Adult ADHD: Impact on Chronic Conditions and Adherence to Medical Recommendations

[Music] welcome to our webinar we are very pleased that you could be with us this afternoon on the topic of adult adhd impact on chronic conditions and adherence to medical recommendations i'm dr mary solanto i'm very pleased to be your host today um i'll share just a bit of background about the genesis of this webinar we on the public policy committee of chan children and adults with adhd we're very impressed by the recent results of a research by dr russell barkley that indicate that adults with adhd are at greater risk for disorders and conditions that affect physical health and that to together take a toll on on expected uh estimated life expectancy so following his lead we wanted to help get the word out to health care providers that identifying and treating adhd is a matter of public health as well as mental health so in this effort we are enormously pleased to have been able to bring together dr barkley today as well as experts in different domains of physical health as each relates to adults with adhd so dr barclay will lead off by presenting the background and implications of his groundbreaking research dr roberto olivario will talk about obesity dr scott collins will talk about smoking and adhd and dr rick molina on drug abuse in adhd and then dr larry culpepper will discuss how primary care practitioners can identify and manage adhd in their adult patients thank you so much mary i really appreciate it and i'm also grateful to chad for inviting me to be a part of this i think very important presentation on the health risks and chronic medical conditions that may be associated with adhd and there are implications for diagnosis and management uh to begin with very quickly this is my disclosure slide for my sources of support for the previous 12 months but i don't want to spend much time on it of course because my time is very short and as mary said i'm with the vcu medical center in the department of psychiatry and the virginia treatment center as well and my presentation is going to be an overview of health outcomes uh with some comments on as mary pointed out the impact of adhd on life expectancy now to begin with to understand why adhd might impact the health outcomes of children and adults with the disorder it helps to understand the nature of the disorder which is that adhd is far more than a disorder of attention much less a problem with hyperactivity or impulsivity it is in fact viewed these days and has been since the 1980s has a disorder of self-regulation and that means therefore that it is associated with a variety of deficits in the neuropsychological executive functions which allow humans to self-regulate their own behavior of which there are at least seven major ones that are recognized by the field of neuropsychology and neuroscience more generally such self-regulation permits the individual to anticipate future hypothetical events that might be associated with current situations and behavior and then to organize their behavior over time in order to maximize their long-term outcome so as fuster said the frontal lobes have a single overarching purpose if we can reduce it to one and that is the cross-temporal organization of behavior to maximize future outcomes over immediate gratification and since adhd clearly interferes with this capacity for anticipating future events and then organizing behavior to maximize the delayed over the immediate event it begins to make sense why adhd would be associated with difficulties in in health as well as impairment if you look at adhd as a disorder of self-regulation then you will see that it is associated with a number of traits that we know predict health outcomes two of these of course are delay of gratification and the second one is the personality trait of conscientiousness which is the ability to contemplate the outcomes of one actions for oneself and others before making the decision to act adhd is highly negatively correlated with that trait and as we know from numerous studies in health psychology conscientiousness is the single best predictor of death by all causes in humans from childhood onward there is no better predictor than that personality trait accounting for upwards of 30 to 40 of the variation in human lifespan and death by all causes so understanding that adhd is negatively associated with the capacity for delay of gratification along with the personality trait of low conscientiousness then we can see that hundreds of times a day people with adhd have to invoke self-regulation in order to make optimal choices that they face in conflict situations between immediate gratification and the delayed outcomes that may be associated with those choices and obviously adhd biases the decision-making of these individuals toward very impulsive choices throughout these daily scenarios and therefore the individual is optimizing momentary consequences over the more important uh delay consequences and if you do that hundreds of times a day with impulsive decision making that is going to have a cumulative impact on the risks that you have for impairment in a variety of major life activities but especially including health and quality of life in addition impulsive choices can on occasion singularly impact the individual's immediate risks for injury and death and we will show that adhd does that as well so it is no surprise that adhd is linked to a variety of adverse outcomes in virtually every major domain of major life activities in which humans engage but specifically we are going to focus on health and health maintenance now for more than 40 years we have known since the work of denny cantwell and james stewart that adhd is associated with a heightened risk for accidental and other injuries across childhood and more recently evidence shows that this continues into adulthood including not only a risk for traumatic brain injuries but risk for accidental injuries of all types including burns lacerations as well as poisonings and so on as a consequence of this we will see that adhd increases markedly the risk of dying by age 10 and if you survive to that age of death by age 45 or so there is also as you know an increased likelihood of criminal behavior as well as reactive aggression toward others as well as bullying and victimization by others as well all of which has implications for the physical health of the individual and their risk for injury we know from large-scale studies in the united kingdom that now have been replicated here in the us that adhd is linked to also an increased risk for intimate partner violence in cohabiting intimate relationships that coupled along with alcohol abuse drug use and even antisocial behavior further heightens the risk but adhd alone is a risk for violence in relationships particularly for reactive aggression and we have known for decades now going back at least 30 years or more that there is a heightened risk for suicide attempts among individuals with adhd we know that depression coupled with adhd heightens the risk for suicidal ideation but it is the impulsivity linked to adhd that you can see here increases the risk for a suicide attempt by four to five times over that scene in typical individuals or even among depressed individuals so again depression for thinking about suicide but it is adhd's impulsivity that increases that risk of a suicide attempt often quite impulsively leading to a much more serious attempt a much greater likelihood of success in the attempt and if it is not successful a greater likelihood of hospitalization as a consequence of the seriousness of the injuries now besides that my work and that of brook molina and earlier other researchers have shown that such as kate fleury for instance that adhd increases risky sexual behavior not only among adolescents but also we have now documented among clinic referred adults as well and that includes not only the risk of earlier start starting sexual activity but a 10 times greater increase in risk for teenage pregnancy and four times greater risk for sexually transmitted disease and then of course because of the lack of use of contraception or at least the reduced likelihood of that along with the greater likelihood of having more sex partners in their lifetime those two alone would increase the likelihood that there would be hpv infection and that of course as you know not only increases the risk for cervical cancer but also for oral and anal cancers as well in mid to late life now going back more than 40 to 50 years we know that adhd has been repeatedly linked to poor physical health that has reports about general health upon reaching adulthood and more recently thanks to the meta-analysis of samuel cortese and others we know that adhd is linked to disrupted sleep inefficient sleep and daytime sleepiness as well and this applies to children and adults with adhd more recently there has been increased interest in showing that adhd in women is associated with a heightened risk for diagnosis of fibromyalgia syndrome and this is seen both in women with fibromyalgia having a high risk of adhd and the inverse as well that's also interesting because we've seen recently in the dimanta study that there is shared genetic liability between adhd and a variety of medical conditions including gout migraine headache and risk for type 2 diabetes among others and as you see here more recently studies have shown that there's a greater risk for gastrointestinal difficulties as well within this population brooke is going to talk about this as well as dr collins later in the program so i won't dwell on it but clearly adhd has been for a long time uh known to be associated with the increased risk of substance abuse a substance dependence and even increased frequency of use starting in adolescence but especially accelerating as we enter adulthood later you're also going to hear evidence presented on the greater risk of adhd for obesity but in addition to obesity it is associated with a variety of impulsive eating patterns eating pathology particularly associated with binge eating uh with a preference for high carbohydrate high sugar containing sort of fast food western style diets this increases the risk for dental infections and dental caries that on top of dental trauma that has been shown to be linked to that increased risk for accidental injury means that there are going to be problems with dental care among these individuals as well and no surprise then if you eat a high sugar diet with high carbs and binge eating you're going to develop not only obesity which we'll hear about later but also downstream a growing risk for type 2 diabetes and as you see here women with adhd by late adolescence have an increased risk for a diagnosis of impulse eating disorders particularly bulimia there is no uh i think doubt then that as we look at this pattern of health-making decisions in these individuals that over time we should expect to see a growing risk for coronary heart disease and the milwaukee study my own study was among the first to show that this was the case that has now been replicated by several other studies show a heightened risk for hypertension uh impaired ratios in hdl to total cholesterol a heightened risk for atherosclerotic plaque in coronary arteries over the next five to ten years using the framingham heart data to predict outcome and so on so we should expect by mid-life to start to see a growing risk for chd problems in this population and then most recently late life we see a growing risk for dementia as well as parkinson's disease and disorders of the basal ganglia and cerebellum more generally what is interesting is that the de montes genome-wide study shows that some of these risks are as a result of shared genetics between adhd and the genetics that contribute to risk for many of these other disorders going further now we have direct evidence over the past decade that adhd doubles to quadruples the risk for early mortality beginning with klein study which is the longest running longitudinal study of adhd children into midlife showing a more than doubling of mortality by age 41 followed later by the study out of syracuse showing that adults with adhd are twice as likely to die within any four year period uh principally as a result of accidental injury but secondarily suicide and then we also have the dallas guard study out of denmark coupled with virtanian study out of sweden uh and then the study by chen in taiwan all large population studies showing that adhd is twice as likely to result in death by age 10 and is more than four and a half times as likely to result in death by midlife again from accidental injury secondary to that would be suicide and most recently in the taiwanese study also a growing risk for death by homicide we also have recently a re-analysis of the swedish data by sun showing again these risks but in a much more detailed fashion interestingly the genome-wide study by de montes also showed that there is shared genetic risk for early mortality even in the parents of adhd children not just in the children as well and we know that of course the parents carry a much higher risk of having the same disorder as their children so it makes sense that they too may suffer from earlier mortality as mary pointed out we looked at all of this evidence and we began to wonder well what about life expectancy if you make it to midlife is adhd going to have some adverse effect on total life expectancy and as a result of my milwaukee longitudinal study and having lots of data on the physical uh outcomes of these children and their health we were able to use some of the algorithms at the university of connecticut their center for life expectancy studies the goldenson research center and we imputed all of our data into their formula and we showed this that if you are diagnosed in childhood regardless of whether you recover from disorder or not you are going to have about a nine year reduction in healthy life uh and about an eight to nine year reduction in total life expectancy as you see in this graph this is healthy life years here this is unhealthy life years which is increasing this is total uh life expectancy and that is just from knowing that you were diagnosed in childhood but if we look at the persistence of the disorder to age 27 we see that those whose disorder persisted have an absolutely 12 and a half year reduction in their healthy life expectancy and overall about an 11 to 12 year reduction in their total life expectancy if their disorder persists even if it doesn't persist there's about a seven year reduction in life expectancy over what we see in the control group followed over the same period of time so why did this happen because when we look at our data set we found that of the 14 variables we were using to predict life expectancy adhd was associated with marked adversity in at least eight or nine of these as you see here and as other presenters will talk about to some extent on those variables as well so we have all of these variables that are reducing the lifespan of these individuals but we went further to look at background factors and we did have a proxy for personality trait of conscientiousness and that was the emotional impulsivity and poor self-regulation scale of my executive function rating scale and what we found is that behavioral inhibition which is a proxy for conscientiousness explained all of these first order risk variables indeed we accounted for nearly 31 of the variation in life expectancy within this data set so what that means then is that clinicians should not only be concentrating on the first order risks but should also be assessing the background factors that have to do with adhd with impulsivity and with poor self-regulation so i hope you've seen in this presentation that besides the disorder of attention we have a serious disorder of self-regulation that produces numerous adverse consequences in major life activities including a adverse effect on health and lifestyle and resulting in a market reduction in life expectancy well beyond that seen with the major risk factors that we are focusing on now in society such as obesity smoking sleep exercise and so on adhd is worse than all of them combined in its reduction of life expectancy and i'll leave it to my other presenters to discuss the implications of these findings for the health care providers who may be listening in thank you mary thank you russ that was really a terrific overview and introduction thank you so much so i'm going to be talking about obesity and when we think of adhd really it's the everyday life things that get affected every adhd affects every life domain and what is more basic than eating um and as dr dr barkley had presented in his talk that we know that people with adhd carry a higher risk of obesity now studies will show even and this starts very young that in studies that look at young individuals in a lab experiment where variables are controlled they look their mood they looked at their liking of food they found that the children between the ages of 10 and 14 who had adhd ate more however what was striking is that it wasn't influenced by their mood state or their level of hunger or even their liking of food it was simply that it was just there other studies have shown that people with adhd have more disruptive eating habits they tended to eat a less nutritious diet and we're very drawn to diets with higher sugar intakes especially in beverages studies in bad bariatric patients have found a high prevalence of people with abd adhd in those samples and this particular study found that almost a third of people who presented for bariatric surgery had adhd but interestingly when the body mass index was looked at even for people over four over a bmi of over 40 it was 43 of that sample had adhd so not only that but even in mean weight loss post surgery they found that those individuals who had adhd lost less weight post surgery than their control subjects what's interesting also is that the patients with adhd also had more treatment visits and needed longer duration uh studies find even with children who presented in clinics for obesity um often will have a high prevalence of adhd this particular is a small sample but studies looking at children who did not need criteria for any other dsm-4 disorder found that 58 of them were found to have adhd which is significantly higher than what we see in the general population of those children with adhd only 40 were diagnosed before the study signifying how under diagnosed actually adhd is it's sort of this myth that it's over diagnosed in fact i find clinically it's more under diagnosed uh similarly fleming found in a sample of severely obese women with a bmi over 35 that almost a third of them had adhd now one might wonder whether being hyperactive being impulsive does that actually protect children from obesity if they're bouncing off the walls and running around uh well actually a study found that the opposite was the case that in fact the bmi scores for this sample of almost 100 adhd male patients was significantly higher than the reference population and again when that bmi was over the 90th percentile we found that adhd was even more common similarly in a study of dutch children found that between boys between 10 and 17 girls who were between 10 and 12 in this sample that having adhd carried with it four times the risk of being overweight now it's not just with eating studies have also shown when following children over the years that not only does adhd significantly predict obesity but it also predicted less physical activity so in this sample when they looked at children between seven and eight and followed them until the age of 16 they found um you know more obesity but also less physical activity and in this particular study found a lack of physical activity having a stronger association with obesity than overeating and so i clinically i would say i see both of those um similarly cortez you found men and women with adhd having a higher body mass index more likely to be obese and this is also after controlling for socioeconomic factors and lifetime mental disorders so adhd alone would be predicting that now why is that when we understand and help our patients understand why having adhd can lead to that it adds to a lot of validation and a lot of much more motivation to start to seek help for these issues and particularly in achieving a more healthy diet there are biological reasons helping people understand that you know an adhd brain is a brain that really is deficient in having certain neural chemicals and neurotransmitters including dopamine which is sort of the neurotransmitter of reward and stimulation and the adhd brain is known as having sort of a reward deficiency syndrome and you know as i tell my patients kale isn't going to produce that reward in the brain unfortunately and so people with adhd are drawn towards more high sugar simple carbs that are going to produce that sort of dopamine hit so to speak in the brain so you have a brain that is by baseline bored and under-stimulated and food and particularly the less nutritious food provides that sort of level of reward in addition a neurochemical known as gaba which is responsible for inhibition the adhd brain is known to have less gaba so now you have an uninhibited bored under-stimulated brain and so it's understandable why food becomes something that becomes very very appealing now clinically with a lot of the patients i work with i specialize not only in adhd patients but i specialize in working with men with eating disorders like bulimia nervosa and binge eating disorder and from my patients will often hear that after some other high dopamine related activity like sex or a real fun event that a lot of times eating and binge eating could be a way of almost keeping that dopamine high going for lack of a better word and so a lot of times with patients they find themselves sort of eating um even after that it doesn't always have to be this sort of negative trigger in addition what we know from dopamine receptors um that they overlap with both obesity and binge eating in research that is done today cognitively people with adhd lack intraceptive awareness which is basically the mindfulness of what's happening inside the body am i hungry am i satisfied am i thirsty all of that requires a tuning in where many people with adhd are out they're sort of more externally oriented and focused so to be a healthy eater you have to have a high degree of intraoceptive awareness executive functioning deficits as dr dr barkley had mentioned i mean to eat healthy you have to have a certain level of executive functioning skills to plan meals to determine to manage time manage to have four different pots going all of that requires a level of executive planning which can be very difficult for people with adhd decision making can be very difficult which can lead a lot of people with adhd to be impulsive about their food decisions um i had a patient many years ago said that he procrastinates which people with adhd are prone to procrastination and a lot of times food can become the behavior to sort of procrastinate with for some people it could be playing video games or watching television but again you have food which is always accessible it's legal and so it becomes the easy go-to for people who are quite impulsive people with adhd are also cognitively overwhelmed by all of the information that a lot of us can be frankly overwhelmed with in terms of what's good to eat what's not or eggs good or eggs bad and sometimes it makes it very difficult for them to sift through that in addition people with adhd will sometimes eat as a way of gaining executive fuel if they feel really fatigued or not motivated that they feel that eating certain food or overeating might actually create that energy which it doesn't really do it doesn't serve that purpose people with adhd are impulsive and we refer to that as the the seafood diet that if they see it they eat it um and simply because it's there and can become very poor it's self-regulation when i have patients monitor how many calories they're eating they vastly underestimate the amount of calories that that they eat because again you have to have a certain level of mindfulness and presence to even be able to know what am i eating how much am i eating how often am i eating people with adhd as dr barkley mentioned um very prone to sleep problems sleep disorders like sleep apnea and not sleeping just because they're overweight um they're pro to sleep apnea even independent of their weight and if you have sleep apnea that could then predispose you to becoming obese and dysregulate your appetite your metabolism people with adhd can get hyper focused and sometimes work through or be into something to the degree where they might skip meals but then once they're done with that activity they're super hungry and ravenous and again are often going to be drawn towards high carb high fat high sugar foods um so they hit this sort of wall of hunger um the eating habits of people with adhd tends to be quite dysregulated they tend to be doing something else i've had patients they eat their breakfast while driving to work which is obviously not safe they are watching television while eating they are here there and everywhere and not sometimes i have i have to work with patients that just sitting down at a dinner table versus standing up and moving around while eating this and that which leads to less mindfulness in terms of what they're eating we've all heard of eating a pint of ben and jerry's when we have a stressful day but for people with adhd certainly emotional triggers like the stress that comes with poor executive function sadness anger poor self-esteem the the emotion or a lack of emotion i guess i hear most from my patients with adhd and who have issues with overeating is boredom that they they are looking for something to stimulate them um one of my patients said it's either gonna be a cigarette i'm gonna smoke i'm gonna bite my nails or i'm gonna eat um it could be a way of coping with un with underlying depression and anxiety of which twenty percent of people with adhd have depression struggle have a depressive episode 30 will have some anxiety at some point in their life food is very rewarding it's very sensory and for people particularly with those hyperactive thoughts that food can be a way of kind of grounding them because it's very sensory driven now in terms of healthy weight loss it can be very difficult because people with adhd are drawn towards instant gratification outcome driven they can be quite impulsive and very impatient um with healthy weight loss which for a male could be up to two pounds a week and for a female one to one and a half pounds a week that's very hard for people with adhd to hear so for any and all of us who are working with patients it's so important especially for physicians who see these patients to encourage them to seek adhd treatment if they have adhd and are struggling with their weight not treating the adhd is undermining treatment of absolutely everything else that they're working on and then in addition see encouraging them to seek support and therapy and the work that i do with patients is mindfulness strategies around eating around shopping around preparing food in terms of being more mindful of the body and those internal cues cognitive behavioral therapy psychotherapy nutritional support can be really helpful as an accountability executive functioning training and really needing a lot of support around that structure and that accountability around healthy weight loss also in terms of parents you know one of the things coming from the eating disorder community it's often seen as very taboo to sort of manage your child's eating and you don't want to be too on top of your your kid because you don't want to inspire an eating disorder and then however i have to say it's very important there's a fine line between um you know sort of being over um compensating for sort of issues that maybe a parent has around body image and so forth but kids with adhd do need a lot of work and support and accountability around their eating um and so it is very important to structure meals sometimes in terms of what you bring you know in the house talking to your children about healthy eating and starting to model that um and is any of us who are in the mental health or the medical profession it's so important in relaying this information with a sense of compassionate validation to understand that these patients really are doing the best they can do with the information they have once they understand adhd because again keep in mind most people are under diagnosed especially if you're over the age of 30 where you know when many many years ago what we knew about adhd is a fraction of what we know now in terms of identification is letting them know a little information goes a long way and once they get that treatment and understand that although they're wired in ways to be more impulsive and to be more sensory seeking um that you know that doesn't mean that they lack willpower or that they can't work on this it just takes you know looking at it through that adhd lens to help them understand the strategies and the treatment that they need in order to help with that because there's a lot of shame wrapped up for a lot of people who are in larger bodies as we've known a lot of discrimination and it's very important that we sort of take that shame away and not have people internalize the sense that they're powerless or weak that once they have the understanding of adhd and its influence on their eating habits that they can that you can see really dramatic effects and medication can be very helpful for that in fact the first fda approved medication for binge eating disorder is vyvanse which is an adhd medication which was not surprising so studies show that when adhd is treated psychopharmacologically that it can help tremendously in executive function across the board especially when it comes to eating but there are obstacles that physicians and clinicians come about in terms of helping patients remembering to take refill follow up patients with adhd are less likely to get a physical exam they often come to the doctor when things are really bad they can be late for appointments they might be less likely to comply with post-surgery recommendations so having that accountability and helping patients seek that support will be really important thank you very much i'm going to talk about adhd and smoking today and cover both some some broad overview as well as a lot of work from my lab over the last 10 or 15 years um so these are my disclosures none of these are really uh relevant for the topic that i'm going to talk about today um so uh three areas that i want to cover today first of all i want to talk about just in general what is the relationship between adhd and cigarette smoking what do we know the second thing is to talk about the kind of the why and why is it that people with adhd smoke more have more difficulty quitting etc and we're going to look at this from a number of different angles and then finally i want to think about clinical considerations uh to take into account when we're taught when we're working with patients that smoke um so this is a this is a really complex relationship this is a a model that we put together a while back now but it shows all of the different ways where features of adhd whether it's the genetic underpinnings the neuropharmacological basis of adhd some of the behavioral things how they can intersect in different ways with different parts of the of the sort of smoking phenomenon from being at risk for initial use all the way up to being at risk for relapsing once you become a smoker and quit so we developed this model so that we could really hone in on individual parts of it to start breaking down this relationship empirically but to begin with let's think about just in general what we know so we've known for a long time like other substances that cigarette smoking and nicotine use are are more prevalent in individuals with adhd so these are data from a couple of different studies showing that in both adults and adolescent samples that the rates of cigarette smoking are significantly higher in adhd versus non-adhd folks nearly double in than the general population and then also that this risk is independent of conduct disorder which is really important because for a long time people thought oh it's just because adhd folks have have conduct disorder and that's what's really driving the relationship that's not the case so my my first foray into looking at the relationship between adhd and smoking was to look at the the association not of a clinical diagnosis but of the symptoms of adhd and how those were related to regular smoking and this was a paper we published back in in o5 looking at in a population-based sample of about 15 000 people young adults what we found was a very orderly relationship as you can see from the figure between self-reported symptoms of adhd uh and risk for uh being an ever regular smoker so this this told us that this risk that we see in clinical populations is most likely driven by the fact that by definition people with adhd have high levels of adhd symptoms and we we and others have gone on to show that these symptoms as well as an adhd clinical diagnosis are associated with other features of that model that i talked about so people with adhd are more likely to start cigarette smoking earlier they progress faster from initial use to regular use they have higher levels of smoking and nicotine dependence even among regular smokers and finally they it's harder for them to quit so there's a greater likelihood of failed quit attempts and poorer cessation outcomes so to highlight a couple of these i want to call attention to some work that's come out of the mta study you may hear a little bit more about this from dr molina later on because this has been a seminal study to understand a range of phenomena in adhd populations but this is a longitudinal study it started as a comparative treatment study when kids were between the ages of seven and nine and then they've been followed now and for the data i'll show you this is 16 years later about two years after the kids were enrolled in the treatment study a sample local normative control group was was recruited uh from the from the individuals who were in the study from their local schools so that it would be matched for at least geographic area and for the most part age and gender so this is a good good way that we can look at smoking behavior over time um and at the 16-year follow-up and this was a paper that was published by my colleague uh duke john mitchell um what we saw was that uh what i what i already mentioned was true in this this well characterized longitudinal sample smokers in the mta group compared to their local comparison peers were significantly more likely to be daily smokers in the past year as well as to have more than uh one foot attempt trying to quit more this shows the smoking onset so you can see the blue bar starts to creep up meaning the cumulative percent or the cumulative risk of being a smoker was greater for the adhd kids earlier and then really importantly on the right here this replicates this phenomenon that i showed you in that big population based study even within a sample of kids that that met a clinical threshold so even among individuals with adhd symptom severity seems to be related to the probability of daily smoking so this just highlights again sort of the the the detailed relationship between adhd and um and smoking so i want to shift attention now and talk a little bit about some of the the the why the mechanisms that underlie a lot of these different features of individuals with adhd and cigarette smoking i want to start with trying to ask the question of why is it that smokers have a harder time quitting than than people who are not adhd well we know that affect and cognition are significantly affected when people try to quit and um they also predict longer term cessation outcomes we know that affect regulation and cognition are also disrupted in adhd in general so these two things combined suggest that maybe this is some sort of perfect storm where we're exacerbating features that are already disrupted in adhd and that that leads to a harder time quitting so we set about to try to understand this phenomenon experimentally and we did this study this is kind of the general design and i'll show you a couple studies with this general design where we bring in adhd and non-adhd smokers we characterize them at baseline and then we bring them in for a couple of different sessions one where they've been uh abstinent overnight and one where they're smoking as usual and we want to look to see sort of how they respond to various laboratory tasks and try to measure their their response to these manipulations so in this particular study we had roughly equal numbers of uh smokers with and without adhd that were pretty well matched across a number of features including their their nicotine severity or their smoking um uh uh yeah their their severity of um uh addiction and what we found here was that uh consistent with our hypothesis we saw these significant interactions such that the adhd group in general so there's a main effect that for things like cpt commission errors which is a measure of impulsivity response style which is a measure of attention allocation they were different but they were significantly more different when they were abstinent so these um and there weren't uh yeah given that there were any baseline group differences this suggests that what we thought which was that these particular processes being disrupted might be playing a role in people um having a harder time quitting so we followed this up actually john again did this a very similar study very similar design but instead of looking at cognitive performance he was looking at emotion regulation and similarly found a very very similar finding here in that the adhd smokers had lower well in this particular case lower values on this which is how long they would persist on a hard difficult task um it was lower overall for the adhd folks and when they were abstinent it was even more that that effect and that difference was even more pronounced so cognition and affect seem to be definitely more disrupted during smoking abstinence in adhd smokers versus non-adhd smokers so another question that we've tried to tackle here is to address this this idea that individuals with adhd are smoking to reduce the requisite symptoms the so-called self-medication hypothesis and the idea here is that you know nicotine we know neuropharmacologically works in many ways similarly to some of the medications that we that we have for adhd so could it be that people are smoking in order to reduce their symptoms and impairments associated with the disorder there's a lot of different ways that we could address this but um for this particular study we did again a pretty similar uh design that i showed you before we wanted to compare smokers um with and without adhd and we wanted to look to see would they work for cigarette puffs when they were abstinent or when they were satiated um and and we wanted to actually measure reinforcement of smoking under those conditions again the the groups were well matched across most of the features except for their their adhd symptoms as we'd expect and what we found was was again this main effect that in general uh adhd smokers and we literally had them in a room where they were working for controlled puffs on a device that we had put together and they had to press a button and every every time they got a puff they had to press more to get the next puff and then more to get the next puff and this is a it's kind of a traditional operant way of measuring drug reinforcement and we showed that this uh this people with adhd work more for cigarette puffs and that difference tends to be more pronounced when they're abstinent compared to when they're satiated now all of the work that i just showed you as well as a number of our other studies have been working in individuals who are already cigarette smokers and we wanted to tackle this really really tricky question of what is it at the very beginning of this process what is it that leads to that risk for when people take a puff of a cigarette for the first time now we obviously can't go and experimentally manipulate um cigarette smoking but we teamed up with a colleague at the university of pittsburgh uh named ken perkins who had developed a paradigm to study this initial reactions to smoking and what what he had done was to use nicotine nasal spray so we designed a study to take that uh approach we got young adults young adult non-smokers um with and without adhd so they we verified they'd never been a smoker we brought them into the lab on three different occasions and we gave them three different doses of nicotine nasal slay blinded so they either got placebo they got a low dose so they got a high dose then they also came in and they actually worked or they made choices for different doses and what we found uh this is again showing that the the groups were um pretty comparable um what we found and it's not as clear here but this is the from the publication is that there were significant differences across the groups uh in that the adhd individuals reported significantly higher pleasant reactions uh and more dizziness and there was actually an interaction for this dizziness initial reaction which tends to be the most robust predictor of subsequent um uh addiction and there were no differences between the groups in terms of their unpleasant reactions moreover what we saw was that there was a main effect in that the individuals with adhd tended to choose nicotine more often than the um than placebo compared to the non-adhd group so what this what the show does is that even when they're exposed even without a history of consistent nicotine use that first exposure there's probably something qualitatively different about getting that first exposure to a cigarette in individuals with adhd who and those who don't have adhd which i think has profound implications for how we think about educating our younger patients and talking to them about the risks of of smoking so lastly um i want to shift gears a little bit to talk about some clinical considerations and in particular one um one thing that i want to target is that there's been some um controversy in the literature that uh that uh stimulant medication in particular may be a risk factor for increasing the rates of substance use including cigarette smoking um there have been there been a few studies published that got a lot of attention and and uh skeptics of the use of stimulant medication really picked up on these to say these are data that show uh that stimulants are actually increasing uh cigarette smoking um and there are a lot of methodological limitations of these and so we we've done a number of studies to try to kind of understand this a little bit better one of the studies that we did is is on the left here is very comparable to a similar study done on the right the difference being that the the medication in these two studies was vyvance versus concerta basically this was these were clinical trials of adult smokers with adhd and the goal was to see whether or not medication could facilitate a smoking cessation attempt so what you what you see is two different groups in each of these figures and uh on the top panels for both the figures what you're looking at is the um the self-reported number of cigarettes per day um up to a particular uh a scheduled quit date which is you know somewhere between baseline and visit one on the left and then there's the actual dotted line on the right but what you see here is that there is no difference between drug and placebo on self-reported cigarettes per day and people who wanted to try to quit smoking um moreover if you look at the bottom panels what you see is that the medication when you look at adhd rating scale scores it worked so it actually reduced symptoms of adhd didn't have any adverse effects on on making it more difficult for people to try to quit smoking um so this is just my my last data slide here showing a meta-analysis that we did showing that um uh basically looking across studies that medication did not have any effects at all on the rates of smoking and in fact it was protective uh and this this effect tended to be more pronounced uh with uh in females when medication use was consistent over time and when uh when there were clinical samples examined so i will i will just wrap it up there and just say that we need to be aware and cognizant of this risk for smoking uh among those who are already smoking we should really think about taking multimodal approaches to promote cessation and obviously as always we need lots of extra work thanks i'd like to start with some key statistics with respect to substance use in this population and some motivating motivating factors first you should know that people who are in treatment for substance use problems often have adhd so across studies we see about a quarter to a third when it is assessed it's often found we also have seen this recently validated patients seeking treatment for cannabis use disorders which has become increasingly relevant as we all know for lots of political and societal reasons we know that adhd makes it harder to succeed in treatment and you've seen plenty of reasons throughout the presentations that we've heard today it's not going to be hard for you to appreciate why that's been the case so what's the prevalence of substance use among people with adults with adhd we know that they are at increased risk of alcohol not surprisingly scott scott talked about the cigarettes we have a huge range of nicotine delivery systems that have been coming about that are now also starting to find their way into all of our research protocols i'm sure as the research unfolds you're going to hear more about that and we know they're at risk for also other substance use disorders we've had a number of reviews that have been done to look at the magnitude of the risk alcohol has been an interesting outcome because across the studies there's quite a fair amount of variability on average we see about a a two-fold increased risk for developing health problems with heavy drinking or alcohol use disorder and here's a slide that helps you understand from our research in pittsburgh with the pittsburgh adhd longitudinal study why some of this variability across studies may have been the case we uh analyzed the data from our our pittsburgh adhd longitudinal study the pals and we looked at a number of different variables that we thought might coalesce with alcohol use and in this case we looked at heavy drinking we looked at problems from heavy drinking so the negative consequences that occur we looked at persistence of adhd in these cases and we also looked at depression and what was very interesting in this study and we recently published is that we had a number of different groups that emerged most importantly look at the green line on the top those are people who had the highest levels of alcohol problems throughout their 20s on the x-axis you can see aged 21 to 29 88 the individuals who had adhd histories were more likely to be in that group not too surprising there was a group in the middle the purple line that did have elevated alcohol problems but they also had more depression individuals with adhd were more likely to be in that group also notice though the depression did not fall in the green bar group so it doesn't always it's not always the case that depression is tracking with alcohol problems finally look at the blue line on the bottom this is what creates the trickiness across the studies when you see sometimes publications showing there's no risk for alcohol in that group they had none of the problems now it doesn't mean they weren't impaired on other measures in our study we have lots and lots of measures and just think about russ barclay's presentation on how many ways people with adhd can have difficulties we're only looking at a few things here in this case no alcohol problems at all if you average that all together you end up maybe saying ah adhd not associated with alcohol problems it's the heterogeneity that's really critical to pay attention to other substance use disorders about a one and a half times increased risk the new york longitudinal study that russ referred to being the longest running study out there at a mean age of 41 they found 14 had a substance use disorder versus 5 percent who didn't have adhd had a substance use disorder and the persistence of adhd mattered again that tends to vary across studies don't think that it's only people who have persisting adhd who are at risk of substance use disorder it's not it does track with it but not a hundred percent of the time scott mentioned the mta study by age 25 we had increased risk for cannabis use disorder and increased use for weekly cannabis use this is critical as a health care provider to pay attention to people may not tell you or admit to or be comfortable with saying that they're having problems from their use but don't forget to assess degree of use because that in and of itself can be something to pay attention to clinically marijuana's become very interesting in the mta study scott mentioned john mitchell who's done some nice studies he with with the mta and other data sets one study that he accomplished with the mta data was to look at reasons that people shared with us in open-ended interviews about why they use cannabis and some of them shared the perception that it's therapeutic for them so we're trying we really don't have a great sense of exactly what this means because for example we know that marijuana has adverse effects on working memory so we also know that people with adhd on average have difficulties with their working memory should cannabis be something that is going to help in that domain absolutely not so there um there are a number of reasons to be concerned about cannabis use in this population and we have a lot of research that we need to do in order to understand that so i'll tell you a little bit about why adhd might contribute to risk for addiction i actually feel like the people everyone who presented before me gave you plenty of reasons to understand for example obesity that is is often studied as a form of an addiction smoking you certainly heard about that i'm going to show you some slides that are kind of similar and pick up on similar factors what i want to point out here is notice the delinquency in the big orange bar on the bottom people investigators used to say oh it's just all the kids with the behavior problems those are the only ones we need to pay attention to and would control for that in the adhd prediction would fall out well we now understand that delinquency yes it does track with substance use almost always except for nicotine in adolescence but it doesn't mean that we should be ignoring all of the other potential factors that might be driving this association and that would be an unfortunate consequence so on the next slide you'll see don't be scared you know you can look at it later if you want to we have two slides like this that basically similar to scott's model my colleague bill pelham and i spent a fair amount of time kind of thinking about what are all the reasons that might explain increase increased risk on the left side in the blue circles you see the the the diagram that basically talks about the the deficits associated with adhd that drive adhd impairments on the far right you see the red upside down triangle that indicates substance use everything else are factors that help us understand why those two things are connected such as academic difficulties social difficulties conduct problems all the impairments at the very top you see treatments at the very bottom you see parenting those are factors that we really do believe moderate the uh the flow of these pathways this is a similar slide we just didn't have room to put it all in one and we emphasize in this one negative affect beliefs and coping pathways we do believe that stress and coping pathways are active the point exact point at which those become active is not 100 percent clear we were recently funded to follow the pals sample into mid-adulthood and we'll be looking at these kinds of pathways to see if they really become activated especially in later age the bottom circle there says differential response to alcohol and other substances scott very nicely highlighted this we do believe there is the potential that this population for lots of genetic and neurobiological reasons has a differential response to substances that may increase their vulnerability that's important important to know so beliefs about alcohol's effects this is a variable that is frequently studied in the substance use literature um and it started with alcohol and the idea here is that people's beliefs their cognitions about the way that a substance affects people will drive to some extent their use and there's lots of data to show that that is indeed the case even very young children way too young to you would think even know what alcohol is begin to form an understanding of what alcohol is based on what they see in the home and we know that these things change with age and with experience and they do drive substance use we often believe that targeting these understandings should affect one's substance use what we've found however that in people with adhd that just trying to affect their understanding doesn't necessarily isn't necessarily likely to help because people with adhd they know what alcohol does both the good things and the bad things but the connections between their beliefs and their behavior is disconnect it's just not well connected so what that does is it challenges the idea that education alone is a sufficient intervention therefore multimodal approaches approaches are most likely to be necessary so how do we treat think now about everything you heard from all the presenters up to me because it all applies there are two papers that are super helpful for you to know about i've cited them on this slide as well on the next as well as on the next slide and i highly recommend that you get them they're extremely well written with great clinical applications they'll give you very specific points for knowing what to do so this first paper i talk about it even though this is a webinar in adults this first paper included some reviews of some studies with adults and the fact that um recommendations for adolescents is is not too dissimilar from what we think about for adults as well with the exception of involving families in this this review was a done by an international panel of 55 experts and they considered the limited evidence base that exists unfortunately on the treatment of adolescents and even adults with substance use disorder and adhd they also brought to bear their clinical experience and basically looked at a long list of recommendations and voted on them and what they came up from this is recommendations that routine screening in both types of patients is recommended therefore consider substance use in your patient's adhd consider adhd in your patients with substance use i'd like to also let let the professionals know that on the nida webpage that they have a quick screen if you just google knight a quick screen there's a nice screener in there for looking at substance use in patients careful consideration of history is critical so for example i talked about marijuana use affecting working memory adhd also hampers working memory well when did that difficulty with working memory and the associated cognitive problems begin careful assessment of the ordering of symptom onset over time is really critical recommendation in there was made for long-acting stimulants for adhd embedded within psychotherapy so this is particularly relevant for the adolescents we know across the studies that treating adhd alone does not reduce substance use disorder so the recommendation was from this panel to couch pharmacotherapy particularly long-acting stimulants within the modalities of treatment that you see i have listed there there was interestingly lack of consensus on an abstinence requirement before treating they just could not bring themselves to that point so this is something that you will need to consider if you're professional treating this comorbidity in your individual patients this other paper carpenter and live-in um is one that was uh conducted to review uh treatment of the literature on adults specifically interestingly they also tapped into the adolescent literature it's unfortunately just because it's so slim and in that review they pointed to the fact that the data on medication effects in adults with adhd and substance use disorder they're just less strong than for adults with adhd alone so the implication there is to realize that when treating adhd in the context of substance use disorder medication treatment can be helpful but the the effects may not be as strong and there are other factors that are going to have to be considered such as if abstinence is desired in the treatment in order to move forward it may be difficult and other resources and therapeutic modalities may be may need to be brought to bear to assist with that if that is the desire um motivation to uh to accomplish that and come regularly to treatment can be challenged challenging assessments of patients can be difficult as i mentioned we often have many other comorbidities that are involved and someone with the expertise to be able to conduct that thorough history may be needed before moving forward with treatment and i mentioned the other comorbidities the conclusions from this paper were that long-acting medications are recommended and then some research recently recent research did show and fran levine was involved with this that sometimes higher doses with really close monitoring actually contribute to a better outcome [Music] and also across studies that have that have been done the good news is substance use has not worsened as a function of using a psychostimulant treatment in this population and that is often a major concern and again multi-modality treatment so motivational enhancement and cognitive behavior therapy have been indicated definitely for substance use both both of those conditions and adhd so i'll be ending on this last slide which is a little bit of a a step to the side of the issue that i've been talking about so many people are concerned about misuse of stimulant medications and we all know that that that has proliferated out in the particularly in college populations and to some extent down into the adolescent age range although not quite as much in pittsburgh we started to think about this issue about seven or eight years ago and started developing some strategies for addressing it we developed a workshop for primary care providers who were treating college students with adhd it's a really brief one-hour workshop where we developed clinical management strategies for the docs and their and their practice staff to use with their patients and in that initial open study we did find reduction in risk which was which was promising and helpful to see and we've now just completed a randomized clinical trial with pediatricians and their teenage patients if you're interested in reading more about that you can see the citations there the journal of adolescent health paper actually lists the strategies in that paper and so that might be helpful for you to see if you're interested in preventing stimulant misuse and diversion i'm going to take a slightly different tact i'm not going to give you a lot of content about adhd itself but what i am going to go through is how do you set your practice up to be able to manage adhd across the lifespan do a really good job of it and not have it really bog down your practice this slide set is really meant uh as a resource so i would encourage you to to download it and use it uh with your colleagues in your practice as you prepare uh and set up your practice to really do a good job with adhd patients so i do have some disclosures none of them are directly relevant to adhd but there they are you know what i want to do is really go through the key roles that we have as a primary care clinicians uh and then particularly uh how we prepare our practice so preparing the practice is really the starting point and obviously we need to have uh recognizing patients really across the lifespan with adhd and i'll talk about that in a minute we need to be able to educate patients and families so we need resources for that because that needs to go on for a long time as they really become expert in their uh particular condition we need to assess patients goals comorbidities impairments because we really again if we aren't in sync with our patients they're not going to adhere long term and the goal with adhd is really lifelong care of this problem as primary care providers we are really the integration of adhd care with care of all the other problems the patient may have and also with preventive care so it doesn't get lost because that itself can be a major uh problem for patients obviously our practices by themselves are not going to be the only source of care for our patients and we need to know how to mobilize family community and web and regional resources for our patients as well and finally fostering long-term adherence and retention and care is critical for patients to have satisfying lives so how do we prepare the practice uh i'm going to go through these uh each with a separate slide but just as an overview we need to clarify the role that we are going to take as a practice do we see our scope of adhd care in primary care being identifying patients and referring them on to a good resource in our community are we actually going to provide them so think about they come to our website they get an appointment they come in for visits uh we see them things happen before and after we see them they go home do we have a reminder system do we help them get prescriptions and so another critical role that we have in primary care is with our community so what's going to be our relationships and agreements with the area schools this is critical to get worked out at the practice level rather than for each patient individually and i've already mentioned the community regional national resources finally and this is critical to the long-term maintenance of of these patients in care is having a patient registry this may be something built already into the emr that you're using but how do we maintain a registry of patients in our practice with adhd and then what's our strategy is going to be to use it to make sure that our patients stay in active care so i mentioned guideline uh i particularly like the canadian guideline because canada is on our family medicine sort of basic primary care assessments so they just naturally think across the lifespan so here uh just as an example of the resources uh available uh already packaged in their guidelines so it's it's both web and and uh downloadable uh format uh i find this a very helpful approach so here's just an example of what's in the canadian guideline and it really steps you through what you need to do the steps you need to do this the approach you need to think through and i find this very helpful in working with staff so they know how to respond efficiently to adhd patients as they're coming in as they're presenting as we're making the diagnosis uh or so patients living with adhd come back over oh you know over the long term for crises for medication adjustments and so forth now we need to recognize adhd there's not a recommendation to screen every patient in primary care settings for adhd so we don't do this universally but there's also right realization that if a patient has any risk factors for adhd then we ought to take a case finding approach and have a practice approach to efficiently recognizing those patients early and moving them into effective care so here are a list of the high risk you know flags if you would be the red flags if a patient comes in demonstrating these over time i or somebody in my practice needs to think about is this patient possibly have adhd and if so uh the for adults the uh adult uh self-report scale uh is very useful and while it looks like a long scale it's in fact just those first six questions that are used for our screening and that's as effective from a from a case finding perspective as using the entire instrument going on to part b does give you a lot of extra information for them working with the patient but part a is all you need just those six questions as a screening base to give you a really good tool for recognizing adhd in the practice now there's another group of uh uh you know patients that we need to look uh carefully at and that's really the first line that adhd in the family because we know that if this one patient in the family with adhd there's quite likely going to be additional it's estimated overall at 76 percent uh but we know a lot about this we know the genes that uh convey risk we know the neurotransmitters that they produce that convey the risk we know how they affect the development of the brain and the white uh long neuron pathways uh that affect communication in the brain we know how they affect brain networks which is really how the brain functions with us so we now understand a lot about how uh you know how adhd is passed down in families but we have to recognize them and we have to recognize that family risk to identify extra patients so if i've got a child with adhd i may well have an adult with adhd that's not recognized yet and vice versa so do think about it as a key screening approach now i talked about implementing the supports in your practice uh is think about it you know do a flowchart of how your patients typically move through the practice and then think about what can be more efficient for myself as a clinician for my team yeah and for the patient so think about what do you want up in your portal uh what uh what educational resources if a patient or family thinks gee i wonder if johnny has adhd is there an educational resource they can go to on on your practice portal that'll help identify screening tools some patients uh uh will use the screening tool uh self-motivated you know think about uh you know sort of these as the tools to set up but also think about how do you get your practice staff together as a team and clearly you have to understand the individual roles that people are going to play and that they expect of each other to play so who's the care manager is each clinician the care manager for their own patients or is there a nurse in the practice or social worker in the practice that takes on uh the role of care manager and what does that mean does it mean that they track does it mean they get in touch periodically does it mean they surveil and make sure they're staying on medications and so forth who administers a tool yeah and if we're dealing with schools who who prompts the school to send in a vanderbilt filter another uh instrument think about uh prescription refills who's going to routinely manage those schedule 2 refills as they as they come in from chronic adhering patients so think about all these points in terms of how does your practice work effectively as a team to manage adhd across the practice across the life span in a way that's satisfying for themselves because they know what they're doing and they know they're doing a good job for their patients and families because they're getting high quality service uh and for you as the uh you know as a key clinician we need to think about our patients because long term if the patient isn't a key team member in managing their own condition they're not going to stay in chronic care really of almost any condition so we know in primary care that shared decision making using motivational interviewing techniques uh and so forth can be very helpful identify what the patient's goals are what are their key goals in life uh in terms of things they want to accomplish uh uh as individuals as well as what is their goal in terms of adhd care so it's your mind that and you can use that in shared decision making and motivational interviewing as you give them the best tools to get uh where they want to go in life schools are critical and this can also be college so for adults this may be college or maybe uh retraining programs uh but who is the key contact in your practice for the school who who knows the key resource in the four elementary schools two high schools and the community colleges in your neighborhood that your patients are going to uh and do you have a key contact so that uh anyone in that school can call up and not have to figure out who do i need to talk to about this person uh who's in our school but we're worried about so think about that and think about the communication with them again this makes uh the job of high quality care very effective also think about what is going to be our role uh overall as a team with school are we going to provide information for iep development are we going to actually go and attend or is our community social worker gonna attend uh iep meetings uh think through all of that and communicate work it out with the school talked about uh resources here are obviously a number of them that you're gonna want you're to want a specialist in learning disorders when you have a patient with that you're also going to want uh you know people in other professionals substance abuse we've already talked about and so forth uh that can be the go-to people that you know they understand adhd and will work with you with patients that have uh that are living with adhd as well so think about who are these key resources and does my team know them so they can use them as well registry i've already talked about you just need to have somebody responsible you need to work it out so you can surveil your adhd practice population and make sure they stay in care and are also keeping up with other preventive maintenance activities and so forth need to integrate this with other care so not uncommonly for our patients to have uh in adult years uh other conditions hypertension cardiovascular disease and so forth you do want to think about how do we organize it so that it works for them and they can be effective in staying on treatment for all of the things that we want them you know taking care of not just the adhd use long-acting preparations use long-acting uh contraceptive for instance uh very healthy and also think through families where you've got multiple members how do they work well to support each other with their adhd so these are all tasks to think through as you set up your practice we need to also have strategies for as patients you know age up through various life transitions uh in terms of taking on new responsibilities when do they shift in terms of who's taking primary responsibility for medication for refills and and so forth and your team has to have a strategy this often can be you know your team can be very helpful in terms of counseling patients as they hit these uh milestones in life and move through them both as individuals and just families now i'm going to bookend uh our overall talk uh we started with discussion about that included you know that adhd has a lot of risk for patients but there's a hopeful message there as well so this is looking at psychiatric comorbidities and it's part of the reason we want to integrate the care so that we are effectively managing all the patients comorbidities as well as the adhd but look at the next two slides these are from sweden and they use national data that's at the individual level so treated women uh and these these are looking at the same women are the same men when they're on treatment and when their treatment lapses and so you can see here across the board that patients who stay you know who are on their meds compared to the same uh individuals when they're not on their meds are much less likely uh to be engaged in crime uh ssri is interesting you'll see the the risk doesn't change there it's not just that they're in care and we're prescribing the medication might be taking care of the actual adhd treatment uh that is uh is key in reducing their risk of uh of criminality here's looking at serious uh transportation actions motor vehicle accidents car rats uh and again this is within individual effects so this is comparing the number of accidents or the number of yeah accidents that they are involved in during months of their life when they are taking adhd medication that from from prescriber data that's also part of the swedish registry compared to months when we know they are not taking their adhd medication because they don't have it yeah and you can see the marked decrease in uh in accidents and particularly if you look at the bottom line motorcycle riders if you're a motorcycle rider don't go out on your motorcycle unless you've taken your adhd medication because uh the 90 reduction uh with medications and the high rate of accidents in that group so what we do be very helpful to our patients and can not only uh help them have a more satisfying life but actually have them uh have more life and i think that is absolutely critical it's what makes it such a rewarding uh you know professional experience to be able to manage 88 adhd with a real high quality over long periods of time for your patients and their families so but really think take a step back organize your practice uh work with your practice team members to have a system of care that is satisfying for you professionally but is really rewarding in terms of the improvement in the lives of your patients the question is a concern about sugars corn corn syrup sugar and other such sugars fructose and if they have a relationship with adhd with appetite and so forth i think you've said that people with adhd tend to look for higher calories sweeter foods what is that relationship yes so it's one of those myths that um sugar causes hyperactivity or adhd symptoms and that's actually not the case it's just that um activities in which there's a lot of sugar like birthday parties with cakes and cupcakes that you're just gonna have a lot of you know hyperactive kids and in that way um the direction is more that people with adhd are very are very attractive to sugar and get a lot of reward from it um in that way so it's almost like the threshold of sweetness you'll often find is a lot higher for people with adhd when they have something that other people might think is sickenly sweet um that people with adhd will report to as being like moderately sweet um in terms of if the question was around preservatives and and all of those you know that is put in foods i mean certainly um that isn't nutritious and that it does it at least temporarily fills people up and even a lot of nutritionists and dietitians will say that you know part of the problem with obesity is not just what people are eating but it's actually what they're not eating and so if we're eating a high sugar diet we're taking our calories in there we're feeling you know satiated maybe after having a lot of calories but it means we're not eating perhaps the proteins the fruits and the vegetables and and those foods so it's not just what people are eating we have to be aware of but looking at the overall diet of what they're also not taking in because they might be relying on you know really nutritionally empty calories in sugar and sugar products our next question is for dr culpepper and it is a question that a parent has regarding her young adult and this young adult again is now managing her own adhd but is not making the appointments not following up the adult is over the age of 21 what can parents be doing to help their young adults with their treatment maintain their their treatment and either doctor dr culpepper or dr olivier i know you both work with young adults what can a parent do sure and uh yeah i think uh you know this is is often a very difficult transition uh because if we as uh providers you need to take care of this sort of mode uh which i don't think most of us do it really sets them up for you know for failure i think what we really need to do is encourage the mother in this case to really be a good coach and support person for her daughter and recognize that her main role is as her mother not as her adhd caregiver and so it's painful sometimes to watch both as a professional and as a a parent but at times uh patients really have to uh you know spend a year two or three recognizing that they have to take ownership of their own problem uh and i think there are a number of things you can do uh during that time one is not constantly focus on the adhd uh you know the the uh the daughter yeah it's a whole person so celebrate her successes celebrate uh uh her um you know the her capacities and and where she is positive uh and uh and basically uh become a a coach viewer if you would in terms of helping her problem solve uh not accepting your solution uh but coming to her own uh strategies or in her own solution to the problems she's encountering uh it's reasonable to not constantly but at practical points uh be able to point out that you know adhd and inadequate care of adhd may be contributing to this uh and uh it's something you might ought to think about making sure uh you're you're getting uh you know the best care for uh maybe helping her identify strategies uh or people in the in the community that can be resources to her uh but the key i think in this situation is for the mother to be mother uh before uh she tries to be adhd provider is there any research with any nicotine research and any association to cannaboid uptake cannabis uptake and other self-medication with thc cbd and a reduction or an alleviation of adhd symptoms uh there's a lot there's a lot there um let me see if i can unpack that a little bit i mean in in general i think that most of the relationships that the question alluded to have not been supported empirically i mean certainly people you know people who have adhd are more likely to use cannabis um people who um and we know that people who use cannabis are also likely to also use nicotine and and tobacco products um but in terms of the sort of the pharmacology of that within adhd i don't think we've investigated that very much your research on estimated life expectancy was there any correlation with treatment that included medication management versus treatment or non-treatment without medication management did you see a change either positive or negative for life expectancy yeah great great question and unfortunately having only 15 minutes didn't allow me to go into all of the nuances about methodology and and our what we had done you can see our paper the journal of attention disorders uh also i summarize it in the adhd report uh my newsletter but long story short is as all longitudinal studies have found treatment during childhood and even early adolescence has no detectable benefits when kids are followed up into young adulthood or adulthood and largely the reason for that is that the vast majority of our children are not in treatment after they leave high school indeed even during high school uh even the mta study which had kids on medication found that only about 25 to 28 of them were being treated in high school with meds even less so with regard to other psychological therapies uh and by the time they were 21 years of age in my study it was below uh 10 to 15 and then below 10 by age 27 so you're you're looking here at largely childhood and early adolescent treated cases who as they get older individually from their families want to say in what's happening to them and then leave home uh are not participating in treatment and although that doesn't sound like it makes any sense it does make sense these people never called you their parents called you their teachers called you they don't see themselves as having a disorder yet they uh are not so motivated if you look at process readiness for change model they're not ready to change in fact they can't wait to get you off their back and get out on their own uh and get away from treatment so every longitudinal study i have looked at that involve treatment shows this to be the long-term course so the answer is no treatment in our study as in others had no effect not only on all the other outcomes we looked at in that study but had no effect on altering life course and estimated life expectancy so uh and that's not something despite the sobering nature of it to get too discouraged about because you would find the same thing in diabetes high blood pressure epilepsy any chronic medical condition in which people opt out of treatment very young you're not going to see any effect of early treatment on life course 10 years later and that makes perfect sense they've gone back to baseline again they've reverted to their previous behaviors despite some maturation there and we don't see that either so that doesn't mean the treatment doesn't work as dr culpepper pointed out and i could give you many other studies on top of those that shows uh that virtually every major domain of life activity that we look at from auto accidents to teen pregnancy to job problems to risk of being fired from a job and so on and substance use all of them show that when treatment is engaged there is a reduction in harm to the individual compared to uh even the months that the individual isn't on treatment so even these within subject comparisons that he mentioned show this to be the case so um you know that that's really convincing data because it helps to take into account other confounding factors in in other randomized trials so i think the treatment definitely would make a difference but it didn't in our study or in other studies because the kids didn't own the disorder didn't continue with it so two things one adam levine and other people on youtube have great videos on owning your disorder number two look at francesca's readiness to change model if necessary uh i reviewed this in my book when an adult you love has adhd to try to help convince caregivers and other around them of what you do based on where the person is in readiness to change and if they're in denial if they're at the pre-contemplation stage that's a very different thing that you will do to help them than it would be if they're at the contemplation stage where you might have a list of providers and other things but long story short treatment in childhood makes no difference to adult outcome we see this often at transition age but we see this all through adulthood a person is going through their primary care provider or their specialist for adhd enters retirement is no longer available they're looking for a new provider and at that point there is a disruption in their treatment and now in many cases the cont the use of stimulant medication has been conflated with opioid use and so there are doctors who are afraid of prescribing or reluctant i should not say afraid for please forgive me they are reluctant how can a person manage this difficulty staying on treatment when they can't find someone who can further the treatment that they have had first of all the chad website has a professional identifier or locator service in canada also cadra c-a-d-d-r-a dot c-a can be helpful in identifying area resources also medicinenow.net i believe it is is another locator service where you enter the condition you're interested in and they will bring up people who have listed themselves as being specialists within that area so those are several good starting points absent those of course contact the local medical center either psychiatry or behavioral pediatrics or behavioral neurology or family practice to ask them where do they identify the most expert individuals in the community as a resource uh and and that's another avenue for it thirdly you can try to find if there's a local chad chapter near you that's also on chad's website and contact their current president uh that group is going to have field tested your region for various professionals who's good who isn't who to go who to stay away from so if you can find those people there's no better resource than families who have pioneered the area already on almost on your behalf so see if you can contact them as well and and then finally although this isn't always very successful look at the state medical directories for psychiatry psychology and these other specialties oftentimes the state association will list their members by specialty and that might be another way of exposing some of these experts that are all relatively well hidden to the rest of us because they don't publish research and they're not nationally visible but that doesn't mean they're not good and useful to you so that would be my suggestion larry what do you think yeah i agree with all of that the only point i would make is sometimes it's easier for patients to find the specialist involved in adhd care in their community than it is a primary care base for that and so that may be where you start as a patient is if you can find at the local uh medical center or i should say uh a lot of times psychiatrists or uh you know psychologists uh you know will be known as the person to go to for adhd care uh they can then guide you in terms of you know ask them as well right now who's a good primary care to go to that uh that accepts adult adhd and that you found works effectively with you and and with uh you know patients with adhd as a way to sort of back you into having a primary care uh provider that's uh uh that's gonna be affected as well well one of the uh just a brief thing i'll just add uh this is brooke molina is we we've we've often found it helpful that um when there are providers who are willing to care but they're just a little bit sheepish about it that if if if the patients do a good job of keeping their records now as their historical records that can be helpful to document the history of diagnosis and treatment and the other thing is willingness to consider the multimodality approach to dealing with the adhd so a patient who comes in who's willing to engage in therapy who's willing to do some homework recognizing the difficulties of doing that with adhd admittedly but isn't just coming in saying i need a prescription if you're if the patient's willing to embrace those kinds of ways of dealing with the difficulties then that just helps in in our experience kind of the the the provider who's a little bit nervous about taking on a new patient yeah i mean what one thing there is before your uh retiring uh provider uh you know has actually closed his practice uh ask him or her for a copy of your record because in most states league patients are entitled uh you know to do that uh so that you've got your record or a good summary of it to then have in your pocket if you would to take to the new provider uh it's often so much easier uh i've been trying to retrieve a record after a retired physician has actually retired and uh the records are now with a medical record room at this hospital or yeah it just becomes a labyrinth to try to get through to actually get the record so uh do grab it before the uh you know our copy of it before the physician has actually shut the door the question is do you see other eating disorders such as orthorexia in addition to anorexia um binge eating disorder dc orthorexia used as a method to control emotions emotional behavior to control symptoms for adhd yes so the the eating disorders that i see the most with adhd are bulimia nervosa binge eating disorder however i have treated as i mentioned i work with boys and men i've treated men with adhd who have anorexia nervosa and for those of you who might not know what orthorexia is not a an actual diagnosis but it's a an eating disorder characterized by people who want to who are obsessed with eating clean and eating pure often organic they tend to be vegan but it tends to be almost we think of it as like on the obsessive compulsive spectrum um and yes i have seen that and you know speaking with with as far as the last question with stimulants i find that you know my role as a clinician in working sometimes with um physicians who are prescribing is sometimes advocating on behalf of my patients in terms of stimulant treatment now if you take something like in the eating disorder community before byvans was approved for binge eating disorder it was seen as very contraindicated to prescribe a stimulant medication to someone with an eating disorder um and especially with anorexia nervosa and so i've had to work you know with with um prescribers and with this particular patient i was working with who had anorexia and he said the anorexia was a way of almost kind of it there was some body image component but also he said it just calmed him from all of the sort of noise that he felt in his head um all the racing thoughts around the adhd and and that it served that kind of function and he was prescribed a low dose of a stimulant and it helped tremendously it was obviously very very closely monitored but that's where i feel you know our work is as clinicians in terms of advocating for our patients in getting that kind of you know treatment but yes i've seen the range but i would say the majority is going to be typically bulimia binge eating disorder you know that said uh thanks roberto um there have been several studies particularly the demontis large genome-wide study involving tens of thousands of adhd and control cases that showed that there's actually a negative relationship between adhd and anorexia whereas it's a positive one between adhd and binge eating pathology and and so people with adhd are actually less likely to get anorexia than as anybody in the general population but as roberto pointed out that doesn't mean you won't see it it just means that the odds are quite low that those two go together so understand that eating pathology across the spectrum from anorexia to binge eating and so on is not all equally likely within an adhd adolescent or adult population it's really the impulse eating pathologies as roberto nicely pointed out is that that is the most common and that you're going to really struggle to deal with uh in trying to get some handle on that eating problem again particularly if they're not being medically managed their adhd right typically with anorexia it's obsessive compulsive disorder that we would see as the most common comorbid condition with anorexia than we would see with adhd indeed can the association of fewer problems while employing medications part of treatment just be a function of those who are doing better anyway uh being more conscientious about their treatment plans in other words both treatment participation and fewer accidents are results are resulting from better adjustment to treatment the the swedish data that i was showing in terms of reduced criminality and reduced um accidents that is using the patient him or herself uh as a comparison so we take uh 100 individuals and in sweden i mean the this is based on swedish registry data they have their entire population so it's not a select group of people it's it's the entire uh adult population we look at those that have a diagnosis of adhd we look at their pharmacy records and we know okay for these three months uh they were picking up their prescriptions regularly uh and they and they did that uh you know for this year and a half but then there's a six month interval where they did not get refills and so we're using the uh prescription uh filling data really to identify patients when they're on treatment and when they're off treatment and if we look uh how many access did this individual have while they were on treatment uh and they have uh you know two accidents a year say when they're on treatment and then we look at the same patient uh the months when they weren't on treatment and we see that during the months they're not on treatment uh they have a much higher rate of accidents they have um than accidents for you uh that's the comparison so uh it's really looking at patients when they're on treatment reasons why they're on and off treatment we don't know so it may be that they're functioning better in other domains in life and that's affecting when they take treatment but it's not uh it's not like we're self-selecting a group of patients to say uh that they're doing better than this other group it's the same patients being compared to themselves that's what makes those studies so compelling is using the patient as their own control but even in the studies that we're not able to do that they do statistically and using randomization as well are able to try to control for the pre-existing characteristics of the individual as the possible predictor of the outcome rather than the treatment and and besides larry's comments this has been shown not just for car crashes and not just for the excuse me criminality but also for teen pregnancy uh to some extent for drug use also for employability and the likelihood that the individual gets fired from a job and more recently even overall mortality is drastically altered as is risk for accidents of all kinds in patients when they're on medication when they're off medication so again these within patient comparisons using large population-wide databases are very compelling about the effectiveness of ongoing treatment at reducing risk for all of these health and wellness variables among others so again i find that all the more reason why we need to be treating these individuals early and often and convincing them to stay with their treatment plan even if they feel they don't need it anymore or they don't like the side effects or they can't afford the medication finding ways to get around these obstacles to keeping them adhering to treatment become increasingly important because you literally can save their life by helping them with treatment as larry has pointed out and there's very few other areas in psychiatry anyway where we have that degree of success with our interventions whether it's anxiety depression or bipolar disorder as we have in the management of adhd dr salancho thank you for uh thank you and to the public policy committee for organizing this this has been very informative very helpful thank you to the presenter to the audience for their attention and [Music] participation you

Channel: Help for ADHD

Views: 43,139

Keywords: ADHD, ADD, Attention Deficit Disorder, Attention Deficit HyperactivevImpulsive Disorder, Adults with ADHD, Teens with ADHD, Teenagers with ADHD, Children with ADHD, #mentalhealthprofessionals, #healthprofessionals, #medicaldocotors, #doctor, #mentalhealth, #smoking, #obesity, #substanceabuse, #russellbarkley, #robertoolivarda, #self-care, #physicalhealth, #diagnoseADHD, ADHDtreatment, TreatingADHD, #ADHDdiagnosis, #diagnosingadhd

Id: WbWe-_jZEeQ

Length: 109min 57sec (6597 seconds)

Published: Wed Mar 17 2021