ADHD in Adults: Separating the Wheat from the Chaff James Chandler, MD FRCPC.

ADHD in Adults: Separating the Wheat from the

Chaff

James Chandler, MD FRCPC

Why the current interest?

• Pharmaceutical companies

• Psychiatry

• Cultural

Pharmaceutical companies

• ADHD is a chronic disease, thus a great market

• Adults with ADHD are directed to take medications even longer than depressed patients

• Many ADHD drugs are now indicated for adults

Concerta, Adderall, Strattera, Ritalin, Alertec

• No disorder, no drug

• Where would Viagra be without Erectile Dysfunction?

Selling ADHD drugs requires

• Identifying more consumers

• Direct to consumer ads with “signs of ADHD”

• Promoting the effectiveness of the treatment

• Pharmaceutical company managed studies which have little application in the real world

Pharmaceutical Strategy

• Producing a demand

• Making people think that not paying attention is abnormal

Psychiatry’s Interest in ADHD

Developmental interests

• Adult psychiatry research now focuses on early forms of adult illnesses– Depression, Bipolar Disorder, Psychosis,

Anxiety Disorder

Developmental Interest

• Child Psychiatry research follows up child illness into adult – ADHD, Autism, Tourettes, Separation

Anxiety Disorder, Traumatized Children

Clinical Observations

• Adult psychiatrists see the hyperactive children of their adult patients

• Child psychiatrists attempt to have a conversation or appointment with the parents of their ADHD patients.

Cultural

• More and more aspects of human behavior are now categorized as disorders requiring treatment

• Aspergers, ED, and now EDS (Excessive Daytime Sleepiness)

Cultural

• Disorder means less responsibility, so having a diagnosis might lessen consequences for misbehavior in general.

• I can’t help it, I have ADHD

What is ADHD in adults?

• The same two symptom dimensions as in children:– Hyperactive-Impulsive– Inattentiveness

Hyperactive-Impulsive

• often fidgets with hands or feet or squirms in seat,

• often leaves seat in classroom or in other situations in which remaining seated is expected

• often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).”

Hyperactive-Impulsive

• often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).”

Hyperactive-Impulsive

• often has difficulty playing or engaging in leisure activities quietly, is often ‘on the go’ or

• often acts as if ‘driven by a motor,’ and

• often blurts out answers before questions have been completed

Hyperactive-Impulsive

• often has difficulty awaiting turn

• often interrupts or intrudes on others (eg, butts into conversations or games)”

Decreased Attention • often fails to give close attention to details

or makes careless mistakes in schoolwork, work, or other activities;

• often has difficulty sustaining attention in tasks or play activities;

• often seems to be not listening when spoken to directly,

Decreased Attention

• often has difficulty organizing tasks and activities,

• often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework),

• often loses things necessary for tasks or activities,

Decreased Attention

• often is distracted easily by extraneous stimuli,

• and is often forgetful in daily activities” [2] .

All present since childhood

What are the neuropsychological basis for

these symptoms?

• 10 years ago this was quite clear, but not any more

• There are no psychological tests which all adults with ADHD do poorly on.

• The neuropsychology of ADHD is so heterogeneous that some patients do poorly on just about any test

Psychological tests can not diagnose ADHD.

• Nevertheless, the more executive function problems, the worse the academic and occupational outcome:

Executive dysfunction

• Organization and planning

• Working memory deficits

• The ability to hold information “ïn your mind” so you can compare scenarios, solutions, and consequences

Executive dysfunction

• Response Inhibition Problems

• Can’t resist an impulse to move, act, or think while on another task

• Sustained attention

• Shifting/Mental Flexibility

• Interference control

What are functional deficits in ADHD in adults?

Occupational and Academic

• More dropouts, lower occupational achievement

• More likely fired

• More likely to quit

• More bankruptcies

• Not as wealthy

Family

• More Separations

• Divorce

Legal

• More driving accidents, arrests for all causes

Psychiatric

• Increased bipolar disorder, depression, anxiety disorder, substance abuse, smoking, Antisocial behavior

Medical

• Increased accidents, head trauma, fractures, poisonings

What are the causes of ADHD?

Genetic

• 75% heritability, but no one gene causes this

• 50% of children of ADHD patient will have some signs of ADHD

Biological Adversity

• Prematurity

• Smoking or drinking in pregnant mother

• Food additives?

• Obstetrical Complications

Psychosocial Adversity• Poverty

• Single parenthood

• Social class

• Chronic family conflict

• Low family cohesion

• Exposure to current, not past, parental psychopathology

• Abuse

What looks like ADHD but isn’t?

• Drug abuse

• Depression

• Hypomania

• Head Injury syndromes

• Post encephalitis, structural brain lesions

What looks like ADHD but isn’t?

• Other toxins

• Horrible home issues

• Neurodegenerative

• On and on………..

How does it classically appear?

• Parents of clearly diagnosed patients of yours with ADHD

• Pearl: if someone has three or more children and none of them have ADHD, probably the parents don’t either.

• Clearly diagnosed ADHD children grown up.

How does it present?• About 1/3 will still be disabled as adults, with

very few growing out of it after age 30.

• Addiction Treatment Centres and follow up

• Depending on the centre, 25-35% of the people in treatment programs have ADHD, too.

• Severe accident follow up

Hyperactive in a wheelchair or rehab unit?

When should you be very suspicious that this is not

ADHD?

• Stable family life, occupation, and just psychological distress

• New onset problems as adult

When should you be very suspicious that this is not

ADHD?

• Come in on their own – not brought by spouse, friend, parent, etc

• Have a list of questions and an organized presentation of their history

Treatment

Three equally challenging issues

Compliance

• Missed appointments

• Drop ins

• script refills

• lost prescriptions vs. diversion

Dealing with the illness

• Dealing with the financial, legal, familial, and physical sequale

• Dealing with having a chronic psychiatric illness

• Dealing with comorbid disorders

Psychotherapy• Few trials, but the only success stories so

far are for skill training with modules on organizing and planning, distractibility, adaptive thinking, and procrastination this one has been used in a double blind trial of persons who were treated with medications and partially responded.

This is the manual from that study and a copy is on the table

This is the therapist manual - copy on the table

Medical Treatment of ADHD in Adults

• First step is to match the drug to the person, given that almost everyone will have some comorbid problem.

Medications

•

Stimulants

• Work immediately

Short acting Stimulants

• Good points: – Most potent of ADHD medications

• Bad Points: – Abusable– need to take three times a day– can cause depression– High street value in academic settings

Short acting Stimulants

• Good choice for: – extremely reliable persons with ADHD that

doesn’t respond to long acting drugs with no history of substance abuse or depression

– Dose is 1mg/kg – about 20-30 mg tid of Ritalin or 10-20mg tid of Dexedrine.

– No insurance

Long Acting Stimulants• Good points:

– once a day and potent.– not abusable

• Bad points: – need to take it before 9am– still can cause mood disorder– doesn’t cover late night– High street value in schools and University

Long Acting Stimulants

• Cost for concerta and Adderall can be over 200 dollars a month at high doses, which are often the case in large persons.

• Dosages

• Concerta and biphentin: roughly 1mg/kg, Adderall roughly .5 mg/kg, Dexedrine Spansules, .5mg/kg,

Non-Stimulants

• All work on the time frame of antidepressants – 8 weeks.

Strattera-

• Good points– 24 hour coverage, once a day– Not abusable– May help comorbid anxiety

Strattera-

• Bad points

• Not that potent

• Still can cause mood disorders

• expensive- over 270 dollars a month for full doses.

• Dosage – start at .5mg/kg, increase to 1-1.2 mg/kg

Welbutrin

• Good points– Also an antidepressant– Unlikely to cause depression– Decreases smoking– Can be combined with stimulants– Works all day

Welbutrin

• Bad points– Not that potent– Dosages -300mg/d– Seizures with Bulimia, Pot

Alertec (Provigil, Modafinil)

• Good points:– Works all day– Not abusable

• Bad points:– Not that potent– More GI side effects– Not that cheap: 200 dollars a month Dosages

200-400 mg/d

Drugs that do not work:

• Effexor

• SRIs

• Atypical antipsychotics

• Mood stabilizers

• Nicotine patch

• cannibis

Realistic outcomes

• Three main possiblilties:

Most likely outcome

• Non-compliant – miss appointments, forget scripts

Next most likely outcome• Combination of side effects and

improvement usually balancing insomnia, depression, and effect.

• Or doesn’t cover enough of the day.

• Usually has less effect on higher level problems in my experience: organization, time management, procrastination

Least likely outcome

• Completely transforms their life with minimal side effects

A realistic approach

• Step 1. proper diagnosis is made ( one visit)

A realistic approach

• Step 2. patient actually comes back a second time to discuss treatment and life management issues with some other responsible adult( tests whether they really can come back)

A realistic approach

• Step 3. Start medication with the understanding that most likely skills training will be needed or couple script with skills training. “Assuming the drug does not work miracles, you will need extra help learning some new skills”

A realistic approach

• Step 4. Monitor comorbid problems

Do not:

• Refill scripts before they are due for stimulants, no matter what the reason

• Refill scripts without the patient coming in more than once in a row

Do not:

• Hesitate to link scripts to drug screens

• Give stimulants directly to patients who live in dormitories

• Get too focused on trying to find the magic drug.

References

• Genetics of adult attention-deficit/hyperactivity disorder.Faraone SV - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 303-21From NIH/NLM MEDLINE

• Driving impairments in teens and adults with attention-deficit/hyperactivity disorder.Barkley RA - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 233-60From NIH/NLM MEDLINE

• Brain function and structure in adults with attention-deficit/hyperactivity disorder.Seidman LJ - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 323-47From NIH/NLM MEDLINE

• Neuropsychological function in adults with attention-deficit/hyperactivity disorder.Seidman LJ - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 261-82From NIH/NLM MEDLINE

• Nonstimulant treatment of adult attention-deficit/hyperactivity disorder.Spencer T - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 373-83From NIH/NLM MEDLINE

• Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder.Adler L - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 187-201From NIH/NLM MEDLINE

•

• Psychosocial treatments for adults with attention-deficit/hyperactivity disorder.Safren SA - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 349-60From NIH/NLM ME

•