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
No funding or support from Industry for any aspect of this presentation or my work
Except my lifelong commitment to
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
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
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
? 50 – 60 adults in an average family practice
Democratic
Male : female 2:1 ◦ Self-perception
Changing prevalence with age
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
Prenatal
◦ Drug use
◦ Alcohol
◦ Tobacco use
◦ Bleeding
◦ Prematurity
◦ Stress
No evidence re diet
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
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
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
Behaviour Description
Anticipatory avoidance Magnifying difficulty of impending tasks and doubts of being able to complete task
Procrastination Deadline-associated stress can help focus
Pseudo efficiency Sense of productivity by completing several easy tasks while avoiding high-priority tasks
Juggling Taking on new projects without completing those already started
Key Symptoms
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
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 email, 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 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
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)
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 activity
Easily bored Impatient Intolerant and frustrated, easily irritated
Impulsive, snap decisions and irresponsible behaviors
Loses temper easily, angers quickly
A tendency
to act first
and think
after
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
Screening
Diagnosis based on behaviours only
Symptoms along a spectrum
Incidental finding
Previous history often undocumented
“Vogue” diagnosis – increasing self-detection
Not diagnostic
Self-Reports
Point out areas for interventions
May identify co-morbid problems ◦ ASRS
◦ Barkley Screener
◦ Weiss Functional Impairment Scale
Assessment
Concentration
Lack of organisation
Forgetful
School / work performance
Underachieving
Relationship instability / conflict
Impulsivity
Family history
Poor self-esteem
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
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?
Do you currently have substantial difficulties with forgetfulness, attention, impulsivity or restlessness that are interfering with
your relationships or your success at work?
Complete ASRS and Complete Diagnostic Interview
Anything positive – move to Step 2
Anything positive – move to Step 3
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
Family
members can
bring a
different
perspective
Management
Education
Structure
Behavioural management
Maintaining self-esteem
Family interventions
Cognitive Behavioural Therapy
Medication
Information about the prevalence
Information about the symptoms
Reading materials
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
Rating Scale
www.med.nyu.edu/psych/assets/adhdscreen18.pdf
Information
www.caddac.ca
www.chaddcanada.org
www.adhdcanada.ca
http://www.caddra.ca/
www.ADHDandYou.ca
www.associationpanda.qc.ca
http://www.attentiondeficit-info.com/home.php
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
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
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
Maintain a sense of humour
Behaviour Description
Anticipatory avoidance Magnifying difficulty of impending tasks and doubts of being able to complete task
Procrastination Deadline-associated stress can help focus
Pseudo efficiency Sense of productivity by completing several easy tasks while avoiding high-priority tasks
Juggling Taking on new projects without completing those already started
◦ Building self-esteem
◦Correcting behaviours during your visit
◦ Identify masquerading (cover-up) skills
◦Goal focused - SPEAR
Stop
Pull-back
Evaluate
Act
Re-evaluate
recognise achievements
find strengths
avoid failures
avoid criticism
cognitive approaches
empowerment
Help with assessment
Identify other issues
Explain and answer any questions
Reading material
Engage as a “coach”
Support
Medication
Stimulants
◦ Methylphenidate
◦ Concerta
◦ Biphentin
◦ Dextroamphetamine
◦ Adderall
◦ Vyvanse
Atomoxetine
Guanfacine
Anti-depressants
Buproprion
Venlafaxine
Desipramine
◦ 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
◦ 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
Start with a test dose
Can use fixed schedule
Can use selectively (as needed)
Can be used in combination with anti-
depressants
Can be used in combination with long-acting
Potential for abuse (resale)
40-120 mgm
Can take up to 2-3 weeks to work
Sleep problems
Fatigue
Upset stomach
Dizziness
Liver damage
Suicidal thoughts
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
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*
Lisdexamfetamine-dimesylate (Vyvanse)
Capsule in the morning. Can dissolve in water
10, 20, 30, 40, 50, 60 mg
30 mg 10-20 mg/day at weekly intervals
70 mg/day
Atomoxetine (Strattera)
Capsule once a day or BID
10, 18, 25, 40, 60, 60 100 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
Sleep
Appetite
Less rebound
Increased arousal / irritibility
Weight loss
Slight increase in blood pressure and heart rate
but not of stroke or MI
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
Buproprion
Venlafaxine
TCAs ◦ Desipramine
◦ Imipramine
SRIS ◦ No evidence of any benefits
Dopamine / Noradrenaline
Reviews – Meta-analyses suggest
Buproprion effective (Verbeeck 2009)
Venlefaxine effective (Treuer 2011)
Desipramine effective (Maidment 2003)
Buproprion more effective than venlefaxine (Habel 2009)
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
