ADD AND GIRLS

ADHASA 2006WITS

DR SHABEER JEEVASPECIALIST PSYCHIATRIST

Melrose arch 011 684 1621

www.adhdclinicjeeva.com

Adult ADHD Studied Adult ADHD Studied

19501950 198019801968 19701968 1970 19871987 1994199419371937

Minimal Brain Minimal Brain DysfunctionDysfunction

Minimal Minimal Brain Brain

DamageDamage

Attention Deficit/Hyperactivity Attention Deficit/Hyperactivity Disorder (Disorder (DSM-III-RDSM-III-R))

Attention Deficit Disorder Attention Deficit Disorder ±± Hyperactivity (Hyperactivity (DSM-IIIDSM-III))

Attention Deficit/Hyperactivity Disorder (Attention Deficit/Hyperactivity Disorder (DSM-IVDSM-IV))

Efficacy of Efficacy of AmphetamineAmphetamine

Hyperactive Child Hyperactive Child SyndromeSyndrome

ADHD: Timeline of Definitions

19301930

Hyperkinetic ReactionHyperkinetic Reactionof Childhood (of Childhood (DSM-IIDSM-II))

19021902

First First Description of Description of ADHD by StillADHD by Still

Age-Dependent Decline of ADHD Symptoms

Biederman J et al. Am J Psychiatry. 2000;157: 816-818.

0

1

2

3

4

5

6

<6 6-8 9-11 12-14 15-17 18-20

SyndromaticCriteria

Functional Impairments

= –0.25 (–0.35, –0.15)

Mea

n N

o. S

ympt

oms

Age (y)Age (y)

Inattention

Impulsivity

Hyperactivity

}}

ADHD In Girls

Is ADHD a disorder in Girls?

• An estimated 1 million girls and women in the United States are affected by ADHD (Arnold et al. J Abnorm Child Psychol 1996)

• The Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed. (DSM-IV) estimates that boys with ADHD outnumber girls with ADHD by as much as 9:1 (American Psychiatric Association 2000) However, community-based studies in which the ratio of boys to girls with ADHD is as low as 2:5:1 indicate that prevalence in girls is understated (Szatmari, Child Adolesc Psychiatry Clin N Am 1992)

• This suggests that school-aged girls with ADHD are less likely to be diagnosed properly, and consequently receive inadequate treatment. (Biederman et al. JAACAP 1999)

Diagnostic issues for girls with ADHD

Core Symptoms:• Both boys and girls with ADHD display the same

core symptoms – Inattention, impulsivity, and hyperactivity.

• Boys tend to have more symptoms of hyperactivity (Arnold J Abnorm Child Psychol 1996)

• In girls, symptoms of inattention are predominant (Biederman et al JAACAP 1999)

Symptoms in Girls

• Hyperactivity in girls may manifest as hyper verbalisation and emotional excitability, rather than the motoric hyperactivity seen in boys (Arnold et al. J Abnorm Child Psych 1996)

Behaviours that may be seen in girls with ADHD

General• School phobia or avoidance

• Dishevelled appearance

• Grooming problems

In School

•Withdrawal in the classroom

•Low academic performance

•Low self esteem

•Poor social skills

(Adapted from: Nadeau, Littman and Quinn, Understanding Girls with AD/HD, Advantage Books 1999)

Comorbidities in girls with ADHD

• Conduct Disorder and oppositional defiant disorder – prevalence in girls with ADHD is about half that found in boys with ADHD (Biederman et al. JAACAP 1999)

• These disorders are associated with the behavioural deviance and aggression that often drives clinical referral. Therefore, the low rates of these disorders in girls and their natural tendency to be less active, more compliant, and less aggressive, may account for the under recognition of ADHD in girls compared with boys.

Symptom profile of girls with ADHD

• Acts before thinking

• Difficulty waiting turn

• Blunt answers

• Interrupts

• Talks excessively

• Difficulty playing quietly

• Fidgety

Symptom profile of girls with ADHDcontinued

• Difficulty remaining seated

• Does not listen

• Loses things

• Easily distracted

• Difficulty following instructions

• Difficulty sustaining attention

• Shifts activities

Pharmacotherapy for ADHD in girls

• Pharmacotherapy combined with behavioural is a highly effective treatment for girls with ADHD (MTA. Arch Gen Psychiatry 1999)

• Stimulants (e.g. MPH or amphetamine) are the first-line pharmacotherapy for treating core symptoms of ADHD (Greenhill et al. JAACAP 2002; AAP, Paediatrics 2001)

• Several studies show that immediate-release (IR) MPH has equivalent beneficial effects in boys and girls (Pelham et al. JAACAP 1989; Sharp et al. JAACAP 1999)

• Of particular relevance to girls is the recent finding that stimulant pharmacotherapy in childhood may be associated with a reduced risk of subsequent drug and alcohol abuse (Wilens et al. Paediatrics 2003)

Non-comorbid (55%)

Anxiety(34%)

MD(20%)

CD (8%)23%

7%

2%

4%7%

Biederman et al. J Am Acad Child Adolesc Psychiatry. 1999;38:966.

Psychiatric Comorbidities in Girls with ADHD

2%

Patients with “ADHD” may suffer Because…..

• Their parents don’t understand them;

• Their teachers can’t stand them;

• Their peers reject them;

• Their spouses and bosses can’t stand their disorganization and intensity;

• They themselves begin to think: “no matter what I do I can’t win…”

Famous People with Attention Deficit and Learning Disorders

• Albert Einstein

•Thomas Edison

•Gen. George Patton

•John F. Kennedy

•Bruce Jenner

•Eddie Rickenbacker

•Harry Belafonte

•Walt Disney

•Steve McQueen

•George C. Scott

•Tom Smothers

•Suzanne Somers

•Jules Verne

•“Magic Johnson”

•Carl Lewis

•Nelson Rockefeller

•Sylvester Stallone

•Cher

•Gen. Westmoreland

•Charles Schwab

•Danny Glover

•John Lennon

•Greg Louganis

•Winston Churchill

•Henry Ford

•Robert Kennedy

•George Bernard Shaw

•Beethoven

•Hans Christian Anderson

•Galileo

•Mozart

•Leonardo da Vinci

•Whoppi Goldberg

•Tom Cruise

•Henry Winkler

•F. Scott Fitzgerald

•Robin Williams

•Louis Pasteur

•Werner von Braun

•Dwight D. Eisenhower

•Lindsay Wagner

•Alexander Graham Bell

•Woodrow Wilson

ATTENTION DEFICIT DISORDER

INATTENTIONIMPULSIVITY

(Distractible) (Act before thinking)

A.D.D.

Girls > Boys

ATTENTION DEFICIT HYPERACTIVITY DISORDER

INATTENTIONIMPULSIVITY

(Distractible) (Act before thinking)

A.D.H.D.

HYPERACTIVITY-IMPULSIVITY CLUSTER + Hyperactivity-boys>girls

Concurrent conditions in dx

O.D.D.O.D.D.

ADHDADHD

C.D.C.D.

S.L.DS.L.D

Prevalence and Genetics of ADHD

6-8% of children; 3-5% of adults Male-Female: 6:1, 3:1, 1:1 All levels of IQ All levels of socioeconomic status Family genetic transmission: 0.91 Inheritance not specific to subtype

Symptoms of Hyperactivity Often Manifest Differently in Adults

DSM-IV Symptom Domain Squirms and fidgets Can’t stay seated Runs/climbs excessively Can’t play/work quietly “On the go”/driven by

motor Talks excessively

Common Adult Manifestation Workaholic Overscheduled/

overwhelmed Self-selects a very active

job Constant activity leading to

family tension Talks excessively

Hyperactivity often changes to inner restlessness

Symptoms of Impulsivity Often Manifest Differently in Adults

DSM-IV Symptom Domain Blurts out answers Can’t wait turn Intrudes/interrupts others

Common Adult Manifestation Low frustration tolerance

− Losing temper− Quitting jobs− Ending relationships− Driving too fast− Addictive personality

Impulsivity in adulthood often carries more serious consequences

Symptoms of Inattention Often Manifest Differently in Adults

DSM-IV Symptom Domain Difficulty sustaining

attention Doesn’t listen No follow-through Can’t organize Loses important things Easily distractible,

forgetful

Common Adult Manifestation Difficulty sustaining attention

− Meetings, reading, paperwork Paralyzing procrastination Slow, inefficient Poor time management Disorganized

Comorbid Psychiatric Disturbances Are Common in Adults With ADHD

Antisocial Disorder (10%)Antisocial Disorder (10%)

Major Depressive Disorder (35%)Major Depressive Disorder (35%)

Bipolar Disorder (15%)Bipolar Disorder (15%)

Anxiety Disorders (40%) Anxiety Disorders (40%)

Substance Abuse Disorders (50%)Substance Abuse Disorders (50%)

Shekim WO et al. Compr Psychiatry. 1990;31:416-425.

Biederman J et al. Am J Psychiatry. 1993;150:1792-1798.

ADHD and Comorbid Conditions

Impulsivity/Hyperactivity

InattentionInattention

ComorbidityComorbidity

Sound of Music

Is It ADHD?

DSM-IV Inattention Symptoms

in Adults with ADHD

% present M F T

• Easy distractibility 85 98 87 .0• Difficulty sustaining attention 88 85 86.5• Difficulty organizing tasks 76 85 80.5• Difficulty listening 76 74 75.0• Difficulty following instructions 71 78 74.5 • Lack of sustained mental effort 68 74 71.0 • Inattention to details 73 67 70.0• Forgetfulness 71 70 70.5• Losing things 61 63 62.0

DSM-IV Hyperactivity-Impulsivity Symptoms

in Adults with ADHD

% present M F Average

Hyperactivity• Running about 67.1 63.0 65.05• Being on the go 64.5 63.0 63.75• Talking too much 55.3 70.0 62.65• Fidgeting 48.7 67.0 57.85• Difficulty engaging in leisure 46.1 44.0 45.05• Leaving seat 34.2 22.0 28.10

Impulsivity

• Difficulty awaiting turn 57.9 70.0 63.95• Interrupting or intruding 50.0 74.0 62.00• Blurting out answers 56.6 59.0 57.80

Associated Symptoms in Adults with ADHD

% present Male Female Total

• A sense of underachievement 92.1 92.6 92.3• An intolerance of boredom 77.6 100.0 88.8• Many projects going 88.5 88.9 87.2

simultaneously• Inability to reach potential 85.5 81.5 83.5• Problems with time management 77.6 88.9 83.3• Impatience 85.5 77.8 83.3• Chronic procrastination 84.2 77.8 81.0• Frequent search for high stimulation 76.3 85.2 80.8• Sense of insecurity 75.0 81.5 78.2 • Feeling disappointed and discouraged 73.7 74.1 73.9• Forgetfulness 76.3 70.4 73.3• Poor self-esteem 75.0 70.4 72.7

Most Frequently Associated Symptoms in Adult ADHD

(cont’d)

% present

M F T• Tendency to say what comes to mind 73.7 70.4 72.0 • Trouble in following “proper” procedure 65.8 77.8 71.8• Nervousness 72.4 62.9 67.7• Stress intolerance 71.1 62.9 67.0• Difficulty enjoying work 63.2 62.9 63.1 • Frequent mood swings 64.5 59.3 61.9• Long standing unhappiness 65.8 55.6 60.7• Impulsivity 52.6 66.7 59.6• Frequent finger drumming 65.8 48.2 57.0

Most Frequently Associated Symptoms in Adult ADHD

(cont’d) % present

M F T• Hot temper 63.2 48.2 55.7• Depression 53.9 48.2 51.0• Frequent job changes 44.7 55.6 50.1• Verbal aggression 53.4 33.3 43.6• Self-destructive behavior 34.2 33.3 33.8• Alcohol abuse 19.7 11.1 15.4 *• Physical aggression 18.4 11.1 14.8• Drug abuse 19.7 3.7 11.7 *• Difficulty with the law 10.5 3.7 7.1*

ADHD Comorbidities: A Developmental Perspective

Pre-schoolPre-school AdolescentAdolescent Adult AdultSchool-ageSchool-age College-ageCollege-age

ODD, CD, ODD, CD, Language DisordersLanguage DisordersLearning problems, Learning problems,

Developmental problems Developmental problems

ODD, CD, Learning ODD, CD, Learning Disabilities, Anxiety DisordersDisabilities, Anxiety Disorders

ODD, CD, LD, ODD, CD, LD, Anxiety and/or Anxiety and/or Mood DisordersMood Disorders

ODD, CD, LD, ODD, CD, LD, Anxiety Disorders Anxiety Disorders Mood DisordersMood DisordersSubstance abuseSubstance abuse

Anxiety Disorders Anxiety Disorders Mood DisordersMood DisordersSubstance abuseSubstance abusePersonality DisordersPersonality Disorders

Comorbidity in Adult ADHD

Disorder Males Females Total

Maj. Dep. 35,71% 54,02% 41,08%

Anxiety Dis 14,76% 27,59% 18,52%

Dysthymic Dis 12,86% 16,09% 13,80%

ODD 5,24% 3,45% 4,71%

CD 0,48% 3,45% 1,35%

ADHD only 36,19% 22,99% 32,32%

19+ 210 87 297

ADHD Life Cycle Changes

Child Adolescent Adult Prevalence 7-13% 6-8% 4-5%

Subtype ADHD>ADD ADHD=ADD ADD>ADHD

Comorbidity ODD,CD + ANX-DEP ANX-DEP LD, LAN D SUB USE, PD

Rx response very good very good very good (high remission/normalization)

Gender and Comorbidity

• More common in males: Aggressive Behavior, Substance Abuse, Conduct and Antisocial Personality Disorder

• More common in females: Anxiety Disorders and Mood Disorders

Conclusions

• ADHD has a high rate of comorbidity in adults

• The determination of associated comorbid disorders in adult ADHD is essential to establish the “goodness of fit” between patient symptom/comorbidity profile and treatment options