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Cherinet Seid, PGY II
OUT LINE Introduction History of ADD Etiology/Risk factors Diagnosis Comorbid disorders Management
Introduction
The only psych disorder 1st recognized in children
Under recognized in adultsAffects 4-5% adults“Persistent ADHD” 15-28%P-ADHD male predominant, A-ADHD notPsychiatric comorbidities
History of ADD1930 - Minimal Brain Damage1960 - Minimal Brain Dysfunction1968 - Hyper-kinetic reaction of
childhood1980 - ADD with/without hyperactivity1987 - ADHDAmphetamines used in 1937Methylphenidate has been on market
since 1955
Common Scenarios
Adults diagnosed in childhood & stopped rxAdolescents progressing to adult servicesUndiagnosed adults with rx-resistant
comorbid Psych disordersUndiagnosed self referred adultsUndiagnosed adults recognized by
others(fam members, health professionals)
Effects of ADHD1. Social & Work impairment$19.5 billion lost human capital/yr in USIncreased risk to be arrested (>2x controls)2. Marital & Parental impairmentRate of divorce & separation double that of
general population3. Accident PronenessHospital visits & Admissions 26 % vs 18%
4.Driving Impairment
0
1
2
3
4
5
6
Total Tickets Speeding tickets Suspensions MVA
Control
ADHD
Effects cont’d5. Substance use
Control ADHD
27
55
0
10
20
30
40
50
60
Case43 yr female, chemist, married, 3 kidsNoticed similar characters as her 10 yr old
son who is recently diagnosed with ADHDHas trouble concentrating, disorganized,
impulsive & forgetfulFrequently misplaces or loses objectsProcrastinates and has difficulty with
punctualityFeels overwhelmed by house hold chores
although husband is supportive and calls her home ‘a disaster area’
Three sub types
I. Predominantly inattentive type
II. Predominantly hyperactive-impulsive type
III. Combo
DSM-IV criteria At least 6 symptoms of inattention
Careless mistakesNot listening Not finishing projectsForgetful Not following throughBeing disorganized Impulsive & forgetfulFrequently losing/misplacing objects
DSM IV cont’d At least 6 symptoms of hyperactivity
Hyperactivity-impulsivity Not able to sit still
Inner feeling of restlessness Always on the go
Talking too much Being impatient
Interrupting Blurting things out
DSM-IV cont’dSxs must be present before age 7
Interfere with ability to function
Persist for more than six months
Manifest in multiple settings
Not be accounted for by other disorders
Risk FactorsBiologic cause More genetic link than asthma, breast ca &
schizophrenia.
Environmental
Frontal cortex hypometabolism
Dopaminergic pathways
Screening for ADHD
Adult Self -Report Scale (ASRS)
18 questions
Assesses DSM-IV symptoms of ADHD
Assessment Process1. Assess current ADHD symptoms
(assessment scales)2. Establish a childhood hx of ADHD3. Assess devt’al & functional impairement4. R/o other psychiatric disorders5. Obtain family hx of psych disorders6. Perform a physical exam, r/o medical causes7. Assess pt’s insight (?same with collateral hx)
DDx of A-ADHDLearning disabilitiesMood disordersAnxiety disordersMixed anxiety/depressionSecondary ADHD syndromes due to
brain injuryOther causes of impaired cognitive &
executive function
Treatment
Need to treat is always based on
functional impairment.
Multimodal Treatment
PsychoeducationRx of comorbid conditionsPharmacological RxsTherapy (marital, individual, social skills,
CBT)Light therapyEnv’tal restructuring & appropriate
physical & special interest activities
PharmacotherapyClass Dose Adverse effectsStimulantsMethylphenidateShort acting
Intermediate acting
Extended release
10-60 mg 2-4x
10-60mg 1-2x
18-108 mg od
Insomnia Headache
Decreased appetite
wt loss Nausea
Bp & pulse changes
Palpitations
Non-stimulantsAtomoxetine 80-100 mg
1-2 x
Constipation Dry mouth
Decreased appetite Insomnia
Sexual dysfunction Dysmenorrhea
AntidepressantsBupropion
Short acting
Extended release
Desipramine
100 mg 2-3x
150-300 mg od
25-300 mg od
Anxiety Insomnia
Decreased appetite Risk of Sz
Irritability Agitation
just remember…
It is worth identifying A-ADHD
Substantial burden of illness
Potential for improvement with rx
Assessment Scaleswww.therapeuticresources.comwww.checkmateplus.comwww.guilford.comwww.mhs.comwww.caddra.cawww.harcourtassessment.comwww.med.nyu.edu/psych/psychiatrist/
adhd.html
References
1. Approach to ADD in adults,Canadian Family Physician, vol 52;Aug 2006
2. Understanding the nature of adult ADHD, Schulich school of Medicine, CME booklet 2007
3. www.uptodate.com