Good afternoon, everyone, and welcome to our next exciting clinical updates talk. The title is ADHD Across the Lifespan, Getting Up to Speed. I have to remind you all, the slides from this session will be available on the clinical – are actually already available on the clinical updates toolkit. And we have a very exciting speaker today, Dr. Leonard Adler, who will be talking on this very, very exciting topic. In terms of Dr. Adler's introduction, he graduated Connell University with a BA in economics and completed medical school at the Emory University School of Medicine. He then went on to complete his residency and chief residency in psychiatry at NYU Grassman School of Medicine, where he has remained on staff since 1986. He is a professor of psychiatry and child and adolescent psychiatry in the NYU Grassman School of Medicine. His research and clinical interests center on attention deficit hyperactivity disorder in adults, mainly focusing on new assessments and treatments. If I may add, he is widely regarded as an international expert on adult ADHD. Please put your hands together as we welcome Dr. Adler. All right, well, thanks, everybody, for coming today. It's a pleasure to be here. It's always great to be at the APA. It's always funny to be at the APA in my hometown. I always tell my staff, try not to book me with my usual stuff. They don't seem to listen to me, so I'm always running back and forth doing some of my – most of my usual stuff and being here, but luckily today I've cleared everything out. So it's really a pleasure to be here. As mentioned, my slides are already up there, so you don't have to take pictures of them, okay? All right? So you don't have to hold up your iPhone. I'm not that pretty that you have to take videos of me, okay? All right? So please just use my slides. They're up there in PowerPoint form. I really put them up there. A couple of the notes on what I tried to do, and this talk is really new today for the clinical updates. I am – when we get to the medication section, I am using slides from meta-analyses. Fair balance is critical in every CME talk, but especially when we talk about adult ADHD. So when we talk about the medication section, you'll note that we're using slides from meta-analyses. We'll get into that later on, okay? So let's get to it. We've got a long talk. It's an hour and a half. I am going to break it up. I think Q&A is critical in these updates. So about halfway through, I'm going to stop, do about 10 minutes or so plus of Q&A, then we'll get back to our – we'll get back to the session. Otherwise, we're going to have a line that's going out the door here at the mic at the end. So I think it's nice for everybody. It's hard to kind of sit for an hour and a half anyway. So we'll stop about halfway through, do some Q&A, and then we'll get back to the rest of the talk. So let's get it going. Here are my disclosures. I've gotten research from, in the last three years, from Shire Takeda, Otsuka, and Coriam – it goes to NYU and not me. I've been a consultant on design of ADHD trials for Shire Takeda, Otsuka, and also just some of the more fun stuff I've done is design the therapeutic use exemption programs for the NFL and MLB. I've received royalty payments as an inventor from NYU for the licensing of the ADHD scales. And because it's CME talk, we're going to be talking about some off-label treatment today. So of associated symptoms of executive function deficits, emotional dysregulation, and sluggish cognitive tempo, and some novel use of a novel form of a prism EFP neurofeedback for ADHD we recently published on. Okay, so just in terms of an overview, we're going to use ADHD as an abbreviation for all attention deficit hyperactivity disorders. That includes AD slash HD and attention deficit disorder. Okay, that's the general nomenclature. ADHD was originally conceptualized as a childhood syndrome, which has received much of the focus of research and the clinical emphasis. Leaving adults with ADHD is generally under-recognized as under-treated, although I will say that seeing over 500 people in this room today means that we're doing something right. This presentation will be on ADHD through the lifespan. We're going to focus a little more on adults because I think that's where the more recent focus on research is, but also I'm an adult psychiatrist. So today in terms of our agenda, we're going to talk about history, epidemiology, somewhat in terms of diagnosis and using rating scales and talk about comorbidity, some about pathophysiology and standard pharmacotherapy in terms of core ADHD symptoms and these sets of co-traveling associated symptoms that are not in the DSM, which include executive function deficits, emotional dysregulation and sluggish cognitive tempo, and also talk about psychosocial treatments. So on the left is a cover of a real book that came out a couple of years ago. It's from a neurologist, said ADHD does not exist. On the right are two of my favorite quotes. So New York's, one of New York's favorite senators, Daniel Patrick Moynihan said, everyone is entitled to their own opinion, but not their own facts. I think saying ADHD doesn't exist is an opinion and not a fact. I think that the evidence which I'll show you today and the preponderance of the evidence really shows that ADHD is a true scientific disorder. And John Kennedy said, too often we enjoy the comfort of opinion without the thorough discomfort of thought. So we're really going to have to think through what we know and what we don't know about adult ADHD. So this is a timeline of what we've called ADHD over the course of years. I want to highlight just a couple different things here. The first clinical descriptions, and actually the descriptions of ADHD go back actually back hundreds of years before this. If you, a chapter that Keith Conner is one of the fathers of ADHD wrote in our textbook on ADHD found descriptions going back to almost the middle ages. But if you go back and look at the clinical descriptions, George Still wrote clinical descriptions of young children that had a lot of hyperactivity impulsivity, and they would be kids that we would diagnose with ADHD today. The first use of medications was in 1937, believe it or not, by George Bradley. Back then we didn't have a lot of diagnostic imaging, but we did have pneumoencephalograms when we would take a picture of the brain, an X-ray of the brain, but introduce air in the tap to create a contrast. Every time we do a tap, we get a headache, but especially if you introduce air. Bradley was looking for a treatment for the post-tap headaches. He gave Benzedrine because we didn't have a lot of treatments at that point. Lo and behold, the kids who were hyperactive before the tap who got Benzedrine were not hyperactive afterwards, and that was our first use of stimulants, and the first time ADHD was first treated. A couple of other notes here, the first time we were actually able to make a full diagnosis of ADHD in adults was in 1987 in DSM-3-R. It was residual up until then, and now we're still using criteria up in DSM-5 in 2013. Here are the pictures of the two people I just mentioned. This is from our textbook in Keith Conner's chapter. You know, here is Bradley, and here is a gentleman describing the first clinical descriptions in kids. So what were the DSM-4 criteria? They're very similar to the criteria we have today. Four major criteria, and they're similar for kids and adults, but they do differ in terms of the symptom loading. Four major criteria, symptoms, impairments, age of onset, and being sure that ADHD is causing the symptoms and impairment and not another mental health disorder. That holds true for DSM-4 and DSM-5. So symptoms before in the past six months, significant symptoms in DSM-4, six of nine inattentive and or six of nine hyperactive impulsive symptoms significantly. In DSM-4, some symptoms before the age of seven significantly. Impairment in two out of three domains, school or work, home and social, and being sure that the symptoms and the impairments are from ADHD and not another mental health disorder. Here are the symptoms. Of note, in DSM-4 and in DSM-5, the symptom domains remain childhood domains that you as clinicians are left trying to interpret what these are like for adults. So here are the inattentive, careless mistakes, trouble sustaining attention, easy distraction, trouble organizing, failure to finish, not listening, avoiding, losing things, forgetfulness, the hyperactivity impulsivity, trouble staying seated, fidgetiness, excessive movement on the go, excessive talking, blurting out, trouble waiting, interrupting, and intruding. How common is it? Well, it's a highly common disorder. Eight to 10% of school age children, the NCSR found 4.4% of adults. The worldwide prevalence rates run 2.5 to 5.2% in the WHO studies in adults. When you classify subtyping or presentations, that is they use subtyping in DSM-4, presentation in DSM-5 based upon the loading of the inattentive versus the hyperactive impulsive symptoms combined is when you meet both criteria, both the inattentive and the hyperactive impulsive. That's the most common in adults, 70% of the time. Inattentive, 25%, and primarily hyperactive impulsive, less than 5%. The male to female ratio is higher in kids than adults, 2 to 1, 4 to 1 in kids, boys to girls. It's close to 1 to 1 in large epidemiologic studies and in our clinic. And in part, this is because females carry a higher burden of the inattentive symptoms and are higher represented in the inattentive presentation. And about 50 to 60% of patients who meet diagnostic criteria in childhood continue to be symptomatic and meet criteria in adulthood. And the prevalence is relatively similar cross-culturally. So you don't have to just believe me, you can believe the CDC, and this is their data from their website. This is looking at the different studies and the different medicines that have been approved over the course of time in both kids and adults, looking at their estimates of prevalence and medications. Of note, there is some correlation between medication approvals and prevalence ticking up somewhat, and that's something for us to think about and talk about. And we will talk about ongoing rates of prevalence and what happened with the pandemic later in talk and increased rates of diagnosis. It's something we'll get to. So one thing you're going to hear me talk about is use a rating scale, okay? Rating scales are important. I think it's important for everybody to become comfortable with a well-validated rating scale. Pick one you like. We have our own. Everyone's going to find something that they like. I'm not going to tell you which one to use, okay? But rating scales will help you create a structured assessment, and one thing that you're going to hear me say throughout is that for assessing an adult with ADHD, there are no shortcuts. I created a screener. We've created this. It helps identify individuals at risk, but no six questions can make a diagnosis, okay? Nothing replaces taking a careful developmental history. Scales help identify symptoms. Scales will help you in terms of your assessments. So here are some. This is a non-exhaustive list. Here are some examples of some pediatric and adolescent scales. They include the case ads, which has an ADHD module, the CBC checklist, the SNAP-4, the ADHDRS, the Vanderbilt, the Kiner scale, and the ASRS. It's not exhaustive, but here are some good examples of some well-validated scales. Now for adult scales, they can be broken out into diagnostic scales, scales that will help you with making a diagnosis and are comprehensive and create semi-structured evaluations, and scales that are clinician-administrated, self-administered, or assess frequency and severity of symptoms that will help you assess symptoms. So again, these are not exhaustive, but there are diagnostic scales, which include Keith Connors' scale, Russell Barkley's scale, Tom Brown's scale, the case ads interview, and we also have an ADHD scale that's diagnostic, the ACDS. For symptoms, these scales vary as to whether you give it to the patient and they take it themselves, they're self-administered, whether they rate the severity of symptoms in terms of how bad they are or how frequent they are, how often they occur. So there's the Brown scale from Tom Brown, and I've given you where you can get them here, okay? The Connors' scale, the Wender-Reimer scale, the ADHD-RS, Barkley's scale, Russ Barkley has a scale, the ASRS you've probably seen. It comes in a screener form for DSM-IV and DSM-V and a full symptom checklist. Symptom checklist is in the public domain, sits on the NYU website, got the 18 symptoms of ADHD in self-report form, you can download it, give it to the patient, and you can get kind of a roadmap of ADHD symptoms that the patient can help you walk through and try to understand their symptoms. And we have a full semi-structured scale called the AISRS. Okay. Now we're going to talk about symptoms that are not part of the DSM, okay? So we've talked about the nine symptoms of inattention and the nine symptoms of hyperactivity impulsivity, but I'm going to lead you down a road talking about symptoms that are important that are not part of the DSM. These include executive function deficits, which are higher level cognitive functions of organization and planning that are very common in ADHD, and I'll show you in a second how common, and Russ Barkley defined nine of them, including response inhibition, trouble with nonverbal, trouble response inhibition, trouble with nonverbal working memory, trouble with verbal working memory, regulating emotion and motivation, and trouble with problems and problem solving, and also problems with working memory and the planning and procrastination and organization are critical here in terms of executive function deficits. So these executive function deficits can be measured with scales for executive functions that are designed just for executive functions, like the brief scale, which is anything but brief, it's 75 items, but it comes in a self-report and an other report item, and it's well-validated for individuals with ADHD and who don't have ADHD, and it's normed for a normative population and you get a measure as to whether they have executive function or not. But ADHD scales also have subscales built in as to whether they measure these symptoms. The Connor scale, the Brown scale, the Barkley scales, and all the NYU MGH scales all do this in their expanded versions. Emotional dysregulation is another symptom set that co-travels with ADHD. So these include rapidly shifting affective disturbances of mood lability. This is not a mood disorder. This is a changeability of mood. It's overreacting. It's context-based to the symptoms, to what's going on during the day. It's an easy bruising of mood. So it is not a formal mood disorder, and we'll use this term of emotional dysregulation to include things in literature. It's been called a variety of things, including emotional impairment, deficits of emotional control, and deficit of self-regulation. Just like executive function deficits, emotional dysregulation symptoms can be defined specifically in scales that measure executive function, like the brief, but also in ADHD scales, including the Wender-Reimer scale, which is heavily weighted towards symptoms of emotional dyscontrol, the Brown scale, the Barclay scale, and the NYU MGH scales. So why am I talking to you about this? So this is old data out of Milstein, 1997 study, looking at the weighting of inattentive versus hyperactive impulsive symptoms in adults. So one thing that I want you to take home is that adults are not just grown-up kids. The inattentive symptoms are more common in adults than they are in kids, and this study goes back a long ways. They looked at 149 consecutive presenting adults and counted significant symptoms, and the inattentive symptoms were twice as common as the hyperactive impulsive ones. So we went ahead and revalidated this. That was a referred sample, but we went ahead and looked in a community-based and managed care sample in the NCSR study with Ron Kessler, and we, lo and behold, many years later found out that the inattentive symptoms were clearly just as we validated. They were 50% more common than the hyperactive impulsive ones. But when you look at the symptoms of executive function deficits, they're equally common as the inattentive symptoms, and the symptoms of emotional dyscontrol are almost as common as the hyperactive impulsive ones. So if you don't look for symptoms of executive function deficits and symptoms of emotional dyscontrol, you're going to be, if you're only sticking to the DSM, you're going to be missing some of these symptoms, and these symptoms are highly impairing in and of themselves. The third set of symptoms I wanted to talk about are sluggish cognitive tempo, and there are nine symptoms, as defined by Russ Barkley, that can co-travel with ADHD about 50% of the time, and they include symptoms of daydreaming, trouble staying awake, easily confused, bored, lethargic, underactive, slow-moving. Why is this important? Well, they're highly impairing when you have both these symptoms and ADHD. I'll show you some data from a study that we did that validates some of Barkley's data, and they're highly consistent on both self and other report when you have, when you're looking at this in individuals with ADHD. These symptoms all occur, all these three traveling, co-traveling symptom sets occur not only with ADHD but in other disorders, but it's important for individuals with ADHD to look at them. Okay, so what did DSM-5 do? They changed the age of onset criteria from 7 to 12, so now it's middle school. So significant symptom onset is now at middle school, okay? That makes some sense because kids in middle school have to have a locker, they change classes, they have to carry a book bag, so, and the literature shows that the individuals with symptom onset middle school onward have the same levels of impairment as the kids that had it with full childhood onset. They reduced the number of required symptoms in the inattentive and the hyperactive group from 6 to 5, so now we're at 5 for adults. They removed the comorbid autism spectrum exclusion, so now you can have autism and ADHD, and they put multidimensionality for the symptom onset before 12, and they gave you some examples of what the symptoms would look like for adults, which are kind of very much like the prompts that we have from our scales, but they didn't include these co-traveling symptoms of executive function deficits, emotional discontrol, and sluggish cognitive tempo. They chose not to include these as part of the symptoms in DSM-5, okay. Why is making the diagnosis correctly important? So adults with untreated ADHD, and this is a summary from a number of studies, are about twice as likely to be arrested, they're twice as likely to be divorced, they're four times as likely to contract a sexually transmitted disease due to risky behavior, they're more likely to be addicted to tobacco with lower quit rates, and they're three times as likely to be unemployed. There are driving consequences too. This is data from Ross Barkley, he actually had his, and this has been validated from when you put them in driving simulators. He actually had his research assistants go into the cars with and actually drive with adults, untreated adults with ADHD. But they have higher rates of traffic violations, speeding violations, drunk driving, licensed suspension, and caused accidents. If you have trouble having your adults with ADHD take their medication, this data can be compelling. So, why is this hard, and why are you guys all here today? There's a reason I've got 450 of you packed into a room today. This isn't easy. The core symptoms of ADHD are present in everyone to some extent. Everybody has some trouble paying attention, has some restlessness. The issue is the pervasiveness of the symptoms, the longitudinal aspect of the symptoms, and impairment. You may have difficulty you may have difficulty from time to time. You may have had a poor night's sleep, but you're not having it throughout your life, and the impairment is what singes a disorder. We don't treat symptoms as psychiatrists. We treat disorders that are impairing. Comorbidities are common, and I'll show you that. They occur 50 to 75% of the time in adults with ADHD. And you have to be certain the symptoms are from ADHD and not the comorbid disorder, and taking a longitudinal history is critical. And the impairment can be relative and difficult to determine, especially in a high-functioning individual. The retrospective recall of childhood symptoms can be difficult, and we recommend strongly, and our scales do this, that when you're taking a history, you put the individual in childhood. You want to have the patient paint a picture of what their childhood was like. You don't want to go ahead and flip back and forth childhood, a symptom in childhood, to a symptom in adulthood. That's not really going to give you a narrative as to what their childhood was like, and will create contamination from current symptoms into childhood and childhood symptoms into adulthood. And finally, as much as we do research on biomarkers and imaging, there's no current litmus test. There's no one test that will help you make a diagnosis. Psychological testing can be informative, but is not diagnostic at this point in time, and is used for psychoeducational reasons in adults, but is not required to make the diagnosis. Okay, so a couple of things on persistence here. This is data from Maggie Sibley out of the MTA. She's put out a couple of great studies in the last couple of years. Looking at persistence of ADHD. And basically they followed patients longitudinally over the course of time. And what you tend to see here, and I just want to highlight, is that symptoms fluctuate in individuals. But they more or less maintain their diagnosis over the course of time with some fluctuation. That's really the key point, is that symptoms do fluctuate. The other thing she studied was adult onset ADHD, which was a hot topic a couple of years ago. These are individuals who were coming in and saying, I had no symptoms in childhood. My symptom onset occurred in adulthood. I had nothing in childhood. And there were some studies that found in certain populations this was occurring, which was surprising to some people because I don't see a lot of patients like that. Well, Maggie went back and looked at the MTA study and found that 95% of the individuals who initially screened positive for late onset ADHD turned actually not to have it. The most common reason was impairment due to substance use or another disorder. So the comorbidity was really what was causing the problem. And most of the late onset cases had an onset in adolescence. So clinically, adult onset ADHD can exist, and I do believe there are cases of it, but it is unusual. And so when you hear hoofbeats, think horses, not zebras. Okay, this is data that we had published a while ago, and I think it still holds true on physician perceptions of adult ADHD. And this is a survey of 400 primary care physicians, all who treated a lot of mental health disorders. They were far less comfortable and knowledgeable treating ADHD as compared to anxiety and depression. And they really thought they didn't receive very thorough clinical instruction at all. And I think this still holds true. Psychiatrists, I still think we have a hill to climb in teaching about adult ADHD. Even my own program, I give lectures on adult ADHD, but not many of them, and I'm vice chair of education. So I still think we have work to do in terms of getting the word out and improving teaching, especially teaching for PCPs. And treatment of children, and this is data from the CDC, about three in four kids receive treatment. And I think more kids with ADHD are receiving treatment than adults. And I think that's an important thing to keep in mind. Adults, they tend to be treated and receive more behavior treatment than adults, and that's something to keep in mind. Okay. Okay. So the pediatric ADHD comorbidities are similar to adult ADHD with some slight differences. I mentioned that rates in adult ADHD are 50 to 75%. And data here you see, this is all out of the CDC, you see 64% having any disorder. And the most common are behavior conduct problems, anxiety, depression, autism, and Tourette's. Autism and Tourette's you're gonna see less of in the adult comorbidities. Here are the common psychiatric comorbidities, antisocial personality disorder, depressive disorders, up to 35% with chronic depression and major depression. Bipolar disorder, combination of anxiety disorders including panic disorder, PTSD, OCD, and substance use disorders. You need to look for these disorders in patients with ADHD. So the history of this is kind of interesting and I'll walk you through it. This was the original data out of the MGH group which is a referred sample. And I'm just showing you the anxiety disorders down here. High rates of multiple anxiety disorders. This data was questioned because it was a referred sample. But when you went ahead and looked at the NCSR sample which was a community-based sample and not a referred sample, you found the same thing. So these comorbidities are real. It's not just that it's something in the water in MGH, in Boston in a referred sample. Okay, this is true. I can tell you because we did the NCSR study and we went into the community and actually did structured interviews of people throughout the country. These diagnoses are real and they were not referred in any way. So it's not because the sample was referred. It's been validated in multiple ways. Same thing for mood disorders. In the original MGH sample, major depression, bipolar, dysthymia. Mood disorders in the community-based sample. This is data from Andy Nirenberg out of the STEP-1000. ADHD and bipolar disorder is highly comorbid. When you look at rates of lifetime ADHD, very high, almost 10%. Current ADHD is 6% in patients with bipolar disorder. So it's a very difficult comorbidity. One of the most difficult comorbidities to treat. Earlier onset of the mood disorder if you have both disorders and more hospitalizations and more episodes. Difficult to treat. So nicotine is another one in terms of substance use disorders. I could spend the entire time talking on substance use disorders. This slide is courtesy of Tim Willens of MGH. Nicotine generally acts as a gateway to substance use. It's important to keep that in mind in your young adults. Nicotine enhances attention and executive function. And adults with ADHD had an earlier onset of nicotine dependence. And young adults with ADHD had earlier, untreated adults with ADHD had earlier onset of substance use. And the meta-analyses have generally shown that treatment with psychostimulants have lowered the risk of substance use than raised it. Let me repeat that. It's counterintuitive. All right, there's a concern that using psychostimulants will raise the risk of substance use disorders. It goes the other way according to the meta-analyses. Treating the ADHD lowers the risk of substance use according to the meta-analyses. The greatest risk of misuse diversion, which means taking medicines that aren't yours or giving them to someone who doesn't have ADHD. Most common at highly competitive schools occurs in individuals with conduct disorders. And most commonly seen in patients who take immediate release mixed amphetamine salts. So if you have college-age students, young adults coming in looking for an ADHD evaluation and are demanding treatment with immediate release mixed amphetamine salts, I want you to think very carefully, okay? A, are they insisting on a specific type of medication that they'll have to take three to four times a day when they have trouble doing things on time? And B, why is it they only want one type of medicine before you've evaluated them, okay? Red flags should go off. Do not pass go. Don't collect $200, okay? Stop. This is a high risk for misuse and diversion. Be very careful with this individual. We tend to recommend preferential use of sustained release medications whenever possible in the adult population, and we'll get to that. That doesn't mean you shouldn't use immediate release, but preferential use of longer-acting medications should be preferentially used. Okay, why don't we hold here and get some questions? I think it's a good time. My voice is kind of getting in the way, so let's stop here if anyone's got a question. Come on up to the mic. Please walk up to the mic and... And don't be shy. Don't be shy, but also state your questions in 30 seconds or less. Any comment on the computer testing for ADHD, I believe there's a Connors test that is out and presumes to help differentiate those who don't and those who do have ADHD. So I'll repeat the question. Any comment on the computer-based testing? They were asking about, I believe the question was on the Connors test, which is a CPT test. Neuropsychological test, that is one form of a neuropsychological test, a CPT test. It is not diagnostic. It can be helpful information, certainly not required in making a diagnosis. It shouldn't be done for everybody. I don't think it should be done. Thank you very much for the presentation thus far. My question is about acquired brain injury where patients present with deficits similar to that of ADHD and whether stimulant medication can be used as treatment in these conditions. So the question was acquired brain injuries in patients and treating them in patients with adult ADHD. So I didn't put that in as one of the comorbidities, but it is. It runs higher, patients with ADHD have higher rates of TBI and patients with TBI have higher rates of ADHD. The treatment's a bit complicated in that you have to be concerned about neurological, you have to get neurological clearance for using appropriate ADHD therapy. So you have to work with a neurologist on this. So I don't have an easy answer for that. Good afternoon. I was wondering if you could comment at some point during the speech about Sandra Kooj's work on circadian rhythm and skipping breakfast and staying up late and sleeping late as she's described in some of her work. Okay, question was on circadian rhythms and ADHD. Different things can be helpful for different people in subsets of individuals. I think it's an evolving area. I'm not sure it's fully ready for prime time. One of the questions I ask every patient, do you eat breakfast? I would say 70% say no. Yeah, I think, as I said, I think adults with ADHD have trouble organizing themselves in the morning. I get simplistic when I discuss this. If you don't put anything in the engine, it's kind of hard to run and pay attention, especially if you're taking a psychostimulant. The tolerability of medications is poor if you're taking them. I'm not talking about a big fatty meal. I'm talking about nothing in the stomach. I really try to have my patients eat something when they're taking their medications. It's not preferable to skip breakfast entirely. A lot of them will skip it regardless. I understand. I can only talk. We can discuss it. Next question. And then I think we'll go to some from the, From the online audience, yes. TV land, yeah. Thank you, that's a very comprehensive across lifespan. You did mention about comorbidity with anxiety disorders. About 30% with adult ADHD. But in my practice, I've seen a lot of people with OCD spectrum being misdiagnosed as adult ADHD. Do you have any data to say what's the percentage of overlap? OCD spectrum? OCD is one of the anxiety disorders that's highly comorbid. So it falls, and we tend to group the anxiety disorders, so it's one of the anxiety disorders that's highly comorbid. And I didn't show the reverse comorbidities in terms of patients with other disorders that actually have ADHD that have been misdiagnosed, that the ADHD is missed. And that's, OCD is one of them. So we don't have any data just to show how much OCD spectrum is within ADHD? Well, because you're dealing with OCD spectrum, you're dealing with a subsyndromal diagnosis, so we tend to have a little bit less data there. All right, thank you. If we can hold, I'm just gonna take, stay, but stay there. We're just gonna take one from the audience first. That's all. Sure, there's one quick question from the audience about the slides again. Just to reiterate, all the slides will be on the clinical updates toolkit. So starting off from a barrage of questions, question one is, which patient will you prefer to start Adderall categories versus methylphenidate? Well, we're jumping the gun on medicines. That's the next part of the talk. Let me preface this by saying, I don't have one medicine I use. I'm an adult with ADHD. So I don't have any particular patient that I start on amphetamines versus methylphenidate. I take a careful history. Often, if there's a history of response in childhood to a medication, we look for that. If they've responded to a methylphenidate well in childhood and just didn't continue it, we'll try to use that. We also look, and the amphetamines tend to be a little more potent, so that may be a factor in the decision. It's also preparation in terms of sustained release and the method of sustained release that's important. But no, I don't have one type of medication that I use. So a couple of questions on the use of cannabis. First is, where is cannabis in the ADHD as many youth are using it to help them focus? And second is that cannabis has often muddled the picture for ADHD evaluation. Would you refuse to complete an evaluation if an individual is actively using cannabis? So this is something we're, you know, that we, we're, I'm gonna steal a punchline. The American Professional Society of ADHD and Related Disorders is making guidelines for adult ADHD. You'll see that at the end of the talk. We are actively debating how to handle cannabis. It's critical. The thought leaders in this area, I think that what they say is that it depends if it's use or if it makes formal substance use criteria or not. Look, if I had told all my young adults not to use cannabis in New York City, I wouldn't have any young adults I'd be treating. So I don't think we can do that. But the issue is, are they using regularly to the point that it's going to impair my ability to assess their symptoms and or response to medication? I think that's the critical element here. If that reaches that threshold, then I ask them to moderate their use before I can finish the evaluation or initiate treatment. So next is a straightforward. Do symptoms of inattention get sometimes better with age? Do symptoms of inattention get better with age? Do symptoms of inattention get better with age? All of these symptoms get somewhat better with age. Actually, there's an age decline data out of MGH show there's some age decline with all of the intensity of some of these symptoms. They will fluctuate over time. Someone's asked your preferred questionnaire or screener that you use for adults for ADHD. Do I have a preferred screener? Well, I like the ones I made. I mean. So the next one is, how do you suspect an adult has undiagnosed ADHD on an intake for another complaint? So the question was, how do you suspect that someone has adult ADHD when they're coming and complaining about something else? And that's a tough one. You know, I've seen this all the time. And I can say that, you know, I've seen it in patients that I've, you know, when I work with residents and they have someone in treatment and they bring the case in and then I bring this up. There's no one way and there's no one thing that brings this up. But it's the fact that the symptoms of ADHD are sort of there lurking beneath the surface. And the other disorder, although present, may not be getting better. And I think that's the key point. Traditionally, you would expect the other disorder to get better and it's not. And there's something else interfering and it may be the ADHD. Why don't we hold here and get to a couple of questions and then we'll go back to the talk. I promise we'll have more time for Q&A at the end. Thank you. So I have a slightly different context. So I'm from Australia. So we have more kind of rigid guidelines. And in Australia, the guidelines say if a person is coming with symptoms suggestive of ADHD plus another comorbidity, then you must treat the primary condition. And that may mean if the person appears to be more depressed would you do that same here or you are happy to start ADHD treatment and see how the other condition go? I'm trying to understand the question, but I think it is when there's ADHD and a comorbidity, sort of what do you treat first? Yes. Well, as in the rest of medicine, you treat the most impairing disorder first, whatever that may be. If it's ADHD and bipolar disorder, probably gonna treat the bipolar disorder first. If it's ADHD and dysthymia, you may treat the ADHD first. There's no hard and fast rule. And how about ADHD and amphetamine use disorder? Gee, you saved the easy one for last, huh? What's your view on the long acting because I only last for 12 to 14 hours, but in this working environment, probably nobody in this room works less than 16 hours. So how does that work in terms, do you recommend we actually do double dosing with them? And do you also recommend you give a short acting first thing in the morning to actually kick in like if you're a mom getting up and you're actually having to get kids ready for school? Let's save that for the medication section, but I will get, I'll answer it, I promise. Okay, two more and then we'll go back to the talk. I just had a question about, so you go through your scales, you do your diagnostic evaluation. Someone has sub-threshold symptoms. In what setting, if any, would you still consider prescribing stimulants to someone who doesn't meet the full criteria for ADHD? So the question was, if someone has sub-syndromal symptoms, when would I decide to treat, is that correct? The stimulants, yeah. Yeah. With stimulants. Or ADHD medication. ADHD medication, okay. So I'm kind of a reductionist here. And I think it depends what the sub-syndromal symptoms are. So let's say the individual has four inattentive significant and four hyperactive impulsive significant, okay? And they're significantly impaired at work and you interview their significant other at home and they say they're not listening to me and I'm picking up after them like a child. I can't stand it anymore, okay? and there's a childhood onset. Okay, does that person have ADHD according to the DSM? No, right four out of they don't meet the criteria. Okay, would you treat that individual? You would so would I? Okay, that's an easy one Okay the hard ones are when there's really Subsyndromal symptoms and it comes down to the impairment and that's really where I would probably get testing. I tend to test when there's Diagnostic we're like that. I I want us Psychiatrists to think about this like the rest of medicine. When do we do tests? We do tests when there's diagnostic uncertainty Neuropsychological testing in that instance can be quite helpful Okay, last question. I want to get back to the talk Thank you so far it's been an excellent talk I'm an outpatient psychiatrist and I have a question about Diagnosing an adult onset ADHD So you mentioned that usually? And also, I know from some guidelines that adult onset and ADHD first you rule out sort of medical conditions that could be having the same symptoms and substance use and I noticed I have a Population that presents to me in the they are middle-aged and I already ruled out the medical conditions and also ruled out substance use Although you can't completely 100% rule out that but they are high functioning individuals very smart ambitious, but so they Didn't really have a huge degree of impairment when they were In school getting secondary education but they notice the symptoms more when they're in college or do more complex work and to me it seems like that that could be one of the subset of types of ADHD just from practice and also given that after 25 our brain cells are declining Maybe it's natural to see that this sort of like a second peak Okay, so I want to go back over something Adults with ADHD presenting in adulthood Do not have to meet full childhood criteria Retrospectively, okay. They don't have to even be impaired significantly in childhood they have to have significant symptoms in more than one setting Okay All right, so if you're looking for full childhood onset Okay, you're going to only get the most severe individuals as adults Okay, yes, thank you. Thank you and this is okay to write like for insurance Purposes that it's adult onset ADHD or it's not adult on its adult presentation adult presentation Okay, they have adult ADHD it's the way the DSM reads the DSM requires Significant symptom onset multi-dimensionally in childhood. It does not require full childhood ADHD Okay Okay All right, let's go back to the talk I Repeat again for the Q&A section at the end, please come up with the exact question that you have in 30 seconds or less Okay, so we went it so what are all these symptoms and how are these co-traveling symptoms what do they mean so we went ahead and did a factor analysis And looked at Kind of the loading of these symptoms and I'm going to go pretty quickly We looked at the symptoms all we look so our scale has expanded symptom sets that include the symptoms of executive function deficits and emotional discontrol We really found that there were separate symptoms for executive function inattention hyperactivity and then impulsivity separate but most notably Emotional I'm going to highlight this piece. Okay, and this is the most important thing for you to be aware of Okay, emotional discontrol symptoms mood changing frequently and overly sensitive to criticism They track separately from executive function deficits and executive function deficits really drove the bus here when they're present They cause the most impairment for adults with ADHD. You've got to identify them. Okay, but They load heavily on the emotional dysregulation The the impulsivity factor and they occurred in two kinds of patients very noisy ADHD Patients who had lots of symptoms they had the combined presentation and they had lots of symptoms or else They had subtle comorbidities that probably crept in Okay All right, so All right, so this is an example of kind of what neuropsychological tests are done This is from Larry Seidman Who was it mass general? There were five tests that he looked at the CPT one of which is the Connors test that was asked about the stroop-cull The word test which is an interference test trail-making the Verbal fluency test and the Wechsler. Those are the five most common used in over 70 Tests that he looked at. All right. Now Joe Biedermann who passed away. It was one of my mentors a couple He passed away two years ago Looked at the association between executive function deficits Individuals in who had just executive function deficits both executive function deficits and ADHD and ADHD alone And he looked at these tests that I just mentioned. Okay, and And The take-home point here and I'm going to move quickly is that if you have both ADHD and executive function deficits you're more impaired Okay more adults With ADHD had executive function deficits and only 30% of the adults had had executive function deficits Anywhere there was more impairment All right. Now, why don't we do? neuropsychological tests on Adults with ADHD the yield from the testing is not sufficient Biedermann went ahead and He has Venn diagrams, which I didn't put up here for the sake of time But the overlap between yield on neuropsych testing in ADHD is only about 30% Okay It's not sufficient because you're doing it in a one-on-one testing environment for adults with ADHD The yield is not sufficient for educational reasons for testing for higher level Exams be it the the SAT the LSAT the MCAT they all require it and that's fine But to use it diagnostically you're going to miss a lot of bright adults with ADHD Okay on to Understanding ADHD is a highly heritable disorder. This is from Steve Ferron ADHD is the inheritance rate. It's highly heritable runs in families about point seven five percent More than schizophrenia height. You notice is about point nine five And This is the latest data out of a great review that Steve Ferron Wrote in Nature Reviews Primers disease primers if you want to take a look that's where some of the meta-analyses come from It's really the best review of the science. Okay But the reason I'm putting this up here, there are lots of candidate genes. Okay, there is no one gene responsible for ADHD So adult relatives of children with ADHD have elevated rates of ADHD It's about a 40 50 percent chance that one parent will have ADHD in the family If there's a child with ADHD child relatives of adults with ADHD have higher rates of ADHD The heritability as I said runs about 75 to 80 percent and The molecular genetic findings are similar in kids and adults. So this is disorder. That's that is Runs in families. It's heritable, but there are lots of candidate genes Okay Where is this where is the pathophysiology this is a catecholamine neuron presynaptic Presynaptic here are the here are the receptors. Here's the transporter here are vesicles of dopamine and norepinephrine Okay, you remember this you remember how the drugs work I always tell my residents this Okay Amphetamines and methylphenidate block reuptake at the transporter. You don't have to take pictures you have it Okay, you don't For Both norepinephrine and dopamine I'm gonna stay off the There we go anamoxetine and valoxazine of selective norepinephrine reuptake inhibitors They block the norepinephrine transporter and why is amphetamine more potent than methylphenidate? It causes exotitic release of dopamine if you learned anything today take that home Okay Lots of pathways involved this is from the same nature review from Steve Ferron I want you to think about the pathways from the prefrontal cord and unilateral prefrontal cortex Pretty pictures here. You don't have to really stay with all this but feedback from the prefrontal cortex Is really what we're looking at here into In from the PFC Thinking about areas here, okay All right, let's get into pharmacotherapy All right stimulants non stimulants There are two classes of stimulants that are approved the methylphenidate compounds and the amphetamines There are two approved selective norepinephrine reuptake inhibitors anamoxetine and valoxazine In kids, there's an alpha-2 agonist. That's a sustained release. That's approved All right, that's that is guanfacine extended release that is approved in Japan for adults But not in the US Okay So if I wanted to show you pretty slides I could but I'm going to show you a non pretty slide Okay Amphetamines shown on top. This is from the review come in sustain and short acting versions Okay again for adults You don't have to just use I'm gonna speak for adults now. Okay, you can use stimulants or non stimulants the effect size I'm going to talk off this slide because it's too it's too busy. Okay You don't have to just use stimulants stimulants are more potent. Okay The effect size of stimulants is about twice as large as it is at the non stimulants, okay So therefore if you have a patient that's got really significant symptoms, you're going to be more likely to use a stimulant All right, stimulants are controlled substances So if you're a patient that is as active substance use problems, you're going to be more likely to use a non stimulant A Patient with a really bad tick disorder. You're probably going to use a non stimulant first I've just now given you the low-hanging fruit Okay The rest of it comes down to the art form of psychopharmacology and trying to get the right fit for the patient It's not easy The first thing you're going to do and you really need to do this is Check I stop check the prescribing database, okay You have to check the prescribing database, all right before you write a medication All right, it it it it it has almost every state in it and you can see what your patient has taken previously I'll tell you two anecdotes from when I stopped first came out in New York State. I Had one patient who I'd been seeing for a couple of years and Remember when we as prescribers write medication, we don't know we only know what we write at that point We didn't have I stopped. We couldn't see what anyone else wrote so I punched him up in the database and he was taking sustained release mixed amphetamine salts and Lo and behold, this is the first week I stopped was out There was another prescriber who was writing the same prescriptions that I was writing exactly the same and I had no idea and I said to my patient who's dr. So-and-so and he said I don't know who you're talking about. I Said really and I turned the screen around I Said who's dr. So-and-so and he literally ran out of my office with his hair on fire and I reported him to the state and Never heard from him again. I had another patient who was a young young adult woman and I punched her into the I stop and She was on short-acting mixed amphetamine salts and I saw that someone was writing the same prescriptions that I was writing and I said who's dr. So-and-so and she said I don't know what you mean And I turned the screen around I said no really who's dr. So-and-so and she said I have a problem And I said, okay, let's talk about the problem and she went into went into got in patient got inpatient treatment and rehab and recovered so Those two anecdotes tell the story before you you do anything in writing a prescription here check I stop Okay, that's another take-home. I want to leave you with okay so both methylphenidates and amphetamines work They come in short and long acting forms. They come in different preparations Some are barrier release some are small and large beads Some are pro drugs. You have to pick the ones, you know and get the best fit for your for your patients, okay In terms of non stimulants there is Atomoxetine and valoxazine I Don't have one that I use Okay, but we'll talk about some of the meta-analyses now All right This is from Sam Cortese a meta-analysis and Lancet. He's having a meta-analysis, by the way coming out We think sometime this year. So keep your eyes out 133 double-blind randomized control 81 and kids 51 and adults large sample. All right kids and adolescents Amphetamines if you go to the far far far side that means favors drug Okay, amphetamines are highly effective. I think you'd be proprion is a little overemphasized here. Okay, and Amoxetine works methylphenidate works for adults amphetamines methylphenidates Not surprisingly Modafinil is not effective the adult trial Which we were part of it was not that effective Okay Mean change in kids rated by but by teachers and amoxetine methylphenidate And adverse events dropouts one thing to keep in mind for kids Clonidine and guanfacine are just a bit less tolerated Well tolerated they tend to be sedating if you're going to use them in adults as you get the dose up It tends to be sedating and the the adolescent dose is higher. It's four to six milligrams. So the adult dose is going to be high, too and tolerability You know you see issues here They're you know amphetamine they're more similar than different Okay side effects So in the of the stimulants, they're quite similar dry mouth insomnia appetite suppression headache edginess tics psychotic symptoms and Cardiovascular, okay before you start these medications. I'm always asked do I need to have an EKG? This Will be part of the something that what we hope will get you some guidance with the guidelines when they come out but Right now we don't have guidelines for adults. There are guidelines for kids that do talk about this The stimulants will all pick up stimulants and non stimulants will all increase heart rate About the order of five beats a minute blood pressure three points on the average. That's an average Okay, all right, so that means you need to monitor blood pressure and pulse Okay, raise your hand who's got a sphingomanometer in their office Okay, if you don't get one, okay, they're at Walgreens and CVS they cost like 40 bucks, okay Honestly, it's it's it's not hard You Know you can monitor blood pressure and pulse and if you don't know you if you don't ask you don't know or at least work With the primary care doctor, okay in terms of EKGs most adult patients will have had an EKG at some point in their lifetime You need to ask about that in terms of arrhythmias and wolf parkinson-white that'll be picked up at that point But they should have an EKG during the course of stimulant treatment and there'll be more out on this when the guidelines come out The greatest risk actually is in if they is if the in if the patient has an obstructive cardiomyopathy We think about it Stimulants will will cause increased squeeze and if you have an obstructive cardiomyopathy or squeezing against a smaller opening Okay, and that can have serious consequences. So you should take a history for syncope And family history of earlier sudden cardiac death Okay, if you have those things, that's not a hard history to take. Okay because if you do take that history and it's positive hold off on writing the stimulant and Send the patient to the PCP to be evaluated. I mean I have picked up a couple of cases of Intrinsic cardiomyopathies. I had a patient, you know, I said, you know, is there anyone your family who? Died at an early age and he said yeah yeah, there was someone my my I have a couple of male relatives that that passed out and died at an early age and He had earlier told me there was no cardiac history and for him and he said but yeah now doc as you mentioned it's something someone told me I had something a little funny in my EKG and it turned out he had obstructive cardiomyopathy and if I would have given him a stimulant it would have not been good So take that history For adamoxetine, this is data from the registration studies dry mouth insomnia nausea That that can be diminished by taking it with food and sometimes some ginger You do get a little bit more sexual dysfunction with adamoxetine Okay And This is just summarizing the Lancet meta-analyses All Medications except modafinil and adults showed greater efficacy than placebo. Okay, so there are lots of medicines that work All medicines and adults were less efficacious than in kids So generally the medicines and adults have about half the effect size than we see in kids. Okay and this was done but prior to Veloxacine and Veloxacine is now on the market. It is a selective norepinephrine reuptake inhibitor and it does have some preclinical serotonin effects also of note methylphenidate in this analysis was superior in kids and amphetamine was superior in adults, but Take that as you will Okay, I'm going to run through this pretty quickly because I want to leave some time for Q&A here. So this I'm going to show you some data on treating executive function deficits This is a study looking at using lysedex amphetamine to treat executive function deficits These patients all had ADHD and had executive function deficits defined on the brief They were treated with lysedex amphetamine 30-50-70 versus placebo Significant effects on the overall brief score Versus placebo, but one thing I want to highlight here. These are the different subscales Emotional dysregulation tends to be less responsive and the overall magnitude of the effect here in the registration study It was over one the effect size for lysedex amphetamine. You're noticing it's much less here But emotional dysregulation was not significant. Emotional dysregulation is a harder nut to crack So there have been a number of studies that have looked at emotional dysregulation Stimulant trials people have looked at orosmethylphenidate, Concerta, sustained release methylphenidate, a couple of studies on methylphenidate IR and lysedex amphetamine Also bupropion, venlafaxine, and a bunch of studies on Atomoxetine. I'll show you a study from Phil Asherson out of the UK Showing that atomoxetine also can improve Executive function deficits So looking at the effects overall the effect size of 0.35, which 0.34 Which actually is pretty close to the the US effect size actually in ADHD, but again the take-home point Less effect on emotional discontrol. It's harder to get to So overall the executive function deficits effect size about half, and the effect size in emotionless control is less. I'm going to move through this pretty quickly because we're going to run out of time here, so I'm going to skip over some of this. This is a study of sluggish cognitive tempo, where we looked at patients with ADHD alone versus ADHD and sluggish cognitive tempo. The take-home point here is that if you have both conditions, it's much more impairing, and it's not likely that the ADHD symptoms cause the impairment. It's really not good to have both conditions. This is a study we did with Jeff Newkorn's group at Mount Sinai, and when you put both groups together, that was data just from our group, it's really quite impairing to have both disorders. We actually went ahead and did a treatment study on the subset of individuals that had sluggish cognitive tempo, and what you find here, this is looking at the Barclay SET scale, significant effects from lysedexamphetamine and on ADHD ratings. Lysedexamphetamine improved both ADHD and sluggish cognitive tempo. Only about 25% of the change in sluggish cognitive tempo ratings were due to changing ADHD ratings, though. We're not really sure where the rest of the change came from, and that's something we're going to have to look at. Let's talk about the stimulant shortage, which has been a bone of everybody's existence. Just so you know, at one point I had to send their prescription to over 20 pharmacies once to get it filled, so I feel your pain. But if we are feeling pain, imagine what it's like for our patients. This is data from the CDC, Danielson published in MMWR, looking at the percentage of patients with at least one stimulant prescription over calendar years, and we're really looking at the effect of the pandemic. So what you see here is prescription rates going up. 2020 with the pandemic, we're going up. And this is at least one stimulant prescription filled, dramatic increases. This is straight off the CDC. This is an article by Chai and Zhu in JAMA looking at incident prescriptions, meaning no previous prescription from the IQVIA commercial database. So that's a commercial database looking at all prescriptions commercially. And what they found, look at the rates of prescriptions for controlled substances going up, and for non-stimulants also, okay, during the pandemic. All right. So what's happening here is that rates of ADHD are going up during the pandemic, in part due to the ability to do telepsychiatry. I don't know what happened for all of your practices, but when the pandemic hit, we were blessed in being able to throw a switch and go virtual. It meant we were able to see our patients, continue to see them, and also improved access to care. But it also meant that a variety of other types of care was being delivered by different types of providers. But we have to be careful about how the ADHD diagnoses are being made. I want to leave you with that nothing replaces a careful, full, thorough evaluation for an adult with ADHD. And the increased diagnosis rates that occurred during the pandemic are multifactorial. It's not just due to telepsychiatry. Danielson presented some data at the APSARB meeting that showed it was not just telepsychiatry, okay. It's more people are coming in. It's multifactorial. It's due to multiple reasons. We have to be sure that the diagnosis is being made correctly and that the right medicines are getting in to the right people. Otherwise we're all going to bear the burden of this. Misuse and diversion. Short-acting stimulants are the most ones that are misused and diverted. Using short-acting stimulants really should not be the first thing you think about for young adults. And as I mentioned, individuals who persist, insist on reusing immediate-release mixed amphetamine salts, you should tread very carefully and think about using sustained release or non-stimulant medicines. And again, check your controlled substance database. Always document impairment and talk to significant others and parents whenever possible. I'm going to show you some data out of a pilot study we just did on this emotional, on this PRISM-EFP neurofeedback. It's a novel kind of neurofeedback that targets emotional dysregulation through the amygdala. And then I'll close and leave time for feedback. So traditional neurofeedback has targeted basically different areas. It's used sensory motor rhythm neurofeedback or beta-theta ratios. And when a recent meta-analysis by Cortese found it was just not that effective overall. So this is a type of PRISM neurofeedback that looked at downregulation of amygdala. It's been useful in PTSD. And I'm going to move through this because I see people leaving. Either I'm boring them or I'm tiring them out. It's a pilot study where we looked at nine people. Seven of them finished but all had useful data. We basically, they all got better and their ADHD ratings got better. And we were able to train them and have their signal go down through the amygdala. And more to come on this. So words are two on cognitive behavioral therapy. There's a study by Steve Safran looking at CBT with a psychoeducational core, learning skills, cognitive restructuring. He gave it to people who receive either ongoing medicine or medicine plus CBT. The combination group had less depression, lower ADHD scores, and were more likely to be responders. This is Mary Salanto's metacognitive therapy, looking at metacognitive therapy versus supportive therapy. And the change in T-score up is good. In metacognitive therapy was significantly better than in supportive therapy. Environmental modifications can be quite helpful for individuals with adults with ADHD. Avoiding, structuring the environment, avoiding distracting things, organizing your physical space, use your cell phone for planning, reminders, take your medicine, do things once, checklists, can be really critical. All of these things for all your patients, independent of whether they're on medicine or getting CBT can really be helpful. Okay, some take-home points and then we'll close. ADHD is a treatable lifelong neurodevelopmental disorder. There are no shortcuts in making a diagnosis. Take a developmental longitudinal history. All grown-ups were kids once. Use rating scales and gather collaterals when you can. Medications and psychosocial treatments are effective for kids and adults. The effect size of medicines is greater in kids than adults. The effect size of medicines is greater in kids than adults, but they certainly work well in adults. Both stimulants and non-stimulants work in kids and adults, and the effect size of stimulants is larger. Assess for comorbidities and keep in mind when making a treatment plan. Monitor blood pressure and pulse during treatment. And assess for co-traveling symptoms and include them in the treatment plan as they may respond differentially to treatment. So as a coming attraction, I mentioned the guidelines. The American Professional Society of ADHD and Related Disorders is that we are making U.S. guidelines. There are multiple guidelines for kids, including those from ACAP and the American Association of Pediatrics. Multiple international organizations have adult guidelines. There are Canadian guidelines, U.K. guidelines, multiple European guidelines, and Australian guidelines, but none for adults in the U.S. Guidelines are important for patients, because adult ADHD is often underdiagnosed and treated, and the guidelines can provide the latest evidence for you in the field and provide patients with the best information so you can make informed decisions with them. So the guidelines will be out by the end of the year. There will be a period for comment and participation, and I encourage you to do so. When it does come out, it's your opportunity to participate. And I gave you a Q scan so that you can get that if you want to. And let's go to Q&A. So I'm going to take some online questions first, because I have a list of about 60 questions. So I'll be breaking my own rule of 30 seconds, clubbing a few questions to get a gist of it. There is an increased rate of adult patients seeking an ADHD diagnosis. How to ensure that there is legit ADHD if no collateral is available to support the diagnosis? How can we tease real ADHD versus stimulant-seeking patients? And how to increase diagnostic precision if you're relying on patient statements? A corollary to this is many patients look up answers to questionnaires or know what to say, and many patients did not receive a childhood diagnosis for one reason or another. How do you separate those with a true ADHD or ones suffering from U.S. production pressures and high digital inputs? So the question was, how do you pick up malingering? Okay, make it short and sweet. Absolutely, absolutely. So use a structured scale. It's hard to malinger when you're asking, our scales have nine to 12 prompts for every item for adulthood and childhood. Can't fake that. You know, it's really, you don't fake that. A self-report scale, yeah, they can try to fake that. But if the answers seem robotic or schooled, it'll become apparent if you're getting answers from a self-report scale. But you shouldn't just take that at face value. You've got to flesh it out. Don't just take the patient's self-report at face value. You've got to really try to flesh it out. Next question is, in your clinical experience, do you treat the comorbid conditions first prior to exploring an ADHD diagnosis? Since a number of comorbid conditions may have symptoms that mimic ADHD. Sometimes. You treat the most impairing disorder first. How do you proceed with patients that have both bipolar and ADHD when prescribing? Do you try other medications before the stimulants, or do you give less of a dose of stimulants? Well, you know, we always go to literature and try to be evidence-based. But the evidence base is in bipolar disorder and ADHD is rather limited, unfortunately. But common sense tells us that bipolar disorder will be the more impairing of the two disorders. And in general, I think it's important to stabilize the mood first. Because there's a risk that the psychostimulants may be activating and may also cause some insomnia. And there's some literature that if you shift phase of sleep for patients with bipolar disorder, that may trigger a mood episode. So I generally try to stabilize the mood first. Please comment on the comorbidity between ADHD and sleep apnea. So sleep apnea is one of the comorbidities that occurs with ADHD. Often you'll see it co-occur together. It's often not the root cause of the ADHD symptoms, but will be something that will make them not get better. Sleep apnea tends not to have its onset in childhood. And why do you think the ADHD prevalence goes down in adulthood? Is that due to lack of detection earlier? Or is there a fundamental change that happened during development? So we know that brain development occurs normally up to about the age of 21. And for adults, I didn't show you this data, but there's data out of Castellanos and Shaw that show longitudinal. There's a lag in brain development for adults with ADHD that it occurs up to the age of 26. So it would be natural that there would be some symptom improvement up to that point. So one question I'm often asked is, what can we do to improve the chance of remission? And one of the major things we can do is that we know that symptom loading is one of the factors that will influence the chance of remission. The more symptoms you have, the greater impairment you have, the lower the chance of remission. So the greater the symptom load over the course of time, the lower the chance of remission. Treatment matters. Would you know of any research about changes in symptom profile or even onset in perimenopausal women as it relates to ADHD? Yeah, so that's a burgeoning area of research. We're looking at that, certainly. There's a literature showing exacerbation of symptoms around the time of perimenopause. So that's something to keep in mind. How does caffeine relate to ADHD symptoms? Well, I'm holding my cup of coffee here. So you have to assess caffeine intake when you're evaluating a patient. One of my first patients with ADHD that I evaluated when I first started doing this many moons ago, I asked him, what was he doing to try to make this better? And I always tell my trainees to talk to their patients. It's a novel idea. And he said, you know, I drink Diet Coke. And I said, how much? He said, about two cases a day. And I said, is it doing much for your ADHD symptoms? He said, no, not really. Otherwise, I wouldn't be here today. But I'm in the bathroom a lot. So caffeine can often be somewhat helpful in improving arousal and attention. But if you don't assess it, you won't know how much they're using. Same thing for nicotine. But often, it will exacerbate some of the cardiovascular effects of the medications. So you really have to get them to don't have them stop abruptly, because they'll get a whopping migraine. But you do have to have them winnow back on the caffeine use. Otherwise, tolerability of both stimulants and non-stimulants will be affected. Great. How do you compare between atomoxetine versus viloxazine? Viloxazine. So there are no head-to-head studies. So I can't give you a hard answer on that. You know, they're both effective. It may be that viloxazine, because of its preclinical serotonergic effects, may have some slightly different effects. I will say, and this is an N of 1, my own handling of it, I am seeing a little bit less urinary effects with viloxazine. But, you know, the jury's out on all that. I'll have you guys go now. So when a patient comes in and asks for accommodations, like in school or testing, what do you generally recommend? OK. The ADHD. First thing is, go to the website. OK. You have to know what they're asking for. OK. The biggest mistake you can make is trying to write something when the testing organization is asking for something else. So you need to know, have a couple of things. What are they asking for? Have they gotten accommodations previously? OK. A diagnosis of ADHD is necessary, but not sufficient to get accommodations in and of itself. OK. They're going to have to get testing. And you want to be sure that the testing will be testing that will address any of the issues that are raised by the testing organization. OK. The testing will have to show differential functioning in information processing, attention from their peers. OK. And how that peer group is defined differs based upon the organization. But do you know of any evidence base about particular accommodations, if they are truly helpful, like increased time on tests? Like, are they actually helpful in patients with ADHD or no? That's a controversial area. Time is helpful if you know how to use it. OK. Yes, I think it can be helpful. Thanks. OK. My question is, do you think the over-prescribing of stimulants in the past several years will lead to a problem similar to the over-prescribing of opioids years ago? Your question is, do you think the over-prescribing of stimulants would lead to a crisis similar to the opioid crisis? Yes. No, I don't think it's the same as the opioid crisis. I think it's different in that we're talking about medications that patients with ADHD don't tend to, if you have not been clearly shown, if they truly have ADHD, have not been shown to truly misuse or divert, except under specific circumstances. Also, we don't have pharma companies that are creating issues that were created under the opiate system. There are issues in misuse and diversion and over-prescribing. That's very true. But I think we have to be very careful about them. Diagnostic rates are increasing. We have to be careful about that. We want to be sure that the correct, the people who receive an ADHD diagnosis actually have ADHD. That's got to be, there are no shortcuts there. But you want to get the right diagnosis and the right medicine and the right people. Hi. There's something I heard a fair amount through my training, and I've tried to get myself out of it, but I clearly internalized it very much. So I'm wondering what you would say to this idea that anyone would do better with a stimulant, which then sort of suggests that stimulants is like a cognitive doping or something that professionals are doing. I'm sorry they trained you that way. It's really hard to get it out of your head, you know? Literature actually doesn't support that. There is a general sense of improvement of performance and arousal that occurs with taking a stimulant, but that will diminish over the course of time. And the literature tends not to support that in the long run. Thanks. Excuse me. I just want to mention those of you who may have already looked at the toolkit website. We have the slides. They will be mounted. But these slides are not yet on the toolkit, but they will be, I promise you. We have them. I recognize that not all... What's that? They are up? They are on the app. So the toolkit link is different, but I'm glad they are on the app already. They will also be on the toolkit. Right. Yeah. Thank you. I recognize that not all patients on stimulants develop... up decreased appetite to the magnitude of failure to thrive or malnutrition. But for patients who have comorbid alcohol use disorder who may have it complicated by thiamine deficiency, buropodomania, beriberi, Wernicke's encephalopathy, do we have any message from the guidelines on how to avoid malnutrition in those kinds of patients who are also suffering from ADHD? So I'm happy to stay for as long as you guys want to ask questions, so just to let you know. Well, may I say, we can stay for a few more minutes, but staff does have to deal with this room very soon, so yeah. I think this gets down to treating the most impairing disorder first. They have a Wernicke's encephalopathy and ADHD. I'm more worried about their Wernicke's encephalopathy. If they have an alcohol use disorder and they're actively using, I'm more likely to start with a non-stimulant because of the use disorder, independent of the nutritional questions. release and it's very safe to give it because it's long acting and do you see any concerns in that sense? I think I've said I'm concerned. I don't think it's the same as the opiate crisis though for the reasons I detailed. I've also been doing this for a long time so I don't think it's necessarily a new diagnosis. I just think the patients have been there and we're finally getting our education out. It would be, you know, it's sort of like the wise old men examining the elephant. We can examine different pieces of it. People can see the the tail and think it's a feather duster. Someone can see the hose, the nose, and think it's a, you know, it's a hose. But the patient has adult ADHD. That's real. Not all of them have to get stimulants. I've said that today countless times. Not everybody has to get a stimulant nor should they. And first line, the first thing through the door doesn't have to be a stimulant and that's another difference than the the opioid crisis. As a clinician, your job is to make the most accurate diagnosis that you can. The patients coming in saying that they have ADHD, they may or may not be right. My job as an expert is to help you make that most accurate diagnosis. Whether they should get a stimulant or not, that's something that we're going to have to try to reach together, okay? Not everyone who has ADHD has to get a stimulant. Not everyone who has ADHD has to take a medication, okay? All right, I'm going to take questions down below because they're throwing me off the stage, so. Thank you, though, for coming.

ADHD

adulthood

diagnosis

treatment

Dr. Leonard Adler

evaluation

symptoms

pharmacological options

stimulants

non-stimulants

comorbid disorders

neurofeedback

cognitive-behavioral therapy