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Treatment of ADHD

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Treatment of ADHD Kirstyn Kameg, DNP, PMHNP, BC Robert Morris University University Professor Objectives Describe the neurobiology implicated in the etiology of ADHD Identify the DSM-5 criteria for ADHD with an emphasis on making the diagnosis in adults Identify differences in clinical presentation of ADHD between children and adults Select appropriate rating scales to screen for ADHD in adults Identify common comorbid conditions seen in patients diagnosed with ADHD Identify pharmacologic and nonpharmacologic treatment options for ADHD ADHD Is NOT Outgrown Prevalence of ADHD 4-5% of adult US population 3.4% worldwide prevalence 1.6:1 in adults (males to females) Only 1 in 10 adults with ADHD is being treated for it; only 1 in 4 are receiving any treatment for a mental disorder Fayyad, et al. (2007) Cross national prevalence and correlates of adult attention deficit hyperactivity disorder. British Journal of Psychiatry, 190, 402-409, De Graff, et al. (2008) The prevalence and effects of adult attention- deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occupational and Environmental Medicine, 65(12), 835-842. Neurobiology of ADHD ADHD is a brain-based d/o which impacts the PFC Hyperactivity is linked to the motor cortex/prefrontal motor cortex Impulsivity is linked to the orbital frontal cortex Sustained attention and problem solving are linked to the dorsolateral prefrontal cortex Selective attention is linked to the dorsal anterior cingulate cortex Arousal and ADHD Deficient arousal Individuals in a state of hypoarousal may experience inattention, cognitive dysfunction, sleepiness, and impulsivity Assoc with low tonic Da and NE firing Hyperactivity may result from an effort to combat the state of hypoarousal Meds that enhance Da and NE can increase the efficiency of information processing in the PFC and improve the sx of ADHD Arousal and ADHD (cont) Deficient arousal (cont) Pts with ADHD may also experience inefficient information processing during cognitive tasks Unable to selectively attend to a task secondary to failure to activate the ACC Meds that agonize Da 1 and/or alpha 2A adrenergic receptors allow activation of the ACC and thus pts are able to perform tasks accurately Arousal and ADHD (cont) Deficient arousal (cont) Pyramidal neurons in the PFC are “out of tune” and unable to distinguish important signals from unimportant noise Individuals are unable to focus on one thing as all the signals are the same Enhancing Da and NE neurotransmission can improve the signal-to-noise ratio and relieve these sx Arousal and ADHD (cont) Excessive arousal Some pts with ADHD have excessive arousal and can have the same sx as pts with deficient arousal PFC is “out of tune” Hyperarousal is assoc with chronic stress and may be linked to comorbidities such as anxiety, bipolar d/o, and SA Assoc with phasic firing of Da and NE Need to treat by desensitizing Da and NE receptors and steadily downregulate neuronal activity in order to reestablish normal Da and NE firing NET inhibitors and alpha 2 adrenergic agonists seem to desensitize excessive arousal sx May also help with treating comorbid anxiety and mood states assoc with ADHD Changes from DSM-IV to DSM-5 ADHD Examples have been added to the criterion items to facilitate application across the life span The onset criterion has been changed from before age 7 to 12 A comorbid diagnosis with ASD is now allowed For adults—5 symptoms instead of 6 Moved from subtypes to “presentations” DSM-5 Criteria 5/9 Inattentive Symptoms Often: Fails to give close attention to details Difficulty sustaining attention Does not seem to listen Does not follow through on instructions Difficulty organizing tasks or activities Avoids tasks requiring sustained mental effort Loses things necessary for tasks Easily distracted Forgetful in daily activities DSM-5 Criteria 5/9 Hyperactive Impulsive Symptoms Often: Fidgets with hands or feet or squirms in seat Leaves seat in classroom inappropriately Runs about or climbs excessively Has difficulty playing quietly Is “on the go” or “driven by a motor” Talks excessively Blurts out answers before questions are completed Has difficulty waiting turn Interrupts or intrudes on others Additional Criteria Developmentally inappropriate symptoms 5 symptoms from either symptom list Parenthetical clarifications for adults (untested) Childhood onset Presence of symptoms prior to age 12 Treat as being flexible; Barkley, R.A. (2016) recommends age 16 Cross-setting occurrence of symptoms Significant impairment Corroboration of self-report through others Exclusion of other disorders DSM-5 Problems for Adults Inattention list needs to be renamed or broadened Needs to include executive functioning, specifically working memory Too many hyperactive symptoms; not enough of poor inhibition/impulsiveness Symptoms are not developmentally specific Developed for children; need more appropriate items for adults (see next slide) Cutoffs are not developmentally referenced May have to adjust thresholds downward if >16 years to 4 symptoms per list Age of onset of 12 misses 7-10% of eligible adults; recall is highly unreliable Best New Symptoms for Adults 1. Often easily distracted by extraneous stimuli (DSM) 2. Often makes decisions impulsively (EF) 3. Often have difficulty stopping my activities or behavior when I should do so (EF) 4. Often start a project or task without reading or listening to the directions closely (EF) 5. Often show poor follow through on promises or commitments I may make to others (EF) 6. Often have trouble doing things in their proper order or sequence (EF) Best New Symptoms for Adults (cont) 7. Often more likely to drive a motor vehicle much faster than others (EF) For non-drivers, substitute, often have difficulty engaging in leisure activities or doing fun things quietly 8. Often has difficulty sustaining attention in tasks or play activities (DSM) 9. Often has difficulty organizing tasks and activities (DSM) Cutoff would be either 4 of first 7 or 6 of all 9 symptoms Age of onset: childhood-to-adolescence (<16 years) Barkley, R.A. Presented at 5th Annual Conference on ADHD and Executive Dysfunction, Pittsburgh, PA, September 23, 2016 Review of Executive Functions (EF) EFs make possible: Mentally playing with ideas Taking the time to think before acting Meeting novel, unanticipated challenges Resisting temptations Staying focused 90-98% of ADHD adults have EF deficits in daily life 35% or fewer of adults with ADHD have deficits on neuropsychological tests of EF The 5 EFs in Daily Life Activities Self-restraint (inhibition) Cognitive, behavioral, verbal, emotional Self-management of time Consideration of past and future consequences before acting; managing self relative to time and deadlines Self-organization and problem solving Innovating, planning possible response options, rapid assembly and performance of novel goal-directed behavior Self-motivation Substituting positive goal-supporting emotions for negative goal-destructive ones Self-regulation of emotions Impairment in Adult ADHD In clinical as well as epidemiological samples compared to NCs: Learning problems (60%) Less graduated Lower education Lower income Less employed, more sickness leave More job changes (longest job 5 yrs) More often arrested, divorced and more social problems More driving accidents, teenage pregnancies, suicide attempts Higher (mental) health care costs Adult ADHD & Comorbidities Any anxiety disorder (47%) Any mood disorder (38%) Impulse control disorder (20%) Any substance use disorders ( 15%) Symptoms of ADHD may be concealed by the more robust symptoms of these co-occurring conditions Kessler, R.C. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163(4), 716–723. Differential Diagnoses to Consider Anxiety disorders MDD Bipolar disorder Overlapping sx of poor focus, hyperactivity, impulsivity, and irritability Presence of elation, flight of ideas/racing thoughts, grandiosity, hypersexuality, and decreased need for sleep provide the best discrimination between ADHD and BP Comprehensive Evaluation Psychiatric comorbidities Rule out potential organic D&A history etiologies Childhood and Sleep disorders; developmental history nutritional deficiencies (iron, vitamin B12, vitamin Prior assessments and D); seizure disorders; treatment thyroid dysfunction School records Cardiac history; narrow Third party report angle glaucoma; tic Obtain evidence of a disorders; recent use of chronic course of illness sympathomimetic agents without periods of remission ADHD Rating Scales for Adults Adult ADHD Self-Report Scale (ASRS) Barkley Adult ADHD Rating Scale (BAARS) Brown ADD Rating Scale for Adults Conner’s Adult ADHD Rating Scale (CAARS)-self and other Adult ADHD Self-Report Scale 18-items that reflect adult manifestations of ADHD Adopted by the WHO Available online First 6 questions correlate highly with a dx of ADHD 4/6 in shaded areas High suspicion of ADHD Most reliable with limited psych comorbidity Treatment for Adult ADHD Generally, the same medications used for children have the same therapeutic effect in adults Clinical effectiveness is sometimes less Psych comorbidities need to be considered Dose at the higher end of the FDA approved range Patients tend to use
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