F. Xavier Castellanos, M.D., PGRC Institue for Pediatric Neuroscience, New York University Langone Medical Center, 215 Lexington Avenue, 14^th Floor, New York, NY, 10016-6023

Objectives: This Institue will present a range of perspectives relevant to child and adolescent psychiatrists assessing and treating challenging patiens with ADHD.

Methods: Speakers will update clinicians on recent progress in ADHD from DSM-5 to genetics, and brain imaging to non-pharmacologic and pharmacologic treatments. Dr. Castellanos will begin by describing the changes being considered by the DSM-5 Workgroup that are currently undergoing field trials. Dr. Faraone will review the various approaches seeking to understand the substantial genetic substrates of ADHD. Dr. Proal will describe how recent converging brain imaging findings in ADHD now support a focus on specific large-scale functional networks or circuits. Dr. Tannock will underscore the importance of assessing language problems in children with ADHD. Dr. Carlson will address the challenges of mania and ADHD from the perspectives of diagnosis, treatment, and communication with families. Pharmacological treatments remain the mainstay of therapy for ADHD and Dr. McGough will review complex pharmacologic treatments; he will also discuss several alternative nono-medication treatments. Dr. Pelham, one of the pioneers of behavioral treatments for ADHD, will review the strong evidence base in favour of certain non-pharmacological interventions and the multiple benefits of combining treatments in the long run.  

Conclusion: In sum, this Institute will provide new conceptual and practical tools for the management of ADHD by child and adolescent psychiatrists.

2.1 INTRODUCTION AND ADHD IN DSM-5: REVISIONS UNDER CONSIDERATION IN THE FIELD TRIALS

F. Xavier Castellanos, M.D., PGRC Institue for Pediatric Neuroscience, New York University Langone Medical Center, 215 Lexington Avenue, 14^th Floor, New York, NY, 10016-6023

Objectives: The diagnostic criteria for ADHD as evolved through three iterations since DSM-III provided the underpinnings for an increasingly vigorous science. However, the understanding of pathophysiology needed for a truly revolutionary transformation to the core criteria has not yet emerged. This presentation will both set the stage for the Institute and review the options for ADHD being tested in the DSM-5 field trials which are currently underway.  

Methods: We describe the provisional ADHD criteria undergoing field trials.  

Results: Support within the Workgroup is strong for increasing the age of onset criterion to age 12 and for permitting both ADHD and ASDs to be diagnosed contemporaneously. Also under consideration are changes in: 1) The numbers of criteria needed for older adolescents and adults; 2) The increase in the number of illustrative examples to better encompass adults; 3) Whether to increase the number of impulsivity-related items; and 4) Whether to attempt to identify individuals with inattention and few hyperactivity/impulsivity criteria. Conclusion: no definitive decisions have yet been made regarding DSM-5 criteria for ADHD.

2.7 EVIDENCE-BASED NONPHARMACOLOGICAL TREATMENTS FOR ADHD

William E. Pelham Jr., A.B.P.P., Center for Children and Families, Florida International University, AHC 1, Room 140, 11200 SW 8^th Street, Miami, FL, 33199

Objectives: ADHD is a chronic condition that is a major public health problem in the U.S. The vast majority of ADHD children are treated with psychoactive medication alone, and the rates of medication usage have increased exponentially over the past 20 years.

Methods: Although there is ample evidence that medication is beneficial in the short term, it has no demonstrable long-term benefit, suggesting that alternative or adjunctive treatments are necessary. Behavioral interventions and multimodal approaches that combine behavioral and pharmacological components are evidence-based for the short-term treatment of children with ADHD, typically yielding effect sizes that approximate those of stimulant medications (Fabiano et al, 2009).  

Results: The talk reviews recent studies of and the evidence base for these nonpharmacological interventions. The implications for treatment of ADHD children and the costs and benefits to children, families, schools, and society at large are discussed. In contrast to medication, behavioral interventions were developed to remediate the problems in daily life functioning that typically accompany ADHD. Since these domains are key predictors and mediators of long-term outcomes, long-term impact of psychosocial interventions should be more substantial than with medication, but long-term impact is unstudied.  

Conclusion: Although recommended by influential guidelines, the combination of the two treatments has also been understudied, especially with respect to dosing and sequencing of each modality; one major benefit appears to be that low doses of each treatment can be employed, thereby minimizing costs and side-effects.