ADHD and Lifespan

8/3/2019 ADHD and Lifespan

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ADHD Specialists

Richard Ferman, MD

Attention Deficit Hyperactivity Disorder : Challenges Across the Lifespan


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Speaker Background Founder and Medical Director of ADHD Specialists

Child, Adolescent, and Adult Psychiatrist

A graduate of University of California, Los Angeles Schoolof Medicine

Completed Residency at Cedars-Sinai Medical Center, LosAngeles

Fellowship in Child Psychiatry at Cedars Sinai MedicalCenter, Los Angeles


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Attention Deficit Hyperactivity Disorder :

Challenges Across the Lifespan


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ADHD CME Module 1 Objectives

After completing this educational activity, participants

should be able to:

Understand the impact of ADHD from childhood throughadulthood

Identify common diagnostic challenges in diagnosing

ADHD including co-occurring conditions

Discuss the impact of ADHD symptoms on function


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Bridging the Gap: Science &Real World ADHD Issues

Historically, health clinicians have done a poor job ofconnecting with people who have ADHD

Educators are often the first to identify symptoms of ADHD.Often, K-6 Teachers Do this Very Well!

Often research does not look at practical applications in at

home, in the classroom and in the community

Our goal: to bridge the gap between what we know fromscience and what we see the lives of people with ADHD andcoexisting conditions


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QuickTime and adecompressor

are needed to see this picture.








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Attention Deficit Hyperactivity Disorder(ADHD) Clinical Definition:

ADHD is a persistent disabling pattern of behavior. It occurs

more frequently and with greater consequences than is typically

observed in others at a comparable level of development.

AND

All ADHD behaviors can be considered normal for some people, at

some age for a certain time.

With ADHD, these behaviors are theRULEand not the exception

and they are age inappropriate.


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Prevalence

US studies report 3 7% of all children are affected by ADHD.(American Psychiatric Association, 2000)

Accounts for 30% to 50% of all childhood mental health referrals.(Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry. 1999;56:1073-1086.)

Adult prevalence rates consequently vary, but anywhere from 1%to 6% of the general population are believed to meet the strictDSM-IV diagnostic criteria for ADHD. (Wender, 1995)

Outcome data suggest that anywhere from 5% to 75% still showsignificant levels of symptoms into adulthood, depending on whoare used as informants and where the diagnostic cutoff point is set.(Wender, 1995)


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ADHD Worldwide


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The Big Picture Why ADHD?Genetics make up the

largest percentage of ADHD

causes = up to 97% (80% avg.)

Toxins such as tobacco, alcohol,

and lead make up 2% to 10%

of cases

Brain Injuries 1 10%

Levy, F., Hay, D.A., McStephen, M., Wood, C., & Waldsman, I. (1997).


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DSM-IV TR 3 SubtypesAttention Deficit/Hyperactivity Disorder

Predominantly hyperactive-impulsive type

Predominantly inattentive type

Combined type


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Hyperactivity

Inattention

T I M E

(Kordon, Kahl, & Wahl, 2006)


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Executive Functions

Originally referred to a set of neurological processes necessary

for independent and socially responsive living. (Lezak, 1982)

A shorthand for a complex regulative process:

The ability to organize and prioritize.(Wasserstein, 2005)


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ADHD Sx morph into Executive

Function Deficits (impulsivity/inhibition

problems)


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Self-reflection

Self-control

Planning & Forethought

Delay of Gratification

Future oriented

Working memory

Planning

Affect Regulation

Resistance to Distraction

(Wasserstien, 2005)

Other terms for Executive Functions


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The simple core symptoms of Childhood ADHD morph in

adulthood into the more complex deficits in Executive

Functioning found in Adult ADHD.

Problems appear with initiation, procrastination, inhibition,

shifting, sequencing, planning, and self-awareness. (Barkley, 1997; Brown, 2000)

Often appear not to learn because they are unaware of how

they come across to others. (Barkley,1990)

Impairments & Limitations

in Executive Functions appear in Adults.


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Trouble keeping jobs

Difficulty maintaining routines

Poor at organizing money

Missing appointment

Forgets deadlines

Failure to file taxes

Poor tracking of bills and payments

Over due notices

Bank overdrafts (despite means)

Impulse Spending


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ADHD and Lifespan Risks:Untreated ADHD

200% to 300% more risk of substance abuse, caraccidents/infractions, pregnancy

35% drop out of high school Up to 70% underachieve in SES

250% more risk of incarceration

Hypothesized decreased life-expectancy

50-70% have few or no friends

35% will drop out of high school Only 5-10% will complete college

(Harpin, 2005)


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The story of Sherry


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Co-occurring conditions that confound

the Diagnosis:

Oppositional Defiant Disorder (40%)

Language Disorder (30-35%)

Anxiety and Depression (20-25%)***

Specific Learning Disability (15-25%)

Mood disorders (15-20%)

Conduct Disorder (20%)

Substance use disorder (15%)

Tics (15%)


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ADHD presents very differently in girls and in women, and itoften goes unnoticed. Diagnostic criteria are not as sensitive for

detecting ADHD females especially the inattentive type.

Criteria do not account for variations in what is considered

normal or extreme behavior across cultures.

Criteria in the DSM IV-TR are based upon observations of boys

age 4-17 years old. Criteria are adapted for use in Adults.(Wasserstein, 2005)

Limited diversity with Gender,Language, Culture Limitations:


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Diagnostic Mis-Focus

In Children

the Focus = ADHD

Childhood

Anxiety & Depression

are often overlooked.

In Adults

the Focus = Anxiety & Depression

Adult ADHD

is often overlooked


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ADHD is a distinct disorder; the impairments

and the characteristics of ADHD are present

in the absence of comorbid conditions.


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Clinical History:

General Psychological Evaluation,

Childhood History

Developmental History

Family history of psychiatric & neuropsychiatric issues

Specialized Sx Rating Scales: Conners, ADHD-RS

Be mindful of medical mimics

Order labs


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Adhders are poor self reporters

ADHD Adults tend to under report their symptoms

ADHD Teens tend to over report symptoms

Seek corroborating reports (partners, parents, patient,teachers)

Avoid second hand diagnosis

Diagnostic Pitfalls


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Do the Symptoms:

Compromise work or social functioning?

Cause significant suffering to others?

Cause failure to achieve specific life goals?

Cause significant risks to the patient?

How much difficulty is the result of poor recognition of the

problem(s) by the patient?

Is there unreasonable levels of effort required for the patient to

function at reasonable levels? (functional masking)

Focus on functional impairments


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3 Types of Functional ImpairmentOvert:

Losing track of required items for work, home, school

Losing track during conversations with others

Chronic lateness on bills, appointments, taxes, emails

How many areas of your life are out of control?

Covert:Working excessively hard to compensate at great social/personal/professional cost is an impairment

Your doing very well, but at what cost?

Situational:The borrowed prefrontal cortex. Often in sports, very structured or organized schools, over use of

parents/partners, regimented cultures.

Interviews with parents/partners can reveal earlier history of impulsivity/disorganization, inattention todetail, forgetfulness.

It sounds like without that support/structure you would really struggle


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ADHD and Launchers

The overt symptoms may not become apparent until the

ADHDer is Launched into college or into the working

world.

As life demands increase, and as external support decreases or

is withdrawn, ADHD symptoms become more evident.

ADHD can seem to appear out of nowhere.

Detailed history will often reveal prior history of external

support or unusual amounts of effort expended


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Review ADHD definition and prevalence

Symptom presentations across the lifespan

Consequences of untreated ADHD Co-existing conditions

Diagnostic Mis-Focus in Children and Adults

Gender, Culture and Language limitations

Making the ADHD diagnosis Avoiding diagnostic pitfalls

The impact of functional impairments in Adult ADHD


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ADHD CME Module 1

Objectives Review

After completing this educational activity, participants

should be able to:

Understand the impact of ADHD from childhood through

adulthood

Identify common diagnostic challenges in diagnosing

ADHD including co-occurring conditions

Discuss the impact of ADHD symptoms on functioning


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Questions & Answers


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References

ADHD and Lifespan

Documents