Hal Elliott, MD
Associate Professor
Residency Program Director
Department of Psychiatry
East Tennessee State University
Wake Forest University:
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Middle 50% of Students With SAT between 12501390
US NEWS and World Report: #25-30
Davidson College :
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Middle 50% of Students With SAT between 13101440
US News and World Report: #5-11
“A persistent pattern of inattention and/or
hyperactivity-impulsivity that is more frequent
and severe than is typically found in
individuals at a comparable level of
development”
EXECUTIVE FUNCTIONING DISORDER
ADHD: Neurobiologic Basis
Attention Networks
EXECUTIVE CONTROL
ORIENTING (SELECTIVE ATTENTION)
ALERTING
Posner and Raichle. Images of the Mind. Scientific American Books; 1996.
Neural Networks of Attention
 Prefrontal cortex
 Parietal cortex
 Cingulate gyrus
 Limbic structures (amygdala-hippocampus)
 Basal ganglia
 Thalamus
 Brainstem (reticular formation)
 Cerebellum
Seidman LJ et al. Biol Psychiatry. 2005;57:1263-1272.
Anterior Cingulate Cortex Cognitive
Division Fails to Activate in ADHD
Normal Controls
y = +21 mm
ADHD
1 x 10-2
1 x 10-3
y = +21 mm
1 x 10-2
1 x 10-3
Bush G et al. Biol Psychiatry. 1999;45:1542-1552.
Heritability of ADHD
ADHD
Schizophrenia
Panic Disorder
Height
Laarson( 2004)
Rietveld (2003)
Martin (2002)
Kuntsi(2001)
Coolidge (2000)
Thapar (2000)
Willcutt (2000)
Hudziak (2000)
Nadder (1998)
Levy (1997)
Sherman (1997)
Silberg (1996)
Gjone (1996)
Thapar (1995)
Schmitz (1995)
Stevenson (1992)
Edelbrock (1992)
Gillis (1992)
Goodman (1989)
Willerman (1973)
Matheny (1971)
0.0
0.1
0.2
0.3
Mean heritability of ADHD = .75
0.4
0.5
0.6
0.7
0.8
0.9
1
Heritability
Faraone SV et al. Biol Psychiatry. 2005;57:1313-1323.
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Variation in basal ganglia symmetry and in corpus
collosum
PET: Decreased brain glucose metabolism in basal ganglia
of ADHD adults/adolescents (Zametkin et al)
SPECT: Increased striatal availability of a
dopamine transporter ( Krause et al)
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Genetic Studies: Twin and sibling studies most
convincing biologic evidence
Catecholamines and Brain Activity
DLPFC, dorsolateral prefrontal cortex; VLPFC, left ventrolateral prefrontal cortex; BS-ACh, pedunculopontine/laterodorsal tegmental
nuclei; VTA/SN, ventral tegmental area-substantia nigra; NBM, nucleus basalis magnocellularis; LC, locus coeruleus; DA, dopamine; A
acetylcholine; NE, norepinephrine ; NBM, nucleus basalis magnocellularis; VTA, ventral tegmental area; SN, substantia nigra.
Lifetime Course of ADHD Symptoms:
Inattention Domain
Childhood
Difficulty sustaining
attention
 +
Doesn’t listen
No follow-through
Can’t organize
Loses important items
Adulthood
Difficulty sustaining
attention (meetings,
readings, paperwork)
Paralyzing procrastination
Slow, inefficient
Poor time management
Disorganized
Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201; American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC:
American Psychiatric Association; 2000:85-93; Weiss MD, Weiss JR. J Clin Psychiatry. 2004;65:27-37.
Lifetime Course of ADHD Symptoms:
Hyperactivity-Impulsivity Domain
Childhood
Squirming, fidgeting
Can’t stay seated
+ turn
Can’twait
Runs/climbs excessively
Can’t play/work quietly
On the go/driven by motor
Talks excessively
Blurts out answers
Intrudes/interrupts others
Adulthood
Inefficiencies at work
Can’t sit through meetings
Can’t wait in line
Drives too fast
Self-selects very active job
Can’t tolerate frustration
Talks excessively
Interrupts others
Makes inappropriate comments
Adler L, et al. Psychiatr Clin N Am. 2004;27:187-201; American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders, fourth edition, text revision. Washington, DC: American
Psychiatric Association; 2000:85-93; Weiss MD, et al. J Clin Psychiatry. 2004;65:27-37.
Traffic Violations and MVA Among
Young Adults With ADHD
Negative Driving Outcomes From a Driving History Interview
70
P =.003
Subjects Responding Yes
(%)
60
50
ADHD (n = 105)
Control (n = 64)
40
30
P=.007
P=.001
20
P=.001
P=.002
10
0
Drove Before ≥12 Traffic ≥5 Speeding License
≥3 Vehicular
Citations
Licensed
Citations Suspended
Crashes
or Revoked
MVA, motor vehicle accidents.
Barkley RA et al. J Int Neuropsychol Soc. 2002;8:655-672.
“ OFFICER, I AM NOT INEBRIATED…I AM
JUST INEPT.”
Britt Elliott ( 1988)
Individuals With Substance
Use Disorder (%)
P<.001
100
75
80
60
40
20
0
18
Non-ADHD
(n=137)
25
Medicated
ADHD
Unmedicated
ADHD
(n=56)
(n=19)
Biederman J et al. Pediatrics. 1999;104:e20
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Spencer et al: 60% of children with ADHD meet
criteria as adults
Spencer, Biederman, Williams: 663/1700 meet
criteria
Borland and Heckman: 50% of ADHD kids
meet criteria as adults as opposed to 5% of nonADHD siblings
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Distractibility
Organizational problems
Poor task completion
Forgetfulness
Careless errors/ trouble with details
Sequencing problems
Hyper-focusing/ Prioritization Problems
“Deer in the Headlights”
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Authority Issues
Stubbornness
Intolerance of silly rules/ assignments
Relationship problems ( peer and sig. other)
Frequent changes in major/ schools
Poor frustration tolerance
Easily bored
Poor or inconsistent academic performance despite
adequate or even superior intellectual abilities
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Scattered
Anxious/ “Scanning The Horizon”
Irritable
Chronically Late/ Poor Time Sense
Procrastination
Bored Easily/ Restless/ Impatient
Trouble with Math/Directions
Reading Comprehension Problems
Compensatory OC Behavior
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Increase in distress/ anxiety/ disorganization when
responsibility increases/ changes at work, home, or school.
EXAMPLES:
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Birth of child
Promotion
Increase in academic workload
Transitions: First of School Year, Starting College or
Grad School, Moving Rooms, Changing Classes,
Weekday to Weekend, Weekend to Weekday, Awake
to Sleep, Sleep to Awake
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Anxiety Disorders (50%)
Substance Abuse ( 27%-47%)
Antisocial Personality Disorder ( 12%-27%)
Affective Disorders (? %)
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NO COMORBID DX: 40%
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Copeland Symptom Checklist For Adult
ADHD
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Brown Adult ADD Scale( BAADS II)
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Amen Scale
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While ADHD is a clinical diagnosis, consider
psychometric testing if:
Diagnosis is unclear
Accommodations are needed
More details re: exact deficits are needed or if
LD is suspected.
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Childhood Prerequisite
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New Onset: medical work-up indicated
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Consider: endocrine, sleep apnea, drug
interactions, hearing deficit, B12, head injury,
heavy metal, seizure disorder.
MRI/CT, EEG, BP, EKG, baseline labs, etc.
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Why?
Childhood Onset – difficult to get accurate
history, especially in individuals who have IQ
in superior range.
By adulthood comorbidity clouds diagnosis
ADHD is a clinical diagnosis
Schedule II medications/fear of prescribing
Countertransference/Cultural Bias
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Many college students functioning in the
intellectual ly superior range never had to
study before college
Many students had parents to manage all of
their details, scheduling, deadlines, etc
Some students attended exclusive private
schools with very rigid day to day routines.
External organization kept them structured and
limited distractions.
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It isn’t compulsive checking behavior if you
really might forget
Anxiet y will increase catecholamines and can
increase ability to attend
Procrastination creates anxiety when the work
is imminently due….and can increase ability to
attend
Classical conditioning model
But…too many catecholamines cause a shut
down effect.
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“Are you scattered because you are anxious or
are you anxious because you are scattered”
“Are you depressed because you can’t get your
work done or are you not getting your work
done because you are depressed”
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OC sxs as a compensatory mechanism.
Ruminating. Lists. Excessive worry. Worst case
scenarios.
Not usually repetitive over time. Tend to be
day to day worries as opposed to intrusive ego
dystonic obsessions
Thoughts jump from one thought to next as
opposed to focusing on one obsession
Compulsive sxs are less likely to be linked to
obsessive thinking.
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Genetic overlap
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Hyperactivity vs. Mania/Hypomania
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Discreet episodes vs. ongoing symptoms
Of pharmacologic options available for ADHD,
stimulant medications are the:
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Most studied
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Most commonly used
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Most effective
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First-line agents for treatment
Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432; Dulcan M et al, for
the Work Group on Quality Issues of the American Academy of Child and Adolescent
Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S; Greenhill LL et al, for
the Work Group on Quality Issues of the American Academy of Child and Adolescent
Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S-49S.
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DOPAMINE: mediates “verbal fluency, serial
learning, vigilance for executive functioning,
sustaining and focusing attention, prioritizing
behavior, and modulating behavior based on
social cues” (Stahl)
NOREPINEPHRINE: plays role in “sustaining
and focusing attention, as well as in modulating
energy, fatigue, motivation and interest” ( Stahl)
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STIMULANTS: Methylphenidate (Ritalin, Ritalin
LA, Metadate CR, Concerta)
Mixed amphetamine salts ( Adderall, Adderall
XR),
Dextroamphetamine ( Dexedrine, Dextrostat),
Dextroamphetamine long acting ( Vyvanse)
d-methylphenidate ( Focalin)
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Pemoline ( Cylert)…LFT’s
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ANTIDEPRESSANTS/ OTHER
Buproprion ( Wellbutrin)
Venlafaxine ( Effexor)
Duloxetine ( Cymbalta)
Desipramine/ Imipramine
Modafinil ( Provigil)
Clonidine ( catapress)
Atomoxetine (Strattera
SSRI’s for comorbidity….not for core symptoms
Problems with the stimulants
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Schedule II drugs (abuse liability, diversion, medicolegal
concerns)
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30% do not adequately respond or cannot tolerate stimulant
treatment
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Short duration of action (compliance, embarrassment)
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Side effect profile adversely impacting sleep, appetite,
mood, and anxiety
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Concerns about cardiovascular effects, growth suppression,
and tic development
Dulcan M et al, for the Work Group on Quality Issues of the American Academy of Child and
Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S;
Greenhill LL et al, for the Work Group on Quality Issues of the American Academy of
Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2002;41:26S49S; Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996;35:409-432.
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Education
Organizational Help (academic coaching)
Learning Assistance Center @ WFU
Individual and Couples Therapy
CHADD
SNL @ Davidson College
Exercise
Selection of occupation and need for novelty/
difficulty with change
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Leveling the playing field:
Quiet Environment
Extra Time
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UC Berkeley Study:
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Group
Standard Time
LD
13th percentile
Non-LD 82nd percentile
Extra Time
76th percentile
83rd percentile
Accommodations for Resident Physicians with
Attention Deficit Disorder
Academic Psychiatry
Elliott, Arnold, Brenes, Silvia, Rosenquist
August 2007
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Stimulants/ Schedule II drugs
Alteration of sense of self/ blunting of creativity
Non-linear thinkers in the academic environment.
Myth of Laziness. Twice the work for half the
result.
“Left handed learners”
Responsibility
Square Pegs and Round Holes
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“My parents and I have different ideas about
what I should do after graduation. I want to go
to Florence and study Art History. They want
me to move into their pool house and become a
dental hygienist”
Patient J, Senior at WFU
I was a peripheral visionary. I
could see the future, but only way
off to the side.
Steven Wright
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Attentiveness….does not characterize my brothers and me, all
of whom were raised in SC and who have an air of abstraction
and carelessness. None of us have a sense of direction. When
something breaks, we fix it with duct tape…we tend to live in
our own heads than in the actual physical world. We are more
likely to get lost, to forget things, to stare blankly off in the
distance for minutes at a time…at least part of the reason I resist
( taking something like Ritalin) is that I am not convinced the
abstracted end of the mindfulness spectrum is such a bad place
to be. In fact, I kind of like it here.
Sometimes I wonder whether it is an accident that of the three
abstracted Elliott brothers, two have graduate degrees in
philosophy and the other is a psychiatrist.
Carl Elliott, MD, PhD
Better Than Well. American Medicine Meets the American Dream
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“One must still have chaos within oneself to be
able to give birth to a dancing star”
Nietszche
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“ You can dream the American Dream, but you
sleep with the lights on and wake up with a
scream”
Warren Zevon ( Fistful of Rain)
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“ Walk with me out on the wire…”
Bruce Springsteen ( Born To Run)
Evaluation of Adult ADHD
 What to evaluate
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Current symptoms
Impairment
Establishing childhood onset
 How to evaluate
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Role of screening tools
Role of scales (diagnostic and symptom assessment)
Importance of prompts
 Who should evaluate
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Mental health professionals
PCPs
PCP, primary care physician.
Adler L, Cohen J. Psychiatr Clin North Am. 2004;27:187-201;
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision.
Washington, DC: American Psychiatric Association; 2000:8593; Wilens TE, et al. JAMA. 2004;292:619-623.