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neuroscienceCME Journal Club
Premiere Date: Monday, December 14, 2009This activity offers CE credit for:
All other clinicians will either receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.
- Physicians (ACCME/AMA PRA Category 1)
- Nurses (CNE)
- Pharmacists (ACPE)
- Psychologists (APA)
Credit Expiration Date:
Tuesday, December 14, 2010
Faculty
Robert L. Findling, MD (Guest Host)
Professor of Psychiatry & Pediatrics
Case Western Reserve University
Director, Child and Adolescent Psychiatry
University Hospitals Case Medical Center
Cleveland, OH
Natalie Grizenko, MD, FRCPC (Featured Author)
Associate Professor, Department of Psychiatry
McGill University
Medical Chief, Child and Adolescent Program
Douglas Mental Health University Institute
Montreal, QCStatement of Need
Attention-deficit hyperactivity disorder (ADHD) affects 8% of school age children. It presents with symptoms of inattention, hyperactivity/impulsivity, or both. Currently, three subtypes of ADHD are defined: ADHD inattentive (ADHD/I), ADHD hyperactive/impulsive (ADHD/H) and ADHD combined (ADHD/C). However, in the last decade heated debate has emerged that questions how this disorder should be conceptualized, defined, and categorized. Key questions have been: Is it a category or a continuum? and How do comorbidities relate to currently defined subtypes? In these interactive, evidence-based neuroscienceCME Journal Club sessions, the faculty will explore new data that may re-focus how we view ADHD subtypes. Such exploration will allow clinicians to anticipate how developers of the DSM-V might revise ADHD diagnostic criteria. As a result, clinicians will be in a position of opportunity to achieve better individualization of therapy.
- Faraone SV, Biederman J, Friedman D. Validity of DSM-IV subtypes of attention-deficit/hyperactivity disorder: a family study perspective. J Am Acad Child Adolesc Psychiatry 2000;39:300-307.
- Thapar A, Lewis G. Should we be rethinking how we assess and manage ADHD? J Am Acad Child Adolesc Psychiatry 2009;48:1051-1052.
Featured Article: Grizenko N, Paci M, Joober R. Is the inattentive subtype of ADHD different from the combined/hyperactive subtype? J Atten Disord 2009 Sept 22;[Epub ahead of print].
View Abstract
Download Article (PDF format)
Summary:
The Clinical Question
Is ADHD inattentive (ADHD-I) different from ADHD combined/hyperactive (ADHD-C/H) in terms of symptoms, comorbidity, treatment response, and possible genetic and environmental etiologic factors?
Why We Asked It
In the last decade heated debate has emerged that questions whether ADHD-I is a separate disorder instead of a subtype of ADHD. Additionally, there is a paucity of studies comparing the subtypes in terms of treatment response and etiology.
How We Approached the Question
A total of 371 clinically referred children diagnosed with ADHD between 6 and 12 years of age were recruited into a double-blind placebo-controlled trial to assess degree of treatment response with methylphenidate. Comorbidity using the Diagnostic Schedule for Children IV (DISC-IV) was compared in the three subtypes. We also compared specific genotypes that have been identified as possibly linked to ADHD (DAT, DRD4, and 5-HTT) and non-shared environmental risk factors (stress level, smoking, and alcohol consumption during pregnancy, and child birth weight and prenatal and perinatal complications).
What We Found
The combined and hyperactive subtypes were similar but the inattentive subtype had a greater proportion of girls, were older, and presented with less severe symptoms as assessed on the Parents and Teachers Conners’ and the CBCL externalizing T scores.
The ADHD-C and ADHD-H subtypes were combined to form the ADHD-C/H group. The ADHD-C/H group had more comorbid conduct disorder (p = .001) than the ADHD-I group. The ADHD-C/H group had a better treatment response than the ADHD-I group. In fact, 74% of ADHD-C/H were good responders, compared to only 62% for the ADHD-I group (p = .021).
The ADHD-C/H group was also exposed to more moderate stress during the pregnancy compared to the ADHD-I group (31% versus 17%; p = .019) but there were no differences with respect to smoking, alcohol consumption, or mean birth weight. This is in keeping with the previous study (Grizenko et al., 2008) that showed that children whose mothers experienced moderate to severe stress during pregnancy had a greater severity of internalizing and externalizing symptoms.
Comparisons based on genotype revealed that the L/L genotype of 5-HTT (that codes for the serotonin transporter) was more common in ADHD-C/H children versus ADHD-I children (39% versus 17%; p < .001). No significant difference was seen for 2 other genes: DAT (which codes for the dopamine transporter) and DRD4 (which codes for the dopamine receptor). This is in keeping with the strong association found previously (Curran et al., 2005) of the L/L genotype and hyperactivity symptoms. Logistic regression analysis on male probands revealed a significant interaction between L/L genotype and pregnancy stress. Having both the L/L genotype and a history of stress during pregnancy increased the risk for developing ADHD-C/H by 8.4 times.
The Clinical Application
The significant differences found between ADHD-C/H and ADHD-I subtypes raise the possibility that the two may be separate disorders, and may explain why there have been such discrepancies in research reports on treatment efficacy and possible etiological factors for ADHD. Further, if these subtypes are separate disorders, therapy could be better tailored to address the specific symptomatology.Activity Goal
To translate new evidence in the literature into improved diagnosis of ADHD in children and adolescents.
Learning Objectives
At the end of this CE activity, participants should be able to:
- Interpret data supporting the likelihood that ADHD/Inattentive subtype is a separate disorder from, rather than a subtype of, ADHD.
- Identify clinical implications associated with evidence that the ADHD/Inattentive subtype differs from the ADHD/Combined-Hyperactive subtype in terms of comorbidity, treatment response, and possible genetic and environmental etiologic factors.
The following learning objectives pertain only to those requesting CNE credit:
- Review data supporting the likelihood that ADHD/Inattentive subtype is a separate disorder from, rather than a subtype of ADHD.
- Identify clinical implications associated with the evidence that ADHD/Inattentive subtype differs from the ADHD/Combined-Hyperactive subtype in terms of comorbidity, treatment response, and possible genetic and environmental etiologic factors.
Target Audience
Physicians, physician assistants, nurse practitioners, nurses, psychologists, pharmacists, and other healthcare professionals interested in diagnosis and management of ADHD in children and adolescents.
Financial Support
This educational activity is supported by an independent medical educational grant from Shire.
Credit Information
CME Credit (Physicians):
CME Outfitters, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. CME Outfitters, LLC, designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Note to Physician Assistants: AAPA accepts Category I credit from AOACCME, Prescribed credit from AAFP, and AMA Category I CME credit for the PRA from organizations accredited by ACCME.CNE Credit (Nurses):
This continuing nursing education activity was approved by the New York State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
It has been assigned approval code 7ZDSX6-10. 1.0 contact hours will be awarded upon successful completion.CEP Credit (Psychologists):
CME Outfitters is approved by the American Psychological Association to sponsor continuing education for psychologists. CME Outfitters maintains responsibility for this program and its content. (1.0 CE credits)
CPE Credit (Pharmacists):
CME Outfitters, LLC, is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 1.0 contact hours (0.1 CEUs)
Universal Activity Number: 376-000-09-031-L01-P (Live) 376-000-09-031-H01-P (Recorded)
Activity type: Knowledge-based
Post-tests, credit request forms, and activity evaluations can be completed online at www.neuroscienceCME.com (click on the Testing/Certification link under the Activities tab–requires free account activation), and participants can print their certificate or statement of credit immediately (80% pass rate required). This website supports all browsers except Internet Explorer for Mac. For complete technical requirements and privacy policy, visit www. neuroscienceCME.com/technical.asp.Disclosure Declaration
It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer review process. The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.
Dr. Findling has disclosed that he receives or has received research support, acted as a consultant and/or served on a speaker's bureau for Abbott Laboratories, Addrenex Pharmaceuticals, Inc., AstraZeneca Pharmaceuticals LP, Biovail Pharmaceuticals, Inc., Bristol-Myers Squibb Company, Forest Laboratories, Inc., GlaxoSmithKline, Johnson & Johnson Pharmaceutical Research & Development, L.L.C., KemPharm Inc., Eli Lilly and Company, H. Lundbeck A/S, Neuropharm Group plc, Novartis Pharmaceuticals Corporation, Organon Pharmaceuticals USA Inc., Otsuka America Pharmaceutical, Inc., Pfizer Inc., Sanofi-Aventis, Sepracor Inc., Shire Pharmaceuticals, Solvay Pharmaceuticals, Inc., Supernus Pharmaceuticals, Inc., Validus, and Wyeth Pharmaceuticals.
Dr. Grizenko has no disclosures to report.
Unlabeled Use Disclosure
Faculty of this CE activity may include discussions of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices.
CME Outfitters, LLC, the faculty, and Shire do not endorse the use of any product outside of the FDA labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.Questions about this activity? Call us at 877.CME.PROS (877.263.7767).
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