Impairment in Adult ADHD - PDF Free Download

Impairment in Adult ADHD - How impaired is impaired? UKAAN 2016 conference Key challenges and Practical solutions 22 nd April 2016, IET Savoy Place Dr James Kustow Consultant Adult Psychiatrist

Disclosure I have provided Consultancy services to Eli Lilly and Shire I have received speaker fees from Eli Lilly, Jaansen Cilag and Shire I am a member of UKAAN s Executive board and I chair UKAAN s Training committee I am a co-author of the 'Handbook for the Diagnosis and Treatment of ADHD in Adults' (Springer Healthcare) I have a private practice at Nightingale hospital in London

7 reflections on IMPAIRMENT in adult ADHD

1. Don t underestimate the degree and scope of impairment in Adult ADHD

Mean scores in hyperactive-impulsive and inattentive scales Decline of hyperactivity/impulsivity relative to inattention (population data) 1.4 1.2 1 Boys Girls 0.8 0.6 0.4 0.2 0 Hyp-IMP 8-9 Hyp-IMP 13-14 Hyp-IMP 16-17 HYP-IMP: Hyperactivity-impulsivity INN INN 8-9 INN INN 13-14 INN INN 16-17 8-9 13-14 16-17 INN: Inattention Larsson H et al. J Am Acad Child Adolesc Psychiatry 2006;45:973-981.

Impairment in adult ADHD Some of the findings from studies in adults: Relationships are impaired Accidents (RTAs, burns, dog bites etc) are increased Educational and occupational dysfunction is common Criminality is increased Comorbidity is frequently present Unhealthy lifestyles and physical health problems

Impairment in adult ADHD Signs of the disorder may be masked in situations where there: Are frequent rewards / positive affirmation Is lots of structure / supervision (scaffolding) Is passionate interest Is novelty Is external stimulation (e.g. electronic screens) Is high intensity (e.g. professional consultations / interviews)

General approach Allow time Foster collaborative exploration, openness and honesty Show interest and ask lots of questions Have a framework for assessing impairment

DSM5 - defining ADHD Definition of ADHD: A persistent pattern of inattention and/or hyperactivity that interferes with functioning or development American Psychiatric Association: Diagnostic and Statistical Manual (DSM) of Mental Disorders, 5th Edition, 2013

DSM5 criteria Adult ADHD Criteria A: 5 or more symptoms of inattention or hyperactivity-impulsivity Criteria B: Several symptoms present by the age of 12 Criteria C: Several symptoms present in two or more settings Criteria D: Symptoms interfere with or reduce quality of social, educational or occupational functioning Criteria E: Symptoms are not better explained by another condition, such as mood disorder American Psychiatric Association. Diagnostic and Statistical Manual (DSM) of Mental Disorders. 5th Edition 2013

DSM5 Associated features (that support the diagnosis) Development traits Emotional symptoms Education problems Cognitive deficits Mild delays in language, motor or social development are not specific to ADHD but often co-occur. Low frustration tolerance, irritability, mood lability Even in the absence of a specific learning difficulty, academic or work performance is impaired May exhibit cognitive problems on tests of attention, executive function or memory although tests are not sufficiently sensitive or specific to serve as diagnostic indices American Psychiatric Association: Diagnostic and Statistical Manual (DSM) of Mental Disorders, 5th Edition, 2013

NICE - defining impairment Impairment to a degree that most people would consider requires some form of medical, social or educational intervention Without a specialist professional or higher level of intervention to ameliorate the problems, there is likely to be long-term adverse implications for the person affected, as well as problems in the short and medium term Impairment should be pervasive, occur in multiple settings and be at least of moderate severity Significant impairment should not be considered where the impact of ADHD symptoms are restricted to academic/work performance alone, unless there is a moderate to severe impact in other domains

NICE - domains of impairment Psychosocial 1. Work functions Psychiatric 2. Social relationships 3. Coping with daily activities 4. Behavioural problems 5. Distress from the symptoms 6. Low self-esteem 7. Risk for comorbid disorders (addiction, anxiety, depression, personality disorder) NICE Clinical Guideline 72. 2008. http://guidance.nice.org.uk/cg72; 14

DIVA - Impairment domains Work and education Partner and family relationships Social contacts Free time and hobbies Self-confidence and self-image 2 + required for diagnosis

Impairment: Work/Education Adulthood Did not complete education/training needed for work Work below level of education Tire quickly of a workplace Pattern of many short-lasting jobs Difficulty with administrative work/planning Not achieving promotions Under-performing at work Left work following arguments or dismissal Sickness benefits/disability benefit as a result of symptoms Limited impairment through compensation of high IQ Limited impairment through compensation of external structure Childhood Lower educational level than expected based on IQ Staying back (repeating classes) as a result of concentration problems Education not completed / rejected from school Took much longer to complete education than usual Achieved education suited to IQ with a lot of effort Difficulty doing homework Followed special education on account of symptoms Comments from teachers about behaviour or concentration Limited impairment through compensation of high IQ Limited impairment through compensation of external structure

Developmental Impact of ADHD Behavioural disturbance Academic impairment Poor social interaction Lower self-esteem Smoking/alcohol/drugs Antisocial behaviour Co-morbidity Slide from Mina Fazel (based on figure from UKAAN s Handbook of Adult ADHD) Not coping with daily tasks Unemployment Low self-esteem Relationship problems Motor accidents Marital discord Alcohol & substance abuse Mood instability Co-morbidity Pre-school Adolescent Adult School-age College-age Behavioural disturbance Academic impairment Poor social interaction Peer acceptance Co-morbidity Academic failure Not coping with daily tasks Occupational difficulties Low self-esteem Alcohol & substance abuse Injury/accidents Co-morbidity

2. It is important to differentiate symptoms from impairment

Impairment in adult ADHD Adults usually present with impairment (rather than symptoms). Common presentations include: Stuckness / treatment resistance Comorbidities (including substance use) Crises breakdowns in relationships, employment, education..and mental states A struggling partner / parent A&E visits Court appearances

Symptoms vs Impairment SYMPTOMS the behavioural expressions or the actions that are believed to reflect the disorder IMPAIRMENTS the consequences, the outcomes, the costs

Symptoms vs Impairment SYMPTOMS the behavioural expressions or the actions that are believed to reflect the disorder IMPAIRMENTS the consequences, the outcomes, the costs e.g. distractibility at work e.g. losing one s job (possibly as a consequence of the distractibility)

Comorbidity in Adult ADHD From Kooij, J. (2012) Journal of Attention Disorders, online first, April 12, 2012

What predicts what? Studies have demonstrated that different, specific impairments are mediated by particular symptoms / comorbidity: Inattention predicts worse academic performance, work dysfunction, level of employment and life skills Inattention predicts social dysfunction (fully mediated by emotional Sx) Impulsivity predicts family dysfunction (fully mediated by emotional Sx) Comorbidities mainly predict impairment in family and risk domains (e.g. dangerous driving, illegal and sexually inappropriate behaviour and substance misuse) Long term work disability is predicted by high levels of inattention, numbers of comorbid disorders and particular anxiety disorders Negative life events are associated with the severity of ADHD independent of comorbidities

Categorising impairment Category Problems with Activities of Daily Life (ADLs) / Adaptive life skills Explanation Behaviours necessary to live independently e.g. shopping, cleaning, cooking, managing finances etc Functional impairment Executive function impairment Reduced wellbeing (quality of life) Impairment in meeting the expectations of a particular environment / activity e.g. work, relationships, studies, etc. Disrupted executive functions (cognitive processes that regulate and control e.g. working memory, planning, prioritising, goal setting, time, self regulation, behavioural inhibition) Mental and physical health (inc accidents), personal satisfaction and self-worth

Categorising impairment Symptoms (and EF impairments) Impede ADLs Functional impairment Reduced wellbeing Stuckness (and depression)

3. It is worth having a structured approach when assessing impairment

ADHD is NOT a disorder of knowing what to do, but a disorder of being able to do it in the moment (Barkley)

Building a framework key themes 8. Regulating their mood 7. Managing their health 6. Organisation and time management 5. Addictive behaviours? Risk-taking? 4. How they cope with studying 3. Employment issues 2. Patterns / themes in relationships 1. Strengths / skills / talents / interests

WEISS FUNCTIONAL IMPAIRMENT RATING SCALE SELF REPORT (WFIRS-S) Domains include: A. Family B. Work C. School D. Life skills E. Self-concept F. Social G. Risk

A closer look at the WFIRS Self-report scale (validated in both children and adults) Domains include family, work, (school), life skills, self-concept, social and risk Provides a person-specific baseline measure and has been demonstrated to be sensitive to change With medication there is a moderate correlation between symptom improvement and functional improvement Life skills and self concept do not improve to the same degree as other domains with treatment

4. Impairment is the critical to the diagnosis of ADHD but, at the end of the day, it is subjective

Impairment challenges Some challenges of evaluating impairment: It can t be measured it in absolute terms - there are no clearly defined population norms Impairment is often dependent on the environment and the prevailing culture It is a dynamic concept it changes Whether to judge the individual relative to their own potential, or relative to expected norms?

5. Always be clear in your mind what it is that you are treating, and see it as a lifelong, dynamic endeavour (rather than a one-off intervention)

Doctor: I m trying to reduce the symptoms Patient: I know, but what I want is to finish my course / not screw up another relationship / get my tax return done / move forward with my life!

TITRATION ALIGNED PSYCHOEDUCATION (TAP) 4 domains: 1. ADJUSTMENT TO THE DIAGNOSIS - Helps normalise the emotional reaction (and adjustment stages) - Helps address unhelpful schemas and beliefs & allows reframing 2. EDUCATION ABOUT THE DISORDER & TREATMENT APPROACHES - Simple key messages about the disorder and its management 3. EMPOWERMENT & ENGAGEMENT - Identification of STRENGTHS, SKILLS and TALENTS (emphasising +ves) - Building the relationship; Optimising engagement and adherence 4. LIFESTYLE MODIFICATION (10 sub-domains) - Promotion of adaptive LIFESTYLE CHANGES - Introduction of targeted behavioural STRATEGIES

Key transitions 4 important transitions in life, in terms of their potential to destabilise and generate impairment: Leaving school and moving out of the structure and containment of the family home (going to university / into work) Becoming a parent (with all the additional demands, particularly if the child has ADHD) The menopause (in females) Retirement

6. Don t forget the influence of environment, and the prevailing culture on impairment

The Hunter-Farmer theory

Sir Ken Robinson: The impact of industrialisation

All children are born artists the problem is to remain an artist as we grow up (Picasso)

7. Don t forget about physical health when evaluating impairment

ADHD and Physical health ADHD has been associated with a number of physical health problems and markers of physical morbidity: Obesity Diabetes Accidents Eczema and asthma Hypertension Dental problems Somatisation

10 top tips for minimising impairment 1. Advise your patients not to waste their time struggling with the things they are not good at - Align activities / employment with strengths - Avoid / delegate / find creative solutions for weaknesses - Impairment may result from success in a work setting - ADHD friendly employment - often involves risk, novelty, creativity, bursts of activity and relative independence (e.g. self-employed, contractors, entrepreneurs) Teachers Doctors Stockbrokers / traders Pilots Chefs Entertainment / film industry Sales

10 top tips for minimising impairment 2. Help your patients bring in more structure and think about (and change) the environment they inhabit 3. Promote healthy living, in particular, good nutrition and a consistent sleep pattern 4. Educate your patients to really understand and embrace their ADHD 5. Ensure there is a focus on emotional regulation and stress management, with practical guidance

10 top tips for minimising impairment 6. Address addictions where present 7. Recognise and effectively treat other co-existing conditions with good liaison 8. Pull in external resources where necessary, and refer to people who understand ADHD where possible 9. Coach your patients through their relationship difficulties and ordeals focus on communication 10. Warn your patients about common negative outcomes e.g. driving accidents, and urge caution

Thank you