ADHD in Adults Cherinet Seid, PGY II

OUT LINE History of ADD Etiology/Risk factors Diagnosis Introduction History of ADD Etiology/Risk factors Diagnosis Comorbid disorders Management

Introduction The only psych disorder 1st recognized in children Under recognized in adults Affects 4-5% adults “Persistent ADHD” 15-28% P-ADHD male predominant, A-ADHD not Psychiatric comorbidities

History of ADD 1930 - Minimal Brain Damage 1960 - Minimal Brain Dysfunction 1968 - Hyper-kinetic reaction of childhood 1980 - ADD with/without hyperactivity 1987 - ADHD Amphetamines used in 1937 Methylphenidate has been on market since 1955

Myths of ADHD

Common Scenarios Adults diagnosed in childhood & stopped rx Adolescents progressing to adult services Undiagnosed adults with rx-resistant comorbid Psych disorders Undiagnosed self referred adults Undiagnosed adults recognized by others(fam members, health professionals)

Effects of ADHD 1. Social & Work impairment $19.5 billion lost human capital/yr in US Increased risk to be arrested (>2x controls) 2. Marital & Parental impairment Rate of divorce & separation double that of general population 3. Accident Proneness Hospital visits & Admissions 26 % vs 18%

4.Driving Impairment

Effects cont’d 5. Substance use

Case 43 yr female, chemist, married, 3 kids Noticed similar characters as her 10 yr old son who is recently diagnosed with ADHD Has trouble concentrating, disorganized, impulsive & forgetful Frequently misplaces or loses objects Procrastinates and has difficulty with punctuality Feels overwhelmed by house hold chores although husband is supportive and calls her home ‘a disaster area’

Three sub types Predominantly inattentive type Predominantly hyperactive-impulsive type Combo

DSM-IV criteria Careless mistakes Not listening Not finishing projects At least 6 symptoms of inattention Careless mistakes Not listening Not finishing projects Forgetful Not following through Being disorganized Impulsive & forgetful Frequently losing/misplacing objects

DSM IV cont’d Hyperactivity-impulsivity Not able to sit still At least 6 symptoms of hyperactivity Hyperactivity-impulsivity Not able to sit still Inner feeling of restlessness Always on the go Talking too much Being impatient Interrupting Blurting things out

DSM-IV cont’d Sxs must be present before age 7 Interfere with ability to function Persist for more than six months Manifest in multiple settings Not be accounted for by other disorders

Risk Factors Biologic cause Environmental More genetic link than asthma, breast ca & schizophrenia. Environmental Frontal cortex hypometabolism Dopaminergic pathways

Screening for ADHD Adult Self -Report Scale (ASRS) 18 questions Assesses DSM-IV symptoms of ADHD

Assessment Process Assess current ADHD symptoms (assessment scales) Establish a childhood hx of ADHD Assess devt’al & functional impairement R/o other psychiatric disorders Obtain family hx of psych disorders Perform a physical exam, r/o medical causes Assess pt’s insight (?same with collateral hx)

DDx of A-ADHD Learning disabilities Mood disorders Anxiety disorders Mixed anxiety/depression Secondary ADHD syndromes due to brain injury Other causes of impaired cognitive & executive function

Treatment Need to treat is always based on functional impairment.

Multimodal Treatment Psychoeducation Rx of comorbid conditions Pharmacological Rxs Therapy (marital, individual, social skills, CBT) Light therapy Env’tal restructuring & appropriate physical & special interest activities

Pharmacotherapy Class Dose Adverse effects Stimulants Non-stimulants Methylphenidate Short acting Intermediate acting Extended release 10-60 mg 2-4x 10-60mg 1-2x 18-108 mg od Insomnia Headache Decreased appetite wt loss Nausea Bp & pulse changes Palpitations Non-stimulants Atomoxetine 80-100 mg 1-2 x Constipation Dry mouth Decreased appetite Insomnia Sexual dysfunction Dysmenorrhea Antidepressants Bupropion Desipramine 100 mg 2-3x 150-300 mg od 25-300 mg od Anxiety Insomnia Decreased appetite Risk of Sz Irritability Agitation

just remember… It is worth identifying A-ADHD Substantial burden of illness Potential for improvement with rx

Assessment Scales www.med.nyu.edu/psych/psychiatrist/adhd.html www.therapeuticresources.com www.checkmateplus.com www.guilford.com www.mhs.com www.caddra.ca www.harcourtassessment.com www.med.nyu.edu/psych/psychiatrist/adhd.html

References Approach to ADD in adults,Canadian Family Physician, vol 52;Aug 2006 Understanding the nature of adult ADHD, Schulich school of Medicine, CME booklet 2007 www.uptodate.com