Moderator Philip Asherson, MBBS, MRCPsych, PhD Professor of Molecular Psychiatry

1. Latest Insights Into the Awareness, Detection, Diagnosis, and Management of Patients With Adult ADHD Moderator Philip Asherson, MBBS, MRCPsych, PhD Professor of Molecular Psychiatry MRC Social Genetic and Developmental Psychiatry Institute of Psychiatry London, United Kingdom Panelists Iris Manor, MD Child Psychiatrist Director, ADHD Unit Geha Mental Health Center Senior Lecturer Sackler Faculty of Medicine of Tel-Aviv Tel-Aviv, Israel Rajive K. Mitra, MBChB, MRCGPTBC General Practitioner Lambeth Walk Group Practice London, United Kingdom

2. Goals of the Program • Develop a raised awareness of adult ADHD and gain confidence in identifying untreated adult ADHD patients by choosing appropriate screening tools • Recognize the types of comorbidities associated with adult ADHD and how to deal with these in the ADHD context to improve patient outcomes • Assess transitions of adolescent patients with ADHD into adulthood and determine how adults can be effectively diagnosed ADHD = attention-deficit/hyperactivity disorder

3. ADHD in Adults • ADHD in adults has been shown to range from 2% to 5%. • There are serious consequences of undiagnosed adult ADHD across various life domains. • General practitioners and numerous psychiatrists have had no training on this disorder.

4. ADHD in Adults and Children ADHD in children ADHD in adults • 15% retain full DSM-III diagnosis by age 25 years • 50% in partial remission from DSM-III criteria by age 25 years • Overall, around two thirds of children with ADHD have persistence of impairing levels of ADHD symptoms as adults • Prevalence of ADHD in adults estimated between 2.5% and 4.3% Faraone SV, et al. Psychol Med. 2009;36:159-165. Simon V, et al. Br J Psychiatry. 2009;194(3):204-211.

5. Awareness of ADHD • General practitioners have had no training on this disorder. • They don’t think that the disease is a big problem in adults. • Need for training for doctors caring for adults, especially in primary care

6. Clinical Presentation in Adults • Disorganization (“doesn’t plan ahead”) • Forgetfulness (“misses appointments, loses things”) • Procrastination (“starts projects but can’t complete”) • Time management problems (“always late”) • Premature shifting of activities (“starts something but then quickly distracted by something else”) • Impulsive decisions (especially around spending, taking on projects, traveling, jobs, or social plans) • Criminal offenses (speeding, substance abuse) • Unstable jobs and relationships • Low self-esteem (anxiety/depression)

7. Common Risks Associated With ADHD • Mood instability and irritability • Anxiety and depression • Antisocial behavior • Alcohol and drug abuse • Low self-esteem • Driving (and other) accidents • Academic failure • Unemployment • Marital discord • Inconsistent parenting and maltreatment Co-occurring symptoms/syndromes/ disorders Psychosocial impairments

8. World Health Organization Self-Rating Scale Inattention How often do you make careless mistakes when you have to work on a boring or difficult project? How often do you have difficulty keeping your attention when you are doing boring or repetitive work? How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? How often do you have trouble wrapping up the fine 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 do a task that requires organization? When you have a task that requires a lot of thought, how often do you avoid or delay getting started? How often do you misplace or have difficulty finding things at home or at work? How often are you distracted by activity or noise around you? How often do you have problems remembering appointments or obligations? Hyperactivity-Impulsivity How often do you fidget or squirm with your hands or your feet when you have to sit down for a long time? How often do you leave your seat in meetings or other situations in which you are expected to remain seated? How often do you feel restless or fidgety? How often do you have difficulty unwinding and relaxing when you have time to yourself? How often do you feel overly active and compelled to do things, like you were driven by a motor? How often do you find yourself talking too much when you are in a social situation? When you’re in a conversation, how often do you find yourself finishing the sentences of the people that you are talking to, before they can finish them themselves? How often do you have difficulty waiting your turn in situations when turn-taking is required? How often do you interrupt others when they are busy? Adapted from Kessler RC, et al. Psychol Med. 2005;35(2):245-256.

9. When to Refer a Patient to a Specialist • Screening tools can be useful. • The suspicion should be sufficient to refer the patient. • Referral can be useful even if the condition is not severe.

10. Training • Need to encourage training • Especially in medical schools and general practitioner training • Encourage education for this disease, which is especially associated with other conditions like anxiety and mood disorders.

11. Common Manifestations (Other Than DSM-V Criteria) • Procrastination • Poor time management • Difficulty: –initiating tasks • changing to another task • multi-tasking • Adaptive behaviors • Often felt rather than manifested • Quick decisions • Low frustration tolerance • Inattention > hyperactivity (90%:45%) • Mental tiredness

12. Morbidity • A significant cause of distress and impairment in many areas of life • Negative occupational, economic, and psychosocial functions • Academic underachievements • Higher rate of divorce • Higher rate of traffic violations Polanczyk G, et al. Curr Opin Psychiatry. 2007;20(4):386-392. Antai-Otong D. Perspect Psychiatr Care. 2008;44(3):196-201. Simon V, et al. Br J Psychiatry. 2009;194(3):204-211. Biederman J, et al. Am J Psychiatry. 2010;167(4):409-417.

13. Haavik J, et al. Expert Rev Neurother. 2010;10(10):1569-1580. Wilens TE, et al. Expert Rev Neurother. 2011;11(10):1443-1465. Biederman J, et al. Am J Psychiatry. 2000;157(5):816-818. Goodman DW, et al. Postgrad Med. 2011;123(5):14-26. Kooij SJ, et al. BMC Psychiatry. 2010;10:67. Barriers to Recognition and Care Adolescent and adult reluctance to accept diagnosis and need for treatment • Fear of change (unlike children) • Comfort zone with current clinical status and compensatory mechanisms • Feeling that they are mentally or physically “not themselves” on medication • Belief that impairments decline with age; however, functioning does not fully normalize, and compensatory strategies have limitations Nature and frequency of ADHD symptoms often change over the lifespan • A persistence of inattention and reductions in hyperactivity/impulsivity while both symptom domains continue to impair executive function • Adults seem to outgrow diagnostic criteria rather than the disorder • Condition may be difficult to recognize in adults because presentation differs greatly from one patient to another • As patients mature, they may adapt to or compensate for some symptoms

14. Goodman DW, et al. Postgrad Med. 2011;123(5):14-26. Kooij SJ, et al. BMC Psychiatry. 2010;10:67. Transition From Pediatric to Adult Medical Services Is Often Suboptimal • Many adult ADHD patients are lost to follow-up. Patients and caregivers: • Patients and caregivers are not prepared enough for changing treatment needs. • Physicians are unfamiliar with adult ADHD diagnosis and treatment. Logistics: • Lack of access to specialist care and difficulties transitioning medical and supportive treatment from pediatric to adult care settings • Logistical barriers to treatment (eg, patients reaching adulthood lose coverage under their parents’ health insurance or lose access to ADHD medications because the medications are only approved for children in their country)

15. Kooij SJ, et al. BMC Psychiatry. 2010;10:67. Goodman DW, et al. Postgrad Med. 2011;123(5):14-26. Asherson P, et al. J Attention Dis. 2012;16(5 Suppl):20S-38S. Retz W, et al. World J Biol Psychiatry. 2011;12(Suppl 1):89-94. Diagnosis Deficits Underdiagnosis, misdiagnosis, and undertreatment of adult ADHD are widespread. • Only a third of adults with ADHD are thought to be diagnosed in the United States, with far fewer in European countries. • Just 1 in 10 US adults and a minority of European adults with ADHD receive medical treatment.

16. Comorbidity • Affective disorders (bipolar and depression) • Anxiety disorders • OCD and hoarding • ODD and conduct disorder • Substance abuse • Obesity and other eating disorders • Sleep disorders • Mood dysregulation • Personality disorders OCD = obsessive-compulsive disorder; ODD = oppositional defiant disorder Miller TW, et al. J Abnorm Psychol. 2007;116(3):519-528. Antai-Otong D. Perspect Psychiatr Care. 2008;44(3):196-201.

17. Haavik J, et al. Expert Rev Neurother. 2010;10(10):1569-1580. Kooij SJ, et al. BMC Psychiatry. 2010;10:67. Fundamentals of Diagnosis Comprehensive clinical assessment • Systematic assessment of lifetime ADHD history, including: • Childhood onset and current experience • Presence of symptoms and impairment in at least 2 domains, according to DSM-V • Clinical record should include severity of impairments (mild to severe) • Full medical history of psychiatric and somatic treatments • Family history of psychiatric and neurologic problems • Mental status: associated features such as mood lability, temper outbursts, and comorbid disorders • For adults, family history may include ADHD in their own children. • Functional impairments should be confirmed by informants who know patients well.

18. Epstein JN, et al. J Atten Disord. 2006;9(3):504-514. Marchant BK, et al. Psychol Assess. 2013 May 6. [Epub ahead of print] Useful Rating Scales • Adult ADHD Self-Report Scale • Conners Adult ADHD Rating Scale-Observer Version • Diagnostic Interview for ADHD in Adults • Wender-Reimherr Adult Attention Deficit Disorder Scale • Continuous Performance Tests

19. Summary of Key Practice Messages • ADHD is common and an impairing disease. • Diagnosis can be made with training, and tools exist to aid in this process. • It is as easy to diagnose as other mental health disorders.

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