ADHD: when your first drug fails…

don’t be surprised
be prepared
A Longitudinal Case Study of ADHD
Learning Objectives
YOU NEED A PLAN!

1. Understand the challenges and limitations of

pharmacological management of ADHD in Adults

2. Recognize that the most effective initial treatment of

ADHD may target significant comorbidities

3. Feel more confident in your decisions regarding use of

medications to treat ADHD
Presenter Disclosure

 Faculty: James C. Lazowski CD BEng MD PEng FRCPC

 Relationships with commercial interests 2016-2018:

Speakers Bureau/Honoraria:
Bristol Myers Squibb
Lundbeck
Pfizer
Purdue
Sunovion
Shire
Other:
Hold shares of Johnson and Johnson (parent company of Janssen-Ortho)

2
This presentation has not had the
benefit of commercial support
Mitigating Potential Bias

Not Plug and Play!

4
 Prevention
ADHD:
Pharmacological
Treatment In ADHD Pharmacotherapy
Adulthood

Common Comorbidity
 “Happy child but sensitive to criticism and
more threatened by failure”

“generally disorganized…difficult to have him

follow routines”,
Brad: age 8
“peer relationships apparently very good”,

“strong dislike of school”

“teacher reports…distractible and has

difficulty completing tasks”
Brad: Childhood Medical History

 Full
term pregnancy, Mother reported to be “under stress”
normal delivery,
 Adopted at 10 days
 Normal milestones except slight delay in motor milestones.
 Large Acetominophen OD at age 2.
 Recurrent ear infections.
 Strabismus, amblyopia
 “large orthodontic appliance that makes speech difficult”
Brad: Assessments 1978 & 1980

 Psychology and Psychoeducation

 “evidence of significant weakness on the subtest
requiring short-term auditory memory”
 “Significant weakness ... Rapid eye-hand coordination”
 “significant general distractibility factor”
 HTP… “evidence of impulsivity…insecurity, inadequacy,
and underlying depression”
 Psychiatric Diagnosis: Specific Developmental Delay
Reading
 Treatment: Remedial Reading Programme, IEP, IPRC
Impact of Childhood Tx on Psych Outcome in
Adulthood 10-year case-control study of male children aged 6-18 with ADHD
# Patients No Stimulant Stimulant Hazard
p-Value
Used in Model Therapy Therapy Ratio
Major depression 107 0.69 0.24 0.22 <0.001
Conduct disorder 112 0.67 0.22 0.21 <0.001
Multiple (≥2)
anxiety disorders 108 0.60 0.07 0.15 <0.001

Oppositional-
defiant disorder 79 0.88 0.40 0.21 <0.001

Bipolar disorder 116 0.42 0.20 0.47 0.063

Repeated a grade
in school 122 0.63 0.26 0.25 <0.001

Biederman J, et al 2009
ADHD: Impact of Childhood Tx on Psych
80

70

60

50

40

30

20

10

Treatment N=75 No Treatment N=326

Halmoy et al 2009
ADHD: Occupational Outcome
90

80

70

60

50

40

30

20

10

In Work Sick Leave Disability Rehabilitation Unemployed Other

Pension

Patients Controls
Halmoy et al 2009
ADHD: Impact of Childhood Tx on Work
45

40

35

30

25

20

15

10

Work Sick Leave Disability Rehabilitation Unemployed Other

Pension
Treatment No Treatment Halmoy et al 2009
Brad @ 19 - ROH Adolescent Services

 Student,living with very supportive parents, conflicted

relationship with mother, presented for general re-
evaluation.
 Accutane for acne.
 Presentation: Problems mainly with school work.
Difficulty with organization. Motivation problematic.
 Diagnosis: ADHD, LD
 Treatment: No ongoing treatment
 Outcome: Discharge from care after 3 therapy sessions
 Education – Patients, Families, FPs

Therapeutic alliance and Goal setting

• Limit goals to the Achievable
• “Pills don’t give skills”
• No Baseline Wellness
ADHD:
Pharmacotherapy Compliance
• Long Acting Preparations
• Cost and Ease of Refills
• Side effects – real and artefactual
Cessation Planning

Transfer of Care
 PFC Spatial Working Memory Circuit

Norepinephrine
Preferred
(Signal)

A2A

B1 & D1/5 Output

Dopamine D1

Dopamine
Pyramidal Neuron

Non-Preferred
(Noise)
Arnsten 2009
NE & DA Optimize Function of PFC

OPTIMAL

INSUFFICIENT EXCESSIVE

ADHD Impaired
Levels of Catecholamine
(Dopamine and Norepinephrine)
Effect Size (Cohen's d)
ADHD: Best Stimulant Dose?

80

70

60

50

40 OROS MPH
Placebo
30

20

10

0
36 mg/d 54 mg/d 72 mg/d 90 mg/d 108 mg/d Adler et al 2009
 Refill rates by age at 12 months
All ADHD Medications
18

16
16
14
14
12 12.7

10 % 11

9.3
8
8
6

0-5 6-12 13-19 19-24 25-54 >54

Age Categories

Verispan’s Patient Parameters (US) 3/05

CADDY: Male Patients in Great Britain
Prescriptions Received by Age from UK General
Practice Research Database 1999-2006
Prescriptions Received

791 Treatment cessation exceeded the estimated rate of persistence of ADHD.

Reduction in Rx greatest between 16 and 17 y.o. and on.

581

322

172

86 46 24
15 16 17 18 19 20 21
Long-Acting Psycho-stimulant Systems

Vincent, 2007
 Atomoxetine

Bupropion
Specific
Clonidine
Noradrenergic
Agents
Desipramine

Guanfacine
The Plan
0. Assessment /
Family Consultation / 3. Atomoxetine
Treatment Planning 3a. Combine
Atomoxetine
& Stimulant
Psychosocial
treatments
4. Buproprion
or TCA
1. Methylphenidate
or Dexedrine or MAS XR

5. Agent not used

1a. Amphetamine
in Step 4
not used in Step 1

2. Stimulant not used

in Step 1 6. Clonidine or Guanfacine

2a. Amphetamine
not used in Step 2 Consultation

Texas Algorithm for Tx of Simple ADHD Pliszka SR, et al. 2006.

Mono-therapy in Adult ADHD
Mono-therapy Months (percent) LAS IAS SAS
90
ATX BUP A2A

80

70

60

50

40

30

20

10

0 Christensen et al 2010
LAS IAS SAS ATX BUP A2A
Combination Therapy in Adult ADHD
70 Combination Therapy Months
(Percent)

Adjunctive Pharmacotherapy
60
A2A

50
BUP

40
ATX

30
SAS

20
IAS

10
LAS

0
LAS IAS SAS ATX BUP A2A
Primary Pharmacotherapy Christensen et al 2010
Adverse Effects

At optimal dose, few side effects other than transient

decrease in appetite and increase in sleep latency.

At excessive doses side effects similar to caffeine excess:

mild dysphoria, jitteriness, palpitations, headache,
irritability, tremor, loss of appetite.
Use active elucidation of adverse effects to guide dosage
titration.
Brad @ Psychopharmacology Unit 1995
 Running yard maintenance business with partner who carries admin
load. Very good at sales. Seen as generally gregarious and
personable.
 Presentation: Resolving MDE - tx by FP with Venlafaxine XR 150 mg,
clear history of seasonal exacerbations, often overwhelmed by
anxiety.
 Collateral hx from father
 Diagnosis: Major Depressive Episode, Hx of LD
 Treatment: Venlafaxine XR 150 mg, suggests add small doses of
Bupropion for fall exacerbations
 Outcome: Continue meds indefinitely, Do not smoke cannabis, no
follow up.
ADHD: Treating Comorbid PSUD

CAADRA on Substance Abuse:

Abstinence First,
Ambivalent about Marijuana

Alcohol Dependence N = 72 Wilens et al 2008

Acutely abstinent ADHD Adults
DBPCP Atomoxetine 25 -100 mg for 12 wks
Marked improvement ADHD
No difference in time to relapse to heavy drinking
CANMAT Anxiety and Adult ADHD

 Mixed depression and anxiety symptoms

 ADHD drugs appear to have a role
 atomoxetine (open trial) improved ADHD and
comorbid symptoms
 GAD and ADHD (open trials)
 Adjunctive atomoxetine
 Adjunctive extended release mixed amphetamine
salts (extended release)
 Social Anxiety Disorder atomoxetine (RCT)
Katzman et al 2014
Brad @ 27 (1997)
 Still running yard maintenance business,
 falling out with partner,
 Heavily indebted, CRA looking for back taxes and withheld CPP/EI.
 Presentation:
 marked withdrawal, isolation, prominent anxiety,
 self-injurious behaviour, prominent suicidal ideation,
 on Venlafaxine XR 75 mg only
 Assessment Instruments:
 HDRS-17 = 28
 ADD-SCL = 8/9 inattentive, 5/9 hyperactive
 WURS = 48 PRS = 17 Report Cards +++ inattentive
Brad - Assessment & Treatment @ 27

 Diagnosis: Recurrent MDE, ADHD, Probable LD

 Treatment: Trials of multiple medications w/o response
 Finally Desipramine 150 mg bid (level 581) and added Fluoxetine
10 mg to secure response.
 CBT introduced.
 Declined Stimulant
Tried MPH as child “teachers love it”, “I didn’t like me on it”
 Outcome: Full recovery of mood after TWO YEARS,
 Elects to shutdown business, look for specific trades training, Fair
tax adjudication letter successful, consumer proposal accepted.
CANMAT MDE and Adult ADHD
Lines of Treatment Treatment Recommendation

First Line Bupropion

Antidepressant + Long-acting Stimulant
Antidepressant + CBT (behavioural)

Second Line Desipramine

Nortryptyline
Venlafaxine

Third Line Antidepressant + Short-acting Stimulant

Antidepressant + Atomoxetine
Antidepressant + Lisdexamfetamine
Brad @ 32
 Attending Community College,
 Roommate pregnant with his child,
 reconnected with biological parents
 Presentation: struggling academically,
 no accommodations,
 likely had another MDE since 1997
 Assessment: Psychiatric (HDRS-17= 33),
 Family Input – marked irritability at times
 CAARS self report T scores > 80 Inattention & Memory,
DSM-IV inattentive symptoms, ADHD symptoms total
Brad @ 32

 Diagnosis: Recurrent MDE Severe ADHD

 Likely Bipolar Spectrum Disorder
 Treatment: Trials of multiple mood stabilizers
 finally Lamotrigine and MPH effective
 Outcome: Mood recovered over TWO Years
 Withdrew from program,
 Found employment in related field
 Referred to Mood Disorders but DNKA
ADHD: Risk of Bipolar Disorder by Age
40

35

30

25

20 CBCL- PBD Negative

CBCL-PBD Positive
15

10

0
0 1 2 3 4 5 6 7 8 9 10111213141516171819202122232425
Biederman et al 2009
Phenotype vs GWAS Pathway Genetics

ASD Bipolar HIV MDD Null SCZ

ADHD 0.04 <0.001 0.62 0.002 0.73 0.02
ASD <0.001 0.63 0.03 0.79 <0.001
Bipolar 0.91 <0.001 0.64 <0.001
HIV 0.02 0.08 0.97
MDD 0.84 <0.001
Null 0.158

60,000 participants from Psychiatric Genomics Consortium

Pearson correlation of pathway specific enrichment between datasets O’Dushlaine et al 2015
 CANMAT Bipolar Disorder and ADHD
Lines of Treatment Treatment Recommendations

First Line Bupropion

Second Line Mixed amphetamine salts
Methylphenidate
Modafinil
CBT
Third Line Atomoxetine
Venlafaxine
Nortriptyline
Desipramine
Lisdexamfetamine
Brad @ 46
 Present: Separating from spouse,
 male tradesman, working for city
 estranged from 14 yo daughter (by roommate),
 alcohol abuse
 Presentation: presented to ER with suicidal ideation,
conflict with supervisor, off work for 4 months
 Assessment:
 Psychological (union): Depression, Impulsivity
 Psychoeducational (private): ADHD,
 LD both Working Memory and Processing Speed
Brad @ 46
 Diagnosis: Bipolar Disorder, ADHD, ODD?, LD
 Treatment: IPT focused initially on family transition then on
work place issues
 Lamotrigine 200mg
 OROS MPH 72mg
 Lurasidone 40mg
 Outcome: Returning to work
 Work hardening program
 Declared disability and specific accommodations in place
 Some limited restoration of relationship with daughter
 Mood remitted not fully recovered.
ADHD in Older Adults
 Data from Longitudinal Aging Study Amsterdam
 1494 participants screened for ADHD
 231 had structured diagnostic interview
 Estimated prevalence rate of;
Syndromatic ADHD was 2.8%
Symptomatic ADHD was 4.2%

 More symptoms reported in Young elderly (60-70 yrs)

vs older elderly
Michielson et al 2012
ADHD and TS/ OCD

 OCD and comorbid TS – 87% ADHD

More anxiety, more ADHD, more impulsive
More hoarding, sexual/religious, aggressive
Both OCD and TS better on Risperidone
Pimozide improved TS only
Paroxetine (33 mg)effective for rage

Alvarenga et al 2012
Bruggeman et al 2001
Bruun and Budman 1998
Treatment of Comorbid ASD

 Often diagnosed as Personality DO

 No RCT to guide treatment, typically
extrapolated from pediatric literature
 Risperidone and psychostimulants reported in
case studies
 One open label trial of low dose venlafaxine
 Littlesense of progress since early papers on Mikkelson 1982,
Sporn and Pinkser 1981,
the use of stimulants and antipsychotics in Hollander et al 2000,
children Simeon et al 2002,
Roy et al 2009,
Dove et al 2012,
Hofvander et al 2009
Closing Remarks
YOU HAVE A PLAN!
0. Prevention
1. Understand the challenges and limitations of
pharmacological management of ADHD in Adults
2. Recognize that the most effective initial
treatment of ADHD may target significant
comorbidities
3. Be confident in your decisions regarding use of
medications to treat ADHD
The Plan
0. Assessment /
Family Consultation / 3. Atomoxetine
Treatment Planning 3a. Combine
Atomoxetine
& Stimulant
Psychosocial
treatments
4. Buproprion
or TCA
1. Methylphenidate
or Dexedrine or MAS XR

5. Agent not used

1a. Amphetamine
in Step 4
not used in Step 1

2. Stimulant not used

in Step 1 6. Clonidine or Guanfacine

2a. Amphetamine
not used in Step 2 Consultation

Texas Algorithm for Tx of Simple ADHD Pliszka SR, et al. 2006.

Discussion
Resource-Demand Imbalance Over the Life
Course of ADHD

Turgay, A. Et al 2012
Teen views on impact of ADHD and/or meds
Elicited Perceived Problems No Perceived Problems
Comments
School “Sometimes I forget to take “I don't see how it can make you get
[medication] and I will just be better grades, being on medicine. I used
so unfocused that I don't even to be bad but I got good grades, but my
know what the heck is going behavior was bad not my grades.”
on in the classroom.”

Social “When I am off the medicine I “In some ways, [the medicine] worked
feel like a complete moron too good but it killed your social life.”
for being so talkative.”

Personality “When you're off the medicine that is

the only time you can really be you.”

Brinkman W.B. Et al. 2011

Teen views on impact of ADHD and/or meds
Elicited Perceived Problems No Perceived Problems
Comments
Stigma “'You got ADHD? I really don't
want to get to know you.'”
Creativity “I feel more creative on the …” I really do kind of like having ADD …
medicine. When you are I am a really great artist and a great
actually able to focus on writer and I even had some things
something, like drawings, it published so I like it. For me, I think
comes out just beautiful.” it's defined as advanced daydreaming.”

Driving Skills “I never get behind the wheel “I can't really tell a difference how I
unless I am medicated because drive without [medicine]. I've been in
I could get sidetracked too an accident…that was not my fault. I
quickly.” don't think it [medicine] affects me at
all how I drive.”
Brinkman W.B. et al. 2011
MPH doses in transition to adult service
”almost half the recommended dosing”
Variable Category Dose median p-value
(IQR) mg/kg
Comorbidity Yes 0.46 (0.36, 0.70) 0.83
with ASD
No 0.51 (0.31, 0.75)

Total Yes 0.45 (0.36, 0.70) 0.87

Comorbidity
No 0.60 (0.28, 0.73)

Gender Male 0.47 (0.36, 0.70) 0.91

Female 0.53 (0.31, 0.75) Adamou, A. &

Bowers, S. 2011
PFC Connections
ADHD: Pharmacological Mechanisms
 Psychostimulants
 Increase DA in PFC, NAcc, and Striatum
 Increase NE in PFC
 But do not normalize task related activity
 PFC rCBF remains low vs. Normals

 Normalize rCBF in Cerebellar Vermis

 NE Reuptake Inhibitors
 NE neurons also reuptake and release DA in PFC
 Alpha 2A Agonists act in PFC and LC

 But emerging evidence suggests that the real target is

modulation of Glutamatergic transmission

Spencer et al 2014
Synergistic effects of α1, α2 & M1 in PFC
Zhang et al 2013
ADHD: Comparison of NE
Binding
NE Reuptake Ki (nM)
Desipramine 4.0
Atomoxetine 4.7
Duloxetine 7.5
D- Amphetamine 70
Methylphenidate 100
Paroxetine 310
Cocaine 480
Desvenlafaxine 560
Venlafaxine 1260
Dopamine Impact on Executive Function
Floresco 2013
 MAS XR Beaded Delivery System

Immediate-release Bead Extended-release Bead

Bead core Bead core

Drug layer
Drug layer
Overcoating
Overcoating Release-delaying
polymer
40%-50% 50%-60% Overcoating

Adderall XR PM, 2009.

MLR- MPH Delivery 1
OROS® Delivery System

1 2 Medicine
Compartment
#1

Outer Coat of Medicine

Medicine Compartment
#2

Push
Compartment

Morning 1 Hour Later

Tablet Shell
OROS = Osmotic-release oral system.
Chavez B, et al. Ann Pharmacother 2009; 43(6):1084-95.
 Lisdexamfetamine

O CH 3 O
H 2N H 2N
N OH CH 3
H +
H 2N

Site of cleavage d-amphetamine

NH 2 NH 2 (active)
Lisdexamfetamine l-lysine
(Prodrug)

Najib J. 2009
Atomoxetine
Specific NE reuptake inhibitor, causes increased DA levels in
frontal cortex
Recommended when stimulants are contraindicated
Minimal abuse potential, mild anti-anxiety effect
Slow titration will allow CYP 2D6 PM (7-10% pop) time to
express S/E at lower doses, may benefit from lower doses.
Use caution with concurrent use of 2D6 inhibitors (ie
paroxetine, fluoxetine)
Pivotal studies mean dose 93mg, long term mean 100mg
 Bupropion

 NE and DA reuptake inhibitor

 Available in SR (bid) and XL (qd) formats
 Off-label use in ADHD but used for concurrent
SUD or Mood DO
 Side-effects: headache, nausea, dry mouth,
insomnia, sweating, constipation, rare seizures
 Typically require doses of 400 to 450 mg daily
Clonidine

 Alpha 2 adrenergic receptor partial agonist indicated for

treatment of hypertension
 Not approved for ADHD but has shown some benefit
 Reduces symptoms of hyperactivity and impulsivity but
not inattention
 Side-effects: dry mouth, constipation, sedation,
dizziness, hypotension
 Useful as adjunct for insomnia
 Desipramine

 Active metabolite of Imipramine

 NE selective TCA,
 most studied TCA for treatment of ADHD
 Side-effects: dry mouth, constipation, sweating, blurred vision,
insomnia, decreased appetite, tachycardia, increased BP, ECG
changes, orthostatic hypotension, sedation
 Safe in Pregnancy (?)
 Checking Blood Levels can be helpful
 Guanfacine

 α2 agonist that preferentially binds to α2Α receptors

(approximately 100 times greater affinity than α2Β)
 Extended release compound approved for use in
children aged 6-12 and now adolescents
 Available in US as immediate compound for over 20 yrs
 Limited data on efficacy in adults
 No effect seen on executive and memory functions in
healthy males
 Stimulation of post-synaptic α2 in DLPFC increased
Taylor and Russo 2001
sensitivity and bias selectively for sad faces. Muller et al 2005
Schultz et al 2013
 Neuronal Nicotinic Agonists

 Multitude of lab studies showing nicotine and nicotinic agonists

improve memory, processing speed, attention, reaction time, and
executive function
 Substantial literature showing similar cognitive improvements
associated with nicotine administration in human non-ADHD subjects
 Current focus is on partial agonists of alpha 4 beta 2 nicotinic
acetylcholine receptors in the prefrontal cortex
 AZD 3480 effective at 50 mg on CAARS-INV Potter et al
 ABT 089 ineffective at both 40 and 80 mg Bain et al 2012
 Research ongoing to find nicotinic agonists that are safe and tolerable
(fewer GI or cardiovascular side effects)
Emerging Treatments
 Duloxetine n=30 6 wk at 60 mg improved CGI-I and -S Bilodeau et al 2014

 AMPA Receptor Modulator Adler et al 2012

 Org 26576 100 to 300 mg bid DBPCCO

 100 mg bid may have some promise
 Selective D4 Receptor Antagonist Rivkin et al 2012

 MK-0929 no differences in primary or secondary outcomes

 Metadoxine ER DBPCP Manor et al 2012
 Effective at 1400mg/d on CAARS-INV
 TMS Sham CO N=9 no difference Weaver et al 2012

 EEG biofeedback DB Sham not even a trend Logemann et al 2010

 Safe Drug Combos

 Relatively few studies on combination therapy and

mainly pharmacokinetic eg.,
 Guanfacine XR and MPH XR Roesch et al 2013

 Guanfacine XR and Lisdexamfetamine Roesch et al 2013

 Atomoxetine and Buspirone Sutherland et al 2012

 Combination had slightly greater effect

 Long Term Efficacy and Safety
 5 RCTs and 10 Open Label extension studies reviewed for
psychostimulants and atomoxetine
 All RCTs found medication more efficacious than placebo
 Extension studies showed maintained benefit
 Also examined naturalistic/observational studies
 Showed positive correlations between early recognition of ADHD,
stimulant treatment and outcome in ADHD adults

 OROS-MPH 34 wk continuation study DBPC Mean dose 78.4 +/- 32 mg/d

Biederman et al 2010
Fredriksen et al 2012
ADHD: Acute CVS Effects of Meds

Increases in; Systolic BP Diastolic BP Heart Rate

Methylphenidate NS NS 4.5
OROS MPH 3.5 4.0 4.5
Amphetamine 5.4 NS 7.3
Lisdexamfetamine NS NS 2.8, 4.2, 5.2
Desipramine NS 7.1 NS
Bupropion 5.9 NS 6.9
Atomoxetine 3.0 1.0 5.0
Wilens et al 2005 Biederman et al 2006 Adler et al 2009 Wernicke et al
ADHD and Risk of Serious CVS Events
 N= 443,198 in a FDA and AHRQ sponsored study
 150,359 adults aged 25 – 64
806,182 person-years exposure
 two X age, gender, year and site controls
Rx for atomoxetine, MPH, or amphetamine
 Median 1.3 years
 Adjusted rate ratio (and 95% confidence interval)
Current users 0.83 (0.72-0.96)
New users 0.77 (0.63-0.94)
 “apparent protective associations likely represent healthy
Habel et al 2011
user bias”
ADHD in STEP-BD

 Systematic Treatment Enhancement Program - BD

 First 1000 patients, Scant exclusions
 9.5% lifetime ADHD
 More likely male, More likely BPD I (82.8%)
 Earlier Onset (13.9 vs 18.0 yrs), Lower GAF
 More Lifetime Suicide attempts
 More and Earlier Violent Behaviour
 More Comorbidity – ANX, PSUD, PTSD
Nierenberg et al 2005
Nierenberg, A.A. et al 2005
ADHD: Post Secondary Accommodations
 Flexible scheduling for Assignments
 Notes, OHPs, Slides provided
 Digital Voice Recorder
 Plan Class Load
 Frequent Breaks
 Staff support/monitoring
 Quiet environment or headphones
 Additional time for work, tests, exams
ADHD: Workplace Accommodations

 Frequent Supervision and Monitoring

 Active Employment
 Flexible Scheduling
 Coaching
 Daily Goal Setting
 Frequent Breaks
 Quiet Environment or Headphones
ADHD: Family
 Get affected parent into treatment
 Team approach
 Have non-ADHD parent handle school homework
 Let non-ADHD parent handle time critical tasks
 ADHD parent takes care of the BUSY work
 Parental time-out when overwhelmed
 Strike When The Iron is Cold
 Watch out for
 The spouse becoming the parent
 Medication as the cure all
ADHD – ASD Latent Class Analysis
ADHD: Driving Impairment
More Accidents (and more at faults) (2-3x risk)
% with 2+ crashes: 40 vs. 6
% with 3+ crashes: 26 vs 9

Worse Accidents ($4200-5000 vs $1600-2200)

(crash with injuries: 60 vs 17%)

More Citations (Speeding - mean 4-5 vs. 1-2)

More Suspensions/Revocations (Mean 2.2 vs 0.7)

(% suspended: 22-24 vs. 4-5%)
WAIS IV
Full Scale

Verbal Performance

Verbal Working Perceptual Processing

Comprehension Memory Reasoning Speed