Presented by the National Resource Center on ADHD1. Barkley. Attention-deficit hyperactivity...
Transcript of Presented by the National Resource Center on ADHD1. Barkley. Attention-deficit hyperactivity...
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Presented by the
National Resource Center on ADHD
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www.Help4ADHD.org (800) 233-4050
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Daniel Cox, PhD
Director of the Virginia Driving Safety Laboratory
Professor of Psychiatric & Internal Medicine,
University of Virginia School of Medicine
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Ask A Question
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Daniel Cox, PhD
Director of the Virginia Driving Safety Laboratory
Professor of Psychiatric & Internal Medicine,
University of Virginia School of Medicine
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Reducing the Risk of Driving Mishaps Among ADHD Drivers
Daniel J. Cox, PhD, ABPP
University of Virginia
Professor, Department of Psychiatry
Director, Virginia Driving Safety Laboratory
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Bad News
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0% 10% 20% 30% 40% 50% 60%
Fired from job
Incarcerated
Arrested
Serious car accident
Accident prone
Substance abuse
STD
Teen pregnancy
< high school
Repeat a grade
Subjects (%)
ADHD Normal
1. Barkley. Attention-deficit hyperactivity disorder. A handbook for diagnosis and treatment, 1998; 2. Barkley et al. JAACAP 1990; 3. Biederman et al. Arch Gen Psych 1996; 4. Weiss et al. JAACAP 1985; 5. Satterfield, Schell. JAACAP 1997; 6. Biederman et al. Am J Psych 1995.
Looking beyond the classroom Functional Impairment in Individuals with ADHD
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Core symtp0oms of ADHD`
1.Inattention
2.Impulsivity
3.Hyperactivity
4.(Distractable)
Driving Safety
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1. National Highway Traffic Safety Administration. Ann Emerg Med. 1997;29:546-547. 2. Barkley RA et al. Pediatrics.
1993;92:212-218. 3. Barkley RA et al. Pediatrics. 1996;98:1089-1095. 4. Cox DJ et al. J Nerv Ment Dis. 2000;188:230-
234. 5. Nada-Raja S et al. JAACAP. 1997;36:515-522.
ADHD and Driving: A Dangerous Mix
• Motor vehicle accidents are the leading cause of death
in adolescents, and ADHD is a major contributor.1
• Young drivers with ADHD are
– 2 to 4 times more likely to have traffic accidents.2-4
– 3 times as likely to have injuries.3
– 4 times as likely to be at fault.2
– 6 to 8 times more likely to have their license suspended.2,3
• This extends to females as well as males.5
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Our Studies to Assess the Effect of ADHD and Interventions on Driving Safety
– STUDY 1: Simulated driving study of RITALIN® vs placebo1 among college students with and without ADHD
– STUDY 2: Simulated driving study of CONCERTA® vs RITALIN2
– STUDY 3: Simulated and on-road driving study of CONCERTA vs ADDERALL® XR vs Placebo4
– Study 4: On-road assessment of ADHD adolescents study of CONCERTA vs ADDERALL® XR vs Placebo4
– Study 5: On-road assessment of ADHD young adults on and off Daytrana
– Study 6: Simulator study- ADHD driving a manual vs automatic transmission
1Cox DJ Current Psychiatry Reports 13(5):345-50
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Real World Driving Observations: DriveCam.com
• Inattention/distraction and Impulsive over correction
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Good News
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Virtual Reality Driving Simulator
• 165 degree visual field
• Updates every 60 msec
• Performance feedback
– Auditory
– Kinesthetic
– Visual
• Tracks 120 performance
variables
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STUDY 1: RITALIN® vs Placebo Impaired Driving Score
ADHD improvement, P<0.05.
Cox DJ et al. J Nerv Ment Disord. 2000;188:230-234.
Imp
air
ed
Dri
vin
g S
co
re
Average driving
Lower score
denotes
better driving
performance.
-1.5
-1
-0.5
0
0.5
1
1.5
2
2.5
Placebo
ADHD Placebo
Control RITALIN
RITALIN
Control Placebo
ADHD RITALIN
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Plasma Profiles Following Ritalin® tid
and CONCERTA® XL
Swanson J et al. Arch Gen Psychiatry 2003;60:204-211
0 2 4 6 8 10 12
20
16
12
8
4
0
Time (h)
IR MPH 10 mg tid (n=15)
CONCERTA® XL 36 mg qd (n=15)
Co
ncen
trati
on
(n
g/m
L)
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P<0.01 (8:00 PM).
Average driving
Imp
air
ed
Dri
vin
g S
co
re
STUDY 2: CONCERTA® vs RITALIN® Impaired Driving Score
Cox DJ et al. J Am Acad Child Adolesc Psychiatry. 2004;43(3)269-275.
-3
-2
-1
0
1
2
3
4
5
6
2:00 PM 5:00 PM 8:00 PM 11:00 PM
Time
RITALIN tid
CONCERTA qd Equivalent performance
to male drivers 80+ yrs
Equivalent performance
to male drivers 55-59 yrs
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STUDY 3: CONCERTA® vs ADDERALL® XR Impaired Driving Score
Imp
air
ed
Dri
vin
g S
co
re
5:00 PM 8:00 PM 11:00 PM
Placebo
CONCERTA
ADDERALL XR
-2
-1.5
-1
-0.5
0
0.5
1
1.5
2
Time Contrasts: Medication vs placebo P=0.01; CONCERTA vs placebo P=0.001;
ADDERALL XR vs placebo P=0.24; CONCERTA vs ADDERALL XR P=0.03. Cox DJ et al. Poster presented at APA 2005; manuscript in preparation.
Contrasts
Medication vs. placebo; P=.01
Concerta® vs. placebo; P=.001
Adderall® XR vs. placebo; P=.24
Concerta® vs. Adderall® XR ; P=.03
Equivalent performance
to male drivers 75-79 yrs
Equivalent performance
to male drivers 55-59 yrs
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2.9
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
5:00 PM 8:00 PM 11:00 PM
Placebo
CONCERTA
Adderall XR
Subjective ratings (0-5) of driving ability post drive
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-0.3
-0.2
-0.1
0
0.1
0.2
0.3
5:00 PM 8:00 PM 11:00 PM
Time
Plcebo
Adderall XR
CONCERTA qd
a
Average driving
Imp
air
ed
Neu
ro-C
og
nit
ive S
co
re
CONCERTA® vs Adderall® XR Impaired Neuro-Cognitive Score (Distractibility and Visual Memory)
®
®
Academy of Clinical Neuropsychology, 2006, Nov. (In Press)
Contrasts
OROS® MPH vs. Plcebo; P<.001
Adderall® XR vs. placebo; P=.042
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-0.4
-0.1
0.2
0.5
0.8
Inattention Composite Score = Across Midline + Running Stop Signs + No signaling (p =.01)
Inatt
en
tio
n C
om
po
sit
e S
co
re
p=.008 p=.04
Placebo Adderall XR CONCERTA
STUDY 4: CONCERTA vs. Adderall XR On-Road Driving
Cox DJ, J. Child & Adolescent Psychopharmacology, 18(1), 1-10
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Study 5: Routine ADHD driving off and on
long acting MPH (Daytrana)
• 20 young adult (18-25) drivers with ADHD who
routinely do not take medication
• Three months off and the on medication
• Two-camera DriveCam.com video system
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Real World Benefits
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Female Male
Cox, et al, Archives of Pediatrics & Adolescent Medicine. 2008, 162 (8) 793-794
Driv
ing
Erro
rs
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3 months on and off of Daytrana
0
1
2
3
4
5
6
7
8
No Medication Daytrana
Collisions
No Medication
Daytrana
Cox DJ, The Journal of Clinical Psychopharmacology . 32(2):225-30.
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What to look for in a medication
Medications can be extremely helpful
1.Optimal dose
1.Greatest symptom relief: inattention & impulsivity
2. None to tolerable side effects
2.Driver recognizes benefits
3.Long acting
4.No rebound effects
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-1.5
-1
-0.5
0
0.5
1
1.5
20:00 23:00
Manual Automatic
IDS
Study 6:
Non Pharmacological Interventions:
Automatic Vs. Manual transmission
Cox et al, J Atten Disord. 2006;10(2):212-216
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What are non-Medication strategies?
Anything that enhances engagement and reduces distraction
1. Enhance engagement/attention to driving
1. Manual transmission
2. Back-up obstacle alert system
3. No cruise control
4.
2. Minimize distractions
1. Minimal passenger conversations
2. No teen passengers
3. No pets
4. Put cellphone in trunk/deactivate cell phone
5. ?
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Ask A Question
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Daniel Cox, PhD
Director of the Virginia Driving Safety Laboratory
Professor of Psychiatric & Internal Medicine,
University of Virginia School of Medicine
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www.Help4ADHD.org (800) 233-4050
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only; the information presented should not be regarded as medical advice or treatment information.