1 / 34

Workshop on ADHD in Third Level students

Workshop on ADHD in Third Level students. Fiona McNicholas Consultant Lucena Clinic, Rathgar & Our Lady’s Hospital for Sick Children, Crumlin Professor Child & Adolescent Psychiatry, UCD. Martin O’Sullivan Consultant Child and Adolescent Psychiatrist

denzel
Download Presentation

Workshop on ADHD in Third Level students

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Workshop on ADHD in Third Level students Fiona McNicholas Consultant Lucena Clinic, Rathgar & Our Lady’s Hospital for Sick Children, Crumlin Professor Child & Adolescent Psychiatry, UCD Martin O’Sullivan Consultant Child and Adolescent Psychiatrist Mater Hospital and St Vincent’s Hospital Fairview 26 Jan 2006

  2. Overview of Talk • ADHD in children • ADHD in adults • Treatment of ADHD 26 Jan 2006

  3. ADHD- as we know it! Inattention Hyperactivity Impulsivity 26 Jan 2006

  4. Over activity Inattention Impulsivity Symptoms before age 7 (6 ICD) Pervasive across situation Cause impairment of social or educational functioning. Not due to PDD, Psychotic or other mental disorder (anxiety, depression) Diagnostic criteria(ICD/DSM) 26 Jan 2006

  5. Inattention: (6/9) • Fails to give close attention to details or makes careless errors in schoolwork, or other activities • Difficulty sustaining attention in tasks or play activities • Does not seem to listen when spoken to directly • Does not follow through on instructions and fails to finish school work, chores or duties (not due to oppositional behaviour or failure to understand) • Difficulty organising tasks/activities • Avoids, dislikes or reluctant to engage in tasks that require sustained mental effort • Loses things necessary for tasks • Easily distracted by extraneous stimuli • Forgetful in daily activities 26 Jan 2006

  6. Hyperactivity/Impulsivity (6/9) • Fidgets with hands or feet or squirms in chair • Leaves seat in classroom or other in which sitting is expected • Runs about, climbs excessively in situations in which it is inappropriate (restless) • Difficulty playing in activities quietly • ‘On the go’ or ‘driven by a motor’ • Talks excessively • Blurts out answers • Difficulty awaiting turn • Interrupts or intrudes on others 26 Jan 2006

  7. Common Associated Comorbidities 60 40 20 0 (%) Oppositional defiant disorder Anxiety disorder Learning disorder Mood disorder Conduct disorder Substance use disorder Tics Milberger et al. Am J Psychiatry1995; 152: 1793–1799 Biederman et al. J Am Acad Child Adolesc Psychiatry 1997; 36: 21–29 Castellanos. Arch Gen Psychiatry 1999; 56: 337–338 Goldman et al. JAMA 1998; 279: 1100–1107 Szatmari et al. J Child Psychol Psychiatry 1989; 30: 219–230 26 Jan 2006

  8. Prevalence • ICD 1-2 % or DSM IV 3-5% • 30-50% of children referred to child psychiatry clinics have ADHD • Diagnosed in boys 3-4 often than in girls • Persists in 30-50% of patients into adolescence and adulthood (symptom profile may change) • Prevalence in Adults: 2% 26 Jan 2006

  9. School: Language impairment 15-75% Learning Disability 15-40% Low Self esteem Poor social skills Labelled ‘trouble maker’ Poor relationship with parents often secondary and improves with appropriate intervention Family History ADHD Associated problems 26 Jan 2006

  10. Drop out of school 32-40% Rarely complete college 5-10% Under-perform at work 70-80% Have few or no friends 50-70% Engage in antisocial activities 40-50% Experience teen pregnancy 40% Sexually transmitted disease 16% Speed or have car accidents Suffer from depression 20-30% Have a personality disorder 18-25% ADHD more likely than norms to 26 Jan 2006

  11. Symptoms of ADHD Home School After school activities Co-morbidity LD Motor ODD/CD Other child psychiatric disorders Perpetuating factors Family Temperament Environment Informants Parents Child Teacher, Coach, play school, clubs etc Tests Physical examination Rating scales Formal assessments NEPS, SALT, OT, hearing, vision Assessment: History & Observations 26 Jan 2006

  12. ADHD in Adults? • ADHD child grown up • Parent of newly diagnosed ADHD child • Adult recognizing symptoms of ADHD for the first time • New onset ADHD symptoms-’secondary ADHD’ 26 Jan 2006

  13. Issues re Adult ADHD • DSM IV diagnosis valid for children • ? Natural History • Assessment process • Retrospective recall • Multi rater • Inappropriate wording -new scales • Self referral versus childhood continuation • Developmental disorder PDD or Psychiatric disorder such as Depression 26 Jan 2006

  14. Criteria: Childhood criteria meet Current symptoms Impairment Assessment: Clinical interview Collateral Childhood records Rating Sclaes Diagnosis of Adult ADHD 26 Jan 2006

  15. Childhood history Adult symptoms of Motor hyperactivity Attention deficits Plus two of the following: Affective lability Hot tempers, explosive and short lived outbursts Emotional over reactivity Disorganisation, inability to complete tasks Impulsivity DDx: schizophrenia, borderline PD or SUD Associated features Marital instability Sub-optimal academic and vocational success, Alcohol or drug misuse, Family history of ADHD, Antisocial personality disorder Atypical response to psychoactive medications. The UTAH Criteria for adult ADHD 26 Jan 2006

  16. Adult ADHD Rating Scales • Conner’s 4 dimensions • Cognitive Dysfunction • Inattention, disorganization, procrastination, poor memory, poor time management • Hyperactivity • Predominantly inner restlessness, impatience • Emotional Impulsivity • Rages, tempers, anger management issues, mood lability, frustration • Self Esteem & Self worth 26 Jan 2006

  17. Adult Rating Scales • Brown Adult & Adolescent rating Scale • Self report and significant other • ADHD Rating Scale • Developed by Adler et al, Boston group • DSM IV items reworded for adults • How often have you had difficulty in wrapping up the final details of a project once the challenging parts have been done? • ASRS-V1.1 www.adultadd.com 26 Jan 2006

  18. Adult Self Report Scale (WHO) • How often do you have trouble wrapping up the final 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? • How often do you have problems remembering appointments or obligations? • When you have a task that requires a lot of thought, how often do you avoid or delay getting started? • 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 feel overly active and compelled to do things, like you were driven by a motor? 26 Jan 2006

  19. Differences between Adult and Child cases ADHD • Male: female ratio 3:2 vs 3:1 – 10:1 • Source of referral • Motivation for treatment • Who is affected by ADHD? • Insight/ awareness 26 Jan 2006

  20. Functional Impairment • Weiss Functional Impairment Rating Scale (v2 2005)- Margaret D Weiss mweiss@cw.bc.ca Domains: Family Work / School / College Life Skills Self – Concept Social Risk 26 Jan 2006

  21. WFIRS-S • Provides information on breadth and severity of impairment • Can be used to track changes over time • Psychometric properties of the scale currently under investigation 26 Jan 2006

  22. Brown Attention Deficit Disorder Scale 5 important symptom clusters • Getting organised, activating tasks • Sustaining focus, especially reading • Alertness, effort, processing speed, motivation • Affect • Working memory, memory retrieval 26 Jan 2006

  23. Clinical Vignette 1 Walter, 26 • Very superior IQ • Wide variation in College scores, some papers brilliant, others failed • Previous history of Dx ADHD + use of Ritalin – stopped aged 14 • Drops out of College year 3 – many short papers, projects not completed 26 Jan 2006

  24. Clinical Vignette 2 Maria, 24 • Primary school teacher trainee • “Terrible planning, organising” • Procrastinates, late with assignments • Can’t keep up with the reading • Finances in a mess – maxed out on Credit 26 Jan 2006

  25. Clinical Vignette 3 Anthony, 26 • 3rd attempt at third-level degree • Makes good starts then gets bored • Conflict with supervisors • Regular cannabis use • Once supportive parents losing patience 26 Jan 2006

  26. How Medication works: Stimulants Presynaptic Neuron Amphetamine blocks v v Storage vesicle Cytoplasmic DA Amphetamine blocks reuptake DA Transporter Methylphenidate blocks reuptake Synapse Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513. 26 Jan 2006

  27. Treatment - Psychostimulants Methylphenidate or Amphetamine • First line medications for the treatment of AD/HD in adults off-label • Clinical response is dose related >1mg/kg/day • Efficacy rates ~(25-) 70% • Successful treatment results in diminished substance misuse 26 Jan 2006

  28. Psychostimulants II Possible side effects • Insomnia, headaches,anxiety, loss of appetite • Cardiovascular:  BP 4mmHg; bpm +10 26 Jan 2006

  29. Psychostimulants III • Immediate release MPH require two – three doses e.g. Ritalin, Equasym • Extended / sustained release MPH e.g. Ritalin LA, Concerta 26 Jan 2006

  30. Psychostimulants IV • Immediate release Amphetamine • E.g. Dexedrine, Adderall • Extended or sustained release: • E.g. Adderall XR 26 Jan 2006

  31. Non-stimulant medications- Atomoxetine HCl Strattera • Approved by FDA for treatment of adults • Potent selective NA reuptake inhibitor • Not ‘controlled’ • C/I MAOI users, glaucoma • Cautions: liver problems/ cardiovascular/ depression/ suicidality • Await trials in those with depression/ anxiety • Metabolised CYP2D6 enzyme Fluoxetine, Paroxetine and Quinidine inhibit this enzyme 26 Jan 2006

  32. Non-stimulant medications- Other • SSRIs not effective • TCAs – Des., Imip, moderate effect • MAOIs no controlled trials • Bupropion DA NA atypical anti dep • Venlafaxine NA 5HT blocker • Clonidine alpha-2 NA 26 Jan 2006

  33. Conclusions 26 Jan 2006

  34. Questions? 26 Jan 2006

More Related