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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Emerging Trends in the Diagnosis and Treatment of ADHD


GOAL
To educate and update healthcare providers on new and emerging trends in the diagnosis and management of attention deficit/hyperactivity disorder (ADHD).

TARGET AUDIENCE
This program was developed for psychiatrists, primary care physicians, pediatricians, and child and adolescent psychologists.

LEARNING OBJECTIVES
After reading this issue, the participant should be able to:

  • Diagnose ADHD and recognize the comorbidities associated with it.
  • Recognize ADHD as a developmental impairment of executive functions.
  • Identify the manifestations of ADHD in both adolescent and adult populations.
  • Understand the overall diagnostic criteria for ADHD as put forth in Diagnostic and Statistical Manual of Mental Disorders, fourth edition.

ACCREDITATION STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Johns Hopkins School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this continuing medical education activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association Physicians' Recognition Award. Each physician should claim only those hours of credit that are actually spent on the educational activity. Credits are available until the expiration date of November 31, 2004.

This continuing education activity was produced under the supervision of Mark Riddle, MD, Associate Professor, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland.

This program is supported by an unrestricted educational grant from Eli Lilly and Company.

Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

The contents of this issue of Advanced Studies in Medicine include highlights from the 155th Annual Meeting of the American Psychiatric Association.

FACULTY ADVISOR

    Mark Riddle, MD
    Associate Professor
    Department of Psychiatry
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Riddle reports receiving grant/research support from Pfizer Inc; and serving as a scientific advisor to GlaxoSmithKline and Janssen Pharmaceutica Products LP.

PARTICIPATING FACULTY

    Lenard A. Adler, MD
    Associate Professor
    Clinical Psychiatry and Neurology
    Director, Department of Neurology ADHD Program
    New York University School of Medicine
    New York, New York
    • Dr Adler reports receiving grant/research support from Eli Lilly and Company, GlaxoSmithKline, Novartis Corporation, and Pfizer Inc; serving as a consultant to Eli Lilly and Company, Novartis Corporation, Pfizer Inc, and Shire Pharmaceuticals Group; owning stock in Eli Lilly and Company, McNeil Consumer Healthcare, and Pfizer Inc; and receiving honoraria from/serving on the speakers bureau for Eli Lilly and Company, GlaxoSmithKline, Novartis Corporation, Pfizer Inc, Shire Pharmaceuticals Group, and Wyeth.

    Albert J. Allen, MD, PhD
    Senior Clinical Research Physician
    Eli Lilly and Company
    Indianapolis, Indiana
    • Dr Allen reports receiving grant/research support from and owning stock in Eli Lilly and Company.

    Stan Block, MD
    Associate Clinical Professor of Pediatrics
    University of Louisville School of Medicine
    Louisville, Kentucky
    • Dr Block reports receiving grant/research support from Eli Lilly and Company; and serving as a consultant to Eli Lilly and Company and Johnson & Johnson.

    Thomas E. Brown, PhD
    Associate Director
    Yale Clinic for Attention and Related Disorders
    Department of Psychiatry
    Yale Medical School
    Hamden, Connecticut
    • Dr Brown reports receiving grant/research support from Cephalon and GlaxoSmithKline- Beecham Healthcare; and serving as a consultant to Eli Lilly and Company, McNeil Consumer Healthcare, Novartis Corporation, Pfizer Inc, and Shire Pharmaceuticals Group.

    Christopher J. Kratochvil, MD
    Assistant Professor and Assistant Director
    Psychopharmacology Research Center
    University of Nebraska Medical Center
    Omaha, Nebraska
    • Dr Kratochvil reports receiving grant/research support from Eli Lilly and Company, GlaxoSmithKline, and McNeil Consumer Healthcare; serving as a consultant to Alza Corporation, Eli Lilly and Company, and Shire Pharmaceuticals Group; and receiving honoraria from Eli Lilly and Company and Novartis Corporation.

    Mary Elizabeth Roth, MD
    Clinical Professor
    Wayne State University School of Medicine
    Vice President of Medical Affairs
    Sacred Heart Hospital
    Allentown, Pennsylvania
    • Dr Roth reports receiving honoraria from Eli Lilly and Company

    Thomas J. Spencer, MD
    Associate Professor of Psychiatry
    Harvard Medical School
    Assistant Chief, Clinical and Research Program in Pediatric Psychopharmacology
    Massachusetts General Hospital
    Boston, Massachusetts
    • Dr Spencer reports receiving research/grants support from, serving on the speakers bureau for, and as a consultant to Abbott Laboratories, Cephalon, Celltech, GlaxoSmithKline, Eli Lilly and Company, McNeil, Novartis Pharmaceuticals Corporation, and Shire Richwood.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Off Label Product Discussion
Faculty have disclosed that their articles have referenced the following off-label/unapproved uses of drugs or products:

Product
Atomoxetine — Reported by all faculty.

Understanding ADHD
Mark Riddle, MD,* Stan Block, MD,† and Mary Elizabeth Roth, MD‡

Attention-deficit/hyperactivity disorder (ADHD) is a valid syndrome with significant behavioral, social, and educational impairments that may extend into adulthood. Core symptoms include inattention, impulsivity, with or without overactivity that manifest differently across multiple settings. This issue of Johns Hopkins Advanced Studies in Medicine highlights the growing body of scientific research surrounding ADHD, based upon presentations made at the American Psychiatric Association's 2002 Annual Meeting. Internationally recognized thought leaders in the field of ADHD theory and investigation present insights into the origins, manifestations, pathophysiologies, and novel medications for a syndrome that affects 6% to 8% of children and 3% to 4% of adults.1 Yet ADHD still remains widely undiagnosed, for a number of reasons. ADHD often presents with many comorbidities, which include anxiety, behavior and mood disorders, and tics, which frequently confound accurate diagnosis of ADHD as the primary problem.

Once believed to be a childhood syndrome, ADHD is now beginning to be recognized as a disorder that continues into adulthood. In his article, "Issues in the Diagnosis and Treatment of the Adult Patient with ADHD," Lenard A. Adler, MD reviews several longitudinal studies that followed children with ADHD into adulthood. These findings suggest that many of the childhood symptoms may manifest themselves differently into adulthood affecting for example, job performance and social behavior. As with children with ADHD, medication is the principal treatment of symptoms in adults with ADHD. Dr Adler reviews the limited available data regarding the use of stimulants in adults with ADHD, found to be generally efficacious. Clearly, this area is ripe for future investigation.

Albert J. Allen, MD, PhD, emphasizes how important it is to understand the relationship between phenotypes and pathophysiologies in ADHD patients in his article "ADHD: Phenotypes and Pathophysiologies." He reviews the research linking phenotypes and pathophysiologies with ADHD. Dr Allen suggests that future treatment may be selected based on a specific pathophysiology of a patient's phenotype.

Thomas E. Brown, PhD reviews the phenomenology of currently recognized symptoms of ADHD in his article titled, "DSM-IV: ADHD and Executive Function Impairments." He notes that over the last century the focus on ADHD as a hyperactive and impulsive behavior has gradually shifted to a recognition of cognitive impairments as the central and most persistent symptoms of the disorder. Dr Brown evaluates the phenomenology of current recognized symptoms of ADHD and notes that one executive function, that of impairment in regulation of emotion, is not included in the Diagnostic and Statistical Manual of Mental Disorders, forth edition (DSM-IV) criteria for ADHD.

In "New ADHD Treatment Options on the Horizon," Christopher J. Kratochvil, MD, reviews the pharmacologic treatment options available for ADHD. He relates that although ADHD is one of the most common psychiatric disorders of childhood, historically, there have been few pharmacological treatment options available.

Perhaps the most compelling arguments for recognizing and treating ADHD across all age groups are found in data relating to overall health and safety. In addition to academic difficulties, children with ADHD are stigmatized by their behavior. Difficulties with attention span tend to make such children unresponsive to others and unable to follow social cues, as Thomas J. Spencer, MD points out in his article, "From Childhood to Adolescence: Diagnosis and Comorbidity Issues."

Conclusions

The following pages present an excellent overview of current thinking regarding the history, etiology, pathophysiology, diagnosis, and management of ADHD in children and adults. Once thought to be a condition limited to young boys and of short duration, we now know that ADHD is rooted in neurobiological aberrations that persist over time in men and women. The goal of this publication is to provide a whole life perspective to a disorder that is finally becoming better understood by psychiatrists, primary care physicians, and the public at large.

REFERENCES
1. Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York:Guilford Press;1998.

*Associate Professor, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD;  †Associate Clinical Professor of Pediatrics, University of Louisville School of Medicine, Louisville, KY; ‡Vice President of Medical Affairs, Sacred Heart Hospital, Allentown, PA.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.