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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.
TV034
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
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.”
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.”
TV034
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
TV034
Distinguish specific areas of the brain implicated in the pathophysiology of ADHD
Distinguish specific areas of the brain implicated in the pathophysiology of ADHD
LearningObjective
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Define the role of neurotransmission on brain circuitry in ADHD
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
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
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
Define the role of neurotransmission on brain circuitry in ADHD
Define the role of neurotransmission on brain circuitry in ADHD
Learning Objective 2
Distinguish specific areas of the brain implicated in the pathophysiology of ADHD
Distinguish specific areas of the brain implicated in the pathophysiology of ADHD
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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
TV034
Identify how brain neurocircuitry influences treatment strategies to improve patient outcomes
Identify how brain neurocircuitry influences treatment strategies to improve patient outcomes
LearningObjective
TV034
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.
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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
Compare and contrast existing and novel agents for the treatment of ADHD
Compare and contrast existing and novel agents for the treatment of ADHD
LearningObjective
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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”
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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
TV034
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.
TV034
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
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
***
*****
Final visit; LOCFFinal visit; LOCF
-20
-15
-10
-5
0Total Inattention
Hyperactive/Impulsive
Home ADHD-RS-IV
*
***
-20
-15
-10
-5
0Total Inattention
Hyperactive/Impulsive
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
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
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
0 1 2 3 4 5 6 7 8 9 FinalVisitWeek
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
0 1 2 3 4 5 6 7 8 9 FinalVisitWeek
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.
TV034
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
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
TV034
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
Available Psychosocial Treatments for ADHD
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
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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)
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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
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