New CME Outfitters, LLC, is the accredited provider for this …neurosciencecme.com/library/TV-034-030106-05-GFX.pdf · 2006. 10. 20. · Mash, Johnston. 1983. 14. Noe, et al. 1999

TV034

CME Outfitters, LLC, is the accredited provider

for this psychCME continuing education activity.

CME Outfitters, LLC, is the accredited provider

for this psychCME continuing education activity.

TV034

CME Outfitters, LLC,gratefully acknowledges an

educational grant fromCephalon, Inc.,

in support of this CE activity.

CME Outfitters, LLC,gratefully acknowledges an

educational grant fromCephalon, Inc.,

in support of this CE activity.

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The course guide for this activity includes slides, disclosures of faculty financial relationships,

and biographical profiles.

For additional copies of these materials, please visit

neuroscienceCME.com or call 877.CME.PROS.

The course guide for this activity includes slides, disclosures of faculty financial relationships,

and biographical profiles.

For additional copies of these materials, please visit

neuroscienceCME.com or call 877.CME.PROS.

TV034

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Activity Evaluation Form,which are located in the Main Menu under “Post-Test and

CE Credit Forms.”

To receive CE credits for this activity, participants must

complete and submit both a Credit Request Form and an

Activity Evaluation Form,which are located in the Main Menu under “Post-Test and

CE Credit Forms.”

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The faculty have been informedof their responsibility to disclose

to the audience if they will be discussing off-label or

investigational uses (any use not approved by the FDA)

of products or devices.

The faculty have been informedof their responsibility to disclose

to the audience if they will be discussing off-label or

investigational uses (any use not approved by the FDA)

of products or devices.

TV034

Exploring the Neurocircuitryof the Brain and Its Impact on

Treatment Selections in ADHD

March 1, 2006

Exploring the Neurocircuitryof the Brain and Its Impact on

Treatment Selections in ADHD

March 1, 2006

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Distinguish specific areas of the brain implicated in the pathophysiology of ADHD


LearningObjective

TV034

Define the role of neurotransmission on brain circuitry in ADHD


LearningObjective

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Identify how brain neurocircuitry influences treatment strategies to improve patient outcomes


LearningObjective

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Compare and contrast existing and novel agents for the treatment of ADHD


LearningObjective

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PatientPatientPatientFamily

3-5x parental divorce

or separation11,12

2-4x sibling fights13

FamilyFamily3-5x parental

divorceor separation11,12

2-4x sibling fights13

SocietySubstance use

disorders:2x risk8

Earlier onset9

Less likely to quit in

adulthood10

SocietySocietySubstance use

disorders:2x risk8

Earlier onset9

Less likely to quit in

adulthood10

School & Occupation46% expelled6

35% drop out6

Lower occupational status7

School & OccupationSchool & Occupation46% expelled6

35% drop out6

Lower occupational status7

Healthcare System50% in bike

accidents1

33% in ER visits2

2-4x more motor vehicle crashes3-5

HealthHealthccare Systemare System50% in bike

accidents1

33% in ER visits2

2-4x more motor vehicle crashes3-5

Employerparental

absenteeism and

productivity14

EmployerEmployerparental

absenteeism and

productivity14

1. DiScala, et al. 1998.2. Liebson, et al. 2001.3. NHTSA. 1997. 4-5. Barkley, et al. 1993, 1996.

1. DiScala, et al. 1998.2. Liebson, et al. 2001.3. NHTSA. 1997. 4-5. Barkley, et al. 1993, 1996.

ADHD: Impact and OutcomesADHD: Impact and Outcomes

6. Barkley, et al. 1990.7. Mannuzza, et al. 1997.8. Biederman, et al. 1997.9. Pomerleau, et al. 1995.

6. Barkley, et al. 1990.7. Mannuzza, et al. 1997.8. Biederman, et al. 1997.9. Pomerleau, et al. 1995.

10. Wilens, et al. 1995.11. Barkley, et al. 1991.12. Brown, Pacini. 1989. 13. Mash, Johnston. 1983. 14. Noe, et al. 1999.

10. Wilens, et al. 1995.11. Barkley, et al. 1991.12. Brown, Pacini. 1989. 13. Mash, Johnston. 1983. 14. Noe, et al. 1999.

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Why Diagnose?Why Diagnose?

Consensus on who and how many are treated or included in research projects

Diagnosis gives information regarding response to treatment and long-term course

Diagnosis often necessary to obtainspecial services

Treatment planning

Medicolegal reasons

Consensus on who and how many are treated or included in research projects

Diagnosis gives information regarding response to treatment and long-term course

Diagnosis often necessary to obtainspecial services

Treatment planning

Medicolegal reasons

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Inattention

Six or more of the following − manifested often:Six or more of the following − manifested often:

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).American Psychiatric Association. 1994.Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).American Psychiatric Association. 1994.

ADHD: DSM-IV CriteriaADHD: DSM-IV Criteria

Inattention to details/ makes careless mistakesDifficulty sustaining attentionSeems not to listenFails to finish tasks

Inattention to details/ makes careless mistakesDifficulty sustaining attentionSeems not to listenFails to finish tasks

Difficulty organizingAvoids tasks requiring sustained attentionLoses thingsEasily distractedForgetful

Difficulty organizingAvoids tasks requiring sustained attentionLoses thingsEasily distractedForgetful

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Impulsivity/Hyperactivity

Six or more of the following − manifested often:Six or more of the following − manifested often:

ADHD: DSM-IV CriteriaADHD: DSM-IV Criteria

ImpulsivityBlurts out answer before question is finishedDifficulty awaiting turnInterrupts or intrudes on others

ImpulsivityBlurts out answer before question is finishedDifficulty awaiting turnInterrupts or intrudes on others

HyperactivityFidgetsUnable to stay seatedInappropriate running/ climbing (restlessness)Difficulty in engaging in leisure activities quietly“On the go”Talks excessively

HyperactivityFidgetsUnable to stay seatedInappropriate running/ climbing (restlessness)Difficulty in engaging in leisure activities quietly“On the go”Talks excessively

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).American Psychiatric Association. 1994.Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).American Psychiatric Association. 1994.

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InattentionInattention

Impulsivity/HyperactivityImpulsivity/Hyperactivity

ADHD Predominantly Hyperactive-Impulsive Type: 10%– criteria met for

impulsivity/hyperactivity but not for inattention

ADHD Predominantly Hyperactive-Impulsive Type: 10%– criteria met for

impulsivity/hyperactivity but not for inattention

InattentionInattention

Impulsivity/HyperactivityImpulsivity/Hyperactivity

ADHD Combined Type: 50-60%– criteria are met for both inattention

and impulsivity/hyperactivity

ADHD Combined Type: 50-60%– criteria are met for both inattention

and impulsivity/hyperactivity

ADHDDSM-IV Subtypes

ADHDDSM-IV Subtypes

ADHD Predominantly Inattentive Type: 30-40%criteria met for inattention but not for impulsivity/hyperactivity

ADHD Predominantly Inattentive Type: 30-40%criteria met for inattention but not for impulsivity/hyperactivity

Faraone SV, et al. J Amer Acad Child Adolesc Psychiatry 1998;37:185-193.Faraone SV, et al. J Amer Acad Child Adolesc Psychiatry 1998;37:185-193.

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ChildrenChildren Motoric hyperactivityAggressivenessLow frustration toleranceImpulsiveness

Motoric hyperactivityAggressivenessLow frustration toleranceImpulsiveness

Symptoms of ADHD may change from childhood to adulthoodSymptoms of ADHD may change from childhood to adulthood

Wilens T, et al. Ann Rev Psychiatry 1999;19:1-34.Millstein, et al. J Attention Disorder 1997;2:159-166.Wilens T, et al. Ann Rev Psychiatry 1999;19:1-34.Millstein, et al. J Attention Disorder 1997;2:159-166.

AdultsAdultsShifts activitiesEasily boredImpatientRestlessness

Shifts activitiesEasily boredImpatientRestlessness

ADHD Developmental TrendsADHD Developmental Trends

Easily distractedInattentivenessEasily distractedInattentiveness

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Learning Objective 1



Learning Objective 2



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ADHDEtiologyADHDEtiology

ADHD is a heterogeneous behavioral disorder with multiple possible etiologies

ADHD is a heterogeneous behavioral disorder with multiple possible etiologies

CNS insultsCNS insults

ADHDADHD

NeuroanatomicNeurochemicalNeuroanatomicNeurochemical Genetic originsGenetic origins

Environmental factors

Environmental factors

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Dorsal ACC (dACC)“Cognition”

ACC: Functional ImplicationsACC: Functional Implications

Perigenual ACC (pACC)“Emotion”

Dorsal ACC (dACC)“Cognition”

Perigenual ACC (pACC)“Emotion”

Bush G, et al. Trends Cogn Sci 2000;4:215-222.Bush G, et al. Trends Cogn Sci 2000;4:215-222.

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Sowell ER, et al. Lancet 2003;362:1699-1707.Sowell ER, et al. Lancet 2003;362:1699-1707.

A three-dimensional, high-resolution MRI image of the brain of a patient with ADHDshows reductions in the size of specific areas within the frontal and temporal lobes

A three-dimensional, high-resolution MRI image of the brain of a patient with ADHDshows reductions in the size of specific areas within the frontal and temporal lobes

A 3-D High-Resolution MRI Image of the Brain of a Patient with ADHDA 3-D High-Resolution MRI Image

of the Brain of a Patient with ADHD

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LearningObjective

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DRD2DAT

Dopamine Receptor D2 (DRD2)

Dopamine Receptor D4 (DRD4)

Wender PH. Minimal Brain Dysfunction in Children. New York: Wiley; 1971.Levy. 1990.Wender PH. Minimal Brain Dysfunction in Children. New York: Wiley; 1971.Levy. 1990.

DA Deficit Hypothesis of ADHDDA Deficit Hypothesis of ADHD

SNVTA

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D2 ReceptorsD2 Receptors

SynapseSynapse

DopamineDopamineNerveImpulseNerveImpulse

TransporterTransporter

[C11 ] Raclopride[C11 ] Raclopride

Volkow ND, et al. J Neurosci 2001;21:RC121.Volkow ND, et al. J Neurosci 2001;21:RC121.

Dopamine NeurotransmissionEffects of Methylphenidate - “Before”Dopamine Neurotransmission

Effects of Methylphenidate - “Before”

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D2 ReceptorsD2 Receptors

SynapseSynapse

DopamineDopamineNerveImpulseNerveImpulse

Transporter: MPH blocksTransporter: MPH blocks

[C11 ] Raclopride[C11 ] Raclopride

Dopamine NeurotransmissionEffects of Methylphenidate - “After”Dopamine NeurotransmissionEffects of Methylphenidate - “After”

Volkow ND, et al. J Neurosci 2001;21:RC121.Volkow ND, et al. J Neurosci 2001;21:RC121.

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Lee JS, et al. Hum Brain Mapping 2005;24:157.Lee JS, et al. Hum Brain Mapping 2005;24:157.

Regional Cerebral Blood Flow in Children with ADHD

Comparison Before and After Methylphenidate Treatment

Regional Cerebral Blood Flow in Children with ADHD

Comparison Before and After Methylphenidate Treatment

p < 0.01p < 0.01

p < 0.05p < 0.05

+64 mm +42 mm -8 mm -18 mm -40mm+64 mm +42 mm -8 mm -18 mm -40mm

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MethylphenidateNeural Mechanism of Action in the Human Brain

MethylphenidateNeural Mechanism of Action in the Human Brain

Positron Emission Tomography (PET)Radiotracers are available to measure changes in dopamine transporters (DAT) and D2 receptors (DRD2)

Clinical doses of MPH produce >50% DAT blockadeDAT blockade increases extracellular dopamine1,2

Elevated dopamine has multiple effects Decreases background firing and increases signal-to-noise ratio of striatal cells, enhancing task-related neuronal cell firing2

Modulates incentive salience and motivationIncreases in nucleus accumbens may improve attention and performance1,2

Functional (downstream) effects can be monitored By imaging glucose metabolism via PET By imaging blood flow via PET or fMRI

Positron Emission Tomography (PET)Radiotracers are available to measure changes in dopamine transporters (DAT) and D2 receptors (DRD2)

Clinical doses of MPH produce >50% DAT blockadeDAT blockade increases extracellular dopamine1,2

Elevated dopamine has multiple effects Decreases background firing and increases signal-to-noise ratio of striatal cells, enhancing task-related neuronal cell firing2

Modulates incentive salience and motivationIncreases in nucleus accumbens may improve attention and performance1,2

Functional (downstream) effects can be monitored By imaging glucose metabolism via PET By imaging blood flow via PET or fMRI

1. Volkow ND, et al. J Neurosci 2001;21:RC121.2. Volkow ND, et al. J Atten Disord 2002;6(Suppl 1):S31-S43.1. Volkow ND, et al. J Neurosci 2001;21:RC121.2. Volkow ND, et al. J Atten Disord 2002;6(Suppl 1):S31-S43.

TV034

Adapted from: Swanson J, et al. Curr Opin Neurobiol 1998;8:263-271.Adapted from: Swanson J, et al. Curr Opin Neurobiol 1998;8:263-271.

Other Possible Neuroanatomical PathwaysNon-Dopaminergic Pathways

Other Possible Neuroanatomical PathwaysNon-Dopaminergic Pathways

ThalamusThalamusThalamus

Nucleus Accumbens

GlobusPallidus

Nucleus Nucleus AccumbensAccumbens

GlobusGlobusPallidusPallidus

Caudate Nucleus

GlobusPallidus

Caudate Caudate NucleusNucleus

GlobusGlobusPallidusPallidus

ThalamusThalamusThalamus

ModafinilModafinilModafinil

SNSNSN

Prefrontal Cortex

Prefrontal Prefrontal CortexCortex

Anterior CingulateCortex

Anterior Anterior CingulateCingulateCortexCortex

Amphetamine and

Methylphenidate

Amphetamine Amphetamine andand

MethylphenidateMethylphenidate

VTAVTAVTA TMNTMNTMN

TV034



LearningObjective

TV034

Uses of Rating Scales in Assessment

Uses of Rating Scales in Assessment

Establish developmental levelby comparison with normsIdentify comorbid symptomsAssist in differential diagnosisTrack changes in function over timeMonitor effects of starting or changing medicationsEstablish dose-time-action effects

Establish developmental levelby comparison with normsIdentify comorbid symptomsAssist in differential diagnosisTrack changes in function over timeMonitor effects of starting or changing medicationsEstablish dose-time-action effects

TV034

Assess Treatment Effects and Outcomes

Assess Treatment Effects and Outcomes

Even well-trained psychiatrists may be unreliable without standardized symptom/behavior rating scales1

Scales should be used to measure severity and frequency of target symptoms (e.g., Modified Overt Aggression Scale):

Prior to treatment or at baseline evaluationAt regular intervals throughout treatmentDuring acute episodesWhen treatments are changed or discontinued

Even well-trained psychiatrists may be unreliable without standardized symptom/behavior rating scales1

Scales should be used to measure severity and frequency of target symptoms (e.g., Modified Overt Aggression Scale):

Prior to treatment or at baseline evaluationAt regular intervals throughout treatmentDuring acute episodesWhen treatments are changed or discontinued

1. Piacentini J, et al. J Am Acad Child Adolesc Psychiatry 1993;32:658-665.2. Pappadopulos E, et al. J Am Acad Child Adolesc Psychiatry 2003;42:145-161.1. Piacentini J, et al. J Am Acad Child Adolesc Psychiatry 1993;32:658-665.2. Pappadopulos E, et al. J Am Acad Child Adolesc Psychiatry 2003;42:145-161.

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Pharmacotherapy of ADHDPharmacotherapy of ADHDStimulants

Methylphenidate (Ritalin, Focalin, Metadate CD, Ritalin LA, Concerta, Focalin XR)Amphetamine compounds (Adderall, Adderall XR)Dextroamphetamine (Dexedrine, Dex Spansules)

Non-stimulantAtomoxetine (Strattera)

Currently pending FDA approvalModafinil-ADHD (Sparlon)

StimulantsMethylphenidate (Ritalin, Focalin, Metadate CD, Ritalin LA, Concerta, Focalin XR)Amphetamine compounds (Adderall, Adderall XR)Dextroamphetamine (Dexedrine, Dex Spansules)

Non-stimulantAtomoxetine (Strattera)

Currently pending FDA approvalModafinil-ADHD (Sparlon)

FDA approvedFDA approved

FDA approvedFDA approved

Updated 2005 from Wilens TE, et al. Ann Rev Med 2002;53:113-131.Updated 2005 from Wilens TE, et al. Ann Rev Med 2002;53:113-131.

TV034

AACAP. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. Under Review.

AACAP. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. Under Review.

AACAP GuidelinesPharmacotherapy Guidelines

(Under Review)

AACAP GuidelinesPharmacotherapy Guidelines

(Under Review)Recommendation 7. The initial psychopharmacological treatment of ADHD should be a trial with an agent approved by the FDA for the treatment of ADHD

FDA approved medications: dextroamphetamine, d- and d,l-methylphenidate, mixed salts amphetamine, atomoxetine, and modafinil (if approved by FDA)Selection of agent

AAP 2001, International consensus statement (2004), Texas CMAP (revised 2004) have all recommended stimulants first line,particularly when no comorbidity is present“Direct comparisons of the efficacy of atomoxetine to that of MPH and amphetamine have shown a greater treatment effect of the stimulants”

Recommendation 7. The initial psychopharmacological treatment of ADHD should be a trial with an agent approved by the FDA for the treatment of ADHD

FDA approved medications: dextroamphetamine, d- and d,l-methylphenidate, mixed salts amphetamine, atomoxetine, and modafinil (if approved by FDA)Selection of agent

AAP 2001, International consensus statement (2004), Texas CMAP (revised 2004) have all recommended stimulants first line,particularly when no comorbidity is present“Direct comparisons of the efficacy of atomoxetine to that of MPH and amphetamine have shown a greater treatment effect of the stimulants”

TV034

Traditional Stimulant Therapy in ADHD

Traditional Stimulant Therapy in ADHD

Rapid onset of effect (hours)

Dopaminergic activation: attention pathways, striatum, nucleus accumbens

Schedule II

Rapid onset of effect (hours)

Dopaminergic activation: attention pathways, striatum, nucleus accumbens

Schedule II

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OROS® MPH Efficacy7-Day Within-Subject Double-Blind Comparison

Study

OROS® MPH Efficacy7-Day Within-Subject Double-Blind Comparison

Study

Pelham WE, et al. Pediatrics 2001;107:e105. Pelham WE, et al. Pediatrics 2001;107:e105.

Academic Productivity

0

10

20

30

40

50

8:15 10:30 14:05 17:15 19:10

Class Period

Number of Math

Problems Completed

PBO OROS MPH MPH tid(N = 68)

(All Doses) (All Doses)

Academic Productivity

0

10

20

30

40

50

8:15 10:30 14:05 17:15 19:10

Class Period

Number of Math

Problems Completed

PBO OROS MPH MPH tid(N = 68)

(All Doses) (All Doses)

SKAMP Attention Ratings

0

0.5

1

1.5

2

8:15 10:30 14:05 17:15 19:10

Class Period

More Symptoms

SKAMP Attention Ratings

0

0.5

1

1.5

2

8:15 10:30 14:05 17:15 19:10

Class Period

More Symptoms

TV034

MAS XR Efficacy: Academic ProductivityRandomized, Double-Blind,Placebo-Controlled Study

MAS XR Efficacy: Academic ProductivityRandomized, Double-Blind,Placebo-Controlled Study

McCracken JT, et al. J Am Acad Child Adolesc Psychiatry 2003;42:673-683.McCracken JT, et al. J Am Acad Child Adolesc Psychiatry 2003;42:673-683.

0

20

40

60

80

100

120

140

0 1.5 3 4.5 6 7.5 9 10.5 12Hours Post-Dose

Number of Math

Problems Completed

PBOMAS 10mgMAS XR 10mgMAS XR 20mgMAS XR 30mg

(N = 49)

0

20

40

60

80

100

120

140

0 1.5 3 4.5 6 7.5 9 10.5 12Hours Post-Dose

Number of Math

Problems Completed

PBOMAS 10mgMAS XR 10mgMAS XR 20mgMAS XR 30mg

(N = 49)

TV034

Stimulant Medication Side Effects

Stimulant Medication Side Effects

Decreased appetite

Insomnia

Headaches/stomachaches

Irritability/moodiness (rebound)

Motor tics

Decreased appetite

Insomnia

Headaches/stomachaches

Irritability/moodiness (rebound)

Motor tics

TV034

Rationale for Nonstimulant Treatment of ADHD

Rationale for Nonstimulant Treatment of ADHD

Stimulants are extremely effective, but:Poor response or tolerability in some patientsSub-optimal response is not uncommon

Consider alternative treatmentsConsider combination treatment

Relative or labeled contraindications for some comorbid conditions (e.g., tics, anxiety, substance abuse) Some patients will not take stimulantsRisk for diversion or abuse of Schedule II drugs

Stimulants are extremely effective, but:Poor response or tolerability in some patientsSub-optimal response is not uncommon

Consider alternative treatmentsConsider combination treatment

Relative or labeled contraindications for some comorbid conditions (e.g., tics, anxiety, substance abuse) Some patients will not take stimulantsRisk for diversion or abuse of Schedule II drugs

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Study 1

05

1015202530354045

0 1 2 3 4 5 6 7 8 9Week

ADHD-RS Total Score

PBO ATX

* p < 0.01** p < 0.001

* *** ** ** ** ** ** **

Study 1

05

1015202530354045

0 1 2 3 4 5 6 7 8 9Week

ADHD-RS Total Score

PBO ATX

* p < 0.01** p < 0.001

* *** ** ** ** ** ** **

Study 2

05

10152025303540

0 1 2 3 4 5 6 7 8 9Week

* p < 0.05** p < 0.001

** * * ** ** **

Study 2

05

10152025303540

0 1 2 3 4 5 6 7 8 9Week

* p < 0.05** p < 0.001

** * * ** ** **

Atomoxetine vs. PBO in ADHDResults of Two Initial Pivotal Trials

Atomoxetine vs. PBO in ADHDResults of Two Initial Pivotal Trials

Spencer T, et al. J Clin Psychiatry 2002;63:1140-1147.Spencer T, et al. J Clin Psychiatry 2002;63:1140-1147.

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Improvements in ADHD Symptoms as Observed by Teachers and ParentsImprovements in ADHD Symptoms

as Observed by Teachers and Parents

IMPR

OV

EMEN

T

-20

-15

-10

-5

0Total Inattention

Hyperactive/Impulsive

School ADHD-RS-IV

MOD PBO

Mean Score

Change (SEM)

(N = 120) (N = 63)

* p < 0.01 ** p < 0.001*** p < 0.0001

***

*****

-20

-15

-10

-5

0Total Inattention


School ADHD-RS-IV

MOD PBO

Mean Score

Change (SEM)

(N = 120) (N = 63)

* p < 0.01 ** p < 0.001*** p < 0.0001

***

*****

Final visit; LOCFFinal visit; LOCF

-20

-15

-10

-5

0Total Inattention


Home ADHD-RS-IV

*

***

-20

-15

-10

-5

0Total Inattention


Home ADHD-RS-IV

*

***

Swanson JM, et al. J Clin Psychiatry 2006;67:137-147.Swanson JM, et al. J Clin Psychiatry 2006;67:137-147.

TV034

Percentage of Responders on CGI-I Scale

Percentage of Responders on CGI-I Scale

0

10

20

30

40

50

60

70

1 2 3 5 7 9 FinalVisitWeek

Percent Responders

(CGI-I)

MOD-ADHDPBO

(N = 163)

(N = 81)

p = 0.003

p = 0.007

p = 0.027

p = 0.015 p = 0.037

p < 0.0001

0

10

20

30

40

50

60

70

1 2 3 5 7 9 FinalVisitWeek

Percent Responders

(CGI-I)

MOD-ADHDPBO

(N = 163)

(N = 81)

p = 0.003

p = 0.007

p = 0.027

p = 0.015 p = 0.037

p < 0.0001

Biederman J, et al. Pediatrics 2005;116:e777-e784.Biederman J, et al. Pediatrics 2005;116:e777-e784.

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Teacher- / Investigator-Rated ADHD-RS-IV School VersionTeacher- / Investigator-Rated ADHD-RS-IV School Version

10

20

30

40

0 1 2 3 4 5 6 7 8 9 FinalVisitWeek

PBO

MOD-ADHD

p = 0.0005p = 0.001

p = 0.042p = 0.016

p < 0.0001

p = 0.02

(N = 163)

(N = 81)

Mean ADHD-RS-IV Total Score

10

20

30

40


PBO

MOD-ADHD

p = 0.0005p = 0.001

p = 0.042p = 0.016

p < 0.0001

p = 0.02

(N = 163)

(N = 81)

Mean ADHD-RS-IV Total Score

Completer analysisCompleter analysisBiederman J, et al. Pediatrics 2005;116:e777-e784.Biederman J, et al. Pediatrics 2005;116:e777-e784.

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Parent- / Investigator-Rated ADHD-RS-IV Home VersionParent- / Investigator-Rated ADHD-RS-IV Home Version

10

20

30

40


PBO

MOD-ADHD

p < 0.0001

(N = 163)

(N = 81)

Mean ADHD-RS-

IV Total Score

p = 0.003

p = 0.001

p = 0.008p = 0.012 p = 0.009

10

20

30

40


PBO

MOD-ADHD

p < 0.0001

(N = 163)

(N = 81)

Mean ADHD-RS-

IV Total Score

p = 0.003

p = 0.001

p = 0.008p = 0.012 p = 0.009

Completer analysisBiederman J, et al. Pediatrics 2005;116:e777-e784.Biederman J, et al. Pediatrics 2005;116:e777-e784.

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Weiss M, et al. ADHD in Adulthood. Baltimore, MD: The Johns Hopkins University Press; 1999.Weiss M, et al. ADHD in Adulthood. Baltimore, MD: The Johns Hopkins University Press; 1999.

Available Psychosocial Treatments for ADHD


Environmental restructuringClassroom changes; modifications in family, work, leisure activities; structure (e.g., lists, delegating)

Psychosocial treatment of childhood ADHD often utilizes adults to implement change

Parent behavior management trainingSchool-based contingency management

Environmental restructuringClassroom changes; modifications in family, work, leisure activities; structure (e.g., lists, delegating)

Psychosocial treatment of childhood ADHD often utilizes adults to implement change

Parent behavior management trainingSchool-based contingency management

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Weiss M, et al. ADHD in Adulthood. Baltimore, MD: The Johns Hopkins University Press; 1999.Weiss M, et al. ADHD in Adulthood. Baltimore, MD: The Johns Hopkins University Press; 1999.



CBT-based treatments for ADHD symptoms/traits

Supportive psychotherapy for adolescents/adults

Not optimal for ADHD symptom controlMay improve self-esteem, comorbidity, overall adjustment

CBT-based treatments for ADHD symptoms/traits

Supportive psychotherapy for adolescents/adults

Not optimal for ADHD symptom controlMay improve self-esteem, comorbidity, overall adjustment

TV034

King CA, et al. J Am Acad Child Adolesc Psychiatry 1997;36:85-93.King CA, et al. J Am Acad Child Adolesc Psychiatry 1997;36:85-93.

Behavioral Techniques for ADHDBehavioral Techniques for ADHDParent behavior management training

Reinforce positive behaviors / correct negative behaviorsEstablish and maintain house rulesDaily report card

Social skills trainingMore effective in group settings, e.g., school campTarget specific behaviors, e.g., playground aggressionStress conflict resolution Use naturally occurring consequences to teach social skills

Parent behavior management training Reinforce positive behaviors / correct negative behaviorsEstablish and maintain house rulesDaily report card

Social skills trainingMore effective in group settings, e.g., school campTarget specific behaviors, e.g., playground aggressionStress conflict resolution Use naturally occurring consequences to teach social skills

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Atkins, Pelham. 1992;69-88.Barkley RA, Cunningham CE. Arch Gen Psychiatry 1979;36:201-208.Atkins, Pelham. 1992;69-88.Barkley RA, Cunningham CE. Arch Gen Psychiatry 1979;36:201-208.

Behavioral Techniques for ADHDBehavioral Techniques for ADHDSchool setting

Behavioral treatment in school setting similar to the approach used in home with parentsGoal: reduce inattention and disruptive behaviorSpecific school accommodations:

Ensure structure and predictable routinesEmploy cost-response token economy systemsUse daily report cardsTeach organizational and work/study skills

School settingBehavioral treatment in school setting similar to the approach used in home with parentsGoal: reduce inattention and disruptive behaviorSpecific school accommodations:

Ensure structure and predictable routinesEmploy cost-response token economy systemsUse daily report cardsTeach organizational and work/study skills

TV034

ADHD Rating Scale ListingsADHD Rating Scale Listings

www.adhd.net (SNAPIV, SWAN)

www.add.about.com/od/addprimer/a/conners.htm(CPRS, CTRS)

www.dmh.cahwnet.gov/RPOD/child-posi.asp(CBCL)

www.pearsonassessments.com/tests/caars.htm(CAARS)

www.adhd.net (SNAPIV, SWAN)

www.add.about.com/od/addprimer/a/conners.htm(CPRS, CTRS)

www.dmh.cahwnet.gov/RPOD/child-posi.asp(CBCL)

www.pearsonassessments.com/tests/caars.htm(CAARS)

TV034

Clinical PearlsClinical Pearls

Use systematic, reliable rating scales to assess target symptoms

Titrate medication until asymptomatic

Don’t be afraid to increase dose

Don’t forget the psychotherapy of pharmacotherapy

Use systematic, reliable rating scales to assess target symptoms

Titrate medication until asymptomatic

Don’t be afraid to increase dose

Don’t forget the psychotherapy of pharmacotherapy

TV034

Documents

New CME Outfitters, LLC, is the accredited provider for this …neurosciencecme.com/library/TV-034-030106-05-GFX.pdf · 2006. 10. 20. · Mash, Johnston. 1983. 14. Noe, et al. 1999