Dr Jane McCarthy Consultant Psychiatrist, East London NHS Foundation Trust & Visiting Senior Lecturer, Department of Forensic & Neurodevelopmental

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1 Dr Jane McCarthy Consultant Psychiatrist, East London NHS Foundation Trust & Visiting Senior Lecturer, Department of Forensic & Neurodevelopmental Sciences Department, King s College London

2 Prevalence & Aetiology Diagnosis & Recognition Co morbidity Interventions

3 Prevalence rates vary widely from 14 to 60% (Ruedrich,2010) ADHD prevalence 8 x higher in children with ID (Secondary analysis of for National Statistics survey of the Mental Health of Children and Adolescents in Great Britain) (Emerson 2003) About 15% of adult with ID have ADHD (Xentitidis, Maltezos & Asherson, 2014)

4 Drug and alcohol use during pregnancy Maternal infection Encephalitis Some genetic disorders William s syndrome Turner s syndrome Fragile X Phenylketonuria Dichter et al, 2012; Green et al, 2012

5 Diagnostic overshadow attribution of hyperactive, impulsive and inattentive symptoms to the ID itself and thus obscure the identification of ADHD

6 Overactivity and inattention may impair general performance and contribute to lower IQ scores Buchmann et al (2011) suggested it is not possible to diagnose ADHD with certainty in individuals with an IQ below 85

7 DSM-V and ICD-10 ADHD criteria advise that the observed behaviour must be inconsistent with the developmental level Similar symptom picture and developmental course for young children and adults (Simonoff et al, 2007; Xentidis et al, 2010) Increased severity of symptoms in adults with ID (Seager and O Brien, 2003)? Poorer outcome in adult life (Xenitidis et al., 2010)

8 6 item screening tool for ADHD: WHO Adult ADHD self-report scale (Kessler et a., 2005) DIVA (Diagnostic Interview for ADHD in Adults) (Kooik, 2010)

9 The literature suggests that clinicians feel more confident about making a diagnosis of ADHD in patients without ID Adult Psychiatrists more reluctant/ less confident to diagnose and treat ADHD in the context of ID (Bramble et al, 1999;Buckley et al 2006)

10 SE London: Large clinic population of 788 adult patients with ID Only 2% diagnosed with ADHD (Underwood, PhD Thesis, University of London 2012) Surrey: Serving population of 576,000 expect at least 400 diagnosed with ADHD in ID population only 14 recognised & treated (Perera, RCPsych ID Faculty meeting, 2014)

11 Higher risk of co-morbidity Challenging behaviour Stereotypies Self-harm Anxiety Oppositional defiant disorder Tic disorders Sleep problems Simonoff et al, 2013

12 59 Individuals with ADHD and mild-borderline range intelligence and 95 individuals with ADHD and normal intellectual functioning were compared on attentional and response inhibition tasks. Comorbid group had significantly lower scores on the majority of measures in comparison with the ADHD alone group which remained significant after co-varying for level of intellectual functioning Individuals with comorbid ADHD and intellectual disability may be vulnerable to a double deficit from both disorders in certain aspects of cognitive functioning.

13 61% of prisoners with ID had ADHD 26% of prisoners with ADHD had ID Current Mental Health Problems: ID only: 13% ID & ADHD: 54% ADHD only: 66%

14 ADHD can be successfully treated in people with ID (Handen B, Feldman H, Luriee A, et al, 1999; Posey, Aman, Arnold, et al, 2005) Lack of RCTs in the population with ID Open label studies and case reports Methylphenidate has been studied the most

15 Methylphenidate, amphetamine and risperidone have proven efficacy in children Little evidence of worsening of tics or obsessive behaviours Less evidence for adults: Follow NICE guidelines Clinic study of adults with ID showed 43% on stimulant plus antipsychotic or SSRIs (Perera, 2014 personal communication) Limited evidence for psychological & family interventions

16 Common in people with intellectual disabilities ADHD is underdiagnosed and undertreated Training issue for psychiatrists working with adults High level of co-morbidity Treatments have been proven to be efficacious in people with ID

17 Key Reference: Attention-Deficit Hyperactivity Disorder (ADHD). Xenitidis K, Maltezos S & Asherson P. (2014). In: (Eds; E Tsakanikos & J McCarthy) Handbook of Psychopathology in Intellectual Disability. Springer, New York.