www.mghcme.org Diagnosis of Adult ADHD Joseph Biederman, MD Professor of Psychiatry Harvard Medical School Chief, Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD Director, Bressler Program for Autism Spectrum Disorders Massachusetts General Hospital
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www.mghcme.org
Diagnosis of Adult ADHD
Joseph Biederman, MDProfessor of Psychiatry Harvard Medical School
Chief, Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD
Director, Bressler Program for Autism Spectrum DisordersMassachusetts General Hospital
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Disclosures 2018-2019
My spouse/partner and I have the following relevant financial relationships with commercial interests to disclose:
– Research support: Genentech, Headspace Inc., Lundbeck, Neurocentria Inc., Pfizer, Roche TCRC Inc., Shire Pharmaceuticals Inc., and Sunovion.
– Consulting fees: Akili, Jazz Pharma, and Shire– Royalties paid to the Department of Psychiatry at MGH, for a
copyrighted ADHD rating scale used for ADHD diagnoses: Bracket Global, Ingenix, Prophase, Shire, Sunovion, and Theravance
– Financial interest: Avekshan LLC, a company that develops treatments for ADHD. My interests were reviewed and are managed by MGH and Partners HealthCare in accordance with their COI policies
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Paul Wender
“ADHD is probably the most common chronic undiagnosed psychiatric disorder in adults. It is characterized by inattention and distractibility, restlessness, labile mood, quick temper, overactivity, disorganization, and impulsivity. It is always preceded by a childhood diagnosis, a disorder that is rarely inquired about and usually overlooked.”
www.mghcme.orgMoffitt et al. Am J Psychiatry 2015; 172:967–977.
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Adult ADHD
• Symptoms and impairment may emerge due to the accumulation of environmental and genetic risk factors
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Adult ADHD
• Those with lower levels of risk at birth will take longer to accumulate sufficient risk factors and longer to onset with symptoms and impairment
• This multifactorial perspective allows for different risk factors to exert effects at different ages thereby influencing age of onset
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Adult Onset ADHD
• Because these effects are multifactorial, there is no clean separation of etiologic factors in people above and below the ages of 12 years set forth in DSM-V
Faraone and Biederman JAMA Psychiatry Editorial 2016
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70
80
90
100
110
120
130
140
150
0 10 20 30 40 50
Full
Scal
e IQ
Age at Initial Diagnosis
Age at Initial Diagnosis vs Full Scale IQ
IQ and ADHD
• IQ can compensate for the impairments of ADHD
• Can forestall diagnosis of ADHD
Horrigan J, et al. Presented at: 47th Annual AACAP Meeting; October 24-29, 2000; New York, NY.
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Shekim WO, et al. Compr Psychiatry. 1990;31:416-425.
Biederman J, et al. Am J Psychiatry. 1993;150:1792-1798.
Comorbidity in Adults With ADHD
Antisocial Disorder (10%)
Major Depressive Disorder (30-40%)
Bipolar Disorder (15-20%)
Anxiety Disorders (30-40%)
Substance Abuse Disorders (20-50%)
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Disorder ADHD Rate
Major Depression1 20%
Bipolar Disorder2 15%
Generalized Anxiety Disorders3 20%
Substance Abuse4 25%
Re-evaluate refractory patients for ADHD.
ADHD Comorbidity in Adults With Other Psychiatric Disorders
1. Alpert, et al. Psychiatry Res. 1996. 2. Nierenberg, et al. Presented at: APA; May 18-23, 2002; Philadelphia, Pa.3. Fones, et al. J Affective Dis. 20004. Wilens. Psych Clin N Am. 2004.
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1. Quick to get angry or become upset
2. Easily frustrated
3. Over-react emotionally
4. Easily excited by activities going on around me
5. Lose my temper
6. Argue with others
7. Am touchy or easily annoyed by others
8. Am angry or resentful
Deficient Emotional Self Regulation
Scoring: Never (0), Sometimes (1), Often (2), Very Often (3)
DESR: ≥ 95th percentile of total scores in Controls
Surman et al, AJP In Press
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Educational Impairment in High School
*
*
*
*
* p ≤.001
Percentage of Those Who Attended High School
52%
27%
37%
13%
37%
10%
30%
8%
"C" average or lower
Had a tutor
Had special classes
Had to repeat a grade
ADHD (N=464)
Non-ADHD (N=487)
Biederman et al. J Clin Psychiatry. 2006 Apr; 67(4):524-40
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Current Employment Status
*
*
*
*
* P≤.001
Percentage of Each Group
52%
72%
34%
57%
48%27%
14%
5%
Currently employed
Employed full time
Not currently employed
Looking for work
ADHD (N=500)
Non-ADHD (N=501)
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Workplace Impairment
* P≤.001, P≤.05, P≤.01
Easy to concentrate on work
Able to handle large work loads
Unless very interested, unable to pay attention for long periods of time
Organized at work
Sometimes have difficulty following instructions
One of the first that would be considered for a promotion
†
‡
*
*
*
*
Percentage of Those Employed Who "Strongly Agree"
33%59%
52%74%
46%20%
39%69%
5%
11%
31%45%
ADHD (N=261)
Non-ADHD (N=301)
† ‡
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Average Household Income by Education Level Attained