ADHD & ID. Wie gaat promoveren op ADHD & leerproblemen?

ADHD & ID Wie gaat promoveren op ADHD & leerproblemen?

Helaas geen financiële belangen………..

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ADHD & ID [email protected]

Verschillende perspectieven • “Gewoon” ADHD en “gewoon” ID: casuïstiek • Inattention/aandachtstekort als symptoom: casuïstiek • Syndromale verstandelijke beperking: casuïstiek • Rol van stimulantia bij behandeling van………………………………. 18-9-2012

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Onderdiagnostiek • 16 jarige getraumatiseerde hypersexuele delinquent • Opname na arrestatie van dader: familielid en huisgenoot • Tijdens de opname sexuele relatie met groepsgenote • “Dus” risperidon 18-9-2012

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Onderdiagnostiek • Uitgebreide neuropsychologische diagnostiek: aanwijzingen voor sterke fluctuaties in de concentratie • Geen effect op risperidon • Goede reactie op stimulantia • Ook een indicatie voor libidoremmende medicatie 18-9-2012

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Overdiagnostiek • 9 jarige jongen, onrustig en ongehoorzaam in de klas • Geen problemen thuis, school “dwingt” psychiatrisch onderzoek af • “Geen onderzoek schoolbegeleidingsdienst, het is toch ADHD”

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Overdiagnostiek • Aanwijzingen voor leerproblemen: a.Geen problemen thuis met name niet in de schoolvakanties b.Emotionele onrijpheid: vriendjes die jonger zijn of ook moeilijk lerend, kijkt naar TV/DVD op lager niveau • Bevestiging middels de WISC • Succesvolle plaatsing in het SBO 18-9-2012

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Concentratiestoornissen

Noem één psychiatrische ziekte die er niet mee gepaard gaat:……………….

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Concentratiestoornissen • Autisme • Epilepsie • Niet aangeboren hersenletsel: post meningo-encefalitis; CVA; status na neuro-OK • Aanpassingsstoornissen • Schizofrenie (Zie de richtlijn 2012!) • Stemmingsstoornissen 18-9-2012

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Deprivation-specific psychological patterns

Rutter M, Sonuga-Barke EJ, et al. Investigating the impact of early institutional deprivation on development: background and research strategy of the English and Romanian Adoptees (ERA) study. Monogr Soc Res Child Dev. 2010;75 April 18-9-2012

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Deprivation-specific psychological (DSP) patterns • • • •

Quasi-autism Disinhibited attachment Cognitive impairment Inattention/overactivity

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Overdiagnostiek: herkenbaar? • Concentratiestoornissen bij een jonge vrouw met een drankprobleem • Net als haar ouders (ook alcoholgebruik tijdens de zwangerschap!) • Ouders gescheiden, geen contact met zorgzame vader, wel met verwaarlozende moeder (ambivalent/ onveilig/gedesorganiseerd gehecht) 18-9-2012

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Herkenbaar, mee eens? • Leerproblemen te laat ontdekt • “Wel eerder eens bij de RIAGG geweest en die psychiater dacht geloof ik ook wel aan ADHD, ik heb zelfs een tijdje Ritalin gebruikt”. • Averechtse reactie op een stimulantium

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Evidence based: methode • • • a. b. • a. b. c. d.

Pubmed: 569 “hits” Advances in Mental Health & Intellectual Disabilities Proefschriften M. C. Dekker: Psychopathology in children with ID Douma: MH problems in youths with ID Handboeken: A. Dosen C. T. Gualtieri The International Consensus Handbook Emily Simonoff Hyperactivity disorders in children with mental retardation in: Eric Taylor: People with hyperactivity

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Advances in Mental Health & Intellectual Disabilities • Vaktijdschrift onbekend in Pubmed • Estia Centre • Review: Merwood A, Asherson P. Attention deficit hyperactivity disorder: a lifespan genetic perspective. Advances in Mental Health and Intellectual Disabilities. 2011;5(4):33 - 46 18-9-2012

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Anton Dosen Psychische stoornissen, gedragsproblemen en verstandelijke handicap; een integratieve benadering bij kinderen en volwassenen. Assen: Koninklijke Van Gorcum BV; 2005.

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Gualtieri CT. Psychostimulants, dopamine agonists and amantadine. In: Brain injury and mental retardation : psychopharmacology and neuropsychiatry. Philadelphia Lippincott Williams & Wilkins; 2002.

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Arnold R, Gadow KD, Pearson DA, Varley CK. Stimulants. In: Reiss S, Aman MG, editors. The International Consensus Handbook. Psychotropic Medications and developmental disabilities. Columbus OH: Nisonger centre; The Ohio state University; 1998. p. 229-258. 18-9-2012

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Emily Simonoff Hyperactivity disorders in children with mental retardation. In: Eric Taylor, editor. People with hyperactivity: understanding and managing their problems. London: Mac Keith Press; 2007. p. 202-227.

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• Epidemiologie: is er verschil tussen psychiatrisch onderzoek en vragenlijsten door leken of gedragswetenschappers • Ontwikkeling door de jaren heen: • van hyperkinetic disorder tot ADHD 18-9-2012

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• Jacobson JW. Problem behavior and psychiatric impairment within a developmentally disabled population I: Behavior frequency. Applied Research in Mental Retardation. 1982;3(2):121-39.

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Gillberg C, Persson E, Grufman M, Themner U. Psychiatric disorders in mildly and severely mentally retarded urban children and adolescents: epidemiological aspects. Br J Psychiatry. 1986 Jul;149:68-74. 18-9-2012

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Myers BA, Pueschel SM. Psychiatric disorders in persons with Down syndrome. J Nerv Ment Dis. 1991 Oct;179(10):609-13.

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Proefschrift Mariëlle Dekker, 2003 The Diagnostic Interview Schedule for Children–Parent Version is designed to obtain DSM-IV diagnoses and to be administered by trained interviewers who need not have formal clinical training. 18-9-2012

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Gehele groep versus de “impaired” groep Wel en geen hulp: ADD vaakst geen hulp 18-9-2012

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Behandeling • Niveau van de patiënt • Kwaliteit van de diagnostiek/definitie • Targetsymptoom: hyperactiviteit versus inattentie.

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Het goede nieuws We concluded that cognitive and behavioral problems associated with ADHD decline with MPH treatment in children with ADHD/MR, and consistent with the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) study (Jensen et al., 2001), higher MPH doses were more effective. MAAR:This heterogeneity in stimulant response has been reported to be even greater in children with ADHD/MR (Aman, 1996; Aman et al., 2003). Based on this greater heterogeneity of response in children with ADHD/MR and previous reports that some children with ADHD/MR may be at higher risk of an adverse response to stimulants (Handen et al., 1991), the issue of individual variation in MPH response is particularly important for children with ADHD who also have developmental disabilities such as MR and autism.

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Het slechte nieuws In summary, children identified for the dual problems of mental retardation and ADHD had serious behavior and emotional problems nearly 4 years later. The rate of medication use was high overall, and medications having potentially fairly serious side effects were in use. Comorbidity was common, with 6 children having features of conduct or oppositional defiant disorders, 8 having features common to anxiety disorders, and 3 children having features of other significant behavior disorders. Friendships were often rudimentary, and a significant minority had disciplinary problems in school or difficulties with the law. Unlike research conducted with children having ADHD and normal IQ, hyperactivity here was best predicted by an irritability subscale, rather than prior indices of hyperactivity. Presence of anxiety problems was predicted by several subscales describing acting-out behavior. It is still too early to say with confidence, but there is some indication here that ADHD may differ between children with and without low IQ. For example, comordibity with an anxiety disorder may be more common, and the longitudinal relationships may differ for those with mental retardation. At this stage we know very little about ADHD in conjunction with mental retardation, and more research on these youngsters is definitely warranted. Aman MG, Pejeau C, Osborne P, Rojahn J, Handen B. Four-year follow-up of children with low intelligence and ADHD. Res Dev Disabil. 1996 Nov-Dec;17(6):417-32.

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Meer slecht nieuws The adverse side effects of methylphenidate were evaluated in 27 children with attention deficit hyperactivity disorder and IQs of 48 to 74 who participated in a double-blind study of two doses of methylphenidate and placebo. A checklist of 13 side effects, generated from the Physician's Desk Reference, was completed by teachers. Rates of irritability, anxiety, moodiness, and activity level decreased significantly when comparing the placebo with drug conditions. However, medication for six (22%) of the children was discontinued because of the appearance of motor tics (three children) and severe social withdrawal (two children), suggesting that mentally retarded children with attention deficit hyperactivity disorder may be at a greater risk for developing these side effects than the nonretarded population.

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Nog slechter nieuws An attempt was made to evaluate a model predicting stimulant drug response based on attentional characteristics of the participants. Twenty-eight severely and profoundly mentally retarded residents took part in a double blind, placebo controlled trial of methylphenidate (Ritalin). Methylphenidate was administered, for one week each, in a low dose of 0.3 mg/kg and a high dose of 0.6 mg/kg. The results failed to show any clinically relevant differences between placebo and active drug conditions with the exception that methylphenidate caused a significant reduction in food consumption. A variety of subject characteristics, including level of stereotypy, hyperactivity, and IQ were unrelated to drug effect. One positive finding, unrelated to drug effects, was that subdivision of the group by degree of stereotypy provided substantial clinical information about individual subjects. Aman MG, Singh NN. Methylphenidate in severely retarded residents and the clinical significance of stereotypic behavior. Applied Research in Mental Retardation. 1982;3(4):345-58.

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Syndromale aspecten • • • •

Fragiel X syndroom Sex chromosomale afwijkingen 22q11 deletie syndroom LPHN3 en de associatie met ADHD

Syndromale aspecten: fragiel X syndroom BACKGROUND: Fragile X syndrome (FXS) is an early diagnosed monogenic disorder, associated with a striking pattern of cognitive/attentional difficulties and a high risk of poor behavioural outcomes. FXS therefore represents an ideal model disorder to study prospectively the impact of early attention deficits on behaviour. METHODS: Thirtyseven boys with FXS aged 4-10 years and 74 typically developing (TD) boys took part. Study 1 was designed to assess visual and auditory attention at two time-points, 1 year apart. Study 2 investigated attention to multimodal information. Both tested attention markers as longitudinal predictors of risk for poor behaviour in FXS. RESULTS: Children with FXS attended less well than mental-age matched TD boys and experienced greater difficulties with auditory compared to visual stimuli. In addition, unlike TD children, they did not benefit from multimodal information. Attention markers were significant predictors of later behavioural difficulties in boys with FXS. CONCLUSIONS: Findings demonstrate, for the first time, greater difficulties with auditory attention and atypical processing of multimodal information, in addition to pervasive global attentional difficulties in boys with FXS. Attention predicted outcomes longitudinally, underscoring the need to dissect what drives differing developmental trajectories for individual children within a seemingly homogeneous group. Scerif G, et al. Attention across modalities as a longitudinal predictor of early outcomes: the case of fragile X syndrome. JCPP. 2012 Jun;53(6):641-50. 18-9-2012

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Syndromale aspecten: Sex chromosomale afw. In this study, the authors compare attention-deficit hyperactivity disorder (ADHD) symptoms in 167 participants aged 6 to 20 years with 4 types of SCA (XXY n = 56, XYY n = 33, XXX n = 25, and XXYY n = 53). They also evaluate factors associated with ADHD symptomatology (cognitive and adaptive scores, prenatal vs postnatal ascertainment) and describe the clinical response to psychopharmacologic medications in a subset of patients treated for ADHD. METHODS: Evaluation included medical and developmental history, cognitive and adaptive functioning assessment, and parent and teacher ADHD questionnaires containing DSM-IV criteria. RESULTS: In the total study group, 58% (96/167) met DSMIV criteria for ADHD on parent-report questionnaires (36% in XXY, 52% in XXX, 76% in XYY, and 72% in XXYY). The Inattentive subtype was most common in XXY and XXX, whereas the XYY and XXYY groups were more likely to also have hyperactive/impulsive symptoms. There were no significant differences in Verbal, Performance, or Full Scale IQ between children with symptom scores in the ADHD range compared with those below the ADHD range. However, adaptive functioning scores were significantly lower in the group whose scores in the ADHD range were compared with those of the group who did not meet ADHD DSM-IV criteria. Those with a prenatal diagnosis of XXY were less likely to meet criteria for ADHD compared with the postnatally diagnosed group. Psychopharmacologic treatment with stimulants was effective in 78.6% (66/84).

CONCLUSIONS: Children and adolescents with SCA are at increased risk for ADHD symptoms. Recommendations for ADHD evaluation and treatment in consideration of other aspects of the SCA medical and behavioral phenotype are provided. Tartaglia NR, Ayari N, Hutaff-Lee C, Boada R. Attention-deficit hyperactivity disorder symptoms in children and adolescents with sex chromosome aneuploidy: XXY, XXX, XYY, and XXYY. JDBP. 2012 May;33(4):309-18.

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Syndromale aspecten: 22q11 deletie syndroom PURPOSE OF REVIEW: The aim is to discuss the clinical features of psychiatric illness in 22q11.2 deletion syndrome (22q11DS), and to review current evidence that a core neuropsychiatric phenotype could underlie the full spectrum of different presentations. RECENT FINDINGS: Individuals carrying the 22q11.2 microdeletion are at risk for diverse psychiatric diagnoses across the lifespan, including schizophrenia in a significant minority, and anxiety or mood disorder in the majority. Symptoms and cognitive disruptions can be grouped into domains: attention-executive deficits, social-cognitive deficits, anxiety-affective dysregulation, and psychotic phenomena. These domains do not respect the boundaries of traditional diagnostic categories, and can be consistently recognized in children, adolescents and adults. There is early evidence that some symptomdomain disruptions may predict adult psychiatric morbidity. SUMMARY: If a core neuropsychiatric phenotype does exist in 22q11DS, its detection is likely to require dimensional assessment of subtle aspects of cognitive and emotional processing, not encompassed by current diagnostic systems. A core phenotype would account for disruptions across multiple symptom domains, directly reflecting genetic and neurobiological mechanisms. Relative severity of a core phenotype would predict risk for multiple psychiatric disorders, and could, therefore, be an important target for therapeutic and preventive interventions. A core phenotype meeting these criteria has not yet been defined for 22q11DS. Baker K, Vorstman JA. Is there a core neuropsychiatric phenotype in 22q11.2 deletion syndrome? Curr Opin Neurol. 2012 Apr;25(2):131-7. 18-9-2012

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Syndromale aspecten: LPHN3 Recently, a significant association was reported between ADHD and LPHN3 (which codes for latrophilin 3), and replicated in independent samples. Methods: We have examined the association between tag single nucleotide polymorphisms (SNPs) in LPHN3 within the region previously implicated in ADHD. Family based association tests (FBAT) were conducted (n = 380 families) with the categorical diagnosis of ADHD, behavioral and cognitive phenotypes related to ADHD, and response to treatment (given a fixed dose of methylphenidate, 0.5 mg/day). Stratified FBAT analyses, based on maternal smoking and stress during pregnancy, was conducted. Results: Whereas limited association was observed in the total sample, highly significant interaction between four LPHN3 tag SNPs (rs6551665, rs1947274, rs6858066, rs2345039) and maternal stress during pregnancy was noted. Analysis conducted in the sub-group of mothers exposed to minimal stress during pregnancy showed significant associations with ADHD, behavioral and cognitive dimensions related to ADHD, as well as treatment response. Although extensive association was observed with the candidate SNPs, the findings are partially inconsistent with previously published results with the opposite alleles over-transmitted in these studies. Conclusions: These results provide evidence for the interaction between a genetic and environmental factor independently shown to be associated with ADHD. If confirmed in independent large studies, they may present a step forward in unraveling the complex etiology of ADHD. Choudhry Z, et al. LPHN3 and attention-deficit/hyperactivity disorder: interaction with maternal stress during pregnancy. JCPP. 2012 Aug;53(8):892-902. 18-9-2012

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Take home message soms simpel, soms een puzzel

• ADHD en ID vraagt een stapsgewijze benadering • Als stap 1 geen soulaas biedt: a. Uitbreiding diagnostiek: psychiatrisch, neuropsychologisch & syndromaal b. N.a.v. uitkomst uitgebreidere diagnostiek al dan niet medicamenteus behandelen. • Nota bene bijzondere bijwerkingen 18-9-2012

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• Hyperactiviteit bij ID is mogelijk van een andere origine dan in de normale populatie. • Minder effect van stimulantia als er geen attention deficit is……………... • Let op andere oorzaken van hyperactiviteit: geagiteerde depressie, angst, cognitieve en executieve problemen • Syndromale beelden met gedrag dat lijkt op ADHD • DUS: DSM-IV is onvoldoende! • Bredere diagnostiek nodig conform DC-LD 18-9-2012

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ADHD & ID. Wie gaat promoveren op ADHD & leerproblemen?

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