ADHD 101: The Basics of Evaluation and Treatment Michael Lara, MD Diplomate, American Board of Psychiatry and Neurology Private Practice Psychiatry Belmont, CA www.MichaelLaraMD.com

The only factor becoming scarce in a world of abundance is human attention -Kevin Kelly Always seek the advice of a trained health professional before seeking any new treatment regarding your medical diagnosis or condition. Any information received from this course is not intended to diagnose, treat, or cure. This presentation is for information purposes only.

ADHD Defined

What is ADHD? Neurobehavioral disorder beginning in childhood that results in: Inattention Impulsivity Hyperactivity Causes dysfunction in at least two different areas: Peer or family relationships Work or school Home Symptoms are not accounted for by another medical or psychiatric condition

Neurobehavioral disorder beginning in childhood that results in:

Inattention

Impulsivity

Hyperactivity

Causes dysfunction in at least two different areas:

Peer or family relationships

Work or school

Home

Symptoms are not accounted for by another medical or psychiatric condition

ADHD Prevalence ADHD has been found to exist in every country and culture studied Prevalence among children: 5%-8% Prevalence among adults: 4-8% Gender prevalence: Males: 10% Females: 4%

ADHD has been found to exist in every country and culture studied

Prevalence among children: 5%-8%

Prevalence among adults: 4-8%

Gender prevalence:

Males: 10%

Females: 4%

Genetics of ADHD If you have a…. Your risk for having ADHD is… Parent with ADHD More than 50% Brother or sister with ADHD 41% Child with ADHD 25% Identical twin with ADHD 80%

ADHD in Adolescence 3x more likely to fail a grade 3x more likely to be suspended 2x likely to drop out of school Adolescents with ADHD also have: 4x as many serious injuries 3x as many motor vehicle accidents

3x more likely to fail a grade

3x more likely to be suspended

2x likely to drop out of school

Adolescents with ADHD also have:

4x as many serious injuries

3x as many motor vehicle accidents

ADHD in Adulthood ADHD symptoms persist for up to 65% of patients, even though they might not meet full criteria Survey data suggest that 4.4% of adults have ADHD, yet only 10.9% of adults with ADHD received treatment in the prior year 50% to 75% of adults with ADHD also suffer other mental health disorders ( anxiety, mood disorders, substance abuse) Adults with ADHD earn $10K less than those without ADHD

ADHD symptoms persist for up to 65% of patients, even though they might not meet full criteria

Survey data suggest that 4.4% of adults have ADHD, yet only 10.9% of adults with ADHD received treatment in the prior year

50% to 75% of adults with ADHD also suffer other mental health disorders ( anxiety, mood disorders, substance abuse)

Adults with ADHD earn $10K less than those without ADHD

Consequences of Untreated ADHD Problems at home Twice as likely to have been divorced 30% less likely to say they are “completely satisfied” with family life Problems at work Lower earning potential 40% less likely to be employed full time Almost 60% more job changes within past 10 years Problems in life 47% more likely to have received more than one speeding ticket within a 12-month period More than twice as likely to have been arrested

Problems at home

Twice as likely to have been divorced

30% less likely to say they are “completely satisfied” with family life

Problems at work

Lower earning potential

40% less likely to be employed full time

Almost 60% more job changes within past 10 years

Problems in life

47% more likely to have received more than one speeding ticket within a 12-month period

More than twice as likely to have been arrested

What Causes ADD? No single cause has been identified; most likely the result of environmental factors and genetic predisposition Decreased cerebellar volume Hereditary dopamine deficiency DAT1, DRD4, dopamine beta hydroxylase Nutritional deficiency Zinc deficiency, iron deficiency, omega-3 fatty acid deficiency Toxicity Lead, heavy metals Environmental or lifestyle factors can exacerbate symptoms

No single cause has been identified; most likely the result of environmental factors and genetic predisposition

Decreased cerebellar volume

Hereditary dopamine deficiency

DAT1, DRD4, dopamine beta hydroxylase

Nutritional deficiency

Zinc deficiency, iron deficiency, omega-3 fatty acid deficiency

Toxicity

Lead, heavy metals

Environmental or lifestyle factors can exacerbate symptoms

Differences in the ADHD Brain Pre-frontal Cortex Responsible for executive function that regulates time management, judgment, impulse control, planning, organization, and critical thinking Limbic System Regulates emotion. Affects moodiness, irritability, negatively, and the ability to identify and make sense of emotions Reticular Activating System Responsible for arousal and attention; affects attention and impulse control

Pre-frontal Cortex

Responsible for executive function that regulates time management, judgment, impulse control, planning, organization, and critical thinking

Limbic System

Regulates emotion. Affects moodiness, irritability, negatively, and the ability to identify and make sense of emotions

Reticular Activating System

Responsible for arousal and attention; affects attention and impulse control

Role of Cerebellum in ADD Cerebellum responsible for organizing movement, coordination, and timing Studies in children with ADD reveal a diminished size in cerebellar vermis Some hypothesize that training cerebellum through motor/visual coordination exercises may enhance learning and diminish ADD

Cerebellum responsible for organizing movement, coordination, and timing

Studies in children with ADD reveal a diminished size in cerebellar vermis

Some hypothesize that training cerebellum through motor/visual coordination exercises may enhance learning and diminish ADD

Diagnosis of ADHD

Diagnosis of ADHD History and mental status exam by a trained clinician are the cornerstones of a reliable diagnosis Questionnaires or clinician-administered scales are helpful for eliciting symptoms but are insufficient in themselves for making the diagnosis Limited role for neuroimaging MRI, fMRI, PET, or SPECT scans are of limited use in clinical setting but have a role in the research setting

History and mental status exam by a trained clinician are the cornerstones of a reliable diagnosis

Questionnaires or clinician-administered scales are helpful for eliciting symptoms but are insufficient in themselves for making the diagnosis

Limited role for neuroimaging

MRI, fMRI, PET, or SPECT scans are of limited use in clinical setting but have a role in the research setting

Differential Diagnosis of Adult ADHD Anxiety or Mood disorders Major depressive disorder, bipolar disorder Substance Abuse disorder Stimulant or caffeine abuse Neurologic disorders Seizure disorder, traumatic brain injury Nutritional/Metabolic disorders Hypoglycemia, B12 deficiency, hyponatremia Thyroid dysfunction Sleep disorders Apnea, narcolepsy, shift-work sleep disorder

Anxiety or Mood disorders

Major depressive disorder, bipolar disorder

Substance Abuse disorder

Stimulant or caffeine abuse

Neurologic disorders

Seizure disorder, traumatic brain injury

Nutritional/Metabolic disorders

Hypoglycemia, B12 deficiency, hyponatremia

Thyroid dysfunction

Sleep disorders

Apnea, narcolepsy, shift-work sleep disorder

Neuropsychiatric Disorders that have Inattention as a Core Feature Mood Disorders Major Depression, Bipolar disorder Anxiety Disorders Generalized anxiety disorder, PTSD, OCD Psychotic Disorders Premorbid schizophrenia Traumatic brain injury Developmental Disorders Autism, learning disorders, conduct disorder, oppositional defiant disorders Personality Disorders

Mood Disorders

Major Depression, Bipolar disorder

Anxiety Disorders

Generalized anxiety disorder, PTSD, OCD

Psychotic Disorders

Premorbid schizophrenia

Traumatic brain injury

Developmental Disorders

Autism, learning disorders, conduct disorder, oppositional defiant disorders

Personality Disorders

Attention Deficit Trait ADT, a term coined by Dr. Edward Hallowell, is defined as a neurological phenomenon of cortical overload characterized by: Distractability Inner frenzy Impatience ADT may be regarded as a less-severe form of ADD that is triggered by environmental or lifestyle factors

ADT, a term coined by Dr. Edward Hallowell, is defined as a neurological phenomenon of cortical overload characterized by:

Distractability

Inner frenzy

Impatience

ADT may be regarded as a less-severe form of ADD that is triggered by environmental or lifestyle factors

Diagnostic Criteria for ADD: Inattention Six or more of the following symptoms of inattention: Often fails to give close attention to details Often has difficulty sustaining attention in tasks or play Often does not seem to listen when spoken to directly Often does not follow through on instructions Often has difficulty organizing tasks and activities Often avoids tasks that require sustained mental effort Often loses things necessary for tasks or activities Is often easily distracted by external stimuli Is often forgetful in daily activities

Six or more of the following symptoms of inattention:

Often fails to give close attention to details

Often has difficulty sustaining attention in tasks or play

Often does not seem to listen when spoken to directly

Often does not follow through on instructions

Often has difficulty organizing tasks and activities

Often avoids tasks that require sustained mental effort

Often loses things necessary for tasks or activities

Is often easily distracted by external stimuli

Is often forgetful in daily activities

Diagnostic Criteria for ADD: Hyperactivity-Impulsivity Six or more of the following symptoms of inattention: Often fidgets with hands or feet or squirms in seat Often leaves seat in situations where remaining seated Subjective restlessness or inapproriate motoric activity Often has difficulty in engaging in leisure activities Is often “on the go” or often acts as if driven by a motor Often talks excessively Often blurts out answers before question complete Often has difficulty awaiting turn Often interrupts or intrudes on others

Six or more of the following symptoms of inattention:

Often fidgets with hands or feet or squirms in seat

Often leaves seat in situations where remaining seated

Subjective restlessness or inapproriate motoric activity

Often has difficulty in engaging in leisure activities

Is often “on the go” or often acts as if driven by a motor

Often talks excessively

Often blurts out answers before question complete

Often has difficulty awaiting turn

Often interrupts or intrudes on others

Adult Self-Report Scale (ASRS) How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? How often do you have difficulty getting things in order when you have to do a task that requires organization? How often do you have problems remembering appointments or obligations?

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

How often do you have difficulty getting things in order when you have to do a task that requires organization?

How often do you have problems remembering appointments or obligations?

Adult Self-Report Scale (ASRS) When you have a task that requires a lot of thought, how often do you avoid or delay getting started How often do you fidget or squirm with your hands and feet when you have to sit down for a long time? How often do you feel overly active and compelled to do things, as if you were driven by a motor?

When you have a task that requires a lot of thought, how often do you avoid or delay getting started

How often do you fidget or squirm with your hands and feet when you have to sit down for a long time?

How often do you feel overly active and compelled to do things, as if you were driven by a motor?

Treatment Options for ADHD

How is ADD Treated? Behavioral Modification/Coaching Cognitive behavioral therapy Dietary/Nutritional Modifications B-complex vitamins, Omega-3 fatty acids Exercise Rhythmic aerobic activity at 60-70% maximum heart rate High-Intensity Interval Training at >80% maximum heart rate Lifestyle Modification Limit email, cell phone, internet Medication Stimulant and nonstimulant

Behavioral Modification/Coaching

Cognitive behavioral therapy

Dietary/Nutritional Modifications

B-complex vitamins, Omega-3 fatty acids

Exercise

Rhythmic aerobic activity at 60-70% maximum heart rate

High-Intensity Interval Training at >80% maximum heart rate

Lifestyle Modification

Limit email, cell phone, internet

Medication

Stimulant and nonstimulant

Pharmacologic Options

Monoamines and Attention Anxiety Irritability Appetite Attention Concentration Motivation Drive Mood Serotonin Norepinephrine Dopamine

Serotonin Pathway Tryptophan 5-HTP Serotonin Melatonin Tryptophan Hydroxylase (rate-limiting enzyme)

Dopamine and Norepinephrine Pathway Tyrosine L-Dopa Dopamine Norepinephrine Tyrosine Hydroxylase (rate-limiting enzyme) Dopamine ß hydroxylase Phenylalanine

Pharmacologic Options for ADHD Stimulants Methylphenidate (Ritalin) Dexmethylphenidate (Focalin) Transdermal Methylphenidate (Daytrana) Mixed Amphetamine Salts (Adderall) Lisdexamfetamine (Vyvanse) Dextroamphetamine (Dexedrine) Nonstimulant medications Atomoxetine (Strattera) Modafinil (Provigil) Antidepressants Tricyclic Antidepressants Bupropion

Stimulants

Methylphenidate (Ritalin)

Dexmethylphenidate (Focalin)

Transdermal Methylphenidate (Daytrana)

Mixed Amphetamine Salts (Adderall)

Lisdexamfetamine (Vyvanse)

Dextroamphetamine (Dexedrine)

Nonstimulant medications

Atomoxetine (Strattera)

Modafinil (Provigil)

Antidepressants

Tricyclic Antidepressants

Bupropion

Stimulants D-Amphetamine (Dexedrine) Dexedrine tablets 2-4 hr Vyvanse (Dexedrine prodrug) 8-12 hr Mixed Amphetamine Salts (MAS) AdderallXR 6-8 hr Adderall tablets 3-6 hr D,L-Methylphenidate (MPH) Ritalin 2-4 hr Ritalin-SR 8 hr Ritalin-LA 8 hr Concerta 10-12 hr Dexmethylphenidate XR 8 hr Transdermal MPH 9 hr

D-Amphetamine (Dexedrine)

Dexedrine tablets 2-4 hr

Vyvanse (Dexedrine prodrug) 8-12 hr

Mixed Amphetamine Salts (MAS)

AdderallXR 6-8 hr

Adderall tablets 3-6 hr

D,L-Methylphenidate (MPH)

Ritalin 2-4 hr

Ritalin-SR 8 hr

Ritalin-LA 8 hr

Concerta 10-12 hr

Dexmethylphenidate XR 8 hr

Transdermal MPH 9 hr

Non-Stimulants Modafinil (Provigil) Prohistaminergic mechanism of action “ Non-stimulant” stimulant Approved for excessive daytime sleepiness associated with shift-work sleep disorder, obstructive sleep apnea Atomoxetine (Strattera) Norepinephrine reuptake inhibitor in frontal cortex Dosing in evening or morning Delayed time to onset of therapeutic action Antidepressants Tricyclic Antidepressants BupropionXL (WellbutrinXL)

Modafinil (Provigil)

Prohistaminergic mechanism of action

“ Non-stimulant” stimulant

Approved for excessive daytime sleepiness associated with shift-work sleep disorder, obstructive sleep apnea

Atomoxetine (Strattera)

Norepinephrine reuptake inhibitor in frontal cortex

Dosing in evening or morning

Delayed time to onset of therapeutic action

Antidepressants

Tricyclic Antidepressants

BupropionXL (WellbutrinXL)

Nutritional Practices An Overview

An Overview

Nature’s Pharmacopoeia Tryptophan Tyrosine Serotonin Dopamine Norepinephrine

B-Vitamins and ADHD B-vitamins are co-factors in the synthesis of monoamines Most evidence for B-6 (pyridoxine) deficiency, but B-9 (folate) and B-12 deficiencies have been documented High-stress states deplete body’s stores of B-vitamins Antidepressants and stimulant medications are known to deplete B-vitamins Key ingredient in many OTC formulations for ADHD treatment Focus Factor, Synaptol Recommend High-Potency, Hypoallergenic B-Complex with meals every morning

B-vitamins are co-factors in the synthesis of monoamines

Most evidence for B-6 (pyridoxine) deficiency, but B-9 (folate) and B-12 deficiencies have been documented

High-stress states deplete body’s stores of B-vitamins

Antidepressants and stimulant medications are known to deplete B-vitamins

Key ingredient in many OTC formulations for ADHD treatment

Focus Factor, Synaptol

Recommend High-Potency, Hypoallergenic B-Complex with meals every morning

Omega-3 Fatty Acids Form of polyunsaturated fats Omega-3 and Omega-6s are essential fatty acids (EFAs) Different types of Omega-3s EPA and DHA: tuna, salmon, mackeral ALA: dark, leafy green vegetables and flaxseed Recommend 2-5 g of pharmaceutical-grade Omega 3-Fatty Acids www.zonelabsinc.com www.omegabrite.com

Form of polyunsaturated fats

Omega-3 and Omega-6s are essential fatty acids (EFAs)

Different types of Omega-3s

EPA and DHA: tuna, salmon, mackeral

ALA: dark, leafy green vegetables and flaxseed

Recommend 2-5 g of pharmaceutical-grade Omega 3-Fatty Acids

www.zonelabsinc.com

www.omegabrite.com

L-Tyrosine Essential amino acid; precursor for dopamine Reported to also increase PEA, a mild stimulant found in high concentrations in chocolate Benefits include relief of fatigue, ADHD, mental concentration, athletic performance enhancement Side effects include mild weight loss and GI upset

Essential amino acid; precursor for dopamine

Reported to also increase PEA, a mild stimulant found in high concentrations in chocolate

Benefits include relief of fatigue, ADHD, mental concentration, athletic performance enhancement

Side effects include mild weight loss and GI upset

Always seek the advice of a trained health professional before seeking any new treatment regarding your medical diagnosis or condition. Any information received from this course is not intended to diagnose, treat, or cure. This presentation is for information purposes only. Michael Lara, MD Diplomate, American Board of Psychiatry & Neurology www.MichaelLaraMD.com

Always seek the advice of a trained health professional before seeking any new treatment regarding your medical diagnosis or condition. Any information received from this course is not intended to diagnose, treat, or cure. This presentation is for information purposes only.