SPECIALIST PSYCHIATRIST ADD AND GIRLS ADHASA 2006 WITS DR SHABEER JEEVA SPECIALIST PSYCHIATRIST Melrose arch 011 684 1621 www.adhdclinicjeeva.com

ADHD In Girls DR. SHABEER A. JEEVA CHILD & ADOLESCENT PSYCHIATRIST M.D., D.PSYCH., F.R.C.P. (C) The Centre for Medical Excellence 2nd Floor 18 High Street Melrose Arch 2196

ADHD: Timeline of Definitions Minimal Brain Damage Adult ADHD Studied Hyperkinetic Reaction of Childhood (DSM-II) First Description of ADHD by Still Attention Deficit/Hyperactivity Disorder (DSM-III-R) Efficacy of Amphetamine 1902 1930 1937 1950 1968 1970 1980 1987 1994 The definition of ADHD has changed over the years, but the core symptoms of this neurobehavioral syndrome have always been defined by behavioral characteristics. In the early 20th century, these behavioral characteristics were considered the sequelae of an insult to the brain—either a head injury or a central nervous system (CNS) infection. When the characteristics were found in children without a history of such an insult, the CNS damage was considered to be minimal (only manifesting as a behavioral change); hence the term minimal brain damage. Later, the term minimal brain dysfunction was used to describe a cluster of symptoms that included specific learning disabilities, hyperkinesis, impulsivity, and short attention span. Minimal brain dysfunction, however, was vague and overinclusive and lacked predictive validity. In 1937, Bradley et al reported on the effects of amphetamines in reducing disruptive behaviors and improving academic performance of behaviorally disordered children. Amphetamines have been used successfully in the treatment of ADHD for more than 60 years. Dissatisfaction with the term minimal brain dysfunction led to the coining of hyperactive child syndrome. In 1968, DSM-II described the behavioral manifestations of overactivity, restlessness, distractibility, and short attention span as components of a specific syndrome, hyperkinetic reaction of childhood, emphasizing motoric symptoms. More modern classifications (DSM-III, DSM-III-R, DSM-IV) have described the signs and symptoms of the disorder without implying specific etiology (as minimal brain damage did). Current criteria emphasize 3 main behavioral areas—inattention, impulsivity, and hyperactivity. In the 1970s, Wender and colleagues studied adults with ADHD with regard to both characteristics and treatment response. Minimal Brain Dysfunction Hyperactive Child Syndrome Attention Deficit Disorder ± Hyperactivity (DSM-III) Attention Deficit/Hyperactivity Disorder (DSM-IV)

Age-Dependent Decline of ADHD Symptoms 6 } Inattention Syndromatic Criteria 5 Impulsivity 4 } Mean No. Symptoms 3 Functional Impairments Hyperactivity 2 The inattentive symptom cluster of ADHD does not diminish substantially with age. Individuals continue to be well above the syndromatic criteria and very much above the functional impairment demarcations. Hence, attentional symptoms are often the “hidden demon” of the disorder over time. 1 b = –0.25 (–0.35, –0.15) <6 6-8 9-11 12-14 15-17 18-20 Age (y) Biederman J et al. Am J Psychiatry. 2000;157: 816-818.

ADHD In Girls Is ADHD a disorder in Girls? An estimated 1 million girls and women in the United States are affected by ADHD (Arnold et al. J Abnorm Child Psychol 1996) The Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed. (DSM-IV) estimates that boys with ADHD outnumber girls with ADHD by as much as 9:1 (American Psychiatric Association 2000) However, community-based studies in which the ratio of boys to girls with ADHD is as low as 2:5:1 indicate that prevalence in girls is understated (Szatmari, Child Adolesc Psychiatry Clin N Am 1992) This suggests that school-aged girls with ADHD are less likely to be diagnosed properly, and consequently receive inadequate treatment. (Biederman et al. JAACAP 1999)

Diagnostic issues for girls with ADHD Core Symptoms: Both boys and girls with ADHD display the same core symptoms Inattention, impulsivity, and hyperactivity. Boys tend to have more symptoms of hyperactivity (Arnold J Abnorm Child Psychol 1996) In girls, symptoms of inattention are predominant (Biederman et al JAACAP 1999)

Symptoms in Girls Hyperactivity in girls may manifest as hyper verbalisation and emotional excitability, rather than the motoric hyperactivity seen in boys (Arnold et al. J Abnorm Child Psych 1996)

Behaviours that may be seen in girls with ADHD General School phobia or avoidance Dishevelled appearance Grooming problems

In School Withdrawal in the classroom Low academic performance Low self esteem Poor social skills (Adapted from: Nadeau, Littman and Quinn, Understanding Girls with AD/HD, Advantage Books 1999)

Comorbidities in girls with ADHD Conduct Disorder and oppositional defiant disorder – prevalence in girls with ADHD is about half that found in boys with ADHD (Biederman et al. JAACAP 1999)

These disorders are associated with the behavioural deviance and aggression that often drives clinical referral. Therefore, the low rates of these disorders in girls and their natural tendency to be less active, more compliant, and less aggressive, may account for the under recognition of ADHD in girls compared with boys.

Symptom profile of girls with ADHD Acts before thinking Difficulty waiting turn Blunt answers Interrupts Talks excessively Difficulty playing quietly Fidgety

Symptom profile of girls with ADHD continued Difficulty remaining seated Does not listen Loses things Easily distracted Difficulty following instructions Difficulty sustaining attention Shifts activities

Pharmacotherapy for ADHD in girls Pharmacotherapy combined with behavioural is a highly effective treatment for girls with ADHD (MTA. Arch Gen Psychiatry 1999) Stimulants (e.g. MPH or amphetamine) are the first-line pharmacotherapy for treating core symptoms of ADHD (Greenhill et al. JAACAP 2002; AAP, Paediatrics 2001) Several studies show that immediate-release (IR) MPH has equivalent beneficial effects in boys and girls (Pelham et al. JAACAP 1989; Sharp et al. JAACAP 1999)

Of particular relevance to girls is the recent finding that stimulant pharmacotherapy in childhood may be associated with a reduced risk of subsequent drug and alcohol abuse (Wilens et al. Paediatrics 2003)

Psychiatric Comorbidities in Girls with ADHD Anxiety (34%) MD (20%) 7% 7% CD (8%) 4% A study of girls with ADHD at Massachusetts General Hospital reported rates of psychiatric comorbidities in girls that are similar to the rates previously reported for boys. The results of this study emphasize the severity of the disorder in girls and a high level of comorbid psychopathology that must be considered when diagnosing and treating girls with ADHD. MD = mood disorder. 23% 2% Non- comorbid (55%) 2% Biederman et al. J Am Acad Child Adolesc Psychiatry. 1999;38:966.

Patients with “ADHD” may suffer Because….. Their parents don’t understand them; Their teachers can’t stand them; Their peers reject them; Their spouses and bosses can’t stand their disorganization and intensity; They themselves begin to think: “no matter what I do I can’t win…”

Famous People with Attention Deficit and Learning Disorders Albert Einstein Thomas Edison Gen. George Patton John F. Kennedy Bruce Jenner Eddie Rickenbacker Harry Belafonte Walt Disney Steve McQueen George C. Scott Tom Smothers Suzanne Somers Jules Verne “Magic Johnson” Carl Lewis Nelson Rockefeller Sylvester Stallone Cher Gen. Westmoreland Charles Schwab Danny Glover John Lennon Greg Louganis Winston Churchill Henry Ford Robert Kennedy George Bernard Shaw Beethoven Hans Christian Anderson Galileo Mozart Leonardo da Vinci Whoppi Goldberg Tom Cruise Henry Winkler F. Scott Fitzgerald Robin Williams Louis Pasteur Werner von Braun Dwight D. Eisenhower Lindsay Wagner Alexander Graham Bell Woodrow Wilson

ATTENTION DEFICIT DISORDER INATTENTION IMPULSIVITY (Distractible) (Act before thinking) A.D.D. Girls > Boys

ATTENTION DEFICIT HYPERACTIVITY DISORDER INATTENTION IMPULSIVITY (Distractible) (Act before thinking) A.D.H.D. HYPERACTIVITY-IMPULSIVITY CLUSTER + Hyperactivity-boys>girls

Concurrent conditions in dx ADHD S.L.D O.D.D. C.D.

Prevalence and Genetics of ADHD 6-8% of children; 3-5% of adults Male-Female: 6:1, 3:1, 1:1 All levels of IQ All levels of socioeconomic status Family genetic transmission: 0.91 Inheritance not specific to subtype

Symptoms of Hyperactivity Often Manifest Differently in Adults Hyperactivity often changes to inner restlessness DSM-IV Symptom Domain Squirms and fidgets Can’t stay seated Runs/climbs excessively Can’t play/work quietly “On the go”/driven by motor Talks excessively Common Adult Manifestation Workaholic Overscheduled/ overwhelmed Self-selects a very active job Constant activity leading to family tension Talks excessively

Symptoms of Impulsivity Often Manifest Differently in Adults Impulsivity in adulthood often carries more serious consequences DSM-IV Symptom Domain Blurts out answers Can’t wait turn Intrudes/interrupts others Common Adult Manifestation Low frustration tolerance Losing temper Quitting jobs Ending relationships Driving too fast Addictive personality

Symptoms of Inattention Often Manifest Differently in Adults DSM-IV Symptom Domain Difficulty sustaining attention Doesn’t listen No follow-through Can’t organize Loses important things Easily distractible, forgetful Common Adult Manifestation Difficulty sustaining attention Meetings, reading, paperwork Paralyzing procrastination Slow, inefficient Poor time management Disorganized

Comorbid Psychiatric Disturbances Are Common in Adults With ADHD Antisocial Disorder (10%) Major Depressive Disorder (35%) Bipolar Disorder (15%) Anxiety Disorders (40%) Substance Abuse Disorders (50%) These rates indicate the presence of particular disorders over the lifetime of adults with ADHD. Shekim WO et al. Compr Psychiatry. 1990;31:416-425. Biederman J et al. Am J Psychiatry. 1993;150:1792-1798.

ADHD and Comorbid Conditions Impulsivity/ Hyperactivity Inattention In the diagnostic assessment of ADHD it is important to address possible co-occurring psychiatric disorders, referred to as comorbidity, as they may influence treatment and outcome. ADHD is frequently comorbid with other psychiatric disorders. These include disruptive behavior disorders, mood disorders, anxiety, and learning disorders. Comorbidity

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DSM-IV Inattention Symptoms in Adults with ADHD % present M F T Easy distractibility 85 98 87 .0 Difficulty sustaining attention 88 85 86.5 Difficulty organizing tasks 76 85 80.5 Difficulty listening 76 74 75.0 Difficulty following instructions 71 78 74.5 Lack of sustained mental effort 68 74 71.0 Inattention to details 73 67 70.0 Forgetfulness 71 70 70.5 Losing things 61 63 62.0

DSM-IV Hyperactivity-Impulsivity Symptoms in Adults with ADHD % present M F Average Hyperactivity Running about 67.1 63.0 65.05 Being on the go 64.5 63.0 63.75 Talking too much 55.3 70.0 62.65 Fidgeting 48.7 67.0 57.85 Difficulty engaging in leisure 46.1 44.0 45.05 Leaving seat 34.2 22.0 28.10 Impulsivity Difficulty awaiting turn 57.9 70.0 63.95 Interrupting or intruding 50.0 74.0 62.00 Blurting out answers 56.6 59.0 57.80

Associated Symptoms in Adults with ADHD % present Male Female Total A sense of underachievement 92.1 92.6 92.3 An intolerance of boredom 77.6 100.0 88.8 Many projects going 88.5 88.9 87.2 simultaneously Inability to reach potential 85.5 81.5 83.5 Problems with time management 77.6 88.9 83.3 Impatience 85.5 77.8 83.3 Chronic procrastination 84.2 77.8 81.0 Frequent search for high stimulation 76.3 85.2 80.8 Sense of insecurity 75.0 81.5 78.2 Feeling disappointed and discouraged 73.7 74.1 73.9 Forgetfulness 76.3 70.4 73.3 Poor self-esteem 75.0 70.4 72.7

Most Frequently Associated Symptoms in Adult ADHD (cont’d) % present M F T Tendency to say what comes to mind 73.7 70.4 72.0 Trouble in following “proper” procedure 65.8 77.8 71.8 Nervousness 72.4 62.9 67.7 Stress intolerance 71.1 62.9 67.0 Difficulty enjoying work 63.2 62.9 63.1 Frequent mood swings 64.5 59.3 61.9 Long standing unhappiness 65.8 55.6 60.7 Impulsivity 52.6 66.7 59.6 Frequent finger drumming 65.8 48.2 57.0

Most Frequently Associated Symptoms in Adult ADHD (cont’d) % present M F T Hot temper 63.2 48.2 55.7 Depression 53.9 48.2 51.0 Frequent job changes 44.7 55.6 50.1 Verbal aggression 53.4 33.3 43.6 Self-destructive behavior 34.2 33.3 33.8 Alcohol abuse 19.7 11.1 15.4 * Physical aggression 18.4 11.1 14.8 Drug abuse 19.7 3.7 11.7 * Difficulty with the law 10.5 3.7 7.1*

ADHD Comorbidities: A Developmental Perspective ODD, CD, Language Disorders Learning problems, Developmental problems Anxiety Disorders Mood Disorders Substance abuse Personality Disorders ODD, CD, LD, Anxiety and/or Mood Disorders Pre-school Adolescent Adult School-age College-age Over 60% of childhood ADHD continues into adulthood1. 1. Baren M. ADHD in adolescents: Will you know it when you see it? Contemporary Pediatrics 2002; 19: 124-141. ODD, CD, LD, Anxiety Disorders Mood Disorders Substance abuse ODD, CD, Learning Disabilities, Anxiety Disorders

Comorbidity in Adult ADHD Disorder Males Females Total Maj. Dep. 35,71% 54,02% 41,08% Anxiety Dis 14,76% 27,59% 18,52% Dysthymic Dis 12,86% 16,09% 13,80% ODD 5,24% 3,45% 4,71% CD 0,48% 1,35% ADHD only 36,19% 22,99% 32,32% 19+ 210 87 297

ADHD Life Cycle Changes Child Adolescent Adult Prevalence 7-13% 6-8% 4-5% Subtype ADHD>ADD ADHD=ADD ADD>ADHD Comorbidity ODD,CD + ANX-DEP ANX-DEP LD, LAN D SUB USE, PD Rx response very good very good very good (high remission/normalization)

Gender and Comorbidity More common in males: Aggressive Behavior, Substance Abuse, Conduct and Antisocial Personality Disorder More common in females: Anxiety Disorders and Mood Disorders

Conclusions ADHD has a high rate of comorbidity in adults The determination of associated comorbid disorders in adult ADHD is essential to establish the “goodness of fit” between patient symptom/comorbidity profile and treatment options