A Brief History of ADHD

1967: 1980: 1902: 1937: 1995: LEARNING OBJECTIVES DSM‐II defines a DSM‐III defines Sir George Wender publishes Benzedrine “Hyperkinetic Attention Deficit Frederic Still Attention‐Deficit () Reaction of Disorder (ADD) with describes 20 Hyperactivity shown to be Childhood” and without cases of children Disorder in Adults (1st effective for MBD characterized by hyperactivity with attention book about adult and disruptive overactivity and behaviors with an short attention span ADHD) • Identify clinical symptoms of ADHD in children, adolescents and adults organic cause vs “bad parenting” • Understand the developmental course of ADHD, the impairments it may produce in various major life activities, and implications for treatment planning.

1997: • Identify comorbid conditions 1976: 1987: 1917-1928: 1957: Barkley defines ADHD • Encephalitis Methylphenida Wender DSM‐III‐R removes concept of symptoms and behaviors Review key genetic and neuroimaging concepts epidemic leads to te (MPH) describes MBD 2 subtypes and defines across the lifespan “organic brain approved for in adults Attention deficit‐ (symptom of impaired damage”  MBD (foundation for Hyperactivity Disorder impulse control added) • Discuss the MOA comparative efficacy of medical versus psychosocial eventually ADHD in adults) (ADHD) becomes “Minimal interventions Brain Dysfunction” or MBD • Considerations for selection of pharmacotherapeutic interventions 1798: Sir Alexander Crichton is first to describe a “disease of attention” causing “unnatural degree of mental restlessness"

TREATMENT CHALLENGES FOR ADHD OVERVIEW OF DSM‐5 CRITERIA FOR ADHD A. A persistent pattern of inattention and/or hyperactivity‐ that interferes with functioning or development, as characterized by inattention and/or hyperactivity/impulsivity B. Several inattentive or hyperactive‐impulsive symptoms were present prior to age 12 years. Attempting to understand the burden of psychiatric illness C. Several inattentive or hyperactive‐impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or across the lifespan is often complicated because with the relatives; in other activities). progression of time and parallel developmental maturation, D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. the core features of a disorder may present differently. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Reference: https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_ADHD.pdf ADHD: A LIFELONG DISORDER CLINICAL PRESENTATION: AGES 13 TO 18

• Excessive motor activity tends to decrease • Engaging in “risky” behaviors (speeding and 75% 50% driving mishaps) persists persists Children • May have a sense of inner restlessness into into (rather than hyperactivity) • Difficulty with authority figures with ADHD adolescence adulthood • Schoolwork disorganized and shows poor • Poor self‐esteem follow‐through; fails to work independently • Poor peer relationships Adolescents • Comments: “Not living up to with ADHD potential,” “spacey,” “hyper” • Anger, emotional lability Adults with ADHD • Behavioral issues: “Class clown” Prevalence in juvenile population Prevalence in adult 6%-9% population 3%-5% Greenhill LL. J Clin Psychiatry. 1998;59(suppl 7):31-41. Conners CK, Jett JL. ADHD in Adults and Children. Compact Clinicals;1999. Wilens TE. Psychiatr Clin North Am. 2004;27:283-301. Barkley RA, et al. Psychiatr Clin N Am. 2004;27:233-260.

Persistence of ADHD Symptoms in Adulthood ADHD PERSISTENCE INTO ADULTHOOD

• Common myth: that children with ADHD “grow out of it”

• It is generally accepted that children with ADHD face academic and behavioral challenges, have difficulty making friends, and navigating stressful situations

• Often clinicians are not aware of the serious consequences of adult ADHD

• An estimated 4.4% of adults aged 18‐44 years have ADHD*

*According to results from the National Comorbidity Survey Replication in 3199 respondents aged 18 to 44 years. 1. US Census 2000; 2. Kessler RC et al. Am J Psychiatry. 2006;163:716-723. Stahl S (2009). Stahl’s Illustrated Attention Deficit Hyperactivity Disorder. CORE SYMPTOMS OF ADHD: HYPERACTIVITY, IMPULSIVITY, AND INATTENTIVENESS ADHD IN ADULTS MAY LEAD TO POTENTIALLY SERIOUS Symptom Typically Seen in Children Typically seen in Adults CONSEQUENCES Hyperactivity • Talks excessively • Talks excessively • Squirms and Fidgets • Inner restlessness • Run/Climbs excessively • Feelings of being overwhelmed • Cannot work or play • Chose active jobs quietly • Inability to enjoy quiet leisure time 1 • Always “on the go” • Sense of being “driven” • 2x more likely to have been arrested * • Nearly 2x as likely to have been divorced1* Impulsivity • Blurts out answers • Irritability and quick to anger 2† • Cannot wait turn • Blurts out rude or insulting thoughts • 4x more likely to have contracted a sexually transmitted disease • Interrupts others • Reckless driving • Impulsively changes jobs 2† • Quits new projects • 3x more likely to be currently unemployed • Impulsive sexuality Inattentiveness • Difficulty with homework • Complain what they read doesn’t register 1 • Doesn’t listen • Frustrated over inability to organize • 2x more likely to have been involved in 3 or more car crashes * • Forgetful • Poor time management • Problems prioritizing • Loses things • Misplace belongings • Easily distracted • Easily distracted • Prefers to multitask *Results from a population survey of 500 adults with ADHD and 501 gender- and age-matched adults without ADHD that investigated characteristics of ADHD • Inefficient and its impact on multiple domains of functioning; †Data compiled from a study comparing the young adult adaptive outcomes of an original population of 158 children diagnosed as hyperactive and 81 controls followed concurrently for at least 13 years. 1. Biederman J et al. J Clin Psychiatry. 2006;67:524-540; 2. Barkley RA et al. J Am Acad Child Adolesc Psychiatry. 2006;45:192-202. Weiss M , Murray C (2003) Assessment and management of attention-deficit hyperactivity disorder in adults . CMAJ 18: 715-722

ADHD: COMORBID CONDITIONS IN CHILDREN COEXISTING PSYCHIATRIC DISORDERS IN ADULTS 60 55 50 Prevalence in Prevalence in patients 45 Disorder patients with ADHD without ADHD 40 40% 35 30–35% Major Depression 18.6% 7.8% 30 (%) Bipolar Disorder 19.4% 3.1% 25 20–25% 15–25% 20 15–20% 20% 19% Generalized Anxiety 8.0% 2.6% 15 15% Disorder 10 5 Any Anxiety Disorder 47.1% 19.5% 0 Any Substance Use 15.2% 5.6% Disorder Oppositional Language Anxiety Learning Mood Conduct Smoking4 Substance defiant disorder2 disorders3 difficulties2 disorders2 disorder3 use disorder1 disorder5 Impulse Control Disorders 19.6% 6.1% 1MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1076–1086. 2Barkley R. Attention-deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment, 2nd ed. New York: Guilford Press, 1993. Kessler, R C, et al. “The Prevalence and Correlates of Adult ADHD in the United States: Results from the National 3Biederman J, et al. Am J Psychiatry 1991; 148:565–577. Comorbidity Survey Replication.” American Journal of Psychiatry, vol. 4, Apr. 2006, pp. 716–723., 4Milberger S, et al. J Am Acad Child Adolesc Psychiatry 1997;36:37–44. doi:10.1176/ajp.2006.163.4.716. 5Biederman J, et al. J Am Acad Child Adolesc Psychiatry 1997;36:21–29. HERITABILITY OF ADHD

IS ADHD A “REAL” DIAGNOSIS? Martin 2002 Panic Disorder Schizophrenia Height Kuntsi 2001

Coolidge 2000

Willcutt 2000

Hudziak 2000

Nadder 1998

Levy 1997

Sherman 1997

Silberg 1996

Gjone 1996

Thapar 1995

Schmitz 1995

Stevenson 1992

Edelbrock 1992

Gillis 1992

Goodman 1989

Matheny 1980

Willerman 1973

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Mean heritability of ADHD = 0.77

POTENTIAL ETIOLOGICAL FACTORS

• Average heritability of .80 ‐ .85 ETIOLOGY FACTORS CONTINUED • Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions • Possible differences in size of brain structures • Dysfunction in prefrontal lobes • Prefrontal cortex, • Involved in inhibition, executive functions • corpus callosum • Genes involved in dopamine regulation • caudate nucleus • Dopamine transporter (DAT1) gene implicated • Abnormal brain activation during attention & inhibition tasks • 7 repeat of dopamine receptor gene (DRD4) implicated • Gene x environment interactions

Kieling, Gondaves. Tannock. & Castellanos. 2008; Mick &. Faraone, 2008 Genetics

Parents with ADHD Dopamine genes: have >50% chance DA type 2 gene, DA of having a child transporter gene with ADHD (DAT1)

About 25% of Dopamine receptor children with (DRD4, “repeater ADHD have parents gene”) is over‐ who meet the represented in formal diagnostic ADHD patients criteria for ADHD

THE STROOP TEST DORSAL ANTERIOR CINGULATE CORTEX FUNCTIONS DIRECTIONS: Read the word. RED YELLOW GREEN BLUE • Target Anticipation • Error Detection • Target Selection/Attention • Reward based decision making GREEN RED BLUE YELLOW • Novelty Detection • Complex and effortful cognitive BLUE GREEN YELLOW RED • Response Selection processing • Response selection and inhibition • Working Memory YELLOW RED GREEN BLUE • Performance monitoring RED YELLOW GREEN BLUE GREEN RED BLUE YELLOW BLUE GREEN YELLOW RED YELLOW RED GREEN BLUE Bush et al 2000 Stroop JR. J Exp Psychol. 1935;18:643-662. THE STROOP TEST DIRECTIONS: Say the color, don’t read the word. FUNCTIONS OF DLPFC AND VLPFC RED YELLOW GREEN BLUE • Vigilance GREEN RED BLUE YELLOW • Selective and divided attention BLUE GREEN YELLOW RED • Attention shifting • Planning YELLOW RED GREEN BLUE • Executive control • Working memory RED YELLOW GREEN BLUE (Duncan and Owen 2002; Posner and Peterson 1990). GREEN RED BLUE YELLOW • VLPFC in particular has been associated BLUE GREEN YELLOW RED with behavioral inhibition, YELLOW RED GREEN BLUE

Stroop JR. J Exp Psychol. 1935;18:643-662

Role of Neuroimaging in Diagnosis?

• Convergent data from neuroimaging indicate that frontostriatal circuitry is probably dysfunctional in patients with ADHD. PHARMACOTHERAPY OPTIONS FOR ADHD • Functional neuroimaging may eventually be developed into a diagnostically useful clinical test, but it is not clinically useful at this time. CURRENT ADHD MEDICATIONS BLOCK REUPTAKE ISSUES IN ADOLESCENCE AND YOUNG ADULTHOOD AND/OR INCREASE RELEASE OF CATECHOLAMINES • Diversion issues • A study in children and adolescents found that 20% of HCPs were uncomfortable prescribing • 58% would prefer to prescribe a medication that is not a controlled substance • Variable schedules (late/early classes); late‐night study hours • May have trouble accessing services to diagnose or treat ADHD in adults • Prior authorization sometimes required • Insurance often covers medications but no other services

Stockl KM et al. Physician perceptions of the use of medications for attention deficit hyperactivity disorder. J Manag Care Pharm. 2003 Sept‐Oct;9(5)416‐23.

Norepinephrine (NE) Dopamine (DA)

1. Arnsten AFT, et al. J Child Adolesc Psychopharmacol. 2007;17:393-406. 2. Biederman J, Spencer TJ. J Am Acad Child Adolesc Psychiatry. 2000;39:1330-1333. 3. Berridge CW, et al. Biol Psychiatry. 2006;60:1111-1120. 4. Bymaster FP, et al. Neuropsychopharmacology. 2002;27:699-711.

THE MECHANISMS OF ACTION OF AMPHETAMINE WILENS AND SPENCER. HANDBOOK OF SUBSTANCE ABUSE: NEUROBEHAVIORAL PHARMACOLOGY. KEY TAKEAWAYS 1998;501‐513.

AMPH diffuses into Presynaptic Neuron vesicle causing NT 1. Both DA and NE signaling must be maintained in an optimal range in order to release into cytoplasm AMPH blocks AMPH exert maximum efficacy with regard to cognitive functioning and attentional uptake into vesicle processes AMPH • Considering either of these signaling pathways in isolation may only target part of the Storage neural network responsible for cognition and attention vesicle Cytoplasmic NT 2. Taken together, these theories support ADHD as a persistent and pervasive disorder that may require regulating DA and NE signaling continuously AMPH is taken up into cell causing NT NT Transporter AMPH Inhibits release into synapse Protein NT = Neurotransmitter Synapse (Dopamine or Norepinephrine) SCHEDULE II MEDICATIONS • All stimulant drugs for ADHD are Schedule II • Methylphenidate blocks the transporter for dopamine and products. norepinephrine. • Schedule II drugs: • The immediate effect is to increase the synaptic concentration of • Have a high potential for abuse monoamines, producing an increased postsynaptic effect. • Have a currently accepted medical use in • Methylphenidate has a direct effect on DA and a weaker effect on treatment in the United States NE. • Abuse of the drug may lead to severe The relationship between the mechanism of action and clinical benefit has not been established. The mechanism of action is theoretical and based on animal studies. psychological or physical dependence Adapted from Solanto et al, eds. Stimulant Drugs and ADHD. Oxford; 2001; Cho and Segal, eds. Amphetamine and Its Analogs. Academic Press; 1994; Tarter et al, eds. Handbook of Substance Abuse: Neurobehavioral Psychopharmacology. Plenum Press; 1998. Controlled Substances Act. FDA Web site. Available at: http://69.20.19.211/opacom/laws/cntrlsub/cntlsbb.htm. Accessed March 1, 2008.

THE PFC REQUIRES PROPER “TUNING” CATECHOLAMINE METHYLPHENIDATE LONG ACTING 1–4 LEVELS FOR OPTIMAL FUNCTION STIMULANTS

OPTIMAL Generic Name Brand Name Medication Release Methylphenidate Extended Release Orally Cotempla XR‐ 25% immediate release Disintegrating Tablet ODT 75% extended release Methylphenidate Extended Release Aptensio XR 40% immediate release Capsule 60% extended release Methylphenidate Extended Release Tablet Concerta Laser drilled orifice Methylphenidate Extended Release Quillivant XR 20% immediate release Suspension (25 mg/5 mL) 80% extended release INSUFFICIENT EXCESSIVE Methylphenidate Extended Release Quillichew ER 30% immediate release Chewable Tablets 70% extended release Extended Release Focalin XR 50% immediate release Capsule 50% extended release ADHD Stress Methylphenidate Extended Release Ritalin LA 50% immediate release Capsule 50% extended release Levels of Catecholamine Methylphenidate Extended Release Metadate CD 30% immediate release (Dopamine and Norepinephrine) Capsule 70% extended release Methylphenidate Extended Release Tablet Metadate ER

1. Arnsten AFT, et al. J Child Adolesc Psychopharmacol. 2007;17:393-406. Methylphenidate Transdermal System Daytrana Patch worn 9 hours per 2. Granon S, et al. J Neurosci. 2000;20:1208-1215. day 3. Vijayraghavan S, et al. Nat Neurosci. 2007;10:376-384. 4. Zahrt J, et al. J Neurosci. 1997;17:8528-8535. METHYLPHENIDATE SHORT ACTING AMPHETAMINE LONG ACTING STIMULANTS

STIMULANTS Generic Name Brand Name Medication Release d‐ and l‐amphetamine Extended Adzenys XR‐ODT 3 d‐amphetamine to Release Orally Disintegrating Tablet 1 l‐amphetamine ratio Generic Name Brand Name d‐ and l‐amphetamine Extended Adzenys ER 3 d‐amphetamine to Release Oral Suspension (1.25 mg/mL) 1 l‐amphetamine ratio Dexmethylphenidate Tablet Focalin Amphetamine Mixed Salts Extended XR Immediate release and Methylphenidate Tablet Ritalin Release Capsule Delayed release Beads Methylphenidate Chewable Methylphenidate dimesylate Capsules Vyvanse Prodrug of Tablet Chewable Lisdexamfetamine dimesylate Vyvanse Chewables Prodrug of dextroamphetamine Chewable Tablets Methylphenidate Oral Methylin Solution d‐ and l‐amphetamine Sulfate Extended Dyanavel XR 3.2 d‐amphetamine to Solution Release Oral Suspension (2.5 mg/mL) 1 l‐amphetamine ratio Amphetamine Mixed Salts Extended Mydayis 1 type Immediate release bead Release Capsule 2 types of delayed release beads

Dextroamphetamine Extended Release Dexedrine Spansule 30% immediate release Capsule 70% extended release

AMPHETAMINE SHORT ACTING STIMULANTS SIDE EFFECTS OF STIMULANT MEDICATIONS

Generic Name Brand Name d‐ and l‐amphetamine Sulfate Evekeo • Common stimulant TEAEs include appetite suppression, Tablet stomachache, insomnia, and headache. Less common side effects Dextroamphetamine Sulfate Zenzedi of stimulants include tics, emotional lability, irritability, and Tablet increases in heart rate and blood pressure Amphetamine Mixed Salts Adderall • The TEAEs are usually more severe when first initiating the Tablet medication trial and may abate over time Dextroamphetamine Sulfate ProCentra Oral Solution (5 mg/ 5 mL) • TEAEs: treatment‐emergent adverse events CASE STUDY 1: THOMAS CASE STUDY 1: THOMAS

Thomas is an 8 year‐old boy with a long‐standing history of inattention, In this particular case, we chose to switch to a long‐acting liquid distractibility, impulsivity, who presents for an evaluation because his dexmethylphenidate XR 20mg in the morning and methylphenidate IR 5mg in amphetamine compound, 2.5mg/mL, 6mg PO daily, because of a the afternoon has not been effective in reducing fidgetiness, hyperactivity. sibling’s positive response to the same compound. He is making poor grades in school and teachers complain that he is At follow‐up visit, parents reported that conduct had improved, no frequently talking in class. His parents are concerned that he will be expelled behavioral problems were reported by his teachers, attention had from the private school that he is enrolled in. He weighs 82 lbs. He is unable improved, and he no longer needed afternoon supplementation to swallow pills so his mother has been opening capsules to sprinkle over applesauce. with short‐acting methylphenidate.

DIRECT MOA: STIMULATION OF Α‐2A RECEPTORS VIA Α‐2 AGONISTS

The Role of α-2A Receptors Direct stimulation of in ADHD α-2A receptor

Closed ion channel

α-2 agonist Information Network connected

1. Arnsten AFT, et al. J Child Adolesc Psychopharmacol. 2007;17:393-406. 2. Wang M, et al. Cell. 2007;129:397-410. NON STIMULANT FDA APPROVED MEDICATIONS FOR ADHD ALPHA‐2 AGONIST CHALLENGES . Response to alpha‐2 agonists has been shown to be less robust than stimulants. A meta‐ analysis of ADHD treatment studies showed an effect size of 0.58 for compared to 0.99 for stimulants.

Non Stimulants Effect Size Long Acting Stimulants Effect Size 0.63 D‐Amphetamine ER 1.13 • Clonidine ER (Kapvay) Clonidine 0.03 OROS Methylphenidate 0.9 • ER (Intuniv) Guanfacine XR 0.8 Mixed Amphetamine Salts 0.77 XR • Atomoxetine (Strattera) Bidwell LC, Dew RE, Kollins SH. Alpha‐2 Adrenergic Receptors and Attention—Deficit/Hyperactivity Disorder. Current psychiatry reports. 2010;12(5):366‐373. doi:10.1007/s11920‐010‐0136‐4.

Faraone SV. Using Meta‐analysis to Compare the Efficacy of Medications for Attention‐Deficit/Hyperactivity Disorder in Youths. Pharmacy and Therapeutics. 2009;34(12):678‐694.

ALPHA‐2 AGONIST TREATMENT CONSIDERATIONS ALPHA AGONIST SIDE EFFECTS

• Sedation, dry mouth and nasal mucosa . Alpha‐2 agonists can be considered in children • Hypotension*, Bradycardia, ECG abnormalities who have: • Constipation, nausea . Inadequate response to stimulants or atomoxetine • Rebound hypertension if abruptly discontinued* . Adverse effects such as severe insomnia or loss of appetite *These require titration when starting and taper when discontinuing

Giovannitti JA, Thoms SM, Crawford JJ. Alpha‐2 Adrenergic Receptor Agonists: A Review of Current Clinical . Comorbid tics, aggression, eating disorders, or a Applications. Anesthesia Progress. 2015;62(1):31‐38. doi:10.2344/0003‐3006‐62.1.31. potential for drug abuse SALLY TREATMENT COURSE FOR SALLY

• Sally is a 38 year old legal assistant with long standing history 1. Sally was prescribed oros methylphenidate 54 mg po q am of ADHD. because it was approved on her insurance plan. She did not feel it was effective so dose was titrated to 72 mg daily but • She is currently on lisdexamphtamine 50 mg po q am and was still not helpful in improving attention through the day. dextroamphetamine IR 5 mg in the afternoon. This regimen was working well to improve her concentration. 2. She requested a trial of an alternative medication and was prescribed Amphetamine Mixed Salts Extended Release • Her insurance is no longer willing to pay for Capsule ( Mydayis) 25 mg. She responded well and was lisdexamphetamine despite attempts to use a discount able to concentrate throughout the day without coupon from the manufacturer. augmentation with a short acting stimulant medication.

OTHER INTERVENTIONS • Modafinil‐ wake promoting medication. MOA not know. Impact on histamine, NE, DA, Orexin postulated. NONPHARMACOLOGICAL • Buproprion – norepinephrine dopamine reuptake inhibitor INTERVENTIONS TO TREAT • Dasotroline – Serotonin, dopamine, ADHD norepinephrineNon Stimulant reuptake Effect Size inhibitor Modafinil 0.52 Buproprion 0.22 OVERVIEW LIFESTYLE MODIFICATIONS EVIDENCE REVIEW

• Behavioral Therapy Lifestyle Modification Evidence • Parent‐led behavioral therapy Elimination Diet (Food color) Limited data • Classroom‐based behavioral therapy Aerobic Exercise Limited data • Cognitive behavioral therapy (CBT) Dietary intervention therapy and physical activity cannot be • Cognitive Training recommended as evidence-based interventions for global functioning and core ADHD symptoms until better evidence • Neurofeedback of their comparative efficacy is reported in well-designed • Lifestyle modifications and conducted clinical trials

• Restricted elimination diets Sonuga-Barke, E. J. S., Brandeis, D., Cortese, S., Daley, D., Ferrin, M., Holtmann, M., Sergeant, J. (2013). Nonpharmacological interventions for ADHD: Systematic review and meta-analyses of randomized controlled trials of dietary and psychological • Increased physical activity treatments. American Journal of Psychiatry, 170, 275–289. doi:10.1176/appi.ajp.2012.12070991 Cerrillo-Urbina AJ, Garcia-Hermoso A, Sanchez-Lopez M, et al. The effects of physical exercise in children with attention deficit • Psychoeducation hyperactivity disorder: a systematic review and meta-analysis of randomized control trials. Child Care Health Dev 2015; 41: 779-788.

Catalá-López F, Hutton B, Nunez-Beltran A, et al. The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: a systematic review with network meta-analyses of randomised trials. PLoS One. 2017;12(7):e0180355. doi: 10.1371/journal.pone.0180355

EVIDENCE FOR NON PHARMACOTHERAPY CONCLUSIONS INTERVENTIONS • Behavioral therapy is the best supported nonpharmacological intervention to treat 1. ADHD is a highly prevalent psychiatric disorder which is associated with lifelong impairment in ADHD, and has a synergistic effect when used in conjunction with pharmacologic functioning therapy. 2. Environmental factors can contribute to the expression, severity, course, and comorbid • First line treatment in children 4‐5 years of age according to the American Academy conditions of Pediatrics (evidence level A/strong recommendation) 3. Long‐term developmental outcomes for individuals with ADHD can include serious substance • Adjunctive behavioral therapy with pharmacological treatment or behavioral abuse, chronic criminality, depression and suicide therapy alone is recommended in children 6‐11 years of age (evidence level B) 4. Stimulant medications and behavior therapy are currently the only established evidence‐based • Adjunctive behavioral therapy with pharmacological treatment is recommended in treatments for ADHD children 12‐18 years of age (evidence level C) 5. Combined behavioral‐pharmacological treatment has the greatest impact on functional • Cognitive training, neurofeedback, physical activity, and dietary interventions show outcomes, is preferred by parents and teachers, and is most likely to result in normalization of limited efficacy in blinded studies. behavior • Psychoeducation is an important tool in the treatment of ADHD.

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RESOURCES

• Rationale for DSM V proposed changes. American Psychiatric Association. Updated 5/2012 from the ADHD and Disruptive Behavior Disorders Workgroup • http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=3 83#