1. Attention-Deficit Hyperactivity Disorder in Adults and Children Conceptualization, Diagnosis and Treatment An Integrated Approach By Ghada Hamdan-Allen, M.D.

2. 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

3. ADHD: Definition and Course ADHD is a developmentally inappropriate level of hyperactivity, distractibility and impulsivity. hyperactivity inattention impulsivity Age

4. 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

5. 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

6. 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

7. 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 50- 60% of ADHD population compared to 30% in general population –ADHD is common in first degree relatives

8. 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

9. 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

10. 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

11. ADHD: Effect on Parents Increased stress –Worry-Anxiety –Frustration-Anger Lower self esteem –Self blame-depression –social isolation Disruption of employment Increased marital discord Increased alcohol and substance abuse

12. 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

13. ADHD: Diagnosis Clinical interview –History –Rating Scales –Collateral information/Impairment Physical evidence –PE-CPT –Lead level-Thyroid function Co-morbidity

14. ADHD-Diagnosis A Community Effort History –Parents –Spouses/Partners –Day care providers –Teachers –Therapists –Primary care physicians –Social agencies (DHS; Juvenile Court)

15. 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

16. 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

17. 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.orgwww.chadd.org –National Alliance for the Advancement of ADHD care www.naaac.org

18. 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

19. ADHD: Psychopharmacology Address issues of non-compliance Monitor side effects including vital signs/Growth Measure progress by subjective report and rating scales Feedback loop: Psychiatrist PCPPatient Parent/teacher

20. Psychopharmacology-Stimulants Short acting –Ritalin, Methylin, Focalin –Dextrostat Medium acting –Adderall –Metadate Long acting –Concerta –Ritalin LA –Adderall XR –Vyvanse –Daytrana

21. Psychopharmacology-Stimulants Adverse events –Anorexia, weight loss –Insomnia –Headaches –Stomach ache and vomiting –Stereotypy and tics –Increased pulse and BP –Growth?

22. 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

23. Psychopharmacology Antidepressants –Tricyclic antidepressants: Imipramine, Desipramine –Wellbutrin Alpha2 agonists –Clonidine –Tenex

24. 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