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AUGUST 2008 VOL 13 — NO 8 — SUPPL 12

CNS SPECTRUMS
®

T H E I N T E R N AT I O N A L J O U R N A L O F N E U R O P S YC H I AT R I C M E D I C I N E

EXPERT ROUNDTABLE SUPPLEMENT

BEST PRACTICES IN ADULT ADHD:
EPIDEMIOLOGY, IMPAIRMENTS, AND
DIFFERENTIAL DIAGNOSIS
AUTHORS
Lenard A. Adler, MD
Thomas J. Spencer, MD
Mark A. Stein, PhD
Jeffrey H. Newcorn, MD

ABSTRACT
Attention-deficit/hyperactivity disorder (ADHD) is commonly thought to be a pediatric disorder whose symptoms
attenuate or disappear in adulthood. In fact, ~4% of adults in the United States have ADHD, and many of these adults
are unaware that they have the disorder. Because symptoms of ADHD manifest differently in adults and children, physi-
cians who are familiar with childhood ADHD have difficulty identifying the disorder in adults. Adults with ADHD them-
selves may be poor informants about their symptoms and impairments. A high prevalence of mood and other co-morbid
disorders in adults with ADHD can also complicate diagnosis and treatment. Adults with ADHD experience high rates
of anxiety disorders, mood disorders, substance use disorders, and impulse disorders. Adult ADHD is related to impair-
ments in executive functioning and adaptive functioning; these patients have unique deficits related to their roles as
parents, caregivers, and employees. Physicians should use impairments to guide treatment design. Early identification
and treatment of ADHD can alter the developmental course of co-morbid disorders. Unfortunately, metrics for impair-
ment in adult ADHD are still in their infancy.
This Expert Roundtable Supplement represents part 1 of a 3-part supplement series on adult ADHD led by Lenard A.
Adler, MD. In this activity, Thomas J. Spencer, MD, reviews the epidemiology of adult ADHD in the US and around the
world; Mark A. Stein, PhD, reviews data on the impairments resulting from adult ADHD; and Jeffrey H. Newcorn, MD,
discusses the differential diagnosis of adult ADHD and common co-morbidities.

This activity is jointly sponsored by the Mount Sinai School of Medicine and MBL Communications, Inc.

Index M e d i c u s c i t a t i o n : C N S S p e c t r © MBL Communications www.cnsspectr ums.com

EXPERT ROUNDTABLE SUPPLEMENT
An expert panel review of clinical challenges in primary care and psychiatry

Accreditation Statement Target Audience
This activity has been planned and implemented in accor- This activity is designed to meet the educational needs of
dance with the Essentials and Standards of the Accreditation primary care physicians and psychiatrists.
Council for Continuing Medical Education (ACCME) through
the joint sponsorship of the Mount Sinai School
of Medicine and MBL Communications, Inc. The Learning Objectives
Mount Sinai School of Medicine is accredited by the • Review the epidemiology of attention-deficit/hyperactiv-
ACCME to provide continuing medical education for ity disorder (ADHD), including prevalence, persistence,
physicians. and co-morbid tendencies.
• Explain the common impairments associated with adult
ADHD and how to incorporate assessment of impair-
Credit Designation ment levels into the diagnostic process.
The Mount Sinai School of Medicine designates this edu- • Discuss the differential diagnosis and psychiatric co-mor-
cational activity for a maximum of 2 AMA PRA Category 1 bidities that require consideration in the assessment of
Credit(s)TM. Physicians should only claim credit commensurate adult ADHD.
with the extent of their participation in the activity.
Faculty Disclosures
Faculty Disclosure Policy Statement Lenard A. Adler, MD, is a consultant to and on the advisory
It is the policy of the Mount Sinai School of Medicine to boards of Abbott, Cephalon, Cortex, Eli Lilly, Novartis, Ortho-
ensure objectivity, balance, independence, transparency, McNeil, Janssen, Johnson and Johnson, Merck, New River,
and scientific rigor in all CME-sponsored educational activi- Organon, Pfizer, Psychogenics, sanofi-aventis, and Shire; is
ties. All faculty participating in the planning or implementa- on the speaker’s bureaus of Eli Lilly and Shire; and receives
tion of a sponsored activity are expected to disclose to the grant/research support from Abbott, Bristol-Myers Squibb,
audience any relevant financial relationships and to assist Cephalon, Cortex, Eli Lilly, Janssen, Johnson and Johnson,
in resolving any conflict of interest that may arise from the Merck, National Institute of Drug Abuse, New River, Novartis,
relationship. Presenters must also make a meaningful dis- Ortho-McNeil, Pfizer, and Shire.
closure to the audience of their discussions of unlabeled or Jeffrey H. Newcorn, MD, is a consultant to Abbott,
unapproved drugs or devices. This information will be avail- Biobehavioral Diagnostics, Eli Lilly, Lupin, Novartis, Ortho-
able as part of the course material. McNeil, Psychogenics, sanofi-aventis, and Shire; and receives
This activity has been peer reviewed and approved by research support from Eli Lilly and Ortho-McNeil.
Eric Hollander, MD, Chair and Professor of Psychiatry at Thomas J. Spencer, MD, is a speaker for Eli Lilly, GlaxoSmithKline,
the Mount Sinai School of Medicine. Review Date: July 22, Janssen, Novartis, Ortho-McNeil, and Shire; is on the advi-
2008. sory boards of Cephalon, Eli Lilly, GlaxoSmithKline, Janssen,
Novartis, Ortho-McNeil, Pfizer, and Shire; and receives research
support from Cephalon, Eli Lilly, GlaxoSmithKline, Janssen,
Statement of Need and Purpose National Institute of Mental Health, Novartis, Ortho-McNeil,
Although attention-deficit/hyperactivity disorder (ADHD) Pfizer, and Shire.
has traditionally been considered a pediatric disorder, up
to 65% of children diagnosed with this disorder continue Mark A. Stein, PhD, is a consultant/advisor to Abbott, Novartis,
to display behavioral problems and symptoms of the dis- and Pfizer; is a speaker for Novartis and Ortho-McNeil; and
order into their adult lives. ADHD has a deleterious impact receives research support from Eli Lilly, National Institute of
upon the daily functioning of these adults, who often Mental Health, Organon, Ortho-McNeil, and Pfizer.
demonstrate functional impairments in multiple domains,
including educational performance, occupation, and rela-
tionships. Accurate diagnosis of ADHD in adults is challeng-
Acknowledgment of Commercial Support
ing and requires careful consideration of other psychiatric Funding for this activity has been provided by an educa-
and medical disorders. The majority of adults with ADHD tional grant from Shire Pharmaceuticals Inc.
exhibit at least one co-morbid psychiatric disorder, which
may confound a proper ADHD diagnosis. Although adult
ADHD is a substantial source of morbidity in both psychiat-
Peer Reviewer
Eric Hollander, MD, reports no affiliation with or financial inter-
ric and primary care settings, only 25% of adults with this
est in any organization that may pose a conflict of interest.
disorder had been diagnosed in childhood or adolescence.
Among patients who had not received a prior diagnosis,
more than half had complained about ADHD symptoms to To Receive Credit for this Activity
other healthcare professionals, without being diagnosed. Read this Expert Roundtable Supplement, reflect on the infor-
Recognition and treatment of adult ADHD is often based mation presented, and complete the CME posttest and evalua-
on upwardly extended models of child and adolescent care. tion on pages 18 and 19. To obtain credit, you should score 70%
However, differing patterns of co-morbidity and symptom or better. Early submission of this posttest is encouraged. Please
heterogeneity in adults pose new conceptual, diagnostic, submit this posttest by August 1, 2010 to be eligible for credit.
and treatment challenges. Although several organizations
have issued practice guidelines for the assessment of Release date: August 1, 2008
adults with ADHD, there remains confusion and a con- Termination date: August 31, 2010
tinued need to determine best practices with regard to
these patients. The expert opinions of clinical and research The estimated time to complete this activity is 2 hours.
thought leaders in the field provide insight relevant to clini-
cians faced with the task of recognizing impairment and A related audio CME PsychCastTM will also be available
diagnosing adult ADHD. online in September 2008 at:
cmepsychcast.mblcommunications.com and via iTunes.

CNS Spectr 13:8 (Suppl 12) 2 © MBL Communications August 2008

Germany PSYCHIATRISTS Stephen M. MD The University of Texas Medical Branch Stanford University School of Medicine Galveston. Silberstein. Newcorn. MD. Pincus. TX PUBLICATION STAFF CEO & PUBLISHER ASSISTANT EDITOR CHIEF FINANCIAL OFFICER Darren L. NY Shigeto Yamawaki. SC Stefano Pallanti. MD CME COURSE DIRECTOR Martin B. MD. FACP Massachusetts General Hospital of Medicine Hiroshima. MD Hiroshima University School Stephen D. United Kingdom University of Bonn Mark A. Brodeur Carlos Perkins. Jr. Italy Bronx. PhD Philadelphia. MD Thomas J. MD.EDITORS EDITORIAL ADVISORY BOARD EDITOR NEUROLOGISTS Herbert Y. Keller. South Africa Harold A. MD University of Pennsylvania School of Medicine Stephen M. Charney. PhD Chaim Sheba Medical Center Jerome Engel. Mary’s Hospital Medical School INTERNATIONAL EDITOR University of California. Stein. MD. RI University of Cape Town New York. MD Eric Hollander. MD Vanderbilt University Medical Center Mount Sinai School of Medicine University of California. MD University of California. Cummings. MD. MA Philadelphia. MD Siegfried Kasper. MD Charleston.M. MD Jeffrey L. RI Karen Dineen Wagner. United Kingdom Joseph Zohar. PhD Scott L. TX Stanford. PA Dan J. and Ross Lonnie Stoltzfoos—Psychiatry Weekly Rebecca Zerzan Publishers of "Translating Research Advances Into Clinical Practice" The Largest Peer Reviewed Psychiatric Journal in the Nation CNS Spectr 13:8 (Suppl 12) 3 © MBL Communications August 2008 . FRCP. Montgomery. John Spano VP. CA Humberto Nicolini. France Stuart C. MD University of Texas Southwestern Medical Center Eric Hollander. PhD University of Pisa Richard B. Koran. NY Stefano Pallanti. Westenberg. Amery. PhD FIELD EDITOR Dennis S. MD. Schlaepfer. NY Norman Sussman. Brin. MD. Stahl. MD Thomas E. MD COLUMNISTS New York University Medical School Uriel Halbreich. MD Mitchell F. MD University of Florence Pisa. Los Angeles London. MD. NY Irvine. MANAGING EDITOR SENIOR ACQUISITIONS EDITOR STAFF ACCOUNTANT Christopher Naccari Lisa Arrington Diana Tan VP. Nemeroff. Stahl. MD National Hospital for Neurology Stanford. CA Stuart A. TX Providence. Yudofsky. Esq. Austria Madhukar H. PhD Bonn. Stein. MD. CA New York. Spencer. MD University of Pennsylvania New York. Vodilko Bressler. PhD Emory University School of Medicine Tel-Hashomer. Mexico Donatella Marazziti. MD. FRCP. MD Baylor College of Medicine Houston. PhD University of Vienna Vienna. MD Steven George Pavlakis. TN New York. PhD Philadelphia. The Netherlands Paris. Schlaepfer. Los Angeles Atlanta. MD Columbia University Maimonides Medical Center New York. NY Katharine Phillips. Thase. MD. Meltzer. Irvine Nashville. Warren Olanow. MD National Mexican Institute of Psychiatry EUROPE Medical University of South Carolina Mexico City. PhD Mount Sinai School of Medicine Providence. MD. CA Herman G. MD Los Angeles. Schatzberg. PhD ASSOCIATE INTERNATIONAL EDITORS Mark S.. GA Los Angeles. Evans. CA Jeffrey H. MD Brown Medical School Dallas. MD. MD University Hospital Utrecht Hôpital de la Salpêtrière Utrecht. SENIOR EDITOR ACQUISITIONS EDITOR ACCOUNTING INTERN Deborah Hughes Virginia Jackson Stephanie Spano VP. PA Michael E. MD Yves Lecrubier. Jr. MD CONTRIBUTING WRITERS Michael Trimble. FRCPC Brown Medical School Dan J. PA Alan F. Israel University of California. ASSOCIATE EDITORS Michael J. Japan Thomas Jefferson University Charlestown. Stein. San Diego Michael Trimble. MD St. NY ASIA Brooklyn. FRPsych Mount Sinai School of Medicine La Jolla. MD MID-ATLANTIC C. MD London. MD and Neurosurgery Thomas E. Lipton. MD. MD. MD Dwight L. FRPsych Stanford University School of Medicine Lenard A. NY Cape Town. Trivedi. Adler. CA Charles B. Italy Albert Einstein College of Medicine Florence. Rauch. George. PhD Lorrin M. Brodeur Jaime Cunningham Kimberly Schneider Michelisa Lanche SENIOR GLOBAL RECEPTIONIST ACCOUNT DIRECTOR CME DEVELOPMENT MANAGER Kimberly Forbes Richard Ehrlich Shelley Wong INFORMATION TECHNOLOGY SENIOR EDITORS ASSISTANT—ENDURING MATERIALS Clint Bagwell Consulting Peter Cook—Psychiatry Weekly Sonny Santana José Ralat—CNS Spectrums WEB INTERN ART DIRECTOR Adam Schwartz SENIOR ASSOCIATE EDITOR Derek Oscarson Dena Croog—Primary Psychiatry CORPORATION COUNSEL GRAPHIC DESIGNER Lawrence Ross. HUMAN RESOURCES EDITORIAL INTERNS SALES & EVENT COORDINATOR Kimberly A.

Some symptoms must be present before 7 years of age as “minimal brain dysfunction” and “minimal brain damage” (Slide 1). school and home) 1902 by Still. Of 1902 1930 1937 1950 1968 1970 1980 1987 1994 his experience. Significant impairment: social. all of whom had been diagnosed First description of of childhood (DSM-II) Attention Deficit/Hyperactivity with ADHD in childhood. Janssen. D. Eli Lilly. • Inattention and/or hyperactivity/impulsivity ADHD has been described over time in such terms B.5 The first criterion is significant as core features in the Diagnostic and Statistical presence of six out of nine inattentive symptoms and/ Manual of Mental Disorders. MD Introduction In the mid-1970s. academic. Organon. AND DIFFERENTIAL DIAGNOSIS IN ADULT ADHD: INTRODUCTION By Lenard A. had specified that adult ADHD is always preceded by a childhood diagnosis. quick temper. and Shire. Four percent of adult college stu. Disclosures: Dr. Some impairment from symptoms must be present in two or more settings (eg. Novartis. disorganization. 8 until 1987. Patients with six of nine inattentive symptoms Survey Replication has demonstrated that the preva. Fourth Edition. Adler is a consultant to and on the advisory boards of Abbott. a disorder that is rarely inquired about and usually overlooked.6 Though Wender onset of at least some symptoms before 7 years of age. for many individuals the condi- tion is overlooked during childhood and the diagnosis SLIDE 2 is never made. Merck. The second criterion is age of onset. Dr.1 Diagnostic and Statistical Manual of Mental Disorders Criteria Wender’s predictions were later corroborated There are five major criteria for adult ADHD in the (although labile mood and quick temper are not defined DSM-IV (Slide 2). IMPAIRMENTS. for driver’s licenses. Wender said: Minimal brain dysfunction Hyperactive child syndrome ADHD is probably the most common chronic undiagnosed Attention Deficit Disorder psychiatric disorder in adults. it is true that all cases of full ADHD: DSM-IV Criteria5 adult DSM-IV ADHD are preceded by childhood onset A. attention-deficit/hyperactivity disor.3 have the hyperactive/impulsive subtype of ADHD. Cortex. Fourth Edition-Text or hyperactive/impulsive symptoms over the past 6 Revision [DSM-IV-TR]). However.2 The National Co-morbidity months. Symptoms cannot be accounted for by another mental mixture of amphetamine in 1937. Psychogenics. Ortho-McNeil. Janssen. Wender prescribed psycho. and director of the Adult ADHD Program. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry EPIDEMIOLOGY. and Shire.7% ADHD prevalence rate among adults applying the combined subtype. It is characterized by inattention and Hyperactivity (DSM-III) distractibility. National Institute of Drug Abuse. overactiv. have the inattentive subtype of ADHD. Novartis. Symptoms must be present for the past 6 months of significant symptoms. Pfizer. Wender1 studied a cohort of adults presenting with brain damage Hyperkinetic reaction Adult ADHD studied ADHD-like symptoms. restlessness. Johnson and Johnson. At this Minimal time.4%. Attention Deficit/Hyperactivity Disorder (DSM-IV) ity. Eli Lilly. Patients must have dents met DSM-IV 5 criteria for ADHD. ADHD by Still Efficacy of amphetamine Disorder (DSM-III-R) stimulants. and impulsivity. is on the speaker’s bureaus of Eli Lilly and Shire. Patients with lence of ADHD in adults in the United States is ~4. both at the New York University Langone School of Medicine. ADHD was originally described in C. SLIDE 1 der (ADHD) was still believed to be a childhood disorder ADHD: Timeline of Definitions that disappeared with the onset of adolescence. Cortex. New River. Merck. Johnson and Johnson. Adler. Adler is associate professor of psychiatry and child and adolescent psychiatry. Bristol-Myers Squibb. New River.7 whose clinical descriptions of children closely resemble today’s diagnostic criteria for ADHD. Cephalon. Cephalon. Ortho-McNeil. CNS Spectr 13:8 (Suppl 12) 4 © MBL Communications August 2008 . A full adult diagnosis disorder of active ADHD would not be included in the DSM-III-R DSM-IV=Diagnostic and Statistical Manual of Mental Disorders. thus fostering research into adult ADHD. labile mood. It is always preceded by a childhood diagnosis. which successfully produced a response in the adults. or occupational The first treatment for this disorder was a racemic E. Pfizer. Self-report data from Barkley and colleagues4 showed Patients with six of nine of both symptom types have a 4. sanofi-aventis. six of nine of the hyperactive/impulsive symptoms but that only 11% of these patients receive treatment. and receives grant/research support from Abbott.

school. Loses important items Avoids tasks that 9. not staying seated. The frank hyperactivity is often felt rather than manifested because obvious manifestations.1077-1082.46(4):185-188. Adults with untreated ADHD are 78% more likely to be addicted to tobacco and are less likely to quit a tobacco habit. long hours at work may compromise of ADHD. 4th ed text rev. colleagues10 compared the adult adaptive outcomes tion. 2006. Adler L. not following through. New York. Attention-Deficit Hyperactivity Disorder in Adults. underperformance relative to the expected eting. In a population survey of 500 (Slide 3). climbing.1163-1168. more often present ing subjects for 13 years. so it is not or older siblings or old report cards. they should be coded tension is often a consequence of this constant activity. Does not listen 5.” or be significant and fall in the realm of social.3 the onset of ADHD symptoms Adults with ADHD tend to avoid low-activity situations. Adults cope with their without ADHD. running about. • Support staff 11. 1995. Adults ter accounted for by another mental health disorder. Washington. Barkley RA. Faraone SV. • Multi-tasking 7. Still GF. Pediatrics. Preliminary normative data task when required on DSM-IV attention deficit hyperactivity disorder in college students. Biederman and colleagues11 found that symptoms and tend to adapt to them by self-selecting adults with ADHD were twice as likely to be divorced.67:524-540. Heiligenstein E. DC: tasks American Psychiatric Association. NY: impairs their lives Oxford University Press. Some abnormal psychical conditions in children. MD: The Johns Hopkins University Press. Childhood nificant. Fourth. This aimless restlessness in childhood occupational deficit.9 Many adults do not recognize that inattention ADHD adults and 501 gender. 2006. the impairment must ing/working quietly. active lifestyles and using support staff. trouble initiating and com. Washington. Although the disorder is highly co-morbid (ie. such as difficulty sustaining atten. Mick E. Kwasnik D. academic. Conyers LM. Kessler RC. Baltimore. such as constantly mov- Symptoms Manifestation in Adulthood ing about in the workplace. Clinicians are therefore left to interpret The consequences of ADHD symptoms are sig- how those symptoms will manifest in adults. Fischer M. 3. Motor vehicle driving competencies and risks attention Difficulty in teens and young adults with attention deficit hyperactivity disorder. of nearly 140 patients with and without ADHD.and age-matched adults can significantly impact their lives. ie. J Clin Psychiatry.163(4):716-723. 2006. Easily distractible. No follow-through • Changing to another 6. a sexually transmitted disease and three times as and avoiding activities that demand attention in adults likely to be unemployed. or talking excessively. Lancet. follow- losing things. Diagnostic and Statistical Manual of Mental Disorders. It is important and twice as likely to have been arrested. for example.45(2):192-202. CNS Spectr 13:8 (Suppl 12) 5 © MBL Communications August 2008 . Symptoms change over the course of a patient’s life- time. for that disorder and not ADHD. Trokenberg L. The childhood symptoms are squirming and fidg- relative (ie. DC: American Psychiatric Association. J Am Coll Health. migrates to purposeful restlessness in adulthood. Weiss G. Hyperactivity symptoms also change over a patient’s tings. not listening. SLIDE 3 Inattention Symptoms and their Manifestation in Adults References Many adults do not recognize that inattention severely 1. 1987. Young adult outcome of hyperactive forgetful • Self select lifestyle children: adaptive functioning in major life activities. Barkley and inattention symptoms. not play- capabilities of the individual). Finally. Weiss M. symptoms should not be bet. J Am Acad Child Adolesc Psychiatry. 4th ed. trouble with multitasking. Berns AR. or selecting active jobs. Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community. DSM-IV Common Adult DC: American Psychiatric Association. work. 2. Am J Psychiatry. The prevalence and correlates of adult ADHD Symptom Domain Manifestation in the United States: results from the National Comorbidity Survey Replication. Washington. It is important to note that the impairment can be lifetime. Wender PH. Difficulty sustaining • Poor Management 4. Smallish L. Hechtman L. time spent with family. Fletcher K.98(6 Pt 1):1089-1095. • Initiating/completing 1996. These are common complaints.1:1008- 1012. Adults obtaining collaterals (information from surviving parents have a higher cognitive load than children. surprising that the inattentive symptoms become more some impairment from the symptoms must be present problematic as one reaches adulthood. Third. 2000. not organizing. If the often cope with this sense of restlessness by working two symptoms of ADHD only appear during the active phase jobs. Miller MA. 1902. Aleardi M. can be stigmatizing. or in social set. and easy distraction. and those of other disorders will often distinguish them. The symptoms noted in the DSM-IV are specific Impairments in Adult ADHD to childhood. being “on the go” or “motor-driven. when available). Diagnostic and Statistical Manual of Mental Disorders. They found that adults with as poor time management. Monuteaux MC. procrastination. There may be consequences to the individual’s excess Longitudinal history is critical for making the diagnosis activity. or they might plan breaks for such circumstances. ADHD in Adulthood: A Guide to demand attention Current Theory. such as circumstances in which they would have to sit selves over an extended period of time—with the ADHD still. 3rd ed rev. Barkley RA. Barkley R. and the impairments are notable. 1994. in two or more settings. untreated ADHD are four times as likely to contract pleting tasks. Family of another mental health disorder. Spencer TJ. working long hours. Biederman J. 1999. Adaptive behavior 10.1998. Diagnostic and Statistical Manual of Mental Disorders. Cannot organize Procrastination 8. 50% to 75% in adults). symptoms generally preceding those of other disorders. Murphy KR. et al. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry This is best obtained by taking a longitudinal history and to observe how adults deal with their symptoms. Diagnosis and Treatment.

Eli Lilly. Subjects were 18–44 years of The NCS-R sample was meant to independently age (since confounders were thought to be present assess all co-morbid disorders. Janssen. and were Epidemiologic Studies: more likely to be separated or divorced. the cohort. Third Edition. These surveys are less affected by of ADHD until Kessler and colleagues5 conducted the Berkson’s bias.282 individuals with co-morbidity. there been no truly systematic studies of the epidemiology is no referral bias.6) The stated that ADHD could be diagnosed with inattentive subjects determined by this survey to have adult ADHD symptoms alone. yielding a ~4. Novartis. one would expect to find less severe illness and less surveyed a probability sample of 9. because subjects were assessed independent- numerous psychiatric disorders. where African-American patients had less the data regarding adult ADHD. is on the advisory boards of Cephalon. and Shire. had experienced full childhood ADHD—meeting six tency as earlier investigations demanded the presence out of nine criteria in childhood—and showed current of hyperactivity while others did not. Eli Lilly. There is concern depended on the site. GlaxoSmithKline. Spencer is a speaker for Eli Lilly. including ADHD. Spencer is associate professor of psychiatry at Harvard Medical School and associate director of the Clinical and Research Program in Pediatric Psychopharmacology at Massachusetts General Hospital in Boston. some of which depended on the defini. little was known about the epidemiol. Ortho-McNeil. and calculated back rates clinical samples. which extrapolates to a prevalence of ~4% for ment: There were more men than women with ADHD. and receives research support from Cephalon.1 The traditional diagnosis was complicated were used.2 which vey. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry THE EPIDEMIOLOGY OF ADULT ADHD By Thomas J. In the case of the The NCS-R is a definitive epidemiologic study of NCS-R. Ortho-McNeil. Heilegenstein and Psychiatric Co-morbidities of Adult ADHD colleagues4 surveyed college students. However. which was expanded and validated for this sur- Manual of Mental Disorders. mirroring those reported in ing on subjects’ answers. but these samples endorsement of symptoms (Slide 1). Janssen. adult ADHD. The epidemiology of childhood ADHD is ~5% clinical studies of adults with ADHD presenting for treat- to 8%. Spencer. Several rating scales tions used. The survey contained technology and highly trained interviewers. of different disorders. the disorder. but a much lower ratio overall among adults than that observed in childhood. jects who endorsed childhood ADHD responded that ogy of attention-deficit/hyperactivity disorder (ADHD) they continued to have ADHD. whether interviews that these criteria were developed for childhood and versus rating scales were employed. It ly. The rates questions about childhood ADHD and a question about of other disorders in the population were determined Dr. 70% of sub- Until recently. viduals who would benefit from interventions targeting According to a meta-analysis by Faraone and col. including the Adult ADHD Self-Report by the introduction of the Diagnostic and Statistical Scale. Novartis. were less likely to be employed.7% prevalence of adult ADHD. a doctor if they have two disorders. and Shire. using state-of-the-art in individuals >44 years of age). there had ascertained by people seeking treatment.5 were relatively limited. in which patients are more likely to see National Co-morbidity Survey Replication (NCS-R). Disclosures: Dr. producing an In epidemiologic samples. leagues. (Some of these tools are available free online. They may exclude indi- subject or their parent were the source of information. and Shire. 100 individuals who met the ADHD ADHD into adolescence had shown variable rates of criteria and 50 who did not were directly interviewed to persistence. There were also The National Co-morbidity Survey Replication interesting correlates between subpopulations regarding Two quasi-epidemiologic studies provided much of endorsement. GlaxoSmithKline. This resulted in diagnostic inconsis. Remarkably. there appeared to be very initial questionnaires. Pfizer. Diagnosis also persistent symptoms and impairment. MD Introduction persistence into adulthood. Novartis. CNS Spectr 13:8 (Suppl 12) 6 © MBL Communications August 2008 . confirm the validity of the findings. Barkley and colleagues3 sur- veyed adults applying for driver’s licenses.1 ~50% of children with ADHD continue to The various correlates and impairments found in the experience symptoms into adolescence and adult. high rates of co-morbidity. NCS-R mirrored those found in survey studies and in hood. National Institute of Mental Health. Thus. Janssen. In a careful follow-up in adults. Surprisingly. Pfizer. GlaxoSmithKline. the subject pool is not estimated prevalence of 4%. Bottom-up studies following children with and re-interview. Ortho-McNeil. conducted follow-ups depend. and whether the may be too restrictive for adults. Adults with ADHD had lower edu- cation levels.

5 5.8 6. The high impairment rates among ADHD Sex subjects may be a reflection of the chronicity of the dis- Female 35. but only ~10% were receiving treatment for ADHD.05.8 Race Low self-care 6.3 1.7 5.6 2.0 30–44 56.3 5.9 1. There were high conduct. low cognitive functioning (Slide 3).1 SLIDE 3 Education (years) Impairments in 30-Day Functioning Associated With Adult <12 18. persistent ADHD in 11.0 order (many other psychiatric disorders are fluctuant) in Male 64. the same find- ings reported in the NCS-R were reported in this study. there were some outliers.0 3. oppositional defiant disorder. It SLIDE 1 is likely that some patients were being treated inappro- Demographic Correlates of Adult ADHD5 priately for medical disorders that mirrored or masked % OR the ADHD.5 Approximately 40% rent psychiatric disorder (present within the previous of individuals with ADHD were being treated for mental 12 months) (Slide 2).8* ADHD prevalence. bulimia. Spain was the only country Any anxiety 47. United States.8* addition to the low treatment rates.9 1.5 1.4 3. low social functioning. 36% for substance abuse. and in lower-income countries—Lebanon.3 4.0 3.7* An epidemiologic study by Fayyad and colleagues7 Never married 35.6* 69.2 Low cognition 23.2* Retired 0.1 1. and Mexico—the rates Any mood 29.2 investigated populations in 10 countries.9* The demographics were similar: ADHD was more Any psychiatric 66.6 % ADHD % No ADHD OR ≥16 17.05. and for any psychiatric disorder.5 1.7 Rates of adult ADHD SLIDE 2 varied from country to country.7 1. African-American 6.2* 88. including the *P=. *P=. and intermittent explosive disorder). OR=odds ratio.9 0. however.4%. OR=odds ratio. and 89% rates of occupational failure. The study also found higher rates of separa- CNS Spectr 13:8 (Suppl 12) 7 © MBL Communications August 2008 .6 Caucasian 73.0 High time out of role 15.5 1. using a methodology modeled on the NCS-R.3 0. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry by the sample. In the NCS- for anxiety. 70% for impulse R sample. 59% disorder but may be aware of impairments.7 2. In addition. oppositional defiant impairment in virtually every domain.5 1.6 6.5 or substance problems. those with ADHD symptoms experienced disorders (antisocial personality.1 1.3* common among males and those with less education.8 Other 18.8 5.4* Low mobility 8. Subjects are often unaware they have a prevalence rates were 45% for mood disorder.7* ADHD5 12 26.4* 59.432 respondents 18–44 years of age (Slide 4).1 13–15 37.3* Hispanic 15. It appears that ADHD may have prevented successful † Includes antisocial personality disorder.0 Student 4.0 5.2 0.8 2.7 1.0 2. While there was general agreement between most countries. the rate reported in France was >7%. 12-Month Lifetime For example.1 2.9 3.8 1.0 *P=. mood. The researchers retrospectively assessed child- hood-onset. 67% had cur.0 6.7 Other 5. intermittent explosive disorder.8* 35.7* Homemaker 4. OR=odds ratio.9 3. Individuals with ADHD were more Epidemiologic studies tend to discover individuals who likely to have a co-morbid disorder than not.5 This is a much lower treatment rate than for anxiety. matriculation into later grades and resulted in a lesser duct disorder. sta- % OR % OR tistically greater than the average.1 4.7 Marital Cross-National Prevalence and Correlates of Married/cohabitates 52.0 1.0 Adult ADHD Separated/divorced 12. and gambling.5* 45. The average prevalence Psychiatric Comorbidities of Adult ADHD5 rate was 3. Lifetime suffer silently.1 1.9 Low social functioning 18.0 0. Any impulse† 35.1 1.7* Working 71.9* Employment Low role functioning 15.2* with a higher income that also had a lower rate of Any substance 14.05. Age 18–29 43.0* were statistically lower. or substance disorders. con. occupation. Colombia. In general.5 1.7 4.9 4.

Adult ADHD Self-Report Scales (ASRS). et al. 3. and Prevalence of ADHD in Other Disorders7 has a substantial correlation with educational. Faraone SV. 1980. Heiligenstein E.9* severity of these damaging impairments. and 1. 2006. order. The prevalence of ADHD ly for ADHD. Epidemiologic studies of ADHD reveal that while it is a common disorder. environmental. social function.0* ADHD will be necessary to reduce the frequency and 12 OR 3. Pediatrics. J Am Coll Health. low relates of adult attention-deficit hyperactivity disorder.9% in Mexico which implies that there is some interaction between and Lebanon. Available at: www. The prevalence and correlates of adult in the ADHD sample.98(6 pt 1):1089-1095. 2 2.0* 10 % with ADHD 8 References 6 1. France USA 0 1 2 3 4 5 6 7 8 Treatment by a professional varied widely by country. Psychol 4 Med. Barkley R. and 12% had a 6. Berns AR. OR 4. A broader appreciation of 14 OR 4. Diagnostic and Statistical Manual of Mental Disorders. and social impairment. there was seldom treatment specifical- an odds ratio of almost four.hcp.9* Average 3. 20% to 24% in Spain. Barkley RA. CNS Spectr 13:8 (Suppl 12) 8 © MBL Communications August 2008 . While there appeared ders in populations with ADHD. Washington.7 These data are similar to Conclusion those described in the US sample. De Graaf R. SLIDE 6 Prevalence of Comorbid Disorders in ADHD7 40 OR 4. Br J Psychiatry.05. Preliminary normative data on DSM-IV attention deficit hyperactivity disorder in college students. 13. Biederman J. OR=odds ratio.1% in Lebanon. Accessed July 16. DC: American Psychiatric Association. Higher rates of these co-morbid disorders were found 5. 25% had a significant mood dis. it is largely unrecognized in spite of its considerable associated impairments.163(4):716-723. occupa- tional. Miller MA. Adler L. 2006. this population. 2008. Mick E. Kessler RC.med. et al.0* Belgium 10 Spain 5 Netherlands 0 Mood Anxiety Substance Abuse Italy Germany *P=.edu/ncs/asrs. and the Netherlands. associated with adult ADHD included low occupational 7. OR=odds ratio. low physical mobility.2% in Spain. treatment rates over the previous 12 months for disorders other than Fayyad and colleagues7 also examined rates of ADHD were: 50% in the US. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. 0 Mood Anxiety Substance Abuse 3. Kwasnik D. Among respondents with adult ADHD. it affects all areas of life. countries.0* SLIDE 4 35 Cross-national Prevalence and Correlates of Adult ADHD7 % With Co-morbid Disorder 30 OR 3. Cross-national prevalence and cor- function (time out of role). Rather.harvard. Kessler R. National Comorbidity Replication substance abuse disorder.36(2):159-165.1998. but lower than rates of other disor. ADHD in the United States: results from the National Comorbidity Survey Replication. Murphy KR.05.php. Fayyad J. Approximately 10% of to be significant amounts of professional treatment in individuals with a significant mood disorder had ADHD. These rates Belgium. and 1.190:402-409. 9% to 13% in other were substantial. perhaps genetic. or a combination (Slides 5 and 6). 4. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. 3rd ed. the disorders. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry tion and divorce among international adults with ADHD similar to those in the US. Am J Psychiatry. 1996. 2007. *P=. Conyers LM. ADHD is not SLIDE 5 a benign condition. Impairments in functioning Survey. low cognitive function. Rates of 12-month professional treatment was also higher in populations with anxiety disorder for ADHD among respondents with adult ADHD were: and substance abuse than in the general population. 46(4):185-188.4 25 Lebanon 20 Colombia Mexico 15 OR 4. >38% had an anxiety disorder. and low self-care.2% in the US. ADHD among people with other disorders.

symptoms may also change in form and become more subtle. resulting boys. the body of knowledge regarding impairment in adult ADHD is far from complete. Children with ADHD. Moreover. Although ADHD Symptoms hyperactivity and impulsivity symptoms often decline with age. adults tend to overutilize medical group was also less likely to use contraception. like children. They also tend to have unique deficits Attention-deficit/hyperactivity disorder (ADHD) is relating to their specific roles. CNS Spectr 13:8 (Suppl 12) 9 © MBL Communications August 2008 . mostly with ADHD tend to perform poorly at work. impairment may actually increase as less structure is provided outside of school. However. occupa- tional. in their has several jobs or experiences problems in multiple adolescence and adulthood. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry IMPAIRMENT ASSOCIATED WITH ADULT ADHD By Mark A.3 in adults than in children or adolescents (Slide 1). Ortho-McNeil. ity occur in individuals Boyswith ADHD at all age levels. In addition to symptoms declining with age. ings. a contrary trend Follow-Up and Cross Sectional Studies of arises with impairments: they tend to accumulate. trouble with deadlines. and ADHD-Related Impairments therefore may be more obvious than ADHD symptoms Deficiencies in adaptive functioning relative to abil- once a patient reaches adulthood. whether those roles are present in 4% to 6% of adults in the United States. an problems. Difficulty at work can cause hyperactive children were compared to socioeconomic financial stress and may be compounded if the individual status-matched controls.2 Less is known about the relationship between • Hyperactivity • Inattention ADHD symptoms and impairment in adults. and social difficulties. Barkley and in school and often extends to circumstances beyond colleagues4 delineated some of the sexual difficulties school and academics as children get older. Stein is a consultant/advisor to Abbott. In addition. Stein. such as poor relationships with supervi. adult with ADHD and co-morbid antisocial personality and frequent workplace absence. most lay people picture Domains of • Health/Injury Impairment • Occupational Functioning the most prominent symptoms of childhood ADHD— • Social Functioning hyperactivity. Novartis. Adults those with ADHD had an unplanned pregnancy. may experience legal difficulties. and tended to be more promiscuous. For example. Despite these find. and Pfizer. versus 4% of the controls. and Pfizer. and absenteeism.1 a much impairment seems to be related to the co-morbid diagnosis of ADHD was associated with greater marital characteristics of the disorder in adults. Stein is professor in the Department of Psychiatry a the University of Illinois in Chicago and director of the Adult ADHD Clinic. Building upon our knowledge of impairment in adults with ADHD will SLIDE 1 result in a broader range of treatment outcomes which Adult ADHD: Domains of Impairment may be measured and targeted. Adults in a longitudinal study of hyperactive children. have higher rates of substance Dr. These Girls in severe consequences. Moreover. earlier. Organon. or employee. However. tended to have sex 1 year areas of work. difficulties in the workplace. the cumulative effect of untreated or undertreated ADHD in adults contributes to increased academic. diagnosis of the disorder • Self-Esteem requires ADHD symptoms and impairment. ~20% of adults with ADHD reported that they experi- Impairment in children typically begins with problems enced difficulties with sexual adjustment. Adults trols. unemployment. PhD Introduction abuse disorder. than con- sors.5 Sixteen percent of the adolescents and young adults with ADHD were treated for a sexually trans- with ADHD. In the National Co-morbidity Survey Replication. 38% of resources and may have more health difficulties. like children with ADHD. Disclosures: Dr. versus with ADHD. Experience with childhood ADHD clarifies that there is only a Age modest correlation between symptoms and impair- ment. student. The ADHD dent-prone. who were followed into young adulthood. In Annual Impairment occupies a wider range of domains a 1993 longitudinal study by Weiss and Loss Hechtman. and receives research support from Eli Lilly. parent. caregiver. • Academic/School • Adaptive Functioning • Functioning Symptoms and Impairment • Substance Use When considering ADHD. may be more acci- mitted disease. National Institute of Mental Health. is a speaker for Novartis and Ortho-McNeil.

These three examples exemplify the range and sever- Poor interpersonal skills (few friends. During a surgery rotation. much less is known about the impair- Longitudinal studies indicate that young adults and ments experienced by females and by those with the adults with ADHD seem to have more academic and inattentive subtype. the diagnosis of ADHD was less certain in Stephanie’s case. Because of her diagnosis. ity had deficits in adaptive functioning. during which stimulant treatment had resulted • Demoralization and low self esteem in a dramatic improvement in her grades. school. these behaviors were not new: Tom has exhibited childhood symptoms of inattention and impul- • Substance use and abuse sivity. her supervisor work. Tom Emotional problems (low self-esteem) showed clear signs of impairment early on. college completion for an individual with ADHD often Case Examples requires 5–6 years rather than 4 years. Consequently. adults with ADHD become demoralized college. if college is com. Stephanie • Caveat: may be less severe for inattentive type had been very driven and had excelled in her under- graduate courses. 4-year schools. and criminality. He drank heavily. His parents were SLIDE 2 What Do We Know About Impairment? very upset that his tuition costs were not yielding any concrete benefits. Fourth Edition7 criteria Measuring Impairment and consisted primarily of individuals with the com- After obtaining the patient’s history. Tom was also unable to balance his Longitudinal studies of children with ADHD. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry 4% of controls. William was a 31-year-old investment banker. In There are some limitations to ADHD studies as the this situation. marital dissatisfaction) ity of impairment and symptom presentation. Stephanie did not show clear Adaptive deficits signs of impairment until challenged by medical school.7.5 Among those with children. most of the subjects in these studies were male. but was very successful financially. or with relationships (Slide 3). He was generally happy with his career and his social SLIDE 3 life. vocational underachievement (Slide 2). She had been diagnosed with ADHD in col- • Less stability in life lege. Tom clearly exhibited both child and adult • Poor adaptive skill performance symptoms of ADHD and significant impairments. combined type budget. there is no evidence of impairment as he seemed to successfully compensate for his high activity level. He was a little disorganized. Three cases illustrate common impairments associ- pleted at all. In her second year. and had changed his major ~7 times. Often. The major. Many had rated her performance as unsatisfactory. often slept in. and constantly ran out of money as a result. She requested further behaviors. crime) continued. impairments in adaptive functioning. • Chaotic personal and family life (divorces. which has Antisocial behavior (substance abuse. His grade-point average was 1. He had graduated high school at the bottom half • Early and risky sexual behavior of his class. clinicians should bined subtype (inattention plus hyperactivity). He had attended community college and two and convinced that failure is externally determined. substance abuse. along with the aforementioned risk of ated with adults who present for ADHD evaluation and substance abuse. accommodations on some of her testing. treatment decisions are guided more by majority of the longitudinal studies were conducted impairment than ADHD symptoms per se. • Academic and vocational underachievement However. 54% did tion. creates a pattern of Tom was a 24-year-old student in his 6th year of instability. she had received accommodations during the Medical College Similarly. This. and how clinicians might address them. not have custody. a cross-sectional study by Murphy and Admission Test and was subsequently admitted into Barkley6 examined the presenting complaints of a group medical school. Stephanie emotional problems such as low self-esteem. prior to development of the Diagnostic and Statistical Manual of Mental Disorders. moves) Although William displayed some ADHD symptoms. In contrast. and missed many classes. early and risky sexual behavior. In addi- consider acquiring their adult patient’s medical and edu- CNS Spectr 13:8 (Suppl 12) 10 © MBL Communications August 2008 .4. • Less educated than others of cognitive ability and would likely require additional evaluation to deter- • Poor financial management mine if ADHD is the primary cause of her difficulties. • Poor executive functioning Stephanie was a 25-year-old second-year medical student. For example. His parents requested that he be evaluated for Chart Review of Presenting Symptoms of ADHD Adults 6 ADHD out of concern about his high activity level and Poor school/work performance his single marital status. she seemed to of adult patients seeking treatment for difficulty at struggle. antisocial was forgetful and disorganized.

However. it should keep in mind that often patients may not recall their childhood symptoms SLIDE 4 or impairments. Kessler RC. Hyperactive Children Grow Up: ADHD in Children. 1993. has been validated in adults with ADHD. Barkley RA. and intensity. it is also useful to talk to Issues Related to Impairment other informants. Typically. Quality of Life Res. 1994. If communication or marital 10. financially. and the role of childhood Impairment should be at the forefront of the clinician’s conduct problems and teen CD. DC: American Psychiatric Association. 3. J Abnorm Child Psychol. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry cational records.11 The WFIRS-S is a brief ques. the Overlap of co-morbidity with impairment Adult ADHD Quality of Life scale. NY: The Guilford Press.25:264-271. the percentage of bills paid 9. Available at: www. Accessed July 16. 2006. duration. Health-related quality of life in children and on time can become a useful measure for both the adolescents who have a diagnosis of attention-deficit/hyperactivity disorder. marital satisfaction. physicians must be careful to distinguish between treating actual impairing psychiatric disorders Beyond symptom improvement. Adler L.100). New York. Validation of the adult attention-defi- satisfaction are chief complaints. J Am Acad Child Adolesc Psychiatry. 1996. Antshel K. 2nd ed. Am J Psychiatry. especially in adults. Her attention difficulties may have mat. 2008. et al. Fletcher K. Influence of Impairment on Diagnosis and SLIDE 5 Treatment Influence of Impairment on Treatment In recent years. 2002. Weiss G. Smallish L. improved is most certainly undertreated. Smallish L. Fischer M. The adolescent outcome of adaptive functioning. alizing the impairment. Pediatrics. low self esteem) should be the focus or goal tered less than the poor match between her expecta. Improvement in health-related quality of life in children with ADHD: An analysis of placebo of treatment with the patient. follow-up study. 2004. 4. 5. Replication. such as spouses or parents.15:117-129. Miller A. central focus when designing a treatment strategy. Defining the impairment. or intensity to reduce impairment? mance enhancement. Diagnostic and Statistical Manual of Mental Disorders. to the overlap of ADHD and the co-morbidity. Attention deficit hyperactivity disorder adults: comor- bidities and adaptive impairments. 2004.37(6):393-401. patient and the clinician. Other areas of impairment are hyperactive children diagnosed by research criteria: I. Faraone S. The prevalence and correlates of adult key clinical issue.30(5):463-475. spouses can help cit/hyperactivity disorder quality-of-life scale (AAQoL): A disease-specific quality-of-life measure. CADDRA: Canadian ADHD Practice Guidelines. mind during diagnosis. psychological or neu. attendance record) However. percentage of bills paid. and even • Patient may not be best informant (“lots of friends”) childhood ADHD. Klassen AF. for example. children: self-reported psychiatric disorders. Murphy K. J Atten impairment is not specific to the ADHD. therefore.8. Kelsey D. Brod M. We 7. In cases such as Stephanie’s. • Symptoms without impairment is not ADHD ropsychological testing can be helpful. of treatment tions and capabilities.ca or school attendance. Hechtman L. clini- cians use global measures such as the Clinical Global Few standardized impairment measures for adults Impression-Severity scale. and then confirming the targets 8. self-concept. ADHD in the United States: results from the National Comorbidity Survey Impairment is vital to diagnosis and treatment. recommend writing out the chief complaint.14(5):e541-547. Compr Psychiatry. operation.9:465-475. after work. the Weiss Functional Impairment Rating Scale-Self Report (WFIRS-S) is as helpful measures of improvement. listening to spouse. unstable with her IQ. Johnston J. Barkley RA. relationships. There are also quality of life • Often related to ADHD symptoms plus impairments in measures that have been used successfully in children executive and adaptive functioning and adolescents with ADHD. Fischer M. Patients experiencing symptoms of ADHD but not impairment should not be diagnosed with ADHD. Washington. Typically. comorbidity. be adequate in focus.9 A new measure. Barkley R. If a patient has problems controlled studies of atomoxetine. duration. Consequently. Sumner C. Able S. focus. but is related Disord.163(4):716-723.10 In addition. Consider the setting where impairments occur diagnosing ADHD. Fine S. 4th ed. is treatment adequate in and offering medications for the purposes of perfor. The disorder Operationalize impairment and monitoring strategy (eg. and risk. and should be the physician’s 6. An 8-year prospective related to the overlap of ADHD and the co-morbid con. et al. the field has been accused of over. socially) cases. Kratochvil CJ. Swindle R. cannot keep job. is the References 1. life skills. are still in their infancy. attendance records can function (p. of reducing impairment (Slide 5). not just tionnaire that offers a snapshot of patients’ own views to reduce ADHD symptoms but with the ultimate aim of their impairments in the following domains: family.29(4):546-557. Allen AJ. 2006. 2. J Dev Behav Ped. • Impairment guides treatment planning Metrics for impairment in adult ADHD. Perwien AR. social. work. Young adult follow-up of hyperactive dition (Slide 4). adult ADHD is related to impairments in executive and Adolescents and Adults. Although this may occur in some Consider duration or time (at work. gauge improvement. In Stephanie’s • Performance enhancement versus treatment of a psychi- case. 1990. Gordon M. further investigation demonstrated that she had atric disorder an above-average IQ with attentional skills consistent Often the chief complaint (eg. Barkley RA. in which a patient may require Criteria for diagnosis educational accommodations. Treatment must another useful gauge. there is even stronger evidence that ADHD is often underdiagnosed or misdiagnosed. Faries D. Edelbrock CS. Often. 2006.caddra. If the problem is work attendance 11. school. Symptoms versus impairment. CNS Spectr 13:8 (Suppl 12) 11 © MBL Communications August 2008 .

3% of Aggressiveness respondents with ADHD had a co-morbid mood dis- Low frustration tolerance order.2 15 of. Newcorn. sanofi-aventis. and Shire. The reverse is also possible—treatment of the co-morbid disorder Similarly. In the 10 latter case.5% of adults with anxiety disorders have Dr. lation. However. reported co-morbid disorder within the previous 12 months produce improvement or even alleviation of a co-mor- DSM-IV=Diagnostic and Statistical Manual of Mental Disorders. Newcorn is a consultant to Abbott. Inattentiveness Shifts activities SLIDE 3 Easily bored Co-morbidity of Other DSM-IV Disorders with ADHD3 Adults Impatient National Co-morbidity Survey Replication (N=3. 9. Biobehavioral Diagnostics. Eli Lilly.1% of adults with treating co-morbidity or minimizing its developmental mood disorders have ADHD. developed as a result of untreated ADHD. Thus. ADHD remains highly co-morbid across the lifespan with rates often reflecting lifetime occurrence (Slide 1). Disclosures: Dr. Novartis. 15. antisocial disorder. approximately three impact can be an important goal of ADHD treatment times the prevalence seen in the general adult popu- (Slide 2). and distinct from. Lupin. adults with ADHD compared to children with ADHD lescence/adulthood. suggesting that the particular condition Edition. Why Focus on Co-morbidity in Adults with ADHD? tions tend to occur at different times developmentally. substance Co-morbidity should inform treatment decisions because: use disorder [SUD]. physicians must decide which condition 5 to treat first. Psychogenics. more severe mood disorders).1% had a co-morbid anxiety disorder. and distinct from. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry CO-MORBIDITY IN ADULTS WITH ADHD By Jeffrey H. and receives research support from Eli Lilly and Ortho-McNeil.2% Impulsiveness had a SUD. the prevalence of ADHD is higher among may produce improvement in ADHD symptoms.3 Substance abuse disorders 35 Impulse-control disorders It is important to identify co-morbidity because the 30 presence of co-morbid disorders can alter response 25 19. • Co-morbidity may alter the response to ADHD therapy • Co-morbid disorders often require treatment independent of. Ortho-McNeil.1 Prevalence of Other Disorder (%) 45 Mood disorders Anxiety disorders 40 38. and 19. MD Introduction Attention-deficit/hyperactivity disorder (ADHD) is high- ly co-morbid across the life span.1. CNS Spectr 13:8 (Suppl 12) 12 © MBL Communications August 2008 . The nature of co-morbidity may differ in adolescents and the nature of co-morbidity may also differ in late ado. In some instances. 47. individual co-morbid condi. co-morbidity SLIDE 2 is not uniform across time. individuals with other disorders: 13.199) Restlessness 50 47. treating ADHD may 0 Among respondents with ADHD.6 20 to ADHD therapy or require treatment independent 15.2 In addition to changes in the rates of co-morbidity. when co-morbid conditions can be Impairment from co-morbidity increases with age especially impairing (eg. the treatment for ADHD. Fourth bid condition. therapy for ADHD SLIDE 1 • Co-morbidity may alter the sequence of interventions Developmental Trajectory of ADHD Symptoms: From Childhood to Adulthood • Prevention of co-morbidity should be a goal of treatment The nature and frequency of ADHD symptoms changes with age Co-morbidity Rates in Adult ADHD The National Co-morbidity Survey Replication (NCS- Children Motoric hyperactivity R) by Kessler and colleagues3 found that 38.6% had other impulse-control dis- Adolescents Easily distracted orders (Slide 3). Newcorn is associate professor in the Department of Psychiatry at the Mount Sinai School of Medicine in New York City.

but also by the fact ADHD. there ADHD may help explicate the relationship between CNS Spectr 13:8 (Suppl 12) 13 © MBL Communications August 2008 . it 15 13. Similarly. other disorders of impulsivity) Other “comorbid” disorders are likely genetic variants of Longitudinal Studies ADHD (eg. However.3% of adults with impulse-control disorders have colleagues10 found that personality disorders occurred ADHD (Slide 4). ADHD. ADHD may selectively increase the risk for certain co- and 40% to 50% have SUD. which SLIDE 5 is at least five times the rate in the general population. with severe hyperactive/impulsive symptoms.12 25 Mood disorders criteria. This rate of SUD is higher morbid disorders. he ences in the types of patients studied. syndrome. Fourth Edition. such as studies indicate increased risk for antisocial personality Tourette’s disorder. or whether they are truly independent condi- ment of newly diagnosed adults (ie. The estimates of lifetime co-morbidity deter- oppositional defiant disorder may arise in children mined from cross-sectional studies is generally high. ~20% of adults Some “co-morbid” disorders may be a direct reflection of with major depression8 and 15% of adults with bipolar ADHD symptoms and their impact (eg. many of these studies lack systematic data on of affective dysregulation in children and adults with the full range of personality disorders. For example. ADHD (eg. those from follow-up studies of ADHD in childhood are some anxiety and mood disorders may follow directly generally lower. some anxiety disorder9 have ADHD.13 Owing to these and Prevalence of ADHD (%) Impulse-control disorders other complexities in assessment and interpretation. the frequent occurrence disorder. 10. in patients with generalized anxiety disorders. 40% to 50% have anxiety disorders. ADHD+CD. or she could reasonably be expected to develop anxiety Results of several smaller studies parallel those from in these situations. ADHD+BPD) The natural history of ADHD is complicated not only Several disorders share environmental risk factors with by the presence of other disorders. CD) it is not always the case that these other disorders ODD=oppositional defiant disorder. major depression. as illustrated by the high degree of than that found in epidemiologically derived samples.199) Statistical Manual of Mental Disorders. TS=Tourette’s represent co-morbidity (ie. reported ADHD within the previous 12 months and Co-morbidity DSM-IV=Diagnostic and Statistical Manual of Mental Disorders. or other factors. CD=conduct disorder.3 9. depression.8 ity is a consequence of early life co-morbidity. they may be the primary dis. SLIDE 4 Co-morbidity of Adult ADHD with Other DSM-IV Disorders3 One problem with these studies is that the samples were recruited prior to release of the Diagnostic and National Co-morbidity Survey Replication (N=3. Similarly. that not all subjects retain their ADHD diagnosis. cross-sectional tions. Fischer and 12. if a person with ADHD expe- these two approaches are likely accounted for by differ- riences repeated failure in performance situations. It is clear from these data that and mood disorders) assessment of ADHD in patients with other psychiatric Risk for certain “co-morbid” disorders is increased by diagnoses is essential. CD.6 Understanding the Relationship Between ADHD and Similarly. Some co-morbid disorders may be a direct reflec- approach) and longitudinal follow-up of children with tion of ADHD symptoms and their impact. 5 Understanding the Relationship Between ADHD 0 Among respondents with other disorder. For example. BPD=borderline personality disorder. Also. Third Edition. and co-morbidity data were collected in the fol- Anxiety disorders 20 Substance abuse disorders low-up study but not at baseline. In addition. For example. and SUDs.7 Finally. Additionally. the rate of ADHD is 25%. in 40% of hyperactive children followed into young adulthood.14 Further. in patients with SUDs. and are important differences across studies. a follow-up study into adulthood by Mannuzza and colleagues11 found much lower rates. or develop low self-esteem and the NCS-R3-5: 30% to 35% of patients with ADHD have other manifestations of mood disturbance. so would expect “co-morbidity” (eg. order). persis- 10 tent ADHD.8% of adults with SUD have ADHD. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry ADHD. There is confusion as to whether ADHD and other disorders Data on co-morbidity of ADHD in adults come from represent different aspects of the same overarching two different lines of research—retrospective assess- condition. the prevalence rates of other disor- ders may be confounded by the assessment methods Other co-morbid disorders may represent genet- used. among individuals with ADHD is highly impairing and often motivates people to present for treatment. other disorders of This is consistent with the idea that SUD co-morbidity impulsivity. ODD. Thus. co-occurrence of conduct disorder. Co-morbid Disorders the rate of ADHD is 20%. Differences in co-morbidity rates from from ADHD.1 is not thoroughly understood whether adult co-morbid- 12. although most of the longitudinal ic variants within the spectrum of ADHD.5 10. The relationship between ADHD and co-morbid dis- orders is interesting though complex (Slide 5). TS.

underachievement and learning disability can cause sub- ders (ie. grade repetition (especially in contribution of ADHD persistence to the development males). personality disorders in adults with ADHD. Flory and CNS Spectr 13:8 (Suppl 12) 14 © MBL Communications August 2008 . planning and organization. stantial impairments in adults with ADHD. response inhibition. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry ADHD and bipolar spectrum disorder. there may peers who use drugs or by altering biological function- be biological underpinnings to the development of ing in selective brain regions. either by increasing exposure to often fail to recognize them. it is not clear how much these other dis. verbal and visual learning. Individuals with disruptive behavior disorders are at increased risk for a diagnosis of Cluster B personality disorders. For example. set shifting and categorization.17. as defined by The relationship between ADHD and substance abuse having abnormal performance on one of several tests has been highlighted by several research groups.20 including antisocial personality disorder21 There appears to be a specific association between and borderline personality disorder. Personality Disorders Reprinted with permission from: Wilens TE.13 who of executive function (Slide 7). but in fact look more like a co- morbid condition. There learning disability result in increased rates of school drop are also important questions regarding the potential out. 1997. it is not often factors. sero- study by Miller and colleagues23 showed increased tonin. below-average grades. J Nerv Ment Dis.22 The latter point ADHD and nicotine abuse. it suggests of SUD in late adolescence/young adulthood. and the prevalence of nicotine rates of a variety of personality disorders in adoles- use in adults with ADHD is approximately twice that cents with ADHD.18 One caveat of co-morbidity. 0 EFDs=executive functioning deficits. Biederman J. a child of a depressed mother discussed in adults. and memory. Approximately one third of adults ADHD and Substance Abuse with ADHD have executive dysfunction. particularly in those with persistent of the general population.19 While this is twice the generally have found earlier onset and elevated rates prevalence found in adults without ADHD. 0 10 20 30 40 50 60 Age at Onset (years) P≤. Intriguingly. not all Learning Disability co-morbidity within ADHD reflects genetic variation.001. Although the correlation between ADHD and learn- several disorders share common environmental risk ing disability is a major focus in children. Findings from a longitudinal tion by stimulating the release of acetylcholine. environmental effect) but also depression (ie. Thus. et al. This is unfortunate since academic might have increased risk for disruptive behavior disor. selective attention and 10 Higher risk visual scanning.15 Nicotine enhances atten- is often not appreciated. ADHD syndrome. tors also contribute to the development of substance abuse. Executive Function Deficits in Adults With and Without ADHD19 SLIDE 6 35 31% (n=66) ADHD and Substance Use Disorder (SUD) 30 Survival Curve: Risk for SUD 25 Onset in Adults With Untreated ADHD With EFDs (%) 100 20 16% ADHD (n=23) 90 Control 15 80 10 70 Risk for SUD (%) 60 5 50 0 40 ADHD Controls Earlier onset (n=207) (n=145) 30 20 EFDs include: sustained attention/vigilance. the early occurrence in association with ADHD suggests that there could be a window of opportunity SLIDE 7 for treatment. children with early mani. Mick E. and dopamine.14. regarding assessment of adults for the possible pres- festations of disruptive behavior are at substantially ence of learning disability is that it is often difficult to increased risk for conduct and SUDs if they also have clearly distinguish between capacity and achievement. ADHD.14 While many other fac.16 ADHD and due to both genetic and environmental factors).185:475-482.5. The inability to quit smok- ADHD. However. For example. A related area of investigation involves executive orders should be seen as independent conditions or function deficits—which are often considered part reflections of impairment from ADHD. and working below one’s ability. ent report rather than self-report—consistent with the The effects of nicotine may also serve to increase risk observation that individuals with personality disorders for other drug abuse. which that executive dysfunction is not a prerequisite for the stabilizes with age (Slide 6). This finding was more clearly derived from par- ing may be biologically driven in the ADHD population. and parcel of ADHD.

Milroy T. 1996. Biederman J. Mick E.150(12):1792-1798. Donini M. 1993. 11. 1990. History of childhood attention orders and not ADHD. Kay J. Attention-deficit/hyperactivity disorder and the substance use dis- treatment of adults since the majority of adults with orders: The nature of the relationship. Donati D. and to appreciating the complex relationships tion in childhood contributes risk for developing antiso. 2. Attention deficit hyperactivity disorder in adults: comor- are not at all linked to the areas covered in the present bidities and adaptive impairments. Attention deficit hyperactivity disorder in childhood among adults with major depression. Faraone SV. Novella L. 1994. et al. Am J Psychiatry.27:283-201. Am J Psychiatry. Asarnow RF. Drug Targets. Clinical and diagnostic implica- tions of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Fried R. Harty S. Morris-Yates A. Susswein L. Smallish L. symptoms. Am J Psychiatry. Shekim WO.37(6):393-401. counterpart. Weiss G.62(3):213-219. and relevant past history are elicited. Br J Psychiatry. Faraone SV. Wilens TE.153(7):967. which the status of hyperactive boys grown up. Fletcher K. Wilens TE. Biederman J. because anxiety. Biol Psychiatry. 2002. 2006. Miller C. Rey JM. Faraone SV. J Atten Disord. Am J Psychiatry. reason to speculate that this may be the case. Barkley RA. and The “psychiatric review of systems. comorbidity. In addition. Impact of psychometrically defined deficits of executive functioning in adults with attention deficit hyperactivity Co-morbidity is common in adults with ADHD and disorder. patient is asked after the history of the present illness 12. DC: American Psychiatric Association. Sharma V. Andrews G. Hess E. disorder: a controlled study.58(2):99-106. or past history. Halperin JM. 17. Miller CJ. 2007. Fischer M. 2002. Otto M. Understanding 5. Compr Psychiatry. Newcorn JH. Smallish L. 1985. Psychiatry Res. Neuropsychological identification of both ADHD and co-morbid disorders function in adults with attention-deficit hyperactivity disorder. Barkley RA. Mick E. Stewart GW. Young adult follow-up of “Psychiatric Review of Systems” hyperactive children: self-reported psychiatric disorders. Schulz K. 1998. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry colleagues24 showed that early serotonergic dysfunc. Maddocks A. Wilens TE. Singh M. In: Tasman A. or antisocial personality disorder. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Among adults with ADHD. Attention deficit hyperactivity disorder (ADHD) is associated with early onset substance use all domains of function.155(4):493-498.163(4):716-723. Barkley R. Levin ED. Presenting ADHD symp- toms and subtypes in clinically referred adults with ADHD. Hatch M. Petty C. Biederman J. Biederman J. Flory JD. Spencer T. borderline personality disorder. 10. ADHD present to clinics for the treatment of other dis. Mannuzza S. can complicate treatment. Fones CS. Psychiatry. and disruptive behavior disorders. Biol Assessing ADHD and Co-morbidity: The Psychiatry. 2006. Lieberman JA. Adult psychiatric ing psychiatric symptoms and disorders. Halperin JM. constitutes a series of questions regard. Wheeler N. Nicotinic treatment for cognitive dysfunction. PA. 2002. Curr the gold standard for diagnosis in clinical research. W. Kessler RC. Patterns of psychiatric comorbidity. This technique is analogous disorders. and young adults. Malloy P. SUD. History of childhood attention deficit/hyperactivity disorder symptoms and borderline personality co-morbid conditions is not always easily achieved.1(4):423-431. Psychiatry Res. 7. the high rate of co-morbidity of other disorders with cognition. LaPadula M. 9. Fletcher K. Millstein RB. Fischer M. eds. It has not yet been demonstrated that der. Miller SR. The accurate diagnosis of ADHD and 22. Weber W. 1996. other disorders.43(5):369-377. J Nerv Ment Dis. single patient. Adopting a broad developmental perspective is the key to distinguishing ADHD from co-morbid dis- CNS Spectr 13:8 (Suppl 12) 15 © MBL Communications August 2008 . 1980. appear ambiguous or indistinct. in patients in whom these conditions might otherwise 1998.190:410-414. Hechtman L. Halperin JM. Adler L. 6. Young adult follow-up of hyper- active children: antisocial activities and drug use. 1995. Wilens T. It is important for clinicians 20.185:475-482. residual state. Psych Clin N Am. orders. those with more severe and persistent ADHD are demographic profile of a sample of adults with attention deficit hyperactivity disorder.36(2):165-173. 3rd ed. 24. in children with attention-deficit hyperactivity disorder: relationship to later severe depression. Serotonergic function cealed by more robust symptoms of conduct disorder. et al. It is intriguing to consider whether this pernicious course could potentially be ameliorated by treatment. Biederman J. developmental course of other disorders. Fossati A. References However.” like its medical the role of childhood conduct problems and teen CD. but represent a systematic review of 14. with ADHD 3. 1997. Alpert JE. ditions. Newcorn JH. 2000. Spencer TJ. 2008. Saunders: 2008. Psychiatry. 3rd ed. Miyahara S. In addi. Continuities between psychiatric disorders in adolescents and personality disorders in to look for other disorders in patients with ADHD. Philadelphia. Bessler A. early identification and treatment of ADHD can alter the 8. et al.30(5):463-475. Newcorn JH. Perlman T. J Affect Disord. Compr Psychiatry. those with co-morbidity Replication. J Am Acad Child Psychiatry. Klein RG. among multiple disorders which can co-occur in a cial disorder in late adolescence or young adulthood. This is the reverse of what one deficit hyperactivity disorder (ADHD) features among adults with panic disor- sees in children. Gender differences in a sample of adults with attention deficit hyperactivity disorder. 4. Clinical Implications of Co-morbidity in Adults 1997. Am J Psychiatry. Attention deficit this is the case. A clinical and tion.B.31(5):416-425. are likely to have higher levels of impairment. Diagnostic and Statistical Manual of Mental Disorders. Ivanov I.2:159-166. Barkley RA. Murphy K. 2004. Personality characteristics depression may be concealed by more obvious ADHD associated with persistent ADHD in late adolescence. Psychiatric status of hyperac- Incorporating a psychiatric review of systems into the tives as adults: a controlled prospective 15-year follow-up of 63 hyperactive more traditional clinical history can greatly facilitate the children. 2005. J Child Psychol Psychiatry. J Abnorm Child Psychol. Shifts in co-morbidity parallel developmental 21. Rezvani AH. Lapey KA. Biederman J. Spencer T. 16.57(11):1467-1473. Faraone SV. changes in the nature and prevalence of ADHD and 2004. 18. learning disabilities. subtypes at risk and treatment issues. Pollack MH. Spencer T.152(6):895-900. and psychosocial functioning in adults with attention deficit hyper- ADHD is particularly important in the diagnosis and activity disorder.53(1):13-29 Conclusion 19. ADHD symptoms may be con. Nierenberg AA. Compr Psychiatry. at risk for higher levels of co-morbidity. Maffei C. These questions 13.163(10):1730-1738. Washington.45(2):195-211. J Abnorm Child Psychol. but there is 1996. Seidman LJ. Spencer T. Comment in: Am J to look for ADHD in patients with other psychiatric con.24(2):211-220. and less severe 23. et al.44(4):260-268. there are not yet data to indicate whether 1. which is used as 15. Nierenberg AA. to the structured clinical interview. Zaucha K.

For Q: How does one decide whether to simply use a screener context. there is a possibility that the context of individual treatment versus public health. Newcorn: One controversial issue is whether we should invoke a relative or an absolute standard for Dr.4% prevalence rate accounts only for sation by another disorder. However. Q: The high prevalence of ADHD found in the National Co- morbidity Survey Replication (NCS-R)1 is quite startling. duration. Of course. How spectively recalling ADHD symptoms in childhood. cerebrovascular acci. Adler: The evidence base for geriatric ADHD impairment. Q: Faraone and colleagues2 considered issues for ADHD Q: It was once thought that ADHD symptoms followed a not otherwise specified.1 and depression in adults? or a full diagnostic evaluation? Dr. pervasiveness. in older patients. Rather. ria but the childhood age of onset behaved exactly like data from the NCS-R 1 indicate that 43% of ADHD patients the full-ADHD cohort in terms of their impairments and 18–29 years of age experienced a co-morbidity. or any one domain the increased time from childhood. Is the distribution of co. How should this to 56% of those 30–44 years of age. there may be overlapping issues of neuropsycho. including dysthymia and bipolar depression. decreasing with age. For example. It is viewed as a or when childhood cannot be adequately recalled. impairments that can occur with aging (eg. The prevalence of used to examine a general population to identify those ADHD.4% of the United States adult population. but adulthood comprises a longer of temperamental features without consequence. A full diagnostic evaluation less than the prevalence of all depressive disorders put is always necessary to confirm the clinical significance together. the possibility exists that with not simply about grades in school. older. In my clinical experi- ence. and clinicians who treat children appropriate neuropsychological testing can be helpful tend not to identify and treat it when it appears in late in establishing the diagnosis. is at high risk for a disorder. related when these are taken together. Furthermore. not multiple attention disorders. Spencer: Adult attention-deficit/hyperactivity disor. However. Those who treat adults are often not trained to recognize adult ADHD. ADHD is dents). but the child might also be considered fully functional nitive impairment. ADHD and other potential causes of cognitive decline der (ADHD) is an orphan diagnosis. what are the prevalence rates of anxiety disorder such as the Adult ADHD Self-Report Scale (ASRS) Version 1. compared co-morbidities and functional outcomes. affect diagnostic criteria? morbidities therefore different? Would adult ADHD symptoms worsen in even older people? Dr. This gets to the issue of prevalence rates in is fairly limited. adults might have greater difficulty retro- different from the relatively consistent prevalence rates. because B’s are not bad grades. Therefore. mild cog. when the differential between Dr. It of each symptom and to establish the presence of is also lower than the prevalence of anxiety disorders other diagnostic criteria including age of onset. a child with an IQ of 135 who gets B’s in logical impairment for older individuals with ADHD school might be considered impaired because he is not who might be experiencing other potential cognitive achieving grades in accordance with his intelligence. there are more adults than children with ADHD. as compared of function. Spencer: A screening tool is a brief instrument disorders and depressive disorders. period of time than childhood. adolescence or adulthood. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry QUESTION-AND-ANSWER SESSION Q: Rates of treatment vary widely by country and are markedly to younger. and rule out cau- to note that the 4. 4. ADHD. dementia. However. the Dr. ADHD adults who met all crite- linear developmental trend. Newcorn: There is a lower rate of ADHD in adults disorder is often trivialized or treated as an odd group than in children. it is important impairment. Adler: This depends on how you define anxiety Dr. The clinical diagnosis is made when impair- CNS Spectr 13:8 (Suppl 12) 16 © MBL Communications August 2008 . childhood diagnosis. fur- do you account for this disparity? ther complicating the diagnosis.

impairing other domains of an individual’s life. adults with survivors” for surviving an entire childhood of ADHD- ADHD may have difficulty obtaining appropriate treat- associated difficulties without treatment. Dr. and they may or may sionals to treat ADHD. ties rather than any absolute standard. ment services. thin-skinned. given the prevalence of ADHD in adults and Dr. Stein: Not all people present are aware of impair- ments. This is a huge problem. approximately half of conduct dis- impairment is difficult to rate. cheating. all pointing to I am able to identify the disorder in the child’s parent. the fighting. Dr. and are particularly vulnerable to be time-consuming or may be chosen ineffectively. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry QUESTION-AND-ANSWER SESSION ments are seen across multiple settings. Dr. CNS Spectr 13:8 (Suppl 12) 17 © MBL Communications August 2008 . stealing. But in making those determina. Spencer: Oppositional disorder and conduct disor- Dr. Physicians must consider whether Dr. duct disorder and antisocial personality disorder? Dr. especially when there is with the range of personality disorders and psychiatric other psychiatric co-morbidity present. However. et al. 2006. physicians rarely have to con- vince patients that they experience impairment. Diagnosing adult attention deficit ADHD may reflect a different disorder. the same conclusion. Newcorn: In clinics. Adler: It is also important to not take coping strate- gies at face value. I would definitely refer to the individual’s capaci. his or her life were related to ADHD. Newcorn: Longitudinal studies of children with coping mechanisms are helpful or if they are them- ADHD show that those with conduct disorder have selves creating impairment. but at some cost. As a result. Usually it is conduct disorder that progresses into adulthood. et al. too. Spencer: They are sometimes described as “the current manpower limitation. even if the parent was unaware that the difficulties in tions. and come home late or are obsessed with work. Adler: It is important to realize that ignoring rela. co-morbidity found in this population. for example. patients will try to convince physicians that they 1. What is the nature of the relationship between con- functional impairment. Conduct twice as long to complete tasks. Q: How will the interaction of co-morbidities affect the Q: What are some of the differences between clinical popu- treatment of ADHD as a public health concern? lations and those in the epidemiologic samples? Dr. Here. 2006. such as lying. Oppositional disorder is often by compensatory mechanisms.163(10):1720-1729. Spencer T. substance abuse disorder. The patient achieves a order cases remit by adulthood. disorder is a euphemism used for antisocial behavior often families complain that these individuals always in childhood. Faraone SV. that Replication. as they may not want to deal not be aware of their ADHD. Barkley R. Biederman J. Coping strategies can the worst outcome. It is important to note.163(4):716-723. Kessler RC. Stein: Co-morbidities may affect the willingness of Dr. Stein: Clinicians will see patients with a variety primary care physicians and other healthcare profes- of problems and impairments. Fortunately. the impairment the patient may describe as indicating 2. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey have the disorder. Q: Conduct disorder and antisocial personality disorder Dr. Adler L. disorder does not arrive de novo in adulthood. Most References often. Sometimes after evaluating a child with ADHD. hyperactivity disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry. Someone may attain marked by a reactive. were both discussed as co-morbidities occurring with tive impairment will result in missing many cases of ADHD. Antisocial personality level of success. Spencer: Functional impairment may be mitigated der are often confused. blaming others good grades or good performance reviews by taking response but not habitual antisocial actions. Am J Psychiatry.

Learning disorders A. 4. They have lower educational attainment B. 7th Floor. 0. Measures of impairment used in ADHD studies include: Replication (NCS-R). Relative to individuals with ADHD combined type. Weiss Functional Impairment Rating Scale disorder (ADHD)? C. Termination date: August 31. Co-morbidity is more or less continuously present from childhood to adulthood 4. Which statement is not true of adults with ADHD? C. Physicians should only claim credit commensurate with the extent of their participation in the activity. The rate of co-morbidity in longitudinal studies of chil- dren with ADHD followed into adulthood is more or less equal to that seen in cross-sectional studies of newly diagnosed adults with ADHD CNS Spectr 13:8 (Suppl 12) 18 © MBL Communications August 2008 . Mood and anxiety disorders 3. Clinical Global Impressions-Severity scale United States have adult attention-deficit/hyperactivity B. 1% D. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. 1%. This information will be available as part of the course material. They are more likely to be separated or divorced of ADHD in adults is most accurate? D. complete the answer form provided on the following page as directed and return it to CME Director. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. what percentage of adults with C.1% scales) B. much B. The goal of treatment in ADHD is to: D. Credit Designation The Mount Sinai School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s) TM. Rates of substance use disorders continue to increase A. or fax it to 212-328-0600. 5.com. All primary care physicians and psychiatrists may participate in the CME program.cnsspectrums. Reduce symptoms and risk of stimulant abuse ADHD in the US are being treated for ADHD? D. Schizophrenia D. BRIEF. 20% A. Brown A. CME QUESTIONS 1. 100% A. C. AND DIFFERENTIAL DIAGNOSIS Accreditation Statement This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications. Which of the following statements regarding co-morbidity C. CNS Spectrums. Reduce symptoms and impairment 2. A measure of executive functioning (eg. Faculty Disclosure Policy Statement It is the policy of the Mount Sinai School of Medicine to ensure objectivity. They are less likely to be employed 8. Frequently occurring co-morbid conditions in adults with C. 11% 7. True over time in adults with ADHD B. All of the above C. More women than men have adult ADHD A. None of the above A. This quiz is also available at www. NY 10013. you should score 70% or better. independence. Please submit this posttest by August 1. According to the National Co-morbidity Survey. New York. To obtain credit. 50% ADHD include all of the following except: D. Reduce symptoms B. Antisocial personality disorder B. what percentage of adults in the A. Early submission of this posttest is encouraged. transparency. To receive credit for this activity. Inc. False D. EXPERT ROUNDTABLE SUPPLEMENT An expert panel review of clinical challenges in primary care and psychiatry BEST PRACTICES IN ADULT ADHD: EPIDEMIOLOGY. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. 333 Hudson Street. According to the NCS-R. Co-morbidity of mood and anxiety disorders is higher in less is known about the types and stability of impairments adults than children in individuals with the inattentive subtype of ADHD. 2010. 2010 to be eligible for credit. balance. IMPAIRMENTS. B.4% 6. and scientific rigor in all CME-spon- sored educational activities.

A B C D 3. Additional comments: _____________________________________________________________________________________ Name _________________________________________________________Affiliation ___________________________________ Street ____________________________________________________________________________________________________ City ________________________________________________________State ______________ Zip Code ___________________ Tel: _________________________ Fax:____________________________ Specialty _____________________________________ Email_____________________________________________________________________ ❒ Please send certificate via email. A B C D 2. or any of our other CME materials. A B C D 7. please e-mail CME@mblcommunications. Please submit this test by August 1. A B C D EVALUATION SECTION (please provide the information below and print clearly) 1.com ANSWER FORM Expert Roundtable Supplement – Best Practices in Adult ADHD: Epidemiology. what change(s) do you intend to make in your practice? ___________________________________________ 6. Explain the common impairments associated with adult ADHD and how to incorporate assessment of impairment levels in the diagnosic process. Please list three clinical topics you would like to be addressed in future educational activities: Topic 1: _________________________________________________________________________________________________ Topic 2: _________________________________________________________________________________________________ Topic 3: _________________________________________________________________________________________________ 11. Was the format of this activity appropriate for the content being presented? Yes ❑ No ❑ 9. Impairments. to be eligible for credit. New York. and co-morbid tendencies. Early sub- mission of this posttest is encouraged. I certify that I completed this CME activity (signature) ____________________________________ Date ______________________ I have read the CME article and completed this activity in _______________hours. Do you feel these topics should be repeated/updated in future CME activities? Yes ❑ No ❑ If you answered yes. CNS Spectrums 212-328-0600 333 Hudson Street. Did this CME activity provide a balanced. 7th Floor. Please check your preferred formats for CME activities (select one or more): ❑Print media ❑ Internet text ❑ Internet multi-media ❑ Live meeting ❑ PDA ❑ Podcast 10. 2010 To receive credit. including prevalence. what suggestions would you make to improve this activity? _______________________________________ 8. Review the epidemiology of attention-deficit/hyperactivity disorder (ADHD). If you have any questions about this. CNS Spectr 13:8 (Suppl 12) 19 © MBL Communications August 2008 . persistence. Yes ❑ No ❑ C.CME 2 EXPERT ROUNDTABLE SUPPLEMENT CME 2 An expert panel review of clinical challenges in primary care and psychiatry REGISTRATION AUGUST 2008 CME POSTTEST Mail Fax Web CME Director.com Please circle your answers 1. A B C D 6. Yes ❑ No ❑ B. NY 10013 mbl. Does the information you received from this CME activity confirm the way you presently manage your patients? Yes ❑ No ❑ 5. Did this activity increase your knowledge and/or skills in delivering patient care? Yes ❑ No ❑ 4. scientifically rigorous presentation of therapeutic options related to the topic without commercial bias and influence? Yes ❑ No ❑ 7. Yes ❑ No ❑ 3. you should score 70% or better (participants will receive certification for their records in approximately 4–6 weeks). Discuss the differential diagnosis and psychiatric co-morbidities that require consideration in the assessment of adult ADHD. Was this activity relevant to your practice? Yes ❑ No ❑ 2. A B C D 8. A B 5. Will the information you received from this CME activity change the way you will manage your patients Yes ❑ No ❑ in the future? If you answered yes.cmeoutreach. A B C D 4. Were the following objectives met? A. and Differential Diagnosis TERMINATION DATE: August 31. 2010.