Idea Transcript
Recognizing the Unique Faces of Adults with ADHD David Baron, MSEd, DO Temple University School of Medicine
David Baron, MSEd, DO Disclosures
Research/Grants: National Institute on Drug Abuse; National Institute of Mental Health; Quintiles Transnational Corp. Speakers Bureau: None Consultant: California Academy of Family Physicians; Eli Lilly and Company; Singapore Institute of Mental Health; University of Cairo Stockholder: None Other Financial Interest: Member of the Data Monitoring Team for Pfizer Inc.; has authored books published by University Press and Wiley Press Advisory Board: None
Learning Objective Improve recognition and diagnosis of ADHD in adult patients
Adult ADHD How has it been affected by history
– “Psych acne” concept – Character flaws—is poor hearing a lazy ear? – Making sense of what we know about the genetics of ADHD
Diagnosing ADHD Disease of cortical maturation – Tom Insel 5-7-09 Neuro developmental disorder “Quality of life” threatening disorder,
not life threatening disorder
Diagnosing Adult ADHD Core symptoms of inattention, distractibility,
and impulsivity Be sensitive to BOREDOM Importance of comorbidities
– Anxiety – Depression vs. demoralization – Substance abuse/dependence
Must look for life-long patterns of behavior
and self-esteem
ADHD Scales for Adults Symptom Scale
Informant
Rating Criteria
ADHD Rating Scale with adult prompts
Clinician Rated
DSM-IV-TR
ADHD Rating ScaleIV
Patient
DSM-IV
Adult ADHD SelfReport Screener (ASRS)
Patient
DSM-IV TR
Patient
Series of symptom descriptors reported by high school and college students with nonhyperactive ADD
Brown ADD Rating Scale for Adults
See supplemental bibliography for full references.
Scale 0-3 (not at all, mild, moderate, severe) 18 items 0-3 (never or rarely, sometimes, often, very often) 18 items 0-4 (never, rarely, sometimes, often, very often) 18 items 0-3 (never, once a week or less, twice a week, almost daily) 40 items
ADHD Scales for Adults (cont.) Diagnostic Scale
Informant
Adult ADHD Clinical Diagnostic Scale (ACSD) v1.2
Patient
Conners Adult ADHD Rating Scales (CAARS)
Patient and/or observer
Rating Criteria
Scale
DSM-IV TR
0-4 (never, mild, moderate, severe) childhood and adult symptoms, 21 items each
DSM-IV
0-4 (not all, just a little, pretty much, very much) 30 items
See supplemental bibliography for full references.
Issues to Proactively Explore with Patients Concerns over the diagnosis Concerns over “changing who I am” Stigma over stimulant use “Do I have ADHD or AM I ADHD?”
Clinical Presentation Usually life crisis (job, home, relationship) Saw an ad, talked to a friend, DTC Sent by significant other/family member Read (first few chapters at least) of ADD
book or paper
Online information (can be risky) – ASRS online
Clinical Populations to Further Evaluate Heavy smokers who have failed quit
attempts
– Started smoking early
Excessive caffeine intake daily Multiple job changes Multiple divorces Under-achievers in life None of these are diagnostic, but should raise a yellow flag of suspicion
For Objective ADHD Assessment QuotientTM ADHD System developed from the
McLean Motion & Attention Test (MMAT)
– Office-based, non-invasive, 15-20-minute test provides objective measures that correlate with 3 core ADHD symptoms – Tests for ages 6-14 yo and 15-55 yo
FDA clearance with indication for:
“The QuotientTM ADHD System provides clinicians with objective measurements of hyperactivity, impulsivity and inattention to aid in the clinical assessment of ADHD.” (510K #K020800)
Measures ability to:
– Inhibit motor activity – Sustain attention to visual motor task – Suppress impulsive responses
Key Measures
Measures 19 clinically relevant parameters via proprietary Behavior Capture® System and compares to age- and gender-matched controls in reference database
– 6 measures—Involuntary movements and whole movement pattern via upper and lower infrared motion analysis systems – 6 measures—Response characteristics, accuracy, and changes in attention/impulsivity performance on go/nogo task – 7 measures—Shifts in attention and behavioral state in each 30-second test segment
Internet Connection to Analysis Server
Accurately measures performance motion, attention, and impulsivity domains relevant to ADHD PROPRIETARY COMMUNITY REFERENCE DATABASE
Provides direct measurement of the same control functions assessed by conventional, subjective symptom evaluation methods currently in use – DSM-IV criteria – Symptom rating checklists
Individualized assessment, analysis, and report available in < 1 minute providing objective information for initial evaluation & ongoing management of ADHD
Motion Assessment
(> 1 mm, 50 times/second) Non-ADHD: “single bullet in target” representing minimal position changes (10 yo)
ADHD: “shotgun” pattern of relatively large position changes (10 yo)
Dynamic Attention States in 30-Second Intervals Individual Without ADHD
Individual With ADHD
Integrated Composite Scores QUOTIENT™ ADHD SYSTEM INDEX The Quotient™ ADHD System Index includes 19 indices, 6 for motion and 13 for attention The resulting index profile summarizes the degree of agreement between the Quotient™ ADHD Test results of this patient and patients with ADHD QUOTIENT™ ADHD SYSTEM SCALED SCORES Motion Scaled Score Quantification of severity of motion control deficit compared to the community sample Attention Scaled Score Quantification of severity of attention and impulsivity control deficit compared to the community sample Global Scaled Score Combination of indices for this patient as compared to the community sample
Higher scaled scores indicated greater age adjusted deficit and are more strongly associated with the scores that patients with ADHD receive.
Treatment Issues This is not a disease created by pharma to
sell drugs
– Educate patients as to recent advances in understanding ADHD as a brain disease Data supports medications as a mainstay
of treatment and necessary for optimal functioning
– Make the brain more efficient in communicating with itself
Adult ADHD Treatment
No data to demonstrate individual
superiority of one class of medication over another—all work, just not in everyone
Key issues are dosing, length of action,
and side effects
Potential Emerging Therapies* qEEG (quantitative EEG)1 – Some reports of effectiveness Neurofeedback2 Numerous alternative therapies – Limited quality data Guanfacine—old drug, new package3 – Nonstimulant * These treatments are not approved by the FDA 1. Monastra VJ, et al. Neuropsychology 1999;13:424-433. 2. Butnik SM. J Clin Psychol 2005;61:621-625. 3. Taylor FB, et al. J Clin Psychopharmacol 2001;21:223-228.
WiltonLogic* To measure effects of treatments or disease
progression on impulsive behavior in psychiatric and neurological patients
By developing new computerized psychological
tests for assessing impulsive behavior and executive function – – – –
Use laptop computers with touchscreen input Can be administered by lay personnel Translation to animal models considered in design Tests not language-based, cross-cultural use possible
* Pending funding
Score points for good performance Follow progress towards test completion
Accumulate points by completing questionnaires or from the objective tests to earn performance based rewards
Clear visual and auditory feedback so the participant knows the results of each response
Animation to guide responding and increase engagement
Large, brightly colored buttons make accurate responding easy
Status
Examples of Areas Covered by Current Software Impulsive behavior Response inhibition Delay of gratification Reflection impulsivity Risk taking
Executive function Control of attention Working memory Learning Rule following Planning
Currently seeking grant funding Extend validation in young and older healthy subjects Test sensitivity to psychoactive drugs Begin systematic clinical testing in specific disorders such as ADHD, addiction, neuroAIDS
Key to Drug Therapy They all work, just not in everyone No data to support any class is better for
specific symptom (inattention, hyperactivity, impulsivity) Key issue is proper dosing Pharmacogenomics not always a good predictor As in all of clinical medicine, must focus on “life disabilities” and defend the phenotype
Summary Recognize clinical populations that raise
the yellow flag
Utilize screening and diagnostic tools
in practice
Talk with patient about neurobiological
basis of adult ADHD
Current treatments can work, need to
individualize treatment
an educational series offered by CME Outfitters, LLC
This CME/CE activity is co-sponsored by
Recognizing the Unique Faces of Adults with ADHD David Baron, MSEd, DO Brown TE. Brown Attention-Deficit Disorder Scales. http://pearsonassess.com/HAIWEB/Cultures/enus/Productdetail.htm?Pid=015-8029-240&Mode=summary. Accessed July 2009. Butnik SM. Neurofeedback in adolescents and adults with attention deficit hyperactivity disorder. J Clin Psychol 2005;61:621-625. Conners CK, et al. Conners’ Adult ADHD Rating Scale. Available at: http://www.pearsonassessments.com/test/caars.aspx. Accessed July 2009. DuPaul GJ, et al. ADHD Rating Scales-IV: Checklists, Norms and Clinical Interpretations. New York, NY; Guilford Press;1998. Kessler RC, et al. Int J Methods Psychiatr Res 2007;16:53-65. Monastra VJ, Lubar JF, Linden M, et al. Assessing attention deficit hyperactivity disorder via quantitative electroencephalography: an initial validation study. Neuropsychology 1999;13:424-433. Murphy KR, Adler LA. Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales. J Clin Psychiatry 2004;65(Suppl 3):12-17. Taylor FB, Russo J. Comparing guanfacine and dextroamphetamine for the treatment of adult attention-deficit/hyperactivity disorder. J Clin Psychopharmacol 2001;21:223-228.
Supplemental Bibliography for: Recognizing the Unique Faces of Adults with ADHD David Baron, MSEd, DO Slide Title: ADHD Scales for Adults 1. DuPaul GJ, et al. ADHD Rating Scales-IV: Checklists, Norms and Clinical Interpretations. New York, NY; Guilford Press;1998. 2. Conners CK, et al. Conners’ Adult ADHD Rating Scale. Available at: http://www.pearsonassessments.com/test/caars.aspx. Accessed July 2009. 3. Murphy KR, Adler LA. Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales. J Clin Psychiatry 2004;65(Suppl 3):12-17. 4. Kessler RC, et al. Int J Methods Psychiatr Res 2007;16:53-65. 5. Brown TE. Brown Attention-Deficit Disorder Scales. http://pearsonassess.com/HAIWEB/Cultures/enus/Productdetail.htm?Pid=015-8029-240&Mode=summary. Accessed July 2009.
Slide Title: ADHD Scales for Adults (cont.) 1. DuPaul GJ et al. ADHD Rating Scales-IV: Checklists, Norms and Clinical Interpretations. New York, NY; Guilford Press;1998. 2. Conners CK, et al. Conners’ Adult ADHD Rating Scale. Available at: http://www.pearsonassessments.com/test/caars.aspx. Accessed July 2009. 3. Murphy KR, Adler LA. Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales. J Clin Psychiatry 2004;65(Suppl 3):12-17. 4. Kessler RC, et al. Int J Methods Psychiatr Res 2007;16:53-65. 5. Brown TE. Brown Attention-Deficit Disorder Scales. http://pearsonassess.com/HAIWEB/Cultures/enus/Productdetail.htm?Pid=015-8029-240&Mode=summary. Accessed July 2009.