1	Challenges of ADHD During Adolescence & Adulthood Thomas E. Brown, PhD Associate Director, Yale Clinic for Attention and Related Disorders Department of Psychiatry Yale Medical School
2	ADHD: Persistence vs Change (3 different views) Old View: usually outgrown by mid-adolescence (only if one ignores inattention problems) Current View: usually continues into adulthood (just keeps going, like the Energizer bunny) Proposed View: more or less impairing in adolescence/adulthood (depends on challenges and resources)
3	2 ADHD Symptom Sets Hyperactive-impulsive symptoms: impaired ability to inhibit “Inattention” symptoms: impairments in multiple cognitive functions Symptoms of “inattention” usually most persistent and most problematic
4	ADHD Symptoms Over Time
5	ADHD persistence may involve increasing impairment impairment may become more and/or less problematic in adolescence and adulthood Depends on unfolding of: Individual strengths/weaknesses challenges encountered supports available
6	Executive Functions Wide range of central control processes of the brain Connect, prioritize, and integrate cognitive functions–moment by moment Like conductor of a symphony orchestra
7	Brown’s Model of Executive Functions Impaired in ADHD Symptom Characteristics Dimensional, not “all-or-nothing” Everyone sometimes has some impairments in these functions; in ADHD, it is a chronic, severe impairment Situational variability: “If I’m interested” Most persons with ADHD have a few activities where ADHD impairments are absent
8	Brown’s Model of Executive Functions Impaired in ADHD
9	When Are ADHD Impairments Noticeable? Some are obvious very early and are noticeable in preschool years Some are not noticeable until middle elementary or junior high Some are not apparent until child leaves home to go to university or later
10	Adolescents With ADHD Are adolescents! Have all the usual range of limitations, frustrations and challenges as other teenagers Yet are often limited by their ADHD impairments in ability to cope constructively
11	Tasks of Adolescence Requiring Executive Functions Managing time and homework Developing relationships Driving a car Leaving home, modifying connections
12	Emily 13 years old-no dx No complaints when she was in grades 1-6 Problems started in 7^th grade after switch from one teacher most of the day to 6 teachers every day Homework became big problem Multiple “brush fires” of late assignments or inadequate preparation for tests “She couldn’t keep whole picture in mind.”
13	Brian 18 years old-no dx 12^th grade technical school-culinary arts “Excellent worker” as cook 30 hrs/wk Bought own pickup from earnings “A” grades in shop, failing theory course Multiple tickets for stop signs, speeding Unable to graduate without theory course
14	Sean 18 years old- (dx Predom Inattentive) On meds for ADHD 8^th grade thru 12^th Honor student in competitive high school Varsity athlete, shy in social activities No meds in college; fell behind early Excessive alcohol, marijuana, computer Missed many classes and assignments “Just their being around…”
15	Adults With ADHD Are adults! Have all the usual range of limitations, frustrations and challenges as other adults Yet are often limited by their ADHD impairments in ability to cope constructively
16	Tasks of Adulthood Requiring Executive Functions Holding a job and working productively Managing household and finances Managing work while nurturing relationships Parenting and sustaining partnerships
17	Peter 26 years old-no dx Very superior IQ, multiple talents Grades in college varied A-F Dropped out of college end of 3^rd year Held 7 different jobs in 4 years Often late, missed deadlines, mouthy Keeps changing channels, girlfriends “omnipotentiality” vs. getting older
18	Sara 27 years old-no dx Lively, popular jr high school teacher Excellent in classroom, poor paperwork Struggling with graduate course Disorganized laundry, meals, apartment Impulsive purchases, can’t budget Heavy debts, dependent on parents ($)
19	Greg 38 yo man Married 16 yrs- 2 children (14 & 12 yo) Steadily employed Shocked when wife asked for divorce “too much giving; not enough getting” “he needs a mother more than wife” Husband agrees “You’re right” “Mom helped before, you took over”
20	Louis 57 years old CEO of Fortune 500 company Son dx ADHD after failed college 1^st yr Son improved with tx Father sought treatment for self problems similar to son’s; 3 yrs university Supported by admin assistants Anticipating early retirement
21	Additional Complications ADHD often is complicated by one or more additional psychiatric disorders Adults with ADHD have greater risk of psychiatric disorder than non-ADHD Often comorbid disorders are treated while underlying ADHD is not
22	Psychiatric Comorbidities in adults with ADHD 12 mo. Lifetime % OR % OR Any mood 25.5 3.5 45.4 3.0 Any anxiety 47.0 3.4 59.0 3.2 Any substance 14.7 2.8 35.8 2.8 Any impulse¹ 35.0 5.6 69.8 5.9 Any psychiatric 66.9 4.2 88.6 6.3 ⁽¹impulse ⁼ antisocial pd, ODD, CD, Intermittent explosive disorder, bulimia, gambling (from National Comobidity Survey-Replication data presented by R.Kessler at APA, 5/1/04)
23	PUZZLING QUESTIONS! Why are there such high rates of comorbidity between ADHD and so many other disorders? Why is an adult with ADHD 6 times more likely to have at least one additional DSM-IV disorder at some point in life?
24	How Is ADHD Related to Comorbid Disorders? ADHD: developmental impairment of executive functions that organize and regulate many specific functions of the mind c.f.: impaired orchestra conductor Comorbidity: ADHD with 1 or more specific mental functions also impaired c.f.: orchestra player(s) + conductor impaired
25	A Conceptual Growing Edge… Understanding of ADHD as developmentally impaired Executive Functions has broad implications Exec functions cross boundaries of disorders, brain structures and the boundary between pathology and normality ADHD is not just one disorder among many----it cross-cuts other disorders
26	Syndrome of ADD Impairments is involved in most disorders
27	Candidates for ADHD Treatment? Attorney “I’m bright, hard-working, and didn’t make partner-must be ADHD” Physician “I can be really on top of my game in the ER, but the rest of my life is a mess.”
28	Who Should Get Treatment? Only those who are severely impaired in comparison to “average person” of same age? OR Or anyone significantly impaired in comparison to others of same educational level? (White canes vs eyeglasses)
29	What can be done? Need to improve our descriptions of ADHD in adolescent and adult years Recognize ADHD impairments are complex, persistent, may become worse Many challenges in adolescence and adulthood require executive functioning Some do better when out of school, can specialize and/or get support; others suffer even more Medication treatments can be helpful, but need adjustment for task, time frame Educate professionals who care for adults Meds alone not always enough
30	Key Points ADHD=developmental impairment of EF EF development continues into adulthood Some EF impairments are not noticeable until challenged by tasks of adolescence or adult life EF impairments of ADHD should be assessed by clinical interview and self-report Medication treatments often alleviate a wide range of EF impairments of ADHD