ATTENTION DEFICIT DISORDERIN ADOLESCENTS AND

YOUNG ADULTS

Hal Elliott, MDAssociate Professor

Residency Program DirectorDepartment of Psychiatry

Quillen College of MedicineEast Tennessee State University

ADHDor

“Executive Functioning Disorder”

“A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically found in individuals at a comparable level of development”

ADHD: Neurobiologic Basis

ALERTING

EXECUTIVE CONTROL

ORIENTING (SELECTIVE ATTENTION)

Posner and Raichle. Images of the Mind. Scientific American Books; 1996.

Attention Networks

Neural Networks of Attention Prefrontal cortex Parietal cortex Cingulate gyrus Limbic structures (amygdala-hippocampus) Basal ganglia Thalamus Brainstem (reticular formation) Cerebellum

Seidman LJ et al. Biol Psychiatry. 2005;57:1263-1272.

Anterior Cingulate Cortex Cognitive Division Fails to Activate in ADHD

Bush G et al. Biol Psychiatry. 1999;45:1542-1552.

1 x 10-3

1 x 10-2 y = +21 mm

Normal Controls 1 x 10-2

1 x 10-3

y = +21 mm

ADHD

Mean heritability of ADHD = .75 Faraone SV et al. Biol Psychiatry. 2005;57:1313-1323.

ADHD

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Matheny (1971)

Willerman (1973)

Goodman (1989)

Gillis (1992)

Edelbrock (1992)

Stevenson (1992)

Schmitz (1995)

Thapar (1995)

Gjone (1996)

Silberg (1996)

Sherman (1997)

Levy (1997)

Nadder (1998)

Hudziak (2000)

Willcutt (2000)

Thapar (2000)

Coolidge (2000)

Kuntsi(2001)

Martin (2002)

Rietveld (2003)

Laarson( 2004)

Heritability

Panic Disorder Schizophrenia Height

Heritability of ADHD

NEUROBIOLOGY Variation in basal ganglia symmetry and in

corpus collosum

PET: Decreased brain glucose metabolism in basal ganglia of ADHD adults/adolescents (Zametkin et al)

SPECT: Increased striatal availability of a dopamine transporter ( Krause et al)

Catecholamines and Brain Activity

DLPFC, dorsolateral prefrontal cortex; VLPFC, left ventrolateral prefrontal cortex; BS-ACh, pedunculopontine/laterodorsal tegmental nuclei; VTA/SN, ventral tegmental area-substantia nigra; NBM, nucleus basalis magnocellularis; LC, locus coeruleus; DA, dopamine; ACh, acetylcholine; NE, norepinephrine ; NBM, nucleus basalis magnocellularis; VTA, ventral tegmental area; SN, substantia nigra.

Childhood ADD into Adult ADD Spencer et al: 60% of children with ADHD

meet criteria as adults

Spencer, Biederman, Williams: 663/1700 meet criteria

Borland and Heckman: 50% of ADHD kids meet criteria as adults as opposed to 5% of non-ADHD siblings

Lifetime Course of ADHD Symptoms: Inattention Domain

+Difficulty sustaining attentionDoesn’t listenNo follow-throughCan’t organizeLoses important items

Difficulty sustaining attention (meetings, readings, paperwork)Paralyzing procrastinationSlow, inefficientPoor time managementDisorganized

Childhood Adulthood

Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC:

American Psychiatric Association; 2000:85-93; Weiss MD, Weiss JR. J Clin Psychiatry. 2004;65:27-37.

Lifetime Course of ADHD Symptoms: Hyperactivity-Impulsivity Domain

+

Squirming, fidgetingCan’t stay seatedCan’t wait turnRuns/climbs excessivelyCan’t play/work quietlyOn the go/driven by motorTalks excessivelyBlurts out answersIntrudes/interrupts others

Inefficiencies at workCan’t sit through meetings

Can’t wait in lineDrives too fast

Self-selects very active jobCan’t tolerate frustration

Talks excessivelyInterrupts others

Makes inappropriate comments

Childhood Adulthood

Adler L, et al. Psychiatr Clin N Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Washington, DC: American

Psychiatric Association; 2000:85-93; Weiss MD, et al. J Clin Psychiatry. 2004;65:27-37.

0

10

20

30

40

50

60

70

Sub

ject

s R

espo

ndin

g Ye

s (%

)

Drove Before Licensed

≥12 Traffic Citations

≥5 Speeding Citations

License Suspended or Revoked

ADHD (n = 105)Control (n = 64)

≥3 Vehicular Crashes

P =.003

P=.001P=.002P=.001

P=.007

Negative Driving Outcomes From a Driving History Interview

Barkley RA et al. J Int Neuropsychol Soc. 2002;8:655-672.

Traffic Violations and MVA Among Young Adults With ADHD

MVA, motor vehicle accidents.

Driving Problems“ OFFICER, I AM NOT INEBRIATED…I AM

JUST INEPT.”

Britt Elliott ( 1988)

Substance Use Disorders in ADHD Teens Growing Up:

Overall Rate of Substance Use Disorder

Biederman J et al. Pediatrics. 1999;104:e20

0

20

40

60

80

100

Non-ADHD(n=137)

Medicated ADHD

(n=56)

UnmedicatedADHD

(n=19)

Indi

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als

With

Sub

stan

ce

Use

Dis

orde

r (%

)

P<.001

1825

75

Self Rating Scales Copeland Symptom Checklist For Adult

ADHD

Brown Adult ADD Scale( BAADS II)

Amen Scale

Psychoeducational Testing While ADHD is a clinical diagnosis,

consider psychometric testing if:

Diagnosis is unclear Accommodations are needed More details re: exact deficits are needed

or if LD is suspected.

COMORBIDITY IN ADULTS Anxiety Disorders (50%) Substance Abuse ( 27%-47%) Personality Disorder ( 12%-27%) Affective Disorders (multiple estimates)

NO COMORBID DX: 40%

CHRONIC vs. NEW ONSET Childhood Prerequisite

New Onset: medical work-up indicated

Consider: endocrine, sleep apnea, drug interactions, hearing deficit, B12, head injury, heavy metal, seizure disorder.

MRI/CT, EEG, BP, EKG, baseline labs, etc.

Controversy/ Skepticism Re: ADHD in Young Adults

Why? Childhood Onset – difficult to get

accurate history, especially in individuals who have IQ in superior range.

By adulthood comorbidity clouds diagnosis

ADHD is a clinical diagnosis Schedule II medications/fear of

prescribing Countertransference/Cultural Bias

College Student Health at “Highly Selective” Institutions

Wake Forest University: Middle 50% of Students With SAT between

1250-1390 US NEWS and World Report: #25-30 Davidson College : Middle 50% of Students With SAT between 1310-

1440 US News and World Report: #5-11 Both rated “highly selective

ADD Symptoms In College Students:

Distractibility Organizational problems Poor task completion Forgetfulness Careless errors/ trouble with details Sequencing problems Hyper-focusing/ Prioritization Problems “Deer in the Headlights”

ADD in College Students (continued)

Authority Issues Stubbornness Intolerance of silly rules/ assignments Relationship problems ( peer and sig.

other) Frequent changes in major/ schools Poor frustration tolerance Easily bored Poor or inconsistent academic

performance despite adequate or even superior intellectual

abilities

What ADD College/GradStudents Report:

Scattered Anxious/ “Scanning The Horizon” Irritable Chronically Late/ Poor Time Sense Procrastination Bored Easily/ Restless/ Impatient Trouble with Math/Directions Reading Comprehension Problems Compensatory OC Behavior

WHY NOW?( If they didn’t have trouble as small children, doesn’t that

mean they are just lazy?)

Many college students functioning in the intellectual ly superior range never had to study before college

Many students had parents to manage all of their details, scheduling, deadlines, etc

Some students attended exclusive private schools with very rigid day to day routines. External organization kept them structured and limited distractions.

I was a peripheral visionary. I could see the future, but only way off to the side. Steven Wright

“ OVERWHELMED” Adolescents and young adults report an

increase in distress/ anxiety/ disorganization when responsibility increases/ changes at work, home, or school.

EXAMPLES: Birth of child Promotion Increase in academic workload Transitions: First of School Year, Starting

College or Grad School, Moving Rooms, Changing Classes, Weekday to Weekend, Weekend to Weekday, Awake to Sleep, Sleep to Awake

Cause and Effect “Are you scattered because you are

anxious or are you anxious because you are scattered”

“Are you depressed because you can’t get your work done or are you not getting your work done because you are depressed”

Compensatory Anxiety It isn’t compulsive checking behavior if

you really might forget Anxiet y will increase catecholamines and

can increase ability to attend Procrastination creates anxiety when the

work is imminently due….and can increase ability to attend while in “emergency mode”.

Classical conditioning model But…too many catecholamines cause a

shut down effect.

OCD and/vs ADHD OC sxs as a compensatory mechanism.

Ruminating. Lists. Excessive worry. Worst case scenarios.

Not usually repetitive over time. Tend to be day to day worries as opposed to intrusive ego dystonic obsessions

Thoughts jump from one thought to next as opposed to focusing on one obsession

Compulsive sxs are less likely to be linked to obsessive thinking.

Eating Disorders and ADHD

Reports that women with ADHD might be 3-4 times more likely to have an eating disorder

Compensatory for anxiety Possible catecholamine increase with

food rerstriction Catecholamine/Adrenaline rush with

binge eating or bulimic sxs.

BPAD vs. ADHD ADHD often misdiagnosed as Bipolar

Disorder ( and vice versa) Genetic overlap

Hyperactivity /anxiety vs. Mania/Hypomania

Discrete episodes vs. ongoing symptoms

ADHDStimulant Medications

Of pharmacologic options available for ADHD, stimulant medications are the: Most studied Most commonly used Most effective First-line agents for treatment

Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432; Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent

Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent

Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-49S.

PSYCHOPHARMACOLOGYDopaminergic/ Noradrenergic

STIMULANTS: Methylphenidate (Ritalin, Ritalin LA, Metadate CR, Concerta)

Mixed amphetamine salts ( Adderall, Adderall XR),

Dextroamphetamine ( Dexedrine, Dextrostat),

Dextroamphetamine long acting ( Vyvanse)

d-methylphenidate ( Focalin)

PSYCHOPHARM ( cont.) ANTIDEPRESSANTS/ OTHER

Buproprion ( Wellbutrin)Atomoxetine (Strattera)Desipramine/ ImipramineModafinil ( Provigil)Clonidine ( catapress)Intunive (guanfacine )

SSRI’s for comorbidity….not for core symptoms

Why Nonstimulant Treatments for ADHD?

Problems with the stimulants Schedule II drugs (abuse liability, diversion,

medicolegal concerns) 30% do not adequately respond or cannot tolerate

stimulant treatment Short duration of action (compliance,

embarrassment) Side effect profile adversely impacting sleep,

appetite, mood, and anxiety Concerns about cardiovascular effects, growth

suppression, and tic development

Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S;

Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-

49S; Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432.

Non- Medication Intervention

Education Organizational Help (academic

coaching) Learning Assistance Center @ WFU Individual and Couples Therapy CHADD SNL @ Davidson College Exercise Selection of occupation and need for

novelty/ difficulty with change

Family Issues “My parents and I have different ideas

about what I should do after graduation. I want to go to Florence and study Art History. They want me to move into their pool house and become a dental hygienist”

Patient J, Senior at WFU

ACADEMIC ACCOMODATIONS

Leveling the playing field: Quiet Environment Extra Time UC Berkeley Study:

Group Standard Time Extra TimeLD 13th percentile 76th percentileNon-LD 82nd percentile 83rd percentile

Accommodations For Residents

Accommodations for Resident Physicians with Attention Deficit Disorder

Academic Psychiatry

Elliott, Arnold, Brenes, Silvia, RosenquistAugust 2007

Thoughts Re:ADHD Adults

Stimulants/ Schedule II drugs Alteration of sense of self/ blunting of

creativity Non-linear thinkers in the academic

environment. Myth of Laziness. Twice the work for half

the result. “Left handed learners” Responsibility On Square Pegs and Round Holes The Gift of ADD

Creativity and Non-Linear Thinking

“One must still have chaos within oneself to be able to give birth to a dancing star”

Nietszche

Mindfulness and Attentiveness Attentiveness….does not characterize my brothers

and me, all of whom were raised in SC and who have an air of abstraction and carelessness. None of us have a sense of direction. When something breaks, we fix it with duct tape…we tend to live in our own heads than in the actual physical world. We are more likely to get lost, to forget things, to stare blankly off in the distance for minutes at a time…at least part of the reason I resist ( taking something like Ritalin) is that I am not convinced the abstracted end of the mindfulness spectrum is such a bad place to be. In fact, I kind of like it here.

Sometimes I wonder whether it is an accident that of the three abstracted Elliott brothers, two have graduate degrees in philosophy and the other is a psychiatrist.

Carl Elliott, MD, PhD Better Than Well. American Medicine Meets the

American Dream