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End of slide show, click to exit.

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Adult Attention Def= icit Disorder

Supported by NICHD
PHS Grant No. P01 HD 21887

Attention Deficit Disorder

Attention Deficit Disorder

Diagnosis of ADHD (DSM-IV)

Diagnosis of ADHD (DSM-IV)

Diagnostic Issues W= ith Adult Diagnosis

Adults’ Presenting Complaints

Adult Comorbid Characteristics

Prevalence of ADD

Evidence for ADD

Brain Correlates of= ADD

Brain Correlates of ADD
(Normalized Data)

Attention Deficit Disorder

 Adolescence ADD Outcome

Adult ADD Outcome

WFU Study

ADD Outcome SES=

Attention Deficit Disorder

Drug of Choice - Stimulant

Stimulant Side Effe= cts

Stimulant Overdose Effects

Treatment Studies

Effect of Stimulant= s by Age

Alternative Drugs

Combination Treatme= nts

Unproven Treatments= for ADD

Adult Case Study - History

Adult Case Study - Presenting Complaints

Double-Blind Placebo-Controlled Clinical Trial on Ritalin

Double-Blind Placebo-Controlled Clinical Trial on Dexadrine

Placebo Controlled Clinical Trial
Continuous Performance Task

Risks/Barriers Asso= ciated with Treatment

Risks/Barriers Asso= ciated with Treatment

Risks/Barriers Asso= ciated with Treatment

"Mistaken beli= eve that stimulant treatment..."

Positive Features o= f ADD

Footnotes: Future Directions for Research

8th Grade Outcome o= f 1st Grade ADD

Brain Correlates of ADD
(Normalized Data)

"START"

Continuous Performa= nce Test

Continuous Performa= nce Test

Continuous Performa= nce Test

Continuous Performa= nce Test

Continuous Performa= nce Test

Continuous Performa= nce Task

Continuous Performa= nce Task

"END"=

Placebo Controlled Clinical Trial
Temporal Dot Counting

Placebo Controlled Clinical Trial
Spatial Dot Counting

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Adult Attention Def= icit Disorder
Diagnosis, Outcome,= & Treatment
   D. Lynn Flowers, Ph.D
             Department of Neurology
Section of Neuropsy= chology

Supported by NICHD
PHS Grant No. P01 HD 21887
Frank B. Wood, Ph.D= .
Natalie Price, M.A.=
Marianne Meyer, M.A= .
John R. Absher, M.D= .
Fred Fahey, D.Sc.
H. Don Gage, Ph.D
Beth Harkness, M.S.=
Cathy Eades, B.S

Attention Deficit Disorder
Diagnosis
Outcome
Treatment

Attention Deficit Disorder
Diagnosis:
Diagnostic criter= ia, prevalence,  &
evidence for the = disorder
Outcome:
Characteristics in adolescents and adults
Treatment:
Effective medical= and nonmedical treatment,
risks/barriers; a= case study

Diagnosis of ADHD (DSM-IV)
Inattention<= /td>
Does not notice de= tails
Cannot sustain att= ention
Does not seem to l= isten
Does not follow th= rough
Difficulty organiz= ing
Easily distracted<= /font>

Diagnosis of ADHD (DSM-IV)
Hyperactive/Impulsi= ve
Motoric or mental = restlessness
Always “on the go”=
Often talks excess= ively
Often blurts out a= nswers
Difficulty waiting= turn
Interrupts or intr= udes on others

Diagnostic Issues W= ith Adult Diagnosis
Had symptoms of ADD= in childhood
Time and experience= needed to establish early symptoms
Rule out other caus= es

Adults’ Presenting Complaints
Forgetfulness
Confusion, trouble = thinking clearly
Performing below le= vel of competence
Inability to concen= trate
Depression, low sel= f-esteem
Difficulty in findi= ng/keeping jobs
Lack of organizatio= n

Adult Comorbid Characteristics
Antisocial Disorder= s (25%)
Generalized Anxiety= Disorder
Depression or dysth= ymia
Cyclothymic Disorde= r
Substance Abuse (12= -30%) and smoking more common
Learning disabiliti= es (30% comorbidity)

Prevalence of ADD
ADD is the most com= monly diagnosed behavioral disorder of childhood
3% - 5% of children=
1% - 3% of adults (= 50% of those with childhood diagnosis?)--conservatively 3-5 million
Six times more prev= alent in males (?)

Evidence for ADD
Predictive validity=
Highly familial (23= % - 30% have first degree relatives with ADD)
Brain activity prof= ile is replicated
Cross-national stud= ies find similar risk factors (NIH Consensus Report, 1998)

Brain Correlates of= ADD
MRI PET W/O ADD = PET W/ ADD

Brain Correlates of ADD
(Normalized Data)

Attention Deficit Disorder
Diagnosis:
Diagnostic criter= ia, prevalence, & evidence for  t= he disorder
Outcome:
Characteristics in adolescents and adults
Treatment:
Effective medical= and nonmedical treatment, risks/barriers; a case study

 Adolescence ADD Outcome
Poor judgment of co= nsequences
Study habits especi= ally poor
Peer rejection
Disruptive and crim= inal behavior
Academic failure
Substance use
Accidents of all ki= nds

Adult ADD Outcome
Have problems follo= wing through (multiple jobs & lower SES, failed marriages, lower educational attainment)
Poorly organized
Accidents of all so= rts, traffic violations
Trouble with the la= w
More comorbid subst= ance use

WFU Study
n=3D17 -ADD    n=3D14 +ADD
Married        71%    43%
Employed      100%    86%
College Educ.        65%    14%
Depressed/Anx.        35%    29%
ETOH/SU        12%    21%
   (These groups had same childhood SES= )

ADD Outcome SES=
   60 o =3D  -ADD
       + =3D +ADD
S 50           o          o
E                 +
S 40                    +
   30______|_____________|_______
     Child      Adult*
    *F=3D6.95, P < .01

Attention Deficit Disorder
Diagnosis:
Diagnostic criter= ia, prevalence, & evidence for
  the disorder
Outcome:
Characteristics in adolescents and adults
Treatment:
Effective medical= and nonmedical
treatment, risks/= barriers; a case study

Drug of Choice - Stimulant
Common choices:
Ritalin, Dexadrin= e, Cylert
Factors predicting = favorable response:
Accurate diagnosi= s
Attention span de= ficit
Restlessness (men= tal or motor)
Absence of emotional/antisocial disorder

Stimulant Side Effe= cts
Reduced appetite
Insomnia
Headache
Stomachache<= /td>
Tics

Stimulant Overdose Effects
Withdrawal
Crying
Anxiety
Fearfulness<= /td>

Treatment Studies
Studies of the effe= cts of stimulant medication:
  > 100 studies (~ 5000 child subjec= ts)
     < A dozen studies (~ 200 adult subjects)
Stimulants are effe= ctive:
69 - 77% of the t= ime in children
25 - 78% of the t= ime in adults

Effect of Stimulant= s by Age

Alternative Drugs
Common choices:
Tricyclic antidep= ressants, SSRIs,
Antihypertensives= (Clonidine, MAOI)
Deciding factors fo= r use:
No response to st= imulants
Stimulant side ef= fects severe
Rebound effect fr= om stimulants
Anxiety or depres= sion present

Combination Treatme= nts
Medication in combi= nation with:
Behavior management (point/token reward systems, timeout)
Parent/teacher/spou= se training
Note:  Cognitive-behavioral treatment (self-monitoring, verbal self-instruction, problem solving strategies) has not proven effective

Unproven Treatments= for ADD
Ambiguous evidence<= /font>
  Dietary controls
  Biofeedback
Little or no eviden= ce
  Vitamin supplements
  Vestibular stimulation

Adult Case Study - History
44 year old male
1 1/2 years of coll= ege, several technical school attempts
6 major moves, 8 di= fferent jobs, periods of unemployment, over 15 years
Marital discord (2 = marriages, estranged)
Alcohol, smoking, o= ther substance use
Learning disabled (= mild, in reading)
Met criteria for ch= ildhood ADHD

Adult Case Study - Presenting Complaints
In trouble with his= boss (can’t keep up with appointments and paperwork)
On the verge of los= ing his wife
Loses things, forge= tful
Disorganized=
Impatient, makes im= pulsive decisions
Gets bored easily

Double-Blind Placebo-Controlled Clinical Trial on Ritalin
8:00        10:00      12:00     2:00       4:00
BL       Test A                     Test B    Test C
Drug A     Drug B*   Drug C
    *Drug B is always placebo

Double-Blind Placebo-Controlled Clinical Trial on Dexadrine
8:00 10:00
Day 1 BL Test A<= /font>
Drug A*<= /td>
Day 2 BL Test B<= /font>
Drug B
Day3 BL Test C<= /font>
Drug C
*One drug is placeb= o

Placebo Controlled Clinical Trial
Continuous Performance Task

Risks/Barriers Asso= ciated with Treatment
Ritalin exacerbates= effects of Tricyclics
Antidepressants may= increase aggression associated with ADD
MAO-A inhibitors ha= ve potential hypertensive reaction and may elicit mood swings

Risks/Barriers Asso= ciated with Treatment
High doses of stimu= lants have resulted in an increase of compulsive behaviors
High doses of stimu= lants have resulted in motor disorders
Pemoline has result= ed in liver damage (in children)
Tricyclics may indu= ce cardiac arrhythmias
Wellbutron may indu= ce seizures

Risks/Barriers Asso= ciated with Treatment
Many practitioners = do not use structured questionnaires or interviews
Some practitioners = use response to medication as the sole criterion for Dx
PCPs are less likel= y than other physicians to recognize comorbid disorders (per NIH Consensus Report)

"Mistaken beli= eve that stimulant treatment..."
Mistaken believe th= at stimulant treatment of ADD promotes use of illegal substances
Concern that jobs w= ill be jeopardized
Services for ADD ar= e frequently not covered

Positive Features o= f ADD
Creative
Interesting<= /td>
Perform well in a c= risis
Thrive in certain v= ocations:
(Career military,= ER medicine, Athletics,
Politics, etc.)
1/2 have minimal sy= mptoms in adulthood

Footnotes: Future Directions for Research
Develop age-sensiti= ve diagnostic criteria
Study of Inattentio= n alone
Studies of females<= /font>
Studies of adults b= eyond age 30
Effects of ADD on c= ognitive development
Brain imaging befor= e initiation of Tx
Impact of long-term= medication Tx
Can beh. Tx lower s= timulant dose level

8th Grade Outcome o= f 1st Grade ADD
       Hyper      Imp Inatt
Reading Comp. &= lt;.005
Word Retrieval = <.0005
Verbal IQ Estimate = <.005

Brain Correlates of ADD
(Normalized Data)

"START"
  START

Continuous Performa= nce Test
H

Continuous Performa= nce Test
N

Continuous Performa= nce Test
A Z
O H

Continuous Performa= nce Test
H J A<= /td>
I Z E<= /td>
B O N<= /td>

Continuous Performa= nce Test
O I
T S

Continuous Performa= nce Task
Q T N<= /td>
I A H<= /td>
O S Z<= /td>

Continuous Performa= nce Task
B Q
S I

"END"=
      END

Placebo Controlled Clinical Trial
Temporal Dot Counting

Placebo Controlled Clinical Trial
Spatial Dot Counting

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<= /td> = <= /td>
Diagnosis, Outcome, & Treatment
   D. Lynn Flowers, Ph.D
             Department of Neurology<= /font>
Sec= tion of Neuropsychology
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Adult Attention Deficit Disorder
<= /td> =
Supported by NICHD
PHS Grant No. P01 HD 21887
<= /td> =
l = Fred Fahey, D.Sc.
l = H. Don Gage, Ph.D
l = Beth Harkness, M.S.
l = Cathy Eades, B.S
<= /td> = <= /td>
l = Frank B. Wood, Ph.D.
l = Natalie Price, M.A.
l = Marianne Meyer, M.A.
l = John R. Absher, M.D.
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0003.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Attention Deficit Disorder
<= /td> <= /td> <= /td> <= /td>
l = Diagnosis

l O= utcome

l = Treatment

------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0004.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Attention Deficit Disorder
<= /td> <= /td> <= /td> = <= /td> <= /td> <= /td>
l = Diagnosis:
     Diagnostic criteria, prevalence,<= span style=3D'mso-spacerun:yes'>  &
=      evidence for the disorder
l Outc= ome:
     Characteristics in adolescents and adults
l Trea= tment:
     Effective medical and nonmedical<= /font>
trea= tment,
     risks/barriers; a case study
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0005.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Diagnosis of ADHD (DSM-IV)
<= /td> = <= /td> <= /td> <= /td>
l = Inattention
   Does not notice details
   Cannot sustain attention
   Does not seem to listen
   Does not follow through
   Difficulty organizing
   Easily distracted

------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0006.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Diagnosis of ADHD (DSM-IV)
<= /td> = <= /td> <= /td> <= /td>
l = Hyperactive/Impulsive
   Motoric or mental restlessness
   Always “on the go”
   Often talks excessively
   Often blurts out answers
   Difficulty waiting turn
   Interrupts or intrudes on others
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0007.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
= =
Diagnostic Issues With Adult
Diagnosis
<= /td> = <= /td> <= /td>
l Had= symptoms of ADD in childhood
l Tim= e and experience needed to
est= ablish early symptoms
l Rul= e out other causes
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0008.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td>
l For= getfulness
l Con= fusion, trouble thinking clearly
l Per= forming below level of competence
l Ina= bility to concentrate
l Dep= ression, low self-esteem
l Dif= ficulty in finding/keeping jobs
l Lac= k of organization
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Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td>
l Ant= isocial Disorders (25%)
l Gen= eralized Anxiety Disorder
l Dep= ression or dysthymia
l Cyc= lothymic Disorder
l Sub= stance Abuse (12-30%) and
smo= king more common
l Lea= rning disabilities (30% comorbidity)
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Prevalence of ADD
<= /td> <= /td> = = <= /td> <= /td>
l ADD= is the most commonly diagnosed
beh= avioral disorder of childhood
l 3% = - 5% of children
l 1% = - 3% of adults (50% of those with
chi= ldhood diagnosis?)--conservatively 3-
5 mi= llion
l Six= times more prevalent in males (?)
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0011.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Evidence for ADD
<= /td> = <= /td> <= /td> <= /td> <= /td>
l Pre= dictive validity
l Hig= hly familial (23% - 30% have first
deg= ree relatives with ADD)
l Bra= in activity profile is replicated
l Cro= ss-national studies find similar risk
fac= tors (NIH Consensus Report, 1998)
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0012.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Brain Correlates of ADD
    MRI    PET W/O ADD   PET W/ ADD<= br>
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<= /td> =
Brain Correlates of ADD
(Normalized Data)
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f+faL8//AK9H/Czz/wA+0X5//Xo5Zfyv7mH1yj3PR6K84/4Wef8An2i/P/69H/Czz/z7Rfn/APXo 5Zfyv7mH1yj3PR6K84/4Wef+faL8/wD69H/Czz/z7Rfn/wDXo5Zfyv7mH1yj3NL4j/8AILtv94/z WvGq7/xF4zj1yzW32CNlIIZW4OcZzzXnvmxf89E/76FdeETSldWPOxE1UqOUdj//2T== ------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0014.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Attention Deficit Disorder
<= /td> <= /td> <= /td> <= /td> <= /td>
l Dia= gnosis:
     Diagnostic criteria, prevalence, = &
evi= dence for  the disorder
l = Outcome:
     Characteristics in adolescents
= and adults
l Trea= tment:
     Effective medical and nonmedical<= /font>
tre= atment, risks/barriers; a case study
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0015.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
 Adolescence ADD Outcome
<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td>
l Poo= r judgment of consequences
l Stu= dy habits especially poor
l Pee= r rejection
l Dis= ruptive and criminal behavior
l Aca= demic failure
l Sub= stance use
l Acc= idents of all kinds
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0016.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Adult ADD Outcome
<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td>
l Hav= e problems following through
(mu= ltiple jobs & lower SES, failed
mar= riages, lower educational
att= ainment)
l Poo= rly organized
l Acc= idents of all sorts, traffic violations
l Tro= uble with the law
l Mor= e comorbid substance use
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0017.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
WFU Study
<= /td> <= /td> = <= /td>
         n=3D17 -ADD    n=3D14 +ADD<= /font>
Mar= ried     =        71%        43%
Emp= loyed     =      100%        86%
Col= lege Educ.     =      65%        14%
Dep= ressed/Anx.     =      35%        29%
ETO= H/SU     =        12%        21%
   (These groups had same childhood
SES)
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0018.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
ADD Outcome SES
<= /td> <= /td> <= /td> = <= /td> <= /td> <= /td> <= /td>
   60=              o =3D  -ADD
                    + =3D +ADD
S 5= 0     =         o               o
E                 +
S 4= 0                          +
   30______|_____________|_______
     =      Child          Adult*
                   *F=3D6.95, P <
.01
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L43pTGt605zutKc/DepQi3rUpC61qU+N6lSretWsbrWrXw3rWMt61rSuta1vjetc63rXvO61r3kd CAA7 ------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0019.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Attention Deficit Disorder
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td> = <= /td>
l Diag= nosis:
     Diagnostic criteria, prevalence, = & evidence
for<= /font>
     = the disorder
l Outc= ome:
     Characteristics in adolescents and adults
l = Treatment:
     Effective medical and nonmedical<= /b>
=      treatment, risks/barriers; a case=
s= tudy
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Drug of Choice - Stimulant
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
l Com= mon choices:
     Ritalin, Dexadrine, Cylert=
l Fac= tors predicting favorable response:
     Accurate diagnosis
     Attention span deficit
     Restlessness (mental or motor)
     Absence of emotional/antisocial
diso= rder
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0021.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Stimulant Side Effects
<= /td> <= /td> <= /td> <= /td> <= /td>
l Red= uced appetite
l Inso= mnia
l Hea= dache
l Sto= machache
l Tics
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0022.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Stimulant Overdose Effects
<= /td> <= /td> <= /td>
l Wit= hdrawal
l Crying
l Anxi= ety
l Fea= rfulness
------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0023.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Treatment Studies
<= /td> <= /td> <= /td> = <= /td> <= /td>
l Stu= dies of the effects of stimulant
med= ication:
     > 100 studies (~ 5000 child subjects)
     < A dozen studies (~ 200 adul= t
subj= ects)
l Sti= mulants are effective:
     69 - 77% of the time in children<= /font>
     25 - 78% of the time in adults
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Effect of Stimulants by Age
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iTC5vge93Du+5AsJ0vke31i+6ru+7Nu+7vu+8Bu/8ju/9Fu/9nu/+LsoPhcZ2tRW2ERgkvCZ2Jps iMZtotJk+ZvAgIBZ8cFO2qRW//9bwJHAdRCVbxJMBNdUZgq8wdkUGUSQW63mv+3UGo4lW4oFT0Mn A4qWvmhgRmnlKSRMaDVBARvgaJP1lBycw2IQZfSAUTjhvwRmc461Fxp1Ua52BwO0ABQTxPEkwxUn EY1RTTo8xUdQV0Ugqf5bV431M+wkX6d2B0rMAEqkxU18bBl8EflAMVS8xobFWzzXWFnMjcvBxVHw xXXAwLwnx5T3bxOQTlelxmxMxQ/8xhwHcJv1D/HExcNEdHUwT0wQF1LcWE7cxygzcScXyArMwEc8 yRe3cY4lT4+1RMdmB/7iakxMeZ58xpBFbB6MyTp8epjByYbGBCSsZ7fFyC0MqhLv5MM/V3Q/x042 F6e65cqFEAQAOw== ------=_NextPart_01C4074E.E79DD2A0 Content-Location: file:///C:/268210E4/aadd_files/v3_slide0025.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Adult Attention Deficit Disorder
Alternative Drugs
<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
l Com= mon choices:
     Tricyclic antidepressants, SSRIs,=
     Antihypertensives (Clonidine, MAO= I)
l Dec= iding factors for use:
     No response to stimulants<= br>
     Stimulant side effects severe
     Rebound effect from stimulants
     Anxiety or depression present
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Combination Treatments
<= /td> <= /td> = <= /td> <= /td> <= /td> <= /td> <= /td>
Med= ication in combination with:
l Beh= avior management (point/token
rew= ard systems, timeout)
l Par= ent/teacher/spouse training
= Note:  Cognitive-behavioral treatment (sel= f-
= monitoring, verbal self-instruction,
= problem solving strategies) has not proven
e= ffective
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<= /td> = <= /td> <= /td> <= /td>
l Amb= iguous evidence
       Dietary controls
       Biofeedback
l Lit= tle or no evidence
       Vitamin supplements
       Vestibular stimulation
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Adult Case Study - History
<= /td> = = <= /td> <= /td>
l 44 = year old male
l 1 1= /2 years of college, several technical
sch= ool attempts
l 6 m= ajor moves, 8 different jobs, periods
of = unemployment, over 15 years
l Mar= ital discord (2 marriages, estranged)
l Alc= ohol, smoking, other substance use
l Lea= rning disabled (mild, in reading)
l Met= criteria for childhood ADHD
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<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td>
l In = trouble with his boss (can’t keep up
wit= h appointments and paperwork)
l On = the verge of losing his wife
l Los= es things, forgetful
l Dis= organized
l Imp= atient, makes impulsive decisions
l Get= s bored easily
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<= /td> <= /td> = <= /td> <= /td>
8:0= 0     =      10:00        12:00       2:00       4:00
BL<= span style=3D'mso-tab-count:1'>     =     Test A                        Test B
Test C
Dru= g A     =     Drug B*   Drug C<= br>
    *Drug B is always placebo
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= <= /td> = <= /td>
     =       8:00       10:00
Day= 1     BL       Test A
         Drug A*
Day= 2     BL       Test B
         Drug B
Day= 3       BL       Test C
         Drug C
*One drug is pl= acebo
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<= /td> = = <= /td> <= /td>
l Rit= alin exacerbates effects of Tricyclics
l Ant= idepressants may increase
agg= ression associated with ADD
l MAO= -A inhibitors have potential
hyp= ertensive reaction and may elicit
moo= d swings
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<= /td> = <= /td> = <= /td> <= /td>
l Hig= h doses of stimulants have resulted
in = an increase of compulsive behaviors
l Hig= h doses of stimulants have resulted
in = motor disorders
l Pem= oline has resulted in liver damage
(in= children)
l Tri= cyclics may induce cardiac
arr= hythmias
l Wel= lbutron may induce seizures
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<= /td> = <= /td> <= /td> <= /td> <= /td>
l Many practitioners do not use structured
que= stionnaires or interviews
l Some practitioners use response to
med= ication as the sole criterion for Dx
l PCP= s are less likely than other
phy= sicians to recognize comorbid
dis= orders (per NIH Consensus Report)
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= =
Risks/Barriers Associated with=
Treatment
<= /td> <= /td> <= /td> = <= /td> <= /td>
l Mis= taken believe that stimulant
tre= atment of ADD promotes use of illegal
sub= stances
l Con= cern that jobs will be jeopardized
l Ser= vices for ADD are frequently not
cove= red
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Positive Features of ADD
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
l Crea= tive
l Int= eresting
l Per= form well in a crisis
l Thr= ive in certain vocations:
     (Career military, ER medicine, Athletics,
     Politics, etc.)
l 1/2= have minimal symptoms in
adul= thood
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<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
l De= velop age-sensitive diagnostic criteria
l Stu= dy of Inattention alone
l Stu= dies of females
l Stu= dies of adults beyond age 30
l Eff= ects of ADD on cognitive
dev= elopment
l Bra= in imaging before initiation of Tx
l Imp= act of long-term medication Tx
l Can= beh. Tx lower stimulant dose level
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