Transcript - Center for the Study of Learning

Psychiatric and Cognitive Comorbidities in
Developmental Reading/Attention Disorder(s):
Implications for Medical Treatment
Drake D. Duane, M.D.
Institute for Developmental Behavioral Neurology
Arizona State University
Scottsdale / Tempe, Arizona, USA
Historical Progression of
Psychological Constructs of Attention
Mirsky 1991 Focusing - superior temporal and inferior parietal cortices
and corpus striatum (basal ganglia)
Execution - inferior parietal and corpus striatum
Sustaining focus - rostral midbrain mesopontine reticular
formation and midline/reticular thalamus
Stabilize - also rostral midbrain, etc.
Shift - prefrontal cortex (includes anterior cingulate gyrus)
Encoding - hippocampus and amygdala
Historical Progression of
Psychological Constructs of Attention
Barkley 1994 "Response inhibition" essential to attention. Permits
prolongation of internal processing facilitating perception
and memory. Therefore, a direct relationship between
attention and memory. If this mechanism is impaired an
attentional disorder results with the risk of memory
impairment as well.
Historical Progression of
Psychological Constructs of Attention
Executive Function
Inhibition / delayed responding facilitate:
• Sense of time, hindsight and forethought
• Self awareness
• Internalization of language, its control of behavior
• Regulation of affective and motivational states in
subservience to goal-directed behavior
• Reconstitution or disassembling events and messages
from others, the progressive redistribution of their
components to parallel brain systems for selective analysis
Evolution of Clinical Concepts of
Developmental Attention Disorders
Still 1902 - children "defective moral control"
- boys > girls
- comorbid hyperactivity
- difficulties in learning
- CNS and environmental causal factors
Kahn & Cohen 1934
- children survivors of encephalitis lethargica
- behaviorally "driven"
- origin "brainstem damage"
- residential treatment but unable to cope with
outside multiple social demands
Evolution of Clinical Concepts of
Developmental Attention Disorders
Bradley 1937
- administration of Benzedrine (dextro/levo-amphetamine)
results in "paradoxic quieting" of hyperactive children and
"minimal brain dysfunction"
Strauss & Werner 1930's
Intrauterine or perinatal insult to normal brain:
- retardation, at times global
- hyperactive, distractible, impulsive, perseverative
- multiple but variable type/degree of cognitive deficits
- "MBD" = Minimal Brain Damage
Behavioral Criteria for Developmental Attention Disorders
2000: DSM-IV-TR (text revision) Diagnostic Criteria
A. Either (1) or (2)
(1) Six or more of the following symptoms of inattention have persisted for
at least six months to a degree that is maladaptive and inconsistent
with developmental level:
INATTENTION
a) often fails to give close attention to details or makes careless mistakes in
schoolwork, work, or other activities
b) often has difficulty sustaining attention in tasks or play activities
c) often does not seem to listen when spoken to directly
d) often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the work place
e) often has difficulty organizing tasks and activities
f) often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort
g) often loses things necessary for tasks or activities
h) is often easily distracted by extraneous stimuli
i) is often forgetful in daily activities
Behavioral Criteria for Developmental Attention Disorders
2000: DSM-IV-TR (text revision) Diagnostic Criteria (continued)
A. Either (1) or (2)
(2) Six or more of the following symptoms of hyperactivity-impulsivity have
persisted for at least six months to a degree that is maladaptive and
inconsistent with developmental level:
HYPERACTIVITY
a) often fidgets with hands or feet or squirms in seat
b) often leaves seat in classroom or in other situations in which remaining
seated is expected
c) often runs about or climbs excessively in situations in which it is inappropriate
d) often has difficulty playing or engaging in leisure activities quietly
e) is often "on the go" or often acts as if "driven by a motor"
f) often talks excessively
IMPULSIVITY
g) often blurts out answers before questions have been completed
h) often has difficulty awaiting turn
i) often interrupts or intrudes on others
Behavioral Criteria for Developmental Attention Disorders
2000: DSM-IV-TR (text revision) Diagnostic Criteria (continued)
B. Some hyperactive-impulsive symptoms that caused impairment
were present before age 7 years.
C. Some impairment from the symptoms is present in two or more
settings.
D. There must be clear evidence of clinically significant impairment
in social, academic, or occupational functioning.
E. Symptoms do not occur exclusively during the course of a
Pervasive Developmental Disorder, Schizophrenia, or other
Psychotic Disorder, and are not better accounted for by
another mental disorder.
Behavioral Criteria for Developmental Attention Disorders
2000: DSM-IV-TR (text revision) Diagnostic Criteria (continued)
• 314.01: Attention-Deficit/Hyperactivity Disorder, combined type:
both Criteria A1 and A2 are met.
• 314.00: Attention-Deficit/Hyperactivity Disorder, predominately
inattentive type: Criteria A1 but not A2 is met for the past six
months.
• 314.01: Attention-Deficit/Hyperactivity Disorder, predominately
Hyperactive-Impulsive type: Criteria A2 but not A1 is met.
• 314.9: Attention-Deficit/Hyperactivity Disorder not otherwise
specified: for disorders with prominent symptoms of inattention
or hyperactivity that do not meet criteria for Attention-Deficit
/Hyperactivity Disorder.
Volumetric Analysis
G. Hynd 1995, M. Mataro 1997
Reversal of caudate nucleus
R>L asymmetry (basal ganglia)
Maria Mataró PhD, et al., Archives of Neurology, Vol 54 No. 8, August 1997
Volumetric Analysis
Castellanos 1996 - 57 male ADHD, 55 control
ADHD:
- smaller cerebral volume
- decreased R>L caudate asymmetry
- smaller R anterior frontal region
- smaller cerebellum
- reversal of normal lateral ventricle asymmetry
- caudate volume not decreased with age vs controls
Volumetric Analysis
Semrud-Clikeman 2000
- reversed caudate asymmetry
- poorer performance on measures of inhibition
Casey 1997
- poor performance on tests
- response inhibition associated with abnormal volumes
in prefrontal cortex, caudate and globus pallidus but not
putamen
Conclusion - R prefrontal cortex suppresses responses to
salient events, basal ganglia executes the
behavioral response
ADHD Anatomy
Herskovits 1999
- 3 months post head injury of 76 without history of ADHD
- 15 developed secondary ADHD and increased frequency
of lesions R putamen (basal ganglia)
Peterson 2000
- post streptococcal increase in ASO titer in OCD or ADHD
correlated with larger putamen and globus pallidus
(basal ganglia)
ADHD Anatomy
Corpus Callosum Size in Dispute
Mostofsky; Berquin 1998
- smaller cerebellar vermis
- ? role of cerebello-striatalprefrontal cortex in inhibition
and executive function
Functional Anatomy in ADHD
Metabolic Studies
Lou 1990
- hypoperfusion frontal lobes
- methylphenidate increased perfusion
Zametkin 1990
- PET: adult ADHD decreased cortical glucose
metabolism maximal in premotor
and superior prefrontal cortex
- replicated in adolescent ADHD
girls, not in adolescent ADHD boys
Adult Control
Adult ADHD
Functional Anatomy in ADHD
Metabolic Studies
Schweitzer 2000 - 15O H2O PET
- working memory task not localized prefrontal and temporal
cortex but diffuse, mainly occipital in adult ADHD males
Bush 1999 - FMRI
- during Stroop test no activation of anterior cingulate vs controls
Rubia 1999 - FMRI
- hypoperfusion R medial prefrontal cortex and L caudate during
motor inhibition task
Vaidya 1998 - FMRI
- decreased striatal activation on attention task
- methylphenidate increased striatal activation in ADHD but decreased
in controls
Neurochemistry
Dougherty 1999
- 70% increase in dopamine transporter density
Krause 2000
- Tc-99m [TRODAT] - 1 SPECT increased binding to
dopamine transporter
- this was reduced after 4 weeks Rx methylphenidate
Ernst 1999
- [18F] DOPA PET 50% decrease in DOPA
decarboxytase in prefrontal cortex adult ADHD
- in children, increased DOPA in midbrain
Epidemiology
• Vary with definition, diagnostic procedures, methodology,
nature of population, and use of collateral sources.
• Prevalence rates of 3% to 14%
• Estimates in school age children 3% to 7%
• Male to female ratio 3:1
• More prevalent in first degree biological relatives
• 84% adult ADHD at least one affected offspring
• 80% concordance rate in monozygotic twins
Medical Care Uses/Costs
Children & Adolescents With & Without ADHD
Leibson, Katusic, Barbaresi, Ransom & O’Brien
JAMA 2001;285:60-66
Births 1976-1982
• Frequency ADHD
7.5%
• ADHD M/F
3:1
• Multiple medical Dxic categories  ADHD p .05 to < .001
• Non-psych/non-prescription cost ADHD > double
• Trend toward increasing cost with age
Clinical Manifestations and
Co-morbidities of ADHD
• High comorbidity of learning disorder
- reading in 33%
- reading comprehension
- arithmetic
• High comorbidity of emotional disorder
- anxiety
- conduct disorder
- mood disorder (depression)
- oppositional defiant disorder
- obsessive personality traits
- explosive behavior
- 10% tic disorder
Psychiatric Comorbidity
Duane 2002
- Of 200 consecutive children with developmental
disorder 57% had comorbid psychiatric diagnosis:
-
Mood Disorder (depression)
Anxiety Disorder
Obsessive Personality Traits
Conduct Disorder
Oppositional Defiant Disorder
MTA Study 1999
Oppositional Defiant Disorder
Anxiety Disorder
Conduct Disorder
Mood Disorder
40%
34%
14%
4%
Psychiatric Comorbidity with ADHD
Anxiety 25% of ADHD children
Jarrett, Ollendick, Clin Psychol Rev, 28:1266
Recurrent brief depression in 70% adult ADHD
Hesslinger, Tebartz Van Elst, Mochan, Ebert,
Acta Psychiatr Scand, 107:385-9, 2003
Bipolar Disorder “47%” in literature, “Unclear” diagnosis
Review, J Clin Psychiatry, 68:1779-84, 2007
OCB in 11% ADHD children
Arnold, Ickowicz, Chen, Schachar, Can J Psychiatry, 50:59-66, 2005
56 OCD / 43 OCD + ADHD / 95 ADHD – comorbidity s function
Suklodolsky et al, Am J Psychiatry, 162: 1125-32, 2005
Family History in ADHD +/- RD vs. Controls
N = 49/29/13
Controls
ADHD
P
ADHD
+ RD
ADHD
2%
24%
.002
31%
.001
--
RD
6%
31%
.003
69%
<.001
.02
Alc*
33%
48%
NS
46%
NS
--
Depress
14%
45%
.003
38%
.01
NS
0
0
NS
31%
.001
.001
Family Hx
Sleep
P
P
*Ave # affected relatives/affected family – 1.43, 2.42, 2.3; paternal line bias
Academic Risk - ADHD
• 33% have Reading Disorder, many with reading comprehension
and/or arithmetic computation difficulty.
• Comorbid ADHD in Reading Disorder lowers academic outcome
by two years.
• Decreased schooling decreases economic outcome. Lower
socioeconomic status increases risk for substance abuse, poor
job acquisition/retention, failed relationships.
"It would seem, Adeimantus, that the direction in which
education starts a man will determine his future life."
- From The Republic, IV by Plato, 429-347 B.C.
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Rey Osterrieth Complex Figure
- visual perception
- visual motor skill
- short and long term
visual spatial memory
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Rey Auditory Verbal
Learning Test
- verbal learning
and delayed recall
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Letter Cancellation Test
- 1, 2 or 3 letter "proofreading", time, errors of omission
commission, visual attention task
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Digit Span
- forward numeric
auditory attention
- reverse numeric
auditory memory
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Kagan's Matching
Familiar Figure Test
- visual discrimination,
style - slow obsessive,
fast impulsive
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Test of Variables of Attention (TOVA)
- attention using shape
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Conners' Continuous Performance Test (CPT)
- attention using letters
Continuous Performance Test Instructions
This test presents letters, one at a time. You are
to quickly click (press and release) the LEFT mouse
button (or press the space bar) for any letter
except for those from the following list: X
Click the LEFT mouse button (or press the spacebar)
to begin the test.
N
X
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Wisconsin Card Sorting Test - executive function
Assessment:
Executive and Other Cognitive Functions
Neuropsychological Studies
• Other Attention / Executive Function Tests
- Stroop Test
- Trail Making Form A, Form B
- Tower of Hanoi, London or Toronto
ADHD – Acute & Chronic Effects MPH:
Alertness/Cognition/Behavior
Alert
Improved Cognition:
NI LCT
NI DS
NI AVLT Learning Curve
NI AVLT % Recall
N = 10
6/8
7/9
4/6
5/7
N=8
Comparison of Cognitive Effects of Acute Stimulant Test Doses
LCT
AVLT
Time
Errors
Learn Curve
top/total
Recall
DS
CPT
Forward
Back
Baseline
10 mg
MPD
7.5 mg
d amphetamine
7.5 mg
dl amphetamine
3:30
3:10
2:15
2:45
9
4
1
3
7/36
8/40
10/44
9/41
3/7 (43%)
4/8 (50%)
7/10 (70%)
6/9 (67%)
4/8 4
2/8 2
4/8 5
3/8 3
6/8 6
4/8 3
6/8 5
4/8 3
Inattentive
Inattentive
Attentive
Attentive
© Institute Developmental Behavioral Neurology 10/08
Assessment of Social Emotional Comorbidity
Parent
- Achenbach Child Behavior Checklist
(or its equivalent)
Patient
Child
- Children's Depression Inventory
Adolescent/Adult
- Hamilton Depression Scale
- Minnesota Multiphasic Personality Inventory
- Yale Brown Obsessive Compulsive Rating Scale
- Spielberger Anxiety Rating Scale
Specific Intervention Techniques
• Parent education and consultation
• School consultation, interventions and accommodations
• Medication management (with informed consent) for
specific target symptoms. (Note: Medication may assist
the child to become more manageable, but does not
teach social and adaptive skills, or compensate for gaps
in knowledge or study skills.)
• Psychosocial treatments and behavioral management
• Individual psychotherapy where indicated.
The Case
for
Genomic
Medicine
Medication Options
In Developmental Disorders
Attention = Increase Dopamine
1. Psychostimulants
Pemoline: Cylert*
Methylphenidate: Ritalin - Focalin - Concerta
Methylin - Metadate - Daytrana
Amphetamine: Dexedrine - Adderall - Desoxyn - Vyvanse
see chart
2. Psychotropics (antidepressants)
Wellbutrin
Prozac
15-60 d
see SSRIs
Zoloft
3. Provigil (modafinil) - 100, 200 mg
½ -2/d
7-15 d
4. Strattera* (atomoxetine) - 10, 18, 25, 40, 60 mg 1/d
* May cause liver dysfunction
© Institute Developmental Behavioral Neurology R 10/08
Psychostimulants
In Developmental Disorders
Name
Effect
Duration
Time for
Effect
Trade (generic)
Dose/Form 1
Side Effects 2
Cylert (pemoline)*
18.75, 37.5, 75 mg;
chewable
6-8 hrs
3-4 days
Daytrana
12.5, 18.75, 25, 37.5 patch
6-10 hrs
1 hour
- Aggression
Ritalin
5, 10, 20 mg tabs,
20 mg SR
10, 20, 30, 40 mg LA
3-4 hrs
6-8 hrs 3
6-8 hrs
1 hour
- Anxiety
2.5, 5, 10 mg tabs
5, 10, 20 mg XR
4-6 hrs
6-8 hrs
1 hour
- Obsessive/
compulsive
behavior
Concerta
18, 27, 36, 54 mg tabs
6-10 hrs
1 hour
Methylin
5, 10, 20 mg;
10, 20 mg ER
3-4 or
6-8 hrs
Metadate
10, 20, 30 mg CD
6-8 hrs
Methylphenidate
Focalin (dextro)
- Tics
-  Appetite, weight
-  Sleep
1 - Any medication can be specially formulated into any size, liquid or spansule
2 - Except liver dysfunction, most can be “blocked”
3 - Often erratic blood levels during the day
*Possible liver dysfunction
© Institute Developmental Behavioral Neurology R 10/08
Psychostimulants
In Developmental Disorders
Trade (generic)
Name
Dose/Form 1
Effect
Duration
Time for
Effect
Side Effects 2
Amphetamine
Adderall (mixed
amphetamine salt)
5, 7.5, 10, 12.5,
15, 20, 30 mg tabs
5, 10, 15, 20, 25,
30 mg XR
Dexedrine
(d-amphetamine)
5 mg tablets
5, 10, 15 mg spansules
Vyvanse
(Lisdexamphetamine)
20, 30, 40, 50
60, 70 mg capsules
Desoxyn
(meth-amphetamine)
5 mg tablets
4-6 hrs
1 hour
6-10 hrs
1 hour
4-6 hrs
6-8 hrs
1 hour
1 hour
10-12 hrs
1 hour
- Aggression
- Anxiety
- Obsessive/
compulsive
behavior
- Tics
-  Appetite, weight
6-8 hrs
1 hour
-  Sleep
1 - Any medication can be specially formulated into any size, liquid or spansule
2 - Except liver dysfunction, most can be “blocked”
© Institute Developmental Behavioral Neurology R 10/08
Non-Stimulants
In Developmental Disorders of Attention
Trade (generic)
Name
Effect
Duration
Time for
Effect
Dose/Form
Tofranil
(imipramine)
75, 100, 125, 150 mg caps
10, 25, 50 mg tabs
12 hour
2-4 wks
HA,  wt, drowsiness
dry mouth, ECG 
Norpramine
(desipramine)
25, 50 mg caps
24 hour
10, 25, 50, 75, 100, 150 mg tabs
2-4 wks
“
“
“
Pamelor
(nortriptyline)
10, 25, 50, 75 mg caps
2 mg/ml liquid
24 hour
2-4 wks
“
“
“
Elavil
(amitriptyline)
10, 25, 50, 75, 100,
150 mg tabs
12 hour
2-4 wks
“
“
“
Wellbutrin
(buproprion)
75, 100 mg tabs
100, 150 mg SR
8-12 hour
12-18 hour
2-4 wks
Sz, agitation, HA,
insomnia
Effexor
(venlafaxine)
25, 37.5, 50, 75, 100 mg tabs
37.5, 75, 150 mg XR
12 hour
18 hour
2-4 wks
N, sedation, GI upset
Catapres
(clonidine)
0.1, 0.2, 0.3 mg tabs
0.1, 0.2, 0.3 mg/d TTS patch
6-8 hour
1-3 days
24 hour/5-7 d 1-3 days
sedation, orthostatic BP,
dry mouth, rebound  BP
if quick withdrawal
6-8 hour
“
Tenex (guanfacine)1 1 mg tab
1 – used as “add-on” Rx, may reduce aggression,
tics – as may atypical neuroleptics
1-3 days
Side Effects
“
“
© Institute Developmental Behavioral Neurology R 10/08
Medication Options
In Developmental Disorders
Memory
Increase Acetylcholine (if not corrected with attention)
1. PhosChol 900 (phosphatidylcholine)
(or lecithin 1200 mg)
2-4/d
30 d, nausea
Broad Cognitive Enhancement (non-psychostimulants)
1. Piracetam (Nootropil) - 800 mg 3-6/d
2. Ergoloid (Hydergine) - 1 mg 1 or 2/d
10-30d,  talking
© Institute Developmental Behavioral Neurology R 10/08
Anti-Seizure Medications
In Developmental Disorders
Name
Trade
(Generic)
Dose Size
(mg)
Common
Side Effects
Barbiturates
-Mysoline
(phenobarbitol)
(primidone)
15, 30, 60, 100
50, 250
drowsiness
drowsiness, confusion
Hydantoins
Dilantin
(phenytoin)
30, 50, 100
unsteadiness, rash
 gums,  hair
Benzodiazepines
Klonopin (clonazepam)
.5, 1.0, 2.0
wafer .25, .5, 1, 2
2, 5, 10
2.5, 5, 10, 15, 20
drowsiness
100, 300, 400,
600, 800
dizziness, fatigue
Class
Valium
Diastat
Amino Acids
(diazepam)
(diazepam gel)
Neurontin (gabapentin)
drowsiness
drowsiness
© Institute Developmental Behavioral Neurology R 10/08
Anti-Seizure Medications
In Developmental Disorders
Class
Name
Trade
(Generic)
Others
Depakote (valproic acid)
Tegretol
(carbamazepine)
Carbatrol (carbamazepine)
Newer
Antiseizure
Medications
Trileptal
Lamictal
(oxcarbazepine)
(lamotrigine)
Topamax
(topiramate)
Gabitril
(tiagabine)
Keppra
(levetiracetam)
Zonegran (zonisamide)
Dose Size
(mg)
Common
Side Effects
125 sprinkle;
250, 500 reg & ER
100 chew, 200;
100, 200, 400 XR;
liquid
100, 200, 300
N, V, tremor,  wt, hair loss
150, 300, 600
25, 100, 150, 200;
chewable 2, 5, 25
25, 100, 200
15, 25 sprinkle
2, 4, 12, 16, 20
dizziness, fatigue, N, V, tremor
rash, dizziness, drowsiness
dizziness, drowsiness,
 Na+, rash,  CBC,  liver
“
“
drowsiness,  concentration,
renal stone,  weight
dizziness, drowsiness,
irritability, tremor
250, 500, 750 (liquid) dizziness, drowsiness
25, 50, 100
drowsiness, irritability
© Institute Developmental Behavioral Neurology R 10/08
Medication Options
In Developmental Disorders
Selective Serotonin Reuptake Inhibitors (SSRI)
Prozac
(fluoxetine)
- 10, 20 mg; liquid
- 90 mg
1/d
1/w
Zoloft
(sertraline)
- 25, 50, 100 mg; liquid
1/d
Luvox
(fluvoxamine)
- 25, 50, 100 mg
- 100, 150 mg CR
2/d
1/d
Paxil
(paroxetine)
- 10, 20, 30, 40 mg; liquid
- 12.5, 25, 37.5 mg CR
1/d
1/d
Celexa
(citalopram)
- 20, 40 mg
1/d
Lexapro
(escitalopram)
- 10, 20 mg; liquid
1/d
Anafranil
(clomipramine)
- 25, 50, 75 mg
1 or 2/d
Side Effects:
GI
HA
15-60d
 sweats
±  weight
±  sex
© Institute Developmental Behavioral Neurology R 10/08
Medication Options
In Developmental Disorders
Selective Noradrenergic Reuptake Inhibitor (SNRI)
Effexor - 37.5, 75, 150 mg XR
(venlafaxine)
Cymbalta - 30, 60 mg
(duloxetine HCl)
Side Effects:
- nausea
-  sweating
Dopaminergic Antidepressant
Wellbutrin [Zyban] - 150, 300 mg XL
(bupropion)
Side Effects:
- agitation
- sleep disturbance
© Institute Developmental Behavioral Neurology R 10/08
Medication Options
In Developmental Disorders
Atypical Neuroleptics
Risperdal
(risperidone)
- .25, .5, 1, 2, 3, 4 mg tab
- liquid; .5, 1, 2 mg M tab
Seroquel
(quetiapine)
- 25, 50, 100, 200, 300 mg
Zyprexa
(olanzapine)
- 2.5, 5, 10, 15, 20 mg
- 5, 10 mg Disintetab
Geodon
- 20, 40, 60, 80 mg; liquid
(ziprasidone)
Side Effects:
1-3d
 appetite
drowsiness
nausea
restlessness
Abilify
- 5,10,15, 20, 30 mg
(aripiprazole)
© Institute Developmental Behavioral Neurology R 10/08
Elements of Psychosocial Treatments
• Direct contingency management:
- Positive and negative contingencies applied to child in
structured environments
- Rewards for achieving targeted positive behaviors and
consequences for misbehaviors
• Clinical cognitive behavior therapy with behavior
management techniques of prompt consistent responses
to appropriate and inappropriate behaviors, coordinated
in the home, school and community settings
• Social skills training for specific adaptive skills
NIMH Mulimodal Treatment Study of
Children with ADHD
• 14 month, multi-center, randomized, controlled trials
• 579 children, ages 7 to 9, grades 1 to 4
• DSM-IV ADHD, combined type
• State of the art treatments
- MTA Cooperative Group, Arch Gen Psychiatry,
56: 1073-1086, 1999
- MTA Cooperative Group, Pediatrics, 113:754-761, 2004
MTA Treatment Comparisons
• Medication management only: methylphenidate three times a
day, 7 days a week, adjusted for best dose, other medications if
necessary; algorithmic dose adjustments; general advice and
readings; case management by prescribing physician.
• Intensive behavioral treatment only: Parent training; structured
teacher consultation; 8 week summer treatment program; 12
week half time classroom behavioral specialist; case
management by therapist/consultant.
• Medication management and behavioral treatment (combined)
• Community based care: after assessment by study team, parents
could seek community care. (Note: approximately two-thirds
received medication in community.)
MTA Study - 14 Month Outcomes
Summary 1
For children age 7-10 with ADHD (combined
type), well-delivered medication is superior to
behavioral management and may be sufficient
for ADHD symptoms
Behavioral management is an acceptable
treatment for those preferring not to use
medication
MTA Study - 14 Month Outcomes
Summary 2
For some outcomes other than ADHD, the
combination of medication and behavioral
management may be preferable:
- parent-child conflict
- academic difficulties
- social skills
- anxiety symptoms
- oppositional /aggressive symptoms
- consumer satisfaction
MTA Study - 14 Month Outcomes
Summary 3
For some subgroups of children, the combination
of medication and behavioral management may
be preferable (for some outcomes):
- children with anxiety disorders
- children with high levels of socio-economic
and/or family stressors
Psychiatric Comorbidity Limits the
Extent to Which Medical or
Behavioral Therapy are Effective
In the face of high anxiety, deep depression,
obsessive worry - cognition/attention are
impaired and until reduced, cognition cannot be
normalized by stimulant medication.
Note - psychostimulant medication may induce or aggravate
anxiety and/or obsessive worry, or even in toxic doses or
sensitive individuals induce psychosis.
Institute for Developmental
Behavioral Neurology
10210 N. 92nd Street, Suite 300
Scottsdale, Arizona 85258
Ph: 480-860-1222
Fx: 480-860-0029
e-mail: [email protected]
www.arizonaneurology.com