ADHD nelle ragazze e donne. Topics ADHD IS NOT OUTGROWN. in boys only?

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ADHD nelle ragazze e donne come identificare gli estremi di ansia e emozione, il tipo disattento, come risolvere i problemi di vita quotidiana Dr. J.J. Sandra Kooij Psychiatrist Head Program Adult ADHD
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ADHD nelle ragazze e donne come identificare gli estremi di ansia e emozione, il tipo disattento, come risolvere i problemi di vita quotidiana Dr. J.J. Sandra Kooij Psychiatrist Head Program Adult ADHD & Expertise Centre Adult ADHD PsyQ, psycho-medical programs The Hague, the Netherlands Topics Transition of ADHD from childhood to adulthood Prevalence of ADHD in children and adults Underdiagnosis of girls and women Are girls and women lost to Chronic Fatigue Syndrome or Burn-out? Neurobiology and genetics of ADHD Clinical picture and diagnostic assessment Comorbidity and gender Treatment Resources: books and internet Professional ADHD Networks in Europe ADHD IS NOT OUTGROWN in boys only? 1 ADHD children grow up ADHD in adults is a relatively new diagnosis Professional recognition is increasing But ADHD in adults has not yet been integrated in professional education Children with ADHD may stay as long as possible with pediatrician or GP, or are lost to follow up (until age 38!) Adults: aware of their condition and actively looking for help (internet) Patient organisations for adults are emerging Children: Prevalence of ADHD in children and adults USA 4-8% % persisting ADHD 50-60% Adults: USA 4-5% 10 countries (mean) 3.4% ITALY 2.8% Faraone 2003; Kessler 2006; Murphy & Barkley, 1996; Kooij 2005; Fayyad 2007 Treatment % per country in people with ADHD Medical treatment Mental treatment Any treatment Belgium Italy NL Treatment for ADHD USA Fayyad Prevalence (%) ADHD and gender: Men more often ADHD? Children M : F Adults M : F Clinical studies 2-9 x 1-2 x General population studies 2-3 x 1-1.5x Taylor 2004; Nice guidelines 2008; Kessler 2006; Fayyad 2007; Kooij 2005 Gender differences children and adults Childhood M F Adulthood M=F Underdiagnosis in girls Girls have more ADD Girls with ADHD (n=140) Boys with ADHD (n=140) Combined Hyperactive/ impulsive Inattentive Biederman 1994, Causes of underdiagnosis of ADHD in girls Referral bias ADD subtype Internalising comorbidity (depression, anxiety, premenstrual dysphoric disorder) Complaints girls and women with AD(H)D PMDD Chaotic Distracted No Overview Overwhelmed Moodswings ADD Unmotivated Tired Depressed Low selfesteem Lazy Panic Girls and women 2x more often ADHD inattentive type But majority has still ADHD combined type Women have to organise themselves, family, household, childrens agenda s and their job Being a women with ADHD is a job from hell, always late, forgetting things Chaos and tiredness their daily bread Low selfesteem and uncertainty about capabilities the result 4 Room with a view? Is ADHD like Chronic Fatigue Syndrome (CFS)? Inattentive girls referred for being tired? Clinical studies: boys more often ADHD Epidemiological research: girls similar percentage ADHD as boys ADHD in girls is less well known, and their behaviour less disruptive than in boys Boys have more often: ADHD, combined type More severe hyperactivity Externalising comorbidity (oppositional defiant or aggressive behaviour) Being disruptive helps to get help. Biederman ea, 1994; 2002, 2004; 2005 Girls are not disruptive Inattention takes continuous mental effort, leading to exhaustion but may be chronically tired! 5 What happens to girls and women with AD(H)D? Potential referral to neurologist or pediatrician for complaint of being tired or sleepy CFS: 4x as often in girls In women with ADHD, often past diagnosis of CFS Are girls and women with ADD or ADHD lost to CFS? Gerger, APA 2007; van de Putte 2006 Tired girls and overlap with ADHD Chronic tired Les sportive More often anxiety, depression, obesity (higher BMI) Family members with ADHD and CFS Hereditary factor: concordance twin studies (.5) Mothers: also tired, depressed, anxious en working less hours Lower results on same attention tasks as in ADHD (interference) Van de Putte, 2006 ADHD and CFS need further study Screening for ADHD in Burnout or CFS group Methylphenidate treatment in subgroup with diagnosis of ADHD may ameliorate tiredness and inattention Physical complaints in ADHD need further study (RSI, burnout, neck- and backpains, obesity, chronic tiredness, chronic sleepproblems) 6 Neurobiology of ADHD Highly heritable (80% of variance explained by genetic factors) Neurobiological disorder: brain 5% smaller and less active 8 kandidate genes, esp. dopaminergic (DRD2,4,5, DAT1) ADHD as an inhibition deficit based on dopamine deficiency Methylphenidate: dopamine agonist; acts as inhibitor of associations, moodswings, restlessness and impulsivity Thapar 1999; Faraone 2005; Castellanos 2002; Bush 2006 Kessler 2006; Kooij 2005 ADHD symptom scores in twin studies: highly heritable Boomsma 2003 Martin 2002 Kuntsi 2001 Coolidge 2000 Thapar 2000 Willcutt 2000 Hudziak 2000 Nadder 1998 Levy 1997 Sherman 1997 Silberg 1996 Gjone 1996 Thapar 1995 Schmitz 1995 Stevenson 1992 Edelbrock 1992 Gillis 1992 Goodman 1989 Matheny 1980 Willerman Heritability Other biological, non-hereditary factors During pregnancy: High bloodpressure Smoking Alcoholabuse Bleeding/infections Associated with premature birth and low birthweight During delivery: Hypoxia (2%) 7 Developmental trajectories of brainvolumes (Castellanos et al., JAMA,2002) Anterior Cingulate (Cognitive Division) Fails to Activate in ADHD MGH-NMR Center & Harvard- MIT CITP Bush et al., Biol. Psychiatry, 1999 Normal Controls ADHD y = +21 mm -2 1 x 10 y = +21 mm -2 1 x x x 10 8 The brain in ADHD compared to NCs: Smaller, Hypoactive & Impaired functioning Clinical picture of ADHD Lifetime symptoms of Attention-Deficit/Hyperactivity Disorder: Inattention: distracted, chaotic, forgetful, late, difficulty making decisions, organising and planning, no sense of time, procrastination Hyperactive: (inner) restlessness, tense, talkative, busy; coping by: excessive sporting/alcohol abuse/avoiding meetings Impulsive: acting before thinking, impatient, difficulty awaiting turn, jobhopping, binge eating, sensation seeking In addition in 90% of adults, lifetime: Moodswings (5x/day) and Anger outbursts APA 1994; Kooij 2001, 2010; Conners 1996 Decrease of hyperactivity in adults Hyperactivity is adjusted, compensated for, or experienced as more inner restlessness : Avoiding meetings where you have to sit stil Excessive sporting Hectic job full of change Cannabis / alcohol / tranquillisers against restlessness Talkativeness, inner restlessness The decrease in marked outward visible hyperactivity has presumably been the reason why we mistakenly have thought that ADHD was outgrown 9 Inattention most invalidating symptom in adults Adults need more attention than children: Procrastination Chaos Difficulty organising Being late Difficulty reading and remembering Forgetting things or appointments And yet using no watch or agenda! ADHD in DSM-IV Attention-deficit/hyperactivity disorder 18 criteria: 9 attention problems (A) and 9 hyperactive/impulsive criteria (HI) Diagnosis in childhood from 6/9 of one or both domains 3 subtypes: ADHD, inattentive type (also ADD) (10-15%) ADHD, hyperactive/impulsive type (3%) ADHD, combined type (85%) Problems with DSM-IV criteria Developed and validated for use in children 4-16 yrs of age Formulation based on behaviour like climbing in trees In children: informant report by parents/teachers In adults: selfreport Formulation not tailored to adults, not for selfreport Diagnostic threshold not tailored to adults Age of onset ( age 7) not remembered by adults or their old parents Age of onset age 7 never validated in children Age of onset in DSM-V will be: age ALL LEAD TO UNDERIDENTIFICATION AND UNDERDIAGNOSIS OF ADULTS! Barkley 2002; Kooij 2005; Faraone 2000, 2004, Impairment in adult ADHD In clinical as well as epidemiological samples compared to NCs: Learning problems (60%) Less graduated Lower education Lower income Less employed, more sickness leave More job changes (longest job 5 yrs) More often arrested, divorced and more social problems More driving accidents, teenage pregnancies, suicide attempts Higher (mental) health care costs Biederman 2006; Kooij 2001, 2005; Barkley 2002; Manor, in prep 2008 Comorbidity in ADHD children (in 66%) and gender Oppositional Defiant Disorder M F Conduct Disorder M F Autism Spectrum Disorders M F Anxiety F M Depression M F Premenstrual Dysphoria F Substance abuse disorders F M! Bipolar Disorders M F Biederman 1994, 2002, 2004 Comorbidity in adults with ADHD ADHD comes seldom alone: 75% at least one other disorder 33% two or more Mean: 3 comorbid disorders Biederman 1993; Kooij 2001, Comorbidity in adult ADHD % M : F Depression (60% SAD) = Bipolar Disorder (88% BP II) 10 = Anxiety Disorders F M SUD M F Smoking 40 F M Cluster B Pers. Disorders 6-25 M F Sleeping Problems (DSPS?) 75 = Muscle, joint, neck- and backpain?? Biederman 1991,1993, 2002; Weiss 1985; Wilens 1994; Kooij 2001, 2004, 2010; van Veen 2010; Amons 2006; Cropsey 2008 Diagnostic Assessment Screening instruments (ASRS, CAARS, ADHD- RS, BADDS, WURS) ASRS online: Structured Diagnostic Interviews based on DSM-IV (CAADID, DIVA 2.0) NEW: DIVA 2.0 Now available in Dutch, English and Norwegian Translation in 12 languages Next: Swedish Spanish DIVA 2.0 online free of charge: 12 Cutoff current DSM-IV criteria in adults? Epidemiological study (n=1800): adults were significantly more impaired starting from 4/9 current ADHD criteria: of inattention as well as hyperactivity/impulsivity in both genders, and in young and old people effect remained significant after controlling for impairment due to comorbidity (GHQ) ADHD proved to have its own contribution to impairment, independent of comorbidity C/ 6/9 symptoms in childhood and 4 or more current DSM-IV symptoms may lead to diagnosis of ADHD in adulthood Kooij 2005 Outline Diagnostic Assessment Early onset in life Chronic persistent course Chronic impairment or compensation/coping causing secondary impairment Mainstay of ADHD diagnosis is: CHRONICITY The period that ADHD symptoms are remembered will be longest in older adults Ultrashort screening of ADHD in adults 1. Are you usually restless? 2. Are you usually easily distracted or chaotic? 3. Do you usually do things before thinking? If 1 of 3 answers = yes: 4. Did you have this symptom all your life? If yes, further diagnostic assessment of ADHD Kooij Additional assessment Neuropsychological: no test available with diagnostic valid properties. Only differences on group-, not individual level regarding executive functioning Neuro-imaging: differences on grouplevel, no diagnostic test DNA: possibly in the future a risk-gene test Event Related Potentials: differences on grouplevel, no diagnostic test Endophenotypes: combinations of neuroimaging, genes and neuropsychology: no test so far ADHD, sleep, circadian rhytm, mood and weight ADHD 78% 10% 27% 18%? DSPS 25% BP II 20% SAD Overweight Goikolea 2007; Amons & Kooij, 2006; Kooij 2001 Lewy 2006; van Veen 2010 Sleep problems in 120 adults with ADHD Difficulty going to bed on time 78% falling asleep 70% sleeping through 50% getting up in the morning 70% daytime sleepiness 62% This lifetime pattern in 60%, suggestive of Delayed Sleep Phase Syndrome (DSPS) Kooij, SLTBR Melatonin rhythm melatonin DLMO clock time Delayed Circadian Rhythm in Adults with Attention-Deficit/Hyperactivity Disorder and Chronic Sleep Onset Insomnia Biological Psychiatry 2010 Jun 1;67(11): Maaike M. Van Veen, J.J. Sandra Kooij, A. Marije Boonstra, Marijke C.M. Gordijn, Eus. J.W. Van Someren Results sleep onset insomnia in 40 adults with ADHD SOI (n=30) no-soi (n=9) p Sleep start (hr) 1:42±1:22 0:14±1: * Sleep end (hr) 9:27±1:44 8:26±0: ** Total sleep duration (hr) Sleep efficiency (%) 6:53 7: * * * Student s t-test; equal variances assumed ** Welch s t-test; equal variances not assumed Significance kept at p Results Dim Light Melatonin Onset (DLMO) DLMO 23:15 ± 1:19 (n=26) SOI no-soi p 22:00 ± 0:54 (n=8) 0.02* * Student s t-test; equal variances assumed Significance kept at p 0.05 Late sleep = short sleep late meals Possible impact of a delayed rhythm on weight and health: Sleeping late may lead to a short sleep duration Short sleep duration is associated with obesity Adults with ADHD tend to skip breakfast Breakfast skipping is associated with obesity ADHD patients suffer from eating problems in 80%, mostly binge eating Their weight fluctuates kg s Obesity is associated with diabetes, cardiovascular disease and cancer Kooij, in prep 2010; Dubois 2008; Boere 2008; Mota 2008; Copinschi 2007; van Cauter Probability Sleep loss causes loss of control over appetite Leptin (satiety hormone) and ghrelin (hunger hormone) Leptin levels very sensitive to sleep duration Leptin levels much lower after sleep restriction Reducing sleep duration by 2 hours lowers the levels of this satiety ( fullness ) signal During a sleep restriction study (n=12), levels of leptin decreased by 18% and levels of ghrelin increased by 28%, leading to increased appetite and feelings of hunger Thirteen epidemiologic studies in adults and 8 in children have reported that sleep loss is associated with increased BMI Sleep loss was identified as a novel risk factor for insulin resistance and type 2 diabetes Lauderdale 2006; van Cauter 2004 ; Spiegel 2004, 2005; Copinschi 2005; Shea 2005 ADHD index predicts weight and binge eating Binge eating group Obese group Normal weight group ADHD index CAARS Davis 2009 More ADHD in obese patients ADHD in obese patients 27-34% ADHD in extreme obesity 43-57% (BMI 40) Obesity in ADHD Higher BMIs in ADHD than controls in children and adults 34% of ADHD is overweight (controls 29%) 30% is obese (vs controls 22%) OR 1.58 overweight; OR 1.81 obesity Altfas 2002; Agranat 2005; Fleming 2005; Davis 2009; Pagoto 2009; Spencer 1996; Holtkamp 2004; Kooij in prep Take home delayed rhythm in many adults with ADHD life-long pattern long term health consequences Pay ATTENTION to Sleep and Rhythm! Treatment of ADHD and comorbidity 1. Psycho- education 2. Parent training in children 3. Discontinue alcohol/drugs 4. Medication for ADHD and comorbidity 5. Light Therapy 6. Coaching 7. Cognitive Behaviour Therapy 8. Support or Advocacy Groups Safren 2005, Weiss 2003; Kooij 2010 Psycho-education to patient and partner Prevalence in children and adults Heredity and biological backgrounds Comorbidity Consequences of ADHD and comorbidity Sorrow about lost opportunities Treatment options and limitations What happens after diagnosis 18 Discontinue Alcohol and Drugs Depending on severity in special clinic Registration of (ab)use per day Willingness to cooperate Before medication: decrease or discontinue During medication: discontinue. If not: adjustment of dose / dosing schedule or collaboration ends Order of treatment in comorbid ADHD In adults, first treat depression, anxiety, bipolar disorder, SUDs, then add stimulant for ADHD In case of personality disorder: first treat ADHD Light therapy for circadian disturbances 5-10 days 30 min lux 40 cm: For seasonal affective disorder: 30% For delayed sleep phase syndrome: 70% For ADHD? For overeating? Levitan 1999, 2002; Amons 2006, Rybak 2006, Psychological treatment Coaching : practical, supportive and directive, similar to cognitive behaviour therapy interventions: time management (watch, timer, agenda, mobile phone/pda) organising daily life (household, children, administration) reorientation on education or work planning time/intimacy with spouse getting overview over finances addressing process of acceptance of the disorder and need for medication learning social and organisational skills Coaching: Planning of Time Problem No overview over time, bad planning, coming too late Target Good overview and planning Method Weekschedule: regular and variabel appointments in one scheme Target-schedule: max. 3 realistic targets, small steps, evaluation per week Learn to use watch, timer and agenda to get a sense of time Coaching: Managing Chaos Problem Target Method Paper all over the place, mess, or dirty Order out of chaos and overview Asking for help at home Learning to clear up, prioritise throw away, making decisions, everything in small steps. Developing a system to keep order 20 Books on Coaching / CBT Adventures in fast forward Nadeau ADD in the workplace Nadeau ADD and the college student Quinn Mastering your adult ADHD Safren Coaching in groups Targetgroup: learning to attain personal goals in small steps Skills group: learning organisational, administrative, time management skills Women with ADHD: psycho-education and support group, registration premenstrual mood changes Docters/psychologists with ADHD Cognitive behaviour therapy group Sleep education and intervention group (sleephygiene, light in morning and melatonin in evening) Patient organisations (AIFA Italy, NLs Balans, Impuls; ADDISS UK, Zit Stil Belgium) Advocacy groups Chat groups ADHD café s Trained patients educate new ones (ADHD patients help each other- Dutch project) 21 ADHD and relationship First treat the patient Partner often burn-out Psycho-education also for partner Ask partner s involvement and opinion concerning treatment Inventarise problems Support both patient and partner Learning to negotiate Partnergroup Psychotherapy Cognitive behaviour therapy: adressing problems with impulsecontrol, selfesteem Schema Focussed therapy? Mindfulness? Relationship therapy: individual / group Supportgroup for partners/parents Supportgroup by experienced trained patients to new ones Safren 2005, 2006, 2007; Zylowska 2008; Schuijers & Kooij, 2007 Psycho-analytic therapy Not effective for core-symptoms of ADHD. Maybe useful for: Insight in low selfesteem and history of black sheep Learning to accept the diagnosis and consequences If indicated, psycho-analytical therapy comes after psycho-education, medication and coaching 22 ADHD in adults Diagnostic Assessment and Treatment Dr. J.J.S. Kooij Pearson Assessment and Information, 2010, Amsterdam Team Adult ADHD, PsyQ The Hague PsyQ 2e landelijke ADHD-Dag, Oktober 2009: 140 Fte in 25 locaties in NL 23 Adults want help PsyQ, the Hague and the Netherlands N=1200 patients in the Hague, only local referrals Mean age 38 Males: females = 1.5 : 1 PsyQ currently has 30 locations with ADHD teams around the country Most referrals at new locations are for adult ADHD: unmet need Rapid increase in expertise and availability of patient care for adult ADHD in the Netherlands Next step: annual training adult ADHD for residents throughout the country (Dutch Network Adult ADHD) Last decade development of professional ADHD networks: National ADHD Networks European Network Adult ADHD Conclusions ADHD exists in many varieties in both children and adults, and both men and women Variation in clinical presentation due to subtypes, comorbidity, age and gender Lack of knowledge in professionals esp. in girls and women must be addressed 24 Conclusions DSM-IV criteria and threshold should be adjusted to age and gender ADHD can be treated effectively Assess comorbidity and treat these disorders often first, before the ADHD BOOKS on GIRLS & WOMEN & ADHD 25
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