1. ADHD in Adults
Cherinet Seid, PGY II

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

3. 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

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

5. Myths of ADHD

6. 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)

7. 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%

8. 4.Driving Impairment

9. Effects cont’d
5. Substance use

10. 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’

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

12. 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

13. 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

14. 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

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

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

17. 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)

18. 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

19. Treatment
Need to treat is always based on functional impairment.

20. 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

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

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

24. Assessment Scales www.med.nyu.edu/psych/psychiatrist/adhd.html

25. 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