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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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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