Attention deficit hyperactivity disorder ADHD and disruptive behaviour disorders Clinical implications and treatment practice suggestions
Attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): Clinical implications and treatment practice suggestions Stan Kutcher , , a, Michael Amanb, Sarah J. ... Greenhillh, Michael Hussg, Vivek Kusumakara, Daniel Pinei, Eric Taylork and Sam Tyanoj Attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs) are classified somewhat differently internationally due to the use of two different classification systems––the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSMIV; ([American Psychiatric Association, 1994])) and the International Classification of Diseases, 10th Edition (ICD10; ( [World Health Organisation, 1993])). DSMIV ADHD is one of the most commonly diagnosed childhood psychiatric disorders, and is estimated to affect 3–5% of school age youngsters ([Popper, 1988 and Buitelaar, 2002]); the term `youngsters will be used to refer collectively to children and adolescents. It is characterised by persistent impairments in attention (or concentration) and/or symptoms of hyperactivity and impulsivity. ADHD is a chronic condition, associated with poor outcome in terms of academic achievement, social problems and employment instability ( [Weiss et al. ... Diagnosis of ADHD is about three to four times more common in males than in females ( [Ross and Ross, 1982 and Gaub and Carlson, 1997]), although this gender imbalance may be inflated to some extent by referral biases (more boys are sent for clinical assessment of ADHD than girls), and the imbalance has also been found to be less pronounced in adolescence than in childhood ( [Offord et al. ... The DBDs of DSMIV comprise conduct disorder (CD), oppositional defiant disorder (ODD) and DBD-not otherwise specified. ... As with ADHD, the literature suggests that this gender imbalance may become less pronounced in older samples ( [McGee et al. ... (Psychopharmacologic treatment would not be appropriate for cases of ODD in the absence of comorbidity, unless severe aggression and/or destructive behaviour persisted despite attempts at psychosocial interventions of established efficacy). The DBDs of ICD10 include hyperkinetic disorder and CD, with ODD being one form of CD. ... Likewise, hyperkinetic disorder is the counterpart to DSMIV ADHD, although the diagnostic criteria of hyperkinetic disorder are stricter, requiring severe, persistent and pervasive impairment in psychological development due to high levels of inattentiveness, restlessness and impulsivity. ... Prevalence rates of hyperkinetic disorder are, therefore, considerably lower (about 1.5% in school age youngsters) than those for ADHD ([Taylor, 1994]). In other respects, however, and particularly in terms of the treatment suggestions provided in this paper, what is said for ADHD can also be considered true for hyperkinetic disorder. ADHD can be subtyped as: (a) primarily inattentive type; (b) primarily hyperactive/impulsive type; or (c) combined type (presence of inattention and hyperactivity/impulsivity). In contrast, ICD10 hyperkinetic disorder is only subtyped by whether or not CD is also present (see comorbidity section below). ... Irrespective of diagnosis, some researchers have attempted to subtype aggression that can be seen in a variety of psychiatric conditions, including ADHD and DBDs. ... It is also possible that particular forms of treatment may prove to be more effective at treating one form of aggression than another ( [Malone et al. ... Rationale Among researchers and clinicians around the world, there are concerns that youngsters with ADHD/DBDs are not receiving the appropriate treatment that they need. Considerable research data indicate a biological basis to these disorders (see below), and compelling evidence has demonstrated their association with poor long-term outcomes in untreated cases. Effective treatments are available, and yet many such youngsters do not receive adequate treatment. Reasons for this are multiple, but a significant hindrance is the lack of public and professional awareness and/or understanding of the nature of these disorders. Much of the lay community tends to view persistent abnormal behaviour as evidence that a youngster is either `mad, sad or just plain bad, with youngsters with ADHD, ODD and/or CD falling in the latter category. This is one reason why many such children are never referred for medical attention for their disruptive behaviours, or are not presented until many years of untreated problems have passed. A shift in attitude to change the categorisation `bad to `handicapped is required to facilitate earlier identification and treatment of these youngsters. ... Medical communities worldwide are, at varying rates, beginning to accept the idea that ADHD is a medical condition that should be treated but, as yet, many fewer professionals accept that CD is also a medical condition that warrants treatment. One potential means of addressing this problem is to bring to their attention data emerging from neuroimaging, neurobiology and genetic research, which indicate the biological aspects of ADHD and CD, and the results of studies examining the long-term outcomes of treated versus untreated cases. There is another concern that even when the willingness to treat is present, potentially effective treatments for ADHD and/or CD are not optimally applied. A major problem is the lack of relevant knowledge, skills and tools that exists among the majority of healthcare providers to whom many youngsters with these disorders are presented. ... Intended outcomes of the meeting The goal of the international consensus meeting, and of this paper, was to try to address these concerns as follows: (1) promoting the discussion and dissemination of pertinent research findings––results that indicate the biological natures of ADHD and DBDs, and establish the need to treat youngsters with these disorders; (2) reviewing and, where necessary, overseeing the development of assessment tools useful for Primary Care Providers (PCPs; tools for screening, diagnosing and monitoring treatment outcome; and (3) producing practical suggestions on the diagnosis and treatment of these disorders that have international relevance and applicability. In order to produce treatment suggestions with international utility, it was recognised that these suggestions would need to be flexible to accommodate international and regional differences, such as: substantial differences in the availability of specialists; differences in diagnostic classification systems used; differences in health policy regarding under what circumstances referrals are made, and to which kinds of specialists those cases are referred; differences in the availability and licensing of particular psychopharmacological preparations, and the availability of health professionals trained in psychosocial treatments of demonstrated efficacy; and others. For these reasons, the consensus suggestions presented in this paper do not prescriptively state which group of professionals should carry out the diagnostic procedure, nor do they specify which particular qualifications should be held by the `specialists to whom certain cases should ideally be referred. The suggestions also do not require that a particular diagnostic classification system is adhered to. (While, for convenience, the treatment option pathways make use of DSMIV terminology for diagnoses, the treatment pathways are considered to be equally applicable to youngsters with the corresponding ICD10 diagnoses). Furthermore, the psychopharmacologic treatment options recommend classes of medication rather than specific agents. The consensus treatment options are designed to guide the treatment of youngsters who have already been accurately diagnosed with ADHD or hyperkinetic disorder (with or without ODD) and/or CD. These disorders have common components (e. ... Cases of ADHD and/or CD with other comorbidities (e. ... depressive or anxiety disorders) are not addressed by these consensus treatment options because they require different approaches to treatment; such cases may be most appropriately referred for immediate specialist attention. Indeed, many authorities recommend that cases of ADHD with any type of comorbidity should be referred for specialist attention. ... Methods At the request of Johnson and Johnson Pharmaceuticals, Dr Stan Kutcher, Professor and Head of Psychiatry at Dalhousie University, Canada (an expert in child and adolescent psychopharmacology) was asked to chair an international group of experts in the domains of ADHD and DBDs. ... Nationally or internationally recognised authority in DBDs (research publications, regional or national guidelines development, clinical expertise) was also taken into account. ... The faculty presentations collectively reviewed the following aspects of ADHD/DBDs: epidemiology, comorbidity, neurochemistry, genetics, neuroimaging, means of diagnosis, means of measuring outcome, pharmacological treatment and non-pharmacological treatment. The Johnson and Johnson presentations consisted of clinical updates on the safety and efficacy of the long-acting methylphenidate (MPH) preparation, Concerta, and the atypical antipsychotic, risperidone. All presentations were followed by an open discussion of the strengths, weaknesses and implications for clinicians of the data presented. ... Each work group was given the task of developing treatment option pathways for ADHD/DBDs. These treatment options were then presented to, and discussed by, all attendees. Three new work groups were then established and each was given a different set of questions to deliberate concerning current and future treatment practices. ... Key message: do not be satisfied with a single diagnosis; keep assessing to uncover likely comorbidities; accurate diagnosis is essential to improve the prognosis Accurate differential diagnostic assessment is a pre-requisite to providing effective treatment. ... The consensus of the attendees was that a clinical interview applying established diagnostic criteria (DSMIV or ICD10) is essential to the diagnosis of ADHD/DBDs. ... For example, the timing and chronicity, as well as the symptom onset, should be considered carefully in order to rule out the possibility of post traumatic stress disorder or a bipolar disorder in which the attentional and behavioural disturbances are primarily a function of a manic or hypomanic state ([Kutcher, 2000, Kusumakar et al. ... The possibility of sensory receptive disorders (e. ... It is not sufficient to simply establish that ADHD or a particular DBD diagnosis is present. It is crucial to determine whether other DBDs are also present and, if so, whether one is primary, because the recommended forms of treatment differ accordingly. ... anxiety disorder, depressive disorder, substance abuse disorder) or complicating health conditions exist. ... Key message: comorbidity is the norm rather than the exception Attendees acknowledged that comorbidity is the norm rather than the exception for youngsters with ADHD/DBDs. About 50% of youngsters with ADHD are comorbid for ODD and/or CD ([Wolraich et al. ... From the reverse perspective, almost all children under 12 years of age who have CD or ODD also meet the criteria for ADHD ( [Reeves et al.