Attention-Deficit Hyperactivity Attention-Deficit Hyperactivity Disorder in Adults and Disorder in Adults and

ChildrenChildrenConceptualization, Diagnosis and TreatmentConceptualization, Diagnosis and Treatment

An Integrated ApproachAn Integrated ApproachBy By

Ghada Hamdan-Allen, M.D.Ghada Hamdan-Allen, M.D.

ObjectivesObjectives

• Define and diagnose Attention-Deficit Hyperactivity Disorder using clinical criteria.

• Recognize the integrated community approach to diagnosing and treating ADHD.

• Improve management of ADHD

ADHD: Definition and CourseADHD: Definition and Course

• ADHD is a developmentally inappropriate level of hyperactivity, distractibility and impulsivity.

•

hyperactivity

inattention

impulsivity

Age

ADHD: EpidemiologyADHD: Epidemiology

• Prevalence– 4-12% of children under 18– 4.7% of adults– Female to male ratio: 10:1 in children and 2:1

In adult clinical samples.– ADHD is over-represented in adoptees and

lower SES

ADHD: Differential DiagnosisADHD: Differential Diagnosis

• Conduct disorder• Oppositional defiant disorder• Tourette’s disorder• Anxiety disorder• Learning disorder• Mood disorders: unipolar and bipolar• Substance use disorder• Developmental disorders• Personality disorder

ADHD: EtiologyADHD: Etiology• Prenatal and perinatal:

– Exposure to drugs, smoking and alcohol in utero(3/10)

– Low birth weight(3/10)– Parental ADHD(8/10)– Maternal age at birth(1/10)

• Environmental:– Lead toxicity– Low SES– Medications: anti- seizure and asthma treatment

ADHD: EtiologyADHD: Etiology

• Genetic– Monozygotic twins are more concordant than

dizygotic twins– ADHD heritability factor is 0.75-0.91– Candidate genes: 7-repeat allele of

D4dopamine receptor gene is present in 50-60% of ADHD population compared to 30% in general population

– ADHD is common in first degree relatives

ADHD: EtiologyADHD: Etiology• Model of executive function:

– Response inhibition: controls verbal and motor impulses

– Nonverbal working memory: sense of self in relation to past & future

– Verbal working memory: self questioning and description. Using language to rule conduct

– Self regulation of emotions and behavior– Reconstitution: analysis of past experience to

formulate new responses that help us achieve our goals

ADHD: EtiologyADHD: Etiology

• Neurological:– Less active prefrontal cortex affects memory

and response inhibition– Anterior cingulate gyrus dysfunction affects

cognition– SPECT studies show increase binding at

dopamine transporter protein

ADHD: Areas of ImpairmentADHD: Areas of Impairment

• Performance limitations– Academic difficulty in school (25% repeat a grade)– Lower level of occupational advancement

• Socialization– Children are stigmatized by their behavior– Adolescents demonstrate social problems

• Few friends• Poor participation in group activities• Vulnerable to drug abuse and antisocial groups• Increased MVA

ADHD: Effect on ParentsADHD: Effect on Parents

• Increased stress– Worry -Anxiety– Frustration -Anger

• Lower self esteem– Self blame -depression– social isolation

• Disruption of employment • Increased marital discord• Increased alcohol and substance abuse

ADHD: Indicators of Impairment in ADHD: Indicators of Impairment in AdultsAdults

• Impairment– Occupational difficulty– Low self esteem– Poor parenting– Legal problems– Health concerns– Injuries– MVA, speeding tickets– Smoking– Substance abuse– Relationship problems

• Improvements– More efficient– Better organized– Enjoy social activities– Stable marriage– Improved parenting– Financial responsibility– Contain aggressive

impulses– Decrease THC

dependence

ADHD: DiagnosisADHD: Diagnosis

• Clinical interview– History– Rating Scales– Collateral information/Impairment

• Physical evidence– PE -CPT– Lead level -Thyroid function

• Co-morbidity

ADHD-DiagnosisADHD-DiagnosisA Community EffortA Community Effort

• History– Parents– Spouses/Partners– Day care providers– Teachers– Therapists– Primary care physicians– Social agencies (DHS; Juvenile Court)

ADHD-DiagnosisADHD-DiagnosisA Community EffortA Community Effort

• Rating Scale: to corroborate clinical diagnosis– Conner's– ADHD-RS

• Clinical Interviews:– Determine impairment in school/home/job

settings– Make assessment for comorbid conditions– Physical exams and tests

ADHD: TreatmentADHD: Treatment• Psycho-education

– Reframe– compromise

• Environmental restructuring– Lists, PDA, cell phones– Encourage ADHD friendly occupations and hobbies

• Psycho-pharmacology– FDA approved: Stimulants; Atomoxetine– Off-label: antidepressants; alpha-2 adrenergic

agonists

Bibliotherapy for Adults with ADHDBibliotherapy for Adults with ADHD

• Books– Driven to distraction by Hallowell and Ratey– ADHD in Adulthood by Weiss, Trokenberg Hechtman

and Weiss

• Video– ADHD in Adults by Barkley

• Organizations– www.chadd.org– National Alliance for the Advancement of ADHD care

www.naaac.org

ADHD: PsychopharmacologyADHD: Psychopharmacology

• Short term trials are recommended in the beginning

• Choice of medications is based on:– Duration– Co-morbidity– Target symptoms– Patient preference– Family history– Past medication history – Risk of abuse

ADHD: PsychopharmacologyADHD: Psychopharmacology

• Address issues of non-compliance

• Monitor side effects including vital signs/Growth

• Measure progress by subjective report and rating scales

• Feedback loop:

Psychiatrist

PCPPatient

Parent/teacher

Psychopharmacology-StimulantsPsychopharmacology-Stimulants

• Short acting – Ritalin, Methylin, Focalin– Dextrostat

• Medium acting– Adderall – Metadate

• Long acting– Concerta– Ritalin LA– Adderall XR– Vyvanse– Daytrana

Psychopharmacology-StimulantsPsychopharmacology-Stimulants

• Adverse events– Anorexia, weight loss– Insomnia– Headaches– Stomach ache and vomiting– Stereotypy and tics– Increased pulse and BP– Growth?

Psychopharmacology-StratteraPsychopharmacology-Strattera

• Mechanism of action– NE transporter blockade– Increase dopamine in prefrontal cortex

• No increase in nucleus accumbens• No increase in the striatum

• Adverse events– Decreased appetite– Somnolence– Dyspepsia– Elevation of pulse and BP– Sexual dysfunction

PsychopharmacologyPsychopharmacology

• Antidepressants– Tricyclic antidepressants: Imipramine,

Desipramine– Wellbutrin

• Alpha2 agonists– Clonidine– Tenex

ADHD-An integrated ApproachADHD-An integrated Approach

• Interdisciplinary Communication– PCP/Specialist/Parents/School/Therapist

• When to refer?– Comorbidity– Poor response– Polypharmacy

• Know the community resources.– School based services– Remedial counseling