Diagnosis of Adult ADHD - Amazon S3...Inattention Drives Presentation of ADHD in Adults 0 10 20 30 40 50 60 70 80 90 100 Inattentive % Affected Hyperactive/ Impulsive Endorsed Symptom

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Diagnosis of Adult ADHD

Joseph Biederman, MDProfessor of Psychiatry Harvard Medical School

Chief, Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD

Director, Bressler Program for Autism Spectrum DisordersMassachusetts General Hospital

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Disclosures 2018-2019

My spouse/partner and I have the following relevant financial relationships with commercial interests to disclose:

– Research support: Genentech, Headspace Inc., Lundbeck, Neurocentria Inc., Pfizer, Roche TCRC Inc., Shire Pharmaceuticals Inc., and Sunovion.

– Consulting fees: Akili, Jazz Pharma, and Shire– Royalties paid to the Department of Psychiatry at MGH, for a

copyrighted ADHD rating scale used for ADHD diagnoses: Bracket Global, Ingenix, Prophase, Shire, Sunovion, and Theravance

– Financial interest: Avekshan LLC, a company that develops treatments for ADHD. My interests were reviewed and are managed by MGH and Partners HealthCare in accordance with their COI policies

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Paul Wender

“ADHD is probably the most common chronic undiagnosed psychiatric disorder in adults. It is characterized by inattention and distractibility, restlessness, labile mood, quick temper, overactivity, disorganization, and impulsivity. It is always preceded by a childhood diagnosis, a disorder that is rarely inquired about and usually overlooked.”

Adult ADHD28

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Is ADHD a Valid Diagnosis in Adults?

SYNDROMATIC CONTINUITY

Family-Genetic Studies

Treatment Effectiveness

Comorbidity and Neuropsychological Deficits

Impairments

Imaging Studies

Wender PH. J Clin Psychiatry. 1998;59(suppl 7):76-79. Spencer et al. J Clin Psychiatry. 1998;59:59-68.

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Adult ADHD Studied

1950 19801968 1970 1987 19941937

Minimal Brain

Dysfunction

Minimal Brain

Damage

Attention Deficit/Hyperactivity

Disorder (DSM-III-R)

Attention Deficit Disorder ± Hyperactivity

(DSM-III)

ADHD Residual Type (First Adult ADHD Dx

Attention Deficit/Hyperactivity Disorder (DSM-IV)

Efficacy of Amphetamine

Hyperactive Child

Syndrome

ADHD: Timeline of Definitions

1930

Hyperkinetic Reaction

of Childhood (DSM-II)

1902

First Description of ADHD by Still

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Changes in DSM-5 ADHD

• “Neurodevelopmental” - not “disruptive”• ≥ 6/9 inattentive or ≥ 6/9 impulsive/hyperactive

symptoms over last six months (>5 for adults)• Symptoms caused impairment by age 12 (no

longer 7)• ASDs no longer exclusionary• No more “subtypes”; Inattentive / Hyperactive-

impulsive / Combined are now “Presentations”• Restricted inattentive subtype: In Appendix,

worthy of further study

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Adult ADHD characterized by continuous lifelong

impairments and pervasiveness

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. 2000.

Diagnosis of ADHD in Adults: DSM-V Diagnostic Criteria

Presentation: (1) inattention symptoms,(2) hyperactivity-impulsivity symptoms, or (3) both

Onset: some symptoms <12 years of age (childhood onset)

Chronicity: >6 months of disturbance (persistent)

Domains affected: cross-situational (home, work, school)

Functioning: evidence of impairment (can be relative)

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Reduced MPFC-PCC Coupling ReflectsCurrent Diagnostic State of ADHD

Mattfeld et al. Brain: A Journal of Neurology 2014, epub: June 10, 2014

Psychopharmacology Course 2017

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Neural Basis of Persistent ADHD

• Persistent ADHD alters intrinsic functional organization of the brain

• Findings supports the idea that adult ADHD diagnosis reflects a true brain difference


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Inattention

Impulsivity/Hyperactivity

ADHD: Core Symptom Areas


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Diagnosis of ADHD in Adults: DSM-V Symptoms

Inattention

• Careless mistakes

• Difficulty sustaining attention

• Easily distracted

• Difficulty organizing

• Fails to finish tasks (frequently shifts activities)

• Seems not to listen

• Avoids tasks requiring sustained attention

• Loses things

• Forgetful

Hyperactivity/Impulsivity

• Unable to stay seated

• Fidgets

• Excessive movement (internal restlessness)

• “On the go”

• Excessive talking

• Blurts out answers

• Difficulty waiting turns (impatience)

• Interrupts or intrudes

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Symptoms of Inattention Often Manifest Differently in Adults

American Psychiatric Association. 1994. 83-85., ADHD in Adulthood 1999, Weiss, Hechtman and Weiss

DSM IV Symptom Domain Common Adult Manifestation


• Doesn’t listen

• No follow through

• Can’t organize

• Loses important items

• Easily distractible, forgetful


– Meetings, reading, paperwork

• Paralyzing procrastination

• Slow, inefficient

• Poor time management

• Disorganized

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Symptoms of Hyperactivity Can Manifest Differently In Adults


• Squirms and fidgets

• Can’t stay seated

• Runs/climbs excessively

• Can’t play/work quietly

• “On the go” / “Driven by motor”

• Talks excessively

• Workaholic

• Overscheduled/overwhelmed

• Self-select very active job

• Constant activity

• Talks excessively


Hyperactivity often changes to inner restlessness

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Symptoms of Impulsivity Often Manifest Differently In Adults


• Low frustration tolerance

– Losing temper

– Quitting jobs

– Ending relationships

– Driving too fast

– Addictive personality


Impulsivity in adulthood often carries more serious consequences

•Blurts out answers

•Can’t wait turn

•Intrudes/interrupts others

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AdulthoodChildhood

Hopelessness, frustration, giving up

Chronic failure

Unwanted pregnancy, sexually transmitted disease, divorce

Impulsivity, carelessness

Antisocial personality disorder, criminality

Oppositional defiant or conduct disorder

AddictionDrug experimentation

Car accidents/injuriesMultiple injuries

Job failure/underemployment

Becomes

Becomes

Becomes

Becomes

Becomes

BecomesSchool failure or underachievement

ADHD Impairment Persists

Courtesy of W. Dodson, MD.

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Patient attempts to compensate and time invested in the compensation is an important diagnostic indication.


Diagnosis of ADHD in Adults: Patient Compensation Efforts

Patients usually:

• Set up rigid schedules

• Pursue areas of interest with extreme zeal

• Seek careers/situations with controllable stimuli

• Make use of organizational tools

• Impose own “time-outs” during stimulus overload situations (take walks/disappear)

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Course of ADHD Symptoms Over Time by Sex: A Growth Curve Model

Age by Sex Interaction: NS

Biederman et al. 2009Psychopharmacology Course 2017

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Age-Dependent Decline and Persistence of ADHD Throughout the Lifetime

Faraone et al. Nature Reviews Disease Primers 2015

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ADHD: Course of the Disorder

Inattention

Time

Hyperactivity

Impulsivity


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Inattention Drives Presentationof ADHD in Adults

0

10

20

30

40

50

60

70

80

90

100

Inattentive

%

Affected

Hyperactive/

Impulsive

Endorsed Symptom Clusters

N=149

P<.05

Millstein R et al. J Atten Disord. 1997;2:159-166.

90%

45%

www.mghcme.orgWilens T, Dodson W. J Clin Psych.

Diagnosis of ADHD in Adults:Common Clinical Histories

• Difficulties in elementary or secondary school

– Comments: “not living up to potential,” “spacey,” “hyper”

– Behavioral issues: “class clown”

• Difficulties in college

– Incomplete degree or longer time to complete degree

– Difficulty engaging in further education

• Difficulties at work

– Underachievement (mixed reviews)

– Low efficiency: Longer time to complete tasks

• Difficulties at home

– Poor organization, does not complete tasks

– Strained relationships with spouse and kids(who also may have ADHD)

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Diagnosis of ADHD in Adults: Examples of Adult ADHD Scales

Some Symptom Assessment Scales

• Brown ADD Scale

• Conners Adult ADHD Rating Scale

• Wender-Reimherr Adult Attention

• ADHD Rating Scale

• Barkley Current Symptoms Scale

• Adult Self-Report Scale v 1.1(18-item symptom assessment and screener)

• Adult Investigator Symptom Report Scale (AISRS)

Diagnostic Scales

• Conners Adult ADHD Diagnostic Interview

• Barkley Current Symptoms Scale (with supplemental Barkley scales)

• Brown ADD Scale Diagnostic Form

• Structured Diagnostic Interviews ADHD Module

Adler L, Cohen J. Psych Clin N Amer. 2004; 27:(2):187-201

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Murphy P, Schachar R. Am J Psychiatry. 2000;157:1156-1159; Conners CK. J Clin Psych.

1998;59(suppl 7):24-30; ASRS v1.1. Available at: www.adultADD.com/2_2_recognizing/screener.jsp.

Accessed November 26, 2003.

Diagnosis of ADHD in Adults: Validity ofSelf-Reports

• Self-report reliable and useful in diagnosisof ADHD in adults

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Spearman’s Rank Correlations Examining the Association between the AISRS (Clinician) and ASRS (SELF)

A. Whole Sample (N=54) B. Males (N=24) C. Females (N=30)

D. Age ≤40 Years (N=28) E. Age >40 Years (N=26)

rs=0.65, df=52, p<0.001 rs=0.68, df=22, p<0.001rs=0.69, df=28, p<0.001

rs=0.64, df=26, p<0.001 rs=0.70, df=24, p<0.001

Biederman et al JAD 2018

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Is ADHD Always a Childhood Onset Disorder?

www.mghcme.orgMoffitt et al. Am J Psychiatry 2015; 172:967–977.

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Adult ADHD

• Symptoms and impairment may emerge due to the accumulation of environmental and genetic risk factors

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Adult ADHD

• Those with lower levels of risk at birth will take longer to accumulate sufficient risk factors and longer to onset with symptoms and impairment

• This multifactorial perspective allows for different risk factors to exert effects at different ages thereby influencing age of onset

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Adult Onset ADHD

• Because these effects are multifactorial, there is no clean separation of etiologic factors in people above and below the ages of 12 years set forth in DSM-V

Faraone and Biederman JAMA Psychiatry Editorial 2016

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70

80

90

100

110

120

130

140

150

0 10 20 30 40 50

Full

Scal

e IQ

Age at Initial Diagnosis

Age at Initial Diagnosis vs Full Scale IQ

IQ and ADHD

• IQ can compensate for the impairments of ADHD

• Can forestall diagnosis of ADHD

Horrigan J, et al. Presented at: 47th Annual AACAP Meeting; October 24-29, 2000; New York, NY.

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

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

Comorbidity in Adults With ADHD

Antisocial Disorder (10%)

Major Depressive Disorder (30-40%)

Bipolar Disorder (15-20%)

Anxiety Disorders (30-40%)

Substance Abuse Disorders (20-50%)

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Disorder ADHD Rate

Major Depression1 20%

Bipolar Disorder2 15%

Generalized Anxiety Disorders3 20%

Substance Abuse4 25%

Re-evaluate refractory patients for ADHD.

ADHD Comorbidity in Adults With Other Psychiatric Disorders

1. Alpert, et al. Psychiatry Res. 1996. 2. Nierenberg, et al. Presented at: APA; May 18-23, 2002; Philadelphia, Pa.3. Fones, et al. J Affective Dis. 20004. Wilens. Psych Clin N Am. 2004.

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1. Quick to get angry or become upset

2. Easily frustrated

3. Over-react emotionally

4. Easily excited by activities going on around me

5. Lose my temper

6. Argue with others

7. Am touchy or easily annoyed by others

8. Am angry or resentful

Deficient Emotional Self Regulation

Scoring: Never (0), Sometimes (1), Often (2), Very Often (3)

DESR: ≥ 95th percentile of total scores in Controls

Surman et al, AJP In Press

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Educational Impairment in High School

*

*

*

*

* p ≤.001

Percentage of Those Who Attended High School

52%

27%

37%

13%

37%

10%

30%

8%

"C" average or lower

Had a tutor

Had special classes

Had to repeat a grade

ADHD (N=464)

Non-ADHD (N=487)

Biederman et al. J Clin Psychiatry. 2006 Apr; 67(4):524-40

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Current Employment Status

*

*

*

*

* P≤.001

Percentage of Each Group

52%

72%

34%

57%

48%27%

14%

5%

Currently employed

Employed full time

Not currently employed

Looking for work

ADHD (N=500)

Non-ADHD (N=501)

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Workplace Impairment

* P≤.001, P≤.05, P≤.01

Easy to concentrate on work

Able to handle large work loads

Unless very interested, unable to pay attention for long periods of time

Organized at work

Sometimes have difficulty following instructions

One of the first that would be considered for a promotion

†

‡

*

*

*

*

Percentage of Those Employed Who "Strongly Agree"

33%59%

52%74%

46%20%

39%69%

5%

11%

31%45%

ADHD (N=261)

Non-ADHD (N=301)

† ‡

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Average Household Income by Education Level Attained

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Symptom domains

▪ Hyperactivity

▪ Inattention

▪ Impulsivity

ADHD: The Disorder

Psychiatric comorbidities

▪ Anxiety and mood disorders

▪ Disruptive behavior disorders

(conduct disorder and

oppositional defiant disorder)

+

Functional impairmentsSelf

▪ Low self-esteem

▪ Accidents and injuries

▪ Smoking

▪ Substance abuse

▪ Delinquency

School / Work

▪ Academic difficulties,

underachievement

▪ Employment difficulties

Home

▪ Family stress

▪ Parenting difficulties

Social

▪ Poor peer relationships

▪ Socialization deficit

▪ Relationship difficulties

Lead to

Documents

Diagnosis of Adult ADHD - Amazon S3...Inattention Drives Presentation of ADHD in Adults 0 10 20 30 40 50 60 70 80 90 100 Inattentive % Affected Hyperactive/ Impulsive Endorsed Symptom