Adult ADHDAdult ADHD

Delicia GarnerDelicia Garner

March 25, 2006March 25, 2006

Master’s Project PresentationMaster’s Project Presentation

Adult Attention Deficit Adult Attention Deficit Hyperactivity DisorderHyperactivity Disorder

Prevalence = 100 million adultsPrevalence = 100 million adults Imbalance of chemical messengers in Imbalance of chemical messengers in

the brain that results in difficulties:the brain that results in difficulties: FocusingFocusing Organizing and prioritizing workOrganizing and prioritizing work Filtering out or ignoring distractionsFiltering out or ignoring distractions Thinking before actionThinking before action Delaying gratificationDelaying gratification

Childhood ADHDChildhood ADHD Common myth: that children with ADHD Common myth: that children with ADHD

“grow out of it”“grow out of it” But 65% of children diagnosed continue But 65% of children diagnosed continue

having symptoms into adulthoodhaving symptoms into adulthood Most people know the problems that Most people know the problems that

children with ADHD face – academic and children with ADHD face – academic and behavioral trouble at school, difficulty behavioral trouble at school, difficulty making and keeping friends, and stressful making and keeping friends, and stressful family situationsfamily situations

Few people are aware of serious Few people are aware of serious consequences of Adult ADHDconsequences of Adult ADHD

Consequences of Adult Consequences of Adult ADHDADHD

Adults with untreated ADHD areAdults with untreated ADHD are More than More than twicetwice as likely to as likely to have been have been

arrestedarrested 78%78% more likely to be more likely to be addicted to tobaccoaddicted to tobacco TwiceTwice as likely to have been as likely to have been divorceddivorced More than More than twicetwice as likely to as likely to have droppedhave dropped

out of high schoolout of high school TwiceTwice as likely to have held as likely to have held 6 or more jobs6 or more jobs

in the past 10 yearsin the past 10 yearsfrom: ADHD in Adults (A Guide to ADHD and Effective from: ADHD in Adults (A Guide to ADHD and Effective

Treatment) Treatment)

Recognizing Adult ADHDRecognizing Adult ADHD

Constant Constant disorganizationdisorganization, poor time , poor time management, and failure to plan aheadmanagement, and failure to plan ahead

Frequent Frequent forgetfulnessforgetfulness, often losing , often losing thingsthings

Continual problems Continual problems startingstarting or or finishingfinishing projectsprojects or tasks or tasks

ImpulsiveImpulsive decision making, and decision making, and saying saying things without thinkingthings without thinking

Ongoing problems Ongoing problems concentratingconcentrating and and paying attentionpaying attention

Continued…Continued…

Extreme Extreme restlessnessrestlessness or or fidgetinessfidgetiness Poor Poor angeranger control control Difficulty keeping Difficulty keeping jobsjobs MartialMartial problems and problems and relationship issuesrelationship issues

from: ADHD in Adults (A Guide to ADHD and Effective from: ADHD in Adults (A Guide to ADHD and Effective Treatment) Treatment)

ADHD in Children and ADHD in Children and AdultsAdults

The same, but differentThe same, but different Adult ADHD more difficult to Adult ADHD more difficult to

recognize, which is why many adults recognize, which is why many adults remain undiagnosedremain undiagnosed

Core impairments of ADHD - Core impairments of ADHD - inattention, hyperactivity, and inattention, hyperactivity, and impulsivity- remain the sameimpulsivity- remain the same

But the symptoms that result usually But the symptoms that result usually change as people get olderchange as people get older

Childhood Symptoms Childhood Symptoms Versus AdultVersus Adult

Hyperactivity Hyperactivity Can’t sit still, Can’t sit still,

always on the goalways on the go Climbs or runs at Climbs or runs at

inappropriate timesinappropriate times

Physical Physical ImpulsivityImpulsivity

Does things that Does things that result in injuriesresult in injuries

RestlessnessRestlessness Can’t stay focused on Can’t stay focused on

one thingone thing Is fidgety or impatientIs fidgety or impatient

Verbal ImpulsivityVerbal Impulsivity Says the “wrong Says the “wrong

thing” or speaks out thing” or speaks out of turnof turn

Continued…Continued… Has problems Has problems

waiting one’s turnwaiting one’s turn

InattentionInattention Can’t pay close Can’t pay close

attention in class attention in class or complete or complete schoolworkschoolwork

Interrupts others Interrupts others excessivelyexcessively

InattentionInattention Has difficulty Has difficulty

concentrating at concentrating at work and finishing work and finishing taskstasks

from: ADHD in Adults (A Guide to ADHD and Effective from: ADHD in Adults (A Guide to ADHD and Effective Treatment)Treatment)

ADHD: A Genetic LinkADHD: A Genetic Link

If a close family member has ADHD, If a close family member has ADHD, then the patient is at an increased then the patient is at an increased riskrisk

Especially ask about parents, Especially ask about parents, children and siblingschildren and siblings

Why so difficult to Why so difficult to diagnose?diagnose?

Lack of guidelines for primary care Lack of guidelines for primary care providersproviders

Lack of objectively verifiable testsLack of objectively verifiable tests Diagnostic criteria structured more Diagnostic criteria structured more

toward childhood diagnosestoward childhood diagnoses High rate of media attention predisposing High rate of media attention predisposing

adults toward self diagnosesadults toward self diagnoses Common comorbiditiesCommon comorbidities Concern of schedule II drug abuseConcern of schedule II drug abuse

Clinical PresentationClinical Presentation

Criteria for ADHD are specified in the Criteria for ADHD are specified in the Diagnostic and Statistical Manual of Diagnostic and Statistical Manual of Mental Disorders, fourth edition Mental Disorders, fourth edition (DSM-IV)(DSM-IV)

DSM-IV describes 3 subtypes of ADHDDSM-IV describes 3 subtypes of ADHD Predominately hyperactivePredominately hyperactive Predominately inattentivePredominately inattentive Mixed type with symptoms of other 2 Mixed type with symptoms of other 2

categoriescategories

DSM-IV Criteria A for DSM-IV Criteria A for ADHDADHD

For diagnoses, 4 criteria must be For diagnoses, 4 criteria must be met (Criteria A,B,C, and D)met (Criteria A,B,C, and D)

Criteria A has 2 subgroupsCriteria A has 2 subgroups EitherEither subgroup 1 or subgroup 2 subgroup 1 or subgroup 2

must be met in order for clinical must be met in order for clinical diagnoses diagnoses

Subgroup 1 of Criteria ASubgroup 1 of Criteria A Classic examples of Classic examples of inattentioninattention from from

subgroupsubgroup 11 Often fails to give close Often fails to give close attention to detailsattention to details or or

makes makes careless mistakescareless mistakes in work or other in work or other activities activities

Often has difficulty Often has difficulty sustaining attentionsustaining attention Often does not seem to Often does not seem to listenlisten when spoken to when spoken to

directly directly Often does not Often does not follow through on instructionsfollow through on instructions and and

fails to finishfails to finish duties in the workplace duties in the workplace Often has difficulty Often has difficulty organizing tasksorganizing tasks and activities and activities Often Often loses thingsloses things necessary for tasks or activities necessary for tasks or activities Often Often forgetfulforgetful in daily activities in daily activities

Subgroup 2 of Criteria ASubgroup 2 of Criteria A Classic examples of Classic examples of hyperactivity-hyperactivity-

impulsivityimpulsivity Often Often fidgetsfidgets with hands or feet or squirms in with hands or feet or squirms in

seat seat Often runs about or climbs excessively in Often runs about or climbs excessively in

situations in which it is inappropriate (in situations in which it is inappropriate (in adolescents or adults, may be limited to adolescents or adults, may be limited to subjective subjective feelings of restlessnessfeelings of restlessness) )

Is often "Is often "on the goon the go" or often acts as if "driven by " or often acts as if "driven by a motor" a motor"

Often Often talks excessivelytalks excessively Often Often blurts out answersblurts out answers before questions have before questions have

been completed been completed Often Often interruptsinterrupts or intrudes on others or intrudes on others

Criteria B, C, and DCriteria B, C, and D B. Some hyperactive-impulsive or B. Some hyperactive-impulsive or

inattentive symptoms that caused inattentive symptoms that caused impairment were present before age 7 impairment were present before age 7 years. years.

C. Some impairment from the symptoms C. Some impairment from the symptoms is present in two or more settings (e.g., is present in two or more settings (e.g., at school [or work] and at home). at school [or work] and at home).

D. There must be clear evidence of D. There must be clear evidence of clinically significant impairment in clinically significant impairment in social, academic or occupational social, academic or occupational functioningfunctioning

Criticisms of DSM-IVCriticisms of DSM-IV never been validated in adults never been validated in adults doesn’t include developmentally doesn’t include developmentally

appropriate symptoms for adults appropriate symptoms for adults fails to identify some significantly fails to identify some significantly

impaired adults who would benefit from impaired adults who would benefit from treatment treatment

the subtlety and subjectivity of ADHD the subtlety and subjectivity of ADHD symptoms in adults and the absence of a symptoms in adults and the absence of a single gold standard for confirming single gold standard for confirming diagnoses makes assessment challenging diagnoses makes assessment challenging

Differential DiagnosesDifferential Diagnoses

Comorbidity is rule rather than exception Comorbidity is rule rather than exception High rates of the following are found High rates of the following are found

among ADHD patients in virtually every among ADHD patients in virtually every study:study: antisocial personality antisocial personality learning disabilities learning disabilities substance abuse substance abuse major depression major depression anxiety disordersanxiety disorders

Other pertinent Other pertinent associationsassociations

Bipolar 1 (which usually occurs with Bipolar 1 (which usually occurs with more severe forms of ADHD)more severe forms of ADHD)

earlier onsets for major depressive earlier onsets for major depressive disorderdisorder

dysthymia dysthymia oppositional defiant disorder oppositional defiant disorder conduct disorder conduct disorder

Medical Conditions that Medical Conditions that Mimic ADHDMimic ADHD

HyperthyroidismHyperthyroidism petit mal and partial complex petit mal and partial complex

seizures seizures hearing deficits hearing deficits hepatic disease hepatic disease lead toxicity lead toxicity sleep apnea sleep apnea drug interactionsdrug interactions

Pharmacological Pharmacological TreatmentTreatment

STIMULANTS!!!!!!!STIMULANTS!!!!!!! Methylphenidate and amphetamine 1Methylphenidate and amphetamine 1stst

lineline Well-tolerated and safeWell-tolerated and safe Need to adjustNeed to adjust Most brand names are simply different Most brand names are simply different

delivery systems of Methylphenidate delivery systems of Methylphenidate (Ritalin®, Concerta®, Metadate CD®) (Ritalin®, Concerta®, Metadate CD®)

Pharmacological Pharmacological TreatmentTreatment

Nonstimulants (Wellbutrin®, Nonstimulants (Wellbutrin®, Strattera®)Strattera®) Antidepressants by natureAntidepressants by nature Effect not as robust as stimulantsEffect not as robust as stimulants But useful in patients that can’t tolerate But useful in patients that can’t tolerate

stimulant side effects, or have addictive stimulant side effects, or have addictive tendencies or comorbidities tendencies or comorbidities

Psychosocial TreatmentsPsychosocial Treatments

PsychoeducationPsychoeducation Educate the patient on their diagnosisEducate the patient on their diagnosis

PsychotherapyPsychotherapy Individual or groupIndividual or group

Behavioral/self-management skillsBehavioral/self-management skills Cognitive behavior therapyCognitive behavior therapy Skill building in planning and organizationSkill building in planning and organization

Other therapiesOther therapies Marriage/family (career) counseling, Marriage/family (career) counseling,

coachingcoaching

SummarySummary

Many symptoms of childhood ADHD Many symptoms of childhood ADHD extend into adulthoodextend into adulthood

Adult ADHD presents differently Adult ADHD presents differently than childhood inthan childhood in SymptomsSymptoms Social and economic consequencesSocial and economic consequences Psychosocial modes of treatmentPsychosocial modes of treatment

Summary (Continued)Summary (Continued)

Adult and childhood ADHD are the Adult and childhood ADHD are the same insame in Diagnostic criteria (inattention, Diagnostic criteria (inattention,

distractibility, impulsivity)distractibility, impulsivity) Pharmacological treatment (stimulants)Pharmacological treatment (stimulants)

Correct diagnosis and treatment Correct diagnosis and treatment improves outcomes exponentiallyimproves outcomes exponentially

DSM-IV has shortcoming but must DSM-IV has shortcoming but must widely trusted criteria on handwidely trusted criteria on hand

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