Overview of Adult Attention-Deficit Hyperactivity Disorder

1. Overview of Adult Attention-Deficit Hyperactivity Disorder Glenn Ashkanazi, PhD March 16, 2009

2. Take The Test • Never Rarely Sometimes Often Very Often • How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? • How often do you have difficulty getting things in order when you have to perform a task that requires organization? • How often do you have problems remembering appointments or obligations? • When you have a task that requires a lot of thought, how often do you avoid or delay getting started? • How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? • How often do you feel overly active and compelled to do things, like you were driven by a motor?

3. Score • Q#1,2,3 • Sometimes, Often, Very Often = 1 point each • Q#4,5,6 • Often, Very Often = 1 point • Total >4 (may be consistent w/ADHD)

4. Controversial • www.adhdfraud.org • http://hamptonroads.com/node/357171 • http://www.youtube.com/watch?v=VRPqaTy5oFA

5. “Hidden Disorder” • Symptoms obscured by: • Problems in relationships • Problems with organization • Problems with mood • Problems with substance abuse • Problems with employment • Problems, problems, problems

6. “Hidden Disorder” (cont.) • “Children outgrow ADHD” • Past focus on hyperactivity • Decrease by teen years • Current: • Focus on inattention & impulsivity

7. Prevalence (Children) • School age children in US (3-7%) (DSM-IV) • Gender: males (2-10:1) • Most cited (6:1) (referred samples) • 30-85% show symptoms into adulthood

8. Prevalence (Adults) • Adults in US (2-10%) • 4-5% most often cited (Kessler, 2005) • Persistence of Childhood ADHD • Prospective studies • Only Four>50% retention • Variations in selection/diagnostic criteria • Changes in sources of information • Persistence difficult to estimate

9. Etiology • “Executive Function Dysfunction” • Activate • Organize • Integrate • Manage • Self-regulation/self-control

10. Etiology (cont.) • Transition of Model • Then: Attention/Hyperactivity • Now: Developmental Disorder of Self-Dysregulation That Extends Across Time and Settings

11. Etiology (cont.) • Neurochemical transmission problem • (dopamine,norepinephrine) • Genetic: primary factor? • Parent w/ADHD = 57% of ADHD child • NO adult onset

12. “Difficult” pregnancy Prenatal exposure to EtOH/Tobacco Premature delivery Low birth weight High lead levels Injury to prefrontal regions When Heredity NOT a Factor

13. Diagnosis • Extensive support for symptom thresholds for children (Lahey et al., 1994) • Use of DSM-IV criteria for adults remains controversial (Riccio et al., 2005) • Criteria designed for, and based on, studies w/children • Lack of validation studies w/adults (Belendiuk, 2007)

14. Diagnosis (cont.) • Use of DSM-IV-TR • Symptom lists inappropriately worded for adults • Dx thresholds too restrictive • Some Sxs not even listed: • Procrastination, overreacting to frustration, poor motivation, insomnia, time mgmt problems • Level of impairment different btwn adults and children (marital, occupational, etc)

15. Diagnosis (cont.) • 3 Sub-types: (DSM-IV-TR) • Attention Deficit /Hyperactivity-Impulsivity Disorder-Predominantly Inattentive Type (ADHD-I) (314.00) (most common) • Attention Deficit /Hyperactivity-Impulsivity Disorder-Predominantly Hyperactive-Impulsive Type (ADHD-H) (314.01) • Attention Deficit /Hyperactivity-Impulsivity Disorder-Combined Type (ADHD-C) (314.01)

16. Diagnosis (cont.) • Longitudinal Studies: • Developmental influence • ADHD Sxs decrease with age (National Academy for the Advancement of ADHD Care, 2003) • Hyperactivity-Impulsivity (decrease) • Inattentiveness (persists)

17. Diagnosis (cont.) • True remission or measurement problem? • Several studies suggest DSM-IV criteria are too stringent for adult Dx. • Use of deviance model indicates higher rates • Potential New Model: • Norm-referenced vs. criterion-referenced Dx • Determining ADHD symptom thresholds specific to age groups • Developmentally Referenced Criterion (DRC) • 98th percentile; +2 SD

18. Diagnosis (cont.) • Abandon DSM-IV-TR? • Re-examine • Adults in different settings • Adults have different demands • Adults live & work independently • Children in more structured settings • Children under adult supervision

19. Diagnosis (cont.) • Either • Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level

20. Inattention Sxs • (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has difficulty organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities 

21. Hyperactivity • 2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level

22. Hyperactivity • a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often "on the go" or often acts as if "driven by a motor" (f) often talks excessively

23. Impulsivity • (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games)  • B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.  • C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).  • D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.  • E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder). 

24. Diagnosis (cont.) • Some hyperactive – impulsive or inattentive symptoms that caused impairment were present before age seven years • Some impairment from the symptoms is present in two or more settings • (e.g. at school, or work AND at home)

25. Diagnosis (cont.) • There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning • The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder and are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, personality disorder,etc.)

26. PTSD^ Mental retardation Substance intoxication* Bipolar disorder* Tourette’s Syndrome Depression Adjustment disorder Brain injury * = ADHD-C (severity) ^ = ADHD-H Brain tumors Multiple sclerosis Epilepsy Stroke Dementia Liver/renal problems Drug side effects Hyper/hypo-thyroidism Differential Diagnosis

27. Assessment Process • Comprehensive Evaluation Overview • Assess Psychopathology • Assess Functional Impairments • Assess Pervasiveness • Assess Age of Onset • Rule-Out Other Disorders That Explain Condition

28. Assessment Process (cont.) • Interview with patient and significant others • Developmental history • Medical/Psychiatric history • School/Work history • Past evaluations • Past treatments • Present/past ADHD symptoms • Impairment history

29. Assessment process (cont.) • 4 Core Questions: • Is there credible evidence that the patient experienced ADHD type symptoms in early childhood that by middle school years led to chronic impairment across settings? • Is their credible evidence that ADHD type symptoms currently causes the patient substantial and consistent impairment across settings?

30. Assessment process (cont.) • 4 core questions (cont.) 3. Are there explanations other than the ADHD that better accounts for the clinical picture? 4. For patients who meet criteria for ADHD, is there evidence for the existence of comorbid conditions?

31. Semi-structured Interviews • Conners Adult ADHD Diagnostic Interview for DSM-IV(CAADID) (Epstein, 2000) • Symptoms, developmental course, ADHD risk factors and comorbid psychopathology • Good test-retest reliability for Dx and symptoms • Good concurrent validity (Epstein, 2006)

32. Rating Scales • Conners Adult ADHD Rating Scales (CAARS) (Conners, 1999) • Self-report and observer scales • Test-retest high (.85-.95) • Correct classification rate = 85%

33. Assessment process (cont.) • Neuropsychological Testing • No single test or battery of tests has adequate predictive validity or specificity • Useful to support results from history, rating scales & analysis of current functioning

34. Neuropsychological Testing • Review of 35 studies (Woods, 2002) • Discrepancies between adults w/ADHD and normal controls on executive function • Stroop Tasks • Visual Attention • Response Inhibition • Continuous Performance Test (CPT) Computer-based • Attention (Sustained & Selective) • Impulsivity • Vigilence

35. Stroop

36. Comorbidities • Children: • 44% of children with ADHD=1other psych. Dx • 32% of children with ADHD=2 other psych. Dx • 11% of children with ADHD=3 other psych. Dx

37. Comorbidities (cont.) • Depression • Major (16-31%) • Dysthymia (19-37%) • Anxiety • Children (25%) • Adults (24-43%) (GAD) • Learning disability • 10-90%

38. Comorbidities (cont.) • Anti-social personality disorder • 7-18% • Bipolar disorder • 10% in adults • Tics/Tourette’s • ADHD children = 7% • Tourette children = 60% w/ADHD

39. Comorbidities (cont.) • Substance-abuse • 14-33% SA pts have ADHD • Lifetime rates of EtOH dependence/abuse = 32-53%

40. Malingering • Conscious fabrication or exaggeration of physical or psychological symptoms in the pursuit of a recognized goal (APA, 1994) • Benefits: • Stimulant Medications • Disability Benefits • Tax Benefits • Academic Accommodations • Symptom Validity Testing

41. Treatment • Children’s Guidelines for Treatment • American Academy of Pediatrics, 2001 • Adults = ??? • Overview • Symptom reduction/minimize neg effects • Education • Psychotherapy • Pharmacological

42. Treatment (cont.) • Education • Diagnosis is crucial • Signs and symptoms • Why diagnosis not made sooner? • Psychotherapy • Secondary emotional symptoms • Cognitive behavioral therapy

43. Treatment (cont.) • Drugs • Well established in children with ADHD (Wilens, 2003) • Stimulants (first line drugs) • Children (70-80% respond) • Adults (25-78% respond) (30% don’t!!!!) • Methylphenidate (Ritalin) • Amphetamine compounds (Adderall) • Dextroamphetamine (Dexedrine)

44. Treatment (cont.) • Drugs (cont.) • Release of norepinephrine and dopamine • Stimulant side effects: • Insomnia • Decreased appetite • Decreased weight • Irritability • Tics • Headache • Potential for Abuse

45. Treatment (cont.) • Stimulant administration: • Short-acting,low dose = titrate up • Move towards longer acting stimulants • Concerta = 6-12 hours • Ritalin SR = 6-8 hours • Cylert = 8-10 hours (possible liver damage) • If one doesn’t work, try another

46. Treatment (cont.) • Anti-depressants • Tri-cyclics (Desipramine-Norpramin; Atomoxetine-Strattera)** • Bupropion (Wellbutrin)-atypical • Venlafaxine (Effexor)-atypical • SSRIs = not shown to be effective **=Desipramine, then Strattera best

47. Medication Compliance • Adults compliant for brief period of time (i.e. 2 months) (Perwien, 2004) • ADHD medication adherence significantly and positively correlated with ADHD symptom severity (Safran, 2007)

48. Psychosocial Intervention • CBT • Self-Mgmt Skills Training • Environmental Restructuring • Psycho-education • Individual Psychotherapy • Family Therapy • Marital/Couple Therapy • Vocational Counseling • ADHD Coaching

49. Psychosocial Intervention • Cognitive Behavioral Therapy • Well-suited for adults ADHD • Many develop negative beliefs about the self • Treatment of co-morbid diagnoses • Treatment of functional problems • Focus on Training in: (Barkley, 2006) • Time Mgmt • Organizational Skills • Communication Skills • Decision-Making • Self-Monitoring • Chunking Large Tasks into Smaller Ones • Changing Faulty Cognitions

50. Future Directions • Prevalence of ADHD in criminal justice system-candidates for Tx. • Incidence of ADHD in geriatric population • ADHD in ethically and culturally diverse populations • Identify ADHD “profiles” • Empirically valid? • Differentially respond to treatments