UNDERSTANDING AND MANAGING ADHD: FROM CHILDHOOD TO ADULTHOOD

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UNDERSTANDING AND MANAGING ADHD FROM CHILDHOOD
TO ADULTHOOD

• LARISSA ELGUDIN, MD
• ASSISTANT CHIEF, BEHAVIORAL HEALTH SERVICES
• OHIO PERMANENTE MEDICAL GROUP
• CLINICAL INSTRUCTOR OF PSYCHIATRY
• CASE WESTERN RESERVE UNIVERSITY SCHOOL OF
  MEDICINE
• CLEVELAND, OHIO

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HISTORY OF ADHD

• 1845 - Dr. Heinrich Hoffman (a German physician
  and poet) wrote an illustrated book about
  children and their characteristics, "The Story of
  Fidgety Philip"
• 1902 - Dr. George Still (a British pediatrician)
  described impulsivity and identified a disorder
  "Defect of Moral Control"
• 1922 - The symptoms associated with ADHD were
  given the name "Post-Encephalitic Behavior
  Disorder"
• 1937 - Dr. Charles Bradley (Providence, RI)
  introduced the use of stimulants in children who
  were hyperactive
• 1957 - Ritalin was introduced as the drug of
  choice to treat hyperactivity
• 1960 - Stella Chess described Hyperactive Child
  Syndrome
• 1968 DSM-II introduced the diagnosis of
  Hyperkinetic Reaction of Childhood
• 1980 DSM-III the diagnosis of Attention
  Deficit Disorder
• 1994 DSM-IV described three groups of Attention
  Deficit Hyperactivity Disorder

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DSM-IV-TR DIAGNOSIS OF ADHD

• SYMPTOMS OF INATTENTIVENESS
• Failure to give close attention to details,
  constant careless mistakes in schoolwork, work or
  other activities
• Difficulties sustaining attention
• Inability to listen when spoke to directly
• Failure to follow through on instructions and
  failure to finish tasks or duties
• Difficulties organizing tasks and activities
• Avoidance to engage in tasks that require
  sustained mental efforts
• Loss of things that are necessary for tasks or
  activities
• Distractibility
• Forgetfulness

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DSM-IV-TR DIAGNOSIS OF ADHD

• SYMPTOMS OF HYPERACTIVITY/IMPULSIVITY
• Fidgety with hands or feet
• Inability to remain seated
• Running or moving excessively feeling restless
• Difficulties playing or engaging in activities
  quietly
• Being often on the go or driven by a motor
• Talking excessively
• Blurting out answers before questions have been
  completed
• Difficulties awaiting turn
• Interrupting or intruding on others

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DSM-IV-TR DIAGNOSIS OF ADHD

• Some symptoms were present before age 7 years
• Symptoms are present in two or more settings
  (school, work, home etc)
• Symptoms cause significant impairment social,
  academic, occupational
• Symptoms can not be accounted for by another
  mental disorder

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ADULT ADHD

• 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 childhood diagnosis, a
  disorder that is rarely inquired about and
  usually overlooked.
• By P.H. Wender, Attention-Deficit Hyperactivity
  Disorder in Adults, 1995

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ADULT ADHD

• Common Adult Manifestation
• Poor time management
• Difficulty initiating and completing tasks
• Trouble with multitasking
• Procrastination
• Avoiding activities that demand attention
• Forgetfulness
• Trouble with losing things (keys, papers, bills,
  etc)
• Sense of restlessness
• Fidgety
• Inability to wait
• Poor driving skills
• Inability to maintain the same job - changing
  jobs

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EPIDEMIOLOGY

• Prevalence in school-age children
• 3-7 (DSM-IV-TR)
• 4-12 (Pediatrics 2001)
• 8-10 (Clinical Practice Guideline of American
  Academy of Pediatrics 2000)
• Prevalence of adult ADHD
• 4.7 (Barkley et al 1996)
• 4 (Heilegenstein et al 1998)
• 4.4 (National Co-morbidity Survey Replication
  (NCS-R) 2006)
• 70 of subjects with childhood ADHD endorsed
  symptoms of ADHD in adulthood (NCS-R 2006)

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EPIDEMIOLOGY OF ADULT ADHD

• Fayyad and colleagues - done epidemiologic study
  in 10 countries including USA.
• Retrospective assessment of 11,432 respondents
  18-44 years of age.
• The average prevalence rate of ADHD was 3.4.
• Rate in France 7, statistically greater than
  the average.
• Lower-income countries low prevalence rate of
  ADHD, except Spain where rate was also low.

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EPIDEMIOLOGY OF ADULT ADHD
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How Is It Diagnosed?

• Diagnosis of ADHD is a clinical diagnosis
• Rating scales and checklists for children
• Vanderbilt Diagnostic Parent and Teacher Scales
• Child Behavior Checklist (Achenbach)
• Teacher Report Form (Achenbach)
• Conners Parent and Teacher Rating Scales
• ADHD Rating Scale-IV (DuPaul)
• Swanson, Nolan, and Pelham (SNAP-IV) and SKAMP
• Home Situations Questionnaire-Revised (HSQ-R) and
  School Situations Questionnaire-Revised (SSQ-R)
  (Barkley)

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How Is It Diagnosed?

• Rating scales and checklists for adults
• Conners Adult ADHD Rating Scale (CAARS)
• Wender Utah Rating Scale (WURS)
• Brown Attention-Deficit Disorder Scales (Brown
  ADD Scales)
• Adult ADHD Self-Report Scale (ASRS-v1.1)
• The ASRS Symptom Checklist was developed in
  conjunction with the World Health Organization
  (WHO) and the Workgroup on Adult ADHD.
• The ASRS Symptom Checklist comes in different
  languages.
• Self-report forms have been psychometrically
  evaluated and found valid and reliable as
  diagnostic tools for adult ADHD.

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CO-MORBIDITY OF CHILDHOOD ADHD

• Oppositional Defiant Disorder 1/3-1/2 of
  children with ADHD
• Conduct Disorder 20-40 may develop a more
  serious pattern of antisocial behavior
• Learning Disabilities 20-30
• Tourette Syndrome and other Tic Disorders
• Depression up to 33
• Anxiety Spectrum Disorders up to 30
• Bipolar Disorder around 16 may meet criteria
  for mania
• Substance Abuse Disorders 15-19

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CO-MORBIDITY OF CHILDHOOD ADHD
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CO-MORBIDITY OF ADULT ADHD
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CO-MORBIDITY OF ADULT ADHD
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TREATMENT OVERVIEW

• Multimodal treatment approach
• Parent and child education (or adult) about
  diagnosis and treatment
• Specific behavior management techniques
• Pharmacological treatment
• Appropriate educational programs and supports

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PHARMACOLOGICAL TREATMENT OF ADHD
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BEHAVIORAL TREATMENT

• Behavior modification is the only non-medical
  treatment for ADHD with a large scientific
  evidence base.
• The scientific literature, the National Institute
  of Mental Health, and many professional
  organizations (AAP, AACAP) agree that
  behaviorally oriented psychosocial treatments --
  also called behavior therapy or behavior
  modification -- and stimulant medication have a
  solid base of scientific evidence demonstrating
  their effectiveness.