Workshop on ADHD in Third Level students

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Workshop on ADHD in Third Level students Powered By Docstoc
					Workshop on ADHD in Third Level students
Martin O’Sullivan
Consultant Child and Adolescent Psychiatrist Mater Hospital and St Vincent’s Hospital Fairview

Fiona McNicholas
Consultant Lucena Clinic, Rathgar & Our Lady’s Hospital for Sick Children, Crumlin Professor Child & Adolescent Psychiatry, UCD

26 Jan 2006

Overview of Talk
• ADHD in children • ADHD in adults • Treatment of ADHD

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ADHD- as we know it!

Inattention Impulsivity

Hyperactivity

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Diagnostic criteria
(ICD/DSM) • • • • Over activity Inattention Impulsivity Symptoms before age 7 (6 ICD) • Pervasive across situation • Cause impairment of social or educational functioning. • Not due to PDD, Psychotic or other mental disorder (anxiety, depression)

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Inattention: (6/9)
– Fails to give close attention to details or makes careless errors in schoolwork, or other activities – Difficulty sustaining attention in tasks or play activities – Does not seem to listen when spoken to directly – Does not follow through on instructions and fails to finish school work, chores or duties (not due to oppositional behaviour or failure to understand) – Difficulty organising tasks/activities – Avoids, dislikes or reluctant to engage in tasks that require sustained mental effort – Loses things necessary for tasks – Easily distracted by extraneous stimuli – Forgetful in daily activities

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Hyperactivity/Impulsivity (6/9)
• Fidgets with hands or feet or squirms in chair • Leaves seat in classroom or other in which sitting is expected • Runs about, climbs excessively in situations in which it is inappropriate (restless) • Difficulty playing in activities quietly • „On the go‟ or „driven by a motor‟ • Talks excessively • Blurts out answers • Difficulty awaiting turn • Interrupts or intrudes on others

26 Jan 2006

Common Associated Comorbidities
60 40

(%)
20 0
Oppositional Anxiety Learning defiant disorder disorder disorder Mood Conduct disorder disorder Substance use disorder Tics

Milberger et al. Am J Psychiatry 1995; 152: 1793–1799 Biederman et al. J Am Acad Child Adolesc Psychiatry 1997; 36: 21–29 Castellanos. Arch Gen Psychiatry 1999; 56: 337–338 Goldman et al. JAMA 1998; 279: 1100–1107 Szatmari et al. J Child Psychol Psychiatry 1989; 30: 219–230 26 Jan 2006

Prevalence
• ICD 1-2 % or DSM IV 3-5%

• 30-50% of children referred to child psychiatry clinics have ADHD
• Diagnosed in boys 3-4 often than in girls • Persists in 30-50% of patients into adolescence and adulthood (symptom profile may change) • Prevalence in Adults: 2%

26 Jan 2006

Associated problems
• School: • Language impairment 1575% • Learning Disability 1540% • Low Self esteem • Poor social skills • Labelled „trouble maker‟

• Poor relationship with parents
– often secondary and improves with appropriate intervention

• Family History ADHD

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ADHD more likely than norms to
• Drop out of school 32-40% • Experience teen pregnancy 40% • Sexually transmitted disease 16% • Speed or have car accidents • Suffer from depression 20-30% • Have a personality disorder 18-25%

• Rarely complete college 510%
• Under-perform at work 70-80% • Have few or no friends 50-70% • Engage in antisocial activities 40-50%

26 Jan 2006

Assessment: History & Observations
• Symptoms of ADHD – Home – School – After school activities Co-morbidity – LD – Motor – ODD/CD – Other child psychiatric disorders Perpetuating factors – Family – Temperament – Environment

• Informants
– Parents – Child – Teacher, Coach, play school, clubs etc

•

• Tests
– Physical examination Rating scales – Formal assessments NEPS, SALT, OT, hearing, vision

•

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ADHD in Adults?
• ADHD child grown up • Parent of newly diagnosed ADHD child • Adult recognizing symptoms of ADHD for the first time • New onset ADHD symptoms-‟secondary ADHD‟

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Issues re Adult ADHD
• DSM IV diagnosis valid for children • ? Natural History • Assessment process
– Retrospective recall – Multi rater – Inappropriate wording -new scales

• Self referral versus childhood continuation • Developmental disorder PDD or Psychiatric disorder such as Depression
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Diagnosis of Adult ADHD
• Criteria:
– Childhood criteria meet – Current symptoms – Impairment

• Assessment:
– – – – Clinical interview Collateral Childhood records Rating Sclaes

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The UTAH Criteria for adult ADHD
• Childhood history

• Adult symptoms of – Motor hyperactivity – Attention deficits
• Plus two of the following: – Affective lability – Hot tempers, explosive and short lived outbursts – Emotional over reactivity – Disorganisation, inability to complete tasks – Impulsivity

• DDx: schizophrenia, borderline PD or SUD • Associated features
– Marital instability – Sub-optimal academic and vocational success, – Alcohol or drug misuse, – Family history of ADHD, – Antisocial personality disorder – Atypical response to psychoactive medications.

26 Jan 2006

Adult ADHD Rating Scales
• Conner‟s 4 dimensions
– Cognitive Dysfunction
• Inattention, disorganization, procrastination, poor memory, poor time management

– Hyperactivity
• Predominantly inner restlessness, impatience

– Emotional Impulsivity
• Rages, tempers, anger management issues, mood lability, frustration

– Self Esteem & Self worth
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Adult Rating Scales
• Brown Adult & Adolescent rating Scale
– Self report and significant other

• ADHD Rating Scale
– Developed by Adler et al, Boston group – DSM IV items reworded for adults
• How often have you had difficulty in wrapping up the final details of a project once the challenging parts have been done?

• ASRS-V1.1 www.adultadd.com
26 Jan 2006

Adult Self Report Scale (WHO)
• 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 do 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 your 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?

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Differences between Adult and Child cases ADHD
• • • • • Male: female ratio 3:2 vs 3:1 – 10:1 Source of referral Motivation for treatment Who is affected by ADHD? Insight/ awareness

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Functional Impairment
• Weiss Functional Impairment Rating Scale (v2 2005) - Margaret D Weiss mweiss@cw.bc.ca Domains: Family Work / School / College Life Skills Self – Concept Social Risk
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WFIRS-S
• Provides information on breadth and severity of impairment • Can be used to track changes over time • Psychometric properties of the scale currently under investigation

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Brown Attention Deficit Disorder Scale
5 important symptom clusters • Getting organised, activating tasks • Sustaining focus, especially reading • Alertness, effort, processing speed, motivation • Affect • Working memory, memory retrieval
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Clinical Vignette 1
Walter, 26 • Very superior IQ • Wide variation in College scores, some papers brilliant, others failed • Previous history of Dx ADHD + use of Ritalin – stopped aged 14 • Drops out of College year 3 – many short papers, projects not completed
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Clinical Vignette 2
Maria, 24 • Primary school teacher trainee • “Terrible planning, organising” • Procrastinates, late with assignments • Can‟t keep up with the reading • Finances in a mess – maxed out on Credit

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Clinical Vignette 3
Anthony, 26 • 3rd attempt at third-level degree • Makes good starts then gets bored • Conflict with supervisors • Regular cannabis use • Once supportive parents losing patience

26 Jan 2006

How Medication works: Stimulants
Presynaptic Neuron
Amphetamine blocks

vv
Cytoplasmic DA

Storage vesicle

Amphetamine blocks reuptake

DA Transporter

Synapse
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Methylphenidate blocks reuptake

Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513.

Treatment - Psychostimulants
Methylphenidate or Amphetamine • First line medications for the treatment of AD/HD in adults off-label • Clinical response is dose related >1mg/kg/day • Efficacy rates ~(25-) 70% • Successful treatment results in diminished substance misuse
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Psychostimulants II
Possible side effects • Insomnia, headaches,anxiety, loss of appetite • Cardiovascular:  BP 4mmHg; bpm +10

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Psychostimulants III
• Immediate release MPH require two – three doses e.g. Ritalin, Equasym • Extended / sustained release MPH e.g. Ritalin LA, Concerta

26 Jan 2006

Psychostimulants IV
• Immediate release Amphetamine • E.g. Dexedrine, Adderall • Extended or sustained release: • E.g. Adderall XR

26 Jan 2006

Non-stimulant medicationsAtomoxetine HCl
Strattera
• • • • • Approved by FDA for treatment of adults Potent selective NA reuptake inhibitor Not „controlled‟ C/I MAOI users, glaucoma Cautions: liver problems/ cardiovascular/ depression/ suicidality • Await trials in those with depression/ anxiety • Metabolised CYP2D6 enzyme Fluoxetine, Paroxetine and Quinidine inhibit this enzyme
26 Jan 2006

Non-stimulant medicationsOther
• • • • • • SSRIs not effective TCAs – Des., Imip, moderate effect MAOIs no controlled trials Bupropion DA NA atypical anti dep Venlafaxine NA 5HT blocker Clonidine alpha-2 NA

26 Jan 2006

Conclusions

26 Jan 2006

Questions?

26 Jan 2006


				
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