ADHD Across the Ages: Focus on the Adultneurosciencecme.com/pdf/TV-063CourseGuide.pdf · ADHD Across the Ages: Focus on the Adult 2 INFORMATION FOR PARTICIPANTS Statement of Need

ADHD Across the Ages:Focus on the Adult

A Free, One-Hour CME/CNE/CEP/NASW/CPE On Demand ActivityRelease Date: December 2, 2009

Credit Expiration Date: December 2, 2010On the Web: www.neuroscienceCME.com

FACULTY: David W. Goodman, MD, James McCracken, MDMODERATOR: David Baron, MSEd, DO

This continuing education activity is provided by

This educational activity is supported by an independent medical educational grant from Shire.

TV-063-120209-19FINALSYLLABUS AND COURSE GUIDE

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ADHD Across the Ages: Focus on the Adult

2 www.neuroscienceCME.com

INFORMATION FOR PARTICIPANTSStatement of NeedOne of the common misconceptions about ADHD is that it occurs only in children. The reality is that ADHD can affect people of all ages. It is estimated that in the United States alone, nearly 8 million adults have ADHD. While inattentiveness, impulsivity, and hyperactivity are the same hallmark features of both child and adult ADHD, these symptoms often manifest quite differently in adults. For example, hyperactivity in the child may be excessive running and climbing, while in the adult it is driving too fast. Impulsivity in the child can show up as blurting out answers in class, whereas for the adult interrupting colleagues during a business meeting would be likely. Recognition of the symptoms of ADHD that impact everyday life—at home, at work, and socially—is critical. The good news is that adult ADHD is a treatable medical condition, when recognized and addressed with an eye toward optimal management. Current data suggests that further continuing education and professional development is warranted to address clinical practice gaps related to diagnosis and management of ADHD in adults.

In this neuroscienceCME On Demand activity, expert faculty will explore best evidence to help clinicians achieve best practice as it relates to assessment, diagnosis, and management of adult ADHD.

Davidson MA. ADHD in adults: a review of the literature. J Atten Disord 2008;11:628-641.

Newcorn JH, Weiss M, Stein MA. The complexity of ADHD: diagnosis and treatment of the adult patient with comorbidities. CNS Spectr 2007;12(Suppl 12):1-14.

Activity GoalTo improve knowledge and performance through translation of best available evidence pertaining to adult ADHD diagnosis and management, given the absence of practice guidelines.

Learning ObjectivesAt the end of this CE activity, participants should be able to:

• Increase clinical suspicion and screening for adult ADHD to improve detection rates.

• Apply criteria to definitively diagnose adult ADHD and potential comorbid conditions.

• Develop a strategy for tailoring individualized, comprehensive treatment plans using the best available evidence, given the absence of practice guidelines.

Target AudiencePhysicians, physician assistants, nurse practitioners, nurses, psychologists, social workers, certified case managers, pharmacists, and other healthcare professionals interested in diagnosis and management of adults with ADHD.

CREDIT INFORMATIONCME Credit (Physicians)

CME Outfitters, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CME Outfitters, LLC, designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Note to Physician Assistants: AAPA accepts Category I credit from AOACCME, Prescribed credit from AAFP, and AMA Category I CME credit for the PRA from organizations accredited by ACCME.

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It has been assigned code 6WASUP-PRV-0680. 1.0 contact hours will be awarded upon successful completion.

Note to Nurse Practitioners: The content of this CNE activity pertains to Pharmacology.

CEP Credit (Psychologists)CME Outfitters is approved by the American Psychological Association to sponsor continuing education for psychologists. CME Outfitters maintains responsibility for this program and its content. (1.0 CE credits)



NASW Credit (Social Workers)This program was approved by the National Association of Social Workers (provider #886407722) for 1 continuing educationcontact hour.

CPE Credit (Pharmacists)CME Outfitters, LLC, is accredited by the Accreditation Council for Pharmacy Education as a provider of continuingpharmacy education. 1.0 contact hours (0.1 CEUs)Universal Activity Number: 376-000-09-032-L01-P (live presentation)

376-000-09-032-H01-P (recorded programs)

All other clinicians will either receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

Financial SupportThis educational activity is supported by an independent medical educational grant from Shire.

CREDIT REQUIREMENTSSuccessful completion of this CE activity includes participating in the live or recorded activity, reviewing the course materials, and following the appropriate set of instructions below within 30 days of completion of the activity:

Option A:To complete your credit request form, activity evaluation, and post-test online, and print your certificate or statement of credit immediately (70% pass rate required), please visit www.neuroscienceCME.com and click on the Testing/Certification link under the Activities tab (requires free account activation).—OR—Option B:• Complete the credit request form and activity evaluation located in the back of this syllabus. Successfully complete the

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There is no fee for participation in this activity. The estimated time for completion is 60 minutes.Questions? Please call 877.CME.PROS.

FACULTY BIOS & DISCLOSURESDavid W. Goodman, MDDr. Goodman is Assistant Professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. He is also Director of the Adult Attention Deficit Disorder Center of Maryland in Lutherville and Medical Director of Suburban Psychiatric Associates, LLC. A 1983 graduate of Albany Medical College of Union University, Dr. Goodman completed a medical/psychiatric internship at Baltimore City Hospital and his psychiatric residency at The Johns Hopkins Hospital in 1986. Board Certified in psychiatry in November 1987, he became Associate Director of the psychiatric in-patient unit at Sinai Hospital, Baltimore, MD, for two years. Since 1989, Dr. Goodman has continued a full time clinical practice focusing on the diagnosis and treatment of mood disorders, adult Attention Deficit/Hyperactivity Disorder, Panic Disorder, and Obsessive-Compulsive Disorder. For over twenty years, he has been teaching psychiatric residents at The Johns Hopkins Hospital. Dr. Goodman has presented over 500 lectures to primary care physicians, psychiatrists, medical specialists and the general public. His psychiatric commentary has been featured on national (ABC World News, CNN Anderson Cooper 360, ESPN Sports Center) and regional television around the country, PBS and national affiliate stations, national magazines (U.S. News and World Report, Wall Street Journal, New York Times, USA Weekend Magazine, BusinessWeek) and radio interviews around the country. Dr. Goodman has been a Principal Investigator for multi-site Phase II and III drug trials for the treatment of adult Attention Deficit/Hyperactivity Disorder and Major Depression. Dr. Goodman is the lead author on the largest adult ADHD trial published. He has published articles in professional journals,



authored four book chapters and is the author of The Black Book of ADHD. He continues to treat patients in a full time clinical practice.

James McCracken, MDDr. McCracken is the Joseph Campbell Professor of Child Psychiatry and Director of the Division of Child and Adolescent Psychiatry at the UCLA NPI-Semel Institute (formerly the Neuropsychiatric Institute) in Los Angeles. Dr. McCracken is the principal investigator of the National Institute of Mental Health (NIMH) P50 Research Center, “Translational Research to Enhance Cognitive Control,” which aims to develop and test innovative treatments for cognitive deficits associated with childhood psychiatric illnesses.

His other current areas of research include family-genetic studies of childhood disorders and the testing of new pharmacologic treatments for a variety of neuropsychiatric disorders in children, including attention-deficit/hyperactivity disorder (ADHD), autism, obsessive-compulsive disorder, and anxiety disorders.

Dr. McCracken received medical and postgraduate training at Baylor College of Medicine, Duke University, and UCLA before joining the faculty at UCLA in 1987. He is the recipient of several honors and awards, including the American Psychiatric Association (APA) Young Psychiatrist Research Award.

He has published more than 180 papers in the area of child psychiatry and serves on the editorial board of the Journal of Child and Adolescent Psychopharmacology.

Dr. McCracken holds memberships in various local, national, and international professional organizations, including the APA, American Academy of Child and Adolescent Psychiatry, American College of Psychiatrists, International Society for Research in Child and Adolescent Psychopathology, Biological Psychiatry, and the Society for Neuroscience. He is listed in both the Best Doctors in America and America’s Top Doctors databases.

David Baron, MSEd, DO (Moderator)Dr. Baron is Professor and Chair of the Department of Psychiatry at Temple University School of Medicine. His current research interests include ADHD in substance abuse, ADHD treatment patterns in adolescents and adults, and ADHD in athletes. Dr. Baron began working in ADHD in 1988 with a group at NIMH looking at brain changes in ADHD adolescent boys. He has lectured internationally on the topic and consulted with the Singapore military on ADHD in new recruits.

Disclosure DeclarationIt is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all its CE activities. Faculty must disclose to the participants any significant relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer review process. The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Dr. Goodman has disclosed that he receives research grants from Cephalon, Inc., Eli Lilly and Company, Forest Laboratories, Inc., New River Pharmaceuticals, Inc., Ortho-McNeil, and Shire Pharmaceuticals. He receives honoraria from the American Professional Society of ADHD and Related Disorders, Audio-Digest Foundation, CME Inc, Eli Lilly and Company, Excepta Medica, Forest Laboratories, Inc., JB Ashton Associates, Medscape, Neuroscience Education Institute, Ortho-McNeil, Shire Pharmaceuticals, Synermed Communications, Temple University, Veritas Institute, WebMD, and Wyeth Pharmaceuticals. Dr. Goodman is on the speakers bureaus of Forest Laboratories, Inc., McNeil Pediatrics, Shire Pharmaceuticals, and Wyeth Pharmaceuticals. He serves as a consultant to Avacat, Clinical Global Advisors, Eli Lilly and Company, Forest Laboratories, Inc., Ortho-McNeil, New River Pharmaceuticals, Inc., Novartis Pharmaceuticals Corporation, Schering-Plough Corporation, Shire Pharmaceuticals, and Thomson Reuters, and receives royalties from MBL Communications.

Dr. McCracken has disclosed that he receives grants from Aspect Medical Systems, Inc., Bristol-Myers Squibb Company, and Seaside Pharmaceutical, Inc. He serves as a consultant to BioMarin Pharmaceutical Inc. and Novopharm.

Dr. Baron has disclosed that he receives grants from the National Institute on Drug Abuse and the National Institute of Mental Health. He serves as a consultant to California Academy of Family Physicians, Eli Lilly and Company, Singapore Institute of Mental Health, and University of Cairo. He is also on the Data Monitoring Team of Pharmaceutical Product Development, Inc. (PPD).



Unlabeled Use DisclosureFaculty of this CE activity may include discussions of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices.

CME Outfitters, LLC, the faculty, and Shire Pharmaceuticals do not endorse the use of any product outside of the FDA labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

Activity SlidesThe slides that are presented in this activity are available for download and printout at the neuroscienceCME website:www.neuroscienceCME.com. Activity slides may also be obtained via fax or email by calling 877.CME.PROS.



Abbreviation List

ADHD Attention-deficit hyperactivity disorder

ADHD-RS ADHD Rating Scale

AISRS ADHD Investigator Symptom Rating Scale

ASRS Adult Self-Report Rating Scale

BADDS Brown ADD Scale

BP Blood pressure

bpm Beats per minute

CAARS Conners’ Adult ADHD Rating Scales

CHADD Children and Adults with Attention Deficit/Hyperactivity Disorder

DSM-IV Diagnostic and Statistical Manual of Mental Disorder, 4th edition

ER Extended-release

FDA Food & Drug Administration

GAD Generalized anxiety disorder

GI Gastrointestinal

HR Heart rate

Hx History

IR Immediate-release

MAS Mixed amphetamine salts

MDD Major depressive disorder

MPH Methylphenidate

OCD Obsessive-compulsive disorder

PE Physical exam

PTSD Post-traumatic stress disorder

SUD Substance use disorder

WHO World Health Organization



This educational activityis supported by an

independent medicaleducational grant from

Shire.

The course guide for thisactivity includes slides,disclosures of facultyfinancial relationships,

and biographical profiles.

For additional copies ofthese materials, please

visit neuroscienceCME.comor call 877.CME.PROS.

To receive CE credits for thisactivity, participants may

either complete the post-testand evaluation online at

neuroscienceCME.com/testor complete and submit botha Credit Request Form and an

Activity Evaluation Form,which are included in the

course materials.

CME Outfitters, LLC,is the accredited providerfor this neuroscienceCME

continuing educationactivity.



Moderator:David Baron, MSEd, DO

Professor

Department of Psychiatryand Behavioral Sciences

Department of Neuroscience

Temple University School of Medicine

Philadelphia, PA

David Baron, MSEd, DODisclosures

Research/Grants: National Institute on DrugAbuse; National Institute of Mental Health

Speakers Bureau: None

Consultant: California Academy of FamilyPhysicians; Eli Lilly and Company; SingaporeInstitute of Mental Health; University of Cairo

Stockholder: None

Advisory Board: None

Other Financial Interest: Data MonitoringTeam of Pharmaceutical Product Development,Inc. (PPD)

David W. Goodman, MD

Director, Suburban PsychiatricAssociates, LLC

Director, Adult Attention DeficitDisorder Center of Maryland

Assistant Professor, Johns HopkinsUniversity School of Medicine, Dept. of

Psychiatry and Behavioral Sciences

Baltimore, MD

Please be sure to indicatethe media format utilized

(live broadcast, livewebcast, Internet archive,or rebroadcast/videotape)

and the date ofparticipation on the

forms provided.



David W. Goodman, MDDisclosures

Stockholder: None


Other Financial Interest: Receives honorariafrom American Professional Society of ADHDand Related Disorders; Audio-DigestFoundation; CME Inc; Eli Lilly and Company;Excepta Medica; Forest Laboratories, Inc.;JB Ashton Associates; Medscape; NeuroscienceEducation Institute; Ortho-McNeil; ShirePharmaceuticals; Synermed Communications;Temple University; Veritas Institute; WebMD;Wyeth Pharmaceuticals; receives royalties fromMBL Communications

James McCracken, MD

Joseph Campbell Professor of ChildPsychiatry and Director

Division of Child and Adolescent Psychiatry

Semel Instituteand David Geffen School of Medicine

Staff Physician atResnick Neuropsychiatric Hospital

University of California at Los Angeles

Los Angeles, CA

James McCracken, MDDisclosures

Research/Grants: Aspect MedicalSystems, Inc.; Bristol-Myers SquibbCompany; Seaside Pharmaceutical, Inc.

Speakers Bureau: None

Consultant: BioMarin PharmaceuticalInc.; Novopharm

Stockholder: None


Other Financial Interest: None

David W. Goodman, MDDisclosures

Research/Grants: Cephalon, Inc.; Eli Lillyand Company; Forest Laboratories, Inc.; NewRiver Pharmaceuticals, Inc.; Ortho-McNeil;Shire Pharmaceuticals

Speakers Bureau: Forest Laboratories, Inc.;McNeil Pediatrics; Shire Pharmaceuticals;Wyeth Pharmaceuticals

Consultant: Avacat; Clinical Global Advisors;Eli Lilly and Company; Forest Laboratories,Inc.; Ortho-McNeil; New RiverPharmaceuticals, Inc.; NovartisPharmaceuticals Corporation; Schering-PloughCorporation; Shire Pharmaceuticals; ThomsonReuters



ADHD Across the Ages:Focus on the Adult

December 2, 2009Supported by an independent medical

educational grant from Shire

LearningObjective 1

Increase clinicalsuspicion and screeningfor adult ADHD toimprove detection rates

LearningObjective 2

Apply criteria todefinitively diagnoseadult ADHD andpotential comorbidconditions

The faculty have beeninformed of their

responsibility to discloseto the audience if they will

be discussing off-labelor investigational uses(any use not approvedby the FDA) of products

or devices.



LearningObjective 1

Increase clinicalsuspicion and screeningfor adult ADHD toimprove detection rates

“ADHD is probably the most common chronicundiagnosed psychiatric disorder in adults.[It is] a disorder that is rarely inquiredabout and usually overlooked.”- Paul Wender, MD

“A main obstacleto diagnosing and treating

ADHD in adults is a failure to trainphysicians to have clinical suspicion for it.”

- Jim McCracken, MD

Adult ADHDConsider the Possibility

1. Kessler RC, et al. Psychol Med 2005;35:245-256.2. Kessler RC, et al. Am J Psychiatry 2006;163:716-723.

Clinically significantsymptoms persist intoadulthood for 2/3 of

individuals1

Roughly 8 million U.S.adults have ADHD2

8 million

Adult ADHDCommon, but Under-Recognized

LearningObjective 3

Develop a strategy fortailoring individualized,comprehensive treatmentplans using the best availableevidence, given the absenceof practice guidelines



Dulcan M. J Am Acad Child Adolesc Psychiatry 1997;36(Suppl):85S-121S.

Diagnostic ChallengesContributing to Under-Diagnosis

Low level of clinical suspicion

Symptoms need “translation”

Establishing childhood onset can be difficult

Presence of comorbid disorders can beconfounding

Patient insight can vary regarding impactof behaviors

Functional impact is not easy to assessdue to compensation

Conundrum exists when symptom fall shortof diagnostic criteria

Dulcan M. J Am Acad Child Adolesc Psychiatry 1997;36(Suppl):85S-121S.

Proper Steps in Diagnosis

Childhood Adulthood

Adler L, Cohen J. Psychiatr Clin North Am 2004;27:187-201.

Symptom Manifestation in AdultADHD, Compared to Child ADHD

Squirming, fidgeting

Can’t stay seated

Can’t wait turn

Runs/climbs excessively

Can’t play/work quietly

On the go/driven by motor

Talks excessively

Blurts out answers

Intrudes/interrupts others

Needs to move

Can’t sit through meals, meetings

Impatient

Drives too fast

Prefers very active job

Poor frustration tolerance

Talks excessively

Makes inappropriate comments

Interrupts others

1. Kessler RC, et al. Arch Gen Psychiatry 2007;64:543-552.2. Kessler RC, et al. Am J Psychiatry 2006;163:716-723.3. Kessler RC, et al. Psychol Med 2005;35:1073-1082.4. Merikangas KR, et al. Arch Gen Psychiatry 2007;64:543-552.5. Tandon R, et al. Schizophr Res 2008;102:1-18.

6.7%

4.4%

2.7%2.0%

1.0%

0%1%2%3%4%5%6%7%8%9%

10%

Major

Depression

Adult ADHD GAD Bipolar

Disorder

Schizophrenia

Pre

vale

nce

Adult ADHDRelative Prevalence

1

2 3

4

5



Rosler M, et al. Eur Arch Psychiatr Clin Neurosci 2006;256:i3-i11.

Use Scales to EvaluateSymptoms and Functioning

ADHD Rating Scale (ADHD-RS)

Barkley Adult ADHD Rating Scale

Brown ADD Scale (BADDS) Diagnostic Form

Conners’ Adult Attention-Deficit Rating Scale(CAARS)

Wender-Reimherr Adult Attention-Deficit DisorderScale

WHO Adult ADHD Self-Report Scale (ASRS)Symptom Checklist-v1.1 and short form ASRSscreener

Interview Tools and Rating Scales for Adult ADHDListed alphabetically

LearningObjective 2

Apply criteria todefinitively diagnoseadult ADHD andpotential comorbidconditions American Psychiatric Association. Diagnostic and Statistical Manual

of Mental Disorders, 4th edition, text revision. Washington, DC:American Psychiatric Association 2000.

Diagnosis Relies on “Extrapolating”Childhood Criteria

DSM-IV-TR Criteria for ADHD6 of 9 possible inattentive symptoms,and/or6 of 9 possible hyperactive-impulsivesymptomsOnset in childhood before age 7Symptoms present for >6 monthsImpairment in more than one settingNot due to another mental disorder

Pearl PL, et al. Ann N Y Acad Sci 2001;931:97-112.

Adult ADHDDifferential Diagnosis

Other psychiatric disorderse.g., Asperger’s, Tourette’s, substance abusedisorder, OCD, anxiety, mood disorders

Sleep deprivation or sleep disorders; stress

Chronic and acute illnesse.g., hypothyroidism, diabetes, seizures

Medication effectse.g., corticosteroids, anticonvulsants, caffeine

Hearing or visual problems



Kessler RC, et al. Am J Psychiatry 2006;163:716-723.

0

10

20

30

MDD Bipolar GAD PTSDSocialPhobia

SUD

Respondents

(%)

ADHD

No ADHD

Comorbidity in Adult ADHDNational Comorbidity Survey

Replication (N = 3199)

LearningObjective 3

Develop a strategy fortailoring individualized,comprehensive treatmentplans using the best availableevidence, given the absenceof practice guidelines

Components ofAdult ADHD Treatment

1. Faraone SV, et al. Am J Psychiatry 2006;163:1720-1729.

What If Not All Criteria Are Met?

Appropriateness of directly applying thecriteria to adults has been questioned

Data from a 2006 study1

Adults who meet all other criteria for thedisorder except the age of onset criterion stilldemonstrated levels of functional impairment,psychiatric comorbidity, and familialtransmission comparable to those seen in adultswho met the age of onset criterion

Subsequent versions of DSM may includealternative approaches for making validand reliable ADHD diagnosis in adults



Drugs@FDA. http://www.accessdata.fda.gov/Scripts/cder/DrugsatFDA.Accessed November 23, 2009.

Agents FDA-Approvedfor Adult ADHD

Medication Daily Dose

Atomoxetine40 mg

max. 100 mg

Dexmethylphenidate XR(dMPH-XR)

10 mgmax. none

Lisdexamfetamine30 mg

max. 70 mg

Mixed amphetamine salts XR(MAS-XR)

20 mgmax. none

OROS Methylphenidate HCl18 or 36 mgmax. 72 mg

4-Week, Double-Blind, Placebo-Controlled, Forced Titration Study(N = 255)

* p .001 compared to placebo

Weisler RH, et al. CNS Spectr 2006;11:625-639.

-14.4*-12.9*-12.6*

-6.6

-16

-14

-12

-10

-8

-6

-4

-2

0

Placebo

MAS-XR

20 mg40 mg60 mg

AD

HD

-RS

Change

from

Baseline

MAS-XR Efficacyin Adult ADHD


Spencer TJ, et al. Biol Psychiatry 2007;61:1380-1387.

5-Week, Double-Blind, Placebo-Controlled, Fixed-Dose Study(N = 221)

-16.9*

-13.4*-13.7*

-7.9

-20

-18

-16

-14

-12

-10

-8

-6

-4

-2

0

Placebo

dMPH-XR

20 mg

30 mg

40 mg

AD

HD

-RS

Change

from

Baseline

dMPH-XR Efficacyin Adult ADHD

56%

11%

44%

89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Children Adults

Untreated

Treated

1. CDC. Morb Mort Wkly Rpt 2005;54:842-847.http://www.cdc.gov/ncbddd/adhd/data.htm.

2. Kessler RC, et al. Am J Psychiatry 2006;163:716-723.

Adult ADHD is Under-Treated

1 2




Adler LA, et al. J Clin Psychiatry 2008;69:1364-1373.

Placebo

Lisdexamfetamine

30 mg

50 mg

70 mg

-18*-17.4-16.2

-8.2

-20

-18

-16

-14

-12

-10

-8

-6

-4

-2

0

AD

HD

-RS

Change

from

Baseline

Lisdexamfetamine Efficacyin Adult ADHD

4-Week, Double-Blind, Placebo-Controlled, Forced Titration Study(N = 420)

1. Weisler RH, et al. CNS Spectr 2006;11:625-639; 2. Adler L, et al. Presentedat: 158th Meeting of the American Psychiatric Association, Atlanta, GA, May 21-25, 2005; 3. Goodman DW, et al. CNS Spectr 2005;10(Suppl 20):26-34.

Side Effectswith Stimulant Medication

Insomnia

GI upset

CardiovascularBP increased 2-4 mmHgHR increased 2-4 bpm

Decreased appetite

Weight loss

Headaches

Dry mouth

Constipation

Hand tremors

Irritability

Research on individualstimulants has generallyshown no doserelationship with sideeffects in group data1,2

Some research hasshown side effects may bemore likely in stimulant-naïve patients3

1. Verispan’s VONA, MAT ending February 2005.2. Verispan’s VONA, MAT ending May 2008.3. Verispan’s VONA, MAT ending April 2009.

1 2 3

Increased Use of IR,Despite Recommendations

40 4145

21

3335

13 14 14

0

5

10

15

20

25

30

35

40

45

2/04-2/05 5/07-5/08 4/08-4/09

Perc

ent

Long-Acting Stimulants

Immediate-Release Amphetamine

Immediate-Release MPH

34 4947

* p = .01 compared to placebo; ** p < .001 compared to placebo

Medori R, et al. Biol Psychiatry 2008;63:981-989.

OROS-MPH

CAARS

Change

from

Baseline

OROS-MPH Efficacyin Adult ADHD

5-Week, Double-Blind, Placebo-Controlled, Fixed-Dose Study(N = 401)

18 mg

36 mg

72 mg

Placebo

-13.7**

-11.5*-10.6*

-7.6

-20

-18

-16

-14

-12

-10

-8

-6

-4

-2

0



Atomoxetine in Adult ADHDSide Effects

* All significant vs. placebo

Michelson D, et al. Biol Psychiatry 2003;53:112-120.

Side Effect* Atomoxetine (%) Placebo (%)

Dry mouth 21 7

Insomnia 21 9

Nausea 12 5

Decreased appetite 12 3

Decreased libido 7 2

Erectile difficulty 10 1

Dizziness 6 2

Increased BP (systolic, diastolic): 1-3 mm HgIncreased HR: 5 bpm

1. Weiss M, et al. J Atten Disord 2008;11:642-651.2. Safren SA, et al. Behav Res Ther 2005;43:831-842.3. Solanto MV, et al. J Atten Disord 2008;11:728-736.

Psychosocial Interventions for Adult ADHD1

EducationPatients and family membersImportance of medication adherenceBooks and websites

Behavior and cognitive therapies2

Structure routinesAudio and visual cuesConsistent consequences for behavior

IndividualSelf-esteem issuesSocial skills and relationship issues3

Academic and occupation accommodationsCoaching

Education for Patient and Family

Understanding the disorderMedical causeNot due to character weakness

Environmental restructuringWorkplace/career changesADHD-friendly modifications in family, home,leisure activitiesStructure, lists, delegating, tools

ADHD resourceshttp://www.chadd.orghttp://www.add.orghttp://www.naaac.orghttp://www.adhdcoaches.orghttp://www.addwarehouse.comhttp://www.help4adhd.org

-6

-3.1 -2.9

-4.5

*-5.0

*

-9.5

*-11

-10

-9

-8

-7

-6

-5

-4

-3

-2

-1

0

Total Inattentive

Hyperactive/

Impulsive

* p < .001 † Baseline scores: atomoxetine 33.6; placebo 33.2‡ Baseline scores: atomoxetine 34.9; placebo 34.2

Michelson D, et al. Biol Psychiatry 2003;53:112-120.

Mean C

hange f

rom

Baseline

†

-6.7

-3.5-3.2

-4.7

*-5.8

*

-10.5

*-11

-10

-9

-8

-7

-6

-5

-4

-3

-2

-1

0

Total Inattentive

Hyperactive/

Impulsive

Study 1 Study 2

Atomoxetine (n = 141)

Placebo (n = 139)

Atomoxetine (n = 129)

Placebo (n = 127)

Atomoxetine Efficacyin Adult ADHD



Clinical Connections

ADHD is very common in both childrenand adults—screen for ADHD regardlessof age

Diagnostic accuracy is enhanced byconsidering:

Presenting symptomsAge of onsetLongitudinal course: chronic, pervasive,impairingFamily psychiatric history

Look for concurrent psychiatriccomorbidities

Clinical Connections

Use symptom scales for baselinetarget symptoms and change withtreatment

Use a multimodal approach thatincludes education, psychosocialinterventions, and pharmacotherapyto achieve the most effectivetreatment outcomes

www.neuroscienceCME.com

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Bibliography

Adler L, Cohen J. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am 2004;27:187-201.

Adler L, et al. Presented at: 158th Annual Meeting of the American Psychiatric Association, Atlanta, GA, May 21-25, 2005.

Adler LA, Goodman DW, Kollins SH, et al; 303 Study Group. Double-blind, placebo-controlled study of the efficacy and safety of lisdexamfetamine dimesylate in adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry 2008;69:1364-1373.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Washington, DC: American Psychiatric Association; 2000.

Drugs@FDA. Available at: http://www.accessdata.fda.gov/Scripts/cder/DrugsatFDA. Accessed November 23, 2009.

Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 1997;36(Suppl):85S-121S.

Faraone SV, Biederman J, Spencer T, et al. Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry 2006;163:1720-1729.

Goodman DW, Ginsberg L, Weisler RH, Cutler AJ, Hodgkins P. An interim analysis of the Quality of Life, Effectiveness, Safety, and Tolerability (QU.E.S.T) evaluation of mixed amphetamine salts extended release in adults with ADHD. CNS Spectr 2005;10(Suppl 20):26-34.

Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med 2005;35:245-256.

Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006;163:716-723.

Kessler RC, Adler LA, Barkley R, et al. Patterns and predictors of attention-deficit/hyperactivity disorder persistence into adulthood: results from the national comorbidity survey replication. Biol Psychiatry 2005;57:1442-1451.

Kessler RC, Brandenburg N, Lane M, et al. Rethinking the duration requirement for generalized anxiety disorder: evidence from the National Comorbidity Survey Replication. Psychol Med 2005;35:1073-1082.

Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K, Walters EE. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2006;63:415-424.

Medori R, Ramos-Quiroga JA, Casas M, et al. A randomized, placebo-controlled trial of three fixed dosages of prolonged-release OROS methylphenidate in adults with attention-deficit/hyperactivity disorder. Biol Psychiatry 2008;63:981-989.

Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry 2007;64:543-552.

Michelson D, Adler L, Spencer T, et al. Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry 2003;53:112-120.

Pearl PL, Weiss RE, Stein MA. Medical mimics. Medical and neurological conditions simulating ADHD. Ann N Y Acad Sci 2001;931:97-112.

Rosler M, Retz W, Thome J, Schneider M, Stieglitz RD, Falkai P. Psychopathological rating scales for diagnostic use in adults with attention-deficit/hyperactivity disorder (ADHD). Eur Arch Psychiatry Clin Neurosci 2006;256(Suppl):i3-i11.

Spencer TJ, Adler LA, McGough JJ, Muniz R, Jiang H, Pestreich L; Adult ADHD Research Group. Efficacy and safety of dexmethylphenidate extended-release capsules in adults with attention-deficit/hyperactivity disorder. Biol Psychiatry 2007;61:1380-1387.

Tandon R, Keshavan MS, Nasrallah HA. Schizophrenia, “just the facts” what we know in 2008. 2. Epidemiology and etiology. Schizophr Res 2008;102:1-18.

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Verispan’s VONA, MAT Ending May 2008.

Verispan’s VONA, MAT Ending April 2009.

Weisler RH, Biederman J, Spencer TJ, et al. Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial. CNS Spectr 2006;11:625-639.



Post-TestParticipants are required to complete the post-test to assess their achievement of the educational objectives for this activity. To obtain a certificate or statement of credit, you must complete the post-test and indicate your answers on the Post-Test Responses section found on the credit request form. You must complete both this post-test and the evaluation to receive credit. A score of 70% is required for credit.


1. As many as _____ of children with ADHD will have clinically significant symptoms persist into adulthood.

A. 33%

B. 50%

C. 67%

D. 90%

2. Which of the following statements is correct regarding the prevalence of adult ADHD, relative to other psychiatric conditions?

A. Adult ADHD is more common than depression

B. Adult ADHD is more common than bipolar disorder

C. Adult ADHD is more common than generalized anxiety disorder

D. B and C

E. All of the above

3. True or False: The impact of ADHD on functioning is often easy to assess in adults because, unlike children, adults generally fail to compensate for their symptoms.

A. True

B. False

4. Which of the following is NOT a rating scale for use in adult ADHD?

A. Barkley Adult ADHD Rating Scale

B. Brown ADD Scale (BADDS) Diagnostic Form

C. Conners’ Adult Attention-Deficit Rating Scale (CAARS)

D. School Situations Questionnaire

5. DSM-IV criteria for diagnosis of ADHD requires onset of symptoms during childhood before what age?

A. Age 3

B. Age 7

C. Age 10

D. Age 12

6. Comorbidity with MDD and bipolar disorder is approximately ____ in adults with ADHD, according to the National Comorbidity Survey Replication.

A. 10%

B. 20%

C. 50%

D. 85%

7. Which of the following agents is NOT FDA-approved for treatment of ADHD in adults?

A. Dexmethylphenidate XR

B. Lisdexamfetamine

C. Guanfacine

D. Atomoxetine

E. Mixed amphetamine salts XR

F. OROS Methylphenidate

8. According to the study by Weisler RH et al, all doses of mixed amphetamine salts-XR improved ADHD-RS scores by ______ points from baseline.

A. 4 to 7

B. 8 to 11

C. 12 to 15

D. 16 to 19

9. True or False: Some research has shown that side effects may be more likely in stimulant-naïve patients.

A. True

B. False

10. Over recent years, the use of immediate release amphetamine has _____________, despite clinical recommendations.

A. Increased

B. Decreased

C. Remained the same

This continuing educationactivity is provided by

TV-063-120209-19FINAL

CE Credit Request FormADHD Across the Ages: Focus on the AdultA CME/CNE/CEP/NASW/CCMC/CPE On Demand Activity

To receive CE credit, you must complete both this form and an evaluation form, and return the completed forms via mail to CME Outfitters, ATTN: CE Forms Processor, 1395 Piccard Drive, Suite 370, Rockville, MD 20850; or, FAX to 240.243.1033 for fastest service. Forms must be sub-mitted within 30 days of completion of activity. A certificate or statement of credit will be mailed to you within 4–6 weeks of our receiving this form and the evaluation form.

To complete your credit request/activity evaluation online, and print your certificate or statement of credit immediately, please visitwww.neuroscienceCME.com and click on the Testing/Certification link under the Activities tab (requires free account activation).

PLEASE PRINT CLEARLY (Form must be filled out completely to process CE credit)

First Name, MI, Last Name: __________________________________________________________________________________________________

Specialty Area: ___________________________________________________________________________________________________________

I am a: q Physician q Physician Assistant q Nurse Practitioner q Nurse q Psychologist

q Social Worker q Pharmacist q Other: ___________________________________________________

Degree: q MD q DO q PhD q NP q RN q PharmD q MSW q Other: ____________

I participated in a: q LIVE broadcast q LIVE webcast q LIVE audio feed q Internet archive q Rebroadcast/Videotape q Podcast

Participation Date: ________ / ________ / _______________

Complete Mailing Address: _________________________________________________________________________________________________

City: ___________________________________________________________________ State:_________________Zip:________________________

Business Phone: ______________________________________________________Fax: ________________________________________________

Email: ___________________________________________________________________________________________________________________

Type of CE credit requested: q CME/Physicians (max. 1.0 ________ ) q CNE/Nurses (1.0) q CEP/Psychologists (1.0) q NASW/Social Workers (1.0) q CPE/Pharmacists (1.0) q Others (1.0 CME Attendance Certificate)

Please see syllabus and course guide pages 2–3 for credit information and requirements.

How long did it take you to complete this activity? _____ hours________ minutes

Post-Test Responses (Enter letter of correct response; 70% score required for CE credit):

1. ________ 2. ________ 3. ________ 4. ________ 5. ________ 6. ________ 7. ________ 8. ________ 9. ________ 10. _______

How did you learn about this continuing education activity?

q Postcard/direct mail q Email q Internet q Colleague q Fax q Other: __________________

Please rate your interest in participating in future neuroscienceCME educational activities (1=highly interested, 5=uninterested): _____

What formats do you prefer for learning? (Please rank the top three; 1 = most preferred):

______ Symposium ______ Audioconference ______ Internet ______ CD-ROM

______ Journal ______ Satellite Broadcast ______ Monograph ______ Other: __________________________

As a result of my participation in this activity, I will commit to:

• Sharing information from this activity with staff and colleagues. q Yes q No

• Utilizing the assessment tools described in this activity to develop an individualized management/care plan for each of my patients. q Yes q No

• Analyzing overall improvement in patient management/carethrough use of the therapeutic options described in this activity. q Yes q No

Signature: _____________________________________________________________________________ Date:____________________________


This continuing educationactivity is provided by

TV-063-120209-19FINAL

CE Activity EvaluationADHD Across the Ages: Focus on the AdultA CME/CNE/CEP/NASW/CCMC/CPE On Demand Activity

To receive CE credit, you must complete both this form and a credit request form, and return the completed forms via mail to CME Outfitters, ATTN: CE Forms Processor, 1395 Piccard Drive, Suite 370, Rockville, MD 20850; or, FAX to 240.243.1033 for fastest service. Forms must be sub-mitted within 30 days of completion of activity. A certificate or statement of credit will be mailed to you within 4–6 weeks of our receiving this form and the credit request form.

To complete your credit request/activity evaluation online, and print your certificate or statement of credit immediately, please visitwww.neuroscienceCME.com and click on the Testing/Certification link under the Activities tab (requires free account activation).

1. The content level was: q Too easy q About right q Too difficult Strongly Agree Strongly Disagree

2. Objective(s) were related to the overall purpose/goal of the activity (to improve knowledge and 5 4 3 2 1performance through translation of best available evidence pertaining to adult ADHD diagnosisand management, given the absence of practice guidelines).

3. The course met the stated objectives:• Increase clinical suspicion and screening for adult ADHD to improve detection rates. 5 4 3 2 1• Apply criteria to definitively diagnose adult ADHD and potential comorbid conditions. 5 4 3 2 1• Develop a strategy for tailoring individualized, comprehensive treatment plans using 5 4 3 2 1

the best available evidence, given the absence of practice guidelines.

4. The educational materials were useful. 5 4 3 2 1

5. The visual aids were useful and appropriate. 5 4 3 2 1

6. The overall activity was excellent. 5 4 3 2 1

7. The physical environment/format was conducive to learning. 5 4 3 2 1

8. The moderator was effective at facilitating the faculty discussion. 5 4 3 2 1

9. Rate the quality of the faculty member(s) listed below, from 5 (Excellent) to 1 (Poor):

Clinical Teaching Level of Speaker Content Relevance Strategies ExpertiseDavid W. Goodman, MD 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1James McCracken, MD 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1

10. Will you change the way you practice based on this activity? q Yes q No

If no, is it because you already practice this way? q Yes q No

If no, please explain: __________________________________________________________________________________________________________

11. Do you feel the activity was balanced and objective? q Yes q No

If no, please state reasons: _____________________________________________________________________________________________________

12. Do you feel the activity was free of commercial bias? q Yes q No

If no, did it negatively impact the educational value of this activity? q Yes q No

If yes, please state reasons: ____________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

13. What was the most useful information you gained from this activity? _________________________________________________________________

__________________________________________________________________________________________________________________________

14. Suggested topics for future activities: ___________________________________________________________________________________________

__________________________________________________________________________________________________________________________

15. General comments/suggestions: _______________________________________________________________________________________________

__________________________________________________________________________________________________________________________

16. I participated in a: q LIVE broadcast q LIVE webcast q LIVE audio feed q Internet archive q Rebroadcast/Videotape q Podcast

17. Participation date: ________ / _________ / ____________________

18. I am a: q Physician q Physician Assistant q Nurse Practitioner q Nurse q Psychologist q Social Worker q Pharmacist q Other: ________________________________________________________

Thank you for your feedback. Your comments will be reviewed carefully and ultimately used to guide the development of our future continuing education activities.


TV-063-120209-19FINAL

Attendance Form for GroupsPlease complete and FAX to 240.243.1033

Activity Title and Faculty:ADHD Across the Ages: Focus on the Adultwith David W. Goodman, MD, James McCracken, MD, and David Baron, MSEd, DO

Site/Institution Name: __________________________________________________________________________

Practice Setting: _______________________________________________________________________________

Address:______________________________________________________________________________________

City: _____________________________________________________ State: ________ ZIP: __________________

Site Coordinator: ________________________________ Phone: ________________________________________

Fax: __________________________________ Email: _________________________________________________

Completion Date: ___________ We participated in a: _________________________________________________

Attendee Name (please print) Please Circle Discipline

_________________________________ MD DO PA NP RN Pharm Psychol Other: __________

















Please FAX completed form to 240.243.1033 and use additional sheets as necessary.Questions? Call 877.CME.PROS. Thank you for participating in this CME Outfitters continuing education activity!

q Community Mental Health q State Mental Health q Private Practice q Primary Care q Other:

q LIVE broadcast q LIVE webcast q LIVE audio feedq Internet archive q Rebroadcast/Videotape q Podcast


Documents

ADHD Across the Ages: Focus on the Adultneurosciencecme.com/pdf/TV-063CourseGuide.pdf · ADHD Across the Ages: Focus on the Adult 2 INFORMATION FOR PARTICIPANTS Statement of Need