Understanding Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adults, Slides of Public Health

Download Understanding Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adults and more Slides Public Health in PDF only on Docsity! Overview of Adult Attention-Deficit Hyperactivity Disorder Docsity.com Take The Test • Never Rarely Sometimes Often Very Often • How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? • How often do you have difficulty getting things in order when you have to perform a task that requires organization? • How often do you have problems remembering appointments or obligations? • When you have a task that requires a lot of thought, how often do you avoid or delay getting started? • How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? • How often do you feel overly active and compelled to do things, like you were driven by a motor? Docsity.com “Hidden Disorder” (cont.) • “Children outgrow ADHD” – Past focus on hyperactivity – Decrease by teen years • Current: – Focus on inattention & impulsivity Docsity.com Prevalence (Children) • School age children in US (3-7%) (DSM-IV) • Gender: males (2-10:1) – Most cited (6:1) (referred samples) • 30-85% show symptoms into adulthood Docsity.com Prevalence (Adults) • Adults in US (2-10%) – 4-5% most often cited (Kessler, 2005) • Persistence of Childhood ADHD – Prospective studies • Only Four>50% retention • Variations in selection/diagnostic criteria • Changes in sources of information – Persistence difficult to estimate Docsity.com Etiology (cont.) • Neurochemical transmission problem – (dopamine,norepinephrine) • Genetic: primary factor? – Parent w/ADHD = 57% of ADHD child • NO adult onset Docsity.com When Heredity NOT a Factor • “Difficult” pregnancy • Prenatal exposure to EtOH/Tobacco • Premature delivery • Low birth weight • High lead levels • Injury to prefrontal regions Docsity.com Diagnosis • Extensive support for symptom thresholds for children (Lahey et al., 1994) • Use of DSM-IV criteria for adults remains controversial (Riccio et al., 2005) – Criteria designed for, and based on, studies w/children – Lack of validation studies w/adults (Belendiuk, 2007) Docsity.com Diagnosis (cont.) • Longitudinal Studies: – Developmental influence • ADHD Sxs decrease with age (National Academy for the Advancement of ADHD Care, 2003) – Hyperactivity-Impulsivity (decrease) – Inattentiveness (persists) Docsity.com Diagnosis (cont.) – True remission or measurement problem? • Several studies suggest DSM-IV criteria are too stringent for adult Dx. • Use of deviance model indicates higher rates – Potential New Model: • Norm-referenced vs. criterion-referenced Dx – Determining ADHD symptom thresholds specific to age groups » Developmentally Referenced Criterion (DRC) » 98th percentile; +2 SD Docsity.com Diagnosis (cont.) • Abandon DSM-IV-TR? – Re-examine • Adults in different settings • Adults have different demands • Adults live & work independently • Children in more structured settings • Children under adult supervision Docsity.com Hyperactivity • 2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level Docsity.com Hyperactivity • a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often "on the go" or often acts as if "driven by a motor" (f) often talks excessively Docsity.com Impulsivity • (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games) • B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. • C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). • D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. • E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder). Docsity.com Differential Diagnosis 1. PTSD^ 2. Mental retardation 3. Substance intoxication* 4. Bipolar disorder* 5. Tourette’s Syndrome 6. Depression 7. Adjustment disorder 8. Brain injury * = ADHD-C (severity) ^ = ADHD-H 9. Brain tumors 10. Multiple sclerosis 11. Epilepsy 12. Stroke 13. Dementia 14. Liver/renal problems 15. Drug side effects 16. Hyper/hypo-thyroidism Docsity.com Assessment Process • Comprehensive Evaluation Overview – Assess Psychopathology – Assess Functional Impairments – Assess Pervasiveness – Assess Age of Onset – Rule-Out Other Disorders That Explain Condition Docsity.com Assessment Process (cont.) • Interview with patient and significant others – Developmental history – Medical/Psychiatric history – School/Work history – Past evaluations – Past treatments – Present/past ADHD symptoms – Impairment history Docsity.com Semi-structured Interviews • Conners Adult ADHD Diagnostic Interview for DSM-IV(CAADID) (Epstein, 2000) – Symptoms, developmental course, ADHD risk factors and comorbid psychopathology – Good test-retest reliability for Dx and symptoms – Good concurrent validity (Epstein, 2006) Docsity.com Rating Scales • Conners Adult ADHD Rating Scales (CAARS) (Conners, 1999) – Self-report and observer scales – Test-retest high (.85-.95) – Correct classification rate = 85% Docsity.com Assessment process (cont.) • Neuropsychological Testing – No single test or battery of tests has adequate predictive validity or specificity – Useful to support results from history, rating scales & analysis of current functioning Docsity.com Comorbidities • Children: – 44% of children with ADHD=1other psych. Dx – 32% of children with ADHD=2 other psych. Dx – 11% of children with ADHD=3 other psych. Dx Docsity.com Comorbidities (cont.) • Depression – Major (16-31%) – Dysthymia (19-37%) • Anxiety – Children (25%) – Adults (24-43%) (GAD) • Learning disability – 10-90% Docsity.com Comorbidities (cont.) • Anti-social personality disorder – 7-18% • Bipolar disorder – 10% in adults • Tics/Tourette’s – ADHD children = 7% – Tourette children = 60% w/ADHD Docsity.com Treatment • Children’s Guidelines for Treatment – American Academy of Pediatrics, 2001 • Adults = ??? • Overview – Symptom reduction/minimize neg effects – Education – Psychotherapy – Pharmacological Docsity.com Treatment (cont.) • Education – Diagnosis is crucial – Signs and symptoms – Why diagnosis not made sooner? • Psychotherapy – Secondary emotional symptoms – Cognitive behavioral therapy Docsity.com Treatment (cont.) • Drugs – Well established in children with ADHD (Wilens, 2003) • Stimulants (first line drugs) • Children (70-80% respond) • Adults (25-78% respond) (30% don’t!!!!) – Methylphenidate (Ritalin) – Amphetamine compounds (Adderall) – Dextroamphetamine (Dexedrine) Docsity.com Treatment (cont.) • Anti-depressants – Tri-cyclics (Desipramine-Norpramin; Atomoxetine- Strattera)** – Bupropion (Wellbutrin)-atypical – Venlafaxine (Effexor)-atypical – SSRIs = not shown to be effective **=Desipramine, then Strattera best Docsity.com Medication Compliance • Adults compliant for brief period of time (i.e. 2 months) (Perwien, 2004) • ADHD medication adherence significantly and positively correlated with ADHD symptom severity (Safran, 2007) Docsity.com Psychosocial Intervention – CBT – Self-Mgmt Skills Training – Environmental Restructuring – Psycho-education – Individual Psychotherapy – Family Therapy – Marital/Couple Therapy – Vocational Counseling – ADHD Coaching Docsity.com