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Workshop on ADHD in Third Level students

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1 Workshop on ADHD in Third Level students
Martin O’Sullivan Consultant Child and Adolescent Psychiatrist Mater Hospital and St Vincent’s Hospital Fairview Fiona McNicholas Consultant Lucena Clinic, Rathgar & Our Lady’s Hospital for Sick Children, Crumlin Professor Child & Adolescent Psychiatry, UCD 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
The core symptoms of ADHD as defined in the DSM-IV and ICD-10 diagnostic criteria are inattention, impulsivity and hyperactivity The differences between these diagnostic criteria will be outlined later. 26 Jan 2006

4 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) 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 (%) Clinicians should consider comorbid conditions when developing a treatment plan. Up to 40% of children with ADHD have oppositional defiant disorder, 20% have conduct disorder and 10%–20% have mood disorder. Only 7% have tics or Tourette’s syndrome but 60% of those with this syndrome have ADHD1. The risk of serious psychopathology later in life is significantly increased when ADHD is left untreated. However, it is not known whether long-term treatment reverses this risk2. Up to 44% of ADHD children may have at least one other psychiatric disorder, 32% have two others and 11% have at least three other disorders3. 1. Goldman LS et al. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. JAMA 1998; 279: 2. Barkley RA. Attention-Deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment. New York: Guilford Press, 1988. 3. Szatmari P et al. ADHD and differences among correlates. J Am Acad Child Adolesc Psychiatry 1989; 28: Oppositional defiant disorder Anxiety disorder Learning disorder Mood disorder Conduct disorder Substance use disorder Tics 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: 219–230 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 Associated problems Poor relationship with parents Family History ADHD
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 26 Jan 2006

10 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% 26 Jan 2006

11 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 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 Developmental Impact of ADHD
Behavioural problems Academic problems Difficulty with social interactions Self-esteem issues Legal issues, smoking and injury Occupational failure Self-esteem issues Relationship problems Injury/accidents Substance abuse Behavioural disturbance Pre-school Adolescent Adult School-age College-age Over 60% of childhood ADHD continues into adulthood1. 1. Baren M. ADHD in adolescents: Will you know it when you see it? Contemporary Pediatrics 2002; 19: Behavioural disturbance Academic problems Difficulty with social interactions Self-esteem issues Academic failure Occupational difficulties Self-esteem issues Substance abuse Injury/accidents 26 Jan 2006

14 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

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

16 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. 26 Jan 2006

17 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

18 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 26 Jan 2006

19 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

20 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

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

22 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

23 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

24 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

25 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

26 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

27 How Medication works: Stimulants
Presynaptic Neuron Amphetamine blocks v v Storage vesicle Cytoplasmic DA CNS stimulant medications, such as methylphenidate and amphetamines, modify neurotransmission at the synaptic junction. Neurochemically, methylphenidate is thought to block the reuptake of noradrenaline and dopamine into the presynaptic neurone and increase the release of these monoamines into the extraneuronal space1, stimulating neuronal activity. Amphetamines enhance dopamine release and block its reuptake. 1. CONCERTA® Package Insert. Mountain View, CA: ALZA Corporation, 2000. Amphetamine blocks reuptake DA Transporter Methylphenidate blocks reuptake Synapse Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998; 26 Jan 2006

28 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

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

30 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

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

32 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

33 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

34 Conclusions 26 Jan 2006

35 Questions? 26 Jan 2006

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