treatments diagnosis and challenges in ADHD

1. Edward Thomas Lewis III, M.D.
Clinical Assistant Professor
Attending Physician, Institute of Psychiatry
Associate Director, Forensic Psychiatry Fellowship
Medical University of South Carolina
Department of Psychiatry and Behavioral Sciences
Division of Community and Public Safety Psychiatry

2. • Addiction Psychiatry background
• Not subspecialty trained in child and adolescent
psychiatry
• No relevant financial disclosures

3. • Explore background information
about ADHD
• Diagnosing ADHD in Adults
• Discuss common treatments for
ADHD
• Understand challenges in working
with adults who present with ADHD
symptoms

4. What is ADHD?
 Consistent pattern of inattention
and/or hyperactivity-impulsivity
that interferes with functioning
and/or development.
 Inattention
 Hyperactivity
 Impulsivity

5. Inattention
 Wandering off task
 Lacking persistence
 Difficulty sustaining focus
 Disorganized
 Not due to defiance or lack of
comprehension

6. Hyperactivity
 Excessive motor activity
 Fidgeting
 Tapping
 Talkativeness
 Extreme restlessness (in adults)
 Frustrating peers due to elevated
activity

7. Impulsivity
 Hasty actions that occur in the
moment
 Minimal forethought
 High potential for harm to the
individual
 Social Intrusiveness
 Major Life Decisions

8. ADHD: How Common?
 Global population surveys suggest
ADHD occurs in about 5% of
children and 2.5% of adults.
 More frequent in males than
females
 2:1 M:F in children
 1.6:1 M:F in adults
 50% of children with ADHD will
experience attenuation of
symptoms as they progress into
adulthood

9. Adult ADHD: How Common?
 2.5 – 4.0% of the population
 Hyperactive / Impulsive
presentation is more common in
males
 Adults with ADHD have 4 – 9x
higher prevalence of comorbid
mental health diagnoses
 Bipolar Disorder
 Anxiety Disorders

10. ADHD: Risk Factors
 Very low birth weight
 Smoking during pregnancy
 History of child abuse, neglect,
multiple foster placements,
neurotoxin, infection, or alcohol
exposure in utero
 First degree biological relative with
ADHD

11. ADHD: Progression of Symptoms
 Begins in childhood
 Hyperactivity predominates in
preschool-aged children
 Most often identified in elementary
school
 Inattention is often predominant

12. ADHD: Progression of Symptoms
 Hyperactivity may improve into
adolescence and adulthood, but
restlessness, inattention, poor
planning, and impulsivity persist
 Substantial number of children
with ADHD will remain relatively
impaired into adulthood

13. Negative Consequences of ADHD
 Reduced educational performance
 Social rejection
 Poorer occupational performance
 Higher probability of
unemployment
 Interpersonal conflict
 More likely to be injured
 Traffic accidents
 Obesity
 Incarceration
 Conduct Disorder
 Substance Use Disorders

14. Diagnosing Adult ADHD
https://www.advancingadhd.com/diagnosis

15. Diagnosing Adult ADHD
https://www.advancingadhd.com/diagnosis

16. Emotional Dysregulation (ED)
 Deficiency in executive or cognitive
management of emotions
 Self-regulation of frustration, impatience,
anger
 Emotional Impulsivity
 Mesolimbic Circuitry (“Bottom Up”)
 Deficient Emotional Self-Regulation
 Prefrontal Cortex (“Top Down”)
 Not in DSM-5
 35-70% adults with ADHD experience ED

17. Testing for ADHD: Behavior
Rating Scales
https://www.jaacap.org/article/S0890-8567(09)62182-1/fulltext

18. Testing for ADHD: Behavior
Rating Scales
https://www.jaacap.org/article/S0890-8567(09)62182-1/fulltext

19. Adult ADHD: Scales and Testing
 Role for Neuropsychological Testing
 Continuous Performance Test (CPT)
 World Health Organization (WHO)
Adult ADHD Self-Report Scale
(ASRS)
 Brown Attention-Deficit Disorder
Scale (BADDS)

20. Adult ADHD: ASRS
 Six question scale
 Designed for community samples
 Positive results require follow-up
diagnostic assessment by trained a
clinician
 Score of four or greater is positive

21. Adult ADHD: ASRS
https://www.hcp.med.harvard.edu/ncs/asrs.php

22. Adult ADHD: ASRS
https://www.hcp.med.harvard.edu/ncs/asrs.php

23. Adult ADHD: BADDS
 40-item screening instrument
 Designed for primary/preschool,
school-age, adolescent, and adult
populations
 Based on Thomas Brown’s model of
cognitive impairment in ADHD

24. Treating Adult ADHD:
Pharmacotherapy
 Stimulant medications are front-line management
 National Comorbidity Survey Replication (NCS-R)
 FDA approved medications for Adult ADHD
 Extended release mixed amphetamine salts (Adderall
XR)
 Lisdexamfetamine dimesylate (Vyvanse)
 Atomoxetine (Strattera)
 Bupropion (Wellbutrin)

25. Treating Adult ADHD:
Psychosocial Treatments
 CBT
 Negative Thoughts
 Perfectionism
 Over-estimation of one’s
competence
 Comorbid Depression, Anxiety
 Organizational Skills Training
 Data for CBT in children vs. adults
with ADHD
http://namirockland.org/cbt.html

26. Treating Adult ADHD: Substance
Use Disorders (SUD)

27. Neurobiology of Addiction
https://www.google.com/search?q=hijacking+of+limbic+system&source=lnms&tbm=isch&sa=X&ved=0ahUKEwj3t97R9IvfAhWoTd8KHckaCl0Q_AUIDigB&biw=1920&bih=934#imgrc=-V6hjWyv2C_tUM:&spf=1544123599719

28. Neurobiology of Addiction:
Hijacking of Limbic System
https://www.google.com/search?q=hijacking+of+limbic+system&rls=com.microsoft:en-US:IE-Address&source=lnms&tbm=isch&sa=X&ved=0ahUKEwimnp_M-ovfAhVikuAKHbQlCaQQ_AUIDigB&biw=1920&bih=934#imgrc=UDv2lr0cOu8gXM:&spf=1544125201097

29. Neurobiology of Addiction
Wanting
Liking
Repeated use over time
Needing

30. Treating Adult ADHD: Substance
Use Disorders (SUD)
 ADHD has a prevalence of 22% in
adults with SUD
 More severe disease burden
 Higher comorbidity
 Dopamine System
 Reward Pathways
 Prefrontal Cortex
 Medication Management
 Strategies
 Psychotherapy
 Integrative CBT

31. Treating Adult ADHD: Psychiatric
Comorbidities
 Bipolar Disorder
 Anxiety Disorders
 Depressive Disorders

32. References
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). Arlington, VA: Author.
• Faraone, S. V., & Antshel, K. M. (2008). Diagnosing and treating attention-deficit/hyperactivity
disorder in adults. World psychiatry : official journal of the World Psychiatric Association (WPA),
7(3), 131–136.
• Giulio Perugi, Alessandro Pallucchini, Salvatore Rizzato, Vito Pinzone & Pietro De Rossi (2019)
Current and emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity
disorder (ADHD), Expert Opinion on Pharmacotherapy, DOI: 10.1080/14656566.2019.1618270
• Lopez PL, Torrente FM, Ciapponi A, Lischinsky AG, Cetkovich‐Bakmas M, Rojas JI, Romano M,
Manes FF. Cognitive‐behavioural interventions for attention deficit hyperactivity disorder (ADHD)
in adults. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD010840. DOI:
10.1002/14651858.CD010840.pub2.
 Scrandis, Debra. Diagnosing and treating ADHD in adults. The Nurse Practitioner. 43(1):8–10,
JANUARY 15, 2018 DOI: 10.1097/01.NPR.0000527741.90830.97. PMID: 29240618.
 Van der Burg, D., Crunelle, CL, Matthys, F, Van den Brink, W. diagnosis and treatment of
patient with comorbid substance use disorder and adult attention-deficit and hyperactivity
disorder: a review of recent publications. Curr Opin Psychiatry. 2019 Jul;32(4):300-306.

33. Questions?
Contact: Lewiset@musc.edu