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Volume 9 Number 8 2004

STANLEY P. KUTCHER, M.D., EDITOR

FOCUS

Adult Deficit Hyperactivity Disorder CONTENTS

Richard H. Weisler, MD Focus • Adult Attention Deficit Attention–deficit/hyperactivity disorder (ADHD)—characterized by devel- Hyperactivity Disorder 1 opmentally inappropriate degrees of impulsivity, hyperactivity, and inatten- tion—is one of the most prevalent chronic health conditions in children, af- fecting approximately 10% of school–age youth in the United States. Practitioner Pointer ADHD is a neurobehavioral disorder of childhood onset that frequently • Natural Course of persists into adolescence and adulthood, and although adult onset of ADHD Symptoms and Effect is not thought to occur, clinical presentation may not appear until adulthood. of Treatment 8 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) recognizes 3 subtypes of ADHD: predominantly inattentive, pre- dominantly hyperactive/impulsive, and combined. While hyperactivity and impulsivity may be relatively easy to identify in a child with ADHD, these SUPPLEMENT INCLUDED: symptoms tend to remit with age, leaving inattentive symptoms that may be More overlooked in adults with the disorder. Alternatively, adults may present with New Research inattentive symptoms that were not recognized in childhood or did not meet earlier diagnostic criteria that emphasized motoric symptoms. Consider a sample of 149 clinically referred adults with ADHD, of whom more than 90% reported inattentive symptoms to the clinician investigator. When diag- nosed using DSM–IV criteria, 56% of these patients met the diagnostic crite- ria for ADHD combined subtype, 37% for inattentive subtype, and only 2% met the criteria for hyperactive/impulsive subtype. This profile of ADHD subtypes differs dramatically from that typically observed in children with ADHD. Epidemiologic data collected during an update of the National Comorbidity Survey indicate that the prevalence of adult ADHD according Child & Adolescent Psychopharmacology News to DSM–IV criteria is 4.4% in the United States. As many as 9 million is an independent publication that accepts no advertising or other outside support.

CAPN • 1 adults in the US may therefore be af- whereas adulthood tasks involve or- EDITORIAL BOARD Stanley P. Kutcher, M.D., Editor fected by ADHD, making it an impor- ganization, future , Dalhousie University, tant public health problem consider- balancing competing demands, and Halifax, NS ing the negative impact on independent thinking. Failure to Normand Carrey Dalhousie University long–term social, emotional, aca- perform academically is the single Mina K. Dulcan demic, driving, and vocational out- most common reason for the initial Northwestern University Medical School, Chicago, IL comes. Feelings of social and aca- referral of children and adolescents Bruce Ferguson demic inadequacy and low with ADHD, and academic difficul- University of Toronto, Toronto, ON David Gardner self– that develop in child- ties may impact later academic Dalhousie University, hood are often carried through ado- achievement and occupational suc- Halifax, NS lescence and into adulthood, and cess in adulthood. Adults with Barbara Geller Washington University School of , some adults with ADHD describe an ADHD often have a history of poor St. Louis, MO awareness that they “just don’t seem job performance, academic Laurence Greenhill New York State Psychiatric Institute, to get it.” Adults with ADHD may be underachievement, and chronic New York, NY socially obtuse as well as impulsive, stress associated with a poor ability to Rachel G. Klein New York State Psychiatric Institute, and this translates into turbulent in- manage responsibilities that other New York, NY terpersonal relationships—both ro- adults take for granted. The restless- Lili Kopala Dalhousie University, Halifax, NS mantic and in the workplace. Results ness, distractibility, inattention, and James T. McCracken of a national survey of 500 adults impulsivity inherent to adult ADHD UCLA Neuropsychiatric Institute, Los Angeles, CA with ADHD and 501 age– and gen- underlie the typical functional im- Mark Riddle der–matched adults without ADHD pairments, such as John Hopkins Medical Institute, Baltimore, MD illustrate the life impairments associ- when facing complex tasks and the Neal Ryan University of Pittsburgh, Pittsburgh, PA ated with the disorder. Significantly inability to finish complicated pro- Jovan Simeon fewer adults with ADHD had at- jects. Yet many adults with ADHD University of Ottawa, Ottawa, ON tended college, twice as many had are able to channel the nov- Child & Adolescent Psychopharmacology News been divorced, and half as many were elty–seeking and intellec- (ISSN 1085-0295) is published eight per year (Feb, Mar, May, June, Aug, Sept, Nov, and Dec) by completely satisfied with their tual curiosity into high–energy, de- The Guilford Press, 72 Spring Street, New York, NY 10012. Periodicals postage paid at New York, NY, and professional life and career track. manding careers as physicians, at additional mailing offices. lawyers, stockbrokers, sales people, SUBSCRIPTION PRICE: Volume 9, 2004 (eight issues) Individuals $150.00 ($160.00, Canada and for- Neurobiology of Adult ADHD and entrepreneurs. eign) and Institutions, $225.00 ($235.00, Canada and foreign). Orders by MasterCard, VISA, or American Express can be placed by phone at 800-365-7006, Fax Although the neurobiologic basis of Adult ADHD: A Valid 212-966-6708, or E-mail [email protected]; in New ADHD has not been completely de- York, 212-431-9800. Payment must be made in U.S. Psychiatric Diagnosis? dollars through a U.S. bank. All prices quoted in U.S. fined, dysfunction of dopaminergic dollars. Pro forma invoices issued upon request. Visit our website at www.guilford.com. and noradrenergic pathways and ab- Faraone and colleagues reviewed the va- Guilford’s GST registration number: 137401014 CHANGE OF ADDRESS: Please inform publisher normalities in frontal networks or lidity of adult ADHD based on the at least six weeks prior to move. Enclose mailing label frontal–striatal dysfunction are premise that validity of any psychiatric with change of address. Claims for lost issues cannot be honored four months after mailing date. Duplicate among the factors implicated. It is diagnosis is derived from a pattern of copies cannot be sent to replace issues not delivered because of failure to notify publisher of change of ad- well established that the consistent data, with standard valida- dress. Postmaster: Send address changes to Child & Adolescent Psychopharmacology News, Guilford medications potentiate the actions of tion criteria including family history, Press, 72 Spring Street, New York, NY 10012. both and treatment response, laboratory studies, Photocopying of this newsletter is not permitted. Inquire for bulk rates. in the synapse. Neuropsychologic clinical course, and outcome. Clinical models of ADHD stress impairment symptoms of adult ADHD are not unlike

IMPORTANT NOTICE in executive function as a fundamen- those of children, though the intensity This publication is intended to provide accurate and tal deficit in ADHD. Impaired execu- of various symptoms may change with authoritative information regarding the subject matter covered. It is sold with the understanding that the pub- tive function includes deficits in age. Hyperactivity may not be problem- lisher is not engaged in rendering medical, psychologi- (verbal and nonver- atic in adults, but impulsivity, cal, financial, legal, or other professional services. The recommended doses of medications cited in bal), self–regulations (affect, motiva- distractibility, and restlessness can lead this newsletter are not meant to serve as a guide for prescribing of medications. tion, and arousal) and the ability to to significant impairments when jug- Physicians, please check the manufacturer’s product analyze behavior and synthesize novel gling the complexities of daily life. information sheet or the PHYSICIAN’S DESK REF- ERENCE for further information and contraindica- responses. As in children with ADHD, these tions. Childhood tasks typically require functional impairments occur in multi- Copyright © 2004 by The Guilford Press simple responses to the specific de- ple domains, often including poor edu- Printed in the United States of America mands of parents or teachers, cational performance, occupational

CAPN • 2 problems, and relationship difficulties. academic and test records that provide sion of a patients’ clinical history. A Adults with ADHD have increased support for an ADHD diagnosis that survey of primary care and rates of mood, anxiety, substance use, was frequently missed. practices revealed that more than 90% and antisocial personality disorders. The reliability and validity of of adults with undiagnosed ADHD were The validity of ADHD is strongly sup- self–ratings of symptoms associated self–referred in both practice settings ported by family studies, which have with other types of psychiatric diagno- and more than 50% of previously demonstrated that adult relatives of ses have been demonstrated, and the undiagnosed adults had complained ADHD children are at increased risk same is true for adult ADHD. Studies about ADHD symptoms to other health for ADHD as are the child relatives of have shown that adults with ADHD professionals in the past, so a quick ADHD adults. Twin studies estimate can provide an accurate assessment of screening tool may be particularly useful the heritability of ADHD to be about their own behavior, and good correla- forthisdisorder. 0.70. This number means that about tions between subjects’ and informants’ A number of other commonly used 70% of the variance in phenotype can ratings have been demonstrated if the diagnostic and self–report rating scales be attributed to genetic rather than en- questionnaires contain reasonably spe- are available to assist the clinician vironmental factors. Prefrontal cific statements regarding past and with an accurate diagnosis of adult dopaminergic has been present behavior. ADHD. The Brown ADD Scale is a demonstrated in both children and Most primary care physicians and psy- 40–item frequency scale completed by adults with ADHD, and the profile of chiatrists have not been trained to diag- patients that explores the executive neuropsychologic deficits in adults par- nose or treat adult ADHD. A survey of function aspects of that are allels that of children, with impair- 400 primary care physicians (all of associated with ADHD. A more thor- ments in vigilance, motoric inhibition, whom treated at least 30 patients per ough Brown ADD Scale Diagnostic , and verbal learn- week with any combination of ADHD, Form is also available and can be used ing and working memory. In addition, , , generalized for diagnosing ADHD. Both the clini- the response rate of stimulant–treated , or obsessive compul- cian–rated and self–report Brown adults with ADHD is similar to that of sive disorder) revealed that 48% did not ADD Scales have been validated and stimulant–treated children with feel confident diagnosing ADHD in are available from The Psychological ADHD. Thus, available evidence adults. The survey was conducted in Corporation (San Antonio, TX). The substantiates adult ADHD as a valid conjunction with Lenard Adler, MD, Conners’ Adult ADHD Diagnostic In- psychiatric diagnosis. and the Adult ADHD Program at the terview for DSM–IV surveys the pres- New York University School of Medi- ence of the 18 DSM–IV ADHD symp- Diagnosis of Adult ADHD cine. Only 34% of respondents reported toms. The screening version of the being “very knowledgeable” or “ex- Conners’ Adult ADHD Rating Scale DSM–IV and Diagnostic Rating tremely knowledgeable” about adult (CAARS) is a 30–item frequency Scales ADHD; by contrast, 92% of respondents scale completed by patients that in- said the same for depression. The survey cludes the 18 items outlined in the Adult ADHD can be reliably diagnosed results indicated that lack of clinical in- DSM–IV. (The clinician–adminis- using the DSM–IV criteria, which in- struction in the diagnosis and treatment tered and self–report versions of the cludes the following key aspects of the of adult ADHD and lack of a screening CAARS have been validated and are diagnosis: 1) current symptoms, includ- tool for adult ADHD are barriers to ap- available through Multi–Health Sys- ing at least 6 of 9 symptoms for one of propriate diagnosis of the disorder in tems, Inc., North Tonawanda, NY.) the three ADHD subtypes (combined, adults. Adler and colleagues developed a The ADHD Rating Scale inattentive, or hyperactive/impulsive), new symptom assessment tool, an (ADHD–RS) is an 18–item scale 2) childhood–onset of symptoms, 3) 18–item Adult ADHD Self–Report based on the DSM–IV criteria (avail- persistent symptoms (ie, at least 6 Scale (ASRS) Symptom Checklist able through Guilford Publications, months or longer), and 4) at least 2 do- (available at http://www.med.nyu.edu/ Inc., NY). The ADHD–RS was devel- mains of impairment (ie, work, home, Psych/training/ adhdscreen18.pdf) to oped and standardized as a rating scale social life). Because obtaining informa- assist physicians in evaluating ADHD for children, but clinician–raters can tion from a parent or employer may be symptoms in adult patients. The ASRS be trained to use this scale for adults. problematic, clinicians usually must is based on the 18 items of the DSM–IV Adult–specific prompts have been de- rely on the subject’s accurate account of and was validated in a well–character- veloped by Adler and colleagues for current symptoms and recollection of ized adult ADHD population, and can use with the ADHD–RS. The clini- childhood symptoms. It is often possi- be completed and scored quickly and cian–rated versions of these rating ble for patients to obtain copies of their used to initiate a more thorough discus- elementary, middle, and high school

CAPN • 3 scales also can be used to monitor economic impact of ADHD and treatment of ADHD with stimulant treatment effectiveness over . associated comorbidities in adults is medications provides against the needed. development of SUDs. Adult ADHD and Psychiatric Comorbidity Adult ADHD and Substance Use Treatment of Adult ADHD Disorders Psychiatric comorbidity is quite com- Appropriate pharmacotherapeutic in- mon with ADHD, and may affect as There has been much concern over tervention early in the course of the many as 3 in 4 patients. Mood disor- stimulant exposure potentially lead- disorder may improve academic and ders, including major depression, ing to substance use disorders social outcomes and limit the psychi- dysthymia, and bipolar disorder are (SUDs), yet adults with ADHD sel- atric and interpersonal complications comorbid with ADHD in 19% to 37% dom seek and rarely abuse associated with ADHD. In children of patients. Comorbid anxiety may be them. In fact, untreated ADHD is a and adolescents with ADHD, the re- present in 25% to 50% of adults with significant risk factor for SUDs (even sponse to stimulant medications is ro- ADHD. Determination of whether after correcting for other factors, bust—a response rate of 70% has been the primary diagnosis is ADHD versus such as socioeconomic status and documented for both immediate–re- depression or anxiety is difficult when ). Substance use dis- lease and patients present with anxiety, depres- orders are often comorbid with formulations. When sive symptoms, conflicts at work or ADHD; for example, the lifetime adults with ADHD are dosed appropri- home, or even . Be- prevalence rate of alcohol depend- ately with stimulant medications in cause of the symptom overlap be- ence in adults with ADHD is approx- controlled studies, the response rate is tween the mood–regulating symp- imately 20% for women and 35% for similar to that observed in children. toms of ADHD and the symptoms of men. Many individuals with un- Spencer and colleagues were the first anxiety and mood disorders, clini- treated ADHD may self–medicate in to demonstrate that adequate doses of cians are likely to treat the presenting an attempt to improve adaptive func- stimulant medications in adults with symptoms of depression or anxiety but tioning. For example, children with ADHD led to a good response. In two the ADHD is often undiagnosed. In ADHD start smoking much earlier small, –controlled, crossover the adult patient who is than their peers, and adult patients studies, response rates of 70% were ob- nonresponsive to medications for de- withADHDaremorelikelytosmoke served using 1.0 mg/kg/d of pression or anxiety, ADHD may be and have more difficulty in quitting. methylphenidate or 0.9 mg/kg/d of present but unrecognized. For exam- The subjective and behavioral ef- mixed amphetamine salts ple, in a patient who is unresponsive fects of may improve con- (®). Although the response to selective inhib- centration and increase alertness and to stimulants was dramatic in both itors for a diagnosis of depression, a arousal in these patients. Well–con- studies, immediate–release stimulant longitudinal history maybe helpful in trolled, longitudinal studies suggest formulations were used. assigning the symptoms to the appro- that pharmacologic treatment for Adults with ADHD, who may be im- priate diagnosis— ADHD symptoms ADHD significantly lowers the risk pulsive, forgetful, and disorganized, are tend to persist throughout the life- for SUD in the high–risk, mid–ado- likely to benefit from once–daily for- span and are less episodic than those lescent age group that experiment mulations of stimulant medications. A of comorbid mood or anxiety disor- with illicit . A longitudinal variety of extended–release stimulant ders. Administration of the Hamilton study of adolescent boys with ADHD medications are available, including Anxiety Scale (HAM–A), the Ham- revealed that pharmacotherapy of Adderall XR®, a novel, extended–re- ilton Depression Scale (HAM–D), or ADHD was associated with an 85% lease capsule formulation of mixed am- the Beck Depression Inventory in ad- reduction in risk for SUD in ADHD phetamine salts in which 50% of the dition to an ADHD symptom rating youth, and a recent meta–analysis of dose is formulated as immediate–re- scale may be required to determine if all long–term studies that examined lease pellets and 50% as delayed–re- ADHD is the primary problem and SUD outcomes among pharmacolog- lease pellets; Ritalin LA®, a long–act- the other disorders are comorbid. Di- ically treated and untreated youths ing methylphenidate formulation with rect medical costs (eg, inpatient, out- with ADHD revealed a 2–fold reduc- a bimodal release profile that simulates patient, and prescription costs) tion in risk for drug and alcohol use twice–daily dosing; Concerta®, an for adults with ADHD are approxi- disorders in stimulant–treated OROS® delivery system that provides mately double that of age– and gen- youths with ADHD. These studies an initial bolus of methylphenidate fol- der–matched adults without ADHD. provide substantial evidence docu- lowed by a controlled rate of release; Further study of the full medical and menting the protective effect that Metadate® CD, in which 30% of the

CAPN • 4 administered methylphenidate dose is greater reduction in symptoms while re- cardiovascular risks. During both released immediately and 70% of the ceiving Adderall XR 60 mg. In a short–term and long–term Adderall dose is formulated for extended release; long–term, open–label extension study XR treatment, mean changes in systolic and Focalin® XR, and extended–re- of Adderall XR, 16% of participants (2–3 mm Hg) and diastolic blood lease formulation of dexmethyl- were receiving Adderall XR 20 mg/d, pressures (1 mm Hg) were small in phenidate. Long–acting stimulant for- 37% were receiving 40 mg/d, and 47% magnitude. mulations are associated with improved were receiving 60 mg/d after up to 18 medication compliance and the phar- months of treatment. Studies of other Nonstimulant Medications for maceutical properties of stimulant medications in adults with Adult ADHD extended–release stimulant formu- ADHD also indicate that higher doses lations may prevent abuse of these may be required for optimal effective- The study of nonstimulant medication medications. ness in adolescents and adults with treatment options for adult ADHD is ADHD. In a community assessment an active area of research. Strattera® Adderall XR for Adult ADHD study of 264 adolescents and 136 adults () is a selective treated with Concerta for 9 months, norepinephrine reuptake inhibitor In the largest adult ADHD stimulant Stein and colleagues reported that 11% (SNRI) that reduces ADHD symp- study to date, treatment with of subjects withdrew due to lack of effi- toms in adults with ADHD and was re- once–daily Adderall XR 20, 40, and cacy at the highest dose (54 mg/d), sug- cently approved for this indication by 60 mg led to significant, positive clin- gesting that higher stimulant doses may the US FDA, but the effect is less ro- ical responses in adults with ADHD. be necessary. In a long–term, open–la- bust than that of stimulant medica- At least a 30% decrease in bel extension of Focalin XR (effective tions. In 515 adults with ADHD who ADHD–RS scores occurred in 74% of at half the dose of racemic participated in two randomized, dou- patients receiving Adderall XR 20 methylphenidate), approximately 25% ble–blind, placebo–controlled, mg, 80% of patients receiving 40 mg, of subjects in the study were receiving a 10–week studies of Strattera, the effect and 82% of patients receiving 60 mg. mean daily dose of >20 mg, 38% were sizes were 0.35 and 0.4. A long–term Baseline symptom severity was similar receiving 20 to 30 mg/d, and 38% were study of Strattera adults with ADHD for both men and women and symp- receiving >30 mg/d. The distribution of indicated continued effectiveness for tom reduction (decrease of 13–14 stimulant doses in these long–term, up to 2 years. The initial dose was 50 unit points on the ADHD–RS) was open–label studies of adults with mg/d and the dose could be increased similar for both groups. Based on ADHD is likely to be representative of up to 160 mg/d based on CAARS:Self–report scores, the mag- real–world clinical practice. and efficacy. At endpoint, the most nitude of ADHD symptom improve- The most common associ- common doses were Strattera 50 mg/d ment was similar 4 hours and ated with stimulant medications in (16% of participants), 80 mg/d (23%), 12 hours after a single morning dose adults with ADHD include dry mouth, 120 mg/d (51%), and 160 mg/d (7%). of Adderall XR. These results suggest < decreased appetite, insomnia, and For adults receiving 100 mg/d, ap- that Adderall XR provides significant headache. In the Adderall XR and proximately 40% experienced a reduc- symptom relief throughout the day > Focalin XR studies of adults, side effects tion of 30% on the CAARS, and of and into the evening hours for adults > were typically mild and not dose–re- those receiving 100 mg/d, 50% expe- with ADHD. Adderall XR is the first lated. Stimulant–associated side effects rienced this level of symptom reduc- stimulant medication to receive US tend to diminish over time. In the tion. Of the 384 patients who enrolled Food and Drug Administration long–term Adderall XR study, 84% of in the long–term Strattera study, 25% (FDA) approval to treat adult adults reported a side effect during the withdrew because of lack of efficacy. ADHD. first month of treatment compared with Themostcommonsideeffectsre- Optimal results (ie, greater reduction 33% during the second month and only ported during long–term Strattera in target symptoms for an individual pa- 10% at month 5 and beyond. Less than treatment were dry mouth, headache, tient) may be observed at higher doses 6% of participants reported that side ef- insomnia, and erectile dysfunction; of stimulant medications. In the adult fects outweighed the beneficial effects side effects led 11% of adults to Adderall XR study, adults with mild of treatment with Adderall XR. The withdraw from the study. ADHD symptoms (ADHD–RS base- use of stimulant medications in the Other nonstimulant medications line score <32) had significantly greater treatment of adults with ADHD ap- that have been studied for the treat- reduction in symptoms while receiving pears to be quite safe from a cardiovas- ment of adult ADHD include tricyclic Adderall XR 20 mg, while adults with cular perspective, although amphet- , , and severe ADHD symptoms (ADHD–RS amine abuse and misuse may pose venlafaxine; however, the efficacy and baseline score <32) had significantly safety of these medications for adult

CAPN • 5 ADHD are less well defined than the and anxiety. A combination of cogni- with ADHD and ultimately improve safety and efficacy of stimulants be- tive strategies and behavioral self–efficacy, educational attainment, cause the nonstimulant studies have management principles can help pa- work performance, and social compe- typically included a small number of tients learn to organize, prioritize, and tence. If the spouse, family, and boss subjects treated for a short period of accomplish various tasks. Learning to are aware that the patient’s symptoms time. A larger (N =162) short–term, establish realistic timelines for and problems are due to ADHD, they placebo–controlled, optimal–dose long–term and completing the may be more supportive and study of Wellbutrin XL® demonstrated smaller steps needed to achieve these accommodating. a medication effect size of 0.6 in adults goals is an important cognitive tech- with ADHD, and 50% of patients nique that counselors may use for pa- achieved a decrease of >30% in tients with ADHD. Accommodations ADHD–RS total scores. Other medica- in the workplace also may be helpful, Mark Dillon was a 27–year–old student tions currently in clinical development for example, using white noise to when a college instructor pointed out for the treatment of ADHD include a block distractions or limiting inter- the discrepancy between the quality of methylphenidate patch, a nicotinic an- ruptions from phone calls or e–mails. his written homework and his class alogue, a glutamate AMPA Diligent use of a daily planner, work. Mark’s homework assignments modulator, and a chemically novel whether paper or digital, is helpful for were completed accurately and submit- inhibitor of dopamine and any adult in the fast–paced environ- ted on time, but the instructor noticed norepinephrine reuptake. ment that is modern–day life, but for that he was a slow learner and too de- the adult with ADHD, a daily plan- pendent on other classmates for help Psychosocial Treatment ning ritual may be crucial to success in during class. In addition, Mark’s low Strategies for Adult ADHD both their personal and career envi- test scores did not reflect the quality of ronment. Educational resources for his written assignments. The instructor Though ADHD is a neurobiologic dis- ADHD may help adults attain a suggested that he see a counselor at the order and symptoms tend to improve of control instead of feeling helpless university’s health services center. considerably with pharmacologic treat- and frustrated. Support groups are Mark was then referred to a ment, most adults with ADHD will available locally and nationally. for a complete evaluation. benefit from supportive therapies to Some adults may benefit from One of the DSM–IV criteria for a di- cope with day–to–day issues. Psycho- personal , and there are agnosis of adult ADHD is onset of logical therapies for adults with ADHD many personal coaches who specialize symptoms before age seven years. As include counseling, learning to use be- in coaching adults with ADHD. part of the diagnostic evaluation, havior management principles and Mark’s psychiatrist completed a thor- cognitive strategies, improving organi- Conclusion ough history, including documenta- zation skills, and implementing aca- tion of behavior and academic perfor- demic or vocational accommodations. The vast majority of adults with mance as a child and adolescent. In Individual counseling may help the pa- ADHD have never been diagnosed or elementary and middle school, Mark’s tient examine and understand existing treated, and as such adult ADHD is a academic performance bounced coping strategies and determine what major public health problem because around between that of a mediocre and methods are working and where there is of the significant consequences. Ap- a good student. “I would watch Tom a need for improvement. propriate screening for adult ADHD and Jerry and Woody Woodpecker car- Therapists can teach the adult pa- may help identify those patients who toons while doing my homework and tient the communication skills neces- might benefit from a thorough diag- didn’t get much done.” He talked and sary to improve the important rela- nostic evaluation. If DSM–IV diagnos- joked in class and was frequently writ- tionships in their life, and family or tic criteria for adult ADHD are met, ten up for bad behavior. “I would not marital counseling also may be useful. discussion of medication options and give my parents the written warnings Behavior management principles, psychosocial interventions can begin. from the teachers, and invariably the such as a reward and punishment sys- This may include referrals to other teacher would call my house and I’d be tem, can help patients learn self–rein- health professionals as appropriate, as punished.” Despite being punished, forcement skills. Cognitive therapy well as provision of information re- Mark said, “My behavior did not can be particularly effective for pa- garding support groups and other edu- change. I was always quick tempered tients who have developed distorted cational resources. The self–awareness and distractible. I would say the wrong beliefs about themselves as a result of gained through a diagnosis of adult thing or do the wrong thing and it chronic ADHD symptoms, especially ADHD may diminish frustration and made it hard for me to have real if these beliefs have led to depression embarrassment for the adult patient friends.” In high school, Mark was def-

CAPN • 6 initely known as the class clown. He and a 10–pound weight loss. At 186 cm to progress and success in his academic was in the 50th percentile of his gradu- (6’1”) and 96.4 kg (212 lb), Mark’s body career and personal life. Now, as a ju- ating class and had a 2.7 GPA at a non- mass index (BMI) was 28 kg/m2 when nior, his GPA is 3.8. “I went from think- competitive high school. Looking he enrolled in the study; he weighed ing I was almost retarded and needing back, Mark says “My parents and 91.8 kg (202 lb) 4 weeks later. This to drop out of college to thinking I had a teachers were so frustrated with me, amount of weight loss was not problem- lot of academic opportunities. Now, I they were just glad that I graduated atic given that his physician had previ- look forward to what the future will from high school.” ously suggested that he lose 25 pounds bring.” Mark’s GPA was 1.8 and he was on to attain a BMI <25 kg/m2. Mark also academic probation in his sophomore experienced mild emotional lability at Address correspondence to Richard H. year of college when he was first re- 40 mg/d, but this did not require any Weisler, MD, 700 Spring Forest Rd., Suite ferred to the psychiatrist, who, after dose adjustment or any intervention. 125, Raleigh, NC 27609; E–mail: confirming a diagnosis of ADHD, gave Like other side effects typically associ- [email protected] Mark the option of enrolling in the ated with the stimulant class of medica- short–term, placebo–controlled study tions, appetite suppression and weight Suggested Reading of Adderall XR. At study baseline, loss diminish over time, much to the Biederman, J, Faraone, S.V., Monuteaux, M.C., Mark’s ADHD–RS total score was 34 dismay of some adult patients. In clini- Bober, M., & Cadogen, E. (2004). Gender ef- (20 on the inattentive subscale and 14 cal studies of Adderall XR in children, fects on attention–deficit/hyperactivity disor- on the hyperactive/impulsive adolescents, and adults, average der in adults, revisited. ;55, 692–700. subscale). At week 1, his ADHD–RS changes in blood pressure and heart Faraone, S.V., Biederman, J., Spencer, T., et al. total score was 22, and at week 3, it was rate were small and not clinically im- (2000). Attention–deficit/hyperactivity dis- 18. Test scores on his academic portant. Mark’s BP was 128/84 mm Hg order in adults: An overview Biological Psychi- atry, 48 , 9–20. coursework started to improve shortly at baseline and 126/82 at the end of the Faraone, S.V., Spencer, T.J., Montano, B., & after starting the study. After the 4–week study and has remained stable Biederman, J. (2004). Attention–deficit/hy- 4–week study was complete and sub- during long–term Adderall XR treat- peractivity disorder in adults. A survey of cur- jects’ doses were unblinded, it was re- ment. Mark’s HAM–D and HAM–A rent practice in psychiatry and primary care. Archives of Internal Medicine, 164, vealed that Mark had been randomized scores were 5 and 15 at baseline and did 1221–1226. to receive Adderall XR 40 mg/d; his not change much during the course of DuPaul, G.J., Power, T.J., Anastopoulos, A.D., ADHD–RS total score was 18 at study the short–term study or during Reid, R. (1998). ADHD Rating Scale-IV: Checklists, Norms, and Clinical Interpretation. endpoint. At that time, Mark and his subsequent treatment. New York: Guilford Press. psychiatrist decided to continue treat- By the end of the semester (after two Kessler, R.C., Adler, L., Ames, M., et al. The ment with Adderall XR and increase months on Adderall XR 40 mg/d), World Health Organization Adult ADHD Self–report Scale (ASRS): A short screening his dose to 60 mg/d to determine if a Mark had a 2–letter grade improve- scale for use in the general population. Psycho- higher dose might further improve his ment in almost all of his courses. He logical Medicine ,In press. ADHD symptoms. However, Mark re- also said that he felt much more at ease Wilens, T.E., Faraone, S.V., Biederman, J., & ported feeling impatient at times while socially. Mark continues to work with a Gunawardene, S. (2003). Does stimulant therapy of attention–deficit/hyperactivity dis- taking 60 mg, and it was decided that coach that he met through a local order beget later substance abuse? A meta–an- his optimal dose was 40 mg/d based on ADHD support group. The coaching alytic review of the literature. Pediatrics, 111, ADHD–RS scores and overall process nurtures personal awareness 179–185. Wilens, T.E.(2003). Drug therapy for adults with tolerability. and responsibility. By focusing on exec- attention–deficit/hyperactivity disorder. Mark did experience mild side effects utive functioning skills (eg, planning, Drugs, 63, 2395–2411. while taking Adderall XR, including prioritizing, and analyzing), the coach dry mouth, a slight decrease in appetite, helps Mark develop strategies that lead

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CAPN • 7