Attention deficit hyperactivity disorder in adults

1. Attention deficit hyperactivity disorder in adults NURLIYANA BINTI DZULKARNAIN

2. ADHD-DEFINITION • Based on DSM-1V-TR criteria,defined as developmentally inappropriate poor attention span or age-inappropriate features of hyperactivity and impulsivity or both • At least for 6 months, occur before 7 years old • Cause impairment in academic or social functioning • Considered a childhood disorder

3. ADHD-CLASSIFICATION • The DSM-IV, or Diagnostic and Statistical Manual of Mental Disorders, 2000 edition, defines three types of ADHD: • Aninattentivetype • A hyperactive/impulsivetype • A combinedtype

4. Adult ADHD-Symptoms Inattentive type (ADHD-I) • Procrastination • Indecision, difficulty recalling and organizing details required for a task • Poor time management, losing track of time • Avoiding tasks or jobs that require sustained attention • Difficulty initiating tasks • Difficulty completing and following through on tasks • Difficultymultitasking • Difficulty shifting attention from one task to another

5. Adult ADHD-Symptoms Hyperactive/Impulsive-type (ADHD-H) • Chooses highly active, stimulating jobs • Avoids situations with low physical activity or sedentary work • May choose to work long hours or two jobs • Seeks constant activity • Easily bored • Impatient • Intolerant to frustration, easily irritated • Impulsive, snap decisions and irresponsible behaviors • Loses temper easily, angers quickly

6. Adult ADHD-Diagnosis • DSM-IV-TR criteria were developed for children and adolescents-cannot always applied to adults-alteration to criteria to fit adult symptoms • Symptoms stated in criteria not appropriate in adults-rely on observations to childhood activities • Under report the severity of symptoms • Impairment also include social and leisure activities,parenting,and intimate relationships

7. Adult ADHD-Diagnosis • Establishing whether the symptoms were also present in childhood, even if not previously recognized • Combination of a careful history of symptoms up to early childhood, including corroborating evidence from family members, previous report cards, etc. along with a neuropsychiatricevaluation • Also screening tests,ruling out depression,substanceabuse,anxiety,hyperthyroidism

8. Adult ADHD-Neurobiology • Structural differences(neuroimaging methods) • Significant reductions in Total cortical grey matter,prefontal and anterior cingulate volumes and right putamen/globuspallidus grey matter • Thinning of cerebral cortex in networks that mediate attention and executive fxRight hemisphere involving the inferior parietal lobule,dorsolateralprefontal anterior cingulate cortices

9. Adult ADHD-Neurobiology • Neurochemistry Near infrared spectroscopy • Increases oxygenated Hb in ventrolateralprefontalcortex,indicating reduced activation of this area in task related actvtsmarked in working memory • Higher N-acetyl-aspartate/creatine ratios in the prefrontal corticosubcotical region and left centrumsemiovale.

10. ADULT ADHD-Neurobiology • Neurochemistry Positron emission tomography (PET) • Involvement of dopamine transporter • Lower dopamine D2/D3 receptor activity in caudate ,hippocampus and amygdala Magnetic Resonance Imaging (MRI) • Reduced activation of the ventral prefontalcortex,anteriorcingulate cortex and striatum

11. IMPACT OF ADULT ADHD • Professional and economic impact -More likely to change jobs -Work productivity is lowerconcentrationdifficulties,disorganization and reduced ability to cope with large workload • Social problems -Lack of friendships & poor relationship with parents -Relationship difficulties -Problems adjusting after marriage -Parenting-more likely to have lack of parental discipline,-ve parent child interactions

12. IMPACT OF ADULT ADHD • Comorbidities -Mood disorders and anxiety disorders occur with greater frequency in adults with ADHD -Bipolar disorder -Substance abuse disorder • Sleep and activity disturbances -Difficulty in falling asleep and numerous waking throughout the nightdaytime fatigue -Driving accidents-attributed to impulsivity,inattention,loss of concentration and fatigue

13. ADULT ADHD-TREATMENT • Current guidelines by AACAP,CADDRA and BAP-combination therapy recommended:- • Psychoeducation, • An initial trial medication with titration to an individual effective dose, • Assesment of residual symptoms • Long term community follow-up • NICE Guidelines • Methylphenidate is first line drug • If ineffective or unacceptable-Atomoxetineor Dexamfetamine

14. ADULT ADHD-Treatment • First line-Pharmacotherapy -1st choice-Methylphenidate(psychostimulant) • Mechanism-Reuptake inhibition of monoamine transportersincreases levels of dopamine and norepinephrine in the brain • Available as immediate release (IR),extended release (ER),OROS MPH -2nd choice • Atomoxetine(non psychostimulant) -inhibit norepinephrine transporter

15. ADULT ADHD-TREATMENT • Pharmacotheraphy-Concerns • Methylphenidate -Abuse-esp short acting prescriptions risk of being injected or snorted -Risk of adverse cardiovascular events-MI and hypertension -Amphethamine-better side effect profile,better tolerated • Atomoxetine(non-stimulant medications) -Rare-increase potential for liver damage and suicidal ideation

16. ADULT ADHD-TREATMENT • Psychosocial treatment • As adjunctive treatment • CBT(15 weeks) -Motivational interviewing and practice -Repetition and review of skills such as organizing and planning,reducingdistractibility,problemsolving,adaptive thinking in times of stress. • Dialectic behavioural therapy(3 months) -Sessions discussing mindfullness,emotion regulation and impulse control -Also undertake daily exercises and reading educational materials regarding ADHD.

17. Thank you For your attention 