Managing attention deficit in adults in your office Nick Kates MB.BS FRCPC MCFP(hon) Chair, Dept. of Psychiatry, McMaster University Cross Appointment, Dept. of Family Medicine, McMaster University Quality Improvement Advisor, Hamilton Family Health Team No funding or support from Industry for any aspect of this presentation or my work Except my lifelong commitment to Self-referred - concerned about his mood Recent life stresses Inconsistent work and relationship history Met criteria for ADD + PHQ score was 14 Was also depressed – poor response to Buproprion Seen a year later – mood was brighter and wanted to start a stimulant Positive response to Methylphenidate Referral for assessment of Bipolar Affective Disorder Mood swings consistent with cyclothymia Consistent history of problems with attention, distractibility, academic underachievement Two diagnoses eventually established Some overall improvement with Lithium Reluctant to start Ritalin 6 - 9 % of all children 25-78% continue to have problems as adults 4-5% of all adults Could be third most prevalent psychiatric disorder ? 50 – 60 adults in an average family practice Democratic Male : female 2:1 ◦ Self-perception Changing prevalence with age 70 adults in your practice 20% of mothers, 25-30% of fathers have ADHD 20-45% co-morbid depression (genetic link) 25% have alcohol and drug problems 0-27% Bipolar affective disorders (one way co-morbidity) 10-40% have anxiety disorders Significant increases in incarceration rates Increased likelihood of being in an MVA Prenatal ◦ Drug use ◦ Alcohol ◦ Tobacco use ◦ Bleeding ◦ Prematurity ◦ Stress No evidence re diet Postnatal ◦ Head trauma ◦ Brain hypoxia ◦ Lead poisoning ◦ Streptococcal Bacterial Infection Triggers auto-immune antibody attack of basal ganglia No evidence re diet No credible social theory Prefrontal Cortex - 4 functions ◦ Working memory ◦ Self-regulation of affect / arousal ◦ Internalisation of speech ◦ Reconstitution - Behavioural analysis ◦ Self regulation ◦ Future directed ◦ self-control of emotions Dopaminergic and noradrenergic pathways Prevalence continues to decrease with age Adults more likely to “act in” than “act out” Sometimes can be adaptive Some individuals present when structure of home / school is removed Behaviour Description Anticipatory avoidance Magnifying difficulty of impending tasks and doubts of being able to complete task Procrastination Deadline-associated stress can help focus Pseudo efficiency Sense of productivity by completing several easy tasks while avoiding high-priority tasks Juggling Taking on new projects without completing those already started Key Symptoms Difficulty sustaining Difficulty sustaining attention in attention for homework, meetings, at work, home chores, etc. responsibilities Loses things Disorganized, poor time Appears to be not listening management Trouble with follow through Inefficient, procrastinate Easily distracted Trouble with follow through Daydreams Poor memory, forgetful Distracted Loses things Avoids tasks with mental effort Can’t stay in seat, Can’t sit through squirming, fidgeting, meetings (checking always on the go email, scribbling notes) Can’t wait turn, blurts out Impatient (hates answers waiting in lines), Can’t work or play quietly, runs, climbs excessively interrupts others Drives fast, likes active Intrudes and interrupts others jobs, always on the go Talks excessively Inner restlessness Restless Impatient Can’t wait turn, Doesn’t matter about blurts out answers consequences Intrudes and Makes inappropriate interrupts others comments (“no Quits school, gets mental filter”) into trouble with the Relationship and law marital difficulties Rushes into things Spends money Takes risks beyond means Accident prone Frequent job/career Impatient/interrupts changes Criteria ◦ Inattention ◦ Impulsive / hyperactivity ◦ Both 5 or more symptoms (was 6) Greater than 6 months Persistent and Maladaptive At least two domains ◦ Before the age of 12 (was 7) Avoiding tasks or jobs that require concentration Difficulty initiating tasks Difficulty organizing details required for a task Difficulty recalling details required for a task Poor time management, losing track of time Indecision and doubt Hesitation of execution Difficulty persevering or completing and following through on tasks Delayed stop and transition of concentration from one task to another Chooses highly active, stimulating jobs Avoids situations with low physical activity or sedentary work May choose to work long hours or two jobs Seeks constant activity Easily bored Impatient Intolerant and frustrated, easily irritated Impulsive, snap decisions and irresponsible behaviors Loses temper easily, angers quickly A tendency to act first and think after Present along a spectrum Symptoms improve with age ◦ ? Maturational process ◦ Learning new skills ◦ Developing adaptive compensatory mechanisms Presence doesn’t always require treatment Treatment decisions based upon extent to which it interferes with daily activities Screening Diagnosis based on behaviours only Symptoms along a spectrum Incidental finding Previous history often undocumented “Vogue” diagnosis – increasing self-detection Not diagnostic Self-Reports Point out areas for interventions May identify co-morbid problems ◦ ASRS ◦ Barkley Screener ◦ Weiss Functional Impairment Scale Assessment Concentration Lack of organisation Forgetful School / work performance Underachieving Relationship instability / conflict Impulsivity Family history Poor self-esteem Patients presenting with: Major Mood and Anxiety D/O (including poor response to treatment) Drug abuse or drug dependence Poor school performance as a child (not reaching potential) Frequent job changes or moving often Frequent driving infractions Higher number of accidents than average population Have you ever been diagnosed with ADHD? Do you have a family of ADHD (siblings, children, parents or extended family)? Did you have any difficulty in school? Did you daydream or have difficulty payment attention? Did you get your homework done on time? Were you disruptive? Anything positive – move to Step 2 Do you currently have substantial difficulties with forgetfulness, attention, impulsivity or restlessness that are interfering with your relationships or your success at work? Anything positive – move to Step 3 Complete ASRS and Complete Diagnostic Interview Symptoms Course / Time Frame School / work performance - underachieving Other mental health issues / diagnoses Family functioning Relationship history Legal history Drug use Family history History from family Family members can bring a different perspective Management Education Structure Behavioural management Maintaining self-esteem Family interventions Cognitive Behavioural Therapy Medication Information about the prevalence Information about the symptoms Reading materials Driven to Distraction Edward Hallowell and John Ratey Delivered from Distraction Edward Hallowell and John Ratey You mean I’m not lazy, crazy or stupid Kate Kelly and Peggy Ramundo Rating Scale www.med.nyu.edu/psych/assets/adhdscreen18.pdf Information www.caddac.ca www.chaddcanada.org www.adhdcanada.ca http://www.caddra.ca/ www.ADHDandYou.ca www.associationpanda.qc.ca http://www.attentiondeficit-info.com/home.php Daily list of tasks - keep it manageable Keep an appointment book / planner Keep notepads in accessible places Use a personal dictaphone or cell phone to write things down Post key messages in visible places ie car Develop a filing system - file everything immediately Ask a friend / family member to remind you of important events / appointments Memory aids Learn to tolerate Organizational aids mood swings Task fragmentation Nutrition Prioritization Sleep hygiene Favour routines Physical activity / Reinforce success exercise Time management Reduce screen time, skills alcohol, drugs Set personal / attainable goals Reward yourself when these have been attained If don’t work out take a time out to review the situation Develop daily routines Use the structural approaches Stress management Maintain a sense of humour Behaviour Description Anticipatory avoidance Magnifying difficulty of impending tasks and doubts of being able to complete task Procrastination Deadline-associated stress can help focus Pseudo efficiency Sense of productivity by completing several easy tasks while avoiding high-priority tasks Juggling Taking on new projects without completing those already started ◦ Building self-esteem ◦ Correcting behaviours during your visit ◦ Identify masquerading (cover-up) skills ◦ Goal focused - SPEAR Stop Pull-back Evaluate Act Re-evaluate recognise achievements find strengths avoid failures avoid criticism cognitive approaches empowerment Help with assessment Identify other issues Explain and answer any questions Reading material Engage as a “coach” Support Medication Stimulants ◦ Methylphenidate ◦ Concerta ◦ Biphentin ◦ Dextroamphetamine ◦ Adderall ◦ Vyvanse Atomoxetine Guanfacine Anti-depressants Buproprion Venlafaxine Desipramine ◦ Short acting (2-4 hours) ◦ Up to 80 mgm. / day ◦ Up to 3 divided doses ◦ Can be combined with long-acting ◦ Side-effects Sleep Appetite Rebound Tics ◦ Short acting (3-4 hours) ◦ Slow release (spansules) 5 and 10 mgm ◦ Up to 40 mgm. / day (twice the potency of MPH) ◦ Divided doses ◦ Can be combined with long-acting ◦ Side-effects