Adult Attention-Deficit/ Hyperactivity Disorder: Practical Treatment Guidelines Umesh Jain B.Sc., M.D., F.R.C.P.(C), D.A.B.P.N., Ph.D., M.Ed. (Cand.) Hospital for Sick Children /Centre for Addiction and Mental Health Adolescent and Adult ADHD Research Service 4/20/2004 1
Disclosures Research Public-based funding Canadian Institutes of Health Research Ontario Mental Health Foundation Ontario Problem Gambling Foundation Ministry of Health of Canada and Ontario Hospital for Sick Children Foundation Industry-based funding Eli Lilly Purdue Pharma GSK (SKF) Janssen-Ortho Celltech Novartis Sponsorships Above plus Abbott Pfizer AstraZeneca Rhone-Poulec Wyeth Apotex Shire Bristol Myers Squibb 4/20/2004 2
Objectives Review the Diagnosis of ADHD Current Medication Treatment Guidelines Review of Psychological Approaches Behavioral Management 4/20/2004 3
Diagnosis of ADHD Still an observational diagnosis DSM-IV Criteria though threshold could be too high, thought still the standard Likely 4/9 (Barkley et al., 2001) Shouldn t apply age 7 criteria (Applegate et al., 1996) Semi-structured interview should be done Measurement of Impairment 4/20/2004 4
Subtype Evaluation ADHD, Combined Subtype most common most have concurrent symptoms related to anxiety ADHD, Inattentive may be related to mood disorder may be etiologically different from ADHD ADHD, Hyperactive-impulsive rare Prison population 4/20/2004 5
Self-Report Rating Scales Brown Adolescent ADD Rating Scale - seems to be weighted to ADHD-I Conner s ADHD Rating Scales (children + adolescents + adults) Good norms Wender Utah Rating Scale Heavily weighted to ADHD-C Good if collateral fills it out Public domain (Ward et al., 1993) with scoring system 4/20/2004 6
Psychoeducational Classroom ADHD, Inattentive Subtype Focused blank stare ADHD, Combined Subtype Easy to pick out Office setting, make them do a task 4/20/2004 7
Personality Disorder Evaluation Both have Passive-aggressive will present as Oppositional Defiant Disorder ADHD, Combined linked to Cluster B Borderline Antisocial ADHD, Inattentive linked to Cluster A Avoidant Obsessive-compulsive 4/20/2004 8
Medication Management Stimulants Adults methylphenidate max 1 mg/kg/day Dextro-amphetamine 0.5 mg/kg/day ( Dexedrine Spansules is twice this but per day) Dextro-amphetamine salts (Adderal XR) MPH LA preparations now available (Concerta) 4/20/2004 9
Catecholamine-based medications Atomoxetine (Strattera) Large scale study in children and adults Noradrenaline based Buproprion (Wellbutrin) Dopamine agonist shows good results Buspirone (Buspar) Case series with positive effects 4/20/2004 10
Combination Interventions SSRI + Stimulants SSRI = Dextro-amphetamine > Placebo in ADHD-I Dextro-amphetamine > SSRI > Placebo ADHD-C Stimulants + Mood Stabilizers Methylphenidate + Lithium 4/20/2004 11
Combination Interventions Stimulants + Atypical Neuroleptics Best for patients with high impulsivity Borderline or Antisocial PD Possibility of some Bipolar variant Good as a means to counter appetite problems 4/20/2004 12
Psychological Strategies Problem Focused Therapy Patients like direction CBT Gives patients control Psychodynamic Therapy Gives patient feelings of trust 4/20/2004 13
Dynamic Issues Early attachment problems False Self Detachment from primary self Attention Deficit or Deficit Attention Patients need to be listened to Issues around trust Unconditional acceptance 4/20/2004 14
Behavioral Strategies Lifestyle alterations Busy life Organizational Issues Time management Anger Management Impatience and burden Relationship Problems Unconditional Acceptance 4/20/2004 15
Substance Abuse- Self Medication Gravitate to dopamine agonists (e.g. cannabis and cocaine) May use alcohol leading to serotonin dysregulation Problems with minor tranquilizer and opiate agonist use OCD analgesics can be a problem 4/20/2004 16
Practical Issues ADHD as a disability diagnosis ADHD as a legal defense ADHD as a need for accommodation As a student 4/20/2004 17
Practice Points Presentation of a Mood Disorder Psychoeducation Conservative Medication Management Probable Combination Interventions 4/20/2004 18
Community Resources Adolescent and Adult ADHD intake 416-535-8501 x4374 ruth_barton@camh.net 4/20/2004 19