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Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder (ADHD). Brian B. Doyle, MD . Adults with ADHD. What is ADHD? How do you diagnose it in adults ? How do you treat with medication? What other treatments help?

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understanding and treating adults with attention deficit hyperactivity disorder adhd
Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder (ADHD)

Brian B. Doyle, MD

adults with adhd
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?
what is adhd
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.

diagnosing adhd
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.

symptoms of inattention
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
hyperactive impulsive symptoms
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
slide9
Criterion D: There is clear evidence of significantimpairment in social, academic or occupational functioning
slide10

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

initial evaluation 1 clinical interviews
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
evaluation 2 standardized rating scales
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
evaluation 4 family
Evaluation 4: Family
  • History of ADHD, results of treatment
  • History of other disorders
evaluation 5 information from a significant other or parent
Evaluation 5: Information from a significant other or parent
  • Documentation
  • Interview data
  • Rating scales
evaluation 7 other assessments
Evaluation 7: Other assessments
  • Educational
  • Psychological testing
  • Neuropsychological testing
  • Neuroimaging
  • Vocational
adhd subtypes
ADHD Subtypes
  • Combined
  • Predominantly inattentive
  • Predominantly hyperactive/impulsive
  • Not otherwise specified
differential diagnosis of adhd
Differential Diagnosis of ADHD
  • Psychiatric
  • Medical
  • Dietary
  • Malingering
  • Normal behavior
psychiatric disorders associated with adhd
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
the biology of adhd
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
the biology of adhd cont d
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
biology neurotransmitters
Biology: Neurotransmitters
  • Dopamine relates to attention
  • Norepinephrine relates to hyperactivity/impulsivity
  • Current thinking: multiple neurotransmitter systems are involved
biology of adhd genetics
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
comprehensive treatment for adhd
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)
slide27

Rx Goal : Enhance Resilience (Charney, 2005)

  • Optimism
  • Altruism
  • Moral compass
  • Faith and spirituality
  • Humor
  • Role model
  • Social supports
  • Face fears
  • Life mission
  • Training
medication for adhd
Medication for ADHD
  • CNS stimulants and other medications
  • Result : moderate to marked improvement in 60-70% of adult ADHD patients
  • Rarely “magic,” by itself
cns stimulants for adhd
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
cns stimulants
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
methylphenidate stimulants
Methylphenidate stimulants
  • Concerta
  • Daytrana
  • Focalin
  • Focalin XR
  • Metadate CD
  • Ritalin HCl
  • Ritalin LA
amphetamine stimulants
Amphetamine stimulants
  • Adderall
  • Adderall-XR
  • (Adderall-XXR)
  • Dexedrine
  • Dexedrine spansules
med trial with adderall xr
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
cns stimulant trial dangers
CNS Stimulant Trial: Dangers
  • Rise in blood pressure or pulse
  • Insomnia
  • Irritability/signs of mania
  • Loss of appetite
  • Jitteriness
  • Hypersexuality
  • Worsened anxiety, depression, psychosis
stimulants abuse and adhd patients
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
non cns stimulants for adult adhd
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”
strattera atomoxetine
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
ineffective treatments for adhd
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
adult adhd active psychotherapy
Adult ADHD: Active Psychotherapy
  • Support and psychoeducation
  • Cognitive behavioral treatment
  • Psychodynamic treatment
  • Couples treatment
  • Family treatment
  • “Coaching”
comorbid adhd be vigilant
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
adhd comorbid affective disorder
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
adhd and bipolar disorder
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
adhd and anxiety disorders
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
adult adhd and substance abuse
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
adhd and substance abuse cont d
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
treatment refractory adhd
Treatment-Refractory ADHD
  • Lack of response to medication
  • Many/severe comorbid disorders
  • Unsupportive or hostile family
  • Character pathology
treatment refractory adhd1
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)
adhd and women
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
adhd and families
ADHD and Families
  • Problems are multi-generational
  • The spouse can be unsupportive or overburdened or both
  • Think in terms of the family system
adhd in adults summary
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
enhance resilience
Enhance Resilience
  • Optimism
  • Altruism
  • Moral compass
  • Faith and spirituality
  • Humor
  • Role model
  • Social supports
  • Face fears
  • Life mission
  • Training
references books
References: Books
  • Doyle BB: Understanding and Treating Adults with ADHD, 2006
  • Adler L: Scattered Minds, 2006
  • Barkley RA: Attention Deficit Hyperactivity Disorder, 3rd Ed, 2006
  • Solanto MV, Arnsten AFT, Castellanos FX: Stimulant Drugs and ADHD, 2001
references websites
References: Websites
  • www.CHADD.com
  • www.ADDvance.com
  • www.drbriandoyle.com