1. Hal Elliott, MD Associate Professor Residency Program Director Department of Psychiatry East Tennessee State University

2. Wake Forest University :  Middle 50% of Students With SAT between 1250- 1390  US NEWS and World Report: #25-30 Davidson College :  Middle 50% of Students With SAT between 1310- 1440  US News and World Report: #5-11

3. “A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically found in individuals at a comparable level of development” EXECUTIVE FUNCTIONING DISORDER

6. ADHD: Neurobiologic Basis ALERTING EXECUTIVE CONTROL ORIENTING (SELECTIVE ATTENTION) Posner and Raichle. Images of the Mind. Scientific American Books; 1996. Attention Networks

7. Neural Networks of Attention  Prefrontal cortex  Parietal cortex  Cingulate gyrus  Limbic structures (amygdala-hippocampus)  Basal ganglia  Thalamus  Brainstem (reticular formation)  Cerebellum Seidman LJ et al. Biol Psychiatry. 2005;57:1263-1272.

8. Anterior Cingulate Cortex Cognitive Division Fails to Activate in ADHD Bush G et al. Biol Psychiatry. 1999;45:1542-1552. 1 x 10 -3 1 x 10 -2 y = +21 mm Normal Controls 1 x 10 -2 1 x 10 -3 y = +21 mm ADHD

9. Mean heritability of ADHD =.75 Faraone SV et al. Biol Psychiatry. 2005;57:1313-1323. ADHD 0.00.10.20.30.40.50.60.70.80.91 Matheny (1971) Willerman (1973) Goodman (1989) Gillis (1992) Edelbrock (1992) Stevenson (1992) Schmitz (1995) Thapar (1995) Gjone (1996) Silberg (1996) Sherman (1997) Levy (1997) Nadder (1998) Hudziak (2000) Willcutt (2000) Thapar (2000) Coolidge (2000) Kuntsi(2001) Martin (2002) Rietveld (2003) Laarson( 2004) Heritability Panic Disorder Schizophrenia Height Heritability of ADHD

10.  Variation in basal ganglia symmetry and in corpus collosum  PET: Decreased brain glucose metabolism in basal ganglia of ADHD adults/adolescents (Zametkin et al)  SPECT: Increased striatal availability of a dopamine transporter ( Krause et al)  Genetic Studies: Twin and sibling studies most convincing biologic evidence

11. Catecholamines and Brain Activity DLPFC, dorsolateral prefrontal cortex; VLPFC, left ventrolateral prefrontal cortex; BS-ACh, pedunculopontine/laterodorsal tegmental nuclei; VTA/SN, ventral tegmental area-substantia nigra; NBM, nucleus basalis magnocellularis; LC, locus coeruleus; DA, dopamine; ACh, acetylcholine; NE, norepinephrine ; NBM, nucleus basalis magnocellularis; VTA, ventral tegmental area; SN, substantia nigra.

12. Lifetime Course of ADHD Symptoms: Inattention Domain ++ Difficulty sustaining attention Doesn’t listen No follow-through Can’t organize Loses important items Difficulty sustaining attention (meetings, readings, paperwork) Paralyzing procrastination Slow, inefficient Poor time management Disorganized Childhood Adulthood Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:85-93; Weiss MD, Weiss JR. J Clin Psychiatry. 2004;65:27-37.

13. Lifetime Course of ADHD Symptoms: Hyperactivity-Impulsivity Domain ++ Squirming, fidgeting Can’t stay seated Can’t wait turn Runs/climbs excessively Can’t play/work quietly On the go/driven by motor Talks excessively Blurts out answers Intrudes/interrupts others Inefficiencies at work Can’t sit through meetings Can’t wait in line Drives too fast Self-selects very active job Can’t tolerate frustration Talks excessively Interrupts others Makes inappropriate comments Childhood Adulthood Adler L, et al. Psychiatr Clin N Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association; 2000:85-93; Weiss MD, et al. J Clin Psychiatry. 2004;65:27-37.

14. Subjects Responding Yes (%) Drove Before Licensed ≥12 Traffic Citations ≥5 Speeding Citations License Suspended or Revoked ADHD (n = 105) Control (n = 64) ≥3 Vehicular Crashes P =.003 P=.001 P=.002 P=.001 P=.007 Negative Driving Outcomes From a Driving History Interview Barkley RA et al. J Int Neuropsychol Soc. 2002;8:655-672. Traffic Violations and MVA Among Young Adults With ADHD MVA, motor vehicle accidents.

15. “ OFFICER, I AM NOT INEBRIATED…I AM JUST INEPT.” Britt Elliott ( 1988)

18. Biederman J et al. Pediatrics. 1999;104:e20 0 20 40 60 80 100 Non-ADHD (n=137) Medicated ADHD (n=56) Unmedicated ADHD (n=19) Individuals With Substance Use Disorder (%) P<.001 18 25 75

21.  Spencer et al: 60% of children with ADHD meet criteria as adults  Spencer, Biederman, Williams: 663/1700 meet criteria  Borland and Heckman: 50% of ADHD kids meet criteria as adults as opposed to 5% of non- ADHD siblings

22.  Distractibility  Organizational problems  Poor task completion  Forgetfulness  Careless errors/ trouble with details  Sequencing problems  Hyper-focusing/ Prioritization Problems  “Deer in the Headlights”

23.  Authority Issues  Stubbornness  Intolerance of silly rules/ assignments  Relationship problems ( peer and sig. other)  Frequent changes in major/ schools  Poor frustration tolerance  Easily bored  Poor or inconsistent academic performance despite adequate or even superior intellectual abilities

24.  Scattered  Anxious/ “Scanning The Horizon”  Irritable  Chronically Late/ Poor Time Sense  Procrastination  Bored Easily/ Restless/ Impatient  Trouble with Math/Directions  Reading Comprehension Problems  Compensatory OC Behavior

25.  Increase in distress/ anxiety/ disorganization when responsibility increases/ changes at work, home, or school. EXAMPLES:  Birth of child  Promotion  Increase in academic workload  Transitions: First of School Year, Starting College or Grad School, Moving Rooms, Changing Classes, Weekday to Weekend, Weekend to Weekday, Awake to Sleep, Sleep to Awake

26.  Anxiety Disorders (50%)  Substance Abuse ( 27%-47%)  Antisocial Personality Disorder ( 12%-27%)  Affective Disorders (? %)  NO COMORBID DX: 40%

28.  Copeland Symptom Checklist For Adult ADHD  Brown Adult ADD Scale( BAADS II)  Amen Scale

29.  While ADHD is a clinical diagnosis, consider psychometric testing if:  Diagnosis is unclear  Accommodations are needed  More details re: exact deficits are needed or if LD is suspected.

30.  Childhood Prerequisite  New Onset: medical work-up indicated  Consider: endocrine, sleep apnea, drug interactions, hearing deficit, B12, head injury, heavy metal, seizure disorder.  MRI/CT, EEG, BP, EKG, baseline labs, etc.

31. Why?  Childhood Onset – difficult to get accurate history, especially in individuals who have IQ in superior range.  By adulthood comorbidity clouds diagnosis  ADHD is a clinical diagnosis  Schedule II medications/fear of prescribing  Countertransference/Cultural Bias

32.  Many college students functioning in the intellectual ly superior range never had to study before college  Many students had parents to manage all of their details, scheduling, deadlines, etc  Some students attended exclusive private schools with very rigid day to day routines. External organization kept them structured and limited distractions.

33.  It isn’t compulsive checking behavior if you really might forget  Anxiet y will increase catecholamines and can increase ability to attend  Procrastination creates anxiety when the work is imminently due….and can increase ability to attend  Classical conditioning model  But…too many catecholamines cause a shut down effect.

34.  “Are you scattered because you are anxious or are you anxious because you are scattered”  “Are you depressed because you can’t get your work done or are you not getting your work done because you are depressed”

35.  OC sxs as a compensatory mechanism. Ruminating. Lists. Excessive worry. Worst case scenarios.  Not usually repetitive over time. Tend to be day to day worries as opposed to intrusive ego dystonic obsessions  Thoughts jump from one thought to next as opposed to focusing on one obsession  Compulsive sxs are less likely to be linked to obsessive thinking.

36.  Genetic overlap  Hyperactivity vs. Mania/Hypomania  Discreet episodes vs. ongoing symptoms

37. Of pharmacologic options available for ADHD, stimulant medications are the:  Most studied  Most commonly used  Most effective  First-line agents for treatment Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432; Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-49S.

38.  DOPAMINE: mediates “verbal fluency, serial learning, vigilance for executive functioning, sustaining and focusing attention, prioritizing behavior, and modulating behavior based on social cues” (Stahl)  NOREPINEPHRINE: plays role in “sustaining and focusing attention, as well as in modulating energy, fatigue, motivation and interest” ( Stahl)

39.  STIMULANTS: Methylphenidate (Ritalin, Ritalin LA, Metadate CR, Concerta)  Mixed amphetamine salts ( Adderall, Adderall XR),  Dextroamphetamine ( Dexedrine, Dextrostat),  Dextroamphetamine long acting ( Vyvanse)  d-methylphenidate ( Focalin)  Pemoline ( Cylert)…LFT’s

42. ANTIDEPRESSANTS/ OTHER Buproprion ( Wellbutrin) Venlafaxine ( Effexor) Duloxetine ( Cymbalta) Desipramine/ Imipramine Modafinil ( Provigil) Clonidine ( catapress) Atomoxetine (Strattera SSRI’s for comorbidity….not for core symptoms

43. Problems with the stimulants  Schedule II drugs (abuse liability, diversion, medicolegal concerns)  30% do not adequately respond or cannot tolerate stimulant treatment  Short duration of action (compliance, embarrassment)  Side effect profile adversely impacting sleep, appetite, mood, and anxiety  Concerns about cardiovascular effects, growth suppression, and tic development Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S- 49S; Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432.

44.  Education  Organizational Help (academic coaching)  Learning Assistance Center @ WFU  Individual and Couples Therapy  CHADD  SNL @ Davidson College  Exercise  Selection of occupation and need for novelty/ difficulty with change

45. Leveling the playing field:  Quiet Environment  Extra Time  UC Berkeley Study: Group Standard Time Extra Time LD 13 th percentile 76 th percentile Non-LD 82 nd percentile 83 rd percentile

46. Accommodations for Resident Physicians with Attention Deficit Disorder Academic Psychiatry Elliott, Arnold, Brenes, Silvia, Rosenquist August 2007

47.  Stimulants/ Schedule II drugs  Alteration of sense of self/ blunting of creativity  Non-linear thinkers in the academic environment.  Myth of Laziness. Twice the work for half the result.  “Left handed learners”  Responsibility  Square Pegs and Round Holes

48.  “My parents and I have different ideas about what I should do after graduation. I want to go to Florence and study Art History. They want me to move into their pool house and become a dental hygienist”  Patient J, Senior at WFU

49. I was a peripheral visionary. I could see the future, but only way off to the side. Steven Wright Steven Wright

52.  Attentiveness….does not characterize my brothers and me, all of whom were raised in SC and who have an air of abstraction and carelessness. None of us have a sense of direction. When something breaks, we fix it with duct tape…we tend to live in our own heads than in the actual physical world. We are more likely to get lost, to forget things, to stare blankly off in the distance for minutes at a time…at least part of the reason I resist ( taking something like Ritalin) is that I am not convinced the abstracted end of the mindfulness spectrum is such a bad place to be. In fact, I kind of like it here. Sometimes I wonder whether it is an accident that of the three abstracted Elliott brothers, two have graduate degrees in philosophy and the other is a psychiatrist.  Carl Elliott, MD, PhD Better Than Well. American Medicine Meets the American Dream

53.  “One must still have chaos within oneself to be able to give birth to a dancing star” Nietszche

54.  “ You can dream the American Dream, but you sleep with the lights on and wake up with a scream” Warren Zevon ( Fistful of Rain)

55.  “ Walk with me out on the wire…” Bruce Springsteen ( Born To Run)

58.  Retroactive diagnosis with childhood symptoms a prerequisite  DSM-IV criteria  Parent Connor’s in 95 th percentile OR Childhood hyperactivity, attention problems, and either: behavior problems, impulsivity, over- excitability, or temper outbursts

59. ADULT CRITERIA: Motor hyperactivity, attention problems, affective liability, “hot temper”, emotional over-reactivity, disorganization, inability to complete tasks, impulsivity, etc.

61. Evaluation of Adult ADHD  What to evaluate  Current symptoms  Impairment  Establishing childhood onset  How to evaluate  Role of screening tools  Role of scales (diagnostic and symptom assessment)  Importance of prompts  Who should evaluate  Mental health professionals  PCPs Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:85- 93; Wilens TE, et al. JAMA. 2004;292:619-623. PCP, primary care physician.

64. “I would have called 911, but I couldn’t remember the number” Davis Elliott ( age 3)

67. 0.00.10.20.30.40.50.60.70.80.91.0 Prevalence DSM-II Hyperkinesis DSM-IIIR ADHD LD Sample 15.5 y Feldman (1979) DSM-III ADD Offord (1992) Cantwell & Baker (1989) 8-16 y 9.7 y Hyperactivity Scales 13.4 y 14.2 y 14.9 y 25.1 y 30.4 y Mendelson (1971) August (1983) Barkley(1990) Weiss (1985) Borland & Heckman (1976) 14.3 y 18.5 y 17.4 y 18.3 y 25.5 y Lambert (1987) Mannuzza (1991) Mannuzza & Gittleman (1984) Gittleman (1985) Mannuzza (1993) 14.5 y 10.4 y Biederman (1996) Hart (1995) Chronicity of ADHD: Follow-up Studies of ADHD Faraone SV, et al. Psychol Med. 2006;36:159-165. LD, learning disability; DSM, Diagnostic and Statistical Manual of Mental Disorders; ADD, attention deficit disorder.