Download Notes - ADHD Association of Greater Edmonton

Dr. Nagy Youssef
Summer 2011
Dr. Youssef runs an adult ADHD practice through his Edmonton clinic; one of only two clinics for adult
ADHD in Alberta.
The correct name is ADHD, which includes ADD.
Timeline:
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1845: Heinrch Hoffman's children's story describes Fidgety Phil.
1937: efficiency of amphetamine discovered.
2000: Attention Deficit Hyperactivity Disorder (DSM-IV-TR) included adults, not just children.
Future: understanding ADHD and executive function, with the goal of wellness.
What is it? A neurobiological disorder that starts in childhood (4-10%) and persists into adulthood
(4.4%). 80% still have it as they enter adolescence and 70% continue to have ADHD into adulthood.
Many individuals have learned compensatory skills.
ADHD is caused by genetics, environment, central system injury, and/or neuroanatomic/neurochemical
factors. Premature or post-mature birth can have an effect as well. Usually there is an interplay of
factors. It is NOT caused by bad parenting or poor willpower.
If you have ADHD, you have a 50% chance of having a child with ADHD. It is very heritable.
A mental disorder is a harmful dysfunction.
Until several years ago, medical people didn't realize ADHD continued into adulthood. There was/is a
lack of awareness and training. So adults were receiving haphazard and inconsistent diagnoses. ADHD in
adulthood is under-diagnosed and under-treated.
ADHD is characterized by a delay in cortical maturation. Rate of maturation is slower, but it can catch
up. These are the areas that control executive functions.
It is hard to see ADHD before age 6.
The brain uses glucose as a source of energy. Research shows decreased cerebral metabolism in people
with ADHD.
There is lower activity globally across the ADHD brain (hypoactivity). It is not a localized effect. The
largest reductions are seen in premotor cortex and superior prefrontal cortex.
The anterior cingulate (cognitive division) fails to activate in ADHD.
How is it diagnosed? It needs to be:
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Pervasive: exist in many settings.
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Persistent: duration of at least six months; onset before age 7.
Severe: maladaptive, affect functioning, inconsistent with developmental age...
Must be consistently and persistently impairing in at least two areas of life functioning. Must
significantly impair major aspects of day-to-day life.
ADHD is much more than personality traits and quirks.
Adult symptoms are:
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Inner restlessness
Overwhelmed
Self-selects active jobs
Talks excessively
Fidgets when seated
Impulsive job changes
Drives too fast
Irritability or quickness to anger
Easily distracted and forgetful
Poor concentration
Difficulty finishing tasks
Displacing things
Poor time management
Trouble attending
Statistics:
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3:2 ratio boys to girls.
In adulthood: 56% inattentive type and 44% combined type.
See comorbidity as child ages.
46% expelled, 35% drop out.
Substance abuse: earlier onset and faster progression. Less likely to quit in adulthood.
Absenteeism and productivity levels affected at work.
2 to 4 times as many motor accidents.
Parenting impairments:
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Poorer monitoring of children's behavior.
Higher levels of inconsistent parenting.
More difficulty problem solving.
Inattentive type more problematic than hyperactivity.
Self-esteem, which is hardest to restore.
47% also have anxiety disorder.
38% also have mood disorder (depression, bipolar...).
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Multimodal therapy for adult ADHD includes: medication to control symptoms, psychoeducation,
treatment of comorbid conditions, modification of the environment, appropriate educational/vocational
plans, appropriate physical and special interest activities, family counseling, coaching.
Medication
Medication management: Start low, go slow, keep going. (There is a high inter-individual variability of
dose response.)
Self-report requires patient to identify target symptoms.
ADHD symptoms are evident when a patient is challenged.
Regular follow-up and monitoring is essential. You see a resurgence of symptoms under stress;
medications stop working.
Extended release medications are preferred to cover times of functional impairment, to avoid diversion
and rebound. You see less built-up tolerance to the medication. Also, immediate release is prone to
abuse as street drug. The best way to use immediate release drugs would be to cover the period when a
sustained-release drug is leaving the system and the person gets cranky, etc.
Mg per kg does not apply to psychostimulants for adults, with the exception of amoxetine (which is
more expensive, takes longer to assess effectiveness, and is 20% less effective than stimulants).
Drugs are effective for both types: inattentive and hyperactive. But overall , they are more effective for
the hyperactive type.
Dr. Youssef prescribes Concerta, Biphentin, Adderall, Vyvanse, and Strattera.
Most extended release drugs cost about $100/month.
Vyvanse does the least to suppress appetite or promote sleeplessness. (Better in terms of its effects on
appetite and sleep.)
Generic Concerta is actually a completely different formulation; more like Ritalin SR.
Generic Strattera is about to be released.
Clonidine (long-acting preparation) is not yet released in Canada.
Follow-up should be regular; once a week is ideal. However, there are 5 to 6 weeks between meetings
with Dr. Youssef as he is so busy. Not ideal.
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