attention-deficit hyperactivity disorder in adults and children conceptualization, diagnosis and...
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Attention-Deficit Hyperactivity Attention-Deficit Hyperactivity Disorder in Adults and Disorder in Adults and
ChildrenChildrenConceptualization, Diagnosis and TreatmentConceptualization, Diagnosis and Treatment
An Integrated ApproachAn Integrated ApproachBy By
Ghada Hamdan-Allen, M.D.Ghada Hamdan-Allen, M.D.
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ObjectivesObjectives
• Define and diagnose Attention-Deficit Hyperactivity Disorder using clinical criteria.
• Recognize the integrated community approach to diagnosing and treating ADHD.
• Improve management of ADHD
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ADHD: Definition and CourseADHD: Definition and Course
• ADHD is a developmentally inappropriate level of hyperactivity, distractibility and impulsivity.
•
hyperactivity
inattention
impulsivity
Age
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ADHD: EpidemiologyADHD: Epidemiology
• Prevalence– 4-12% of children under 18– 4.7% of adults– Female to male ratio: 10:1 in children and 2:1
In adult clinical samples.– ADHD is over-represented in adoptees and
lower SES
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ADHD: Differential DiagnosisADHD: Differential Diagnosis
• Conduct disorder• Oppositional defiant disorder• Tourette’s disorder• Anxiety disorder• Learning disorder• Mood disorders: unipolar and bipolar• Substance use disorder• Developmental disorders• Personality disorder
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ADHD: EtiologyADHD: Etiology• Prenatal and perinatal:
– Exposure to drugs, smoking and alcohol in utero(3/10)
– Low birth weight(3/10)– Parental ADHD(8/10)– Maternal age at birth(1/10)
• Environmental:– Lead toxicity– Low SES– Medications: anti- seizure and asthma treatment
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ADHD: EtiologyADHD: Etiology
• Genetic– Monozygotic twins are more concordant than
dizygotic twins– ADHD heritability factor is 0.75-0.91– Candidate genes: 7-repeat allele of
D4dopamine receptor gene is present in 50-60% of ADHD population compared to 30% in general population
– ADHD is common in first degree relatives
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ADHD: EtiologyADHD: Etiology• Model of executive function:
– Response inhibition: controls verbal and motor impulses
– Nonverbal working memory: sense of self in relation to past & future
– Verbal working memory: self questioning and description. Using language to rule conduct
– Self regulation of emotions and behavior– Reconstitution: analysis of past experience to
formulate new responses that help us achieve our goals
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ADHD: EtiologyADHD: Etiology
• Neurological:– Less active prefrontal cortex affects memory
and response inhibition– Anterior cingulate gyrus dysfunction affects
cognition– SPECT studies show increase binding at
dopamine transporter protein
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ADHD: Areas of ImpairmentADHD: Areas of Impairment
• Performance limitations– Academic difficulty in school (25% repeat a grade)– Lower level of occupational advancement
• Socialization– Children are stigmatized by their behavior– Adolescents demonstrate social problems
• Few friends• Poor participation in group activities• Vulnerable to drug abuse and antisocial groups• Increased MVA
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ADHD: Effect on ParentsADHD: Effect on Parents
• Increased stress– Worry -Anxiety– Frustration -Anger
• Lower self esteem– Self blame -depression– social isolation
• Disruption of employment • Increased marital discord• Increased alcohol and substance abuse
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ADHD: Indicators of Impairment in ADHD: Indicators of Impairment in AdultsAdults
• Impairment– Occupational difficulty– Low self esteem– Poor parenting– Legal problems– Health concerns– Injuries– MVA, speeding tickets– Smoking– Substance abuse– Relationship problems
• Improvements– More efficient– Better organized– Enjoy social activities– Stable marriage– Improved parenting– Financial responsibility– Contain aggressive
impulses– Decrease THC
dependence
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ADHD: DiagnosisADHD: Diagnosis
• Clinical interview– History– Rating Scales– Collateral information/Impairment
• Physical evidence– PE -CPT– Lead level -Thyroid function
• Co-morbidity
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ADHD-DiagnosisADHD-DiagnosisA Community EffortA Community Effort
• History– Parents– Spouses/Partners– Day care providers– Teachers– Therapists– Primary care physicians– Social agencies (DHS; Juvenile Court)
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ADHD-DiagnosisADHD-DiagnosisA Community EffortA Community Effort
• Rating Scale: to corroborate clinical diagnosis– Conner's– ADHD-RS
• Clinical Interviews:– Determine impairment in school/home/job
settings– Make assessment for comorbid conditions– Physical exams and tests
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ADHD: TreatmentADHD: Treatment• Psycho-education
– Reframe– compromise
• Environmental restructuring– Lists, PDA, cell phones– Encourage ADHD friendly occupations and hobbies
• Psycho-pharmacology– FDA approved: Stimulants; Atomoxetine– Off-label: antidepressants; alpha-2 adrenergic
agonists
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Bibliotherapy for Adults with ADHDBibliotherapy for Adults with ADHD
• Books– Driven to distraction by Hallowell and Ratey– ADHD in Adulthood by Weiss, Trokenberg Hechtman
and Weiss
• Video– ADHD in Adults by Barkley
• Organizations– www.chadd.org– National Alliance for the Advancement of ADHD care
www.naaac.org
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ADHD: PsychopharmacologyADHD: Psychopharmacology
• Short term trials are recommended in the beginning
• Choice of medications is based on:– Duration– Co-morbidity– Target symptoms– Patient preference– Family history– Past medication history – Risk of abuse
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ADHD: PsychopharmacologyADHD: Psychopharmacology
• Address issues of non-compliance
• Monitor side effects including vital signs/Growth
• Measure progress by subjective report and rating scales
• Feedback loop:
Psychiatrist
PCPPatient
Parent/teacher
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Psychopharmacology-StimulantsPsychopharmacology-Stimulants
• Short acting – Ritalin, Methylin, Focalin– Dextrostat
• Medium acting– Adderall – Metadate
• Long acting– Concerta– Ritalin LA– Adderall XR– Vyvanse– Daytrana
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Psychopharmacology-StimulantsPsychopharmacology-Stimulants
• Adverse events– Anorexia, weight loss– Insomnia– Headaches– Stomach ache and vomiting– Stereotypy and tics– Increased pulse and BP– Growth?
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Psychopharmacology-StratteraPsychopharmacology-Strattera
• Mechanism of action– NE transporter blockade– Increase dopamine in prefrontal cortex
• No increase in nucleus accumbens• No increase in the striatum
• Adverse events– Decreased appetite– Somnolence– Dyspepsia– Elevation of pulse and BP– Sexual dysfunction
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PsychopharmacologyPsychopharmacology
• Antidepressants– Tricyclic antidepressants: Imipramine,
Desipramine– Wellbutrin
• Alpha2 agonists– Clonidine– Tenex
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ADHD-An integrated ApproachADHD-An integrated Approach
• Interdisciplinary Communication– PCP/Specialist/Parents/School/Therapist
• When to refer?– Comorbidity– Poor response– Polypharmacy
• Know the community resources.– School based services– Remedial counseling