What to do with ADHD: Diagnosis and Treatment of ADHD in Adults in Primary Care Settings Cerrone Cohen, MD

ADHD Medications Aptensio XR Concerta Quillivant XR Quillichew ER Focalin XR Ritalin LA Metadate CD Metade ER Adhansia XR Focalin Ritalin Methylphenidate Chewable Methylin Solution Dyanavel Adzensy XR Adderall XR Evekeo Jornay PM Zenzedi Adderall ProCentra Intuniv Kapvay Stratterra Dexedrine Spanules Daytrana MyDayis

Objectives Utilize evidence based criteria to diagnose ADHD in adults and children Understand the role of psychological testing in evaluation of children and adults with ADHD Identify appropriate pharmacologic treatment strategies Understand how to select an initial treatment for ADHD and the management of treatment failure

ADHD: The Diagnosis

Attention Deficit Disorder (with or without hyperactivity) Hyperkinetic Reaction of Childhood Attention Deficit Disorder (with or without hyperactivity) Attention Deficit/Hyperactivity Disorder (with or without hyperactivity) First appeared in 2nd version of DSM in the late 60s Prevalence rates are between 5-10 %. A classroom of 30 kids has 1-3 kids with ADHD Attention Deficit/Hyperactivity Disorder (predominantly inattentive, hyperactive, or combined type)

ADHD Subtypes Predominantly Hyperactive/ Impulsive Presentation Inattentive Presentation Predominantly Combined Presentation Need 6 sx present for 6 months in either domain to have diagnosis for kids, only 5 for adults. Combined type requires meeting criteria for each.  There is also an unspecified category

Inattentive Symptoms Often fails to give close attention to details or makes careless mistakes Often has difficulty sustaining attention in tasks Often does not seem to listen when spoken to Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Must have 6 of 9 sx for 6 months Only need 5 sx if 17 or older Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments

Inattentive Symptoms Often does not follow through on instructions and fails to finish duties in the workplace Often loses things necessary for tasks or activities Often easily distracted by extraneous stimuli Is often forgetful in daily activities Must have 6 of 9 sx for 6 months Only need 5 sx if 17 or older Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments

Hyperactive Symptoms Often fidgets with or taps hands or feet or squirms in seat Often leaves seat in situations when remaining seated is expected Often runs about or climbs in situations where it is inappropriate (feelings of restlessness in adults) Often unable to play or engage in leisure activities quietly Is often “on the go” Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) d. Often unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor” (e.g.,). is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

Hyperactive Symptoms Often talks excessively Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation) Often has difficulty waiting his or her turn (e.g., while waiting in line) Often interrupts or intrudes on others (e.g., butts into conversations or activities, may intrude into or take over what others are doing). Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) d. Often unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor” (e.g.,). is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

ADHD Diagnoses: 5 Must Haves Must have 6/9 (kids) or 5/9 (adults) symptoms for 6 months Must be inconsistent with developmental level (kids) Must occur in more than 1 setting Must interfere with, or reduce the quality of, social, academic, or occupational functioning Must have several symptoms before age 12 4 additional musts

What About Adult Onset?

ADHD is a Pediatric Neurodevelopmental Disorder

ADHD as a Neurodevelopmental Disorder ADHD children have changes on fMRI and research suggests that they have lower activation in the frontal lobes and basal galnglia which control motor functioning and executive function. (planning, working memory) A number of patients have sx that persist into adult hood. There is emerging data to suggest that a number of patients with ‘adult adhd” did not meet criteria in childhood. Structural and Biochemical Changes Genetic Links

ADHD as a Neurodevelopmental Disorder ADHD children have changes on fMRI and research suggests that they have lower activation in the frontal lobes and basal galnglia which control motor functioning and executive function. (planning, working memory) A number of patients have sx that persist into adult hood. There is emerging data to suggest that a number of patients with ‘adult adhd” did not meet criteria in childhood. Symptoms can persist into adult hood

What Happens in Adulthood? Initial study of 2,000 twins 247 children with ADHD Persistent ADHD at age 18 Late Onset ADHD Remitted ADHD at age 18 193 (193) 54 (112 ) (54) Longitudinal study of 2k twins.  Evaluation of childhood ADHD (ages 5, 7, 10, and 12 years). Among participants aged 18 years, ADHD symptoms were evaluated 247 had childhood ADHD 21% (54)of those also met criteria at age 18 166 had adult adhd total 112 (67.6%) never met criteria at earlier interview 54 had persistant childhood sx 166 Adults with ADHD 67% Adults with ADHD had Adult-Onset Adapted From: Evaluation of the Persistence, Remission, and Emergence of Attention-Deficit/Hyperactivity Disorder in Young Adulthood JAMA Psychiatry. 2016;73(7):713-720.

Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Cohort of 1,037 New Zealanders born in 1972 and 1973 and followed to age 38 with 95% retention ADHD diagnoses made by a child psychiatrist at age 11 and 13, with supporting evidence from teachers and parents Assessed again by trained interviewers at age 38 Moffitt et al. Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study. Am J of Psych October 2015

Copyright © American Psychiatric Association. All rights reserved. From: Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study American Journal of Psychiatry Results 6% with ADHD Little overlap between the 2 groups Length of follow up is a strength, unmedicated Limits include small changes in DSM diagnoses from then to now, not sure what happens from adolescence to age 38, some substance abuse a The figure shows that most of the participants who had childhood ADHD did not have adult ADHD, and most of those with adult ADHD did not have childhood ADHD. The childhood and adult ADHD groups comprised virtually nonoverlapping sets. Date of download: 03/12/2019 Copyright © American Psychiatric Association. All rights reserved.

Copyright © American Psychiatric Association. All rights reserved. From: Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study American Journal of Psychiatry Results 6% with ADHD Little overlap between the 2 groups Length of follow up is a strength, unmedicated Limits include small changes in DSM diagnoses from then to now, not sure what happens from adolescence to age 38, some substance abuse a The figure shows that most of the participants who had childhood ADHD did not have adult ADHD, and most of those with adult ADHD did not have childhood ADHD. The childhood and adult ADHD groups comprised virtually nonoverlapping sets. Date of download: 03/12/2019 Copyright © American Psychiatric Association. All rights reserved.

Adult-Onset ADHD Reconsidered investigations are limited by relying on screening instruments to assess ADHD, not considering alternative causes of symptoms, or failing to obtain complete psychiatric histories 239 47 40 24 10 3 2 No ADHD at baseline assessment + Screen as Adults Significant Impairment No Sx in Childhood Not Due to Substances Not Due to another Disorder Cross Situational Sibley et al. Late-Onset ADHD Reconsidered with Comprehensive Repeated Assessments between Ages 10 and 25. Am J Psychiatry. 2018 Feb

Symptoms can persist into adulthood Symptoms can present in adulthood ? ADHD Adhd unspecified Symptoms can persist into adulthood Symptoms can present in adulthood

ADHD: Making the Diagnosis in the Office

ADHD Screening Questionnaires Children Vanderbilt Assessment Scales Conners Comprehensive Behavior Rating Scales Adults Adult ADHD Self-Report Scale (ASRS-v1.1) Connors Adults ADHD Rating Scale (CAARS) 4 additional musts

During the Visit End of the Visit Before the Visit Assess: Symptoms of Inattention and Hyperactivity Onset Contexts Objective Impairment Past mental health treatment/diagnosis Substance Use Make a Diagnosis or Consider referral Consider whether they are appropriate for treatment Consider setting up a return visit to discuss medication PHQ-9 GAD-7 ASRS (+/-) Treat 1st or consider psych referral Consider referral for testing Consider psych referral

What About Special Testing?

ADHD is ultimately a clinical diagnosis Testing can be helpful. Testing is best for helping rule in or out things that may mimic ADHD and other comorbid ocnditions.

ADHD Differential Anxiety Disorders Depression Sleep Disorders Substance Use Disorder Learning Disabilities Normal Unproductive Adult Mimic ADHD but can also coexist. Consider speech and language evaluations, psychometric testing, genetic testing

ADHD: Treatment

Why Treat ADHD in Adults? Increased risk of accidents and injuries Worse academic functioning Increased risk of substance use including early use of tobacco products Lower self esteem Difficulty maintaining employment

Considerations When Choosing a Medication Stimulant or Non Stimulant Short Acting vs Long Acting Cost and Coverage

ADHD Medications Aptensio XR Concerta Quillivant XR Quillichew ER Focalin XR Ritalin LA Metadate CD Metade ER Adhansia XR Focalin Ritalin Methylphenidate Chewable Methylin Solution Dyanavel Adzensy XR Adderall XR Evekeo Jornay PM Zenzedi Adderall ProCentra Intuniv Kapvay Stratterra Dexedrine Spanules Daytrana MyDayis

Contempla 50/50 Ritalin LA 30/70 Concerta Metadate CD

Ritalin, Methylin (methylphenidate) Focalin (dexmethylphenidate) Short Acting Methylphenidates “Ritalins” Concerta Metadate CD Daytrana Metadate ER Ritalin LA Ritalin SR Jornay PM Focalin XR Long Acting Adderall (mixed amphetamine salt) Dexedrine (dextroamphetamine) Short Acting Amphetamines “Adderalls” Long Acting Adderall XR Adzenys Mydayis Dexedrine Spansules Vyvanse* (lisdexamfetamine) Intuniv (guafacine) Kapvay (extended release clonidine) Long Acting Nonstimulants Straterra (Atomoxetine)

Amphetamines vs Methylphenidates The majority of patients will respond to either In general: Amphetamines are mild-moderately more efficacious than methylphenidates In children, methylphenidates may be better tolerated In adults, tolerability is similar Cortese et al Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2018.

Side Effects of Stimulants Lowers seizure threshold Appetite suppression Headaches Worsening anxiety or Irritability Insomnia Increase in BP and HR Decreased height? Other side effects include stomach aches and headaches Stimulants can increase bp and HR Atomexetine can do the same things Do good hx and exam and monitor vitals and cardiac ROS at each visit People with these contraindications may be better managed by a child psychiatrist

Contraindications to Stimulants Seizures or Tics Arrhythmias, CAD, or structural heart disease Substance Use High levels of anxiety or panic symptoms Abnormal HR or BP Weight Issues or Eating Disorders Benzodiazepine Use Other side effects include stomach aches and headaches Stimulants can increase bp and HR Atomexetine can do the same things Do good hx and exam and monitor vitals and cardiac ROS at each visit People with these contraindications may be better managed by a child psychiatrist

Alternatives to Stimulants A2 Agonists Guafacine (Intuniv) or Clonidine ER (Kapvay) Monotherapy or adjunct Long Duration Onset takes weeks Headaches, fatigue, abdominal pain, sedation, low bp Can be given in the evening SNRI Atomoxetine (Strattera) Onset takes weeks Long Duration Weight Based Dosing Needs to be taken Daily Weight loss, GI effects, increase in BP and HR, somnolence, SI Atomexetine (SNRI) onset in 1-4 weeks, give at night. 10-12 hours, dose based on weight. Must give every day, increase sucidal thinking, weightloss, nausea, somnolence, also associated with weight changes A2 agonist. KapVay (clonidine ER)- affective but less so than stimulants, takes 1-2 weeks to work, hypotension etc. Guafancine (more effective than kapvya) –add on or single as with clonidine, less side effects than clonidine; headache, fatigue, abdominal pain, and sedation

Treatment Pearls Short acting and long acting stimulants are not equal It’s okay to dose more than once a day Treat anxiety and depression first ADHD is an everyday problem not a prn problem If ineffective increase the dose, if duration is too short switch or add a dose Other side effects include stomach aches and headaches Stimulants can increase bp and HR Atomexetine can do the same things Do good hx and exam and monitor vitals and cardiac ROS at each visit People with these contraindications may be better managed by a child psychiatrist

Take-Aways The jury is still out on adult-onset ADHD ADHD is a clinical diagnosis Its okay to not to always be productive Don’t be intimidated by stimulants Ask for help if you need it

Questions?