impairment in adhd: implications for - alberta health...
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Dorsolateral and Orbital FrontalSubcortical Circuit Impairment in ADHD: Implications forCircuit Impairment in ADHD: Implications for
Differential Diagnosis and TreatmentJames B. Hale, PhD, ABPdNPediatric Neuropsychologist
Professor of Paediatrics, Psychiatry, and EducationProfessor of Paediatrics, Psychiatry, and EducationUniversity of Calgary
Email: TeachingBrainLiteracy@gmail.com
Joint Grand Rounds of Child and Adolescent Psychiatry and Developmental Paediatrics
Faculty of MedicineUniversity of Calgary
9 April 2015©James B. Hale, PhD, MEd, ABPdN, ABSNP
“Cool” and “Hot” FrontalSubcortical Circuits and Psychopathology: All Neuropsychiatric Disorders y p gy p y
Have AttentionDeficits
Joint Grand Rounds of Child and AdolescentJoint Grand Rounds of Child and Adolescent Psychiatry and Developmental Paediatrics
Faculty of MedicineUniversity of Calgaryy g y
9 April 2015
©James B. Hale, PhD, MEd, ABPdN, ABSNP
“Everyone knows what attention is. It is What is Attention?
ythe taking possession by the mind, in clear and vivid form, of one out of what seem several simultaneously possible objects or trains of thought. Focalization, concentration of consciousness are of itsconcentration, of consciousness are of its essence. It implies withdrawal from some things in order to deal effectively withthings in order to deal effectively with others, and is a condition which has a real opposite in the confused, dazed, William James
Principles ofscatterbrained state.”
Principles of Psychology (1890)
Is this primary attention or executive function?H d t ti l t iHow do we separate cortical tone, primary attention, and executive attention?
Executive FunctionProgramming, Regulating, and Verifying Mental Activityog a g, egu at g, a d Ve fy g e ta ct v ty
Working Memory, MemoryEncoding & Retrieval (HERA)
AssociationMotor
SupplementaryMotor
Premotor Encoding & Retrieval (HERA)
Plan, Organize, Strategize,
ExpressiveLanguage
ExternalControl
Premotor
EXECUTIVE Plan, Organize, Strategize,Monitor, Evaluate, Modify,& Change Behavior
InternalC l
EXECUTIVE FUNCTIONS
Attention, Concentration,& Impulse Control
Control
The Brain Manager
FrontalSubcortical Circuits:Executive ControlExecutive Control
R i
OculoMotor
l
Running, Drawing
W t hi Thi
Decisions, Keeping track,Doing things Oculo
motor
Basal
Cingulate Watching Things,Reading
Doing things quickly
Ganglia/Thalamus
Managing life,Completing Tasks, Writing
Controlling Own Controlling Own Emotions andBehaviour
How does circuit impairment lead to ADHD and other psychopathologies?©James B. Hale, PhD, MEd, ABPdN, ABSNP
Motor Circuit
SupplementaryM t SomatosensoryPrimary
M tMotorCortex
yCortexMotor
Cortex
PremotorCortex Putamen Globus
Pallidus Thalamus
SubstantiaNiNigra
Motor circuit control of praxis, motor coordination, and activity
Oculomotor Circuit
FrontalEyeFields
PosteriorParietalCortex
Prefrontal Caudate Globus ThalamusCortex Nucleus Pallidus Thalamus
SubstantiaNigra
Oculomotor circuit control of visual saccade, attention, and tracking for motor control
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Cingulate Circuit
AnteriorCingulate
LimbicCaudateNucleus Putamen Olfactory
Tubule Nucleus
Accumbens
LimbicStriatum
SubstantiaNigra
GlobusPallidus
ThalamusThalamus
Cingulate circuit control of arousal, decision‐making, and performance monitoring
Dorsolateral Circuit in Learning, Language, and Motor Disorders
DorsolateralPrefrontalCortex
CaudateNucleus
GlobusPallidus Thalamus
SubstantiaNigra COOL
EXECUTIVE
Dorsolateral circuit control of planning, organizing, monitoring, evaluating, hifti d dif i b h i i l di COGNITIVE i hibitishifting, and modifying behaviour, including COGNITIVE response inhibition
Dorsolateral circuit control of working memory, memory encoding, and retrieval
Orbital Circuit in Learning, Language, and Motor Disorders
O bi lOrbitalPrefrontalCortex
CaudateNucleus
GlobusPallidus Thalamus
SubstantiaNigra
HOTEXECUTIVE
Orbital circuit control of self‐governed emotion regulation Lateral orbital circuit more behaviour regulation – EMOTIONAL response inhibitionMedial orbital region important for emotion regulation – reward processing and theory of the mind‐empathy (perception of emotional state more posterior) ©James B. Hale, PhD, MEd, ABPdN, ABSNP
“Cool” and “Hot” FrontalSubcortical Circuits and Psychopathology: The Search for Balancey p gy f
Joint Grand Rounds of Child and AdolescentJoint Grand Rounds of Child and Adolescent Psychiatry and Developmental Paediatrics
Faculty of MedicineUniversity of Calgary
©James B. Hale, PhD, MEd, ABPdN, ABSNP
y g y9 April 2015
“Cool” ADHD vs. Schizophrenia vs. “Hot” Conduct Disorder vs. Anxiety Disordery
• Attention deficit not diagnostic, since all neuropsychiatric disorders have poor attentionADHD i h d l l h i i l d l• ADHD right dorsolateral hypoactivity leads to external distraction
• Schizophrenia left dorsolateral hypoactivity leads toSchizophrenia left dorsolateral hypoactivity leads to internal distraction
• Conduct disorder orbital hypoactivity leads to poor i l l d i diff hemotional control and indifference to others
• Anxiety disorder orbital hyperactivity leads to emotional overcontrol and excessive concern for othersemotional overcontrol and excessive concern for others
• Externalizing disorders overuse initiation structures and underuse inhibitory ones
• Internalizing disorders overuse inhibitory structures and underuse initiation structures(see Arnsted & Rubia, 2012, Milad & Rauch, 2007; Rubia, 2011; Hale & Fitzer, 2015)
Circuit Balance Theory and Psychopathology(Hale et al 2009)(Hale et al., 2009)
Inattention/Distractibility
Inattention/FixationBrain
ImpulsiveBehavior
RepetitiveBehavior
MHyperactivity Hypoactivity
Manager
CircuitUnderactivity
CircuitOveractivity
Regulation problem of cortical‐subcortical circuits©James B. Hale, PhD, MEd, ABPdN, ABSNP
Balance Theory and Comorbidity
• If one circuit is dysfunctional, does the other provideother provide compensatory balance?
• Example: Anxiety comorbid with depressionwith depression
• Decreased dorsolateral and increased amygdala in depression (Siegle et al., p ( g ,2007)
• Increased orbital frontal, amygdala, and anterior ygcingulate in GAD (McClure et al., 2007)
Optimal Executive Function Requires
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Optimal Executive Function Requires Frontal-Subcortical Circuit Balance!
Orbital Prefrontal Circuit and Theory of MindHale & Fitzer, 2015; Applied Neuropsychology: Child
• Theory of Mind – The ability to take the perspective of others or feel empathy
• Does empathy only require perception or does it• Does empathy only require perception, or does it also require action?
• Posterior systems linked to affect perceptionParietal lobe and “mirror” neuronsTemporal lobe and face recognition
• Why is theory of mind linked to the frontal systems?Pars opercularis and imitationM di l bit l t d th f i dMedial orbital cortex and theory of mind
• Balancing orbital function critical, too little or too much is a problem! p
• Balancing perception and action in social relationships
Questions, Questions, QuestionsADHD Pathways, Neurochemistry, and Stimulant Response
• Dorsolateral‐dorsal cingulate (cognitive impulsivity) and orbital‐ventral cingulateimpulsivity) and orbital ventral cingulate (emotional impulsivity) differences?
• Mesocortical (tegmentum‐dorsolateral), ( g ),mesolimbic (orbital‐amygdala‐hippocampus‐nucleus accumbens), andnigrostriatal (substantia nigra‐basal ganglia) dopamine (DA) pathways? What role does Glutamate have? How about GABA?Glutamate have? How about GABA?
• Inverted‐U shape stimulant response in dorsal and ventral systems how do wedorsal and ventral systems, how do we achieve balance?
©James B. Hale, PhD, MEd, ABPdN, ABSNP
“Cool” and “Hot” FrontalSubcortical Circuits and Stimulant Response in ADHDp
Joint Grand Rounds of Child and AdolescentJoint Grand Rounds of Child and Adolescent Psychiatry and Developmental Paediatrics
Faculty of MedicineUniversity of Calgary
©James B. Hale, PhD, MEd, ABPdN, ABSNP
y g y9 April 2015
American Academy of Pediatrics Standard of Care ADHD Medical PracticeStandard of Care ADHD Medical Practice1) Primary care physician should evaluate any child with academic or behaviouralany child with academic or behavioural problems and inattention, hyperactivity, orimpulsivity symptoms
2) ADHD diagnosis: DSMIV criteria, 2 settings, and multisource information for rule outs
3) Coexisting conditions assessment4) Treatment includes medications and/or
evidence‐based behavior therapy, both best5) Titrate maximum medication dose with minimum adverse effects
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Childhood’s Greatest “Behaviour Problem”:Persistent Academic Achievement DeficitsPersistent Academic Achievement Deficits
• ADHD is a neurodevelopmental disorder defined by behavioural criteria, leading to neuropsychological , g p y gheterogeneity and attenuated treatment efficacy
• Are academic deficits the common pathway? Poorer d d t ti i l d ti lik l igrades, grade retention, special education likely in
ADHD (especially if executive deficits)
WHAT CAUSES ADHD ACADEMIC DEFICITS?
OR
P A il bili E i D fi iPoor AvailabilityFor Learning?
Executive DeficitsImpair Learning?
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Methylphenidate (MPH) Treatment and ADHD• MPH effective in 60 to 90% of children with ADHD, but just what does “response” meanresponse mean
• Dopamine agonists (block DA reuptake to reduce frontal‐striatal hypoactivity)to reduce frontal striatal hypoactivity)
• Improves classroom behaviour and peer interactions, but not long‐term academic achievement
• Few serious side effects, but “zombie effect” noted in some childreneffect noted in some children
Best dose for cognition appears to be lowerthan best dose for behavior in good responders(see Arnsten & Pliszka, 2011; Berridge et al., 2006; Hale et al., 2011; Kubas et al., 2012)
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Relevance of ADHD Executive Deficits and Medication Response: CorticalSubcortical Circuit Confirmatory Factor Analysis
WCST PerseverativeResponses
Stroop Color
.43
.73ExecutiveWorkingMemory
(Dorsolateral
Word Correct
Trails BTime
WCST PerseverativeErrors
.55
53 51(DorsolateralDorsal Cingulate
Circuits)Conners’ CPTIIOmissions
Hale Cancellation
Stroop ColorWordCorrect
Trails B
.53
.62
.51
.40
67
.76
Behavioural Inhibition
Hale CancellationTask Time
WSRTConsistentWord Retrieval
Trails BErrors
Conners’ CPTIICommissions
.64
.48
.67
.47
Self Regulation(OrbitalVentralCingulate Circuits)
TOMAL DigitsBackward
CO
Hale CancellationTaskCorrect
G G
.70 .68
.78COWAT
Letters (FAS)GoNo GoCorrect
Sources: Hale et al., (2011) Journal of Learning Disabilities. Kubas et al. (2012) Postgraduate Medicine©James B. Hale, PhD, MEd, ABPdN, ABSNP
14
FrontalSubcortical Impairment and Diagnosis
12
14
Inattentive Type
Combined Type
10
yp
nts
6
8
Participan
4
6
2
0None (+1 SD or more) Low (+.99 to 0) Moderate (0 to -.99) High (-1 SD or less)
Neuropsychological Tests and DSMV Criteria CorrelationsCarmichael et al., 2015; Applied Neuropsychology: Child
DSMV CriteriaBaseline ExecutiveM
Inattention( 2)
Hyper‐Impulsive( 2)
Total Symptoms( 2)Measures r (r2) r (r2) r (r2)
HDCT Correct ‐.15 (.021) ‐.08 (.006) ‐.15 (.023)SRTM Consistent Retrieve .03 (.001) .32 (.104) .27(.072)( ) ( ) ( )
Go‐No Go ‐.08 (.006) .22 (.048) .24 (.058)
CPT Omissions .17 (.030) .13 (.016) .21 (.044)
CPT Commissions 13 ( 018) 06 ( 004) 02 ( 000)CPT Commissions .13 (.018) ‐.06 (.004) .02 (.000)CPT Block Change .19 (.035) .20 (.038) .28 (.078)
Stroop Raw ‐.17 (.030) .31 (.096 ) .37 (.138)
Stroop Errors .01 (.000) .15 (.022) .13 (.018)TMTB Time .33 (.106) .19 (.036) .35 (.125)
TMTB Errors .41 (.170) .31 (.096) .51 (.258)( ) ( ) ( )
Back Digits .18 (.031) .28 (.076) ‐.15 (.021)
Low correlations between DSM‐IV and neuropsychological measures, BUT©James B. Hale, PhD, MEd, ABPdN, ABSNP
Neuropsychological Data, DSMV Criteria, and MPH Response (Carmichael et al., in press; Applied Neuropsychology: Child)
Measure
CognitiveMedicationResponse
( 2)
BehaviouralMedicationResponse
( 2)r (r2) r (r2)
DSM‐IV InattentionRatings (Parent Report) .09 (.008) .03 (.000)
DSM‐IV Hyperactivity‐Impulsivity Ratings (ParentImpulsivity Ratings (Parent Report .30* (.090) .25 (.063)
Dorsolateral‐Dorsal CingulateDorsolateral Dorsal Cingulate“Cool” Circuit Functions Factor .44** (.194) .33* (.109)
Orbital Ventral CingulateOrbital‐Ventral Cingulate“Hot” Circuit Functions Factor .45** (.203) .31* (.097)
©James B. Hale, PhD, MEd, ABPdN, ABSNP
3.5
3.0
No (Apparent) Impairment3.5
3.0
Low Executive Impairment
BehavioralCognitive
BehavioralCognitive
2.5
Mea
n R
ank
2.5
Mea
n R
ank
2.0
1.5
2.0
1.5
B P L HCondition
B P L HCondition
3.5Moderate Executive Impairment
3.5High Executive Impairment
CognitiveCognitive3.0
2.5
Mea
n R
ank
3.0
2.5M
ean
Ran
k
BehavioralCognitive
BehavioralCognitive
2.0
1.5
M
2.0
1.5
M
B P L HCondition
B P L HCondition
B = Baseline; P = Placebo; L = Low Dose MPH; H = High Dose MPH. Lower ranks = better performance and behavior (see Hale et al., 2011).
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Moderate and Severe FrontalSubcortical ImpairmentAnd Statistical Medication Response
18
20
14
16
ts
10
12
rticipant
6
8Pa
0
2
4
0
No Response Cognitive ResponseOnly
Behavioral ResponseOnly
Cognitive andBehavioral Response
Medication Response©James B. Hale, PhD, MEd, ABPdN, ABSNP
Neuropsychological Impairment, Behavioural Diagnosis, and ADHD Medication Responsep
8
10No MPH ResponseCog or Beh MPH ResponseCog and Beh MPH Response
4
6
8
0
2
ADHDInattentive Type ADHDCombined Typeyp yp
©James B. Hale, PhD, MEd, ABPdN, ABSNP
University of CalgaryAlberta Children’s Hospital
ADHD Bi h ti St dADHD Biphentin Study
Joint Grand Rounds of Child and AdolescentJoint Grand Rounds of Child and Adolescent Psychiatry and Developmental Paediatrics
Faculty of MedicineUniversity of Calgary
©James B. Hale, PhD, MEd, ABPdN, ABSNP
y g y9 April 2015
Alberta Children’s Hospital DoubleBlind Placebo Biphentin Protocolp
• Children diagnosed by physician, confirmed by psychologist, consent, and random assignment
• Standard of Care control group = baseline, best dose, 6 months; open trial
• Experimental group = baseline randomized• Experimental group = baseline, randomized placebo, low dose, high dose, best dose, 6 months, blinded trial
• Neuropsychological tests and parent/teacher• Neuropsychological tests and parent/teacher behaviour ratings, academic baseline and 6 months; neuroimaging baseline‐best dose only
• Data rank ordered across conditions with nonparametric randomization tests to determine cognitive and behavioural response separately
• Graphic and statistical response reported to physician/parent for clinical decision‐making
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Drug Trial Example: Lisa• 11 year, 7 month‐old friendly and outgoing girl with love for adventure and being outdoorsA d i d i l• Academic and social concerns: Inattentive, easily distracted, fidgetyFrequently off‐taskq yPoor writing skillsNoncompliant behaviourLi i d i l killLimited social skills
• Comprehensive neuropsychological evaluation revealed neuropsychological, academic and p y gbehavioural data consistent with ADHD
• Following consultation with parents, pediatrician referred Lisa to double‐blindpediatrician referred Lisa to double blind placebo controlled methylphenidate trial
©James B. Hale, PhD, MEd, ABPdN, ABSNP
SubtestBaseline Week 2 Week 1 Week 3
Lisa’s Neuropsychological Response to Stimulant MedicationSubtest
No Medication Placebo 10 mg 20 mgAuditory‐Verbal Measures
WSRT Long‐term Storage 72 (3) 73 (1.5) 73 (1.5) 65 (4)WSRT Consistent LT Retrieval 72 (2) 56 (3) 73 (1) 39 (4)WSRT LTS‐CLTR Ratio 100%(1.5) 77%(3) 100%(1.5) 60%(4)Go‐No Go Correct (30 Possible) 25 (4) 28 (2.5) 28 (2.5) 30 (1)WISC‐IV‐I Digit Span Backward 20 (4) 33 (1) 28 (2) 26 (3)D‐KEFS Inhibition Time 85” (4) 66” (3) 63” (2) 52” (1)( ) ( ) ( ) ( )D‐KEFS Inhibition # of Errors (raw) 8 (4) 2 (3) 1 (1.5) 1 (1.5)
Visual‐Motor MeasuresHale‐Denckla Cancellation (Correct) 26 (4) 30 (2) 30 (2) 30 (2)HaleDenckla Cancellation (Time) 87” (2) 99” (3) 71”(1) 130” (4)Hale Denckla Cancellation (Time) 87 (2) 99 (3) 71 (1) 130 (4)WISC‐IV‐I Spatial Span Backward 43 (2) 23 (4) 28 (3) 44 (1)Trail Making Test‐Part B Errors 1 (3.5) 1 (3.5) 0 (1.5) 0 (1.5)Trail Making Test‐Part B Time 30” (3.5) 30” (3.5) 19” (1) 20” (2)CPT II O i i 47 (2) 49 (4) 47 (2) 47(2)CPT‐II Omissions 47 (2) 49 (4) 47 (2) 47(2)CPT‐II Commissions 50 (3) 49 (2) 47 (1) 56 (4)CPT‐II Reaction Time 57 (3) 58 (4) 56 (2) 55 (1)CPT‐II Reaction Time Standard Error 47 (1) 55 (4) 48 (2) 49 (3)CPT‐II Hit Reaction Time Block Change 54 (4) 45 (2.5) 42 (1) 45 (2.5)CPT‐II Hit Reaction Time ISI Change 48 (3) 55 (4) 43 (1) 45 (2)
AVERAGE COGNITIVE RANK 2.97 2.97 1.64 2.42©James B. Hale, PhD, MEd, ABPdN, ABSNP
Lisa’s Behavioural Response to Stimulant MedicationParent Behavior Ratings
Scale/Subscale Baseline Placebo 10 mg 20 mgBRIEF
I hibit 86 (3) 84 (2) 89 (4) 68 (1)Inhibit 86 (3) 84 (2) 89 (4) 68 (1)Shift 77 (3) 81 (4) 66 (1.5) 66 (1.5)Emotional Control 83 (3) 85 (4) 71 (2) 61 (1)Initiate 73 (2.5) 73 (2.5) 76 (4) 66 (1)Working Memory 74 (2) 82 (3.5) 82 (3.5) 65 (1)Plan/Organize 84 (4) 66 (2) 80 (3) 62 (1)/ g ( ) ( ) ( ) ( )Organization of Materials 70 (3.5) 70 (3.5) 67 (2) 55 (1)Monitor 79 (4) 67 (2) 73 (3) 61 (1)
HSQR Number of Problems 9 (1.5) 13 (4) 9 (1.5) 11 (3)Mean Severity 5.89 (3) 5.92 (4) 5.67 (2) 2.27(1)
Teacher Behaviour RatingsBRIEFBRIEF
Inhibit 53 (4) 49 (2.5) 49 (2.5) 45 (1)Shift 49 (2.5) 49 (2.5) 49 (2.5) 49 (2.5)Emotional Control 46 (2.5) 46 (2.5) 46 (2.5) 46 (2.5)Initiate 65 (3.5) 58 (2) 65 (3.5) 54 (1)Working Memory 68 (4) 61 (2) 65 (3) 54 (1)Plan/Organize 70 (3.5) 58 (2) 70 (3.5) 49 (1)Organization of Materials 69 (3) 69 (3) 57 (1) 69 (3)Monitor 66 (3.5) 52 (2) 66 (3.5) 49 (1)
SSQR Number of Problems 3 (3.5) 2 (1.5) 3 (3.5) 2 (1.5)Mean Severity 1.7 (3) 2.0 (4) 1.0 (1.5) 1.0 (1.5)
APRS Learning 14 (4) 17 (1) 16 (2 5) 16 (2 5)APRS Learning 14 (4) 17 (1) 16 (2.5) 16 (2.5)Impulse Control 18 (3.5) 18 (3.5) 20 (1.5) 20 (1.5)Academic Performance 21 (3.5) 21 (3.5) 24 (2) 25 (1)Social Interest 16 (4) 18 (2) 18 (2) 18 (2)
Classroom Observation – Restricted Academic TaskRAT OffTask 43% (4) 33% (2) 30% (1) 37% (3)
Fidgeting 10% (1.5) 20% (3) 10% (1.5) 37% (4)Vocalization 3% (2) 13% (4) 7% (3) 0% (1)Plays with Objects 17% (2.5) 27% (4) 10% (1) 17% (2.5)OutofSeat 33% (4) 10% (2) 13% (3) 7% (1)
AVERAGE BEHAVIOURAL RANK 3.18 2.78 2.44 1.60©James B. Hale, PhD, MEd, ABPdN, ABSNP
Contrasting Lisa’s Neuropsychological and Behavioural Response to Stimulant MedicationBehavioural Response to Stimulant Medication
4.0Cognitive ResponseB h i l R
3.0Behavioural Response
ank
2.0
Mean Ra
1.0
0.0Baseline Placebo 10mg MPH 20mg MPH
Note. Lower Ranks = Better performance and behaviour;Order of conditions = Baseline, Low Dose, Placebo, High Dose
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Neuroimaging ADHD and MPH Response Structural and Functional MRIStructural and Functional MRI
Joint Grand Rounds of Child and AdolescentJoint Grand Rounds of Child and Adolescent Psychiatry and Developmental Paediatrics
Faculty of MedicineUniversity of Calgary
©James B. Hale, PhD, MEd, ABPdN, ABSNP
y g y9 April 2015
Structure: Cortical Thickness/Regional Brain Volumes
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Structure: Diffusion Tensor Imaging
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Is “Dopamine Insufficiency” Insufficient? Neuropsychological Medication Response and Glutamate
Left Striatum Right PrefrontalExperimental Group:
Experimental Group:Neuropsychological Titration
Neuropsychological Titration
Standard of Care:B h l T
Standard of Care: Behavioral Titration
Behavioural Titration
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Is Cognitive or Behavioural MPH Response More Relevant for Academic Achievement? fMRI Tasks
Multi-Source Interference Task(Bush, Shin)
Momentary Incentive Delay Task(Helfinstein, Kirwan, Benson, Hardin, Pine, Ernst, Fox)
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Discussion• Are academic achievement deficits due to poor • Are academic achievement deficits due to poor availability for learning or executive deficits?
• Doubleblind placebo medication trials detect pneuropsychological and behavioral response
• Children with executive impairment and ADHDC bi d T h b t di ti Combined Type show robust medication response
• Children with low impairment and ADHDInattentive Type less likely to respondInattentive Type less likely to respond
• Differential dorsal and ventral circuit effects could explain why best dose for cognition lower than best p y gdose for behaviour
• Neuropsychological and behavioral medication tit ti d dj t t t t h ld ti i titration and adjunct treatments should optimize both academic and behaviour outcomes
©James B. Hale, PhD, MEd, ABPdN, ABSNP
Find us online: www.educ.ucalgary.ca/braingainFollow us on Twitter: @braingainlab
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©James B. Hale, PhD, MEd, ABPdN, ABSNP
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