Chapters Transcript Diagnosing and Treating ADHD in Adults Dr. Marie Bosch, MD, PHD discusses diagnosing and treating ADHD in adults. Doctor Marie Bosch earned her medical degree and phd in Neuroscience at Washington University School of Medicine in Saint Louis Missouri. She then completed her residency in psych Psychiatry at was U and is currently an assistant professor of Psychiatry with the washi physicians at BJH. Doctor Basti patients for general adult psychiatry, depression, anxiety, bipolar disorder, schizophrenia, substance use disorder A DH A G geriatric psychiatric Psychiatry and is speaking on the topic of adult A DH today. So thank you so much for your time. We really appreciate it. Ok. Thank you for having me on that. I, I was able to hear you for the most part. Are you guys able to hear me? We can hear you breath loud and clear. Ok. Um Yeah, so thank you for having me. Thank you for that introduction. Um Yeah, so I'm gonna be talking to you about um diagnosing and treating a DH D in adults. Um This is something that I do quite frequently in my psychiatry practice here at wash U. Um Basic outline for um for my hour is 1st, 1st section is to talk about making the diagnosis of A DH D in adults, um, things to consider and questions to ask. The second part is um treating a DH D in adults. Um And knowing that this goes beyond just prescribe Adderall, um that it's more nuanced than that and then if we have time at the end, um, there's a few cases that we can try to go over. So when diagnosing a DH D, um, well, I guess one thing to say is this talk is geared towards adults that are coming in for a new diagnosis of A DH D. Um So there's folks that are coming in with a diagnosis of a DH D as Children. Um That's kind of a different scenario. These are patients that are coming in as adults now thinking that they might have a DH D. Um It's very difficult to make this diagnosis in adults for a number of reasons. Um One is that we all experience symptoms of A DH D at various times. It's, but it's not necessarily pathological to sometimes, you know, not pay attention to sometimes be impulsive or forget something or be a little bit disorganized. So where do we draw the line at clinically significant impairment? That's a very um difficult question to answer. Um The other issue is that in mental illness and attention is a universal symptom of mental illness. So it can be um cognitive changes can happen in anxiety, depression, substance use disorders, bipolar disorder, schizophrenia. It's basically part of all of our criteria. Um So how do you know if it's a DH D versus one of those other disorders? The other thing is that a lot of times someone with a DH D may have more than one thing going on. So it's really common to have somebody with a DH D who also has depression or also has anxiety or substance use disorders. So, how do you, how do you tease that apart? Where is there an attention coming from? So it's very, very challenging. And this is um one of the things that I really had to study what I um first started in my outpatient practice. So the key for making a diagnosis of a DH D is that it is a lifelong condition. Somebody doesn't all of a sudden develop a DH D um as an adult. It um and this is something that's important to educate patients on that. It is a neurodevelopmental diagnosis. So you have to talk to them about their childhood history. They have to have had some kind of symptoms as a kid. Um Ideally, we would be able to get objective records or reports from other people um such as talking to a mom or a dad that knew them back then or getting their report cards from their teachers when they were in elementary school as an adult. When you're, when you have patients coming to you with this, that's oftentimes very difficult to, to obtain those records. The other thing is that um self reported memories from when we were Children is all, you know, vulnerable to, um you know, to either inaccuracies, whether it's intentional or unintentional. This is a very um wordy slide, so I'm not gonna read over it. This is basically just the DS M criteria for um for a DH D. Um There's three types, um basically two categories, inattentive A DH D, hyperactive I A DH D or a combination. You can have some of each, you have to have um multiple symptoms with when, within each category they have to be going on for at least six months. This is more for, for kids. Um When you're doing this assessment in adults, we of course, want to see a much longer than six months period of time, excuse me. And also two or more settings. Um My, when I'm doing these assessments, um I'm not only like reading off a, well, I try not to read off a checklist ever, but um it's not just going through a checklist of questions as well. It's also about how they answer questions and look and observing their um, their behaviors, right? So, um oops, sorry, this was, that was not that um the types of questions that you ask can be important as well. So you don't wanna ask, like, have you ever had um trouble remembering things or have you ever lost something? I mean, because that's very vague and everybody is gonna say yes to that. So if you ask more specific questions, like, how are you keeping track of your wallet and your cell phone and your keys? Um, how do you, um, how did, how did you pay attention to your teachers in middle school compared to everybody else in your class? How do you feel when you're sitting through a long movie, um, or a long meeting? Ha, have you see if somebody, um if somebody were to um ask you to pick up something at the grocery store on the way home from work, how likely is it that you would remember to do that? Those kinds of questions can be more helpful um rather than that vague, the vague, like, do you forget to do things sometimes kind of a thing? This is what I started out saying just a minute ago. So mental status exam um is also important kind of observing how they behave in the appointments. So these um a DH D patients oftentimes like if you're reviewing my chart or not my chart epic. A lot of times they're late to appointments or there's no shows because they forgot about appointments. Um Maybe they're late to your appointment. There are those people that are constantly like running 15 minutes behind. Um Also how, how they answer questions when you're asking when you're asking them, these questions? Are they interrupting you? Do they start talking about 11 thing and then wander off topic and then they're like, wait a minute, what was I saying? What was the question? You have to redirect them? Do they look like they're restless or fidgety? Um, do they get distracted by things that are in the office? Um, a lot of times with these patients, you have to, like, redirect them, remind them what you were, um, what you wanted to remind them what the question was. The other thing is that you want excessive ex examples of um these criteria, not just like, you know, a specific, like one time I remember I left my lunch at home and my mom had to drive it up to school for me. You want like, you know, some, a lot of times I'll have patience, like I asked them like um about losing things or um whatever and they say, and they kind of laugh, they're like, yo, yeah, that was like a family joke. I, you know, I was always losing my stuff. Um You know, you want those kinds of examples like excessive things many times, not just every now and then. OK, so the rest of the talk um I divided up, well, not the rest of the talk, the rest of this section I divided up into domains. That's the way I think about diagnosing A DH D, I don't think about um A DH D as the, that the DS M criteria. The what, what I had listed out um on that one side because those criteria were generated for Children. Um So I think about it as domains. So like academic um professional, home life, driving finances. Um And so what I've done here in the next two sides is go through the different domains and um try to give examples of common complaints in somebody who has a DH D. Um So academic is of course, um probably the first one that I think about just because it's a really good indicator, um, of somebody's attention. Um, I always ask about homework. Um, this is one of the most sensitive indicators of whether or not somebody has a DH D is whether or not they did their homework. Oftentimes, what I will hear is I never did my homework or I did it five minutes before class. Um, I always copied somebody else's, I couldn't sit still to do it. I couldn't, you know, even if I did do it, I would lose it or I'd forget to hand it in lots of missing assignments, lots of turning it in late. Those kinds of things. If you have somebody who was really good about doing their homework, I would be highly suspicious of an A DH D diagnosis. Um, also inconsistent grades. So kind of, um, similar to like the homework thought or the homework question. These people would say they would, you know, pretty good test taker, get A's and B's, but they would get C's and D's in their homework because they would just forget to do it or, you know, turn it in half done sometimes. Um These patients have more struggles with math and foreign languages because those topics are repetitive and you have to like practice. Um So that's, that's not always the case, but sometimes I hear that. Um and another good academic um functioning indicator is like, how do they do with their transition to college? Sometimes? What I hear is that they do ok in like grade school, high school and middle school. But a lot of times it's the parents that are helping them stay on top of things. Like parents will sit down with them in elementary school and help them do their homework. Keep them on task. Parents are helping them remember to turn in their assignments. Um Those kinds of things. So once they go to college, they um they don't have that external um um reminder organi organizer. And so now they're struggling to get to remember to do things a lot of times um it takes them extra semesters to graduate, they end up having to drop out of classes, a very wide range of grades. Um A DH D patients are much more likely to drop out of college and many do not graduate on the first attempt. Occupational functioning is another good domain to ask about. Um A DH D patients are more likely to have been fired um to quit a job suddenly sometimes I'll hear, especially for like the hyperactive, um, um, types of patients, they will change jobs when they get bored. Um, they've got it figured out so they're ready to move on to something that's more like, you know, the new shiny thing. Um, they have more job issues because a lot of times they are chronically running late or, um, the inattentive folks are more forgetful and so bosses are having to ask them like, where is that thing that you were supposed to do? Um But they have put it off so long that, you know, it fell off their radar or they're making more mistakes. And so coworkers are having to pick up the slack. Um, meetings might be hard for them to sit through. Sometimes I will have patients that um kind of a at the surface might appear to be workaholics like they're always coming in early, always staying late working super long hours. Um But that could be just because, um because they get so distracted when there's a lot of people in the office. So they, they come in early so they can get some work done when it's quieter, um or they're not very efficient. So they have to stay a lot later and work all these extra hours because they're just not getting um the work done um in a timely manner. Um Sometimes coworkers don't really enjoy having them around because coworkers are having to pick up the slack so it can really affect their self esteem as well. Uh Financial is a, is a domain that I can ask about in adults that would not be like in the, in the regular DS M criteria. Not really something that you'd ask your kids about, but as adults, somebody with a DH d more likely to have impulsive spending habits struggle to maintain bills. Um, they may end up with their utilities cut off just because they kept forgetting to pay the bill on time. Um Difficulty sticking to their budget. Um I, I like to ask them about how they feel about doing tax returns. Like tax returns for somebody with a DH D would be kind of the worst thing in the world because it requires all of those different things that you have to all the different documents that you have to collect in one place. Um So it requires a lot of organization, um social um social situations. So these people are, I will ask about how they are with social interactions, for example, like, are they, do their friends tell them that it seems like they're not really paying attention? Is it like people tell them that they're kind of uh or you have like nicknames when you're a kid, like you're the space cadet or something like that seen as kind of like tuned out or zoned out. Um I was a lot of times I'll ask them like if you're thinking back to when you're in school, if your teacher were to have asked you a question or called on you, would you have been paying attention? Would you know what the question was or would the teacher have to repeat it um asking about, um, you know, in conversations? Does your significant other say, like I told you this already, weren't you paying attention? Those kinds of things? Sometimes these people can be thought of as rude or inconsiderate or intrusive. Um the hyperactive people, like they're interrupting um the other person, they're dominating the conversation, they're talking too loud, they're missing the so social cues from other people putting their foot in their mouth. Um Memory a lot of times A DH D patients describe their memory is not very good, but that's not really like if you, if you do um neuropsychological testing, their memory is not impaired. What we think it, what we think is actually an attention thing. So if they're not noticing the details, then that's going to seem like they're not remembering things that happened, but it's really like they're just not noticing the details. Um forgetfulness. So more likely to forget people's birthdays, forgetting anniversaries, this can ultimately lead to a lot of marital problems. Um A DH D patients more likely to have been divorced, um more likely to be like in a, in a partnership, more likely to be viewed as like the lazy or irresponsible partner and the other person. The other partner in the relationship has to pick up the slack, has to do all the bills. Has to pick up the kids and, um, do all the organization, uh, home functioning. Um, so this would be like how they clean their house, how they cook. Are they able to follow recipes when they go grocery shopping? Do they always, do they, do they bring a list or do they forget the list or they bring the list and then lose it while they're there or, you know, they always forget something. Do they, um, when they're cleaning their house or they like going from starting in one room and then go into another room to put something in the closet and then deciding to reorganize the closet. And then that one thing that they find in their closet reminds them of, you know, this other thing and like, so on and so forth until, like, they never end up getting anything done or when they're doing their laundry, they put it in the washer and forget about it for three days and now it's like mildew and they have to wash it again. The, um, common complaint with like home projects, they're great starter but poor finisher. Um, most of the time a DH D folks don't really enjoy reading for fun. Um, they, somebody who's hyperactive, um, a lot of times if I ask them about how they like doing just like a relaxing evening at home or like sitting, um, sitting still to watch a movie. They, that would not be their favorite thing to do. They prefer to be on the go. They're the people who are talking during the movie, um, distracting other people during movies. Um, also asking about like losing things. So losing your wallet and your keys, forgetting where you parked the car again. You wanna look for, um, lots of examples of this, not just occasionally losing your keys because we've all lost our keys occasionally, but like, you know, locked, locked myself out of my house multiple times. Um, parent had to like, you know, um, pin the, the permission slip to my shirt so that I wouldn't lose it to give it to the teacher at school. Um, those kinds of things, managing health. So this is where, um, sometimes I will like scroll through epic um, to see how often they have no shows to appointments or forget to go to the appointments or how are they at managing their, um, their chronic medical conditions? Like somebody with diabetes, it's more, um, challenging for them to like, stay on top of their insulin regimen. Um, for getting to take their medicine. Um, a lot of times these, these patients because they are forgetful and running late, it's harder for them to maintain a healthy lifestyle. They, um, they're running late, they don't have time to cook dinner or they haven't had time to go to the grocery store. So they just stop off and get mcdonald's on the way home to feed their kids. They are, um, you know, they got so many, um, things lined up, uh, or so many things that they have to get done at home that they don't have time to exercise or they get distracted and they stay up too late so they don't get enough sleep. Um, that's, I mean, all of us do some of these things and sometimes, but it can be a little bit more dramatic in somebody with a DH D. I do always like to ask about driving. Um, if I have somebody who's told me they've run out of gas multiple times, um, then I am suspicious of like an inattentive A DH D. They're not paying attention to the gas meter. A DH D patients are more likely to have had their licenses suspended or revoked, more likely to get, um, speeding tickets, more likely to get into severe traffic accidents, more likely to, um, like, maybe a hyperactive person would be more of like the fast driver, like thrill seeking speeding. Um Road rage is another one that can be maybe more common in a DH D I think if this is like, um, so there's the hyperactive slash impulsive type, but I think a road rage just kind of like emotional impulsivity. Like they, they don't like waiting for their turn, they're restless. So they, you know, they get angry and when they get stuck in traffic. Um, a DH d especially like an adult that's coming in who's had this for their whole life can really affect, um, pe people personally and psychologically. So a lot of times these folks, they may look like they have depression, they have, um, very low self esteem because of a lifetime of making mistakes, like, mess up all the time. I can't do anything. Right. Maybe they have a lot of shame um because of these mistakes that they make, maybe they have a lot of anxiety because they're always worried that they're going to make another mistake or let somebody down might be very insecure. Um Occasionally people will adapt an attitude of apathy. Um What that means is they're um if they're gonna fail anyway, why even bother trying? Um And sometimes these people become hypersensitive to failure. So any kind of like um even like a small thing that they might perceive as a criticism, they are going to take that very personally. And this is kind of the, basically the same thing at what I just said. Um So secondary anxiety like worried about making mistakes because they've made mistakes so many times, sometimes social anxiety can come from a DH D you know, if they've um if there are people that have like interrupted other others so many times or um you know, maybe when they were kids, they were, you know, that hyperactive like invading people's personal space taking over conversations, like maybe that, um, over time that's made them feel more anxious in social situations because they, they could pick up on the, the fact that the other kids think that they're kind of annoying. Um, or if they're maybe the, um, inattentive type and they're kind of worried about other people noticing that they can't remember the words or people are judging them, um, emotional impulsivity. I kind of alluded to this before. Um I see this a lot in a DH D patients, these instant mood swings. Um Now, of course, this is not isolated to a DH D but I, I tend to see it more. It's kind of maybe a soft side for a DH D. Um Sometimes you'll see, um people like have attempts to hyper organize to try to cope with their symptoms, but then it ultimately causes them a lot of high stress. Like they're constantly like getting organizers, um, planners and trying to ride everything out, but then they, they lose the planner or they, or they forget about it after a week and, and then they've gone back to, you know, their chaotic lifestyle and I'm not able to stay consistent with things. Um, always good to ask about family history. Um, 25% of um, first degree relatives also will have a DH D. Um A lot of what I see in my clinic is parents that are coming to me whose child has just been diagnosed with a DH D. And then when they're talking to the pediatrician about the A DH D symptoms and like with their child, then they're like, wait a minute, I was just like that when I was a kid. So that's pretty common. Um, again, the key here is that you have to get a childhood history of some kind of a DH D symptoms. Um, ask how long this stuff has been going on. Um You know, a lot of times, you know, somebody who has true A DH D is gonna say as long as I can remember, they say it's just been the last like couple of years since, you know, you know, whatever just happened, maybe, um maybe not as likely, I like to ask about childhood nicknames or legendary stories if there's anything. Um you know, like they're the, they're the person that's always running late or they were always losing their shoes or they always got locked out of the house. Um Again, the best indicator in childhood, unreliable and incomplete homework performance. I always ask about homework collateral information. This would be nice. Um This is a benefit maybe of seeing Children because you have the parents and the teachers that are um easy to ask for this collateral information as when we're seeing adults. Um this is not as easy. So, but you have to find a way to ask them about childhood. So I will sometimes ask them to talk to their, a lot of times I asked them to talk, talk to their parents about what they were like as a kid ask if there's report cards available. If they do have report cards available, I would look for things like, um, she doesn't apply herself. She could do better if she just paid more attention. She doesn't live up to her potential needs to put in her more effort. She doesn't hand in the assignments on time. Not very organized. Um, that would be more the inattentive type of symptoms. There's also, um, like the hyperactive kids oftentimes, hyperactive kids get picked up earlier because they are disruptive for the teachers and it's difficult for the teachers to continue teaching the other kids because of how much disruption that kid is causing. So, um, or if they're the kid that's talking too much or distracting the other kids or, um, some questions I sometimes ask, like, do you remember if your teacher would, would move you, like, because you were talking too much to people, would they have to move you to a different place in the classroom or did, did your teacher make you come sit up by her desk in the front of the classroom so she could keep a better eye on you or would you have to go sit in the, in the hallway to do your homework because you would get too, too distracted by the other kids? Um, those kinds of things um important key is that success doesn't always rule out a DH D. Um, so just because somebody was able to graduate from college or has a, you know, master's degree or whatever, doesn't mean that they don't have a DH D um, sometimes they're coming to you when there's a change in circumstances that exposes their weakness. So common one is, um, a kid who just starts college. So they went from being at home with parents where parents were really helping them stay organized and stay on top of assignments versus now they're at college and they're independent and they have to do it themselves. Um And so that really exposes their weaknesses, other examples. Um somebody who retires from the military, so a lot of a DH D folks might go into the military that's very regimented, very structured. They do much better when they have that external structure, but then when it's time to retire, um then they realize that they're, they're just all over the place and disorganized. Um, divorce from a well organized spouse. We talked about the, um, a DH D can cause marital issues. Um So if, and those in a DH D patients are more likely to end in those relationships are more likely to end in divorce. So once that happens, um you know, if the other partner was the one who is well organized, staying on top of paying the bills and whatnot and that, that divorce. Um now the patient realizes that. Oh, hey, I can't remember. Like my power keeps getting, oops, my utilities are getting shut off and things like that because I keep forgetting to pay the bills. Um Sometimes somebody will get a promotion to a less structured job. Um or they've left work to stay home with their kids. So work was providing the structure and now that they're home and they have to, it's very unstructured. They're realizing that it's really difficult to stay organized. So those are some circumstances. Um Things that I commonly hear from a DH D patients, like I had to work twice as hard as my classmates to keep up. I didn't have time for sports because that took me so long to do my homework. Um The folks who are more likely to get missed during childhood um are the ones that are high, like have high intelligence um and not very much hyperactivity. The um so the high intelligence they're able to like do really well on the tests even though they never did their homework. So they still managed to pass maybe mediocre grades in the end. Um But nothing like got flagged because they weren't like failing. Um And then again, hyperactivity, hyperactivity, like I said before, those kids are more likely to get picked up um in childhood because they are so disruptive further testing. Um So me personally, as a psychiatrist, I don't um typically do any kind of further testing um there are um psychologists who do neuropsychological testing. Um So this is not something that I require for treatment, but it can be helpful, especially if the patient is looking for accommodations for school or if they're gonna look um ask for accommodations for a standardized testing, uh tests that the neuropsychological evaluations that would be required. Um There's a couple of um scales that I will some that I have done before the A SRS the adult A DH D self report scale. I do a lot of times give this to patients. Um but I don't find it particularly helpful because it's very, because it is a subjective self report. Um People tend to over report and answer, you know, very frequently for all of these questions. So not very sensitive, sometimes I'll just give it to patients um as like an additional piece of evidence for the insurance company so that they will actually prove medications, the diva um diagnostic interview for A DH D in adults. I've only done this on one occasion. Um It's pretty time intensive. You have to have somebody else um participate in it, somebody else that knows them. So me the patient, a parent, um somebody who knew them when they were a kid. Um So I don't, I don't do that on a regular basis. A key uh thing to keep in mind is that medication trials should never be used diagnostically. Most of us are going to be more focused if we take a stimulant. Um, so it doesn't necessarily mean that we all have a DH D and the converse is also true just because somebody took a stimulant and it didn't help, doesn't mean that they don't have a DH D. So medication trials are not a diagnostic tool at all. Um, I guess you guys are probably mostly primary care doctors is my understanding. Um, I, as a psychiatrist feel um very comfortable getting referrals from you guys. If you're not sure about whether or not somebody has a DH D, I'm always happy to see them to do the assessment myself. Um comorbid conditions. So, um I think I mentioned this at the start. Um A DH D um a lot of condition. So it's probably the norm to have more than just a DH D. So, so somebody with a DH D, especially an adult who's had it their whole life and was never diagnosed. It's really common for them to have developed like secondary anxiety, depression, hyperactive A DH D folks are more likely to turn to substances. They, because they're very impulsive personality disorders as well. Um My theory behind borderline personality and a DH D is that um well, um an A DH D kid difficult to manage parents don't know, know what to do. Maybe a little bit more likely to have a negative attitude towards their kids or some trauma may happen. And then ultimately that one that person may end up as a borderline personality patient. Um So lots of comorbid conditions with a DH D and then the differential as well. So, like I said before, the just, you know, somebody coming to you for trouble concentrating doesn't necessarily mean that they have a DH D it could be anxiety, they could be really worried about something and their thoughts are getting distracted by this, this worry, they're not sleeping very well because they're like laying awake at night, worrying about stuff. Um Depression can cause cognitive um cognitive symptoms. Um I've had people that thought they were having early onset dementia. Um you know, trouble concentrating, trouble remembering things. It's actually depression, substance use disorders are always asking about how much are they drinking? How much marijuana are they using that can make um you know, over using any of those substances can, can make a person look like they have a DH D um bipolar disorder. Um The somebody who, so if you think about the criteria for mania, um there those people like in a manic episode would be um talking a lot, they'd be very hyperactive, they'd be starting a lot of projects, not finishing them. Um They'd be impulsive so that, that there's a lot of overlap between bipolar mania symptoms as and the hyperactive A DH D. So it's, it can be challenging to tell that, tell those two apart. Um The key with like a DH D is that it's maybe not as severe as a man. Well, it's not as severe as a manic episode and also a DH D is lifelong versus bipolar is, is, you know, discrete episodes and much more severe, um, personality disorders as well. If I have somebody coming to me who, um, sounds like they have bi excuse me, borderline personality or carries a diagnosis of borderline personality. I'm going to be screening for a DH D because that's, there's a lot of comorbidity there. Um But it also they also can um look very similar, right? So borderline personality, those people are impulsive, they use more substances. They um they have that emotional ability. So is it a borderline personality or is it a DH D they look a lot alike? Um OK. So before I move on to discussing treatment, do we have any questions about making a diagnosis of a DH D in adults? If you think of questions, you can always put them in the Q and A in the chat and we can get them at the end of the talk as well. Ok. So treating a DH D in adults. Um This is just a co uh the cover of one of the, the books I always like to give people book recommendations. Um But the point of the point that I want to make in this talk is that treating a DH D is more than just giving somebody a stimulant. Um I like to think of it with four parts. So educating the person medication is one part um and then coaching and psychotherapy, which are kind of um kind of similar. It's hard to kind of draw a line between the two. I like to use the phrase pills don't teach skills because sometimes people are just looking for a medicine to solve all their problems. But that's really not the way treatment of A DH D works. Um The pills like the medicine is not going to solve all the problems. They do have to learn some techniques for um for organization or time management and they have to um um you know, we have to help them kind of continually tweak those techniques and skills that they're, they're trying to learn the medicines can help, make it easier to learn those skills. Um I also like to think of a DH D as an ongoing, excuse me, managing a DH D as an ongoing process, kind of like managing diabetes or high blood pressure. It's um it's a lifestyle, not necessarily a destination. So I'm continuing to work on it as we go along. Um in the education category, especially somebody who has never been diagnosed with a DH D. Um and is coming to me as an adult um educating them about um you know, the effects of untreated A DH D might have had on their life, right? Whether it's the emotional um aspects or the self esteem from constantly making these mistakes. Um I also educate them that it is treatable that um that there is hope. Um But they do have to be motivated to work at it and follow through with um the things that we're working on. One important I idea or concept is helping them to accept their limitations. So, rather than thinking that I should be able to do this, everybody else can do this, like let go of that notion, um work with your limitations, you know, or work around them, right? You know, don't, don't feel so bad about um don't compare yourself to other people and, you know, really work to try to create an A DH D friendly lifestyle. Um So medications, there's um stimulants, of course are the first line. Um and then there's some non stimulants that I'll talk a little bit about strea or Adam et is a norepinephrine selective reuptake inhibitor, Wellbutrin or buPROPion is um another antidepressant that can be um I think it's dopamine and norepinephrine. So a little bit stimulating, not as effective as strea or stimulants, but um I do occasionally use it and have with some success cloNIDine and Guanfacine. I don't recommend these for adults with A DH D. These are more for um Children with hyperactive A DH D. They can be calming for that. Um for that type of patient, not as much evidence on um being helpful for an adult with a DH D. Um I think the clinical trial say that it really doesn't help much with like attention and focus. So, um, I rarely start a patient. Start my adult patients on these medicines. If they were already on it. When it came to me, I, I'll probably continue it unless it's causing them side effects. Um, I like to educate people on, um, the benefits of stimulants. Um, because they are some of the most effective medicines that we have in psychiatry even more effective than antidepressants for a lot of patients. Um you know, helping people stay on task, be less distractible, more efficient, make fewer mistakes, have better time management. It really can help their overall self esteem as well. Um And sometimes can even help anxiety because they're not um just worried about making mistakes. Um Generally stimulants fall into two classes. There's lots of different brand names, but um to help keep it organized in my mind, I just think about the two classes of stimulants. So the amphetamine derivatives, which is Adderall, um Vance Evko and then the methylphenidate derivatives, there's even more brands in the methylphenidate class. So Concerto Ritalin Meta Date, um da I can't think of all of them. Um Both stimulants, just different um pharmacological makeup. Um I always start with extended release formulations um especially in adults where, you know, it's we have busy days. It's hard to remember to take something twice, two or three times a day. So I just do the once a day, extended release medicines. Um There is some evidence that the amphetamine derivatives are a little bit more effective in adults. So typically I'll start with outer all Xr. Um But if I have somebody maybe with a lot of anxiety, it's reasonable to start with the methylphenidate because um methylphenidate derivatives are more tolerable. Um typically, and I always start low um and go slow when I'm increasing. So with Adderall xr, I start at 10 mg and just go up by 5 to 10 every, every month if needed. Um I do a lot of like pretreat um counseling about um side effects. So making sure that they know that these medicines can cause insomnia if you forget to. Um you forget your morning xr it's ok to just skip that day. You don't have to take it every day. Um If somebody is having insomnia from an XR, I might switch to the short acting um because that will wear off sooner, um or you know, have them just take the medicine or earlier in the day. Um Appetite suppression, most adults do not have a problem with this um potential side effects. And in fact, most of the time it's really not an issue. Um You worry about that more in kids because you want kids to, to be eating so they can grow, you don't wanna have um um Right. So blood pressure is one that I do monitor regularly in adults So, um you know, if somebody is getting high blood pressure from the stimulant, I'll either lower the dose or stop the stimulant. Um And I will never start a stimulant on somebody who already has high blood pressure. I'd want them to get that under control. Um Of course, I say C PC P on here, but you guys are all PC PS. So, um you have probably some of you may have gotten referrals from some of my patients who I send back to their primaries to get their blood pressure under control so that we can manage their A DH D. Um If, if I have somebody who has so stimulant sick, they are stimulating, they can make people feel a little bit more anxious or jittery or like they've had too much coffee to minimize this. I typically will start very low, go slow. If somebody is having anxiety, I'll either lower the dose or switch to a different class or different um a different brand. So, you know, if I'm starting somebody on Adderall and it's making them too anxious, switching to a methylphenidate, um derivative, oftentimes can help um rebound. What I mean by this is when the medicine wears off um in the evening. So these medicines have very short half life when it wears off. Some people will get um more like fatigue or irritability or mood changes when it wears off. Um So to manage that the long acting usually is less likely to cause, um, that rebound. Sometimes you can add on a tiny dose of like a short acting in the afternoon to kind of, um, like, ease them down a little bit better if somebody has ticks. Um, that's a risk benefit discussion because stimulants they don't, well, they don't cause ticks, they can make ticks worse. Um, I don't know that I've ever actually done this but you could in theory, add on medicine to help manage the ticks. Um if they really had very bad A DH D but, and needed treatment, if somebody and I always tell people that there is a risk of uh developing mania or psychosis with um before we start the stimulants. Um And if, if that did happen, then they would, would, I would stop the medicine immediately and re evaluate um what their diagnosis is, but I don't have like a set algorithm. Um But in general, my, my thought process goes like this. So if I think somebody has a DH D, but they also have anxiety. I always treat that first. Um Because of course, we don't really know where their baseline is if they're, if they're very anxious. So oftentimes start an SSR I um if they have comorbid depression and a DH D, it's reasonable to try buPROPion or Wellbutrin because that can, in theory treat both. Um If it's only a DH D and nothing else is going on or everything else is well, controlled, then a lot of times I'll just start with Adderall Xr and titrate. Um And then kind of go from there, you know, if they're having intolerable side effects, try something from the other class concert. It is a nice long acting methylphenidate derivatives. Oh, and I forgot to change the slide. So Vance is one of the amphetamine derivatives that a lot of people really, really like it's smoother than Adderall. Um I wrote in here that insurance doesn't want to prove it because it's, it was still brand name, but it just went off brand name a couple of months ago. Um Sometimes I will do um like my preference is always long acting. Um but some patients prefer the short acting if they, if they like to have more control, like if they um you know, they work different amounts of um hours on different days and they don't wanna have the medicine in their system if they're only working four hours or you know, or if they're having like appetite suppression and want to be able to enjoy their lunch more or whatever. So short acting, um I will allow people to have short acting as long as I'm not concerned about them abusing it, which in most cases is not, not a worry. Oh other medicine. So, so the nonstimulant, so strea ad Amoxin um I have had some success in this with um particularly folks who have a lot of anxiety from stimulants. Um and then Wellbutrin, like I said, if somebody has comorbid depression, um but not, tends to not be as effective for a DH D. And then I talked about the Guanfacine and cloNIDine already. I don't ever use those in adults. Um special circumstances. So pregnancy always a risk benefit discussion. We don't have a lot of data and using stimulants for a DH D in during pregnancy. Um Historically, most of the time I recommend it just to stop the stimulant. Um there, especially if it's just mild to moderate A DH D. Some studies indicate a small risk of cardiac malformations with methylphenidate that's not seen with amphetamines. I think other studies that have come out say that that's maybe not the case. Um So, but I mean, if somebody in the end, if somebody has um severe A DH D and is at risk of getting into a severe car accident or losing their job, um it, you know, for that patient, it's probably better to continue the medicine that is working for them. Um Just with counseling about the risks. Um you know, the, the data that we do have on stimulants and pregnancy. Um Most of that of course, comes from women who are abusing stimulants like amphetamine use disorder. So it's not exactly, I mean, it's not the same population but the data that we do have regardless um is reassuring uh for the most part. So maybe we will have more evident more data on this going forward. Breastfeeding. Again, risk benefit discussion. Um The the stimulants are still um and found in the breast milk. We think maybe methylphenidate derivatives are better because it's um hardly any is found in the breast milk. Um short acting might be better in these situations because they can time it with their um time the dosing with their nursing schedule. So, you know, nurse right before you take it and then wait to nurse again after the medicine is out of your system. If somebody has a history of substance use disorder, kind of depends on how recent the substance use disorder is. Um If you know, if they have a history of stimulant use disorder, I would be very cautious. I would probably wanna check your urine drug screens and have a period of sobriety. If somebody's, um, you know, using alcohol daily or marijuana daily again, probably would want to see a trial. Um, excuse me, a period of sobriety, maybe some, maybe some urine drug screens, although it kind of depends on the patient whether or not I require that. Um If they're, if they're still using, then I'd probably start with strea or buprofen first. Um Never, I, I would never give somebody stimulants if I knew that they were um using marijuana or alcohol or anything else daily. Um I do also wanna make sure that um and manage expectations. I wanna make sure that people don't expect the medicine to like, solve all of their problems. It's just a tool to help them apply their efforts. They still have to put in the work. These are the books that I send people in a Mychart message. Um I tell them to use them more as like a manual, not as I don't ever expect them to sit there and read it cover to cover, but use it kind of like as a reference guide, like turn to the chapter that deals with the um problem that you're currently struggling with and agree that chapter also, having somebody who knows you and like your partner or um family member, read the book as well. Can be very helpful because then you have like more people on your team helping you and then the ot department um occupational therapy does ot for a DH D that some of my patients have really liked. OK. That was the end of the talk. Um So I just noticed there was a couple of questions. So Tracy Norfleet, this is so helpful with the slides from the presentation. Be available. I don't know the answer to that. Um I can certainly, well, I think I already sent them to whoever's in charge. Oh, usually this whole recording it will be recorded uh if you're just wanting the slides and Doctor Bosch is OK with sending those to me. I am happy to go ahead and send those slides out, but we will have the uh the actual recording I can send that out as well. Yeah, I, yeah, I'm happy to send out the slides if anybody wants those. Um ok. Um, occasionally I'm asked to write a note to allow an oops to allow an adult to have extra time to take a test, like a bar exam or CPA test. Um Is that reasonable? I do. So who um John, can you clarify what you mean by this? Like are they asking for um like they have a DH D and they're asking for time? Let me see if I can allow him to talk. Hold on one second. I didn't realize they couldn't talk. No, that's ok. Um Doctor Voler, if you wanna get off mute, you should be able to clarify. Can you hear me now? Yes. Yeah, I, no, I'm talking about some of it's not been diagnosed just, but they're saying I have trouble with tests and I need more time. And does that make you think of ad D a DH D or, or is it ok to just let them have more time? I mean, ii I would probably be ok um with just letting them have more time. Um No, I wouldn't like for me, I would be very careful about like wanting to, I guess what I would say is, does that work if you just write a letter like to let them have more time without it does. So if it works, then I would probably do it too. But, um, like, if somebody, like, in my experience, when somebody, especially, like, with the bar, I'm a little bit surprised about that, like, the medical boards and like, um, you know, the standardized testing for like, um, the sats and things like that, maybe not the sats because I don't see kids but the medical boards for sure. They, they always require like, um, a formal diagnosis of a DH D from a neuropsychologist. So I'm a little surprised just writing a letter to allow extra time works. But if it works and then I would just leave it vague. Like I, I wouldn't write, they have a DH D in there unless you were sure. Does that answer your question? It does. Yeah. Thank you. Ok. Um OK. And then doctor holder, we can just mute until, and that would be great. Ok. So, um it looks like we still have a few minutes so we can talk about some of these cases. Um I meant for this to be a kind of a conversation. So if they can't talk then maybe I'll, I guess I could just talk through it myself. Um, so there, pardon? Sorry. I know that just with that many people, I it's difficult. Yeah. No, that makes sense. Ok. So 30 year old female presents for a DH D evaluation after her son was just diagnosed with a DH D. And she noticed similarities between herself and her son. This is a very common scenario that happens in my practice. Um What is your differential? And what do you, what else do you wanna know? So, um I mean, what else you wanna know? Of course, is like, does she have a childhood history of any of these A DH D symptoms? And what is your differential like? Is she having anxiety? Like does there, is there something going on with her with her kid that's making her anxious or is there something else going on in her life that um or is, or is she having depression? I mean, so you gotta think about like anxiety, depression or is she like drinking too much um alcohol? I think this happened a lot during the pandemic. Um People were just like having a few glasses of wine every night. I mean, that's going to make it harder for us to pay attention as well if we're um using too many substances. So don't just automatically assume that because somebody wants um thinks they have a DH D that, that's what's going on to keep keeping a bigger picture in mind. All right. So some other symptoms that she described, she misses her, she regularly misses doctor's appointments, she misses appointments for her son. She's always running late chaos trying to get out the door. She's always losing her keys and her wallet. She leaves laundry in the washing machine for days at a time. And has to wash it again. Husband had to take over managing the finances. Um, she's also ended up developing a lot of psychiatric symptoms. A lot of anxiety because of these unfinished projects that pile up. She worries that she's gonna make more mistakes. Um, a lot of self doubt and feelings of worthlessness, some depression because she's made so many mistakes and, um, hasn't been able to, to complete things. She doesn't use any regular alcohol or any other other kind of substances. And she, so this would be her childhood history again. This is the key to the A DH D they have to have some kind of symptoms as a kid. Um, she was quiet, not disruptive in class, but her teachers would say she could do better if she applied herself. Um, mom had to sit with her to help her finish her homework. It took a long time and there was a lot of struggles at home, mostly had B's and C's College was terrible. Eventually ended up dropping out, has run out of gas multiple times. So this is a case that seems pretty, um consistent with an inattentive A DH D picture um, treatment plan. Let me see what I did here. Yeah. So I would probably start this person on a stimulant. Um, see them back regularly to um, kind of manage the side effects. Talk to her about, um, you know, all of those other things that I went through and I don't want to rehash all of my slides all over again. Um OK. Case number two, a 28 year old female with a prior diagnosis of bipolar disorder who presents for transfer of care for treating depression. Um So what else? What do you want to know? This is very vague. Um So whenever I have somebody who's coming to me with a diagnosis of bipolar, I always want to review whether or not they actually have bipolar disorder because like I said before, bi bipolar disorder um is often missed mis misdiagnosed, like something like a DH D can be, can look like bipolar disorder because these people can be hyperactive and talk a lot in those kinds of things. Um So I, again, I would wanna hear about their childhood history like how long these symptoms have been going on. Um Of course, I mean, this person is coming in for treatment of depression. So we would probably start there and then do what we can with the history. So, um or get as far as we can with like her past psychiatric history. So this particular patient depressed, as long as I can remember, um her symptoms of depression are low mood, feeling worthless, recurrent suicidal thoughts, s history of self harm cutting. So this sounds kind of like borderline personality. Um when she has um the manic symptoms that she's had like instant mood swings, rapid changes, minute to minute, lots of anger and yelling and screaming. Um However, it usually only lasts a few hours and never more than one or two days. Um That means this, like based on this history, this person does not have bipolar disorder because that is not what a manic episode looks like. Um, very impulsive, lots of substances, shopping, too much binge eating again. This does sound like like borderline personality. But what I had said before, a lot of borderline personality patients actually do have a DH D as well. Childhood history. Um So what were they like as a kid? She was always sucking in class, never did her homework or maybe she did it five minutes before it was due. She couldn't sit still. Teachers didn't know what to do with her. She had, they made her sit in the front of the classroom so that she couldn't distract the other kids. She was always losing things. Parents were always mad at her because they had to keep buying her stuff again. Her parents were just always frustrating. Her parents are always frustrated with her. There were always arguments at home. They're chronically in invalidating her. Like why can't you be like more like your sister? Lots of fighting. Um And then in her teens starts rebelling. Six class starts using marijuana, got in with the wrong crowd. Um Then she as a young adult, she starts college, ends up dropping out, changes her major. A bunch of times starts and tops several times, starts and stops college. Several times never ends up graduating. Has held many jobs, loses them because she's always running late or she makes too many mistakes. She used to binge drink and use marijuana occasionally, but not so much anymore. I started seeing psychiatrists in her teens. They thought she had bipolar disorder because of these mood swings. She's taken all of the medicines, Ssris, excuse me, lamoTRIgine, benzodiazepines Topamax, but nothing ever works. Um Recently she started a new job and um for example, maybe at wash U and now she can see a wash U doctor and finally wants to get her mental health um in order. So my differential in this situation and this is again another like case that I see on a pretty regularly like example of a case, this is not one particular person, but this is common to what I see it coming to my clinic. So, you know, sounds like it could be a DH D could be borderline personality like I alluded to earlier, I feel like a lot of times borderline personality kind of develops from a place of like this difficult to control a DH D kid and parents don't know what to do with them. So they wind up being invalidated and, and then the kid turns and you know, there's lots of yelling and fighting and they turn to substances. So um yeah, so I would just explain kind of my thought process. Um and yeah, I would probably start that person on a stimulant, I guess, depending on, I mean, of course, it depends on a lot of things. If she was also depressed. Actually, I take that back, she was also having depression. I probably would start her on wellbutrin because of what I said before. Wellbutrin is reasonable if somebody's having depression and I think they have a DH D. Um, ok. I don't know, there's only five minutes left. I don't know if you guys want me to do this last case or not. Something else do questions and then see if we have time because it looks like you have um at least two questions. So it's the same question. Ok. So how are you managing these shortages and switching meds for the patient? Um Yeah, it's been, it's been horrible. So, um basically we're having um because I have to send in new prescriptions. Um If their pharmacy is out, basically I have a dot Phrase and I tell the patient like call the pharmacy see if they have any other dose sizes available. So my 1st, 1st choice would be, do they have another dose size that can get us to your dose? For example, if they're on um Adderall Xr 20 do they, does the pharmacy have the tens? So can we do um take two of the Adderall Xr 10 or you know, or five and a 15 or do they have like if they're on XR do they have the short acting and we can try short acting um kind of in a pinch. So that, that's my first suggestion. Um Some pharmacies are better at um communicating with patients. Walgreens and CV. SS are the least likely to be willing to talk about options with their patients. So I will recommend switching to um like a local pharmacy um like Millbrook or the can pharmacy has been pretty good about helping us through this shortage. Um So then like, if neither of those things work, then I have to pay. I told the patient they have to call around and find a pharmacy that has it in stock. Um which again, some pharmacies are better than others at like actually giving people that information. Um And then um uh OK, my least favorite option is to switch to a different A DH D medicine, but I have done that before. Like in the end, sometimes it just run, turn um boils down to what does the pharmacy have. And that's what I'll give you. Unfortunately. Um If wellbutrin does not work for ad ed but helps depression. Can you have? Uh Yes. So the answer to that question, yes, you can do both. Um Just I would we talk to the patient a lot about like this is gonna be a lot of stimulating medicine. You would probably more at risk for like being overly stimulated or sleep like, you know, watching for anxiety, sleep issues. Um Those kinds of things. Any other questions, my own person, I just put it in the, the chat too though. But I know with my own experience with my prescription and my son's prescription, I basically would have the provider printed off and I did find that a lot of the mercy pharmacies of dear Begs and, and also a lot of the little like mom and pop pharmacies would have it. This is definitely what I tell people like do like mom and um I don't know, actually it's been like so long since I actually printed off the paper strips. I don't even know if we have like paper scripts, stuff in, in our clinic anymore. So I don't know about that one. Yeah. Um conversion from long acting to short acting. Is it 1 to 1? Yes. So like um 10 of Adderall. So Adderall Xr 10 mg would be the equivalent to five B ID. Um So yes, 1 to 1 and timing typically for if you're doing short acting, I would do um like um after breakfast and then like after lunch, something like that. Um ok. Well, we're out of time. Oh, sorry. No, I was gonna say due to time I think we'll have to wrap it up and if anyone does have any more questions, please feel free to email me. Um I can also if Doctor Bosch is ok with giving your email address, I am happy to put that in the follow up email. Um So we'll get your, your questions answered. Ok? Thank you for having me. Thanks so much. Have a great day. Created by Presenters Marie A. Bosch, MD, PHD Assistant Professor of Psychiatry View full profile
