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ADHD in school age children

Immediate problems with longterm consequences

EQ071: March 2004

What is ADHD?

EQ071: March 2004

Attention Deficit/Hyperactivity Disorder (DSM-IV)


A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development Must cause significant impairment in social or academic (occupational for adults) functioning or marked distress
American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders, Fourth Edition. Washington, DC. American Psychiatric Association; 1994:7885.

EQ071: March 2004

Hyperactivity disorders (ICD-10)


In ICD-101, the term hyperkinetic disorder is roughly equivalent to ADHD (combined type) as diagnosed by DSM-IV Narrower criteria and more stringent than DSM-IV2
1 World Health Organization. International Classification of Diseases (ICD-10). Geneva: WHO; 1992; 2 Taylor E et al. Eur Child Adolesc Psychiatry 1998;7:184200.

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How common is ADHD?

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Worldwide prevalence in school age children and adolescents


Prevalence estimates depend on the choice of diagnostic tool and the age of the children (older children show a lower prevalence)1

1.914.4% (DSM-III or DSM-III-R)1,2 1.717.8% (11.417.8% DSM-IV)3,4


Estimates for the school age population range from: 312%1,5,6
1 Reviewed in Scahill L & Schwab-Stone M. Child Adolesc Psychiatr Clinics N Am 2000;9(3):541 555; 2 Landgren M et al. Eur Child Adolesc Psychiatr 2003;12:162171; 3 Reviewed in Elia J et al. N Engl J Med 1999;340(10):780788; 4 Taylor E et al. Eur Child Adolesc Psychiatry 1998;7:184200; 5 Reviewed in Brown RT et al. Pediatrics 2001;107(3):E43; 6 Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am 2000;9(3):711 726.

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What effect does ADHD have on a childs school performance and achievement?

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ADHD usually becomes apparent in primary school


Diagnosis often only confirmed once child starts school
Symptoms may only appear in a structured setting demanding task completion Depends on teachers observations in the classroom Teacher can compare patterns of compliance, on-task behaviour and disruptiveness with other children pursuing similar tasks

Diagnosis currently made in primary school setting: 79 years old


Greenhill LL. J Clin Psychiatry 1998;59(Suppl 7):3141.
EQ071: March 2004

Indications of ADHD in primary school children


Inattention
Trouble following instructions Tasks not completed Disorganised (messy desk or cluttered book bag) Careless, messy, work full of mistakes Teacher may feel that the child is not listening/has not heard

Hyperactivity-impulsivity
Difficulty remaining seated and excessive fidgetiness (squirming in the seat, noisily manipulating objects on the desk) Answers to questions blurted out before the teacher has a chance to finish Comments made out of turn Interrupts the teacher during lessons and other pupils during quiet study
Greenhill LL. J Clin Psychiatry 1998;59(Suppl 7):3141.

EQ071: March 2004

Impaired learning in primary school


ADHD children are poor academically1,2
Impaired academic adjustment Impairments in fundamental skills:
Reading Spelling Arithmetic

Placed in special education groups

1 Barkley RA et al. J Consult Clin Psychol 1990;58(6):775789. 2 Landgren M et al. Eur Child Adolesc Psychiatr 2003;12:162171.

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ADHD persists into adolescence


7080% of adolescents who had ADHD in childhood continue to have social, academic and emotional difficulties16
Poorer performances in verbal learning, vigilance and maths task Greater off-task behaviour More fidgeting and out-of-seat behaviour More suspensions More failures to complete full time education

Some present with ADHD for the first time as adolescents showing:1
Chronic academic underachievement and irritability Disorganised school work with poor follow-through Failure to complete independent academic work

1 Greenhill LL. J Clin Psychiatry 1998;59(Suppl 7):3141; 2 Barkley RA et al. J Am Acad Child Adolesc Psychiatry 1990;29:546557; 3 Barkley RA et al. J Am Acad Child Adolesc Psychiatry 1991;30(5):752761; 4 Evans SW et al. Exp Clin Psychopharmacol 2001;9(2):163175; 5 Mannuzza S et al. Arch Gen Psychiatry 1993;50:565576; 6 Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am 2000;9(3):711726.

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What are the clinical treatment objectives for children with ADHD?

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Improving functioning during the school day: an important clinical objective


Key ADHD treatment objectives for clinicians (spontaneous)
Other Maximise convenience Reduce violence/aggression Minimise dosage Ensure compliance Minimise side effects Reduce impulsiveness Improve self-esteem Reduce hyperactivity Improve social functioning Improve inattention Improve family relationships General symptom improvement Improve school functioning

0%

10%

20%

30%

40%

50%

60%

70%

Proportion of respondents

Quantitative interviews with 42 UK paediatric/child & adolescent psychiatrists and 8 UK paediatricians. Data on file, Celltech Pharmaceuticals, 2003.
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What times of day are most important for control of ADHD symptoms?

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Are there any specific times of the day when control is most important?
Importance of control at different times
School day 10.0 All day, 24-hour control Morning

Holidays

7.5

Afternoon

5.0 Non-organised after-school activities Playtime at school

Weekdays Evening

Lunchtime at school

N=48
Organised after-school activities

Quantitative interviews with 42 UK paediatric/child & adolescent Total (48) psychiatrists and 8 UK paediatricians. Data on file, Celltech Pharmaceuticals, 2003.
EQ071: March 2004

What are the pros and cons of current treatments for ADHD for children in school?

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Many children require treatment for ADHD during the school day
22.5% of all school age children in North America receive drug treatment for hyperactivity1
This equates to about 2 million children1

90% of these children receive methylphenidate (MPH)1,2

1 Reviewed in Greenhill LL. J Clin Psychiatry 1998;59(Suppl 7):314. 2 Greenhill L. Child and Adolescent Psychiatric Clinics of North America 1995;4:123168.

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Methylphenidate: benefits for primary school children and adolescents


Children with ADHD methylphenidate treatment improves:13
Classroom behaviour Classwork and academic learning Peer and parent interactions

Adolescents with ADHD methylphenidate treatment improves:


Classroom behaviour and academic performance4,5
Note taking Quiz performance Written language Study assignments

Likely to translate into long-term gains in academic achievement5


1 Pelham WE et al. J Consult Clin Psychol 2002;70(2):320335; 2 Reviewed in Carlson CL & Bunner MR. J School Psychol Rev 1993;22:184198; 3 Yang P et al. Psychiatry Clin Neurosci 2004;58:3741; 4 Evans SW & Pelham WE. J Abnormal Child Psychol 1991;19:537552; 5 Evans SW et al. Exp Clin Psychopharmacol 2001;9(2):163175.
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Problems with taking a drug for ADHD during the school day1,2
Supervision requires the school nurse or equivalent personnel
Bureaucracy of using a classified drug in the school

Inadequate supervision of those taking short-acting stimulant medication can lead to noncompliance
Missed doses lead to worsening of attention and behaviour

Education policy may prevent the involvement of school personnel, leaving individuals responsible for their own treatment
1 Greenhill L. Child and Adolescent Psychiatric Clinics of North America 1995;4:123168. 2 Swanson J. CNS Drugs 2003;17(2):117131.

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The stigma of taking medication at school


Of 77 parents of children with ADHD attending the 1999 US Children and Adults with ADHD conference
59% considered that their childs self esteem had suffered as a result of taking medication at school and thought their child was embarrassed by taking their medication

Swanson J. CNS Drugs 2003;17(2):117131.

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Advantages of drug treatments that do not require a midday dose


Avoids stigma of having to take medication during school or at college or in the workplace Improves supervision of treatment
Parent can administer the dose before the child leaves for school Supervision problems and noncompliance during the day are avoided

Less bureaucracy for the school

Swanson J. CNS Drugs 2003;17(2):117131.

EQ071: March 2004

What are the long-term consequences of childhood ADHD?

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ADHD in childhood: consequences for adult academic achievement16


Poorer educational achievement
Attended special schools Failed to finish school Failed to go on to college More academic problems when in school
Lower class marks More failed courses

Poor occupational attainment by 25 years old7


Poorer occupational rankings Poorer work adequacy, independent working and task completion (employer rating) More likely to be laid-off

1 Seidman LJ et al. Biol Psychiatry 1998;44:260268; 2 Biederman J et al. Am J Psychiatry 1993;150:1792 1798; 3 Weiss G et al. J Am Acad Child Psychiatry 1985;24(2):211220; 4 Elia J et al. N Engl J Med 1999;340(10):780788; 5 Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am 2000;9(3):711726. 6 Barkley RA. J Clin Psychiatry 2002;63(Suppl 12):1015. 7 Mannuzza S et al. Arch Gen Psychiatry 1993;50(7):56576.

EQ071: March 2004

Early poor academic achievement has long-term consequences


In adults whose ADHD symptoms decreased during adolescence and are not present in adulthood, achievement is similar to that of normal subjects for:1,2
Occupational achievement Social functioning Substance use

Academic achievement remains poor1,2

1 Mannuzza S et al. Arch Gen Psychiatry 1988;45(1):1318. 2 Manuzza et al. Arch Gen Psychiatry 1993;50:565576.

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ADHD in young adults


ADHD can persist from childhood into adult life1,2 Up to 50% of children with ADHD become adults with ADHD36 ADHD can present for the first time in adulthood6

1 Seidman LJ et al. Biol Psychiatry 1998;44:260268; 2 Biederman J et al. Am J Psychiatry 1993;150:1792 1798; 3 Gittelman R et al. Arch Gen Psychiatry 1985;42:937947; 4 Weiss G et al. J Am Acad Child Psychiatry. 1985;24(2):211220; 5 Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am 2000;9(3):711726; 6 Barkley RA. J Clin Psychiatry 2002;63(Suppl 12):1015.
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ADHD in childhood: outcomes as adults


Many adults who had ADHD in childhood continue to have:16
Stuttering, speech and language disorders Anxiety disorders Restlessness High impulsivity (e.g. more car accidents, move house more often) Interpersonal problems and sexual problems (many divorced or separated) Higher rates of antisocial personality disorders (e.g. conduct disorder) Substance abuse (particularly with co-existing conduct and antisocial disorders)

1 Seidman LJ et al. Biol Psychiatry 1998;44:260268; 2 Biederman J et al. Am J Psychiatry 1993;150:17921798; 3 Gittelman R et al. Arch Gen Psychiatry 1985;42:937947; 4 Weiss G et al. J Am Acad Child Psychiatry 1985;24(2):211220; 5 Elia J et al. N Engl J Med 1999;340(10):780788; 6 Reviewed in Mannuzza S & Klein RG. Child Adolesc Psychiatr Clinics N Am 2000;9(3):711726.

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Towards optimal outcomes for children with ADHD


Drug treatment should be tailored to maximise attention during the school day
Short-term benefits during the school day Long-term benefits for academic achievement and job prospects

Ideal drug treatment regimens do not require a lunchtime dose


To minimise stigma To improve compliance To reduce the burden on the school and on teachers

Drug treatment should be used in conjunction with appropriate behavioural and psychosocial interventions

EQ071: March 2004