Diagnostic Assessment, Treatment, and

Lifespan Clinic for ADHDBrescia– June 2014

Dr. J.J. Sandra Kooij, MD PhD

Psychiatrist, head Department Adult ADHDand Expertise Centre Adult ADHDPsyQ, psycho-medical programs

The Hague, the Netherlands

Topics• Clinical picture• Gender and age• Prevalence • Diagnostic assessment, DIVA 2.0 • Differential diagnosis• Circadian rhythm disturbances in

ADHD and relationship with mood and health

• Treatment• Lifespan Clinic for ADHD

Adult ADHDDiagnostic Assessment and

Treatment

JJS Kooij, 3rd edition2012

www.springer.comSearch for ‘Adult ADHD’

Including DIVA 2.0Including DIVA 2.0

Clinical picture of ADHD

Lifetime symptoms of Attention-Deficit/Hyperactivity Disorder:

• Inattention: distracted, chaotic, forgetful, late, difficulty making decisions, organising and planning, no sense of time, procrastination

• Hyperactive: (inner) restlessness, tense, talkative, busy; coping by: excessive sporting/alcohol abuse/avoiding meetings

• Impulsive: acting before thinking, impatient, difficulty awaiting turn, jobhopping, binge eating, sensation seeking

In addition in 90% of adults, lifetime: • Moodswings (5x/day) and Anger outbursts

APA 1994; Kooij 2001; Conners 1996

Decrease of hyperactivity

Hyperactivity is adjusted, compensated for, or experienced as more‘inner restlessness’:

• Avoiding meetings where you have to sit stil• Excessive sporting• Hectic job full of change• Cannabis / alcohol / tranquillisers against restlessness• Talkativeness, inner restlessness

The decrease in marked outward visible hyperactivity has presumably been

the reason why we mistakenly have thought that ADHD was outgrown

Inattention most invalidating symptom in

adultsAdults need more attention than children:

• Procrastination• Chaos• Difficulty organising• Being late• Difficulty reading and remembering• Forgetting things or appointments• Using no watch or agenda!

ADHD in DSM-IV

• Attention-deficit/hyperactivity disorder• 18 criteria: 9 attention problems (A) and 9

hyperactive/impulsive criteria (HI)• Diagnosis in childhood from 6/9 of one or

both domains 3 subtypes:• ADHD, inattentive type (also ADD) (10-15%)• ADHD, hyperactive/impulsive type (3%)• ADHD, combined type (85%)

DSM-5 changes in ADHD

Subtypes = nowPresentation types

NEURO-DEVELOPMENTAL

DISORDERS

Cutoff adoles-cents & adults 5/9

ADHD + ASS

Impairment in ≥ 2 situations, but more situations given

More examples of behaviour

Age of onset < 12 years

Severity

Impairment in adult ADHD

In clinical as well as epidemiological samples compared to NCs:

• Learning problems (60%)• Less graduated• Lower education• Lower income• Less employed, more sickness leave• More job changes (longest job 5 yrs)• More often arrested, divorced and more social problems• More driving accidents, teenage pregnancies, suicide

attempts• Higher (mental) health care costs

Biederman 2006; Kooij 2001, 2005; Barkley 2002; Manor, 2010

ChildrenM : F

AdultsM : F

Clinical studies 2 - 9 x 1 - 2 x

General population studies

2 - 3 x 1 - 1.5x

ADHD and gender: Men more often ADHD?

ADHD and gender: Men more often ADHD?

Taylor 2004; Nice guidelines 2008; Kessler 2006; Fayyad 2007; Kooij 2005

Gender differences children and adults

Childhood

Underdiagnosis in girls

Adulthood

M>>F

M=F

Girls have more ADD

0102030405060708090

100

Girls with ADHD(n=140)

Boys with ADHD(n=140)

Prev

alen

ce (

%) Combined

Hyperactive/ impulsiveInattentive

Biederman 1994, 2004

Causes of underdiagnosis of ADHD

in girls

ADD subtype

Internalising comorbidity

(depression, anxiety, premenstrual dysphoric disorder)

Referral bias

Complaints girls and women with AD(H)D

PMDD

No Overview

Moodswings

Tired

Low self-esteem Lazy

Panic

Depressed

Unmotivated

Overwhelmed

DistractedChaotic

ADD

Girls and women 2x more often ADHD inattentive

type• But majority has still ADHD combined type• Women have to organise themselves,

family, household, childrens’ agenda’s and their job

• Being a women with ADHD is ‘a job from hell’, always late, forgetting things …

• Chaos and tiredness their daily bread• Low selfesteem and uncertainty about

capabilities the result

Room with a view?

Is ADHD like Chronic Fatigue Syndrome (CFS)?

Inattentive girls referred for being´tired´?

• Clinical studies: boys more often ADHD• Epidemiological research: girls similar percentage ADHD as

boys

ADHD in girls is less well known, and their behaviour less disruptive

than in boys …

Boys have more often:• ADHD, combined type• More severe hyperactivity• Externalising comorbidity (oppositional defiant or aggressive

behaviour)

Being disruptive helps to get help….Biederman ea, 1994; 2002, 2004; 2005

Girls are not disruptive …

Inattention takes continuous mental effort,

leading to exhaustion …

… but may be chronically tired!

ADHD and CFS need further study

• Screening for ADHD in Burnout or CFS group

• Methylphenidate treatment in subgroup with diagnosis of ADHD may ameliorate tiredness and inattention

• Physical complaints in ADHD need further study (RSI, burnout, neck- and backpains, obesity, chronic tiredness, chronic sleep-problems)

BOOKS on GIRLS & WOMEN &

ADHD

ADHD in older adults

An epidemiological study by M. Michielsen, E. Semeijn, H. Comijs, D.J.H. Deeg, A. Beekman, J.J.S. Kooij

ADHD IS NOT OUTGROWN

Fayyad J Br J Psychiatry. 2007 May;190:402-9; Kooij JJS Psychol Med. 2005 Jun;35(6):817-27; Kessler RC J Occup Environ Med. 2005 Jun;47(6):565-72.; Kessler RC Am J Psychiatry. 2006 Apr;163(4):716-23.

?

Prevalence of ADHD in Prevalence of ADHD in children and adultschildren and adults

Children• USA 3 - 7%

Adults • USA 4 - 5%• 10 countries (mean) 3.4%

APA 2000; Faraone 2003; Kessler 2006; Murphy & Barkley, 1996; Kooij 2005; Fayyad 2007

Age-Specific Prevelence of ADHD Remission

0

10

20

30

40

50

60

70

<6 6 to 8 9 to 11 12 to 14 15 to 17 18 to 20

Age (year)

% R

emit

ted

Syndromatic

Symptomatic

Functional

Persistence of ADHD depends on definition of remission

Biederman, 2000

Treatment % per country

in adults with ADHD

Fayyad 2007

Medicaltreatment

Mentaltreatment

Anytreatment

Treatment for ADHD

Belgium 10.4 13.8 21.5 0

Italy 10.6 4.4 11.9 0

NL 18.6 18.8 23.8 1.9

USA 27.9 28.6 49.7 13.2

Old people reporting childhood ADHD symptoms

• Swedish sample, 1599 people aged 65-80 yrs• WURS, cutoff ≥ 36• Prevalence of self rated childhood ADHD

symptoms 3.3%, comparable to ADHD in children and adults

• M > F (71 % vs 29%)• Young = older groups

Taina Guldberg- Kjär, 2009

Old people reporting childhood ADHD symptoms IIADHD compared to no ADHD group:

• more divorce/no relationship (34% vs 12%)• more childhood problems• more jobs (> 5)• worse current health, worse current

memory

Taina Guldberg- Kjär, 2009

Dutch epidemiological study ADHD in adults

• N=1800, age 18-75• Self reported DSM-IV ADHD-Rating Scale• Prevalence 1 - 2.5% (cutoff 6, resp. 4 current

symptoms)• Hyperactivity: small, significant age dependant

decline, but not for Inattention and Impulsivity• Group 60-75 yrs = 17.7% of the study population• Prevalence in this oldest group 0.3 - 3% (cutoff 6,

resp. 4 current symptoms)

Kooij ea 2005

Case studies in older adults• Case studies in older adults indicate

similar symptoms and impairment in old age and similar treatment response

• Epidemiological and controlled clinical trials lacking

- Manor I. Clin. Neuropharmacology 2011 - Biederman J. JAMA 1998- Da Silva M.A. Journal of Attention Disorders 2008- Parker R. JAMA 1999- Brod M. Qual Life Res 2011

ADHD in older adults

An epidemiological study by M.

Michielsen, E. Semeijn, H. Comijs,

D.J.H. Deeg, A. Beekman, J.J.S.

Kooij

Michielsen 2012, 2013; Semeijn 2013a,b

Marieke Michielsen & Evert

Semeijn

Presenting their posters in Berlin, ADHD Congress, 2011

Study on the prevalence of ADHD in older people

• Data were used from the

Longitudinal Aging Study Amsterdam (LASA)

• Collection started in 1992/93• Physical, emotional, cognitive

and social functioning • Follow-up every three years

MethodsTwo - phase design: screening and diagnostic interview

Phase 1 Screening list sample

N=1494

Medium scoring group InvitedN=93

High scoring group InvitedN=84

Low scoring group InvitedN=94

Phase 2 Interviewed

N=85

Phase 2 Interviewed

N=80

Phase 2 Interviewed

N=69

Refused: 7Unable: 2

Refused: 12Unable: 2

Deceased : 1

Refused: 12Deceased : 1

Screening list by Barkley1 Is often easily distracted by extraneous stimuli or irrelevant thoughts

2 Often makes decisions impulsively

3 Often has difficulty stopping his or her activities or behaviour when he or she should do so

4 Often starts a project or task without reading or listening to directions carefully

5 Often shows poor follow-through on promises or commitments he or she may make to others

6 Often has trouble doing things in their proper order or sequence

7 Often more likely to drive a motor vehicle much faster than others (excessive speeding)Alternative: Often has difficulty engaging in leisure activities or doing fun things quietly

8 Often has difficulty sustaining attention in tasks or play activities

9 Often has difficulty organizing tasks and activities

Barkley RA, Murphy KR, Fischer M. ADHD in adults: What the science says. The Guilford Press; 2007.

ADHD diagnoses

Two diagnostic categories, based on DIVA 2.0

were used:

Syndromatic ADHD, full blown DSM-IV diagnosis- 6/9 symptoms in present time and childhood

Symptomatic ADHD, sub-clinical diagnosis- 4/9 symptoms in present time and 6/9 childhood

Prevalence of ADHD in older

people in the general Dutch

population

Syndromatic ADHD Symptomatic ADHD

% 95% Cl % 95% Cl

Total 2.80.86–4.64

4.22.05–6.39

Sex

Men 3.0 -0.20–6.12 4.6 0.96–8.39

Women 2.6 0.38–4.72 3.8 1.39–6.24

Age: 61-95 years: lower prevalence of ADHD in the older old. Women: 59%

Michielsen 2012

ADHD and anxiety/depression in

older people• ADHD was associated with more

anxiety and depressive symptoms cross-sectionally as well as longitudinally compared to controls.

Michielsen 2013

ADHD and physical health in older people

• ADHD in older people was associated with chronic nonspecific lung diseases (CNSLD), cardiovascular diseases, and number of chronic diseases.

• ADHD was negatively associated with self-perceived health.

Semeijn 2013

ADHD and social functioning in older

peopleADHD in older people:

• was associated with being divorced or never married• less family members in their network• emotional loneliness

Level of ADHD symptoms was associated with more

• emotional and social loneliness • lower income level• NB depressive symptoms play an important role in

the association between ADHD and loneliness

Michielsen, submitted

Conclusions• The prevalence and comorbidity with anxiety

and depression in older people with ADHD, show similar patterns as in younger age groups

• Regarding physical health there are indications that older people with ADHD may have worse health outcomes and may die younger

• Lower income, less intimate relationships, less family relationships, more loneliness and depression in older people with ADHD

ADHD is not outgrown

in older people

Impairment isnot

diminishing

Similar prevalence rates

Similar medicationresponse

RCT’s needed

Lifespan clinics needed!

Can ADHD be treated in older people?

• 15 case studies: patients (m, f), age 67-81 yrs• ADHD from childhood, diagnosis in

(grand)children, who respond favorable to medication for ADHD

• Lifespan restlessness, irritability, impulsiveness and distractedness leading to impairment

• Succesfully treated with stimulants in old age• Monitoring cardiovascular side effects before

and during treatmentWetzel 2008; Da Silva & Louza, 2008; Standaert, Kok & Kooij, 2010; Manor ea, 2011

Implications for patient care• ADHD is not outgrown in older persons• Impairment is not diminishing• Similar prevalence rates across the lifespan (3-5%)• Lifespan patient services are needed• Case reports indicate similar response to

medication as in adults and children• RCTs needed in older people with ADHD using

stimulants• More research needed into the impact of ADHD with

age on social, psychiatric and somatic functioning

COMORBIDITY in ADHD

ADHD comes seldom alone:

• 75% at least one other disorder• 33% two or more

Mean: 3 comorbid disorders

Comorbidity in adults with ADHDComorbidity in adults with ADHD

Biederman 1993; Kooij 2001, 2004

Comorbidity in ADHD?Comorbidity in ADHD?

• Depression (60% SAD) 20-55%• Bipolar Disorder (88% BP II) 10%• Anxiety Disorders 20-30%• SUD 25-45%• Smoking 40%• Cluster B Pers. Disorders 6-25%• Sleeping Problems (DSPS) 75%• Muscle, joint, neck- and backpain ??

Biederman 1991,1993, 2002; Weiss 1985; Wilens 1994; Kooij 2001, 2004; van Veen 2010; Amons 2006

The other way round: ADHD is

comorbid in 20% of psychiatric

patients

• SUD: 20% (Trimbos Institute)• Anxiety disorders: 20% (PsyQ)• Bipolar II: 20% (PsyQ)• Borderline PD: 35% (Radboud University)

And in accordance to epidemiological data USA: 20%

vd Glind 2005; Rops 2010 in prep; Roodbergen 2010 in prep; Fones 2004; van Dijk 2010 in prep; Kessler APA 2007; Fayyad 2007

12 month comorbidity with ADHD

in adults, epidemiological study USAOR % ADHD % comorbid D

in comorbid D in ADHD

_____________________________________________Mood Ds 3.8* 20.4 31.7Anxiety Ds 3.8* 17.1 51.1SUDs 2.8* 18.1 14.2

1 Disorder 3.0* 11.6 24.52 Disorders 3.9* 14.5 14.43+ Disorders 8.3* 26.5 26.6Any disorder 4.4* 15.9 66.3

Kessler, APA 2007

OR for comorbidity in active

ADHD compared to ADHD, in

remission

0

1

2

3

4

5

6

7

8

9

Any MoodD

Depr Panic/GAD BP I /II PTSD

Active ADHD ADHD in remission

3,9*

2,5O R

8,2*

3,9

6,2

3,5

3,9*

1,2

4,3*

1,6

Kessler, APA 2007

Conclusions Epidemiological study

Kessler• 1 in 5 mood disorders are comorbid with

ADHD• Depression is comorbid in 30% of ADHD • ADHD has an earlier onset than mood,

anxiety or SUDs• ADHD is a riskfactor for a range of comorbid

disorders• Treatment/remission of ADHD leads to

lower occurence of mood-, panic disorder, and PTSD Kessler APA 2007

ADHD or Borderline?Overlap• Impulsivity is hallmark of both• Frequent moodswings & irritability in 90% of adults with

ADHD

Differential diagnosis• Inattention and hyperactivity only in ADHD• ADHD starts in childhood, borderline in adolescence• Emptiness, manipulative behaviour, all good-all bad patterns

specific to borderline• History of neglect or sexual abuse typical in borderline, not

ADHD

Comorbidity• 6-25% of adults with ADHD also have cluster B personality

disorder• 35% of borderline patients also have ADHD

Kooij 2006; van Dijk in prep, 2009

Chance of addiction ADHD vs controls

0

5

10

15

20

25

30

35

40

%

Controls With med. Without med.(n=45)

Wilens, 2003

0 10 20 30 40 50 600

0.1

0.2

0.3

0.40.5

0.6

0.7

0.8

0.91

Age at onset

ADHDControls

p<0.05Lik

ely

ho

od

Wilens 1997

Substance Use Disorder:

Age at onset in ADHD compared to controls

Substance Use Disorder:

Age at onset in ADHD compared to controls

ADHD and SUD

• Medication treatment of ADHD does not increase chance of SUD

• Research suggest a protective effect of stimulants against substance abuse

Wilens 2003

ADHD & the circadian

rhythm in adults with ADHD

Implications for sleep, mood and health

J.J. Sandra Kooij, MD PhDPsychiatrist, Head Dutch Expertise Center

Adult ADHD, PsyQ, psycho-medical programsThe Hague, The Netherlands

Adult ADHD is highly comorbid

with circadian based disorders75% has comorbidity (mean 3 disorders):

• Depression (60% SAD) 25-50%• Anxiety 25%• Substance Use Disorders 20-45%• Personality Disorders 6-25%• Eating Disorders (BN) 9%• Binge eating 86%• Obesity 30%• Sleepproblems, DSPS pattern 75%

Kooij 2001 NTG;145(31):1498-501; Kooij 2004, Psychol Med;34(6):973-82, Kooij 2012, book Adult ADHD; van Veen 2010, Biol Psychiatry 67(11): 1091-6; Biederman 1993, AJP;150(12):1792-8; Kessler 2006, AJP;163(4) :716-23; Pagoto 2009, Obesity;17(3):539-44. Davis 2009, J Psychiatr Res;43(7):687-96. Kooij & Bijlenga, in press.

ADHD and sleepproblems in

childrenSubjective measures:

• Sleep onset latency / bedtime resistance

• Difficulty waking up• Fragmented sleep• Decreased sleep efficiency• Excessive daytime sleepiness

Objective measures (MSLT, actigraphy, PSG, DLMO):

• Excessive Daytime Sleepiness (EDS)• Periodic limb movement disorder (PLMD) / Restless Leg Syndrome

(RLS)• Reduced % REM sleep• Obstructive Sleep Apnea Syndrome (OSAS)• Delayed Sleep Phase Syndrome (DSPS): DLMO 45 min delayed

Corkum 1998, JAACAP;37(6):637-46;Corkum 1999, JAACAP;38(10):1285-93; Corkum 2001, Sleep;24(3):303-12; Konofal 2007, Sleep Med;8(7-8):711-5; Philipsen 2006, Sleep Med Rev, 10(6):399-405; Gaultney 2005, Behav Sleep Med;3(1):32-43; Lecendreux 2000, J Child Psychol Psychiatry;41(6):803-12; Golan 2004, Sleep;27(2):261-6; Boonstra 2007, Sleep;30(4):433-42; Oosterloo 2006, Psychiatry Res;143(2-3):293-7; van der Heijden 2005, Chronobiol Int;22(3):559-70. Van der Heijden 2006, J Sleep Res;15(1):55-62 ; Sobanski 2008, Sleep;31(3):375-81; Sadeh 2006, Sleep Med Rev;10(6):381-98.

Sleep questionnaire in 120 adults with ADHD

Difficulty …

• going to bed on time: 78%• falling asleep: 70%• sleeping through: 50%• getting up in the morning: 70%• daytime sleepiness: 62%

This pattern lifetime in 60%, suggestive of Eveningness or Delayed Sleep Phase Syndrome

Kooij, Society of Light Treatment and Biological Rhythms 2007

Chronotypes: being a lark or an owl

• Morningtype: gets up early, active in morning (20-25%)• Eveningtype: late to bed, active in evening (20-25%)• In between: 50%• Normal variation may differ +/- 2 hrs• More variation disallows normal participation in society• Clockgenes define chronotype and biological rhythm• Zeitgebers: light through the eyes in the morning, and

melatonin production in the brain at night synchronise us with the light/dark cycle of the world

• Artificial light may delay melatonin production at night (computer!)

Sleep phase delay in ADHD

0

5

10

15

20

25

30

normal type

eveningtype

Melatonin level

Time

Characteristics of 40 consecutive ADHD patients

Sleep Onset Insomnia (SOI)

No SOI

N 31 (78%) 9 (22%)

Male 17 (55%) 4 (44%)

Age, mean (SD) 28.2 (7.6) 30 (11.9)

ADHD, combined type

29 (94%) 5 (56%)

ADHD, inattentive type

2 (6%) 4 (44%)

Alcohol (U/wk) 6.76 5.67

Nicotine (Sig/day) 8.16 1.11

Sleep diagnosis ns ns

Van Veen 2010, Biological Psychiatry;67(11):1091-6.

Dim Light Melatonin Onset (DLMO):

delayed N=40 adults with ADHD w/wo Sleep Onset Insomnia

versus healthy controls

ADHDTotal

SOI no-SOI HC p: ADHDvs HC

p: SOIvs HC

DLMO (hr ± sd)

22:57 ± 1:20

23:15 ± 1:19

22:00 ± 0:54

21:34 ± 0:45

0.000

0.000

Van Veen ea, 2010

- 78% of consecutive ADHD patients had SOI- DLMO: 105 min later in SOI vs HC- After DLMO, it generally takes 2 hours to fall asleep

Van Veen ea 2010

24 hour movement patterns ADHD + SOI compared to controls (actigraphy)

New study: core and skin

temperature, DLMO and activity

patterns • N=12 ADHD+DSPS (medication naïve) and 12 controls• 5 consecutive days and nightsResults: • More variable bedtimes in ADHD, but melatonin onset is the

same every day in both groups• DLMO 1.5 hours later in ADHD• Sleep duration 1 hr shorter on days before workdays in

ADHD• Second delay, between DLMO and sleep onset was ≥ 1 hr

longer in ADHD• Melatonin, activity and temperature were all delayed to a

similar degree in ADHD• Overall temperatures were lower in ADHD• Colder hands in ADHD, related to sleep onset difficulties

Bijlenga, J Sleep Res, 2013 Aug 16

24 hr Activity,Core and Skin Temperature, in ADHD versuscontrols

Bijlenga, J Sleep Res 2013, Aug 16

ADHD patients lack any sense of time

Clinical experience: adults with ADHD seem to lackany sense of time, as well as any rhythm in day/night

Their habitually being late has been regarded as part of their inattentiveness, a planning problem, but may in

factreflect a fundamental problem of the biological clock

Nucleus supra chiasmaticus (NSC): the

biological clock

Hypothalamic nucleus, just above the chiasma opticum

ADHD, circadian rhytm, sleep,

mood and season

Goikolea 2007, Psychol Med;37 (11):1595-9; Amons 2006, J Affect Disord;91(2-3):251-5; Lewy 2006, Proc Natl Acad Sci U S A;103(19):7414-9; Van Veen 2010, Biol Psychiatry 67(11): 1091-6

Bijlenga 2013, J Att Disord; 17(3):261-75 Bijlenga 2013, J Sleep Res. Aug 16 epub

ADHDADHD

BP IIBP II

SADSAD

DSPSDSPS

100%

OverOverweightweight

75%

30%

10%

ADHD and disturbed rhythms

ADHD may not only be associated with circadian, but alsowith cyclical and seasonal disturbances, leading toproblems with impulsiveness, eating, sleeping and mood:

• Impulsivity/novelty seeking has been associated with eveningness• Lack of sleep rhythm may lead to lack of rhythm in eating and

activity patterns as well• Evening types, or those with a delayed sleep phase may prefer

irregular work or work in night-shifts, thereby increasing the sleep phase delay, as well as obesity

• ADHD has a higher percentage of Seasonal Affective Disorder (SAD) or winter depression, and possibly also of Premenstrual Dysphoric Disorder than normal

Barkley 1997, J Dev Behav Pediatr,18(4):271-9;Amons 2006, J Affect Disord;91(2-3):251-5 Caci 2004, Eur Psychiatry.;19(2):79-84. Levitan 2004, Biol Psychiatry;56(9):665-9

Antunes 2010, Nutr Res Rev.(1):155-68.

Circadian disturbance, ADHD and health

• ADHD is associated with chronic DSPS• ADHD patients often work in night shifts or are active at

night• May be gene-environment interaction: circadian preference

based on (clock)genes and dopaminergic pathways

• But: chronic work (>30 yrs) in night shifts is associated with higher risk of (breast)cancer

• Melatonin acts as a circadian anti-cancer signal at night• Among others (light at night), chronic low melatonin levels

may protect less well against development of cancer

is ADHD a high riskgroup for cancer?

Schernhammer 2001, J Natl Cancer Inst;93(20):1563-8; Schernhammer 2005, Eur J Cancer;41(13):2023-32; Hansen 2001, J Natl Cancer Inst;93(20):1513-5; Blask 2005, Endocrine;27(2):179-88. Moser 2006, Conf Proc IEEE Eng Med Biol Soc;1:424-8; Verkasalo 2005, Cancer Res;65(20):9595-600.

Short sleep and cancer risk

• Shift work is considered carcinogenic in the long term (IARC 2007)

• Sleep loss by shiftwork is associated with higher incidence of breast- and prostate cancer

• Short sleep short exposure to and/or low levels of melatonin

• Melatonin has anti-oxidative properties and protects against cancer growth

• Animal research shows inhibiting effects of melatonin on cancer growth and increased survival

• In humans, first studies with melatonin in cancer patients ongoing

Schernhammer 2004, 2006; Parent ea 2012; Sigurdardottir ea 2012; Anisimov ea 2012

Cancer risk and exposure

to light@night• Use of artificial light at night stops melatonin

production through the eyes, feedback to pineal gland

• The light coming from TV, PC or Ipad also suppresses melatonin production and delays natural sleep onset easily by hours

• Light is the natural antidote to melatonin and wakes us up every day …

• Timing of light may be crucial for health in general• Women with total visual blindness have less

cancer than sighted women

Flynn-Evans ea, 2009

Hypothesized relations

Skipping breakfastBinge eating

No rhythm in mealsHigher glucose levels

Obesity, DM, Hypertension,

Cardiovascular disease,Cancer

Delayed rhythmShorter sleep durationLower melatonin levels

Less protected against cancer

Ramsey & Bass 2009, Proc Natl Acad Sci USA;106(11):4069-70; Rüger 2009, Rev Endocr Metab Disord;10(4):245-60. Kooij 2012

ADHD indexCAARS

Pro

babi

lity

Normal weight group

Obese group

Binge eating group

Davis 2009, J Psychiatr Res;43(7):687-96

ADHD index predicts weight and binge eating

Late sleep = short sleep late meals

Possible impact of a delayed rhythm on weight and health:

• Sleeping late may lead to a short sleep duration• Short sleep duration is associated with obesity• Adults with ADHD tend to skip breakfast• Breakfast skipping is associated with obesity• ADHD patients suffer from eating problems in 80%, mostly binge

eating• Their weight fluctuates 10 - 20 kg’s• ADHD is associated with increased BMI• Obesity is associated with diabetes, cardiovascular disease and

cancer

Kooij 2012, book Adult ADHD; Dubois 2009, Public Health Nutr;12(1):19-28; Boere 2008, NTG;152(6):324-30; Davis 2009, J Psychiatr Res;43(7):687-96;Mota 2008, Ann.Hum.Biology;35(1)1-10;Copinschi 2000, Novartis Found Symp;227:143-57 Spiegel 2005, J Appl Physiol;99(5):2008-19

Sleep loss causes loss of control over

appetiteLeptin (satiety hormone) and ghrelin (hunger

hormone):

• Reducing sleep duration by 2 hours already lowers levels of leptin, the satiety ("fullness") signal

• Sleep restriction study (n=12): leptin ↓ by 18% and ghrelin ↑ by 28%, leading to increased appetite and feelings of hunger

• 13 epidemiologic studies in adults and 8 in children: sleep loss is associated with increased BMI

• Sleep loss is a novel risk factor for insulin resistance and type 2 diabetes

Lauderdale 2006, Am J Epidemiol;164(1):5-16; Lauderdale 2009, Am J Epidemiol;170(7):805-13. Spiegel 2005, J Appl Physiol;99(5):2008-19; Copinschi 2005, Essent Psychopharmacol;6(6):341-7; Shea 2005, J Clin Endocrinol Metab;90(5):2537-44;

Sleep duration USA

0

1

2

3

4

5

6

7

8

9

10

1960 2002 2004 2006

sleep duration

Kripke 2002; Keith 2006; Lauderdale 2006

As sleep time fell in USA, average weights roseWhether and how sleep time and weight are connected is still unclear

Proposed treatment / prevention of obesity in ADHDTo reset the clock and increase sleep duration:

• Psycho education on the meaning of time, the light/dark cycle for sleep, appetite, metabolic entrainment, mood and health

• Sleep hygiene (early to bed and early to rise …)• No light@night, shower before going to bed, bedsocks• Melatonin in evening*• Light in morning

To reduce binge eating and weight gain:

• Treatment of comorbidity (depr/anx)• Treatment of ADHD with stimulant• Exercise, diet

*Melatonin has not been reviewed or approved by the FDA for the treatment of sleep disorders. Kooij, book Adult ADHD 2012

Melatonin treatment

• To fall sleep: 3 mg at 22:00 in order to sleep at 23:00

• To reset the clock: 0.1 mg - 0.5 mg between 16:00 and 19:00, in steps of 1.5 hour/wk from the normal sleep time to the desired bedtime

• Circadin 2 mg for those who wake up nevertheless at 03:00 am

• No light exposure of tablets of melatonin!

Lewy 2005, 2006, continued; Kooij 2012 Book Adult ADHD

Light therapy in the morning• Especially in winter more sleep phase delay• More difficult to get up on time• Inducing strong early morning light artificially,

usually does work as sunlight in summer• Melatonin is reduced through closed eyelids by

light, which is our natural wake up call• Light box of 500 W, or Light therapy device

10.000 lux and timer 30 min before wake up time• Wake Up Light uses only 75 W and does not wake

all patients with delayed sleep phase• Warning: 500 W light becomes hot and contains

UVA+BRybak ea 2006

Adult ADHDDiagnostic Assessment and

Treatment

JJS Kooij, 3rd edition2012

www.springer.comSearch for ‘Adult ADHD’

Including DIVA 2.0Including DIVA 2.0

Outline Diagnostic Assessment

• Early onset in life• Chronic persistent course• Chronic impairment or

compensation/coping causing secondary impairment

Mainstay of ADHD diagnosis is: CHRONICITY

The period that ADHD symptoms are remembered will be longest in older adults

Ongoing translations, now 15 languages

Available DIVAs: 1. Danish2. Dutch3. Catalan4. English5. Finnish6. French7. German8. Italian9. Norwegian10. Romanian11. Swedish12. Spanish13. Turkish14. Portuguese15. Brazilian Portuguese

Next: 1. Hebrew2. Japanese3. Iranian

DIVA 2.0

Diagnostic Interview

www.divacenter.eu

Italian translation:Luana Salerno &Stefano Pallanti

Diagnostic Assessment

• 3 hour interview with patient, spouse and family (DIVA)

• Childhood onset and lifetime ADHD symptoms and impairment

• Comorbidity• Order and content of proposed

treatment

DIVA 2.0 • DIVA 2.0 has been developed to facilitate

appropriate and careful diagnostic assessment of ADHD in adults

• DIVA-5 will be developed in 2014• This semi-structured diagnostic

instrument still needs interpretation by a (trained) clinician

• DIVA 2.0 should therefore not be used by patients for selfreport

ADHD is a clinical diagnosis

• Interview patient and partner: lifetime symptoms and impairment of ADHD and comorbid disorders

• School reports if available• If possible, parents/sibs about childhood

onset• Patient is best informant, though tends to

underreport severity• No neuropsychological diagnostic test

(battery) • No validated instruments in Europe

Kooij 2003, 2008; Ferdinand 2004

Treatment of ADHD in adults

1. Psycho- education2. Medication for ADHD and comorbid

disorders3. Coaching / Cognitive Behaviour

Therapy4. Light therapy for SAD and delayed

sleep5. Support or Advocacy GroupsSafren 2005, Weiss 2003; Kooij 2003

Medication Proven Effective for ADHD

1. Stimulants- Methylphenidate (short and longacting)- Dex-amphetamine (short and longacting, combination preparations)

2. Atomoxetine3. Bupropion XL4. Modiodal5. Tricyclic antidepressants

Place of medication in treatment

• Medication is very effective and comes first after psycho-education

• ADHD patients have a short attention span

• After 3 months they quit treatment if medication is not taken or ineffective

• Coaching without medication is less effective due to less attentiveness, irritability, forgetting appointments and tasks, and no show

• First treat most severe disorder, usually depression, anxiety, bipolar disorder, SUDs; then add stimulant for ADHD

• In case of personality disorder: first treat ADHD

Order of treatment in comorbid ADHD

Order of treatment in comorbid ADHD

Methylphenidate (Mph)

• Best studied (> 250 RCTs)• 50 years of clinical experience• Response: 70% children, 50-70% adults• Effect size .9• Better executive functioning • Safe, little side effects• Effective 20 min. after ingestion• Not addictive when used orally (but short acting can be when

injected or snored)• Inhibits reuptake of DA / NA • Short acting: too difficult to use due to frequent dosing need and

low compliance; risk of abuse• Long acting best advice

Faraone 2003, Volkow ea 2002, Pietrzak 2006

Combination treatment the rule in adult ADHD

75% of adult ADHD patients has comorbiditymostly sleep problems, anxiety, depression

orSUDs

Combined treatment is the rulerather than the exception

Light therapy and ADHD

5 days – 30 min – 10.000 lux – 40 cm:

• For seasonal affective disorder: in 30%• For delayed sleep phase syndrome: in

70%• For ADHD? • For overeating?

Levitan 1999, 2002; Amons & Kooij 2006, Rybak 2006,2007

Psychological treatment‘Coaching’: practical, supportive and directive, similar

to cognitive behaviour therapy interventions:

• time management (watch, timer, agenda, mobile phone/PDA)

• organising daily life (household, children, administration)

• reorientation on education or work• planning time/intimacy with spouse• getting overview over finances• addressing process of acceptance of the disorder and

need for medication• learning social and organisational skills

Coaching and Cognitive Behaviour

Therapy• Coaching is practical / skills oriented (planning,

using watch and agenda)• CBT is more cognitive oriented (selfesteem,

negative thinking, impulscontrol)• Both share: transparency, here and now,

structured and goal directed• In ADHD patients too much homework or

assignments (CBT) may induce feelings of failure, coaching is more practical, decreasing difficulty of tasks as needed by the patient

• The coach is more equal to the patient, in CBT the therapist is not

Adults want help

PsyQ, in the Hague and in the Netherlands:

• 1300 patients in the Hague, only local referrals

• Mean age 38 yrs• Males: females = 1.5 : 1• PsyQ currently has now 28 locations and

teams around the country• Most referrals at new locations are for adult

ADHD (40-50%): unmet need …• Rapid increase in expertise and availability of

patient care for adult ADHD in the Netherlands

The ADHD Lifespan Clinic

The ADHD Lifespan Clinic?• A place where ADHD patients of all ages

can be diagnosed and treated• A place where professionals are specialists

in ADHD and comorbidities throughout the lifespan

• A place where you can easily return to in case of relapse or need of adjustment of treatment, and where your lifetime patient record file is always available

• An excellent place for longitudinal cohort and family studies of ADHD

Current organisation of Mental Health Care for ADHD

1. General Child Psychiatry2. General Adult Psychiatry3. General Psychiatry for older people

IMAGINE HAVING ADHD …… in childhood

• Your parents will turn to a pediatrician or to child psychiatry where you usually get help after a long time waiting

IMAGINE HAVING ADHD …

… in adulthood

• Your GP will tell you that ADHDdoes not exist in adults, and send you to general mental health care

… where you will be diagnosedwith one or more other disordersthat are usually comorbid with ADHD, but your ADHD is not recognised

• This is due to lack of knowledge in professionals who have never been educated about this highly prevalent disorder in adulthood

IMAGINE HAVING ADHD

… in old age

• Your GP now really startslaughing when you ask for diagnostic assessment, although your daughter and granddaughter were recently diagnosed with ADHD, and successfully treated

… you really thought there was still some hope for you as well, but you find out that innovative new knowledge isusually very reluctantly implemented in mental health care

IMAGINE HAVING ADHD - IN OUR TIME -

• The good news is that new knowledge and treatment options are available

• The bad news is that general mental health care services usually don’t deliver it

• When you outgrow the safe heaven of child psychiatric care, you’ re facing a desert of ignorance and disbelief among professionals

• When you enter adult psychiatry YOU are the one to teach your physician and therapist about ADHD

• When you enter old age psychiatry, you will have to repeat the same effort for the second time

Conclusion

You will have difficulty finding expertise on your disorder

during a lifetime

Or:

Your life will be over before new knowledge will be implemented

in general mental health care!

Who can deliver lifespan services to ADHD patients?

• The hands of child psychiatry are too short to continue treatment in / after adolescence

• The last two decades, adult psychiatry, let alone general mental health care for older people, has not taken the challenge of implementing care for ADHD in their daily practice

• This has not happened anywhere in the world …• So why wait any longer?• An organisation that does not take into account

the lifespan course of ADHD cannot do the job

10 year Anniversary of (the 28) PsyQ Programs Adult ADHD in the Netherlands, October 2013

AIMS AND ACTIONS

• Raising awareness that ADHD is a lifelong condition

• Improving diagnosis and treatment in Europe (Consensus Statement, conferences, publications, European textbook, DIVA 2.0 translations)

• Ongoing research and development• Increasing availability and access to services• Italian representatives: prof. Pallanti & Luana

Salerno

www.eunetworkadultadhd.com

Conclusions• Treatment of ADHD requires a lot of effort, no one

can do it alone• ADHD treatment needs a specialised multi-

disciplinary team, best in lifetime perspective• After spreading the word to the media and

patient organisations,• The unmet need will lead to a rapid increase of

requests for diagnosis and treatment• Start educating young professionals from the

beginning• Cooperate and support each other nationally, i.e.:• How is your Italian ADHD Network doing?• Dedication, not money is the most important

factor for success

• For patient driven & patient oriented research

• First online questionnaire inventarising most needed subjects from both patients and researchers

• Preferred research subjects (n=219): ADHD and Mood, Health, ASS, and Sleep)

• Patients determine which research will be funded: patient empowerment!

www.adhdfund.com

• Researchers determine research, based on patients’ preferences, and contribute as well

• Limited time to get funded, private and professional networks get involved

• Only succesful when large crowd of people is involved, international, worldwide fund

• Independent, no sponsoring pharma• Started: April 2014 at www.adhdfund.com

Follow ADHDFund at Facebook and Twitter!

4th UKAAN CONGRESS: Mind, Brain and Body

Sept 10-12, 2014• London• UKAAN, European Network Adult ADHD &

APSARD

http://www.ukaan.org