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26 Jan 2006 Workshop on ADHD in Third Level students Fiona McNicholas Consultant Lucena Clinic, Rathgar & Our Ladys Hospital for Sick Children, Crumlin.

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Presentation on theme: "26 Jan 2006 Workshop on ADHD in Third Level students Fiona McNicholas Consultant Lucena Clinic, Rathgar & Our Ladys Hospital for Sick Children, Crumlin."— Presentation transcript:

1 26 Jan 2006 Workshop on ADHD in Third Level students Fiona McNicholas Consultant Lucena Clinic, Rathgar & Our Ladys Hospital for Sick Children, Crumlin Professor Child & Adolescent Psychiatry, UCD Martin OSullivan Consultant Child and Adolescent Psychiatrist Mater Hospital and St Vincents Hospital Fairview

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

3 26 Jan 2006 InattentionHyperactivity Impulsivity ADHD- as we know it!

4 26 Jan 2006 Diagnostic criteria (ICD/DSM) 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)

5 26 Jan 2006 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

6 26 Jan 2006 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

7 26 Jan 2006 Common Associated Comorbidities (%) Milberger et al. Am J Psychiatry 1995; 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– Oppositional defiant disorder Anxiety disorder Learning disorder Mood disorder Conduct disorder Substance use disorder Tics

8 26 Jan 2006 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%

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

10 26 Jan 2006 ADHD more likely than norms to 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%

11 26 Jan 2006 Assessment: History & Observations 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

12 26 Jan 2006 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

13 26 Jan 2006 Developmental Impact of ADHD Pre-schoolAdolescent Adult School-ageCollege-age Behavioural disturbance Behavioural disturbance Academic problems Difficulty with social interactions Self-esteem issues Behavioural problems Academic problems Difficulty with social interactions Self-esteem issues Legal issues, smoking and injury Academic failure Occupational difficulties Self-esteem issues Substance abuse Injury/accidents Occupational failure Self-esteem issues Relationship problems Injury/accidents Substance abuse

14 26 Jan 2006 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

15 26 Jan 2006 Diagnosis of Adult ADHD Criteria: –Childhood criteria meet –Current symptoms –Impairment Assessment: –Clinical interview –Collateral –Childhood records –Rating Sclaes

16 26 Jan 2006 The UTAH Criteria for adult ADHD 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.

17 26 Jan 2006 Adult ADHD Rating Scales Conners 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

18 26 Jan 2006 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

19 26 Jan 2006 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?

20 26 Jan 2006 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

21 26 Jan 2006 Functional Impairment Weiss Functional Impairment Rating Scale (v2 2005) - Margaret D Weiss Domains: Family Work / School / College Life Skills Self – Concept Social Risk

22 26 Jan 2006 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

23 26 Jan 2006 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

24 26 Jan 2006 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

25 26 Jan 2006 Clinical Vignette 2 Maria, 24 Primary school teacher trainee Terrible planning, organising Procrastinates, late with assignments Cant keep up with the reading Finances in a mess – maxed out on Credit

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

27 26 Jan 2006 vv Storage vesicle DA Transporter Cytoplasmic DA Methylphenidate blocks reuptake Presynaptic Neuron Synapse Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998; Amphetamine blocks reuptake Amphetamine blocks How Medication works: Stimulants

28 26 Jan 2006 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

29 26 Jan 2006 Psychostimulants II Possible side effects Insomnia, headaches,anxiety, loss of appetite Cardiovascular: BP 4mmHg; bpm +10

30 26 Jan 2006 Psychostimulants III Immediate release MPH require two – three doses e.g. Ritalin, Equasym Extended / sustained release MPH e.g. Ritalin LA, Concerta

31 26 Jan 2006 Psychostimulants IV Immediate release Amphetamine E.g. Dexedrine, Adderall Extended or sustained release: E.g. Adderall XR

32 26 Jan 2006 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

33 26 Jan 2006 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

34 26 Jan 2006 Conclusions

35 Questions?

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