NorthShore
ADHD Clinic
Creating Clarity
ADHD
Practical Office Solutions
Anthony M. Ocana
MSc, MD, CCFP, ABAM
aocana62@wordpress.com
NorthShore ADHD Clinic
604-913-8183
northshoreadhd.com
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NorthShore ADHD Clinic
Disclosures
Dr. Ocana has received…
 speaker honoraria from… Astra, Janssen, Lilly, Shire, Purdue and Wyeth…
 consulting fees from… Lilly, Lundbeck, Shire and Janssen
 educational grants from… Janssen, Lilly, Shire, Purdue, GSK
 research funding from GSK and Shire
 Some of the treatments mentioned in today’s seminar have not been
approved by the Canadian HPB or American FDA.
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NorthShore ADHD Clinic
Practical Office Solutions
Overview
ADHD…
What does it look like?
What is it?
Is it real?
How do I make the diagnosis?
What are the treatment options/ benefits/ risks?
When should I refer?
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© NorthShoreADHD
ADHD Clinic
Clinic
NorthShore
ADHD…What is it?
Overview
 Genetic differences…
 in dopamine circuits
 made dysfunctional…
 by changes in environment
Hallmark Symptoms
 Can’t focus
 Can’t get things done (on time)
 Can’t sit still
 Impulsive/ Impatient
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Dopamine Circuit
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Symptom
Narrative
Attention
Inattention
Can’t focus
Make mistakes
Can’t stick to task
Can’t listen
Lose
Forget
Executive Function
Disorganization
Can’t organize
Can’t prioritize
Can’t manage time
Motor Control
Hyperactivity
Fidget
Can’t sit still
Busy mind
Talk too much
Impulse Control
Impulsivity
Can’t foresee consequences
Blurts things out
Interrupts
Reward
Boredom
Procrastinate
Start, but lose interest
Can’t wait
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Stimulant Circuits
Attention
Executive Function
Impulse Control
Motivation
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Motor Control
Reward
NorthShore ADHD Clinic
ADHD is A Family Affair
Heritability



genotype is 80% (Twin studies)
phenotype is 40-60% (ADHD Parents will have ADHD child)
Transmission is 25% (ADHD Children will have and ADHD parent)

Increased risk of ODD
Correlates with family history of Addiction
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Murray & Johnston, J Abnorm Psychol, 2006; Sonuga-Barke et al. Am Acad Child Adolesc Psych, 2002
ADHD… Is it real?
Genetics
Defective genes are dopamine associated
D4, D5, DAT, DBH, SNAP-25, 5HTT
Anatomy
Size/ activity reductions in dopamine-rich areas
prefrontal cortex, basal ganglia, cerebellum
Physiology
Degree of dopamine deficit predicts ADHD Symptoms
distractibility, irritability, impulsivity, executive dysfunction
Pharmacology Symptom remission with dopaminergic agents
Stimulants, Wellbutrin, Strattera
Co-morbidity
Hypo-dopaminergic phenotype
associated with other impulse control disorders
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NorthShore ADHD Clinic
ADHD… is it real?
Failed activation
of cingulate gyrus in ADHD
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Bush et al. Biol Psychiatry 1999;45:1542
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Current Standard of Care
Controversial
Do not diagnose
Do not treat
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NorthShore ADHD Clinic
Treatment Gap
… not over-treated
Only 50% with ADHD seek help…
Few MDs comfortable diagnosing
Only 25% receive an accurate diagnosis…
Even fewer MDs are comfortable managing ADHD
Only 10% receive any treatment
Common medications have ++ side effects
Only 5% are properly treated to full remission at 1yr
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Empathy Gap
Lack of empathy for suffering
Under-function is misunderstood
Stigma - moral/ ethical prejudice
(stupid, lazy, incompetent)
Extreme Implications
education/ vocation/ legal/ medical/ justice
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NorthShore ADHD Clinic
Functional Impairment
Repeat a grade
ADHD
< high school
Non-ADHD
Teen pregnancy
STD
Substance abuse
Accident prone
Serious car accident
Arrested
Incarcerated
Fired from job
0%
10%
20%
30%
40%
50%
60%
Subjects (%)
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1. Barkley. Attention-deficit hyperactivity disorder, 1998; 2. Barkley et al. JAACAP 1990; 3. Biederman et al. Arch Gen Psych 1996; 4. Weiss et al.
JAACAP 1985; 5. Satterfield, Schell. JAACAP 1997; 6. Biederman et al. Am J Psych 1995.
NorthShore ADHD Clinic
Attention
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NorthShore ADHD Clinic
Inattention
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NorthShore ADHD Clinic
ADHD Assessment
…in four to five visits (not less)
Narrative
Clinician-administered ASRS
Review of Co-morbidity
Risk Assessment/ Exam
Treatment Options
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NorthShore ADHD Clinic
Narrative Assessment
What symptoms do you have?
Have you had these all your life?
How much of a problem have they caused?
Who else in your family has these traits?
How do they affect your life?
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NorthShore ADHD Clinic
ADHD
Functional Enquiry
How do they affect your life?
Childhood
School
Home
Work
Financial
Career
Interpersonal
Family of origin
Intimate (partner, children)
Social
Health
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NorthShore ADHD Clinic
NorthShore ADHD Clinic
Adult Self Report Scale
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Cognitive / Executive
Hyperactive / Impulsive
1.
2.
3.
4.
5.
6.
7.
8.
9.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Easily Distracted
Can’t stick to task
Careless mistakes
Difficulty listening
Forgets
Loses/ misplaces
Difficulty organizing
Avoid / procrastinate
Fails to finish tasks (on time)
Fidgets
Leaves seat
Busy Mind
Difficulty unwinding/relaxing
Talks excessively
Lack of fore-sight / hindsight
Speak out of turn
Interrupts others
Difficulty waiting
ADHD Diagnosis
… it’s all about impairment
Narrative

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endorses impairment of function
since childhood
more than two domains
ASRS



endorses 6/9 symptoms
either cognitive/ executive or hyperactive/ impulsive
associated with moderate/ severe or extreme impairment
Lifetime

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Impact is severe/ extreme or catastrophic
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ADHD and Co-morbid Disorders
Depression
ADHD
Substance Use
Bipolar Disorder
Impulse Control Disorder
Eating Disorder
Sleep Disorder
Personality Disorder
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Co-Morbidity
Mood Disorder
Anxiety
Depression
Mood and Behavioural Instability
Bipolar
Substance Abuse
Impulse Control Disorder
Impulsive Aggression
Gambling/ Shopping/ Eating/ Sex
Self Injurious Behaviour
Psychosis
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NorthShore ADHD Clinic
ADHD and Co-morbid Disorders
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Prevalence (%)
30
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Biederman. Am J Psychiatry. 1993;150(12):1792. Biederman. Psychiatry Research 1994;53:13 Shekim.
Compr Psychiatry. 1990;31(5):416. Kessler et al. Am J Psychiatry. 2006; 163:716-723
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Physical Exam
Family Hx
 sudden cardiac death
 cardiac defect
 pediatric cardiac surgery
Personal Hx
 cardiac Hx/ sx
 fainting during exercise
Other Hx
 Hx of seizure
 Hx of sleep apnea
 Hx of head injury
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Exam
 Ht/ Wt
 BP/ HR
 Cardio-pulmonary
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What can we do?
Assess
Support/ Validate
Educate
Activity/ Diet / Sleep/ Lifestyle
Coaching/ Counselling
Stress Management
Medicate
Advocate
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NorthShore ADHD Clinic
Mechanism of Action of Medication
Dopamine
Atomoxetine
Blocks re-uptake of
dopamine in PFC
Methylphenidate
blocks re-uptake
of dopamine
Dopamine
Amphetamine
blocks re-uptake…
and stimulates release
of dopamine
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Dopamine
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Stimulant Protocol
Use long-acting stimulants
Biphentin®, Adderall XR®, Concerta® or Vyvanse®
 Start at the lowest dose
 Increase dose every 5-10 days until response
 Review at 3 - 6 - 9 weeks
 Slowly increase dose to complete remission of symptoms
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NorthShore ADHD Clinic
Stimulant
Dose - Response Curve
Mania / Psychosis
Hyperactive
Agitation/ Anxiety
Response
Remission
Valley of the Zombies
Increasing Dosage
Time (weeks) 0-------1-------2 -------3-------4-------5-------6-------8-------9-------10
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NorthShore ADHD Clinic
Effect - Side effect
Symptom
Improvement
Overstimulation, palpitations, loss of appetite
Area of maximal side effects
Fatigue, irritability, insomnia
Time
7 am
30
Noon
7 pm
Midnight
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Stimulant Side Effects
Over-stimulation
Rebound
 Hyper/ talkative
 Loss of appetite
 Dry mouth
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Jaw tension
Agitated
Reward Seeking
Insomnia
Under-stimulation
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Fatigue
Headache
ADHD symptoms return
Hyper-focus
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Stimulant Risk Management
Over-stimulation/ agitation/ mania/ psychosis
 Hx of mood instability, bipolar, active psychosis
 caffeine…cannabis …stimulants…cocaine…



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Stop stimulants/ decrease cannabis
Avoid meds if sleep deprived, sick or ++ stress
Pre-treat with mood stabilizer (refer)
NorthShore ADHD Clinic
Summary
Primary Care MDs
 Index of suspicion
 Take your time…to assess… manage





Validate ADHD
Assess Co-morbidity…
Manage risk
Educate patient and family
Treat to complete remission
 Refer complicated cases
 Rewarding to treat – Large effect size – Dramatic improvement
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NorthShore ADHD Clinic
North Shore
ADHD Clinic
Creating Clarity
northshoreadhd.com
Anthony M. Ocana
MSc, MD, CCFP, ASAM
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604-913-8183 ext 2235
NorthShore ADHD Clinic