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Diagnostic Assessment, Treatment, and Lifespan Clinic for ADHD

Diagnostic Assessment, Treatment, and Lifespan Clinic for ADHD. Brescia– June 2014 Dr. J.J. Sandra Kooij, MD PhD Psychiatrist, head Department Adult ADHD and Expertise Centre Adult ADHD PsyQ, psycho-medical programs The Hague, the Netherlands. Topics. Clinical picture Gender and age

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Diagnostic Assessment, Treatment, and Lifespan Clinic for ADHD

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  1. Diagnostic Assessment, Treatment, and Lifespan Clinic for ADHD Brescia– June 2014 Dr. J.J. Sandra Kooij, MD PhD Psychiatrist, head Department Adult ADHD and Expertise Centre Adult ADHD PsyQ, psycho-medical programs The Hague, the Netherlands

  2. Topics • Clinical picture • Gender and age • Prevalence • Diagnostic assessment, DIVA 2.0 • Differential diagnosis • Circadian rhythm disturbances in ADHD and relationship with mood and health • Treatment • Lifespan Clinic for ADHD

  3. Adult ADHDDiagnostic Assessment and Treatment Including DIVA 2.0 JJS Kooij, 3rd edition 2012 www.springer.com Search for ‘Adult ADHD’

  4. Clinical picture of ADHD Lifetime symptoms of Attention-Deficit/Hyperactivity Disorder: • Inattention: distracted, chaotic, forgetful, late, difficulty making decisions, organising and planning, no sense of time, procrastination • Hyperactive: (inner) restlessness, tense, talkative, busy; coping by: excessive sporting/alcohol abuse/avoiding meetings • Impulsive: acting before thinking, impatient, difficulty awaiting turn, jobhopping, binge eating, sensation seeking In addition in 90% of adults, lifetime: • Moodswings(5x/day) and Anger outbursts APA 1994; Kooij 2001; Conners 1996

  5. Decrease of hyperactivity Hyperactivity is adjusted, compensated for, or experienced as more ‘inner restlessness’: • Avoiding meetings where you have to sit stil • Excessive sporting • Hectic job full of change • Cannabis / alcohol / tranquillisers against restlessness • Talkativeness, inner restlessness The decrease in marked outward visible hyperactivity has presumably been the reason why we mistakenly have thought that ADHD was outgrown

  6. Inattention most invalidating symptom in adults Adults need more attention than children: • Procrastination • Chaos • Difficulty organising • Being late • Difficulty reading and remembering • Forgetting things or appointments • Using no watch or agenda!

  7. ADHD in DSM-IV • Attention-deficit/hyperactivity disorder • 18 criteria: 9 attention problems (A) and 9 hyperactive/impulsive criteria (HI) • Diagnosis in childhood from 6/9 of one or both domains 3 subtypes: • ADHD, inattentive type (also ADD) (10-15%) • ADHD, hyperactive/impulsive type (3%) • ADHD, combined type (85%)

  8. DSM-5 changes in ADHD Cutoff adoles- cents & adults 5/9 NEURO- DEVELOP MENTAL DISORDERS Subtypes = now Presentation types Age of onset < 12 years ADHD + ASS More examples of behaviour Severity Impairment in ≥ 2 situations, but more situations given

  9. Impairment in adult ADHD In clinical as well as epidemiological samples compared to NCs: • Learning problems (60%) • Less graduated • Lower education • Lower income • Less employed, more sickness leave • More job changes (longest job 5 yrs) • More often arrested, divorced and more social problems • More driving accidents, teenage pregnancies, suicide attempts • Higher (mental) health care costs Biederman 2006; Kooij 2001, 2005; Barkley 2002; Manor, 2010

  10. ADHD and gender: Men more often ADHD? Taylor 2004; Nice guidelines 2008; Kessler 2006; Fayyad 2007; Kooij 2005

  11. Gender differences children and adults Childhood M>>F Adulthood M=F Underdiagnosis in girls

  12. Girls have more ADD Biederman 1994, 2004

  13. Causes of underdiagnosis of ADHD in girls

  14. Complaints girls and women with AD(H)D

  15. Girls and women 2x more often ADHD inattentive type • But majority has still ADHD combined type • Women have to organise themselves, family, household, childrens’ agenda’s and their job • Being a women with ADHD is ‘a job from hell’, always late, forgetting things … • Chaos and tiredness their daily bread • Low selfesteem and uncertainty about capabilities the result

  16. Room with a view?

  17. Is ADHD like Chronic Fatigue Syndrome (CFS)?Inattentive girls referred for being´tired´? • Clinical studies: boys more often ADHD • Epidemiological research: girls similar percentage ADHD as boys ADHD in girls is less well known, and their behaviour less disruptive than in boys … Boys have more often: • ADHD, combined type • More severe hyperactivity • Externalising comorbidity (oppositional defiant or aggressive behaviour) Being disruptive helps to get help…. Biederman ea, 1994; 2002, 2004; 2005

  18. Girls are not disruptive … Inattention takes continuous mental effort, leading to exhaustion … … but may be chronically tired!

  19. ADHD and CFS need further study • Screening for ADHD in Burnout or CFS group • Methylphenidate treatment in subgroup with diagnosis of ADHD may ameliorate tiredness and inattention • Physical complaints in ADHD need further study (RSI, burnout, neck- and backpains, obesity, chronic tiredness, chronic sleep-problems)

  20. BOOKS on GIRLS & WOMEN & ADHD

  21. ADHD in older adults An epidemiological study by M. Michielsen, E. Semeijn, H. Comijs, D.J.H. Deeg, A. Beekman, J.J.S. Kooij

  22. ADHD IS NOT OUTGROWN ? Fayyad J Br J Psychiatry. 2007 May;190:402-9; Kooij JJS Psychol Med. 2005 Jun;35(6):817-27; Kessler RC J Occup Environ Med. 2005 Jun;47(6):565-72.; Kessler RC Am J Psychiatry. 2006 Apr;163(4):716-23.

  23. Prevalence of ADHD in children and adults Children • USA 3 - 7% Adults • USA 4 - 5% • 10 countries (mean) 3.4% APA 2000; Faraone 2003; Kessler 2006; Murphy & Barkley, 1996; Kooij 2005; Fayyad 2007

  24. Persistence of ADHD depends on definition of remission Biederman, 2000

  25. Treatment % per country in adults with ADHD Fayyad 2007

  26. Old people reporting childhood ADHD symptoms • Swedish sample, 1599 people aged 65-80 yrs • WURS, cutoff ≥ 36 • Prevalence of self rated childhood ADHD symptoms 3.3%, comparable to ADHD in children and adults • M > F (71 % vs 29%) • Young = older groups Taina Guldberg- Kjär, 2009

  27. Old people reporting childhood ADHD symptoms II ADHD compared to no ADHD group: • more divorce/no relationship (34% vs 12%) • more childhood problems • more jobs (> 5) • worse current health, worse current memory Taina Guldberg- Kjär, 2009

  28. Dutch epidemiological study ADHD in adults • N=1800, age 18-75 • Self reported DSM-IV ADHD-Rating Scale • Prevalence 1 - 2.5% (cutoff 6, resp. 4 current symptoms) • Hyperactivity: small, significant age dependant decline, but not for Inattention and Impulsivity • Group 60-75 yrs = 17.7% of the study population • Prevalence in this oldest group 0.3 - 3% (cutoff 6, resp. 4 current symptoms) Kooij ea 2005

  29. Case studies in older adults • Case studies in older adults indicate similar symptoms and impairment in old age and similar treatment response • Epidemiological and controlled clinical trials lacking - Manor I. Clin. Neuropharmacology 2011 - Biederman J. JAMA 1998 - Da Silva M.A. Journal of Attention Disorders 2008 - Parker R. JAMA 1999 - Brod M. Qual Life Res 2011

  30. ADHD in older adults An epidemiological study by M. Michielsen, E. Semeijn, H. Comijs, D.J.H. Deeg, A. Beekman, J.J.S. Kooij Michielsen 2012, 2013; Semeijn 2013a,b

  31. Marieke Michielsen & Evert Semeijn Presenting their posters in Berlin, ADHD Congress, 2011

  32. Study on the prevalence of ADHD in older people Data were used from the Longitudinal Aging Study Amsterdam (LASA) Collection started in 1992/93 Physical, emotional, cognitive and social functioning Follow-up every three years

  33. Methods Two - phase design: screening and diagnostic interview Phase 1 Screening list sample N=1494 Low scoring group Invited N=94 Medium scoring group Invited N=93 High scoring group Invited N=84 Refused: 7 Unable: 2 Refused: 12 Unable: 2 Deceased : 1 Refused: 12 Deceased : 1 Phase 2 Interviewed N=85 Phase 2 Interviewed N=80 Phase 2 Interviewed N=69

  34. Screening list by Barkley Barkley RA, Murphy KR, Fischer M. ADHD in adults: What the science says. The Guilford Press; 2007.

  35. ADHD diagnoses Two diagnostic categories, based on DIVA 2.0 were used: Syndromatic ADHD, full blown DSM-IV diagnosis - 6/9 symptoms in present time and childhood Symptomatic ADHD, sub-clinical diagnosis - 4/9 symptoms in present time and 6/9 childhood

  36. Prevalence of ADHD in older people in the general Dutch population Age: 61-95 years: lower prevalence of ADHD in the older old. Women: 59% Michielsen 2012

  37. ADHD and anxiety/depression in older people • ADHD was associated with more anxiety and depressive symptoms cross-sectionally as well as longitudinally compared to controls. Michielsen 2013

  38. ADHD and physical health in older people • ADHD in older people was associated with chronic nonspecific lung diseases (CNSLD), cardiovascular diseases, and number of chronic diseases. • ADHD was negatively associated with self-perceived health. Semeijn 2013

  39. ADHD and social functioning in older people ADHD in older people: • was associated with being divorced or never married • less family members in their network • emotional loneliness Level of ADHD symptoms was associated with more • emotional and social loneliness • lower income level • NB depressive symptoms play an important role in the association between ADHD and loneliness Michielsen, submitted

  40. Conclusions • The prevalence and comorbidity with anxiety and depression in older people with ADHD, show similar patterns as in younger age groups • Regarding physical health there are indications that older people with ADHD may have worse health outcomes and may die younger • Lower income, less intimate relationships, less family relationships, more loneliness and depression in older people with ADHD

  41. Impairment is not diminishing Similar prevalence rates ADHD is not outgrown in older people Similar medication response Lifespan clinics needed! RCT’s needed

  42. Can ADHD be treated in older people? 15 case studies: patients (m, f), age 67-81 yrs ADHD from childhood, diagnosis in (grand)children, who respond favorable to medication for ADHD Lifespan restlessness, irritability, impulsiveness and distractedness leading to impairment Succesfully treated with stimulants in old age Monitoring cardiovascular side effects before and during treatment Wetzel 2008; Da Silva & Louza, 2008; Standaert, Kok & Kooij, 2010; Manor ea, 2011

  43. Implications for patient care • ADHD is not outgrown in older persons • Impairment is not diminishing • Similar prevalence rates across the lifespan (3-5%) • Lifespan patient services are needed • Case reports indicate similar response to medication as in adults and children • RCTs needed in older people with ADHD using stimulants • More research needed into the impact of ADHD with age on social, psychiatric and somatic functioning

  44. COMORBIDITY in ADHD

  45. Comorbidity in adults with ADHD ADHD comes seldom alone: • 75% at least one other disorder • 33% two or more Mean: 3 comorbid disorders Biederman 1993; Kooij 2001, 2004

  46. Comorbidity in ADHD? • Depression (60% SAD) 20-55% • Bipolar Disorder (88% BP II) 10% • Anxiety Disorders 20-30% • SUD 25-45% • Smoking 40% • Cluster B Pers. Disorders 6-25% • Sleeping Problems (DSPS) 75% • Muscle, joint, neck- and backpain ?? Biederman 1991,1993, 2002; Weiss 1985; Wilens 1994; Kooij 2001, 2004; van Veen 2010; Amons 2006

  47. The other way round: ADHD is comorbid in 20% of psychiatric patients • SUD: 20% (Trimbos Institute) • Anxiety disorders: 20% (PsyQ) • Bipolar II: 20% (PsyQ) • Borderline PD: 35% (Radboud University) And in accordance to epidemiological data USA: 20% vd Glind 2005; Rops 2010 in prep; Roodbergen 2010 in prep; Fones 2004; van Dijk 2010 in prep; Kessler APA 2007; Fayyad 2007

  48. 12 month comorbidity with ADHD in adults, epidemiological study USA OR % ADHD % comorbid D in comorbid D in ADHD _____________________________________________ Mood Ds 3.8* 20.431.7 Anxiety Ds 3.8* 17.1 51.1 SUDs 2.8* 18.1 14.2 1 Disorder 3.0* 11.6 24.5 2 Disorders 3.9* 14.5 14.4 3+ Disorders 8.3* 26.5 26.6 Any disorder 4.4* 15.9 66.3 Kessler, APA 2007

  49. OR for comorbidity in active ADHD compared to ADHD, in remission 8,2* 6,2 3,9* 4,3* 3,9* 3,9 3,5 2,5 OR 1,6 1,2 Kessler, APA 2007

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