Attention Deficit Hyperactivity Disorder : Challenges Across the Lifespan

ADHD Specialists Richard Ferman, MD

Speaker Background
Founder and Medical Director of ADHD Specialists Child, Adolescent, and Adult Psychiatrist A graduate of University of California, Los Angeles School of Medicine Completed Residency at Cedars-Sinai Medical Center, Los Angeles Fellowship in Child Psychiatry at Cedars Sinai Medical Center, Los Angeles

Attention Deficit Hyperactivity Disorder : Challenges Across the Lifespan

ADHD CME Module 1 Objectives

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 function

Bridging the Gap: Science & Real World ADHD Issues

Historically, health clinicians have done a poor job of connecting 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 from science and what we see the lives of people with ADHD and coexisting 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 the RULE and not the exception and they are age inappropriate.

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 strict DSM-IV diagnostic criteria for ADHD. (Wender, 1995) Outcome data suggest that anywhere from 5% to 75% still show significant levels of symptoms into adulthood, depending on who are used as informants and where the diagnostic cutoff point is set.
(Wender, 1995)

ADHD Worldwide

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).

DSM-IV TR 3 Subtypes Attention Deficit/Hyperactivity Disorder

Predominantly

hyperactive-impulsive type Predominantly inattentive type Combined type

ADHD: DSM-IV Criteria for Hyperactive-Impulsive Type

Impulsivity/Hyperactivity
Six or more of the following - manifested often:

Impulsivity
Blurts out answer before question is finished Difficulty awaiting turn Interrupts or intrudes on others

Hyperactivity
Fidgets Unable to stay seated Inappropriate running, climbing (restlessness) Difficulty in engaging in leisure activities quietly On the go Talks excessively

(American Psychiatric Association. DSM-IV, 2000.)

ADHD: DSM-IV Criteria for Predominantly Inattentive Type

Inattention
Six or more of the following - manifested often:
Inattention to details/ makes careless mistakes Difficulty sustaining attention Loses things Seems not to listen Easily distracted Fails to finish tasks Forgetful
(American Psychiatric Association. DSM-IV, 2000.)

Difficulty organizing Avoids tasks requiring sustained attention

Hyperactivity Inattention

T I M E

(Kordon, Kahl, & Wahl, 2006)

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)

ADHD Sx morph into Executive Function Deficits (impulsivity/inhibition problems)

Other terms for Executive Functions

Self-reflection Self-control Planning & Forethought Delay of Gratification Future oriented Working memory Planning Affect Regulation Resistance to Distraction

(Wasserstien, 2005)

Impairments & Limitations in Executive Functions appear in Adults.

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)

 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

ADHD and Lifespan Risks: Untreated ADHD

200% to 300% more risk of substance abuse, car accidents/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)

The story of Sherry

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%)

Limited diversity with Gender, Language, Culture Limitations:

ADHD presents very differently in girls and in women, and it often 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)

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

ADHD is a distinct disorder; the impairments and the characteristics of ADHD are present in the absence of comorbid conditions.

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

Diagnostic Pitfalls
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

Focus on functional impairments

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)

3 Types of Functional Impairment

Overt:
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 to detail, forgetfulness. It sounds like without that support/structure you would really struggle

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

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

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

Questions & Answers

References