ADHD: TRANSITION FROM CHILDHOOD TO ADULTHOOD "ADHD IS CHARACTERIZED BY A PATTERN OF BEHAVIOR, PRESENT IN MULTIPLE SETTINGS, THAT CAN RESULT IN PERFORMANCE ISSUES IN SOCIAL, EDUCATIONAL, OR WORK SETTINGS.“

Carmin Powell, PGY1 Clarissa Wong, PGY1 July 16 t h , 2013

“ Received wisdom over the years has been that ADHD has been a disorder of childhood whose symptoms lesson over time… Consequently little attention was paid to the possibility that it might continue into adulthood. ” (Journal of the Royal Society of Medicine, 2004)

OVERVIEW of Adult ADHD ¡  “Although there is a trend towards amelioration of symptoms, a substantial proportion continue to have at least one disabling symptom in adolescence and young adulthood.” ¡  ~30-70% of children with ADHD continue to have symptoms in adulthood ¡  1-7% of adults experience ADHD symptoms ¡  ADHD does not fade at a specific age ¡  Reported reduction in symptoms with advancing age may be explained by acquisition of cognitive strategies to ameliorate features

DSM-V CRITERIA ¡  Combination of severe inattention, hyperactivity and impulsivity ¡  Significant impairment across multiple settings ¡  Symptoms must be present prior to age of 12 yo §  DSM-IV – 7 yo

¡  Children must present with 6 symptoms vs. older adolescents/adults (> 17 yrs) must have 5 symptoms

NEUROBIOLOGY ¡  Not completely understood ¡  Genetic factors ¡  Imbalances in dopaminergic and noradrenergic systems ¡  The Prefrontal Hypothesis ¡  Perinatal exposures

NEUROBIOLOGY ¡  CT/MRI ¡  Structural differences ¡  Smaller volumes in frontal cortex, cerebellum, and subcortical structures ¡  Decrease in volume of corpus callosum

¡  fMRI studies ¡  Hypofunctioning dorsal anterior cingulate cortex ¡  Subnormal metabolism in premotor and superior frontal cortex

STATISTICS ¡  ADHD in ~ 5% of children and 2.5% of adults ¡  Almost 66% of individuals diagnosed as children with ADHD report at least 1 ADHD symptom causing clinically significant impairment during adulthood ¡  ADHD in adults more common in males

DIAGNOSIS ADHD IN ADULTS Symptoms must be: ¡  Present since childhood ¡  Pervasive ¡  Cause functional impairment Rating scales in adults include: ¡  Adult ADD Evaluation Scale (A-ADDES) ¡  Brown Attention Deficit Disorder Scales ¡  Attention Deficit Scales for Adults

Trends in Adults ¡  Motoric hyperactivity less obvious ¡  Difficulties with restlessness, inattention, and poor planning persist ¡  Impulsivity may remain problematic even when hyperactivity has diminished §  Socially inappropriate behavior

¡  Subtle symptoms ¡  Marked inattention, distractibility, organizational difficulties, poor efficiency, appear hectic, problems with prioritizing

SYMPTOMS: CHILDREN VS. ADULTS Children

Adults

Inattention

Short attention span, unmotivated, difficulty following directions in school, can't listen for long, can't remember, everything half finished in home & school

Poor concentration at work, daydreaming, forgetfulness, problematic for college students, rarely sits through TV show, trouble listening to conversation

Impulsivity

Difficulty delaying gratification, low frustration threshold, blurts things out/interrupts, reckless, acts before things, frequent driving accidents*

Poor tolerance to frustration, easy loss of temper, exceptional impatience, makes decisions without thinking, little reflection

Hyperactivity

Fidgety, restless, overtalkative, impaired coordination, poor handwriting

Fidgety, restlessness, dislike being inactive, can't relax, forced immobility produces anxiety

SYMPTOMS: CHILDREN VS. ADULTS Children

Adults

Emotionality, temper & mood

Labile moods, dysphoric to overexcited, disruptive disorders, antisocial problems, short fuse

Similar lability as seen in children, mood shifts, spontaneous roller coaster "ups" are reduced adults but "downs" persist, always seem irritable, anger provoked by stimulus

Stress Intolerance

Difficulty staying with things under pressure, less tolerant of low-arousal tasks, may be an optimal arousal level

Overreactive to normal stress or pressure, inappropriate response to ordinary demands, can't handle things out of ordinary, describes self as "stressed out", "hassled"

Goldstein & Goldstein (1998) and Teeter (1998)

IMPACTS OF ADHD ON ADULT LIFE: LAW ¡  Risky behaviors ¡  Speeding violations ¡  Suspended drivers licenses ¡  MVAs ¡  Crimes ¡  Arrests

EDUCATION ¡  More difficulty in school ¡  Elevated absenteeism ¡  Greater risk of suspension or expulsion ¡  3x more likely to be retained a grade ¡  Score lower on tests of reading achievement ¡  Less likely to complete high school ¡  Only 20% attend college and fewer graduate

EMPLOYMENT ¡  Occupational achievement is lower ¡  Increased risk of chronic conflict with work peers ¡  Lower socioeconomic status ¡  More frequent job changes ¡  Fired from more jobs ¡  Higher risk of homelessness

SOCIAL SKILLS ¡  May exhibit socially inappropriate behavior ¡  Difficulty keeping friends, increased conflict ¡  Lesser quality of romantic relationships ¡  Disputes with partners/spouses ¡  More likely to have had multiple marriages ¡  More likely to become parents at an early age

HEALTH ¡  Increased risk of negative outcomes ¡  Exercise less ¡  Smoke more ¡  Suffer more medical problems ¡  Utilize health care at far higher rate ¡  Risky sexual behavior ¡  More MVAs, more driving violations

COMORBIDITIES ¡  Substance Abuse ¡  Anxiety ¡  Depression ¡  Antisocial personality traits

ADULT ADHD: TREATMENT ¡  In 2004, only 15 controlled studies of stimulants had been reported in adults, with over a hundred in children ¡  ADHD who were treated with stimulants exhibited improved school outcomes, lower rates of absenteeism and grade retention, with modest increases in reading achievement scores. ¡  Medication use for ADHD in adults has increased markedly in US (90% from 2002 to 2005) with adults receiving 1/3 of all prescriptions (mostly stimulants and antidepressants)

CURRENT ADULT TREATMENT ¡  Stimulants (Methylphenidate) §  More cardiovascular risks in adults than in children

¡  Atomoxetine (Strattera, SNRI) is approved for adults ¡  Clonidine (Alpha-2 agonist) ¡  Anti-depressants (TCA) ¡  Long-acting stimulants are most effective treatment, however some experts recommend trial non-stimulant agent first ¡  Recommend combined medication and psychosocial treatment approach

FACTORS AFFECTING OUTCOME Aggression Less self-control Emotional lability Childhood defiance Parental psychopathology Learning disability Lower intellect

Intact household, Above poverty level Consistent parenting style Available to their children --> Most powerful variable of predicting good outcome

WHEN TO TRANSITION CARE? ¡  What is the role of the parent and young adult in providing decision-making? ¡  How do we as clinicians better manage treatment in ADHD affected adults? ¡  What systems should be available for consistent follow-up into adulthood?

REFERENCES ¡  T h o m a s J . S p e n c e r, M D , J o s e p h B i e d e r m a n , M D , a n d E r i c M i c k , S C D . " A t t e n t i o n Deficit/Hyperactivity Disorder: Diagnosis, Lifespan, Comorbidities, and Neurobiology." Journal of Pediatric Psychology 32(6) pp. 631–642, 2007 ¡  N e w t o n - H o w e s , G i l e s . " W h a t h a p p e n s w h e n c h i l d r e n w i t h a t t e n t i o n d e f i c i t / hyperactivity disorder grow up?" JR Soc Med 2004; 97:531-535 ¡  M a n n u z z a , S . & K l e i n , R . G . " L o n g - t e r m p r o g n o s i s i n a t t e n t i o n - d e f i c i t / h y p e r a c t i v i t y d i s o r d e r. " C h i l d a n d A d o l e s c e n t P s y c h i a t r i c C l i n i c s o f N o r t h A m e r i c a , 9 , 7 1 1 - 7 2 6 (2000) ¡  We i s s , G . & H e c h t m a n , L . T. " H y p e r a c t i v e c h i l d r e n g r o w n u p " . S e c o n d E d i t i o n , N e w Yo r k , N Y T h e G u i l f o r d P r e s s ( 1 9 9 3 ) ¡  S t e i n , D a v i d . S . " D e v e l o p m e n t a l a n d B e h a v i o r a l D i s o r d e r s T h r o u g h t h e L i f e S p a n . " Pediatrics (2011) ¡  Ko l a r, D u s a n e t a l . " Tr e a t m e n t o f a d u l t s w i t h A D H D. " N e u r o p s y c h i a t r i c D i s e a s e a n d Tr e a t m e n t , A p r i l 2 0 0 8 ¡  E l l i s o n , A n n e T. " A n o v e r v i e w o f C h i l d h o o d a n d A d o l e s c e n t A D H D : U n d e r s t a n d i n g t h e C o m p l e x i t i e s o f D e v e l o p m e n t i n t o t h e A d u l t Ye a r s " ¡  G o l d s t e i n , S a m P h . D . " C o n t i n u i t y o f A D H D i n A d u l t h o o d : H y p o t h e s i s a n d T h e o r y Meet Reality" ¡  h t t p : / / w w w. d s m 5 . o r g / D o c u m e n t s / A D H D % 2 0 Fa c t % 2 0 S h e e t . p d f. A D H D, A m e r i c a n Psychiatric Publishing ¡  Fa c t S h e e t : A t t e n t i o n D e f i c i t / H y p e r a c t i v i t y D i s o r d e r. A m e r i c a n P s y c h i a c t r i c Association, 2013 ¡  w w w. u p t o d a t e . c o m - A d u l t a t t e n t i o n d e f i c i t h y p e r a c t i v i t y d i s o r d e r ¡  M e d s c a p e - A D H D - P e r s p e c t i v e s f r o m C h i l d t o A d u l t

THANK YOU!