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ADHD in Adults: Separating the Wheat from the Chaff

ADHD in Adults: Separating the Wheat from the Chaff

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ADHD in Adults: Separating the Wheat from the Chaff

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  1. ADHD in Adults:Separating the Wheat from the Chaff James Chandler, MD FRCPC

  2. Why the current interest? • Pharmaceutical companies • Psychiatry • Cultural

  3. Pharmaceutical companies • ADHD is a chronic disease, thus a great market • Adults with ADHD are directed to take medications even longer than depressed patients • Many ADHD drugs are now indicated for adults

  4. Concerta, Adderall, Strattera, Ritalin, Alertec • No disorder, no drug • Where would Viagra be without Erectile Dysfunction?

  5. Selling ADHD drugs requires • Identifying more consumers • Direct to consumer ads with “signs of ADHD” • Promoting the effectiveness of the treatment • Pharmaceutical company managed studies which have little application in the real world

  6. Pharmaceutical Strategy • Producing a demand • Making people think that not paying attention is abnormal

  7. Psychiatry’s Interest in ADHD

  8. Developmental interests • Adult psychiatry research now focuses on early forms of adult illnesses • Depression, Bipolar Disorder, Psychosis, Anxiety Disorder

  9. Developmental Interest • Child Psychiatry research follows up child illness into adult • ADHD, Autism, Tourettes, Separation Anxiety Disorder, Traumatized Children

  10. Clinical Observations • Adult psychiatrists see the hyperactive children of their adult patients • Child psychiatrists attempt to have a conversation or appointment with the parents of their ADHD patients.

  11. Cultural • More and more aspects of human behavior are now categorized as disorders requiring treatment • Aspergers, ED, and now EDS (Excessive Daytime Sleepiness)

  12. Cultural • Disorder means less responsibility, so having a diagnosis might lessen consequences for misbehavior in general. • I can’t help it, I have ADHD

  13. What is ADHD in adults? • The same two symptom dimensions as in children: • Hyperactive-Impulsive • Inattentiveness

  14. Hyperactive-Impulsive • often fidgets with hands or feet or squirms in seat, • often leaves seat in classroom or in other situations in which remaining seated is expected • 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).”

  15. Hyperactive-Impulsive • 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).”

  16. Hyperactive-Impulsive • often has difficulty playing or engaging in leisure activities quietly, is often ‘on the go’ or • often acts as if ‘driven by a motor,’ and • often blurts out answers before questions have been completed

  17. Hyperactive-Impulsive • often has difficulty awaiting turn • often interrupts or intrudes on others (eg, butts into conversations or games)”

  18. Decreased Attention • often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities; • often has difficulty sustaining attention in tasks or play activities; • often seems to be not listening when spoken to directly,

  19. Decreased Attention • often has difficulty organizing tasks and activities, • often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework), • often loses things necessary for tasks or activities,

  20. Decreased Attention • often is distracted easily by extraneous stimuli, • and is often forgetful in daily activities” [2] .

  21. All present since childhood

  22. What are the neuropsychological basis for these symptoms? • 10 years ago this was quite clear, but not any more • There are no psychological tests which all adults with ADHD do poorly on. • The neuropsychology of ADHD is so heterogeneous that some patients do poorly on just about any test

  23. Psychological tests can not diagnose ADHD. • Nevertheless, the more executive function problems, the worse the academic and occupational outcome:

  24. Executive dysfunction • Organization and planning • Working memory deficits • The ability to hold information “ïn your mind” so you can compare scenarios, solutions, and consequences

  25. Executive dysfunction • Response Inhibition Problems • Can’t resist an impulse to move, act, or think while on another task • Sustained attention • Shifting/Mental Flexibility • Interference control

  26. What are functional deficits in ADHD in adults?

  27. Occupational and Academic • More dropouts, lower occupational achievement • More likely fired • More likely to quit • More bankruptcies • Not as wealthy

  28. Family • More Separations • Divorce

  29. Legal • More driving accidents, arrests for all causes

  30. Psychiatric • Increased bipolar disorder, depression, anxiety disorder, substance abuse, smoking, Antisocial behavior

  31. Medical • Increased accidents, head trauma, fractures, poisonings

  32. What are the causes of ADHD?

  33. Genetic • 75% heritability, but no one gene causes this • 50% of children of ADHD patient will have some signs of ADHD

  34. Biological Adversity • Prematurity • Smoking or drinking in pregnant mother • Food additives? • Obstetrical Complications

  35. Psychosocial Adversity • Poverty • Single parenthood • Social class • Chronic family conflict • Low family cohesion • Exposure to current, not past, parental psychopathology • Abuse

  36. What looks like ADHD but isn’t? • Drug abuse • Depression • Hypomania • Head Injury syndromes • Post encephalitis, structural brain lesions

  37. What looks like ADHD but isn’t? • Other toxins • Horrible home issues • Neurodegenerative • On and on………..

  38. How does it classically appear? • Parents of clearly diagnosed patients of yours with ADHD • Pearl: if someone has three or more children and none of them have ADHD, probably the parents don’t either. • Clearly diagnosed ADHD children grown up.

  39. How does it present? • About 1/3 will still be disabled as adults, with very few growing out of it after age 30. • Addiction Treatment Centres and follow up • Depending on the centre, 25-35% of the people in treatment programs have ADHD, too. • Severe accident follow up

  40. Hyperactive in a wheelchair or rehab unit?

  41. When should you be very suspicious that this is not ADHD? • Stable family life, occupation, and just psychological distress • New onset problems as adult

  42. When should you be very suspicious that this is not ADHD? • Come in on their own – not brought by spouse, friend, parent, etc • Have a list of questions and an organized presentation of their history

  43. Treatment

  44. Three equally challenging issues

  45. Compliance • Missed appointments • Drop ins • script refills • lost prescriptions vs. diversion

  46. Dealing with the illness • Dealing with the financial, legal, familial, and physical sequale • Dealing with having a chronic psychiatric illness • Dealing with comorbid disorders

  47. Psychotherapy • Few trials, but the only success stories so far are for skill training with modules on organizing and planning, distractibility, adaptive thinking, and procrastination this one has been used in a double blind trial of persons who were treated with medications and partially responded.

  48. This is the manual from that study and a copy is on the table

  49. This is the therapist manual - copy on the table

  50. Medical Treatment of ADHD in Adults • First step is to match the drug to the person, given that almost everyone will have some comorbid problem.