Adult ADHD Flashcards
Subtypes
Inattention – Attention problems remain stable and impairing throughout the life span and affect academic and organisational functioning.
Impulsivity and Hyperactivity may diminish in adolescence but are transformed into restlessness, driven behaviour, stimulus-seeking behaviour, and discomfort from always being ‘on the go’. This may well continue into adulthood. It is important to understand the transformation of the clinical symptoms because it may have relevance both in terms of dosing effect as well as emergence of anxiety and other side effects.
Diagnosis
There should be a high index of suspicion of possible ADHD in patients who have a lifelong history of problems with attention, disruptiveness or impulsive behaviour. These difficulties may become apparent during routine care in patients who demonstrate typical forms of impairment. They may present with:
organisational skill problems (e.g. missed appointments, poor time management, a desk that has mountain of paper, unfinished projects, inability to comply with medication or follow instructions).
an erratic work history (e.g. changed jobs frequently, fired due to lateness, forgetting appointments and/or being unprepared for meetings, difficulty in delegating tasks, describing employers, employees, or clients as frustrated with them).
anger control problems (e.g. argumentative behaviour with authority figures, being overly controlling as parents, fighting with their child’s teachers, “wild-man” rage episodes).
patients who are over-talkative, interrupt frequently or inappropriately (e.g. talking loudly on a cell phone in the waiting room).
marital problems (e.g. spouse complains he/she doesn’t listen, makes impulsive remarks during arguments, forgets important events like birthdays and anniversaries, past relationship breakdowns).
parenting problems (e.g. forgets to routinely give child medications, difficulty establishing and maintaining household routines such as bedtime and meals, difficulty getting child to school). money management problems (e.g. fails to do taxes, makes frequent overdrafts, runs out of money, buys things “on a whim” they cannot afford).
substance use or abuse (e.g. especially alcohol and marijuana), excessive caffeine or energy drink consumption.
addictions such as collecting/hoarding, compulsive shopping, sexual avoidance or addiction, overeating, compulsive exercising, gambling.
a history of missed appointments or being late for appointments.
frequent accidents, involvement in risk-taking or extreme sports.
problems with driving (e.g., speeding tickets, serious accidents, license revoked or, alternatively, choosing not to drive, or driving too slowly in an attempt to compensate for attention problems
Assessments
Before starting treatment for adults with ADHD, a full assessment should be complete, including:
full mental health and social assessment.
risk assessment for substance misuse and drug diversion.
full history and physical examination, including:
a) assessment of history of exercise syncope, undue breathlessness and other cardiovascular symptoms.
b) heart rate and blood pressure.
c) weight.
d) family history of cardiac disease.
e) examination of the cardiovascular system.
f) an ECG if there is past medical or family history of serious cardiac disease, a history.
Rating scales
Rating scales are divided into clinician-administered and self-report forms. Because symptoms like internalised restlessness, feeling disorganised, and being easily distracted are not always apparent to observers, self-report scales are an effective way to capture the symptoms of adults with the disorder.
Some of the rating scales are: ADHD rating scale (ADHS), Copeland symptom checklist- adult version, The Brown ADD scale, The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADS), Conners Adult ADHD rating scale (CAARS) and Adult Self-report Scale.
Treatments
A typical sequence of interventions would be non-pharmacological and pharmacological:
Psychoeducation: for patient and carers about the disorder, its impacts and how to function. Topics might also include information on sleep management, anger, organisational skills etc.
Behavioural intervention and goal setting: this may include short-term counselling, problems solving around residual deficits with executive function or ADLs, and making life changes to decrease stress by improving insight. ADHD coaching and lifestyle managements (diet, exercise, sleep).
Social interventions: includes social skills training, anger management etc.
Assistive and organisational technologies: various hardware and software to diminish a patient’s reliance
on working memory, to compensate for poor handwriting, and improve time management.
Psychotherapy: for adults with/without comorbid conditions (such as poor self esteem, depression and anxiety) including: self talk, CBT, IPT, family therapy, expressive arts therapy and supportive counselling.
Medications for Adults in ADHD
Drug treatment is the first-line treatment for adults with ADHD with either moderate or severe levels of impairment, unless the person would prefer to try a psychological approach. Drug treatment for adults with ADHD should always form part of a comprehensive treatment program that addresses psychological, behavioural and educational or occupational needs.
Methylphenidate (stimulant) is the first line drug. If methylphenidate is ineffective or unacceptable, dexamphetamine (stimulant) or atomoxetine (non-stimulant) can be tried. When starting drug treatment, adults should be monitored for side effects, particularly people treated with atomoxetine as it can cause agitation, irritability, suicidal thinking and self-harming behaviour, and unusual changes in behaviour, particularly during the initial months of treatment.
If using methylphenidate in adults with ADHD:
initial treatment should begin with low doses (5 mg three times daily for immediate release preparations; the equivalent dose for modified-release preparations).
the dose should be titrated against symptoms and side effects over 4–6 weeks.
the dose should be increased according to response up to a maximum of 100 mg/day.
modified-release preparations should usually be given once daily and no more than twice daily.
modified-release preparations may be preferred to increase adherence and in circumstances where there are concerns about substance misuse or diversion.
immediate-release preparations should be given up to four times daily. If using atomoxetine in adults with ADHD:
for people weighing up to 70 kg, the initial total daily dose should be approximately 0.5 mg/kg; the dose should be increased after 7 days to approximately 1.2 mg/kg/day.
for people weighing more than 70 kg, the initial total daily dose should be 40 mg; the dose should be increased after 7 days up to a maintenance dose of 100 mg/day.
the usual maintenance dose is either 80 or 100 mg, which may be taken in divided doses.
a trial of 6 weeks on a maintenance dose should be allowed to evaluate the full effectiveness of
atomoxetine.
If using dexamphetamine in adults with ADHD:
initial treatment should begin with low doses (5 mg twice daily).
the dose should be titrated against symptoms and side effects over 4–6 weeks.
treatment should be given in divided doses.
the dose should be increased according to response up to a maximum of 60 mg per day. the dose should usually be given between two and four times daily.
All the ADHD medications improve inattention. When comorbid disorders exist, prioritising the key symptoms makes the choice of medications simpler and widens the medication options. For example, aggression may be part of many of the comorbid disorders the patient has, but focussing on this symptom addresses the major area of impairment. It is generally advised that the treatment may be determined by the more severe disorder first. Major mood disorders like depression, bipolar disorders and substance abuse disorders should be identified and treated prior to ADHD. Residual symptoms would then require additional treatments. In complex ADHD, patients may be on more than one medication.
