Experimental fMRI Study on the Comparison of the Brain Function Effects of a Single Dose of Guanfacine and Lisdexamfetamine Relative to Placebo in Children and Adolescents With ADHD.
Phase: NA
Conditions: ADHD
Sponsor: King's College London

Experimental fMRI study on the comparison of the brain function effects of a single 
dose of guanfacine and lisdexamfetamine relative to placebo in children and 
adolescents with ADHD 
 
 
NCT03333668 
 
 
27/03/2019 

Experimental fMRI of Guanfacine and Lisdexamfetamine in ADHD Adolescents 
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1. PROTOCOL FULL TITLE: Experimental fMRI study on the comparison of 
the brain function effects of a single dose of Guanfacine and Lisdexamfetamine 
relative to placebo in children and adolescents with ADHD. 
Protocol Short Title/ Acronym: AGUALIS 
 
Study Identifiers  
ClinicalTrials.gov ID: 
 
REC Number: 
 
UKCRN Number: 
 
Protocol Version 
Number: 
5 
Date: 
27/03/2019 
 
(Co) Sponsor(s) 
Name: 
Professor Reza Razavi 
Vice President & Vice Principal (Research & Innovation)  
Address: 
Room 5.31, James Clerk Maxwell Building 
King’s College London 
57 Waterloo Road, London SE1 8WA 
Telephone: 
02078483224 
Fax: 
 
Email: 
reza.razavi@kcl.ac.uk 
(Co) Sponsor(s) 
Name: 
Carol Cooley 
South London and Maudsley NHS Foundation Trust 
R&D Department  
Address: 
Room W1.11 
Institute of Psychiatry, Psychology & Neuroscience (IoPPN) 
De Crespigny Park 
London SE5 8AF 
Telephone: 
02078480251 
Fax: 
 
Email: 
slam-ioppn.research@kcl.ac.uk 
 

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Chief Investigator  
Name: 
Prof Katya Rubia 
Address: 
Department of Child & Adolescent Psychiatry/SGDP PO46 
Institute of Psychiatry, Psychology & Neuroscience  
King’s College London 
De Crespigny Park 
London SE5 8AF 
Telephone: 
02078480463 
Fax: 
 
Email: 
katya.rubia@kcl.ac.uk 
 
Name and address of Co-Investigator(s), Statistician, Therapy Service, Laboratories 
etc 
Name: 
Oliwia Kowalczyk 
Position/ Role: 
PhD Student  
Address: 
Department of Child & Adolescent Psychiatry/SGDP PO46 
Institute of Psychiatry, Psychology & Neuroscience  
King’s College London 
De Crespigny Park 
London SE5 8AF 
Telephone: 
02078480384 
Fax: 
 
Email: 
oliwia.s.kowalczyk@kcl.ac.uk 
 
Name: 
Prof Mitul Mehta 
Position/ Role: 
Professor of Imaging and Psychopharmacology 
Address: 
Centre for Neuroimaging Sciences (PO89) 
Institute of Psychiatry, Psychology & Neuroscience 
King’s College London 
De Crespigny Park 
London SE5 8AF 
Telephone: 
02032283053 
Fax: 
 
Email: 
mitul.mehta@kcl.ac.uk 
 
 
 

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Name: 
Prof Paramala Santosh  
Position/ Role: 
Professor in Developmental Neuropsychiatry & Psychopharmacology 
Address: 
Department of Child & Adolescent Psychiatry/ASB 
Institute of Psychiatry, Psychology & Neuroscience 
King’s College London 
De Crespigny Park 
London SE5 8AF 
Telephone: 
02078480756 
Fax: 
 
Email: 
paramala.1.santosh@kcl.ac.uk 
 
Name: 
Dr Celine Ryckaert 
Position/ Role: 
Clinical Lecturer 
Address: 
Department of Child & Adolescent Psychiatry 
Institute of Psychiatry, Psychology & Neuroscience 
King’s College London 
De Crespigny Park 
London SE5 8AF 
Telephone: 
 
Fax: 
 
Email: 
celine.ryckaert@kcl.ac.uk 
 
2. Study Synopsis 
TITLE OF EXPERIMENTAL STUDY: 
Experimental fMRI study on the comparison of the brain function 
effects of a single dose of Guanfacine and Lisdexamfetamine 
relative to placebo in children and adolescents with ADHD. 
Protocol Short Title/Acronym: 
AGUALIS 
Study Type: 
Basic Science Study 
Sponsor Name: 
King’s College London 
 
Chief Investigator: 
Oliwia Kowalczyk 
UKCRN Number:  
 
REC Number: 
18/LO/0472 

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Medical Condition or Disease Under 
Investigation: 
Attention Deficit Hyperactivity Disorder (ADHD) 
Purpose of Experimental Study: 
To compare single dose effects of Guanfacine extended release 
(GXR) and Lisdexamfetamine (LDX) relative to placebo and 
compared to controls on ADHD fMRI brain function during 
typically compromised cognitive tasks that are modulated by 
these drugs (motor inhibition, working memory, and sustained 
attention). 
Primary Objective: 
To investigate the common and drug-specific effects of single-
dose GXR and LDX, compared to placebo on brain function in 
ADHD using fMRI. 
Secondary Objective(s): 
To assess the effects of the two drugs on performance on the 
tasks. 
Study Design: 
Cross-sectional, Case-control, Crossover, Placebo Controlled, 
Randomised, Single-dose and Single-site study 
Endpoints: 
1) Brain activation as measured by 
blood−oxygen−level−dependent (BOLD) response as 
obtained by functional magnetic resonance imaging for 
each of the 3 tasks and the resting state. 
2) Dependent variables extracted from performance on 
tasks.  
Sample Size: 
20 ADHD adolescents, 8-20 years 
20 healthy controls, 8-20 years 
Summary of Eligibility Criteria: 
ADHD patients: 
Meeting clinical diagnosis for Attention-Deficit Hyperactivity 
Disorder (ADHD); age range 8-20 years; medication-naïve or 
non-medicated in the 3 months; no comorbid conditions other 
than autism, phobias, eating disorders, oppositional defiant and 
conduct disorder or mild anxiety and depression; IQ > 70; heart 
rate > 65 beats/minute; systolic blood pressure > 90 mm Hg, 
diastolic blood pressure < 90 mm Hg. 
Healthy controls: 
No clinical diagnosis of ADHD or any other major psychiatric 
disorder; age range 8-20 years; psychoactive medication-free; 
no mental health conditions; IQ > 70. 
Intervention  
(Description, 
frequency, 
details 
of 
delivery) 
Each ADHD patient will be scanned 3 times, under either LDX, 
GXR, or placebo, in randomised order (visits 1, 2, 3). Each 
patient will receive one single clinical oral dose of GXR, LDX, 
and placebo and undergo a fMRI scan 4.5 hours after ingestion. 
Then they will receive nothing for a week and then be scanned 
again one week later on the single dose of the other conditions 
(placebo or drug) (visits 1, 2 and 3). 
Healthy controls will be tested once, unmedicated. 
Comparator Intervention: 
Not applicable 
Maximum Duration of the Study for a 
Subject: 
3 weeks 

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Version and Date of Final Protocol: 
Version 5 27/03/2019 
Version 
and 
Date 
of 
Protocol 
Amendments: 
 
 
3. Revision History 
Document ID - (Document 
Title) revision X.Y 
Description of changes from previous revision 
Effective Date 
 
 
 
 
4. Glossary of terms (Optional) 
ADHD = Attention Deficit Hyperactivity Disorder 
fMRI= functional Magnetic Resonance Imaging 
IoPPN = Institute of Psychiatry, Psychology & Neuroscience 
KCL = King’s College London 
LDX = Lisdexamfetamine  
GXR = Guanfacine Extended Release 
5. Protocol Contents 
 
1. 
PROTOCOL FULL TITLE. ..................................................................................................................... 1 
2. 
STUDY SYNOPSIS ................................................................................................................................ 3 
3. 
REVISION HISTORY ............................................................................................................................. 5 
4. 
GLOSSARY OF TERMS (OPTIONAL) .................................................................................................. 5 
5. 
PROTOCOL CONTENTS ...................................................................................................................... 5 
6. 
BACKGROUND & RATIONALE ............................................................................................................ 7 
7. 
STUDY OBJECTIVES AND DESIGN .................................................................................................... 7 
7.1 
STUDY OBJECTIVES ............................................................................................................................... 7 
7.1.1 
Primary endpoints ........................................................................................................................ 8 
7.1.2 
Secondary endpoints ................................................................................................................... 8 
7.2 
STUDY DESIGN ..................................................................................................................................... 8 
7.3 
STUDY FLOWCHART .............................................................................................................................. 8 
8. 
STUDY DESIGN ................................................................................................................................... 11 
8.1 
STUDY DETAILS .................................................................................................................................. 11 
8.2 
FREQUENCY AND DURATION OF INTERVENTION ..................................................................................... 12 
8.3 
SUBJECT COMPLIANCE ........................................................................................................................ 12 
8.4 
STUDY ADHERENCE ............................................................................................................................ 12 
8.5 
CONCOMITANT MEDICATION ................................................................................................................. 12 
9. 
RESEARCH ENVIRONMENT .............................................................................................................. 12 
10. 
SELECTION AND WITHDRAWAL OF SUBJECTS ............................................................................ 13 
10.1 
INCLUSION CRITERIA ........................................................................................................................ 13 

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10.2 
EXCLUSION CRITERIA ....................................................................................................................... 13 
10.3 
SELECTION OF PARTICIPANTS ........................................................................................................... 14 
10.4 
WITHDRAWAL OF SUBJECTS ............................................................................................................. 14 
10.5 
EXPECTED DURATION OF STUDY. ..................................................................................................... 15 
11. 
STUDY PROCEDURES ....................................................................................................................... 15 
12. 
ASSESSMENT OF SAFETY ................................................................................................................ 17 
12.1 
SPECIFICATION, TIMING AND RECORDING OF SAFETY PARAMETERS. .................................................. 17 
12.2 
PROCEDURES FOR RECORDING AND REPORTING ADVERSE EVENTS ................................................... 18 
12.3 
STOPPING RULES ............................................................................................................................ 19 
13. 
STATISTICS ......................................................................................................................................... 19 
13.1 
SAMPLE SIZE ................................................................................................................................... 19 
13.2 
RANDOMISATION .............................................................................................................................. 19 
13.3 
ANALYSIS ........................................................................................................................................ 19 
14. 
STUDY STEERING COMMITTEE ....................................................................................................... 20 
15. 
DATA MONITORING COMMITTEE ..................................................................................................... 20 
16. 
DIRECT ACCESS TO SOURCE DATA AND DOCUMENTS .............................................................. 20 
17. 
ETHICS & REGULATORY APPROVALS ........................................................................................... 20 
18. 
QUALITY ASSURANCE ...................................................................................................................... 20 
19. 
DATA HANDLING ................................................................................................................................ 20 
20. 
DATA MANAGEMENT ........................................................................................................................ 20 
21. 
PUBLICATION POLICY ....................................................................................................................... 21 
22. 
INSURANCE/INDEMNITY ................................................................................................................... 21 
23. 
FINANCIAL ASPECTS ........................................................................................................................ 21 
24. 
SIGNATURES ...................................................................................................................................... 21 
25. 
REFERENCES ..................................................................................................................................... 21 
 

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6. Background & Rationale 
 
Attention Deficit/Hyperactivity Disorder (ADHD) is defined by age-inappropriate problems 
with inattention, impulsiveness, and hyperactivity. ADHD is one of the most common 
childhood disorders affecting 5-10% of children. Currently, stimulants are first-line treatment 
for ADHD (Wilens, 2008). A meta-analysis of fMRI studies of single Methylphenidate (MPH) 
effects shows consistent upregulation and normalisation of the ventral attention system (IFC 
and basal ganglia; Rubia et al., 2014a) which is consistently reduced in ADHD relative to 
controls causing attention and inhibition deficits (Rubia et al., 2014b, Hart et al., 2013). MPH 
also deactivates areas of the default mode network (Rubia et al., 2014a), representing mind 
wandering, which is typically enhanced in ADHD, causing attention lapses and impairing 
performance (Rubia et al., 2014b, Christakou et al., 2013). The mechanisms of action of 
more recently licenced stimulant (Lisdexamfetamine - LDX) and nonstimulant (Guanfacine 
Extended Release - GXR) drugs on ADHD brain function, are, however, unknown. LDX is 
efficacious in reducing ADHD symptoms with larger effect sizes than MPH (Soutullo et al., 
2013). In animal studies, LDX produces more substantial increases in catecholaminergic 
neurotransmission in prefrontal cortex and striatum (Rowley et al., 2014). Cognitively, it also 
improves academic performance, executive functions and attention in ADHD (Turgay et al., 
2010). However, the effect of LDX on brain function in ADHD is unknown. GXR reduces 
ADHD symptoms (Wilens et al., 2015) with larger effect size than Atomoxetine (ATX; Sikirica 
et al., 2013). It is a selective α2-adrenoceptor agonist, enhancing noradrenaline 
neurotransmission in the prefrontal cortex (Wang et al., 2007). Guanfacine improves 
planning, working and emotional memory, associative learning (Jakala et al., 1999, Swartz 
et al., 2008), selective and flexible attention (Fox et al., 2015), while in ADHD it improves 
sustained attention and interference inhibition (Scahill et al., 2001). fMRI and PET studies 
in humans (and animals) show that guanfacine enhances DLPFC, striato-thalamic and 
parietal activation (Swartz et al, 2010) during working memory (McAllister et al., 2011), 
choice behaviour (Kim et al., 2012), selective attention (Clerkin et al., 2009), stress (Fox et 
al., 2012), and emotion processing (Schultz et al., 2013; Schultz et al., 2014). GXR and LDX 
thus have positive effects on ADHD behaviour and cognition, but their underlying brain 
mechanisms are unknown. It is paramount to understand the differential mechanisms of 
action of these two drugs on ADHD brain function relative to each other. 
7. Study Objectives and Design  
7.1 
Study Objectives 
Aim of the study 
The aim of this study is to understand the mechanism of action of two recently licensed 
drugs for ADHD on brain function and cognition. We will compare the brain activation 
changes elicited by Guanfacine extended release (GXR; a non-stimulant drug) with the brain 
activation changes elicited by Lisdexamfetamine (LDX; a stimulant drug) and by placebo in 
20 currently non-medicated patients with ADHD using functional Magnetic Resonance 
Imaging (fMRI). Additionally, we will test 20 unmedicated healthy controls to test for potential 
normalisation of the two drugs on ADHD cognition and brain function. For this purpose, we 
intend to scan participants during their performance of tasks of attention, working memory, 
and inhibition, which we know from previous studies to elicit abnormal brain activation 
patterns in ADHD patients (Rubia et al., 2005; Smith et al., 2006). Additionally, prior to each 
scanning session participants will complete a battery of neurocognitive tasks, which were 
previously shown to be impaired in ADHD (Rubia et al., 2007). ADHD participants 

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performance on the neurocognitive tasks will be compared across sessions and to the 
performance of healthy controls.  
 
Objectives of the Study 
The proposal is for a suitably powered experimental randomised placebo-controlled double-
blind study to test the mechanism of LDX and GXR compared to placebo in ADHD children. 
7.1.1 Primary endpoints 
Brain activation as measured by blood−oxygen−level−dependent (BOLD) response as 
obtained by functional Magnetic Resonance Imaging (fMRI) for each of the 3 tasks and a 
resting state scan. 
1) A working memory task (N-back task) (6 min) 
2) A tracking stop task (9 min) 
3) A parametric sustained attention task (12 min) 
4) A resting state scan (8 min) 
7.1.2 Secondary endpoints 
Dependent variables extracted from performance on the above listed tasks completed in the 
scanner. Dependent variables extracted from performance on the neurocognitive battery of 
tasks: 
1) Go/No-go (5 min) 
2) Interference inhibition (Simon task) (5 min) 
3) Continuous performance task (8 min)  
4) Time discrimination task (5 min) 
5) Vigilance task (7 min) 
7.2 
Study Design 
Cross-sectional, Case-control, Crossover, Placebo Controlled, Randomized, Single-dose 
and Single-site. 
7.3 
Study Flowchart 
For ADHD patients: 
 
 
Pre-assessment 
Visit 1 
 
Visit 2 
Visit 3 
Date  
 
 
 
 
Start / End time 
 
 
 
 
Researcher Administered 
Eligibility checklist 
 
 
 
 
K-SADS (P/C) 
 
 
 
 
Self-Administered 
Background Information (P) 
 
 
 
 
Edinburgh Handedness (C) 
 
 
 
 
SCQ (P)  
 
 
 
 
CPRS (P) 
 
 
 
 
ADHD-RS (P) 
 
 
 
 
Adverse Effects Scale (P) 
 
 
 
 
Neurocognitive Measures 

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WASI (30-40min) 
 
 
 
 
Go/No-go task (5min) 
 
 
 
 
Interference inhibition (Simon) (5min) 
 
 
 
 
Continuous performance task (8min) 
 
 
 
 
Time discrimination task (5min) 
 
 
 
 
Vigilance task (7min) 
 
 
 
 
fMRI Working Memory task (6min) 
 
 
 
 
fMRI Tracking Stop task (9min) 
 
 
 
 
fMRI Sustained Attention task (12min) 
 
 
 
 
fMRI Resting State (8min) 
 
 
 
 
Forms 
Consent form child  
 
 
 
 
Consent form parent  
 
 
 
 
MRI safety form 
 
 
 
 
MRI request form 
 
 
 
 
Receipt of payment 
 
 
 
 
 
1 week 
1 week 
 
PRE-ASSESSMENT 
VISIT 1 
VISIT 2 
VISIT 3 
Eligibility 
Assessments 
LDX / GXR / Placebo 
Neurocog. Battery 
Neurocog. Battery 
Neurocog. Battery 
EH 
K-SADS 
SCQ 
ADHD-RS 
CPRS 
WASI 
AES 
ECG 
BP 
MRI Scan 
MRI Scan 
MRI Scan 
AES 
AES 
AES 
 
 
 
 
 
 
Mock MRI Scan 
 
 
 
 
 
 
 
 
 
 
Figure 1. Schematic overview of the design of the study. ADHD-RS, Attention Deficit Hyperactivity Disorder-Rating Scale; AES, Adverse 
Effects Scale; BP, Blood Pressure; CPRS, Conners’ Parent Rating Scale; ECG, Electrocardiogram; EH, Edinburgh Handedness; K-SADS, 
Kiddie-Schedule for Affective Disorders and Schizophrenia; Neurocog. Battery, Neurocognitive Battery of tasks; SCQ, Social 
Communication Questionnaire; WASI, Wechsler Abbreviated Scale of Intelligence. 
For healthy controls: 
 
 
Pre-assessment 
Visit 1 
 
Date  
 
 
Start / End time 
 
 
Each session of cognitive tasks will consist of the below: 
 
 
 
 
 
Go/No-go (5min) 
Interference 
inhibition  
(Simon task; 
5min) 
Continuous 
Performance 
(8min)  
Time 
Discrimination 
(5min) 
Vigilance (7min) 
Each MRI scan will consist of the below: 
 
 
 
 
 
Structural Scan 
(10min) 
fMRI Working 
Memory (N-back; 
6min) 
fMRI Tracking 
Stop Task (9min)  
fMRI Parametric 
Sustained 
Attention (12min) 
fMRI Resting 
State (8min) 
4.5 hours 

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Researcher Administered 
Eligibility checklist 
 
 
Self-Administered 
Background Information (P) 
 
 
Edinburgh Handedness (C) 
 
 
SCQ (P)  
 
 
CPRS (P) 
 
 
Neurocognitive Measures 
WASI (30-40min) 
 
 
Go/No-go task (5min) 
 
 
Interference inhibition (Simon) (5min) 
 
 
Continuous performance task (8min) 
 
 
Time discrimination task (5min) 
 
 
Vigilance task (7min) 
 
 
fMRI Working Memory task (6min) 
 
 
fMRI Tracking Stop task (9min) 
 
 
fMRI Sustained Attention task (12min) 
 
 
fMRI Resting State (8min) 
 
 
Forms 
Consent form child  
 
 
Consent form parent  
 
 
MRI safety form 
 
 
MRI request form 
 
 
Receipt of payment 
 
 
 
 
 
 
PRE-ASSESSMENT 
VISIT 1 
Eligibility 
Assessments 
Neurocog. Battery 
MRI Scan 
EH 
SCQ 
CPRS 
WASI 
 
 
Mock MRI Scan 
 
 
 
 
 
 
 
 
 
 
Figure 1. Schematic overview of the design of the study. ADHD-RS, Attention Deficit Hyperactivity Disorder-Rating Scale; CPRS, Conners’ 
Parent Rating Scale; EH, Edinburgh Handedness; K-SADS, Kiddie-Schedule for Affective Disorders and Schizophrenia; Neurocog. 
Battery, Neurocognitive Battery of tasks; SCQ, Social Communication Questionnaire; WASI, Wechsler Abbreviated Scale of Intelligence. 
Each session of cognitive tasks will consist of the below: 
 
 
 
 
 
Go/No-go (5min) 
Interference 
inhibition  
(Simon task; 
5min) 
Continuous 
Performance 
(8min)  
Time 
Discrimination 
(5min) 
Vigilance (7min) 
Each MRI scan will consist of the below: 
 
 
 
 
 
Structural Scan 
(10min) 
fMRI Working 
Memory (N-back; 
6min) 
fMRI Tracking 
Stop Task (6min)  
fMRI Parametric 
Sustained 
Attention (12min) 
fMRI Resting 
State (8min) 

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8. Study Design 
8.1 
 Study Details 
There will be two groups. The first group will comprise 20 ADHD patients between 8 and 20 
years who will participate in the double-blind, randomised, active drug condition, within-
group, placebo-controlled experimental fMRI study. The second group will consist of 20 
healthy young people between 8 and 20 years old, who will act as a control group and be 
scanned only once under no drug. Each ADHD participant will be assessed in baseline 
measures during the pre-assessment. Then the ADHD patient will be scanned 3 times under 
each of these 3 drug conditions: GXR, LDX, and placebo. We will compare the patient 
groups under the acute dose of LDX and GXR with placebo in a randomised, within-group, 
placebo-controlled design. Every patient will receive a single typical clinical weight-adjusted 
dose of GXR (0.05mg/kg, being rounded to the closest dose of 1mg, 2mg, or a maximum of 
3mg GXR), LDX (30mg for participants under 30kg, 50mg for participants over 30kg body 
weight) and placebo (10mg Vit C) in one of the scans, in a randomised order. Advice 
regarding drug dosage has been specifically obtained from an experienced child psychiatrist 
with expertise in paediatric psychopharmacology. For fMRI studies of single dose effects, it 
is common practice to use the standard typical clinical target dose that is given to patients 
after a period of titration rather than the initial dose that would be given clinically on the first 
day in continuous clinical drug administration where patients are titrated up to the optimal 
dose. This is to test for the brain effects of a typical dose of the medication under 
investigation in the patient population. This was also done in our previous fMRI studies 
where we tested the single dose effects of a standard clinical dose of Methylphenidate 
(0.03mg/kg) and Atomoxetine (1mg/kg) (Cubillo et al., 2012). 
It is generally agreed that for Guanfacine to show clinical effects, it should be administered 
continuously for approximately 6 weeks. In the case of a single dose study this is a clear 
limitation. Nonetheless, while behavioural effects might need long term administration to 
appear, it has been shown in previous fMRI studies that brain function changes will be 
apparent after a single dose. This is based also on similar observations in studies 
investigating the related drug Atomoxetine, which is also a noradrenalin agonist. 
Atomoxetine is also a non-stimulant medication for ADHD that shows behavioural effects 
after several weeks but we have shown brain function effects after one single dose in ADHD 
patients (Cubillo et al., 2013; Smith et al., 2013). 
ADHD patients will be scanned 4.5 hours after drug administration (where drugs have shown 
to have maximum plasma concentration). They will be scanned 3 times, one week apart, 
under each drug condition (LDX, GXR, placebo). Scanning session duration: 60 min.  
Healthy controls will be scanned once, under no drug condition, and complete the same 
protocol as ADHD patients. 
Each participant will receive £20 for the pre-assessment visit and £50 for each scanning 
session to reimburse them for their time (i.e. £170 in total for ADHD patients and £70 for 
healthy controls). We will also reimburse any travel expenses and can arrange taxis or other 
travel if required. After each visit participants will receive a token showing the amount that 
he or she will be paid for the session (i.e. £20 or £50). Payments will be given at the end of 
the patient’s participation in the study, i.e. they will exchange the tokens they collected for 
money. 

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8.2 
Frequency and Duration of Intervention 
Each ADHD subject is expected to visit the IoPPN for a pre-assessment and 3 testing 
sessions performed at 4 separate visits one week apart.  
The scans will be performed at intervals of 7 days to allow for sufficient washout periods. 
The literature shows that GXR has a half-life of approximately 17 hours (Cruz, 2010) and 
LDX of approximately 9 hours (Boellner et al., 2010). Following the general guideline of 
calculating washout period as 6.5 times the half-life of the drug, the appropriate washout 
period for GXR is 4.6 days and for LDX 2.4 days. Consequently, there should be no drug 
interactions if the scans are performed at 7-day intervals.    
The first scan will be performed approximately a week after the initial assessment (described 
in section 11 of this document). Each ADHD patient will receive a single typical clinical 
weight adjusted oral dose of GXR (0.05mg/kg, being rounded to the closest dose of 1mg, 
2mg, or a maximum of 3mg GXR), LDX (30mg for participants below 30kg, 50mg for 
participants above 30kg body weight), and placebo (10mg Vitamin C) in one of the scans, 
in a randomised order. Patients will be scanned 4.5 hours after drug administration (where 
drugs have shown to have maximum plasma concentration). In each testing session 
participants will complete a 60-minute-long MRI scan consisting of various tasks (described 
in section 11 of this document). Total time for which each subject will be enrolled in this 
study is 3 weeks during which he or she will complete one 4-hour long pre-assessment and 
3 hourly scanning sessions (a total of approximately 7 hours). 
Healthy controls will visit IoPPN twice: for a pre-assessment and for one fMRI and cognitive 
testing session. 
8.3 
Subject Compliance 
Young people with ADHD included in the study will be medication naïve (or not have had 
medication in the past 3 months) and they will have to wait to start their medication (if they 
are planning to have medication) until the end of the study. This may be inconvenient for 
some patients but we will only include participants who are prepared to do this. Furthermore, 
we will attempt to keep the length of the testing period for each patient to a minimum, by 
scanning participants with minimum intervals (1 week) between scans.  
8.4 
Study Adherence 
No adherence issues are expected as this is a single dose study with the medication being 
provided by the researcher on the day of the scan. 
8.5 
Concomitant Medication 
Patients included in the study will be medication naïve or not have taken medication in the 
past 3 months.  
9. Research Environment 
The study will be conducted at an academic institution, the Institute of Psychiatry, 
Psychology & Neuroscience, at King’s College London, UK. The medication will be provided 
by Shire Pharmaceuticals Limited and given to Maudsley Pharmacy who will perform the 
overencapsulation for blinding and dispensing. The PhD student will collect and administer 
the drugs to participants; this will be done under clinical supervision. A Child Psychiatrist (Dr 
Celine Ryckaert) will prescribe the medication, will be present at the end of the session and 
will be on-call during the scan. Additionally, there will be a second psychiatrist working on 
the study who will be able to provide cover for times when Dr Ryckaert is unavailable. All 

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fMRI scans will be completed at the 3T GE scanner at the Centre for Neuroimaging Sciences 
(CNS) at the IoPPN. 
10. Selection and Withdrawal of Subjects  
10.1 Inclusion Criteria  
Twenty young people with ADHD, 8-20 years old, medication-naïve or medication free 
for at least three months, recruited from local clinics, meeting DSM-5 criteria for 
ADHD using ADHD Diagnostic Interview and rating scales.  
- Age range: 8-20 years 
- Medication-naïve or on non-medicated for at least 3 months  
- Meeting DSM-5 diagnosis of ADHD 
- Score above clinical cut-off on the ADHD module of the Kiddie Schedule for Affective 
Disorders and Schizophrenia (K-SADS) (Kaufman et al., 1996) 
- Score above clinical cut-off for ADHD on the short forms of the Conners Parent Rating 
Scales, CPRS (Conners et al., 2008) 
- Score above cut-off on the ADHD Rating Scale, ADHD-RS (DuPaul, et al., 1998) 
- IQ > 70 as tested on the WASI-II (Wechsler et al., 1999) 
Mood and depression symptoms, autism, phobias, anxiety, conduct disorder, oppositional 
defiant disorder, and eating disorders will be allowed. 
Twenty healthy young people, 8-20 years old, will be recruited.  
- Age range: 8-20 years 
- Not using psychoactive medications  
- Score below cut-off for ASD on the Social Communication Questionnaire (SCQ) (Rutter et 
al., 2001) 
- Score below cut-off for ADHD or other disorders on the short forms of the Conners Parent 
Rating Scales, CPRS (Conners et al., 2008) 
- IQ > 70 as tested on the WASI-II (Wechsler et al., 1999) 
10.2 Exclusion Criteria  
Exclusion criteria for ADHD participants: 
- IQ < 70 (Wechsler et al., 1999) 
- Currently on ADHD medication or has been on ADHD medication in the past 3 months 
- Comorbidity with schizophrenia, bipolar disorder, learning disability, OCD, severe 
depression with current suicidal behaviour (as assessed by a clinical interview) 
- Neurological problems, i.e. a history of severe neurological illness, e.g. brain tumour, 
epilepsy or a history of symptomatic seizures, polyneuropathy etc. 
- Substance abuse history 
- Other illness (cardiovascular, renal, hepatic, metabolic) that would impact the data integrity 
or safety of the subject (i.e. contraindicated to any of the treatments) as determined by the 
investigators 

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- Contraindication to MRI. i.e., previous implantation of metallic material, pacemaker, 
implanted medication pumps, neural stimulators, claustrophobia 
- Unable to give informed assent or consent in the case of the parent 
- Contraindications for LDX and GXR use (i.e. advanced arteriosclerosis, agitated states, 
hyperexcitability, hyperthyroidism, moderate or severe hypertension, symptomatic 
cardiovascular disease, heart rate < 65 beats/minute, systolic blood pressure < 90 mm Hg, 
diastolic blood pressure > 90 mm Hg) 
Exclusion criteria for healthy controls: 
- IQ < 70 (Wechsler et al., 1999) 
- Currently on psychoactive medication treatment 
- Diagnosis of a mental health disorder 
- Scoring high on the questionnaires for ADHD (CPRS) or Autism (SCQ) 
- Neurological problems, i.e. a history of severe neurological illness, e.g. brain tumour, 
epilepsy or a history of symptomatic seizures, polyneuropathy etc. 
- Substance abuse history 
- Other illness (cardiovascular, renal, hepatic, metabolic) that would impact the data integrity 
or safety of the subject (i.e. contraindicated to any of the treatments) as determined by the 
investigators 
- Contraindication to MRI. i.e., previous implantation of metallic material, pacemaker, 
implanted medication pumps, neural stimulators, claustrophobia 
- Unable to give informed assent or consent in the case of the parent 
10.3 Selection of Participants  
Patients will be recruited through Child and Adolescent Mental Health Services, via 
advertisement, social media, parent support groups as well as via Trust Consent for 
Contact mechanisms. Potential participants will be identified within the participating NHS 
Trusts (South West London and St George’s Mental Health Trust, Oxleas NHS Foundation 
Trust, Camden and Islington NHS Foundation Trust, Central and North West London NHS 
Foundation Trust, Barnet, Enfield and Haringey Mental Health NHS Trust, Great Ormond 
Street Hospital, City and Hackney CAMHS, South London and Maudsley NHS Foundation 
Trust, East London NHS Foundation Trust, Whittington Health NHS Trust, Guy’s and St 
Thomas’ NHS Foundation Trust, North East London NHS Foundation Trust, West London 
Mental Health NHS Trust).  
The healthy controls will be recruited through advertisement on social media and other 
online platforms, community spaces (e.g. libraries), schools, and newspaper adverts. 
10.4 Withdrawal of Subjects  
There is little evidence for side or adverse effects of the single dose LDX and GXR, hence 
withdrawal due to adverse effects is not expected. Nevertheless, potential adverse effects 
have been listed in the participant information sheet which will be provided to participants 
and their parents for their information. Participation will be discontinued if  
• the participant decides they no longer wish to continue 
• recommended by the investigator 

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Should a patient decide to withdraw from the study, the reason for withdrawal will be 
recorded as detailed as possible.   
Participants who wish to withdraw from the study will be asked to confirm whether they are 
still willing to provide the study specific data at visits that were completed. 
10.5 Expected Duration of Study. 
1st May 2018 – 31st December 2020 
Provided a timely reception of ethical approval we will begin recruitment in May and expect 
to begin testing the first participant by June 2018. We predict that we will be able to test one 
participant a month, depending on participant and scanner availability. We aim to finalise 
data collection by 31st December 2020 latest. Following that, we will begin data analysis, 
preparation of publications, and the PhD student will begin thesis write up.   
11.  Study Procedures  
The following procedure will be followed in this study: 
We will recruit 20 young people aged between 8 and 20 years with a current diagnosis of 
ADHD, who have never taken medication for ADHD (medication-naïve) or who have not 
been on ADHD medication for at least 3 months. All participants will have no history of 
substance abuse and no neurological deficits, learning disability, reading, speech, or 
language disorder, no other major clinical psychiatric disorder other than ADHD and autism, 
and no contraindications for LDX or GXR. These patients will be identified within SLaM and 
other clinics and will have already received a diagnosis of ADHD from a clinician or will be 
on a community waiting list awaiting clinical ADHD assessment. The family will be given a 
letter inviting the patient to participate as well as an information sheet. 
If participants are interested in taking part their informed consent (or that of their parents 
where participants are under 16) will be sought and recorded by the PhD student. The PhD 
student will make sure that the participants have no contraindications to participation in this 
study (including MRI and drug related contraindications). Once they have agreed to 
participate in the study, we will invite parents and their child to come for a pre-assessment 
meeting at the Institute of Psychiatry, Psychology and Neuroscience where we will perform 
the following assessments: 
1) Edinburgh Handedness Inventory (Oldfield, 1971) 
2) IQ (WASI-II) (Wechsler et al., 1999) 
3) Social Communication Questionnaire (Rutter et al., 2001) 
4) Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), ADHD module 
(Kaufman et al., 1996); this assessment will be audio-recorded for reliability purposes, 
consent will be sought 
5) ADHD Rating Scale (ADHD-RS) to measure ADHD symptom severity (DuPaul et al., 
1998) 
6) The Conners-Third Edition: Parent Rating Scales, Short Form [Conner 3- P(S)] to assess 
ADHD severity (Conners, 2008) 
7) ECG; this will be performed to ensure the participants have no cardiac contraindications 
to using LDX or GXR, the results will be reviewed by a doctor; patients who have a heart 
rate below 65 beats/minute will be excluded 
8) Blood pressure; this will be measured in order to be able to exclude patients with systolic 

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blood pressure of < 90 mm Hg and diastolic blood pressure of > 90 mm Hg 
9) Physical measurements (i.e. weight); this will be taken to accurately calculate the 
medication dosage 
Additionally, the patient will be familiarised with the scanner environment by visiting the 
"mock scanner" and trained on the tasks he or she will later complete in the actual scanner. 
If eligible the patient will be invited to come back to the IoPPN to complete the three fMRI 
scans. Each patient will participate in three testing sessions performed at three separate 
visits one week apart. Each patient will receive a single typical clinical weight adjusted dose 
of GXR (0.05mg/kg, being rounded to the closest dose of 1mg, 2mg, or a maximum of 3mg 
GXR), LDX (30mg if below 30kg, 50mg if above 30kg body weight), and placebo (10mg 
Vitamin C) in one of the scans, in a randomised order. After approximately 3.5 hours and an 
hour prior to the scan the participant will complete a battery of the following neurocognitive 
tasks lasting approximately 40 minutes:  
1) Go/No-go - 5 min, assessing the participant’s ability to inhibit a motor response and 
selective attention (Rubia et al., 2007) 
2) Interference inhibition (Simon task) - 5 min, involving a stimulus-response incompatibility 
effect. The task measures interference inhibition and selective attention. In this task, 
subjects have to execute a motor response according to iconic information and to inhibit the 
tendency to make an incorrect response that is triggered by an interfering, and predominant, 
spatial information (Rubia et al., 2007) 
3) Continuous performance task - 8 min, measuring target detection, sustained attention, as 
well as selective attention (Rubia et al., 2007) 
4) Time discrimination task - 5 min, measuring the participant’s ability to discriminate 
between time intervals that differ by several hundreds of milliseconds (Rubia et al., 2007) 
5) Vigilance task - 7 min, assessing vigilance on the detection of signals that are difficult to 
identify (Mackworth, 1948). 
Subsequently, patients will be taken to the MRI suite to undergo a brain scan. Patients will 
be scanned 4.5 hours after drug administration (where drugs have shown to have maximum 
plasma concentration). The researcher at the scan (i.e. PhD student) will not know which 
tablet is given on each occasion. This has been designed this way to minimise bias. 
Medication details will be kept by the supervisor, and will be given to the parents after the 
three scans have taken place, and to the PhD student to group the data once all the subjects 
have been scanned. 
In each scanning session, the participants will complete the following tasks that have shown 
to elicit underactivation in task-relevant regions in ADHD and to be modulated by MPH and 
ATX: 
1) Working memory task (N-back task) - 6min, measuring 3 levels of working memory 
difficulty and will also assess the default mode network decrease with progressively 
increasing working memory (Cubillo et al., 2013, Chantiluke et al., 2014) 
2) Tracking stop task - 9min, measuring motor response inhibition and error monitoring 
(Rubia et al., 2005, 2011; Cubillo et al., 2013) 
3) Parametric sustained attention task - 12min, investigating the effects of increasing load 
on sustained attention on brain activation (Christakou et al., 2013, Murphy et al., 2015) 
4) Resting state fMRI - 8min, measuring intrinsic connectivity networks associated with 
ADHD (default mode network, cognitive control network, dorsal and ventral attention, 

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saliency, and motor networks). 
Total scanning time for each session will be approximately 60 minutes. The duration of 
testing for each subject will be 3 weeks. 
Additionally, a group of 20 healthy age-matched controls will be recruited. Healthy controls 
will have no diagnosis of ADHD or other major psychiatric conditions, they will be 
psychoactive-medication free, have no history of substance abuse and no neurological 
deficits, learning disability, reading, speech, or language disorder. Healthy controls will be 
assessed using the following measures during their first visit at the IoPPN: 
1) Edinburgh Handedness Inventory (Oldfield, 1971) 
2) IQ (WASI-II) (Wechsler et al., 1999) 
3) Social Communication Questionnaire (Rutter et al., 2001) 
4) The Conners-Third Edition: Parent Rating Scales, Short Form [Conner 3- P(S)] to assess 
ADHD and other disorders (Conners, 2008) 
Additionally, the participant will be familiarised with the scanner environment by visiting the 
"mock scanner" and trained on the tasks he or she will later complete in the actual scanner. 
If eligible the participant will be invited to come back to the IoPPN for a testing session that 
will involve the same cognitive and fMRI tasks as conducted with ADHD patients. The 
duration of testing for each healthy control will be one week or less. 
12. Assessment of Safety  
12.1 Specification, Timing and Recording of Safety Parameters.  
MRI is considered safe and non-invasive and there are no reported side effects. However, 
there is a slight risk that the scanner is sometimes perceived as unpleasant and 
uncomfortable. The researchers will be sensitive to this possibility and will suspend testing 
sessions at the request of the participant or at the first signs of distress and discomfort. The 
participant will be informed that he or she is free to terminate the scanning session 
whenever they wants to. Alerting mechanisms ensure easy communication and 
radiographers will constantly check that the participant is content to remain in the scanner. 
Adolescents are sometimes anxious about the scanner. To familiarise them with this new 
environment they will participate in a "mock scan" in an inactive scanner beforehand and 
be trained on the tasks included in the study. They will also be able to tell in the first scan 
whether they are happy to be scanned 3 times. Every effort will be made to ensure that 
they do not feel anxious or claustrophobic. However, if they feel that the scanner is 
frightening to them, they will not have to participate. The same applies for adolescents who 
feel claustrophobic in the scanner. 
The scanner is also noisy and this may be unpleasant for some children. We will, therefore, 
expose them to the noise beforehand in the mock scanner. If the children feel that they 
dislike the noise, they do not have to participate. Also, in order to minimize the discomfort 
of the noise, we will provide all participants with headphones that are specifically designed 
to reduce the noise level. This is standard procedure for all scanning subjects at the IoPPN. 
Participants will be informed of the non-invasiveness and safety of the MRI scan. 
Because we require 3 scanning sessions of 60 minutes of repeated scanning for this 
project, we decided to only scan older children, i.e. young people between 8 and 20 years. 
If the patients for whatever reason are not happy or do not tolerate the repeated scans and 
decide to drop-out of the research they are allowed to do so at any time. 

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During a research MRI scan, information is sometimes obtained about neurological 
abnormalities. This will be assessed by a clinical radiographer who will then inform the 
patient's GP about any unusual anomalies which appear to be a cause for concern. The 
participant's parent/guardian will then be informed about these by the GP.  
Young people with ADHD included into the study will be medication naïve or not had 
medication for at least 3 months and they will have to wait to start their medication (if they 
are planning to have medication) until the end of the study. This may be inconvenient for 
some patients but we will only include participants who are prepared to do this. 
Furthermore, we will attempt to keep the length of the testing period for each patient to a 
minimum, by scanning participants with a minimum intervals (1 week) between scans. 
Taking medication for the first time is a sensitive issue but this study will be under the strict 
guidance of a clinician, i.e. a child psychiatrist (Dr Celine Ryckaert) will be responsible for 
prescribing the medication and for discharging patients, the psychiatrist will also be on call 
on the day of each scan. The side effects (listed in the information sheet) may or may not 
be experienced by patients and this may be uncomfortable and/or distressing for both 
patient and parents. However, we expect that the majority of our participants will be 
recruited via clinics where they will be expecting to be prescribed medication for ADHD in 
the near future. This will mean they will most likely have had full and frank discussions 
about the advantages and disadvantages of medication with the clinician and will have 
thought carefully about this issue before being recruited for this study. 
The medication will be overencapsulated for blinding. To make it easy for patients to ingest 
the capsules the smallest size was chosen after consultation with Maudsley Pharmacy. 
The 3T MRI scanner, which is CE marked, will be used for functional neuroimaging protocol 
as well as the conventional structural neuroimaging protocol. One of the functional imaging 
protocols will involve the use of multi-echo scanning sequence. The multi-echo sequence 
will significantly improve the quality of the resting state data, as it will reduce motion, 
respiration, cardiac function, and other non-neuronal artefacts. The sequence will be 
applied to the resting state scan only as the resting state data is highly sensitive to such 
artefacts. The enhanced functional multi-echo neuroimaging protocol used in the Institute 
of Psychiatry Centre of Neuroimaging Studies includes minor modification of the 
conventional use of the CE marked scanner. A customised pulse sequence program (i.e. 
software) has been developed to allow enhanced functional multi-echo imaging on the 
General Electric Magnetic Resonance Imaging (MRI) scanner to be used for this study. As 
application of this sequence involves using the MRI scanner outside its CE marking, a 
formal risk assessment was undertaken in order to investigate the safety implications of 
the use of this sequence (and in particular any additional risks relative to the manufacturer 
provided version) and to ensure appropriate procedures were in place to manage such 
risks. No additional risks were identified, and the sequence can therefore be used with 
standard precautions. Since its implementation, the sequence has been successfully 
applied in studies involving human participants 
12.2 Procedures for Recording and Reporting Adverse Events 
While there are side effects associated with long-term use of LDX and GXR, the single dose 
administration is unlikely to cause side effects. Nonetheless, any adverse effects will be 
monitored with a standardised parental questionnaire developed by Hill and Taylor (2001), 
extended to include GXR and LDX related side effects. Furthermore, a clinician will be on 
call for the scanning day in the unlikely case of any adverse effects. Moreover, potential side 
effects associated with the drugs (such as: drowsiness, headache, dizziness, dry mouth, 
fatigue, gastrointestinal problems, loss of appetite, palpitation, elevated blood pressure, 

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muscle spasm, euphoric mood) have been included in the information sheets for patient’s 
and their parents’ information.  
In case of any serious adverse events (SAE) standard HRA reporting procedures will be 
followed. Related and/or unexpected SAE will be reported to the relevant Research Ethics 
Committee within 15 days of the Chief Investigator becoming aware of the event. All other 
safety reporting, including progress reports, declaration of conclusion, and summary of final 
report, will be performed according to the HRA guidelines.  
12.3 Stopping Rules 
Changes in safety rules are very unlikely and there are no reasons why the study should be 
stopped. 
13. Statistics 
13.1 Sample Size 
For fMRI comparisons, a minimum N of 20 has been recommended (Thirion et al., 2007). 
Based on a previous fMRI comparison using whole brain analysis of acute effects of the 
ATX and MPH on the fMRI brain function in the same working memory task as proposed in 
this study, we calculated that for a power of 80% we would need an N of 15 subjects for a 
p < 0.05 and N of 20 for a p < 0.01 (Cubillo et al., 2013). A sample size of 20 is proposed to 
account for the fact that the novel contrast of GXR and LDX may potentially have a smaller 
effect size than the previous comparisons of MPH and ATX. Therefore, to obtain 20 
complete datasets 50 patients or more will be screened. This is done to ensure enough 
participants meet the recruitment criteria and to account for potential dropouts. 
13.2 Randomisation 
This is a within-patient experimental randomisation design. Each patient gets a single dose 
of each of the 3 drugs and will be scanned thereafter. The order of drug administration (LDX, 
GXR, placebo) will be randomised controlling for order effects and the testing will be 
performed in a double-blind fashion. The supervisor will be responsible for the randomisation 
and neither the researcher present at scan (i.e. PhD student) nor the parents and patients 
will know which drug is tested in any given session.  
The unblinding will occur at the end of data collection on approval by the Chief Investigator 
and supervisors. A copy of the blinding will be provided by pharmacy for each study visit to 
the study team for emergency unblinding. A further copy will be provided to a member of the 
Department of Neuroimaging unrelated to the study. They can be called at any time to 
unblind a specific session out of hours if an alternative unblinding option is unavailable. 
Unblinding protocol and reporting will be applied according to the local pharmacy 
procedures. 
13.3 Analysis 
Analyses of brain activation for the fMRI data will be conducted using SPM 
(www.fil.ion.ucl.ac.uk/spm) and FSL (www.fsl.fmrib.ox.ac.uk). All performance data will be 
analysed using SPSS and R. The hypotheses relating activation changes within patients 
after the acute drug administration will be tested using repeated measures ANOVAs with 
each of the 3 drug conditions as repeated measures (placebo, GXR, LDX).  

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Comparison between healthy controls and ADHD patients under placebo and under the two 
drugs will be conducted by 3 ANOVAs to test for brain abnormalities in ADHD relative to 
controls at baseline and to test for potential normalisation of the 2 drugs on brain activation. 
14. Study Steering Committee  
Supervisors will oversee the study. 
15. Data Monitoring Committee  
As this is an experimental study and not a clinical trial we will not have an external data 
monitoring committee. The supervisors of the study will form a data monitoring committee 
and assess the study progress and all other aspects of the study. They will meet once every 
6 months. 
16. Direct Access to Source Data and Documents 
Only the research team and named collaborators will have access to the data.  
17. Ethics & Regulatory Approvals 
This protocol and related documents will be submitted for review to an NHS Research Ethics 
Committee (REC). 
18. Quality Assurance 
Monitoring of this study will be to ensure compliance with Good Clinical Practice and 
scientific integrity will be managed by the study team.  
19. Data Handling  
The supervisor will act as custodian for the study data. The following guidelines will be strictly 
adhered to: 
• Patient data will be anonymised. 
• All anonymised data will be stored on a password protected computer. 
• All study data will be stored in line with the Data Protection Act. 
• All study data will be archived in line with Sponsor requirements. 
• Audio-recordings will be taken on a password protected encrypted smartphone 
provided by KCL for the purpose of this study. Only the study team will have access 
to the smartphone. Participants will provide an opt-in consent to have their recordings 
taken. Where participants will decide not to have their recordings taken this will not 
disqualify them from the study. The recordings will be kept on a password protected 
KCL PC in an anonymised format (as described in the above). Audio-recordings will 
be destroyed upon completion of the study. Nonetheless, participants will have the 
option to request to have their information (i.e. audio-recordings and any other 
material generated by the study) destroyed at any time. 
20. Data Management 
The data will be behavioural data, cognitive performance data, and fMRI data in electronic 
format and password protected. 

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The data to be analysed will be inputted into an SPSS datasheet in a linked-anonymised 
format. 
Data management will follow KCL guidelines. 
21. Publication Policy  
It is intended that the results of the study will be reported and disseminated at international 
conferences and in peer-reviewed scientific journals. 
22. Insurance/Indemnity  
A professional indemnity policy is in place from the sponsor (KCL) for all studies conducted 
at KCL. 
23. Financial Aspects  
Funding to conduct the study is provided by Shire Pharmaceuticals Limited. 
24. Signatures 
 
 
 
 
 
______________________________________ 
_________________________ 
Chief Investigator 
Date 
Print name 
 
______________________________________ 
_________________________ 
Statistician (if applicable) 
Date 
Print name 
25. References  
 
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