Adult ADHD Delicia Garner March 25 2006 Masters

Adult ADHD Delicia Garner March 25, 2006 Master’s Project Presentation

Adult Attention Deficit Hyperactivity Disorder Prevalence = 100 million adults n Imbalance of chemical messengers in the brain that results in difficulties: n Focusing n Organizing and prioritizing work n Filtering out or ignoring distractions n Thinking before action n Delaying gratification n

Childhood ADHD n n Common myth: that children with ADHD “grow out of it” But 65% of children diagnosed continue having symptoms into adulthood Most people know the problems that children with ADHD face – academic and behavioral trouble at school, difficulty making and keeping friends, and stressful family situations Few people are aware of serious consequences of Adult ADHD

Consequences of Adult ADHD n Adults with untreated ADHD are More than twice as likely to have been arrested n 78% more likely to be addicted to tobacco n Twice as likely to have been divorced n More than twice as likely to have dropped out of high school n Twice as likely to have held 6 or more jobs in the past 10 years n from: ADHD in Adults (A Guide to ADHD and Effective Treatment)

Recognizing Adult ADHD Constant disorganization, poor time management, and failure to plan ahead n Frequent forgetfulness, often losing things n Continual problems starting or finishing projects or tasks n Impulsive decision making, and saying things without thinking n Ongoing problems concentrating and paying attention n

Continued… Extreme restlessness or fidgetiness n Poor anger control n Difficulty keeping jobs n Martial problems and relationship issues n from: ADHD in Adults (A Guide to ADHD and Effective Treatment)

ADHD in Children and Adults The same, but different n Adult ADHD more difficult to recognize, which is why many adults remain undiagnosed n Core impairments of ADHD - inattention, hyperactivity, and impulsivity- remain the same n But the symptoms that result usually change as people get older n

Childhood Symptoms Versus Adult Hyperactivity Restlessness n Can’t sit still, always on n Can’t stay focused on the go one thing n Climbs or runs at n Is fidgety or impatient inappropriate times Physical Impulsivity n Does things that result in injuries Verbal Impulsivity n Says the “wrong thing” or speaks out of turn

Continued… n Has problems waiting one’s turn n Interrupts others excessively Inattention n Can’t pay close attention n Has difficulty in class or complete concentrating at work schoolwork and finishing tasks from: ADHD in Adults (A Guide to ADHD and Effective Treatment)

ADHD: A Genetic Link If a close family member has ADHD, then the patient is at an increased risk n Especially ask about parents, children and siblings n

Why so difficult to diagnose? Lack of guidelines for primary care providers n Lack of objectively verifiable tests n Diagnostic criteria structured more toward childhood diagnoses n High rate of media attention predisposing adults toward self diagnoses n Common comorbidities n Concern of schedule II drug abuse n

Clinical Presentation Criteria for ADHD are specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) n DSM-IV describes 3 subtypes of ADHD n Predominately hyperactive n Predominately inattentive n Mixed type with symptoms of other 2 categories n

DSM-IV Criteria A for ADHD For diagnoses, 4 criteria must be met (Criteria A, B, C, and D) n Criteria A has 2 subgroups n Either subgroup 1 or subgroup 2 must be met in order for clinical diagnoses n

Subgroup 1 of Criteria A n Classic examples of inattention from subgroup 1 Often fails to give close attention to details or makes careless mistakes in work or other activities n Often has difficulty sustaining attention n Often does not seem to listen when spoken to directly n Often does not follow through on instructions and fails to finish duties in the workplace n Often has difficulty organizing tasks and activities n Often loses things necessary for tasks or activities n Often forgetful in daily activities n

Subgroup 2 of Criteria A n Classic examples of hyperactivity-impulsivity Often fidgets with hands or feet or squirms in seat n Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) n Is often "on the go" or often acts as if "driven by a motor" n Often talks excessively n Often blurts out answers before questions have been completed n Often interrupts or intrudes on others n

Criteria B, C, and D B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. n C. Some impairment from the symptoms is present in two or more settings (e. g. , at school [or work] and at home). n D. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning n

Criticisms of DSM-IV never been validated in adults n doesn’t include developmentally appropriate symptoms for adults n fails to identify some significantly impaired adults who would benefit from treatment n the subtlety and subjectivity of ADHD symptoms in adults and the absence of a single gold standard for confirming diagnoses makes assessment challenging n

Differential Diagnoses Comorbidity is rule rather than exception n High rates of the following are found among ADHD patients in virtually every study: n antisocial personality n learning disabilities n substance abuse n major depression n anxiety disorders n

Other pertinent associations Bipolar 1 (which usually occurs with more severe forms of ADHD) n earlier onsets for major depressive disorder n dysthymia n oppositional defiant disorder n conduct disorder n

Medical Conditions that Mimic ADHD Hyperthyroidism n petit mal and partial complex seizures n hearing deficits n hepatic disease n lead toxicity n sleep apnea n drug interactions n

Pharmacological Treatment n STIMULANTS!!!!!!! Methylphenidate and amphetamine 1 st line n Well-tolerated and safe n Need to adjust n Most brand names are simply different delivery systems of Methylphenidate (Ritalin®, Concerta®, Metadate CD®) n

Pharmacological Treatment n Nonstimulants (Wellbutrin®, Strattera®) Antidepressants by nature n Effect not as robust as stimulants n But useful in patients that can’t tolerate stimulant side effects, or have addictive tendencies or comorbidities n

Psychosocial Treatments n Psychoeducation n n Psychotherapy n n Educate the patient on their diagnosis Individual or group Behavioral/self-management skills Cognitive behavior therapy n Skill building in planning and organization n n Otherapies n Marriage/family (career) counseling, coaching

Summary Many symptoms of childhood ADHD extend into adulthood n Adult ADHD presents differently than childhood in n Symptoms n Social and economic consequences n Psychosocial modes of treatment n

Summary (Continued) n Adult and childhood ADHD are the same in Diagnostic criteria (inattention, distractibility, impulsivity) n Pharmacological treatment (stimulants) n Correct diagnosis and treatment improves outcomes exponentially n DSM-IV has shortcoming but must widely trusted criteria on hand n

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