Transcript Attention-Deficit Hyperactivity Disorder in Adults and

Attention-Deficit Hyperactivity
Disorder in Adults and
Children
Conceptualization, Diagnosis and Treatment
An Integrated Approach
By
Ghada Hamdan-Allen, M.D.
Objectives
• 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 Course
• ADHD is a developmentally inappropriate
level of hyperactivity, distractibility and
impulsivity.
inattention
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Age
ADHD: 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 Diagnosis
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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: 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: 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 5060% of ADHD population compared to 30% in
general population
– ADHD is common in first degree relatives
ADHD: 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: 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 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
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Few friends
Poor participation in group activities
Vulnerable to drug abuse and antisocial groups
Increased MVA
ADHD: Effect on Parents
• Increased stress
– Worry
– Frustration
-Anxiety
-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
Adults
• Impairment
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Occupational difficulty
Low self esteem
Poor parenting
Legal problems
Health concerns
Injuries
MVA, speeding tickets
Smoking
Substance abuse
Relationship problems
• Improvements
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More efficient
Better organized
Enjoy social activities
Stable marriage
Improved parenting
Financial responsibility
Contain aggressive
impulses
– Decrease THC
dependence
ADHD: Diagnosis
• Clinical interview
– History
– Rating Scales
– Collateral information/Impairment
• Physical evidence
– PE
-CPT
– Lead level -Thyroid function
• Co-morbidity
ADHD-Diagnosis
A Community Effort
• History
– Parents
– Spouses/Partners
– Day care providers
– Teachers
– Therapists
– Primary care physicians
– Social agencies (DHS; Juvenile Court)
ADHD-Diagnosis
A 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: 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 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: Psychopharmacology
• Short term trials are recommended in the
beginning
• Choice of medications is based on:
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Duration
Co-morbidity
Target symptoms
Patient preference
Family history
Past medication history
Risk of abuse
ADHD: Psychopharmacology
• Address issues of
non-compliance
• Monitor side effects
including vital
signs/Growth
• Measure progress by
subjective report and
rating scales
• Feedback loop:
Parent/teacher Psychiatrist
Patient
PCP
Psychopharmacology-Stimulants
• Short acting
– Ritalin, Methylin, Focalin
– Dextrostat
• Medium acting
– Adderall
– Metadate
• Long acting
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Concerta
Ritalin LA
Adderall XR
Vyvanse
Daytrana
Psychopharmacology-Stimulants
• Adverse events
– Anorexia, weight loss
– Insomnia
– Headaches
– Stomach ache and vomiting
– Stereotypy and tics
– Increased pulse and BP
– Growth?
Psychopharmacology-Strattera
• Mechanism of action
– NE transporter blockade
– Increase dopamine in prefrontal cortex
• No increase in nucleus accumbens
• No increase in the striatum
• Adverse events
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Decreased appetite
Somnolence
Dyspepsia
Elevation of pulse and BP
Sexual dysfunction
Psychopharmacology
• Antidepressants
– Tricyclic antidepressants: Imipramine,
Desipramine
– Wellbutrin
• Alpha2 agonists
– Clonidine
– Tenex
ADHD-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