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Attention-Deficit Hyperactivity Disorder in Adults and Children Conceptualization, Diagnosis and Treatment An Integrated Approach By Ghada Hamdan-Allen, M.D. Objectives • Define and diagnose Attention-Deficit Hyperactivity Disorder using clinical criteria. • Recognize the integrated community approach to diagnosing and treating ADHD. • Improve management of ADHD ADHD: Definition and Course • ADHD is a developmentally inappropriate level of hyperactivity, distractibility and impulsivity. inattention • Age ADHD: Epidemiology • Prevalence – 4-12% of children under 18 – 4.7% of adults – Female to male ratio: 10:1 in children and 2:1 In adult clinical samples. – ADHD is over-represented in adoptees and lower SES ADHD: Differential Diagnosis • • • • • • • • • Conduct disorder Oppositional defiant disorder Tourette’s disorder Anxiety disorder Learning disorder Mood disorders: unipolar and bipolar Substance use disorder Developmental disorders Personality disorder ADHD: Etiology • Prenatal and perinatal: – Exposure to drugs, smoking and alcohol in utero(3/10) – Low birth weight(3/10) – Parental ADHD(8/10) – Maternal age at birth(1/10) • Environmental: – Lead toxicity – Low SES – Medications: anti- seizure and asthma treatment ADHD: Etiology • Genetic – Monozygotic twins are more concordant than dizygotic twins – ADHD heritability factor is 0.75-0.91 – Candidate genes: 7-repeat allele of D4dopamine receptor gene is present in 5060% of ADHD population compared to 30% in general population – ADHD is common in first degree relatives ADHD: Etiology • Model of executive function: – Response inhibition: controls verbal and motor impulses – Nonverbal working memory: sense of self in relation to past & future – Verbal working memory: self questioning and description. Using language to rule conduct – Self regulation of emotions and behavior – Reconstitution: analysis of past experience to formulate new responses that help us achieve our goals ADHD: Etiology • Neurological: – Less active prefrontal cortex affects memory and response inhibition – Anterior cingulate gyrus dysfunction affects cognition – SPECT studies show increase binding at dopamine transporter protein ADHD: Areas of Impairment • Performance limitations – Academic difficulty in school (25% repeat a grade) – Lower level of occupational advancement • Socialization – Children are stigmatized by their behavior – Adolescents demonstrate social problems • • • • Few friends Poor participation in group activities Vulnerable to drug abuse and antisocial groups Increased MVA ADHD: Effect on Parents • Increased stress – Worry – Frustration -Anxiety -Anger • Lower self esteem – Self blame -depression – social isolation • Disruption of employment • Increased marital discord • Increased alcohol and substance abuse ADHD: Indicators of Impairment in Adults • Impairment – – – – – – – – – – Occupational difficulty Low self esteem Poor parenting Legal problems Health concerns Injuries MVA, speeding tickets Smoking Substance abuse Relationship problems • Improvements – – – – – – – More efficient Better organized Enjoy social activities Stable marriage Improved parenting Financial responsibility Contain aggressive impulses – Decrease THC dependence ADHD: Diagnosis • Clinical interview – History – Rating Scales – Collateral information/Impairment • Physical evidence – PE -CPT – Lead level -Thyroid function • Co-morbidity ADHD-Diagnosis A Community Effort • History – Parents – Spouses/Partners – Day care providers – Teachers – Therapists – Primary care physicians – Social agencies (DHS; Juvenile Court) ADHD-Diagnosis A Community Effort • Rating Scale: to corroborate clinical diagnosis – Conner's – ADHD-RS • Clinical Interviews: – Determine impairment in school/home/job settings – Make assessment for comorbid conditions – Physical exams and tests ADHD: Treatment • Psycho-education – Reframe – compromise • Environmental restructuring – Lists, PDA, cell phones – Encourage ADHD friendly occupations and hobbies • Psycho-pharmacology – FDA approved: Stimulants; Atomoxetine – Off-label: antidepressants; alpha-2 adrenergic agonists Bibliotherapy for Adults with ADHD • Books – Driven to distraction by Hallowell and Ratey – ADHD in Adulthood by Weiss, Trokenberg Hechtman and Weiss • Video – ADHD in Adults by Barkley • Organizations – www.chadd.org – National Alliance for the Advancement of ADHD care www.naaac.org ADHD: Psychopharmacology • Short term trials are recommended in the beginning • Choice of medications is based on: – – – – – – – Duration Co-morbidity Target symptoms Patient preference Family history Past medication history Risk of abuse ADHD: Psychopharmacology • Address issues of non-compliance • Monitor side effects including vital signs/Growth • Measure progress by subjective report and rating scales • Feedback loop: Parent/teacher Psychiatrist Patient PCP Psychopharmacology-Stimulants • Short acting – Ritalin, Methylin, Focalin – Dextrostat • Medium acting – Adderall – Metadate • Long acting – – – – – Concerta Ritalin LA Adderall XR Vyvanse Daytrana Psychopharmacology-Stimulants • Adverse events – Anorexia, weight loss – Insomnia – Headaches – Stomach ache and vomiting – Stereotypy and tics – Increased pulse and BP – Growth? Psychopharmacology-Strattera • Mechanism of action – NE transporter blockade – Increase dopamine in prefrontal cortex • No increase in nucleus accumbens • No increase in the striatum • Adverse events – – – – – Decreased appetite Somnolence Dyspepsia Elevation of pulse and BP Sexual dysfunction Psychopharmacology • Antidepressants – Tricyclic antidepressants: Imipramine, Desipramine – Wellbutrin • Alpha2 agonists – Clonidine – Tenex ADHD-An integrated Approach • Interdisciplinary Communication – PCP/Specialist/Parents/School/Therapist • When to refer? – Comorbidity – Poor response – Polypharmacy • Know the community resources. – School based services – Remedial counseling