Craig Surman, MD

Scientific Coordinator

Adult ADHD Research Program

Massachusetts General Hospital

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Thrive if You Have ADHD (Or Think You

Might), will be awarded to 5 lucky webinar

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following the webinar.

* Survey link will follow via email.

Ask a Question:

National Resource Center on ADHD

(800) 233-4050 [Select Option 2 to reach the NRC]

www.help4adhd.org

Craig B.H. Surman, MD

Scientific Coordinator,

Clinical and Research Program

in Adult ADHD, Massachusetts General Hospital

Assistant Professor of Psychiatry

Harvard Medical School

Thriving and Striving with Adult ADHD:

Personalize Your Treatment Plan

Dr. Surman’s Lifetime Disclosures

•Speaking / Education

– McNeil, Janssen, Janssen-Ortho, Novartis, Shire and Reed/ MGH

Academy (funded by multiple companies)

•Consulting

– McNeil, Nutricia, Takeda, Shire, Somaxon

•Research Support, MGH Adult ADHD Program

– Abbot, Cephalon, Hilda and Preston Davis Foundation, Eli Lilly,

Magceutics, J & J / McNeil, Merck, Nordic Naturals, Nutricia,

Pamlab, Pfizer, Organon, Shire, and Takeda

Dr. Surman also receives royalties from the following publications:

Typical Concern in Simple ADHD

“I have trouble getting around to, sticking with,

and finishing things.”

DSM-V ADHD

“Neurodevelopmental” - not “disruptive”

Inattentive / Hyperactive-impulsive / Combined “Presentations”

Appendix: Restricted inattentive subtype worth further study

≥ 5 inattentive and / or ≥ 5 impulsive / hyperactive symptoms over last six months

Adult symptom examples listed!

DSM-V ADHD

Symptoms caused impairment by 12

Impairment in 2 or more settings

(school, work, home)

Not explained by another disorder

Autism / PDD non-exclusionary

Two or more informants

Age-dependent Decline

of ADHD Symptoms

Biederman J et al. Age-dependent decline of symptoms of attention deficit hyperactivity disorder:

impact of remission definition and symptom type. Am J Psychiatry. 2000 May;157(5):816-8.

0

20

40

60

80

100

<6 6-8 9-11 12-14 15-17 18-20

Syndromatic remission

Symptomatic remission

Functional remission

Age (years)

Age-specific prevalence of remission from ADHD among 138 boys,

according to definition of remission and symptom type

n=138

World-wide Prevalence of ADHD

11,422 Adults in 10 countries age 11 to 44

Prevalence:

Overall - 3.4%

Low income - 1.9%

Higher income - 4.2%

• Early childhood

– Requires simple responses, demands are limited,

environment is structured

• Adulthood

– Increased need for organization, prioritization,

self-structuring and planning

– Greater consequences from lack of structure in

independent life

ADHD and the Demands of Development

In Childhood

0

10

20

30

40

50

60

70

80

90

100

Adult ADHD

ADHD Type

%

In Adulthood

44%

56%

Combined Type

Inattentive Type

78%

22%

Spencer et al

“Simple” ADHD is marked by limited control over how a person engages in the

moment*

Thus poor control over:

- sensory processing, thought and intention

= inattention

- physical, verbal, emotional expression

= impulsivity

- drive and physical activity

= hyperactivity

(*This is one way of looking at ADHD - not the only!)

Inattentive ADHD: disengagement from low salience tasks

Difficulty:

– Focusing on low novelty tasks

– Ignoring “shiny” (interesting) distractions

– Working towards long-term rewards

– Keeping on track without “multitasking”

Stress & pressure increase salience

– Creates reactive rather than proactive pattern

– Extra hours and late nights

Impulsive / Hyperactive ADHD: low control over choice & pace

Impulse control (choice):

• Making good choices - shopping, emails, talking …

• Waiting

• Holding thoughts / plans in mind to act on later

Activity control (pace):

• Speed of physical activity / communication

• Feeling grounded, at ease

• Tolerating low activity tasks

Survey on ADHD Impact

in Adults

• Objective: to compare the employment rates and income levels

of patients with ADHD to those without

• Random sampling of US households with telephones

• Adults aged 18–64 years

• Self-reports of diagnosis of ADHD as adults

• Sample size

– n=500 with ADHD

– n=501 without ADHD (control group)

Biederman J, et al. MedGenMed. 2006;8(3):1-9.

Outcomes in

500 ADHD + 500 non-ADHD Adults

0 10 20 30 40 50 60 70 80

Been divorced

Been arrested

Employment

Addicted to tobacco or smoking

Recreational drug use

College Graduate

Income <25K

%

ADHD Control

36% of ADHD patients reported medication use Biederman et al. J Clin Psychiatry. 2006;67:524-540.

MGH-NMR Center & Harvard-MIT CITP. Bush, et al. Biol Psychiatry. 1999;45:1542-1552.

-3

-3

Normal control ADHD

• blood flow decreased at anterior cingulate

(cognitive division) = fails to activate in ADHD

Functional imaging of ADHD

Anterior Cingulate

Cortex

1 x 10-2 y = +21 mm

Frontal Striatal

Insular network

1 x 10-2 y = +21 mm

Storage

vesicle

DA Transporter

Cytoplasmic DA

Methylphenidate

inhibits

Presynaptic Neuron

Synapse

Methylphenidate (MPH):

Mechanism of Action

Wilens T, Spencer T. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513.

Amphetamine (AMP):

Mechanisms of Action

AMP Inhibits

AMP is taken up

into cell causing DA

release into synapse

AMP diffuses into

vesicle causing DA

release into cytoplasm

Presynaptic Neuron

Storage

vesicle

DA Transporter

Protein

Cytoplasmic DA

AMPH

AMPH

Synapse

AMP blocks

uptake into vesicle

Wilens T, Spencer T. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513.

LOCF

MAS XR Long-term Efficacy

*P<.05 by 1-sample t test of mean change from baseline of long-term study.

Subthreshold

ADHD Tra

nsit

ion

(n

= 2

21)

Short-term Study Long-term Open-Label Extension

Mean

AD

HD

-RS

To

tal

Sco

re

Month Week

Biederman. 158th Annual APA Meeting; 2005; Atlanta, Ga.

* * * * * * * * *

* * *

0

5

10

15

20

25

30

35

Baseline 1 2 3 4 2 4 6 8 10 12 14 16 18 20 22 24

Tips for Optimizing Treatment

Define target traits + track over time

Want tools for “simple” “comorbid” and other

“organizational” challenges

Meds improve “simple” symptoms, but:

– Mood/personality/Sleep/Nutrition impairment not ok

– Should compensate impairment - not “enhance”

– E.g., of healthy use: Self-care “homework”/practice

– increase gradually, limit other sympathomimetics

– Higher than FDA approved doses may be useful

– Mild / part-of-day side effects? Change release pattern

– Watch for withdrawal / decreased effect

Typical Concern in Comorbid ADHD

“I do not feel like myself or function like I

used to.”

12 Month Comorbidity in 18-44 Year Old Adults

in National Comorbidity Survey - Replication

ADHD

No ADHD p < .05 vs. No ADHD

Kessler et al, 2006

N = 3,199

*

* *

*

* *

*

Organizational Challenges Beyond the Core Symptoms of ADHD:

Control of Engagement across roles and over time

Typical Complaint:

“I don’t do the right things

at the right time or keep healthy routines.”

(Occurs in other disorders)

Cognitive Behavioral Therapy

(CBT)

Appropriate for adults with ADHD

– Able to do homework and learn new habits

– On medication, persisting functional impairment

– No response to medication

group treatment is recommended first line; cite cost

– Not desire medications

– Not adhere to medications

National Institute for Health and Clinical Wellness, 2008 (UK)

Cognitive-Behavioral Goals

Changing cognitions

– Positive thinking

Address distortions, doubt, blame

– Cognitions <-> Feelings <-> Behavior

Changes in behavior

– New skills and new habits

Organization

‘Keys, wallet, ID’

Courtesy of Solanto, Mary, Mt. Sinai/NY ADHD Center

Cognitive-Behavioral Approach

Improve awareness of unproductive thoughts, feeling and behavior – Adaptive internal speech, self-instruction

Introduce more productive thoughts and behaviors Components to change behavior – Self-accepting perspective

– New skills and habits

Reinforce and generalize new patterns – E.g., Cues: trouble getting started (cue) first step is too big

(solution is to break task down into parts);

“Out of sight, out of mind” (reduce distraction) (Solanto et al, 2010)

MGH CBT Modules

3 core modules

– Psychoeducation about ADHD and training in organizing and planning

use of calendar and task list

problem-solving training (generating alternatives, picking the best solution)

breaking down overwhelming tasks

– Skills to reduce distractibility,

Timing attention span; writing down distractions

– Cognitive restructuring

Thinking more adaptively in distress situations

Optional modules

– Skills against procrastination

– Including family member for support

Review and relapse prevention

Safren et al, Mastering Your Adult ADHD, Oxford University Press

Safren, S. A. et al. JAMA 2010;304:875-880.

Self-report Current Symptoms Scale Score Mixed Effects Analysis

n=31

n=39

Treatment Options

Simple ADHD

vs.

ADHD + Executive Problems

Sleep Dysfunction in 182 Adults

with and 182 without ADHD

* *

*

*

*p<0.003; Not

accounted for by

Axis I comorbidity

% reporting “Quite often” or “Often”

Surman et al, 2009

Example of Improving An Unhealthy Self-Regulatory

Pattern: Sleep

• ADHD medication can help engage plan

• Use principles to create plan for change:

• Identify critical choice moments + best plan

– e.g. when to wind down, start bedtime routine

• Steer around pitfalls: – e.g. sleep environment (screens dark !)

– No new projects time

• Create reward

– (e.g. reading in bed)

• Foster accountability

– (e.g. spouse expectation, call friend)

Treatable Factors

-ADHD symptoms

-Other limits to adjustment e.g., comorbidity; negative self-talk

-Self-regulation skills

self-care; executive; emotional

-Environmental Accommodation

Resources

www.CHADD.org and CHADD groups

www.help4adhd.org National Resource Center on ADHD

“FASTMINDS” www.drsurman.com / amazon.com

Other books on Adult ADHD including:

- books by Rostain & Ramsey; Solanto; Safren et al on cognitive behavioral therapy

Ask a Question:

Craig Surman, MD

Scientific Coordinator

Adult ADHD Research Program

Massachusetts General Hospital

www.help4adhd.org

800.233.4050

Win a copy of Fast Minds!!!

A copy of Dr. Surman’s book, Fast Minds: How to

Thrive if You Have ADHD (Or Think You

Might), will be awarded to 5 lucky webinar

participants who complete the evaluation survey

following the webinar.

* Survey link will follow via email.