Understanding and Treating Understanding and Treating Adults with Adults with

Attention Deficit Hyperactivity Attention Deficit Hyperactivity Disorder (ADHD)Disorder (ADHD)

Brian B. Doyle, MD Brian B. Doyle, MD

Adults with ADHDAdults with ADHD What is ADHD?What is ADHD?

How do you diagnose it in adults ? How do you diagnose it in adults ?

How do you treat with medication?How do you treat with medication?

What other treatments help?What other treatments help?

What is the impact of comorbid conditions?What is the impact of comorbid conditions?

How do you deal with treatment-refractory ADHD?How do you deal with treatment-refractory ADHD?

What is ADHD?What is ADHD?

A syndrome in which symptoms of A syndrome in which symptoms of inattention, of inattention, of hyperactivity/impulsivity, or both, hyperactivity/impulsivity, or both, significantly interfere with the significantly interfere with the capacity to work or to love, or both.capacity to work or to love, or both.

Diagnosing ADHDDiagnosing ADHD

Criterion A: At least 6 of 9 symptoms Criterion A: At least 6 of 9 symptoms of inattention, or at least 6 of 9 of inattention, or at least 6 of 9 symptoms of symptoms of hyperactivity/impulsivity, or both, hyperactivity/impulsivity, or both, have persisted for at least 6 months. have persisted for at least 6 months. Symptoms are maladaptive, Symptoms are maladaptive, inconsistent with developmental inconsistent with developmental level.level.

Symptoms of InattentionSymptoms of Inattention

Fails to attend to details Fails to attend to details Fails to sustain attention on taskFails to sustain attention on task Fails to listenFails to listen Fails to finish jobsFails to finish jobs Poor at planning and organizing Poor at planning and organizing Loses things frequentlyLoses things frequently Easily distracted by extraneous stimuliEasily distracted by extraneous stimuli Often forgetfulOften forgetful Avoids sustained mental effortAvoids sustained mental effort

Hyperactive/Impulsive Hyperactive/Impulsive Symptoms Symptoms

Can’t sit quietlyCan’t sit quietly Has to get up and move aroundHas to get up and move around Subjective restlessnessSubjective restlessness Hard to engage in leisure quietlyHard to engage in leisure quietly ““On the go” or “driven”On the go” or “driven” Talks excessivelyTalks excessively Speaks without thinking; blurts outSpeaks without thinking; blurts out Has difficulty waiting his or her turnHas difficulty waiting his or her turn Interrupts or intrudes on othersInterrupts or intrudes on others

Criterion B: Symptoms causing Criterion B: Symptoms causing impairment were present impairment were present

before age 7 yearsbefore age 7 years

Criterion C: Impairment from Criterion C: Impairment from the symptoms is present in the symptoms is present in two two

or more settings or more settings (eg, work and home)(eg, work and home)

Criterion D: There is clear Criterion D: There is clear evidence of evidence of significantsignificant

impairment in social, academic impairment in social, academic or occupational functioningor occupational functioning

Criterion E: The symptoms are Criterion E: The symptoms are not better accounted for by not better accounted for by

another mental disorder (eg, another mental disorder (eg, mood or anxiety disorder, mood or anxiety disorder,

substance abuse, personality substance abuse, personality disorder)disorder)

Initial Evaluation Initial Evaluation 1: Clinical Interviews1: Clinical Interviews

Past and present ADHD symptomsPast and present ADHD symptoms How, where symptoms cause How, where symptoms cause

impairmentsimpairments Alternative and comorbid disordersAlternative and comorbid disorders Developmental history/impulsesDevelopmental history/impulses Strengths*Strengths* Mental status examinationMental status examination

Evaluation Evaluation 2: Standardized Rating Scales2: Standardized Rating Scales

Adult ADHD Self Report ScaleAdult ADHD Self Report Scale Barkley System of Diagnostic ScalesBarkley System of Diagnostic Scales Brown Attention-Deficit Disorder Brown Attention-Deficit Disorder

ScalesScales Conners Adult ADHD Rating ScaleConners Adult ADHD Rating Scale

Evaluation 3: Medical history Evaluation 3: Medical history and assessments and assessments

Evaluation 4: FamilyEvaluation 4: Family

History of ADHD, results of treatmentHistory of ADHD, results of treatment History of other disordersHistory of other disorders

Evaluation 5: Information from Evaluation 5: Information from a significant other or parenta significant other or parent

DocumentationDocumentation Interview dataInterview data Rating scales Rating scales

Evaluation 6: School and Evaluation 6: School and work assessmentswork assessments

Evaluation 7: Other Evaluation 7: Other assessmentsassessments

EducationalEducational Psychological testingPsychological testing Neuropsychological testingNeuropsychological testing NeuroimagingNeuroimaging VocationalVocational

ADHD Subtypes ADHD Subtypes

CombinedCombined Predominantly inattentivePredominantly inattentive Predominantly hyperactive/impulsivePredominantly hyperactive/impulsive Not otherwise specifiedNot otherwise specified

Prevalence of ADHD in Prevalence of ADHD in adults: 4.4%adults: 4.4%

(National(National Comorbidity Study, 2006) Comorbidity Study, 2006)

Differential Diagnosis of ADHD Differential Diagnosis of ADHD

PsychiatricPsychiatric MedicalMedical DietaryDietary MalingeringMalingering Normal behaviorNormal behavior

Psychiatric Disorders Psychiatric Disorders Associated with ADHDAssociated with ADHD

Anxiety disordersAnxiety disorders Affective disorders, uni- and bipolar*Affective disorders, uni- and bipolar* Learning disordersLearning disorders Substance abuse disordersSubstance abuse disorders Tourette’s Disorder Tourette’s Disorder Schizophrenia and other psychotic Schizophrenia and other psychotic

disorders disorders Mental retardationMental retardation Pervasive developmental disordersPervasive developmental disorders Personality disordersPersonality disorders

The Biology of ADHDThe Biology of ADHD

Attention is a complex state Attention is a complex state mediated by several areas of the mediated by several areas of the brainbrain

Frontal lobe dysfunction is central Frontal lobe dysfunction is central but not the only site of the disorderbut not the only site of the disorder

The Biology of ADHD, cont’dThe Biology of ADHD, cont’d

Less gray and white matter Less gray and white matter Decrements in the dorsal prefrontal Decrements in the dorsal prefrontal

cortexcortex Decrements in the cerebellumDecrements in the cerebellum Decrements in the striatumDecrements in the striatum

Biology: NeurotransmittersBiology: Neurotransmitters

Dopamine relates to attentionDopamine relates to attention Norepinephrine relates to Norepinephrine relates to

hyperactivity/impulsivity hyperactivity/impulsivity Current thinking: multiple Current thinking: multiple

neurotransmitter systems are neurotransmitter systems are involvedinvolved

Biology of ADHD: GeneticsBiology of ADHD: Genetics

Family studies: more first-degree Family studies: more first-degree relatives of affected individualsrelatives of affected individuals

Twin studies: higher concordance in Twin studies: higher concordance in identical than in fraternal twinsidentical than in fraternal twins

Adoption studies: nature>nurtureAdoption studies: nature>nurture Molecular studies: candidate genes Molecular studies: candidate genes

affect neurotransmitter systems affect neurotransmitter systems

Comprehensive Treatment for Comprehensive Treatment for ADHDADHD

Always starts with educationAlways starts with education Usually includes medicationUsually includes medication Usually includes psychotherapyUsually includes psychotherapy Good alliance with significant othersGood alliance with significant others May need other resources (coaches, May need other resources (coaches,

etc)etc)

Rx Goal : Enhance Rx Goal : Enhance Resilience Resilience

(Charney, 2005)(Charney, 2005) OptimismOptimism AltruismAltruism Moral compassMoral compass Faith and spiritualityFaith and spirituality HumorHumor Role modelRole model Social supportsSocial supports Face fearsFace fears Life missionLife mission TrainingTraining

Medication for ADHDMedication for ADHD

CNS stimulants and other CNS stimulants and other medicationsmedications

Result : moderate to marked Result : moderate to marked improvement in 60-70% of adult improvement in 60-70% of adult ADHD patientsADHD patients

Rarely “magic,” by itselfRarely “magic,” by itself

CNS Stimulants for ADHDCNS Stimulants for ADHD

Helpful, but less than in childrenHelpful, but less than in children Biggest problem in adults is Biggest problem in adults is

underdosingunderdosing Usual daily dosage range is Usual daily dosage range is

50-100 mg of methylphenidate, 50-100 mg of methylphenidate, 30-50 mg of dextroamphetamine 30-50 mg of dextroamphetamine

Try both, since 25% respond to one Try both, since 25% respond to one but not the otherbut not the other

CNS CNS Stimulants:Stimulants:

Active cardiovascular heart disease or Active cardiovascular heart disease or uncontrolled hypertensionuncontrolled hypertension

Active, untreated substance abuseActive, untreated substance abuse Drug-abusing patients with less than Drug-abusing patients with less than

three months of documented three months of documented abstentionabstention

Current symptoms or past history of Current symptoms or past history of bipolar disorder, especially maniabipolar disorder, especially mania

PsychosisPsychosis

Do Do NOTNOT UseUse

Methylphenidate stimulantsMethylphenidate stimulants

ConcertaConcerta DaytranaDaytrana FocalinFocalin Focalin XRFocalin XR Metadate CDMetadate CD Ritalin HClRitalin HCl Ritalin LARitalin LA

Amphetamine stimulantsAmphetamine stimulants

AdderallAdderall Adderall-XRAdderall-XR (Adderall-XXR)(Adderall-XXR) Dexedrine Dexedrine Dexedrine spansulesDexedrine spansules

Med Trial with Adderall XRMed Trial with Adderall XR

10 mg po each morning for 3-7 days10 mg po each morning for 3-7 days Raise by 10 mg increments each 3-7 days Raise by 10 mg increments each 3-7 days

until there is no further improvement, or until there is no further improvement, or there are bad side effects, or boththere are bad side effects, or both

Establish consistent use before prn useEstablish consistent use before prn use Seek lowest dosage with best efficacySeek lowest dosage with best efficacy Modulate dosage over 6 months to a yearModulate dosage over 6 months to a year

CNS Stimulant Trial: CNS Stimulant Trial: DangersDangers

Rise in blood pressure or pulseRise in blood pressure or pulse InsomniaInsomnia Irritability/signs of maniaIrritability/signs of mania Loss of appetiteLoss of appetite JitterinessJitteriness Hypersexuality Hypersexuality Worsened anxiety, depression, Worsened anxiety, depression,

psychosispsychosis

Stimulants, Abuse,Stimulants, Abuse,and ADHD Patientsand ADHD Patients

CNS stimulants are CNS stimulants are rarelyrarely abused by abused by ADHD patientsADHD patients

Used properly, they Used properly, they decreasedecrease the the likelihood of later substance abuse in likelihood of later substance abuse in these patientsthese patients

If there is comorbid substance abuse, If there is comorbid substance abuse, treat it first treat it first

Non-CNS Stimulants for Adult Non-CNS Stimulants for Adult ADHDADHD

Atomoxetine (Strattera): YesAtomoxetine (Strattera): Yes Bupropion (Wellbutrin): YesBupropion (Wellbutrin): Yes Tricyclic antidepressants: Yes Tricyclic antidepressants: Yes Monoamine Oxidase Inhibitors: YesMonoamine Oxidase Inhibitors: Yes SSRIs, SNRIs: NoSSRIs, SNRIs: No Alpha-agonists: No (?)Alpha-agonists: No (?) Nicotine and cholinergic agents: ?Nicotine and cholinergic agents: ? Modafinil (Provigil): Not alone, “layered” Modafinil (Provigil): Not alone, “layered”

Strattera (atomoxetine)Strattera (atomoxetine)

Titrate to 80-120 mg qd for 4-6 Titrate to 80-120 mg qd for 4-6 weeksweeks

Watch for irritability, nausea, Watch for irritability, nausea, sedation, delayed urination, less sedation, delayed urination, less libido, delayed orgasm, higher blood libido, delayed orgasm, higher blood pressure and pulsepressure and pulse

Hepatic symptoms: discontinue Hepatic symptoms: discontinue statstat Mild-moderate improvement Mild-moderate improvement

IneffectiveIneffective Treatments for Treatments for ADHDADHD

Meds: lithium carbonate; amantadine; l-Meds: lithium carbonate; amantadine; l-Dopa; D-,L-phenylalanine; tyrosine; Dopa; D-,L-phenylalanine; tyrosine; antiyeast medicationsantiyeast medications

Dietary supplements: acetylcarnitine; Dietary supplements: acetylcarnitine; gingko biloba; phosphatidylserine; gingko biloba; phosphatidylserine; essential fatty acids such as gamma-essential fatty acids such as gamma-linolenic acid and docosahexanoic acid; linolenic acid and docosahexanoic acid; megavitamins; DMAE megavitamins; DMAE (dimethylaminothanol)(dimethylaminothanol)

Dietary manipulations Dietary manipulations

Adult ADHD: Adult ADHD: Active Psychotherapy Active Psychotherapy

Support and psychoeducationSupport and psychoeducation Cognitive behavioral treatmentCognitive behavioral treatment Psychodynamic treatmentPsychodynamic treatment Couples treatmentCouples treatment Family treatmentFamily treatment ““Coaching”Coaching”

Comorbid ADHD: Comorbid ADHD: Be VigilantBe Vigilant

The The rulerule, not the exception, not the exception Look for ADHD in the anxious or Look for ADHD in the anxious or

depressed or substance-abusing depressed or substance-abusing patient; look for anxiety and patient; look for anxiety and depression and substance abuse in depression and substance abuse in the ADHD patientthe ADHD patient

““Treat what’s worst, first”Treat what’s worst, first” Personality disorders worsen prognosisPersonality disorders worsen prognosis

ADHD : Comorbid Affective ADHD : Comorbid Affective DisorderDisorder

At least 25% of ADHD patients are At least 25% of ADHD patients are depressed depressed

At least 25% of depressed patients At least 25% of depressed patients have ADHDhave ADHD

Strattera and the SSRIs: escitalopram Strattera and the SSRIs: escitalopram (Lexapro) or sertraline (Zoloft) don’t (Lexapro) or sertraline (Zoloft) don’t compete for the metabolic pathway compete for the metabolic pathway

ADHD and Bipolar DisorderADHD and Bipolar Disorder

An estimated 5-10% of adult ADHD An estimated 5-10% of adult ADHD patients have bipolar disorderpatients have bipolar disorder

Screen for it Screen for it by using a rating scale by using a rating scale

(eg, Mood Disorders Questionnaire) (eg, Mood Disorders Questionnaire) and data from significant others, and data from significant others, familyfamily

Stabilize mood before treating ADHDStabilize mood before treating ADHD

ADHD and Anxiety DisordersADHD and Anxiety Disorders

An estimated 50% of ADHD patients An estimated 50% of ADHD patients have 1 or more anxiety disordershave 1 or more anxiety disorders

Stimulants “worsen” anxiety, but full Stimulants “worsen” anxiety, but full treatment of ADHD lessens ittreatment of ADHD lessens it

Adult ADHD and Substance Adult ADHD and Substance AbuseAbuse

10% chance of current substance 10% chance of current substance abuse, 50% chance of past abuse, abuse, 50% chance of past abuse, 20-50% chance of 20-50% chance of future abusefuture abuse

Incidence higher in antisocial Incidence higher in antisocial personality disorderpersonality disorder

ADHD and Substance Abuse, ADHD and Substance Abuse, cont’dcont’d

Vigilance Vigilance Information from patient and othersInformation from patient and others Treat substance abuse firstTreat substance abuse first Document three or more months of Document three or more months of

abstinence before treating ADHDabstinence before treating ADHD Treat the abstinent patient with Treat the abstinent patient with

Strattera and/or stimulants, but stay Strattera and/or stimulants, but stay vigilantvigilant

Treatment-Refractory ADHDTreatment-Refractory ADHD

Lack of response to medicationLack of response to medication Many/severe comorbid disordersMany/severe comorbid disorders Unsupportive or hostile familyUnsupportive or hostile family Character pathology Character pathology

Treatment-Refractory ADHDTreatment-Refractory ADHD

Combine stimulants with Combine stimulants with atomoxetine or bupropionatomoxetine or bupropion

Combine atomoxetine or bupropion Combine atomoxetine or bupropion with a stimulant with a stimulant

Add modafinilAdd modafinil Try TCA (alone or with stimulant)Try TCA (alone or with stimulant) Alpha-agonistAlpha-agonist MAOI (alone)MAOI (alone)

ADHD and Women ADHD and Women

Girls have ADHD, Girls have ADHD, with significant with significant morbidity and higher risk of drug morbidity and higher risk of drug abuseabuse

Women with ADHD can founder when Women with ADHD can founder when they have childrenthey have children

Issues concerning pregnancy and Issues concerning pregnancy and breast-feeding require coordinated breast-feeding require coordinated carecare

ADHD and FamiliesADHD and Families

Problems are multi-generationalProblems are multi-generational The spouse can be unsupportive or The spouse can be unsupportive or

overburdened or bothoverburdened or both Think in terms of the family systemThink in terms of the family system

ADHD in Adults: Summary ADHD in Adults: Summary

Keep the diagnosis in mindKeep the diagnosis in mind Evaluate thoroughlyEvaluate thoroughly Assess for comorbidity, especially Assess for comorbidity, especially

affective disorder and substance affective disorder and substance abuse abuse

Identify strengthsIdentify strengths Treat what’s worst, firstTreat what’s worst, first Enhance resilienceEnhance resilience

Enhance ResilienceEnhance Resilience

OptimismOptimism AltruismAltruism Moral compassMoral compass Faith and spiritualityFaith and spirituality HumorHumor Role modelRole model Social supportsSocial supports Face fearsFace fears Life missionLife mission TrainingTraining

References: BooksReferences: Books

Doyle BB: Doyle BB: Understanding and Understanding and Treating Adults with ADHDTreating Adults with ADHD, 2006, 2006

Adler L: Adler L: Scattered MindsScattered Minds, 2006, 2006 Barkley RA: Barkley RA: Attention Deficit Attention Deficit

Hyperactivity DisorderHyperactivity Disorder, 3, 3rdrd Ed, 2006 Ed, 2006 Solanto MV, Arnsten AFT, Castellanos Solanto MV, Arnsten AFT, Castellanos

FX: FX: Stimulant Drugs and ADHDStimulant Drugs and ADHD, 2001, 2001

References: WebsitesReferences: Websites

www.CHADD.comwww.CHADD.com www.ADDvance.comwww.ADDvance.com www.drbriandoyle.com