Managing attention deficit in adults in your office

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Kristopher Atkinson
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1 Managing attention deficit in adults in your office Nick Kates MB.BS FRCPC MCFP(hon) Chair, Dept. of Psychiatry, McMaster University Cross Appointment, Dept. of Family Medicine, McMaster University Quality Improvement Advisor, Hamilton Family Health Team

2 No funding or support from Industry for any aspect of this presentation or my work Except my lifelong commitment to

3 Self-referred - concerned about his mood Recent life stresses Inconsistent work and relationship history Met criteria for ADD + PHQ score was 14 Was also depressed poor response to Buproprion Seen a year later mood was brighter and wanted to start a stimulant Positive response to Methylphenidate

4 Referral for assessment of Bipolar Affective Disorder Mood swings consistent with cyclothymia Consistent history of problems with attention, distractibility, academic underachievement Two diagnoses eventually established Some overall improvement with Lithium Reluctant to start Ritalin

5 6-9 % of all children 25-78% continue to have problems as adults 4-5% of all adults Could be third most prevalent psychiatric disorder? adults in an average family practice Democratic Male : female 2:1 Self-perception Changing prevalence with age

9 70 adults in your practice 20% of mothers, 25-30% of fathers have ADHD 20-45% co-morbid depression (genetic link) 25% have alcohol and drug problems 0-27% Bipolar affective disorders (one way co-morbidity) 10-40% have anxiety disorders Significant increases in incarceration rates Increased likelihood of being in an MVA

11 Prenatal Drug use Alcohol Tobacco use Bleeding Prematurity Stress No evidence re diet

12 Postnatal Head trauma Brain hypoxia Lead poisoning Streptococcal Bacterial Infection Triggers auto-immune antibody attack of basal ganglia No evidence re diet No credible social theory

13 Prefrontal Cortex - 4 functions Working memory Self-regulation of affect / arousal Internalisation of speech Reconstitution - Behavioural analysis Self regulation Future directed self-control of emotions Dopaminergic and noradrenergic pathways

14 Prevalence continues to decrease with age Adults more likely to act in than act out Sometimes can be adaptive Some individuals present when structure of home / school is removed

16 Behaviour Anticipatory avoidance Procrastination Pseudo efficiency Juggling Description Magnifying difficulty of impending tasks and doubts of being able to complete task Deadline-associated stress can help focus Sense of productivity by completing several easy tasks while avoiding high-priority tasks Taking on new projects without completing those already started

17 Key Symptoms

18 Difficulty sustaining attention for homework, chores, etc. Loses things Appears to be not listening Trouble with follow through Easily distracted Daydreams Difficulty sustaining attention in meetings, at work, home responsibilities Disorganized, poor time management Inefficient, procrastinate Trouble with follow through Poor memory, forgetful Distracted Loses things Avoids tasks with mental effort

19 Can t stay in seat, squirming, fidgeting, always on the go Can t wait turn, blurts out answers Can t work or play quietly, runs, climbs excessively Intrudes and interrupts others Talks excessively Restless Impatient Can t sit through meetings (checking , scribbling notes) Impatient (hates waiting in lines), interrupts others Drives fast, likes active jobs, always on the go Inner restlessness

Can t wait turn, blurts out answers Intrudes and interrupts others Quits school, gets into trouble with the law Rushes into things Takes risks Accident prone

20 Can t wait turn, blurts out answers Intrudes and interrupts others Quits school, gets into trouble with the law Rushes into things Takes risks Accident prone Impatient/interrupts Doesn t matter about consequences Makes inappropriate comments ( no mental filter ) Relationship and marital difficulties Spends money beyond means Frequent job/career changes

21 Criteria Inattention Impulsive / hyperactivity Both 5 or more symptoms (was 6) Greater than 6 months Persistent and Maladaptive At least two domains Before the age of 12 (was 7)

22 Avoiding tasks or jobs that require concentration Difficulty initiating tasks Difficulty organizing details required for a task Difficulty recalling details required for a task Poor time management, losing track of time Indecision and doubt Hesitation of execution Difficulty persevering or completing and following through on tasks Delayed stop and transition of concentration from one task to another

Chooses highly active, stimulating jobs Avoids situations with low physical activity or sedentary work May choose to work long hours or two jobs Seeks constant

23 Chooses highly active, stimulating jobs Avoids situations with low physical activity or sedentary work May choose to work long hours or two jobs Seeks constant activity Easily bored Impatient Intolerant and frustrated, easily irritated Impulsive, snap decisions and irresponsible behaviors Loses temper easily, angers quickly

24 A tendency to act first and think after

25 Present along a spectrum Symptoms improve with age? Maturational process Learning new skills Developing adaptive compensatory mechanisms Presence doesn t always require treatment Treatment decisions based upon extent to which it interferes with daily activities

26 Screening

27 Diagnosis based on behaviours only Symptoms along a spectrum Incidental finding Previous history often undocumented Vogue diagnosis increasing self-detection

29 Not diagnostic Self-Reports Point out areas for interventions May identify co-morbid problems ASRS Barkley Screener Weiss Functional Impairment Scale

31 Assessment

32 Concentration Lack of organisation Forgetful School / work performance Underachieving Relationship instability / conflict Impulsivity Family history Poor self-esteem

$a child (not reaching potential) Frequent job changes or moving often Frequent driving infractions Higher number of accidents than average$

33 Patients presenting with: Major Mood and Anxiety D/O (including poor response to treatment) Drug abuse or drug dependence Poor school performance as a child (not reaching potential) Frequent job changes or moving often Frequent driving infractions Higher number of accidents than average population

34 Have you ever been diagnosed with ADHD? Do you have a family of ADHD (siblings, children, parents or extended family)? Did you have any difficulty in school? Did you daydream or have difficulty payment attention? Did you get your homework done on time? Were you disruptive? Anything positive move to Step 2 Do you currently have substantial difficulties with forgetfulness, attention, impulsivity or restlessness that are interfering with your relationships or your success at work? Anything positive move to Step 3 Complete ASRS and Complete Diagnostic Interview

37 Symptoms Course / Time Frame School / work performance - underachieving Other mental health issues / diagnoses Family functioning Relationship history Legal history Drug use Family history History from family

38 Family members can bring a different perspective

39 Management

40 Education Structure Behavioural management Maintaining self-esteem Family interventions Cognitive Behavioural Therapy Medication

41 Information about the prevalence Information about the symptoms Reading materials

42 Driven to Distraction Edward Hallowell and John Ratey Delivered from Distraction Edward Hallowell and John Ratey You mean I m not lazy, crazy or stupid Kate Kelly and Peggy Ramundo

43 Rating Scale Information

44 Daily list of tasks - keep it manageable Keep an appointment book / planner Keep notepads in accessible places Use a personal dictaphone or cell phone to write things down Post key messages in visible places ie car Develop a filing system - file everything immediately Ask a friend / family member to remind you of important events / appointments

management skills Learn to tolerate mood swings Nutrition

45 Memory aids Organizational aids Task fragmentation Prioritization Favour routines Reinforce success Time management skills Learn to tolerate mood swings Nutrition Sleep hygiene Physical activity / exercise Reduce screen time, alcohol, drugs

46 Maintain a sense of humour Set personal / attainable goals Reward yourself when these have been attained If don t work out take a time out to review the situation Develop daily routines Use the structural approaches Stress management

Behaviour Anticipatory avoidance Procrastination Pseudo efficiency Juggling Description Magnifying difficulty of impending tasks and doubts of being able to complete task

47 Behaviour Anticipatory avoidance Procrastination Pseudo efficiency Juggling Description Magnifying difficulty of impending tasks and doubts of being able to complete task Deadline-associated stress can help focus Sense of productivity by completing several easy tasks while avoiding high-priority tasks Taking on new projects without completing those already started

48 Building self-esteem Correcting behaviours during your visit Identify masquerading (cover-up) skills Goal focused - SPEAR Stop Pull-back Evaluate Act Re-evaluate

49 recognise achievements find strengths avoid failures avoid criticism cognitive approaches empowerment

50 Help with assessment Identify other issues Explain and answer any questions Reading material Engage as a coach Support

51 Medication

52 Stimulants Methylphenidate Concerta Biphentin Dextroamphetamine Adderall Vyvanse Atomoxetine Guanfacine Anti-depressants Buproprion Venlafaxine Desipramine

54 Short acting (2-4 hours) Up to 80 mgm. / day Up to 3 divided doses Can be combined with long-acting Side-effects Sleep Appetite Rebound Tics

55 Short acting (3-4 hours) Slow release (spansules) 5 and 10 mgm Up to 40 mgm. / day (twice the potency of MPH) Divided doses Can be combined with long-acting Side-effects Sleep Appetite Rebound

57 Start with a test dose Can use fixed schedule Can use selectively (as needed) Can be used in combination with antidepressants Can be used in combination with long-acting Potential for abuse (resale)

58 mgm Can take up to 2-3 weeks to work Sleep problems Fatigue Upset stomach Dizziness Liver damage Suicidal thoughts

59 1-7 mgm, once daily Can take up to 2 weeks to work Not a stimulant Selective alpha 2A-adrenergic receptor agonist. Reinforces receptors in the brain Can be used in conjunction with a stimulant Swallowed not crushed Stop gradually

60 Product Admin Availability Starting Dose Titration Max Dose Methylphenidate hydrochloride extended-release (Concerta) Tablet in the morning 18, 27, 36, 54 mg 18 mg/day (morning) PRN adjusted weekly 72 mg/day Methylphenidate hydrochloride controlled release (Biphentin) Capsule, in the morning, Can be sprinkled on food 10, 15, 20, 30, 40, 50, 60, 80 mg 10 mg OD (morning) *up to 0.25/mg/kg 10 mg weekly up to max 1 mg/kg/day Not exceeding 80 mg/day Mixed salts amphetamine extended-release (Adderall XR) Capsule in the am. Can sprinkle on applesauce 5, 10, 15, 20, 25, 30 mg 10 mg OC (morning) 5-10 mg weekly up to 20 mg 30 mg/day* Lisdexamfetamin e-dimesylate (Vyvanse) Capsule in the morning. Can dissolve in water 10, 20, 30, 40, 50, 60 mg 30 mg mg/day at weekly intervals 70 mg/day Atomoxetine (Strattera) Capsule once a day or BID 10, 18, 25, 40, 60, mg 40 mg/day (total dose) Up to 60 mg/day after 7-14 days, Up to 80 mg/day after another 7-14 days 100 mg/day Guanfacine (Intuniv) Tablet once a day 1, 2, 3, 4 mg 1 mg Increase weekly by 1 mg Can be used to augment a stimulant 7 mg in adults, 4 in children, 4 in combination

61 Sleep Appetite Less rebound Increased arousal / irritibility Weight loss Slight increase in blood pressure and heart rate but not of stroke or MI

64 Reviews Meta-analyses suggest Faraone 2010 Long-acting no different from short-acting Amphetamine derivatives slightly more effective than methylphenidates Stimulants more effective than anti-depressants

65 Dopamine / Noradrenaline Buproprion Venlafaxine TCAs Desipramine Imipramine SRIS No evidence of any benefits

66 Reviews Meta-analyses suggest Buproprion effective (Verbeeck 2009) Venlefaxine effective (Treuer 2011) Desipramine effective (Maidment 2003) Buproprion more effective than venlefaxine (Habel 2009)

67 High prevalence Can present in many different ways No diagnostic test / use screening tools Provide information about the problem Help provide structure Variety of medication options

Attention Deficit Hyperactivity Disorder State of the Art. Christopher Okiishi, MD

Attention Deficit Hyperactivity Disorder State of the Art Christopher Okiishi, MD What is ADHD? Three subtypes: Inattentive (under diagnosed, esp. in girls) Hyperactive Impulsive Combined Impairments must