Transcript Overview of Adult Attention

Overview of Adult AttentionDeficit Hyperactivity Disorder
Glenn Ashkanazi, PhD
March 16, 2009
Take The Test
Never
Rarely
Sometimes
Often
Very Often
How often do you have trouble wrapping up the final details of a project,
once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to
perform a task that requires organization?
How often do you have problems remembering appointments or
obligations?
When you have a task that requires a lot of thought, how often do you
avoid or delay getting started?
How often do you fidget or squirm with your hands or feet when you have
to sit down for a long time?
How often do you feel overly active and compelled to do things, like you
were driven by a motor?
Score
Q#1,2,3

Sometimes, Often, Very Often = 1 point
each
Q#4,5,6

Often, Very Often = 1 point
Total >4 (may be consistent w/ADHD)
Controversial
www.adhdfraud.org
http://hamptonroads.com/node/357171
http://www.youtube.com/watch?v=VRPq
aTy5oFA
“Hidden Disorder”
Symptoms obscured by:
Problems in relationships
 Problems with organization
 Problems with mood
 Problems with substance abuse
 Problems with employment
 Problems, problems, problems

“Hidden Disorder”
(cont.)
“Children outgrow ADHD”
Past focus on hyperactivity
 Decrease by teen years

Current:

Focus on inattention & impulsivity
Prevalence (Children)
School age children in US (3-7%)
(DSM-IV)
Gender: males (2-10:1)

Most cited (6:1) (referred samples)
30-85% show symptoms into adulthood
Prevalence (Adults)
Adults in US (2-10%)

4-5% most often cited (Kessler, 2005)
Persistence of Childhood ADHD

Prospective studies
Only Four>50% retention
 Variations in selection/diagnostic criteria
 Changes in sources of information


Persistence difficult to estimate
Etiology
“Executive Function Dysfunction”
Activate
 Organize
 Integrate
 Manage

Self-regulation/self-control
Etiology (cont.)
Transition of Model
Then: Attention/Hyperactivity
 Now: Developmental Disorder of SelfDysregulation That Extends Across Time
and Settings

Etiology (cont.)
Neurochemical transmission problem

(dopamine,norepinephrine)
Genetic: primary factor?

Parent w/ADHD = 57% of ADHD child
NO adult onset
When Heredity NOT a
Factor
“Difficult” pregnancy
Prenatal exposure
to EtOH/Tobacco
Premature delivery
Low birth weight
High lead levels
Injury to prefrontal
regions
Diagnosis
Extensive support for symptom thresholds for
children (Lahey et al., 1994)
Use of DSM-IV criteria for adults remains
controversial (Riccio et al., 2005)


Criteria designed for, and based on, studies
w/children
Lack of validation studies w/adults (Belendiuk,
2007)
Diagnosis (cont.)
Use of DSM-IV-TR
Symptom lists inappropriately worded for
adults
 Dx thresholds too restrictive
 Some Sxs not even listed:



Procrastination, overreacting to frustration, poor
motivation, insomnia, time mgmt problems
Level of impairment different btwn adults
and children (marital, occupational, etc)
Diagnosis (cont.)
3 Sub-types: (DSM-IV-TR)



Attention Deficit /Hyperactivity-Impulsivity
Disorder-Predominantly Inattentive Type (ADHD-I)
(314.00) (most common)
Attention Deficit /Hyperactivity-Impulsivity
Disorder-Predominantly Hyperactive-Impulsive
Type (ADHD-H) (314.01)
Attention Deficit /Hyperactivity-Impulsivity
Disorder-Combined Type (ADHD-C) (314.01)
Diagnosis (cont.)
Longitudinal Studies:

Developmental influence

ADHD Sxs decrease with age (National
Academy for the Advancement of ADHD Care,
2003)


Hyperactivity-Impulsivity (decrease)
Inattentiveness (persists)
Diagnosis (cont.)

True remission or measurement problem?
Several studies suggest DSM-IV criteria are too
stringent for adult Dx.
 Use of deviance model indicates higher rates


Potential New Model:

Norm-referenced vs. criterion-referenced Dx

Determining ADHD symptom thresholds specific to
age groups
 Developmentally Referenced Criterion (DRC)
 98th percentile; +2 SD
Diagnosis (cont.)
Abandon DSM-IV-TR?

Re-examine
Adults in different settings
 Adults have different demands
 Adults live & work independently
 Children in more structured settings
 Children under adult supervision

Diagnosis (cont.)
Either
1.
Six (or more) of the following symptoms
of inattention have persisted for at least
six months to a degree that is
maladaptive and inconsistent with
developmental level
Inattention Sxs
(a) often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish
school work, chores, or duties in the workplace (not due to oppositional
behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
Hyperactivity
2. Six (or more) of the following
symptoms of hyperactivity-impulsivity
have persisted for at least six months to
a degree that is maladaptive and
inconsistent with developmental level
Hyperactivity
a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other
situations in which remaining seated is expected
(c) 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)
(d) often has difficulty playing or engaging in leisure
activities quietly
(e) is often "on the go" or often acts as if "driven by a
motor"
(f) often talks excessively
Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations
or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused
impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more
settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in
social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a
Pervasive Developmental Disorder, Schizophrenia, or other Psychotic
Disorder and are not better accounted for by another mental disorder
(e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a
Personality Disorder).
Diagnosis (cont.)
Some hyperactive – impulsive or
inattentive symptoms that caused
impairment were present before age
seven years
Some impairment from the symptoms is
present in two or more settings

(e.g. at school, or work AND at home)
Diagnosis (cont.)
There must be clear evidence of clinically
significant impairment in social, academic, or
occupational functioning
The symptoms do not occur exclusively
during the course of a pervasive
developmental disorder, schizophrenia or
other psychotic disorder and are not better
accounted for by another mental disorder
(e.g. mood disorder, anxiety disorder,
personality disorder,etc.)
Differential Diagnosis
PTSD^
Mental retardation
Substance
intoxication*
4. Bipolar disorder*
5. Tourette’s Syndrome
6. Depression
7. Adjustment disorder
8. Brain injury
* = ADHD-C (severity)
^ = ADHD-H
1.
2.
3.
9.
10.
11.
12.
13.
14.
15.
16.
Brain tumors
Multiple sclerosis
Epilepsy
Stroke
Dementia
Liver/renal problems
Drug side effects
Hyper/hypo-thyroidism
Assessment Process
Comprehensive Evaluation Overview
Assess Psychopathology
 Assess Functional Impairments
 Assess Pervasiveness
 Assess Age of Onset
 Rule-Out Other Disorders That Explain
Condition

Assessment Process
(cont.)
Interview with patient and significant others




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
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Developmental history
Medical/Psychiatric history
School/Work history
Past evaluations
Past treatments
Present/past ADHD symptoms
Impairment history
Assessment process
(cont.)
4 Core Questions:
1.
2.
Is there credible evidence that the patient
experienced ADHD type symptoms in early
childhood that by middle school years led to
chronic impairment across settings?
Is their credible evidence that ADHD type
symptoms currently causes the patient
substantial and consistent impairment across
settings?
Assessment process
(cont.)
4 core questions (cont.)
3. Are there explanations other than the
ADHD that better accounts for the clinical
picture?
4. For patients who meet criteria for ADHD,
is there evidence for the existence of
comorbid conditions?
Semi-structured
Interviews
Conners Adult ADHD Diagnostic
Interview for DSM-IV(CAADID)
(Epstein, 2000)
Symptoms, developmental course, ADHD
risk factors and comorbid psychopathology
 Good test-retest reliability for Dx and
symptoms
 Good concurrent validity (Epstein, 2006)

Rating Scales
Conners Adult ADHD Rating Scales
(CAARS) (Conners, 1999)
Self-report and observer scales
 Test-retest high (.85-.95)
 Correct classification rate = 85%

Assessment process
(cont.)
Neuropsychological Testing
No single test or battery of tests has
adequate predictive validity or specificity
 Useful to support results from history,
rating scales & analysis of current
functioning

Neuropsychological
Testing
Review of 35 studies (Woods, 2002)

Discrepancies between adults w/ADHD and
normal controls on executive function

Stroop Tasks



Visual Attention
Response Inhibition
Continuous Performance Test (CPT) Computer-based



Attention (Sustained & Selective)
Impulsivity
Vigilence
Stroop
Comorbidities
Children:
44% of children with ADHD=1other psych.
Dx
 32% of children with ADHD=2 other psych.
Dx
 11% of children with ADHD=3 other psych.
Dx

Comorbidities (cont.)
Depression
Major (16-31%)
 Dysthymia (19-37%)

Anxiety
Children (25%)
 Adults (24-43%) (GAD)

Learning disability

10-90%
Comorbidities (cont.)
Anti-social personality disorder

7-18%
Bipolar disorder

10% in adults
Tics/Tourette’s
ADHD children = 7%
 Tourette children = 60% w/ADHD

Comorbidities (cont.)
Substance-abuse
14-33% SA pts have ADHD
 Lifetime rates of EtOH dependence/abuse
= 32-53%

Malingering
Conscious fabrication or exaggeration of
physical or psychological symptoms in the
pursuit of a recognized goal (APA, 1994)
Benefits:

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Stimulant Medications
Disability Benefits
Tax Benefits
Academic Accommodations
Symptom Validity Testing
Treatment
Children’s Guidelines for Treatment

American Academy of Pediatrics, 2001
Adults = ???
Overview
Symptom reduction/minimize neg effects
 Education
 Psychotherapy
 Pharmacological

Treatment (cont.)
Education
Diagnosis is crucial
 Signs and symptoms
 Why diagnosis not made sooner?

Psychotherapy
Secondary emotional symptoms
 Cognitive behavioral therapy

Treatment (cont.)
Drugs

Well established in children with ADHD
(Wilens, 2003)
Stimulants (first line drugs)
 Children (70-80% respond)
 Adults (25-78% respond) (30% don’t!!!!)



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Methylphenidate (Ritalin)
Amphetamine compounds (Adderall)
Dextroamphetamine (Dexedrine)
Treatment (cont.)
Drugs (cont.)
Release of norepinephrine and dopamine

Stimulant side effects:

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
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Insomnia
Decreased appetite
Decreased weight
Irritability
Tics
Headache
Potential for Abuse
Treatment (cont.)
Stimulant administration:
Short-acting,low dose = titrate up
 Move towards longer acting stimulants

Concerta = 6-12 hours
 Ritalin SR = 6-8 hours
 Cylert = 8-10 hours (possible liver damage)


If one doesn’t work, try another
Treatment (cont.)
Anti-depressants
Tri-cyclics (Desipramine-Norpramin;
Atomoxetine-Strattera)**
 Bupropion (Wellbutrin)-atypical
 Venlafaxine (Effexor)-atypical
 SSRIs = not shown to be effective
**=Desipramine, then Strattera best

Medication Compliance
Adults compliant for brief period of time
(i.e. 2 months) (Perwien, 2004)
ADHD medication adherence
significantly and positively correlated
with ADHD symptom severity (Safran,
2007)
Psychosocial
Intervention

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
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CBT
Self-Mgmt Skills Training
Environmental Restructuring
Psycho-education
Individual Psychotherapy
Family Therapy
Marital/Couple Therapy
Vocational Counseling
ADHD Coaching
Psychosocial
Intervention
Cognitive Behavioral Therapy

Well-suited for adults ADHD

Many develop negative beliefs about the self



Treatment of co-morbid diagnoses
Treatment of functional problems
Focus on Training in: (Barkley, 2006)
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Time Mgmt
Organizational Skills
Communication Skills
Decision-Making
Self-Monitoring
Chunking Large Tasks into Smaller Ones
Changing Faulty Cognitions
Future Directions
1.
2.
3.
4.
Prevalence of ADHD in criminal justice
system-candidates for Tx.
Incidence of ADHD in geriatric population
ADHD in ethically and culturally diverse
populations
Identify ADHD “profiles”
Empirically valid?
Differentially respond to treatments
Future Directions (cont.)
5. Effectiveness of Psychosocial
Treatments
6. ADHD coaching and academic
accomodations