ADHD in Adults: Separating the Wheat from the Chaff

1. ADHD in Adults:Separating the Wheat from the Chaff James Chandler, MD FRCPC

2. Why the current interest? • Pharmaceutical companies • Psychiatry • Cultural

3. Pharmaceutical companies • ADHD is a chronic disease, thus a great market • Adults with ADHD are directed to take medications even longer than depressed patients • Many ADHD drugs are now indicated for adults

4. Concerta, Adderall, Strattera, Ritalin, Alertec • No disorder, no drug • Where would Viagra be without Erectile Dysfunction?

5. Selling ADHD drugs requires • Identifying more consumers • Direct to consumer ads with “signs of ADHD” • Promoting the effectiveness of the treatment • Pharmaceutical company managed studies which have little application in the real world

6. Pharmaceutical Strategy • Producing a demand • Making people think that not paying attention is abnormal

7. Psychiatry’s Interest in ADHD

8. Developmental interests • Adult psychiatry research now focuses on early forms of adult illnesses • Depression, Bipolar Disorder, Psychosis, Anxiety Disorder

9. Developmental Interest • Child Psychiatry research follows up child illness into adult • ADHD, Autism, Tourettes, Separation Anxiety Disorder, Traumatized Children

10. Clinical Observations • Adult psychiatrists see the hyperactive children of their adult patients • Child psychiatrists attempt to have a conversation or appointment with the parents of their ADHD patients.

11. Cultural • More and more aspects of human behavior are now categorized as disorders requiring treatment • Aspergers, ED, and now EDS (Excessive Daytime Sleepiness)

12. Cultural • Disorder means less responsibility, so having a diagnosis might lessen consequences for misbehavior in general. • I can’t help it, I have ADHD

13. What is ADHD in adults? • The same two symptom dimensions as in children: • Hyperactive-Impulsive • Inattentiveness

14. Hyperactive-Impulsive • often fidgets with hands or feet or squirms in seat, • often leaves seat in classroom or in other situations in which remaining seated is expected • 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).”

15. Hyperactive-Impulsive • 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).”

16. Hyperactive-Impulsive • often has difficulty playing or engaging in leisure activities quietly, is often ‘on the go’ or • often acts as if ‘driven by a motor,’ and • often blurts out answers before questions have been completed

17. Hyperactive-Impulsive • often has difficulty awaiting turn • often interrupts or intrudes on others (eg, butts into conversations or games)”

18. Decreased Attention • often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities; • often has difficulty sustaining attention in tasks or play activities; • often seems to be not listening when spoken to directly,

19. Decreased Attention • often has difficulty organizing tasks and activities, • often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework), • often loses things necessary for tasks or activities,

20. Decreased Attention • often is distracted easily by extraneous stimuli, • and is often forgetful in daily activities” [2] .

21. All present since childhood

22. What are the neuropsychological basis for these symptoms? • 10 years ago this was quite clear, but not any more • There are no psychological tests which all adults with ADHD do poorly on. • The neuropsychology of ADHD is so heterogeneous that some patients do poorly on just about any test

23. Psychological tests can not diagnose ADHD. • Nevertheless, the more executive function problems, the worse the academic and occupational outcome:

24. Executive dysfunction • Organization and planning • Working memory deficits • The ability to hold information “ïn your mind” so you can compare scenarios, solutions, and consequences

25. Executive dysfunction • Response Inhibition Problems • Can’t resist an impulse to move, act, or think while on another task • Sustained attention • Shifting/Mental Flexibility • Interference control

26. What are functional deficits in ADHD in adults?

27. Occupational and Academic • More dropouts, lower occupational achievement • More likely fired • More likely to quit • More bankruptcies • Not as wealthy

28. Family • More Separations • Divorce

29. Legal • More driving accidents, arrests for all causes

30. Psychiatric • Increased bipolar disorder, depression, anxiety disorder, substance abuse, smoking, Antisocial behavior

31. Medical • Increased accidents, head trauma, fractures, poisonings

32. What are the causes of ADHD?

33. Genetic • 75% heritability, but no one gene causes this • 50% of children of ADHD patient will have some signs of ADHD

34. Biological Adversity • Prematurity • Smoking or drinking in pregnant mother • Food additives? • Obstetrical Complications

35. Psychosocial Adversity • Poverty • Single parenthood • Social class • Chronic family conflict • Low family cohesion • Exposure to current, not past, parental psychopathology • Abuse

36. What looks like ADHD but isn’t? • Drug abuse • Depression • Hypomania • Head Injury syndromes • Post encephalitis, structural brain lesions

37. What looks like ADHD but isn’t? • Other toxins • Horrible home issues • Neurodegenerative • On and on………..

38. How does it classically appear? • Parents of clearly diagnosed patients of yours with ADHD • Pearl: if someone has three or more children and none of them have ADHD, probably the parents don’t either. • Clearly diagnosed ADHD children grown up.

39. How does it present? • About 1/3 will still be disabled as adults, with very few growing out of it after age 30. • Addiction Treatment Centres and follow up • Depending on the centre, 25-35% of the people in treatment programs have ADHD, too. • Severe accident follow up

40. Hyperactive in a wheelchair or rehab unit?

41. When should you be very suspicious that this is not ADHD? • Stable family life, occupation, and just psychological distress • New onset problems as adult

42. When should you be very suspicious that this is not ADHD? • Come in on their own – not brought by spouse, friend, parent, etc • Have a list of questions and an organized presentation of their history

43. Treatment

44. Three equally challenging issues

45. Compliance • Missed appointments • Drop ins • script refills • lost prescriptions vs. diversion

46. Dealing with the illness • Dealing with the financial, legal, familial, and physical sequale • Dealing with having a chronic psychiatric illness • Dealing with comorbid disorders

47. Psychotherapy • Few trials, but the only success stories so far are for skill training with modules on organizing and planning, distractibility, adaptive thinking, and procrastination this one has been used in a double blind trial of persons who were treated with medications and partially responded.

48. This is the manual from that study and a copy is on the table

49. This is the therapist manual - copy on the table

50. Medical Treatment of ADHD in Adults • First step is to match the drug to the person, given that almost everyone will have some comorbid problem.