Cherinet Seid, PGY II

OUT LINE Introduction History of ADD Etiology/Risk factors Diagnosis Comorbid disorders Management

Introduction

The only psych disorder 1st recognized in children

Under recognized in adultsAffects 4-5% adults“Persistent ADHD” 15-28%P-ADHD male predominant, A-ADHD notPsychiatric comorbidities

History of ADD1930 - Minimal Brain Damage1960 - Minimal Brain Dysfunction1968 - Hyper-kinetic reaction of

childhood1980 - ADD with/without hyperactivity1987 - ADHDAmphetamines used in 1937Methylphenidate has been on market

since 1955

Common Scenarios

Adults diagnosed in childhood & stopped rxAdolescents progressing to adult servicesUndiagnosed adults with rx-resistant

comorbid Psych disordersUndiagnosed self referred adultsUndiagnosed adults recognized by

others(fam members, health professionals)

Effects of ADHD1. Social & Work impairment$19.5 billion lost human capital/yr in USIncreased risk to be arrested (>2x controls)2. Marital & Parental impairmentRate of divorce & separation double that of

general population3. Accident PronenessHospital visits & Admissions 26 % vs 18%

4.Driving Impairment

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1

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6

Total Tickets Speeding tickets Suspensions MVA

Control

ADHD

Effects cont’d5. Substance use

Control ADHD

27

55

0

10

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60

Case43 yr female, chemist, married, 3 kidsNoticed similar characters as her 10 yr old

son who is recently diagnosed with ADHDHas trouble concentrating, disorganized,

impulsive & forgetfulFrequently misplaces or loses objectsProcrastinates and has difficulty with

punctualityFeels overwhelmed by house hold chores

although husband is supportive and calls her home ‘a disaster area’

Three sub types

I. Predominantly inattentive type

II. Predominantly hyperactive-impulsive type

III. Combo

DSM-IV criteria At least 6 symptoms of inattention

Careless mistakesNot listening Not finishing projectsForgetful Not following throughBeing disorganized Impulsive & forgetfulFrequently losing/misplacing objects

DSM IV cont’d At least 6 symptoms of hyperactivity

Hyperactivity-impulsivity Not able to sit still

Inner feeling of restlessness Always on the go

Talking too much Being impatient

Interrupting Blurting things out

DSM-IV cont’dSxs must be present before age 7

Interfere with ability to function

Persist for more than six months

Manifest in multiple settings

Not be accounted for by other disorders

Risk FactorsBiologic cause More genetic link than asthma, breast ca &

schizophrenia.

Environmental

Frontal cortex hypometabolism

Dopaminergic pathways

Screening for ADHD

Adult Self -Report Scale (ASRS)

18 questions

Assesses DSM-IV symptoms of ADHD

Assessment Process1. Assess current ADHD symptoms

(assessment scales)2. Establish a childhood hx of ADHD3. Assess devt’al & functional impairement4. R/o other psychiatric disorders5. Obtain family hx of psych disorders6. Perform a physical exam, r/o medical causes7. Assess pt’s insight (?same with collateral hx)

DDx of A-ADHDLearning disabilitiesMood disordersAnxiety disordersMixed anxiety/depressionSecondary ADHD syndromes due to

brain injuryOther causes of impaired cognitive &

executive function

Treatment

Need to treat is always based on

functional impairment.

Multimodal Treatment

PsychoeducationRx of comorbid conditionsPharmacological RxsTherapy (marital, individual, social skills,

CBT)Light therapyEnv’tal restructuring & appropriate

physical & special interest activities

PharmacotherapyClass Dose Adverse effectsStimulantsMethylphenidateShort acting

Intermediate acting

Extended release

10-60 mg 2-4x

10-60mg 1-2x

18-108 mg od

Insomnia Headache

Decreased appetite

wt loss Nausea

Bp & pulse changes

Palpitations

Non-stimulantsAtomoxetine 80-100 mg

1-2 x

Constipation Dry mouth

Decreased appetite Insomnia

Sexual dysfunction Dysmenorrhea

AntidepressantsBupropion

Short acting

Extended release

Desipramine

100 mg 2-3x

150-300 mg od

25-300 mg od

Anxiety Insomnia

Decreased appetite Risk of Sz

Irritability Agitation

just remember…

It is worth identifying A-ADHD

Substantial burden of illness

Potential for improvement with rx

Assessment Scaleswww.therapeuticresources.comwww.checkmateplus.comwww.guilford.comwww.mhs.comwww.caddra.cawww.harcourtassessment.comwww.med.nyu.edu/psych/psychiatrist/

adhd.html

References

1. Approach to ADD in adults,Canadian Family Physician, vol 52;Aug 2006

2. Understanding the nature of adult ADHD, Schulich school of Medicine, CME booklet 2007

3. www.uptodate.com