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Adult ADHD Delicia Garner March 25, 2006 Master’s Project Presentation.
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Transcript of Adult ADHD Delicia Garner March 25, 2006 Master’s Project Presentation.
Adult ADHDAdult ADHD
Delicia GarnerDelicia Garner
March 25, 2006March 25, 2006
Master’s Project PresentationMaster’s Project Presentation
Adult Attention Deficit Adult Attention Deficit Hyperactivity DisorderHyperactivity Disorder
Prevalence = 100 million adultsPrevalence = 100 million adults Imbalance of chemical messengers in Imbalance of chemical messengers in
the brain that results in difficulties:the brain that results in difficulties: FocusingFocusing Organizing and prioritizing workOrganizing and prioritizing work Filtering out or ignoring distractionsFiltering out or ignoring distractions Thinking before actionThinking before action Delaying gratificationDelaying gratification
Childhood ADHDChildhood ADHD Common myth: that children with ADHD Common myth: that children with ADHD
“grow out of it”“grow out of it” But 65% of children diagnosed continue But 65% of children diagnosed continue
having symptoms into adulthoodhaving symptoms into adulthood Most people know the problems that Most people know the problems that
children with ADHD face – academic and children with ADHD face – academic and behavioral trouble at school, difficulty behavioral trouble at school, difficulty making and keeping friends, and stressful making and keeping friends, and stressful family situationsfamily situations
Few people are aware of serious Few people are aware of serious consequences of Adult ADHDconsequences of Adult ADHD
Consequences of Adult Consequences of Adult ADHDADHD
Adults with untreated ADHD areAdults with untreated ADHD are More than More than twicetwice as likely to as likely to have been have been
arrestedarrested 78%78% more likely to be more likely to be addicted to tobaccoaddicted to tobacco TwiceTwice as likely to have been as likely to have been divorceddivorced More than More than twicetwice as likely to as likely to have droppedhave dropped
out of high schoolout of high school TwiceTwice as likely to have held as likely to have held 6 or more jobs6 or more jobs
in the past 10 yearsin the past 10 yearsfrom: ADHD in Adults (A Guide to ADHD and Effective from: ADHD in Adults (A Guide to ADHD and Effective
Treatment) Treatment)
Recognizing Adult ADHDRecognizing Adult ADHD
Constant Constant disorganizationdisorganization, poor time , poor time management, and failure to plan aheadmanagement, and failure to plan ahead
Frequent Frequent forgetfulnessforgetfulness, often losing , often losing thingsthings
Continual problems Continual problems startingstarting or or finishingfinishing projectsprojects or tasks or tasks
ImpulsiveImpulsive decision making, and decision making, and saying saying things without thinkingthings without thinking
Ongoing problems Ongoing problems concentratingconcentrating and and paying attentionpaying attention
Continued…Continued…
Extreme Extreme restlessnessrestlessness or or fidgetinessfidgetiness Poor Poor angeranger control control Difficulty keeping Difficulty keeping jobsjobs MartialMartial problems and problems and relationship issuesrelationship issues
from: ADHD in Adults (A Guide to ADHD and Effective from: ADHD in Adults (A Guide to ADHD and Effective Treatment) Treatment)
ADHD in Children and ADHD in Children and AdultsAdults
The same, but differentThe same, but different Adult ADHD more difficult to Adult ADHD more difficult to
recognize, which is why many adults recognize, which is why many adults remain undiagnosedremain undiagnosed
Core impairments of ADHD - Core impairments of ADHD - inattention, hyperactivity, and inattention, hyperactivity, and impulsivity- remain the sameimpulsivity- remain the same
But the symptoms that result usually But the symptoms that result usually change as people get olderchange as people get older
Childhood Symptoms Childhood Symptoms Versus AdultVersus Adult
Hyperactivity Hyperactivity Can’t sit still, Can’t sit still,
always on the goalways on the go Climbs or runs at Climbs or runs at
inappropriate timesinappropriate times
Physical Physical ImpulsivityImpulsivity
Does things that Does things that result in injuriesresult in injuries
RestlessnessRestlessness Can’t stay focused on Can’t stay focused on
one thingone thing Is fidgety or impatientIs fidgety or impatient
Verbal ImpulsivityVerbal Impulsivity Says the “wrong Says the “wrong
thing” or speaks out thing” or speaks out of turnof turn
Continued…Continued… Has problems Has problems
waiting one’s turnwaiting one’s turn
InattentionInattention Can’t pay close Can’t pay close
attention in class attention in class or complete or complete schoolworkschoolwork
Interrupts others Interrupts others excessivelyexcessively
InattentionInattention Has difficulty Has difficulty
concentrating at concentrating at work and finishing work and finishing taskstasks
from: ADHD in Adults (A Guide to ADHD and Effective from: ADHD in Adults (A Guide to ADHD and Effective Treatment)Treatment)
ADHD: A Genetic LinkADHD: A Genetic Link
If a close family member has ADHD, If a close family member has ADHD, then the patient is at an increased then the patient is at an increased riskrisk
Especially ask about parents, Especially ask about parents, children and siblingschildren and siblings
Why so difficult to Why so difficult to diagnose?diagnose?
Lack of guidelines for primary care Lack of guidelines for primary care providersproviders
Lack of objectively verifiable testsLack of objectively verifiable tests Diagnostic criteria structured more Diagnostic criteria structured more
toward childhood diagnosestoward childhood diagnoses High rate of media attention predisposing High rate of media attention predisposing
adults toward self diagnosesadults toward self diagnoses Common comorbiditiesCommon comorbidities Concern of schedule II drug abuseConcern of schedule II drug abuse
Clinical PresentationClinical Presentation
Criteria for ADHD are specified in the Criteria for ADHD are specified in the Diagnostic and Statistical Manual of Diagnostic and Statistical Manual of Mental Disorders, fourth edition Mental Disorders, fourth edition (DSM-IV)(DSM-IV)
DSM-IV describes 3 subtypes of ADHDDSM-IV describes 3 subtypes of ADHD Predominately hyperactivePredominately hyperactive Predominately inattentivePredominately inattentive Mixed type with symptoms of other 2 Mixed type with symptoms of other 2
categoriescategories
DSM-IV Criteria A for DSM-IV Criteria A for ADHDADHD
For diagnoses, 4 criteria must be For diagnoses, 4 criteria must be met (Criteria A,B,C, and D)met (Criteria A,B,C, and D)
Criteria A has 2 subgroupsCriteria A has 2 subgroups EitherEither subgroup 1 or subgroup 2 subgroup 1 or subgroup 2
must be met in order for clinical must be met in order for clinical diagnoses diagnoses
Subgroup 1 of Criteria ASubgroup 1 of Criteria A Classic examples of Classic examples of inattentioninattention from from
subgroupsubgroup 11 Often fails to give close Often fails to give close attention to detailsattention to details or or
makes makes careless mistakescareless mistakes in work or other in work or other activities activities
Often has difficulty Often has difficulty sustaining attentionsustaining attention Often does not seem to Often does not seem to listenlisten when spoken to when spoken to
directly directly Often does not Often does not follow through on instructionsfollow through on instructions and and
fails to finishfails to finish duties in the workplace duties in the workplace Often has difficulty Often has difficulty organizing tasksorganizing tasks and activities and activities Often Often loses thingsloses things necessary for tasks or activities necessary for tasks or activities Often Often forgetfulforgetful in daily activities in daily activities
Subgroup 2 of Criteria ASubgroup 2 of Criteria A Classic examples of Classic examples of hyperactivity-hyperactivity-
impulsivityimpulsivity Often Often fidgetsfidgets with hands or feet or squirms in with hands or feet or squirms in
seat seat Often runs about or climbs excessively in Often runs about or climbs excessively in
situations in which it is inappropriate (in situations in which it is inappropriate (in adolescents or adults, may be limited to adolescents or adults, may be limited to subjective subjective feelings of restlessnessfeelings of restlessness) )
Is often "Is often "on the goon the go" or often acts as if "driven by " or often acts as if "driven by a motor" a motor"
Often Often talks excessivelytalks excessively Often Often blurts out answersblurts out answers before questions have before questions have
been completed been completed Often Often interruptsinterrupts or intrudes on others or intrudes on others
Criteria B, C, and DCriteria B, C, and D B. Some hyperactive-impulsive or B. Some hyperactive-impulsive or
inattentive symptoms that caused inattentive symptoms that caused impairment were present before age 7 impairment were present before age 7 years. years.
C. Some impairment from the symptoms C. Some impairment from the symptoms is present in two or more settings (e.g., is present in two or more settings (e.g., at school [or work] and at home). at school [or work] and at home).
D. There must be clear evidence of D. There must be clear evidence of clinically significant impairment in clinically significant impairment in social, academic or occupational social, academic or occupational functioningfunctioning
Criticisms of DSM-IVCriticisms of DSM-IV never been validated in adults never been validated in adults doesn’t include developmentally doesn’t include developmentally
appropriate symptoms for adults appropriate symptoms for adults fails to identify some significantly fails to identify some significantly
impaired adults who would benefit from impaired adults who would benefit from treatment treatment
the subtlety and subjectivity of ADHD the subtlety and subjectivity of ADHD symptoms in adults and the absence of a symptoms in adults and the absence of a single gold standard for confirming single gold standard for confirming diagnoses makes assessment challenging diagnoses makes assessment challenging
Differential DiagnosesDifferential Diagnoses
Comorbidity is rule rather than exception Comorbidity is rule rather than exception High rates of the following are found High rates of the following are found
among ADHD patients in virtually every among ADHD patients in virtually every study:study: antisocial personality antisocial personality learning disabilities learning disabilities substance abuse substance abuse major depression major depression anxiety disordersanxiety disorders
Other pertinent Other pertinent associationsassociations
Bipolar 1 (which usually occurs with Bipolar 1 (which usually occurs with more severe forms of ADHD)more severe forms of ADHD)
earlier onsets for major depressive earlier onsets for major depressive disorderdisorder
dysthymia dysthymia oppositional defiant disorder oppositional defiant disorder conduct disorder conduct disorder
Medical Conditions that Medical Conditions that Mimic ADHDMimic ADHD
HyperthyroidismHyperthyroidism petit mal and partial complex petit mal and partial complex
seizures seizures hearing deficits hearing deficits hepatic disease hepatic disease lead toxicity lead toxicity sleep apnea sleep apnea drug interactionsdrug interactions
Pharmacological Pharmacological TreatmentTreatment
STIMULANTS!!!!!!!STIMULANTS!!!!!!! Methylphenidate and amphetamine 1Methylphenidate and amphetamine 1stst
lineline Well-tolerated and safeWell-tolerated and safe Need to adjustNeed to adjust Most brand names are simply different Most brand names are simply different
delivery systems of Methylphenidate delivery systems of Methylphenidate (Ritalin®, Concerta®, Metadate CD®) (Ritalin®, Concerta®, Metadate CD®)
Pharmacological Pharmacological TreatmentTreatment
Nonstimulants (Wellbutrin®, Nonstimulants (Wellbutrin®, Strattera®)Strattera®) Antidepressants by natureAntidepressants by nature Effect not as robust as stimulantsEffect not as robust as stimulants But useful in patients that can’t tolerate But useful in patients that can’t tolerate
stimulant side effects, or have addictive stimulant side effects, or have addictive tendencies or comorbidities tendencies or comorbidities
Psychosocial TreatmentsPsychosocial Treatments
PsychoeducationPsychoeducation Educate the patient on their diagnosisEducate the patient on their diagnosis
PsychotherapyPsychotherapy Individual or groupIndividual or group
Behavioral/self-management skillsBehavioral/self-management skills Cognitive behavior therapyCognitive behavior therapy Skill building in planning and organizationSkill building in planning and organization
Other therapiesOther therapies Marriage/family (career) counseling, Marriage/family (career) counseling,
coachingcoaching
SummarySummary
Many symptoms of childhood ADHD Many symptoms of childhood ADHD extend into adulthoodextend into adulthood
Adult ADHD presents differently Adult ADHD presents differently than childhood inthan childhood in SymptomsSymptoms Social and economic consequencesSocial and economic consequences Psychosocial modes of treatmentPsychosocial modes of treatment
Summary (Continued)Summary (Continued)
Adult and childhood ADHD are the Adult and childhood ADHD are the same insame in Diagnostic criteria (inattention, Diagnostic criteria (inattention,
distractibility, impulsivity)distractibility, impulsivity) Pharmacological treatment (stimulants)Pharmacological treatment (stimulants)
Correct diagnosis and treatment Correct diagnosis and treatment improves outcomes exponentiallyimproves outcomes exponentially
DSM-IV has shortcoming but must DSM-IV has shortcoming but must widely trusted criteria on handwidely trusted criteria on hand
ReferencesReferences Adler, L. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorderAdler, L. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder . .
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