ADHD in Adults: Separating the Wheat from the Chaff

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ADHD in Adults Separating the Wheat from the
Chaff

• James Chandler, MD FRCPC

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Why the current interest?

• Pharmaceutical companies
• Psychiatry
• Cultural

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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

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Concerta, Adderall, Strattera, Ritalin, Alertec

• No disorder, no drug
• Where would Viagra be without Erectile
  Dysfunction?

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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

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Pharmaceutical Strategy

• Producing a demand
• Making people think that not paying attention is
  abnormal

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Psychiatrys Interest in ADHD
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Developmental interests

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

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Developmental Interest

• Child Psychiatry research follows up child
  illness into adult
• ADHD, Autism, Tourettes, Separation Anxiety
  Disorder, Traumatized Children

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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.

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Cultural

• More and more aspects of human behavior are now
  categorized as disorders requiring treatment
• Aspergers, ED, and now EDS (Excessive Daytime
  Sleepiness)

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Cultural

• Disorder means less responsibility, so having a
  diagnosis might lessen consequences for
  misbehavior in general.
• I cant help it, I have ADHD

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What is ADHD in adults?

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

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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).

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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).

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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

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Hyperactive-Impulsive

• often has difficulty awaiting turn
• often interrupts or intrudes on others (eg, butts
  into conversations or games)

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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,

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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,

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Decreased Attention

• often is distracted easily by extraneous stimuli,
  
• and is often forgetful in daily activities 2 .

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All present since childhood
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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

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Psychological tests can not diagnose ADHD.

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

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Executive dysfunction

• Organization and planning
• Working memory deficits
• The ability to hold information ïn your mind
  so you can compare scenarios, solutions, and
  consequences

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Executive dysfunction

• Response Inhibition Problems
• Cant resist an impulse to move, act, or think
  while on another task
• Sustained attention
• Shifting/Mental Flexibility
• Interference control

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What are functional deficits in ADHD in adults?
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Occupational and Academic

• More dropouts, lower occupational achievement
• More likely fired
• More likely to quit
• More bankruptcies
• Not as wealthy

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Family

• More Separations
• Divorce

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Legal

• More driving accidents, arrests for all causes

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Psychiatric

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

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Medical

• Increased accidents, head trauma, fractures,
  poisonings

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What are the causes of ADHD?
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Genetic

• 75 heritability, but no one gene causes this
• 50 of children of ADHD patient will have some
  signs of ADHD

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Biological Adversity

• Prematurity
• Smoking or drinking in pregnant mother
• Food additives?
• Obstetrical Complications

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Psychosocial Adversity

• Poverty
• Single parenthood
• Social class
• Chronic family conflict
• Low family cohesion
• Exposure to current, not past, parental
  psychopathology
• Abuse

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What looks like ADHD but isnt?

• Drug abuse
• Depression
• Hypomania
• Head Injury syndromes
• Post encephalitis, structural brain lesions

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What looks like ADHD but isnt?

• Other toxins
• Horrible home issues
• Neurodegenerative
• On and on..

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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
  dont either.
• Clearly diagnosed ADHD children grown up.

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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

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Hyperactive in a wheelchair or rehab unit?
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When should you be very suspicious that this is
not ADHD?

• Stable family life, occupation, and just
  psychological distress
• New onset problems as adult

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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

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Treatment
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Three equally challenging issues
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Compliance

• Missed appointments
• Drop ins
• script refills
• lost prescriptions vs. diversion

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Dealing with the illness

• Dealing with the financial, legal, familial, and
  physical sequale
• Dealing with having a chronic psychiatric illness
• Dealing with comorbid disorders

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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.

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

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Medications

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Stimulants

• Work immediately

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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

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Short acting Stimulants

• Good choice for
• extremely reliable persons with ADHD that doesnt
  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

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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
• doesnt cover late night
• High street value in schools and University

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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,

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Non-Stimulants

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

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Strattera-

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

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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

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Welbutrin

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

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Welbutrin

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

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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

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Drugs that do not work

• Effexor
• SRIs
• Atypical antipsychotics
• Mood stabilizers
• Nicotine patch
• cannibis

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Realistic outcomes

• Three main possiblilties

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Most likely outcome

• Non-compliant miss appointments, forget scripts

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Next most likely outcome

• Combination of side effects and improvement
  usually balancing insomnia, depression, and
  effect.
• Or doesnt cover enough of the day.
• Usually has less effect on higher level problems
  in my experience organization, time management,
  procrastination

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Least likely outcome

• Completely transforms their life with minimal
  side effects

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A realistic approach

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

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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)

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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

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A realistic approach

• Step 4. Monitor comorbid problems

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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

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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.

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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