Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder (ADHD)

1. Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder (ADHD) Brian B. Doyle, MD

2. Adults with ADHD • What is ADHD? • How do you diagnose it in adults ? • How do you treat with medication? • What other treatments help? • What is the impact of comorbid conditions? • How do you deal with treatment-refractory ADHD?

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

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

5. Symptoms of Inattention • Fails to attend to details • Fails to sustain attention on task • Fails to listen • Fails to finish jobs • Poor at planning and organizing • Loses things frequently • Easily distracted by extraneous stimuli • Often forgetful • Avoids sustained mental effort

6. Hyperactive/Impulsive Symptoms • Can’t sit quietly • Has to get up and move around • Subjective restlessness • Hard to engage in leisure quietly • “On the go” or “driven” • Talks excessively • Speaks without thinking; blurts out • Has difficulty waiting his or her turn • Interrupts or intrudes on others

7. Criterion B: Symptoms causing impairment were present before age 7 years

8. Criterion C: Impairment from the symptoms is present in two or more settings (eg, work and home)

9. Criterion D: There is clear evidence of significantimpairment in social, academic or occupational functioning

10. Criterion E: The symptoms are not better accounted for by another mental disorder (eg, mood or anxiety disorder, substance abuse, personality disorder)

11. Initial Evaluation 1: Clinical Interviews • Past and present ADHD symptoms • How, where symptoms cause impairments • Alternative and comorbid disorders • Developmental history/impulses • Strengths* • Mental status examination

12. Evaluation 2: Standardized Rating Scales • Adult ADHD Self Report Scale • Barkley System of Diagnostic Scales • Brown Attention-Deficit Disorder Scales • Conners Adult ADHD Rating Scale

13. Evaluation 3: Medical history and assessments

14. Evaluation 4: Family • History of ADHD, results of treatment • History of other disorders

15. Evaluation 5: Information from a significant other or parent • Documentation • Interview data • Rating scales

16. Evaluation 6: School and work assessments

17. Evaluation 7: Other assessments • Educational • Psychological testing • Neuropsychological testing • Neuroimaging • Vocational

18. ADHD Subtypes • Combined • Predominantly inattentive • Predominantly hyperactive/impulsive • Not otherwise specified

19. Prevalence of ADHD in adults: 4.4%(National Comorbidity Study, 2006)

20. Differential Diagnosis of ADHD • Psychiatric • Medical • Dietary • Malingering • Normal behavior

21. Psychiatric Disorders Associated with ADHD • Anxiety disorders • Affective disorders, uni- and bipolar* • Learning disorders • Substance abuse disorders • Tourette’s Disorder • Schizophrenia and other psychotic disorders • Mental retardation • Pervasive developmental disorders • Personality disorders

22. The Biology of ADHD • Attention is a complex state mediated by several areas of the brain • Frontal lobe dysfunction is central but not the only site of the disorder

23. The Biology of ADHD, cont’d • Less gray and white matter • Decrements in the dorsal prefrontal cortex • Decrements in the cerebellum • Decrements in the striatum

24. Biology: Neurotransmitters • Dopamine relates to attention • Norepinephrine relates to hyperactivity/impulsivity • Current thinking: multiple neurotransmitter systems are involved

25. Biology of ADHD: Genetics • Family studies: more first-degree relatives of affected individuals • Twin studies: higher concordance in identical than in fraternal twins • Adoption studies: nature>nurture • Molecular studies: candidate genes affect neurotransmitter systems

26. Comprehensive Treatment for ADHD • Always starts with education • Usually includes medication • Usually includes psychotherapy • Good alliance with significant others • May need other resources (coaches, etc)

27. Rx Goal : Enhance Resilience (Charney, 2005) • Optimism • Altruism • Moral compass • Faith and spirituality • Humor • Role model • Social supports • Face fears • Life mission • Training

28. Medication for ADHD • CNS stimulants and other medications • Result : moderate to marked improvement in 60-70% of adult ADHD patients • Rarely “magic,” by itself

29. CNS Stimulants for ADHD • Helpful, but less than in children • Biggest problem in adults is underdosing • Usual daily dosage range is 50-100 mg of methylphenidate, 30-50 mg of dextroamphetamine • Try both, since 25% respond to one but not the other

30. CNS Stimulants: Do NOTUse • Active cardiovascular heart disease or uncontrolled hypertension • Active, untreated substance abuse • Drug-abusing patients with less than three months of documented abstention • Current symptoms or past history of bipolar disorder, especially mania • Psychosis

31. Methylphenidate stimulants • Concerta • Daytrana • Focalin • Focalin XR • Metadate CD • Ritalin HCl • Ritalin LA

32. Amphetamine stimulants • Adderall • Adderall-XR • (Adderall-XXR) • Dexedrine • Dexedrine spansules

33. Med Trial with Adderall XR • 10 mg po each morning for 3-7 days • Raise by 10 mg increments each 3-7 days until there is no further improvement, or there are bad side effects, or both • Establish consistent use before prn use • Seek lowest dosage with best efficacy • Modulate dosage over 6 months to a year

34. CNS Stimulant Trial: Dangers • Rise in blood pressure or pulse • Insomnia • Irritability/signs of mania • Loss of appetite • Jitteriness • Hypersexuality • Worsened anxiety, depression, psychosis

35. Stimulants, Abuse,and ADHD Patients • CNS stimulants are rarely abused by ADHD patients • Used properly, they decrease the likelihood of later substance abuse in these patients • If there is comorbid substance abuse, treat it first

36. Non-CNS Stimulants for Adult ADHD • Atomoxetine (Strattera): Yes • Bupropion (Wellbutrin): Yes • Tricyclic antidepressants: Yes • Monoamine Oxidase Inhibitors: Yes • SSRIs, SNRIs: No • Alpha-agonists: No (?) • Nicotine and cholinergic agents: ? • Modafinil (Provigil): Not alone, “layered”

37. Strattera (atomoxetine) • Titrate to 80-120 mg qd for 4-6 weeks • Watch for irritability, nausea, sedation, delayed urination, less libido, delayed orgasm, higher blood pressure and pulse • Hepatic symptoms: discontinue stat • Mild-moderate improvement

38. Ineffective Treatments for ADHD • Meds: lithium carbonate; amantadine; l-Dopa; D-,L-phenylalanine; tyrosine; antiyeast medications • Dietary supplements: acetylcarnitine; gingko biloba; phosphatidylserine; essential fatty acids such as gamma-linolenic acid and docosahexanoic acid; megavitamins; DMAE (dimethylaminothanol) • Dietary manipulations

39. Adult ADHD: Active Psychotherapy • Support and psychoeducation • Cognitive behavioral treatment • Psychodynamic treatment • Couples treatment • Family treatment • “Coaching”

40. Comorbid ADHD: Be Vigilant • The rule, not the exception • Look for ADHD in the anxious or depressed or substance-abusing patient; look for anxiety and depression and substance abuse in the ADHD patient • “Treat what’s worst, first” • Personality disorders worsen prognosis

41. ADHD : Comorbid Affective Disorder • At least 25% of ADHD patients are depressed • At least 25% of depressed patients have ADHD • Strattera and the SSRIs: escitalopram (Lexapro) or sertraline (Zoloft) don’t compete for the metabolic pathway

42. ADHD and Bipolar Disorder • An estimated 5-10% of adult ADHD patients have bipolar disorder • Screen for it by using a rating scale (eg, Mood Disorders Questionnaire) and data from significant others, family • Stabilize mood before treating ADHD

43. ADHD and Anxiety Disorders • An estimated 50% of ADHD patients have 1 or more anxiety disorders • Stimulants “worsen” anxiety, but full treatment of ADHD lessens it

44. Adult ADHD and Substance Abuse • 10% chance of current substance abuse, 50% chance of past abuse, 20-50% chance of future abuse • Incidence higher in antisocial personality disorder

45. ADHD and Substance Abuse, cont’d • Vigilance • Information from patient and others • Treat substance abuse first • Document three or more months of abstinence before treating ADHD • Treat the abstinent patient with Strattera and/or stimulants, but stay vigilant

46. Treatment-Refractory ADHD • Lack of response to medication • Many/severe comorbid disorders • Unsupportive or hostile family • Character pathology

47. Treatment-Refractory ADHD • Combine stimulants with atomoxetine or bupropion • Combine atomoxetine or bupropion with a stimulant • Add modafinil • Try TCA (alone or with stimulant) • Alpha-agonist • MAOI (alone)

48. ADHD and Women • Girls have ADHD, with significant morbidity and higher risk of drug abuse • Women with ADHD can founder when they have children • Issues concerning pregnancy and breast-feeding require coordinated care

49. ADHD and Families • Problems are multi-generational • The spouse can be unsupportive or overburdened or both • Think in terms of the family system

50. ADHD in Adults: Summary • Keep the diagnosis in mind • Evaluate thoroughly • Assess for comorbidity, especially affective disorder and substance abuse • Identify strengths • Treat what’s worst, first • Enhance resilience