed morphological differences between ADHD and normal children along the fronto-striatal-cerebellar axis. These early abnormalities have also been shown to change with time (during the course of normal development). Volume cérébral réduit (4%): lobe frontal droit (8%) Ganglions basaux réduits (6%)  normalisation (18 ans) Volume cervelet réduit (12%)  plus prononcé (18 ans) Ces différences de volume se manifestent tôt (6 ans) sont en corrélation avec la sévérité du TDAH sont indépendantes de la médication sont indépendantes des troubles associés Speakers’ notes Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Aetiology Comorbidity Cost Implications

44 ETIOLOGIE Neurophysiologie – flux sanguin SPECT
ADHD – a slide kit for clinicians Educational intent: to illustrate changes in blood flow associated with ADHD SPEAKERS’ NOTES Reduced blood flow is evident in the frontal lobe, parietal lobe (not illustrated on slide), striatum (not illustrated on slide) and cerebellum. In contrast, increased blood flow has been observed in the sensory motor cortex. This is supported by electrophysiological data which have shown decreased neuronal inhibition in this area. SPECT = single positron emission computerised tomography Normal ADHD Frontal lobe â Sensory-motor cortex á Cerebellum â Speakers’ notes Kuperman et al 1990 Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Aetiology Comorbidity Cost Implications

45 ADHD – a slide kit for clinicians
ETIOLOGIE Neurophysiologie – potentiels en relation avec des événements visuels ADHD – a slide kit for clinicians Educational intent: to illustrate the attention deficit seen in the parietal region of ADHD patients SPEAKERS’ NOTES Visual event-related potentials during the continuous performance test (CPT) indicate decreased neuronal energy in the posterior (parietal) attention system. Posterior attentional system decrease Source localisation Activation after presentation of A in CPT A-X (P300) Speakers’ notes Brandeis et al 2003 Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Aetiology Comorbidity Cost Implications

46 ETIOLOGIE Neurophysiologie – auditifs P300
ADHD – a slide kit for clinicians Educational intent: to exemplify the problems with neuronal focusing that accompany ADHD SPEAKERS’ NOTES The slide illustrates electrical activity (P300-wave) during target processing of an auditory odd-ball paradigm. The subject’s attention has to focus on a ‘target’ vs a ‘non-target’ tone and the subject has to press a button immediately after hearing the target tone. Sans médication Without medication With medication Avec médication La médication amène à une normalisation de la focalisation neuronale Speakers’ notes Kuperman et al 1990 Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Aetiology Comorbidity Cost Implications

47 ETIOLOGIE Neurochimie – dopamine et noradrénaline
ADHD – a slide kit for clinicians Educational intent: to outline where/ how various pharmaceutical treatments might work in relation to the activity of noradrenaline and dopamine SPEAKERS’ NOTES Our knowledge of the neurochemical background of ADHD is based mainly on drug studies in humans and animals. These have illustrated the involvement of both noradrenaline and dopamine as well as the frontal lobe and striatum – more recently they have also illustrated the involvement of the cerebellum. Action of MPH is thought to be dependent on DAT characteristics. Théories basées sur la pharmacothérapie Méthylphénidate (MPH) Inhibiteur de la recapture de la dopamine (noradrénaline) Actions principales sur le striatum Transporteur de dopamine (DAT) Densité augmentée dans le striatum Atomoxétine Inhibiteur de la recapture de noradrénaline Augmente la concentration de noradrénaline dans le cortex préfrontal, mais pas dans le n.accumbens/ striatum Speakers’ notes Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Aetiology Comorbidity Cost Implications

48 PSYCHOPHARMACOTHERAPIE Synapses dopaminergique et noradrénergique
ADHD – a slide kit for clinicians Educational intent: to illustrate the noradrenaline and dopamine synapses involved in ADHD SPEAKERS’ NOTES When an electrical signal arrives at the end of the presynaptic neuron, complex metabolic activity leads to the release of noradrenaline and/ or dopamine into the synaptic cleft. Once there, these two neurotransmitters come into contact with both presynaptic (feedback) and postsynaptic (signal transduction) receptors. Dopamine and noradrenaline transporters return free dopamine and noradrenaline from the synaptic cleft back into the presynaptic neuron. DA NEURONE DOPAMINERGIQUE DA DA DOPA DA DOPA décarboxylase R DA R Récepteurs MAO 3,4-dihydroxyphenylalanine DOPA DAT Dopamine DA HVA Transporteur de la dopamine DAT Fente synaptique Monoamine oxidase MAO Présynapse Postsynapse Acide homovanillique HVA Noradrénaline NA NA 3-methoxy-4-hydroxyphenylglycol MHPG NA NA DOPA DA NA DOPA décarboxylase R NA R Récepteurs Dopamine-b hydroxylase MAO Transporteur NA NEURONE NORADRENERGIQUE Speakers’ notes MHPG Overview Efficacy of interventions Psychoeducation Psychopharmacotherapy Psychopharmacotherapy Behaviour modification Algorithm QA Conclusions

49 ETIOLOGIE Neuropsychologie – trouble de la fonction exécutive
ADHD – a slide kit for clinicians Educational intent: to list the ways in which disturbed executive functioning is manifest in ADHD SPEAKERS’ NOTES Practical examples of the executive functioning disturbances listed might relate to: inhibition – stopping at traffic lights, waiting one’s turn planning – using one’s agenda, organising a five-course dinner for six friends working memory – pertains to two functions: maintenance, eg retaining the telephone number of a stranger manipulation, eg being instructed to remember a number (eg ) and then to perform the following calculation: add up the last two digits, add up the first two digits, subtract the sum of the last two digits from the sum of the first two digits (answer is 5) fluency – ability to name all the animals that begin with the letter ‘p’ selective attention – ability to listen to one conversation in a crowded restaurant sustained attention – ability to maintain attention for a long period of time, eg drive for several hours at night without falling asleep cognitive flexibility – ability to switch from one task to another and back again, eg make the dinner, answer the telephone and be able to return to the cooker knowing what to do next interference control – ability to write a letter efficiently while TV is on. Manifestation of the three core symptoms of ADHD: Distraction (inattention) refers to a breakdown in selective attention. This can occur as a result of failure to: divide attention - can’t switch attention from the phone to cooking the dinner focus attention - misses new stimuli, while concentrating on current task. Hyperactivity is an inappropriate level of motor activity for the current situation eg leg swinging while sitting at table or fidgeting constantly with desktop materials while performing a task.  Impulsivity is manifest as responding too quickly and consequently making errors eg subject blurts out first answer that comes to mind. Inhibition (motrice, cognitive et émotionnelle) Planification Mémoire (Working memory) Fluidité du langage Attention sélective et maintenue Flexibilité cognitive ou contrôle d’interférence Ces résultats ne sont pas spécifiques au TDAH Speakers’ notes Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Aetiology Comorbidity Cost Implications

50 ETIOLOGIE Facteurs psychosociaux
ADHD – a slide kit for clinicians Educational intent: to list those psychosocial factors that may have any impact on ADHD manifestation SPEAKERS’ NOTES Although ADHD is by origin mainly biological, the psychosocial environment has shown to be very important because of its modulating effect on outcome. Moreover, symptom severity and expression may also be influenced by psychosocial factors through gene-environment correlations and interactions. (In twin studies, these are included in the additive genetic component.) Passive gene–environment correlations arise because the parents who pass on their genes are the same parents who provide the rearing experience. Active/ evocative gene–environment correlations arise because people’s behaviour serves to select their environment and to influence other people’s responses to them (here ‘active’ refers to the selection effect and ‘evocative’ to the interpersonal effect). Gene-environment interactions describe the indirect effects of genes through their influence on susceptibility to specific environmental risks – in other words, certain environmental factors may have a different impact on individuals who possess a particular gene compared with those who don’t. Low socioeconomic status has been discussed by Sandberg with contradictory findings. Les facteurs modulants comprennent l’instabilité familiale des conflits entre partenaires des troubles mentaux parentaux le manque de compétence éducative une relation parent-enfant négative un faible statut socioéconomique (?) Speakers’ notes Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Aetiology Comorbidity Cost Implications

51 ADHD – a slide kit for clinicians
TROUBLES ASSOCIES ADHD – a slide kit for clinicians Educational intent: to illustrate the frequency of comorbidities SPEAKERS’ NOTES Comorbidity is the rule rather than the exception. ADHD plus conduct disorder and ADHD plus anxiety disorder and probably ADHD plus tic disorder may be sufficiently distinct to warrant classification as ADHD subtypes distinct from pure ADHD. Très fréquents (plus de 50%) ¡ Trouble de la défiance oppositionnelle ou trouble de la conduite Fréquent (jusqu`à 50%) ¡ Problèmes d´apprentissage spécifiques ¡ Trouble anxieux ¡ troubles de l’acquisition de la coordination Moins fréquent (jusqu´à 20%) ¡ Tics ¡ Troubles dépressifs Rarement ¡ Troubles du spectre autistique ¡ Retard mental Plus de 85% des patients ont au moins un trouble associé et approximativement 60% des patients ont au moins deux troubles associés Speakers’ notes Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Comorbidity Comorbidity Cost Implications

52 ADHD – a slide kit for clinicians
CONCLUSIONS ADHD – a slide kit for clinicians Educational intent: to summarise the implications of ADHD   Le TDAH est fréquent invalidant multifactoriel dans son étiologie un fardeau pour l’individu, la famille et la société compliqué dans la plupart des cas par des problèmes additionnels Une détection et un traitement précoces du TDAH sont importants Speakers’ notes Case description Core symtoms Emergence of a concept Classification Epidemiology Aetiology Comorbidity Cost Implications Implications

53 EVALUATION MULTIMODALE
ADHD – a slide kit for clinicians Educational intent: to highlight that assessment is multimodal and that several modes serve several purposes SPEAKERS’ NOTES For the assessment of ADHD, several modes of information gathering are used (interview, questionnaire, observation, physical and psychological examination). Each mode may serve several purposes. Several sources of information are necessary. The clinical interview with the parent is the cornerstone of the assessment. Diagnostic Entretien clinique (parents) Information (enseignant) Observation Diagnostic différentiel Entretien clinique (parents, enfant) Étiologie Examen physique Examen neuropsychologique Troubles associés Entretien clinique (parents) Examen neuropsychologique Examen physique Estimation de la sévérité/ réponse au traitement Questionnaires (parents et enseignants) Estimation de l’atteinte Speakers’ notes Clinical picture Assessment Assessment Differential diagnosis Conclusions

54 ANAMNESE Examen physique
ADHD – a slide kit for clinicians Educational intent: to illustrate the importance of organic assessment in the diagnosis of ADHD  SPEAKERS’ NOTES Acquired biological factors may be responsible for ADHD and therefore have to be investigated. Even if no relevant organic factors can be found at the outset, they should be considered long term when changes in symptomatology arise. Streptococcal infection, for example, may be a modulating factor. BP = blood pressure EEG = electroencephalogram ECG = electrocardiogram Taille, poids, circonférence de la tête, tension artérielle, fréquence cardiaque Anomalies (p.ex. syndrome d’alcoolisme fœtal) Vue, ouïe Coordination motrice Quand un diagnostic différentiel est indiqué Statut neurologique EEG/imagerie neurologique Évaluation génétique Examens métaboliques (p. ex. hyperthyroïdisme) ECG Tests sanguins Speakers’ notes Clinical picture Assessment Assessment Differential diagnosis Conclusions

55 ANAMNESE Examens psychologiques - Tests
ADHD – a slide kit for clinicians Educational intent: to list the psychological tests and observations that may help in diagnosing ADHD  SPEAKERS’ NOTES IQ – use appropriate, nationally normed, IQ test for children. Reading, spelling and mathematics – use appropriate, nationally normed, tests for children. Attention – use cancellation test, dichotic listening, continuous performance task, Posner’s attention network test. Speech and language – use children’s communication checklist (for screening) and further neuropsychological testing as required. Audiology test may be appropriate. Memory – for working memory maintenance use digit forwards test; for working memory manipulation use digit backwards test; for visual working memory use self-order pointing task. Learning – can involve assessment for dyslexia and dyscalculia. Use the appropriate national neuropsychological tests. Perception – usually undisturbed in ADHD patients, although a significant number of male ADHD patients may suffer colour blindness. This should be checked before administration of the Stroop colour word test. Investigation of timing perception and synchronisation is useful. Motor skills – assess clumsiness; the Purdue pegboard, finger tapping and manual dexterity tests may be useful. Executive function domains – test planning (Tower of London), working memory (self-order pointing), inhibition (stop signal task), fluency (word fluency test) and ‘set shifting’ (Trails B). QI (presque toujours indiqué) Capacités lecture écriture calcul Fonctions neurophysiologiques attention apprentissage discours et langue perception mémoire capacités motrices Fonctions exécutives Les tests ne doivent être accomplis que s’ils sont indiqués. Il n´y a pas de test spécifique du TDAH! Speakers’ notes Clinical picture Assessment Assessment Differential diagnosis Conclusions

56 Stratégies de prise en charge
ADHD – a slide kit for clinicians Stratégies de prise en charge TRAITEMENT MULTIMODAL Speakers’ notes

57 VUE D'ENSEMBLE Les divers domaines d’intervention
EINAQ ADHD – a slide kit for clinicians Educational intent: to illustrate multimodal treatment and intervention at different levels  SPEAKERS’ NOTES An individually tailored ADHD treatment must take into account that the child not only has problems of inattention, hyperactivity and impulsivity, but often has coexisting disorders such as conduct or learning disorder and impaired social and academic functioning. The problem spreads to the child’s family in which there are often parenting problems, a lack of control over the child, negative parent-child relationships and even marital stress or parental mental health problems (eg depression, impulsivity, inattention) – these problems are both exacerbated by and, in turn, may exacerbate the child’s problem. In school the child usually exhibits learning difficulties and academic failure, and the teacher-student relationship is often strained. There are problems with peer relationships. Inattention Hyperactivité Enfant Impulsivité Troubles associés Altération du fonctionnement Les difficultés éducatives et relationnelles, le contrôle Famille La charge familiale, la santé mentale des parents Difficultés d'apprentissage et échec scolaire Ecole Détérioration de la relation enseignant-élève Pairs Détérioration des relations avec les autres enfants Requiert des interventions à plusieurs niveaux Speakers’ notes Overview Overview Efficacy of interventions Psychoeducation Psychopharmacotherapy Behaviour modification Algorithm QA Conclusions

58 VUE D’ENSEMBLE Interventions
EINAQ ADHD – a slide kit for clinicians Educational intent: to illustrate the broad types of intervention that may be applied at different levels  SPEAKERS’ NOTES Because different problems are usually present in different arenas – ie child, family, school – different interventions may be used to target the child himself (child-focused), the parent or family (parent-/ family-focused), or the nursery/ school. Patient-focused intervention may comprise psychoeducation of the child, cognitive behaviour therapy with the child and psychopharmacotherapy. Parent- and family-focused intervention may comprise psychoeducation of the parents and parent training (and treatment of the parents if necessary). Teacher- and school-focused intervention may comprise psychoeducation of the teachers and behavioural interventions in the nursery school, school or classroom. In most cases a combination of interventions - so-called ‘multimodal’ treatment - is required. Psychoéducation Visant le patient Psychopharmacothérapie Thérapie cognitive comportementale Psychoéducation Visant les parents Entraînement parental Psychoéducation Visant l’école Interventions sur le comportement Speakers’ notes Overview Overview Efficacy of interventions Psychoeducation Psychopharmacotherapy Behaviour modification Algorithm QA Conclusions

59 Agents pharmacologiques utilisés dans le traitement de l’ADHD*
ADHD – a slide kit for clinicians Stimulants Méthylphénidate ( Rilatine®, Concerta® ) (Traitement de Amphétaminiques première intention Dextroamphétamines recommandé ) Pémoline Antidépresseurs Antidépresseurs tricycliques Bupropion ( Zyban® ) Antihypertenseurs Clonidine ( Catapressan® ) Guanfacine ( Estulic® ) Agents du métabolisme Carnitine Acides gras Les agents pharmacologiques utilisés dans le traitement de l’ADHD sont repris ici. Les stimulants sont généralement les médicaments de première intention pour le traitement de l’ADHD et leur utilisation à cet effet est étayée par les recommandations émises par l’American Academy of Pediatrics, le National Institute for Clinical Excellence et le Scottish Intercollegiate Guidelines Network. * Dans certains pays, ces agents ne sont pas tous disponibles Speakers’ notes Wilens T, et al. ADHD, In Annual Review of Medicine, 2002: 53. Greenhill L. Childhood attention deficit hyperactivity disorder: pharmacological treatments. In: Nathan PE, Gorman J, eds. Treatments that Work. Philadelphia, PA: Saunders; 1998:42-64.

60 ADHD – a slide kit for clinicians
Méthylphénidate:MPH ADHD – a slide kit for clinicians Le MPH est efficace dans la réduction des symptômes centraux d’inattention, d’hyperactivité et d’impulsivité L’utilisation du MPH pour le traitement de l’ADHD est supportée par les recommandations européennes 200 études contrôlées et randomisées avec le MPH ont été publiées Les recommandations suggèrent que le MPH est un traitement efficace pour l’ADHD1,2. Vous trouverez davantage d’informations sur le National Institute for Clinical Excellence (NICE) sur le site Internet: Pour en savoir plus sur le Scottish Intercollegiate Guidelines Network (SIGN), surfez sur le site: Des informations complémentaires sur l’American Academy of Pediatrics (AAP) figurent sur le site: 1. European Guidelines: Mash, Johnston. J Clin Child Psychol 1990; 19: 313. 2. Taylor et al. Eur Child Adolesc Psychiatry 1998; 7: Speakers’ notes

61 PSYCHOPHARMACOTHERAPIE Efficacité des stimulants
ADHD – a slide kit for clinicians Educational intent: to illustrate the efficacy of stimulant treatment according to various parameters SPEAKERS’ NOTES So far, stimulants are the gold standard pharmaceutical treatment for ADHD. However, pharmaceutical management should not be expected to solve all the problems associated with ADHD symptoms. Taux de réponse (%) 75-90 Méthylphénidate 75 Amphétamine 70 Taux de normalisation (%) 50-60 Amélioration des symptômes (%) Échelles de comportement 30-50 EINAQ Speakers’ notes Overview Efficacy of interventions Psychoeducation Psychopharmacotherapy Psychopharmacotherapy Behaviour modification Algorithm QA Conclusions

62 PSYCHOPHARMACOTHÉRAPIE  Critères d’efficacité des stimulants
ADHD – a slide kit for clinicians Educational intent: to continue to indicate that the differential efficacy of the stimulants must be considered  SPEAKERS’ NOTES Stimulants may act differently in different age groups, in children with a low IQ and in certain social contexts. Hence, titration and optimisation of drug treatment within a general treatment programme is necessary, even in the long term. ‘?’ = currently debatable Environnement L'efficacité dépend du contexte (par ex. famille vs école, en combinaison avec une thérapie cognitivo-comportementale) Sévérité/symptômes associés Pas d'influence majeure sur l'efficacité ? EINAQ Speakers’ notes Overview Efficacy of interventions Psychoeducation Psychopharmacotherapy Psychopharmacotherapy Behaviour modification Algorithm QA Conclusions

63 PSYCHOPHARMACOTHÉRAPIE Posologie des stimulants à action brève
ADHD – a slide kit for clinicians Educational intent: to detail the recommended dosages of the short-acting stimulants  SPEAKERS’ NOTES Start methylphenidate with a standard morning dose of 5-10 mg and increase at weekly intervals by 5-10 mg/day. Start amphetamines with a standard morning dose of mg and increase at weekly intervals by 5 mg/day. METHYLPHENIDATE (Rilatine®) (Les noms de marque dépendent du pays) Normalement mg/ jour Dose quotidienne moyenne 35 mg Dose quotidienne maximale 60 mg Normalement 2-3 doses/jour 1 dose/jour suffit dans quelques cas AMPHETAMINES (pas de commercialisation en Europe) EINAQ Une détermination progressive de la posologie est nécessaire Speakers’ notes Overview Efficacy of interventions Psychoeducation Psychopharmacotherapy Psychopharmacotherapy Behaviour modification Algorithm QA Conclusions

64 ADHD – a slide kit for clinicians
Inconvénients du MPH sous forme de Rilatine® Courte durée d’action Pics/creux, fluctuations tout au long de la journée 2 ou 3 prises par jour, risque de mauvaise compliance Problèmes de discrétion Histoire du développement Avant le développement de CONCERTA, le traitement conventionnel par le méthylphénidate impliquait: Trois prises par jour pour assurer une amélioration du comportement pendant la journée d’école et après les heures d’école. La prise à midi, donnée normalement dans le bureau de la direction de l’école, engendre de l’embarras et a des effets négatifs potentiels sur l’observance. L’administration d’une dose le soir impose à l’enfant de rentrer d’abord à la maison avant de se rendre à des activités post-scolaires Problèmes de sécurité: la substance réglementaire doit souvent être conservée dans le bureau de la direction de l’école et être administrée par l’infirmière de l’école. Problèmes de discrétion: l’enfant atteint d’ADHD se sent probablement stigmatisé parce qu’il doit se rendre au bureau de la direction/infirmerie de l’école. Une version à libération prolongée du méthylphénidate a été disponible pendant un certain temps dans certains pays mais les études ont démontré que l’efficacité de cette formule n’était pas aussi bonne que l’administration 3x/j du médicament. Le déclenchement de l’action était plus lent que celui observé avec le MPH à libération immédiate et la réponse individuelle au médicament était hautement variable1. La demande d’un traitement permettant d’éviter les prises du médicament à midi et le soir tout en possédant la même efficacité que l’administration trois fois par jour était très forte. Avant CONCERTA, aucun traitement de première intention n’a offert une efficacité de 12 heures. 1. Pelham WE et al. Once-a-day CONCERTA methylphenidate versus three-times-daily methylphenidate in laboratory and natural settings. Pediatrics 2001; 107(6): e105 Speakers’ notes

65 Utilisation à long terme
Dépendance? Non (possibilité d ’arrêter brutalement pour WE ou vacances) Accoutumance? Faible (études de suivi n ’en montrent pas mais sont à moyen terme) Risque augmenté de consommation de drogue? Non (comorbidité) Retard de croissance? Non (pas retrouvé dans études récentes)

66 Ce qu’il faut retenir… - Bonne efficacité - Bonne tolérance - Rapidité d’action - Maniabilité du produit/sécurité d’emploi - Absence d’accoutumance ou de réaction de sevrage Il n’y a ni tolérance, ni dépendance et les risques d’abus sont faibles - Ancienneté d’utilisation du produit - Sécurité en cas de surdosage - Rareté/réversibilité des effets secondaires

67 Rilatine: Méthylphénidate
4 fois plus de prescriptions aux USA depuis 10 ans… Utilisation surabondante?  Cas traités: meilleure connaissance? Contexte de société? Sujet de controverse

68 ADHD – a slide kit for clinicians
PSYCHOPHARMACOTHERAPIE Utilisation du méthylphénidate en Belgique Educational intent: to illustrate the increase in methylphenidate use in Belgium in recent years 100 80 60 No. de de boîtes de méthylphénidate vendues (000) 40 20 90 91 92 93 94 95 96 97 98 99 00 01 02 EINAQ Année Speakers’ notes Overview Efficacy of interventions Psychoeducation Psychopharmacotherapy Psychopharmacotherapy Behaviour modification Algorithm QA Conclusions