ADHD or PSEUDO-ADHD

Explore Beyond the Symptoms

Dr Annick Vincent, M.D., M.Sc., F.R.C.P.C.
Clinique Focus, Québec, Canada
ADHD or PSEUDO- ADHD
Explore Beyond the Symptoms

Objectives

 Distinguish how the ADHD brain functions differently

 Recognize the impacts of self-modulation difficulties

associated with ADHD across the lifespan

 Identify the problems that can modulate or mimic ADHD

presentation when targeting therapeutic interventions
 Attention Deficit Hyperactivity Disorder

 Neurodevelopmental disorder

ADHD  Frequent and often chronic

 Associated with functional impairments
 Diagnostic = clinical evaluation
 Identification of problematics that could mimic
or aggravate ADHD symptoms
 Treatments aim to reduce symptoms and
associated impairments to help the person
reach the her/his full potential
 ADHD
D = Deficit (and Difference !)

 Neuropsychology
 ADHD = Difficulty to modulate ideas, movements,
behaviors and also emotions

 Brain Imagery
 The ADHD brain is different!

 Neurobiology
 Improving Dopamine and Norepinephrine
neurotransmission reduces ADHD symptoms
ADHD : Different activation pattern of the anterior
cingulate cortex cognitive division

Controls (normal) ADHD

y = +21 mm 1 x 10-2 y = +21 mm 1 x 10-2

1 x 10-3 1 x 10
-3

Bush G et al. Biol Psychiatry. 1999;45:1542-1552

Bush G et al. Biol Psychiatry. 1999;45:1542-1552.
 ADHD : OROS MPH showed greater activation
of the dorsal anterior midcingulate cortex

P = 0.02 vs PBO

• fMRI : week 0 and 6

• OROS MPH group : activation daMCC at W6 vs PBO
• N=21 adults with ADHD ; dose adjusted up to 1.3 mg/kg/day OROS MPH or placebo

Bush et al. Arch Gen Psychiatry. 2008:65:102-114.

Attention Deficit Hyperactivity Disorder

Difficulty to modulate
• Ideas (inattention)
• Movements (hyperactivity)
• Behaviors (impulsivity)
• Emotions (hyper-reactivity/mood dysregulation)
ADHD : Evolution with age

Hyperactivity

Impulsivity Inattention

Time

ADHD in AdultsWhat the Science Says

Russell A. Barkley, Kevin R. Murphy, and Mariellen Fischer
 Adolescence & young adulthood
=
critical period for the development of comorbid
problematics and evolutive trajectory of the person
suffering from ADHD

Clinical and Functional Outcome of Childhood

Attention-Deficit/Hyperactivity Disorder
33 Years Later
Rachel G. Klein, PhD; Salvatore Mannuzza, PhD; Marı´a A. Ramos Olazagasti, PhD; Erica
Roizen, MS; Jesse A. Hutchison, BA; Erin C. Lashua, MA; F. Xavier Castellanos, MD
archgenpsychiatry.2012.271

7
Ability to FOCUS:
What to discuss with your patient

• Notion of self-control

• Attentional fragility is an individual, dynamic and

variable system modulated by numerous factors which
can modulate ADHD symptoms and should be taken
into account in the treatment plan.
© 2017, Julie Boissonneault, Special
Ed Teacher and Annick Vincent,
psychiatrist.

Graphic design and illustrations:

Lorraine Beaudoin, Production
AlphaZULU - services d’imagination.
All right reserved.

For personal use only. For commercial

or educational use, please contact the
authors: trucatout@attentiondeficit-
info.com

Translated from French: TRUC•ATOUT

pour les devoirs et leçons «Je me
concentre ©» (savoirmieuxetre.com).
Illustration from Vincent A, My Brain Still Needs Glasses. 2017, Montréal: Juniper Publishings
Other Tips: attentiondeficit-info.com
Problematics that could mimic or aggravate ADHD
diagnosis and treatment
Medical Psychiatric Others
Cardiovascular problems Mood Disorders Psychosocial problems
Anxiety Disorders Trauma
Epilepsy Psychotic Disorders
Tics Learning Disorders
Head trauma/Concussion Substances use and abuse Language developmental
delay or Disorders
Thyroid disorders Oppositional Defiant
Motor developmental
Anemia Disorder (ODD)
delay or Disorders
Diabetes Conduct Disorcer (CD)
Personnality Disorders
Low or high IQ
Obesity
Autism Spectrum Disorder
Sleep problems/disorders (ASD)

Visual/auditive problems Caddra.ca et Médecin du Québec,août 2013

ADHD and Emotions
ADHD : a 3 D vision

ADHD

Capacity to Self-Modulate Emotions

Capacity to Express Empathy

Should emotional dysregulation be a core feature in the ADHD diagnosis?

Philip Asherson, United Kingdom, International ADHD Conference, Glasgow, May 2015
 ADHD : Impacts on SELF-ESTEEM

Self-esteem may be more fragile

• Low self-esteem
• Feeling incompetent (Impostor Syndrome)
• Sentiment of failure, shame, not being able to
fulfill others expectations and-or reach her/his
potentiel
• Automatic negative self-talk
Présentation Congrès annuel AMPQ, Québec 2017 Copyright Clinique TDAH de Montréal & Clinique FOCUS
Emotional Dysregulation

The person is often:

 Over-sensitive, easily excited by external stimuli

 Over-reactive, susceptible, easily frustrated, short-fused,
with intense emotional reaction /angry outbursts
 Argumentative
 Impatient

DESR in ADHD = > 95th percentile score of controls

Surman et al, American Journal of Psychiatry, 2011
 ADHD Bipolar Disorder
Duration of mood Short-lived Longer episods
swings
Pattern of mood Linked to a specific Can be spontaneous
swings trigger event or cyclic
Symptoms Chronic difficulties to Phases with distinct
self-modulate changes in speed of
attention, ideas and movements
movements, and current with variations
behaviors of energy levels
Evolution Daily since childhood Episodic

Family History ADHD Mood disorders

Mood Dysregulation Mood dysregulation
BEHOND THE SYMPTOMS : DISTINGUISH

Anxiety: performance anxiety, anticipation of failure vs GAD

Verification and order rituals : adaptative routines vs OCD

Tension : agitation/impatience while waiting vs GAD

Procrastination : difficulty to start vs avoidance behavior

Fidgeting : hyperactivity vs hypomanic acceleration

Selfesteem : low/fragile vs depressed mood vs self-emptiness

Mood Instability : hyperreactivity vs Mood Disorder vs BPD

Let’s get wet and dive in
the diagnostic process
ADHD Diagnostic Process

 Clinical evaluation (DSM-5)

 No blood test, medical imaging or specific

neuropsychological testing can confirm or
eliminate an ADHD diagnosis

Canadian ADHD Practice Guidelines

(caddra.ca)
ADHD Diagnostic Process

 Collect information from the person, close relatives and,

when appropriated, from teachers and others sources

 Use specific questionnaires to explore

o Actual symptoms and during childhood
o Associated problematics that could mimic or aggravate
ADHD
o Functional impacts

 Process to a complete clinical interview

ADHD Diagnostic Process
 Check if the actual complaints/symptoms and associated
impairments
 Correspond to DSM-5 ADHD criteria
 Could not be better explained by another problematic
(differential diagnosis)

 Check if ADHD is complicated by the presence of other

problematics (comorbidities)

 If you suspect a … Refer to:

 Learning Disorder a neuropsychologist
 Language Disorder a language specialist
 Coordination Disorder an occupational therapist
Why and when ask for a psychological
evaluation?

A psychological evaluation is particularly interesting for:

 Evaluate IQ, eliminate presence of comorbid
disorders that could alter attentional processes and
assess the possibility of a Learning Disorder (LD).
 Better portray functioning level compaired to mean
 Helpselect specific adaptative measures in school or
work environment in complex cases.
 PRACTICE POINT
Measure symptoms of ADHD Ask the patient/close
- ADHD Inventory Symptoms * relative to identify on
- SNAP-IV * the questionnaire the
most invalidating
- Adult Self-Rating Scale (ASRS) * symptoms

Explore functional impairment

- Weiss Functional Impairment Rating Scale (WFIRS) *
- Driving: JDQ *

Screen for associated problems

- Weiss Symptom Record-2 (WSR-2) *
- Generalized Anxiety Disorder : GAD-7
- Depression: PHQ-9
- Bipolar Disorder : MDQ

* Available in the CADDRA ADHD Evaluation Toolkit

Let’s explore treatment
strategies

Work as a team

Enjoy your expedition!

 ADHD
Pharmacological and Non-pharmacological Treatments

Identify impacts and their timing help target

Why, How and When we intervene

S M A R T Objectives
Specific
Measurable
Aligned on the global treatment plan
Realistic
Timed
 ADHD
Explore Impairments to better select treatment stategies

 Daily Routines, from morning to evening

 Family, Domestic and Social Life
 Academic and professional life
 Self-Regulation and Management
 Time, Space, Organisational skills
 Mood Regulation
 Risk Seeking and Impulsive Behaviors (accidents, driving
spending and sexuality)
• Life Style
 Exercise, Sleep and Nutrition
 Use and abuse
• Energy drinks, Caffeine, Tobacco, Alcohol, Drugs
• Screen time (social network, internet, gaming, series)
 ADHD

Compensate…. But at what cost?

CB = (E+T) x S
Compensatory Burden
=
Energy + Time
needed to put in place all adaptative Strategies
to reduce impacts of ADHD symptoms
ADHD Treatment Steps

Confirm Diagnosis
 # symptoms ? (SNAP-IV – ASRS)
 Since when?
 Associated problematics (WSR-2)
 Impacts ? (WFIRS)

Initiate treatment:
 Educate about ADHD
 Discuss efficacy and costs of current compensatory strategies
 Select, initiate and optimize specific treatments strategies
 Follow-up!
 Refer when specialized help is needed
 ADHD : Multimodal Approach
Select Effective Interventions and Treatments
• Psychoeducation
• Healthy Life Style
• Adaptative Strategies
• Pharmacotherapy
 Psychostimulants
 Non psychostimulants
• CBT and Behaviour Interventions
• Adaptations in academic and professionnal
settings

+Identification and treatment of comorbid disorders

Behavioral interventions can help!

 Do NOT decrease ADHD symptoms

BUT
• Improve parenting skills and self-concept
• Decrease childhood conduct problems

Daley D et al.
J Am Acad Child Adolesc Psychiatry. 2014 Aug;53(8):835-47
Behavioral interventions in attention-deficit/hyperactivity disorder: a
meta-analysis of randomized controlled trials across multiple outcome
domains.
Strategies to Better Manage ADHD

ADHD and Leading a Balanced Life

Conquering Space.

Tips and Tricks for Time Management

ADHD and Emotional Management

Tips and Tricks for Healthy Financial

Management.
cliniquefocus.com and attentiondeficit-info.com, TIPS
ADHD = Adapt !
 Landing Zone
 Take-off Zone
 Solid Furnishing 
 ADHD-friendly storage

 Attract Attention
 Motivate
 Install + Keep Routines
 Choose your fights
 ADHD : A Sprinter Brain

Illustration from Vincent A, My Brain Still Needs Glasses. 2017, Montréal: Juniper Publishings
Other Tips: attentiondeficit-info.com
ADHD : Tips and Tricks for School

QIASA
Questionnaire on Academic Impacts and
Adaptive Strategies for Students with
ADHD (Part A and B) -

Strategies for students with ADHD

cliniquefocus.com et attentiondeficit-info.com, TIPS

Tips for students with ADHD
• Follow a healthy lifestyle
• Plan your studies and assignments
(time-space-stress management)
• Get permission to move around
• Take breaks
• Work in a calm space
• Reduce your distractions
(use headphones or ear plugs and turn off screens)
• Use an erasable pen for handwritten work
• Write with a computer whenever you can
• Use brain mapping and spelling/grammar checking software
ADHD : Fidget to FOCUS!

• Exercise

• Move during planned time out

• Allow movement during activities needing a

high concentration level
Help the child learn to Fidget to FOCUS
… without annoying others!
All children need to move, some more than others!
• Points to discuss:
o Select an mobile position when you can
o Write, draw, scribble, manipulate objects
(accessories: pillow, heavy animal toy, ball,
tangle, paper clip)
o Get active while sitting: pull-push with an
elastic band attached to your chair
o Revise your lessons in action, be imaginative!

Fidget but don’t annoy others: avoid use of hand

spinner or cube in public space
 Emotion Management

TIME OUT!
Body and Brain need to be less
tense to better function

Discuss :
• Muscular relaxation
techniques
• Slow and deep breathing
techniques
• Mindfulness
• Yoga

Apps: HEALTHYMIND, Respirelax, Cardiozen

ADHD Pharmacological Treatment
 ADHD Pharmacological Treatment

• Different products: active ingredient, mode of action,

delivery mechanism, onset and duration of action
• Action on the dopaminergic and/or noradrenergic systems
• Good efficacy and tolerability profiles
• Preferential response observed
• Start low, Go slow, but keep going …
• Find the best balance between clinical effects and side
effects

Individualize treatment!
Response to psychostimulants is non
specific to ADHD diagnosis!
Psychostimulants are indicated for:
•ADHD
•Narcolepsy and Diurnal Hypersomnolence
•Sleep Apnea
•Binge eating (LDX)

Psychostimulants may help (off label use) to reduce cognitive

and fatigue symptoms associated with:
Depression
Head Trauma
Cancer
…
… and could be misused to mask lack of sleep or other unhealty
life style !
ADHD medications act like
eyeglasses for the brain

They help focus

but don’t teach how to read

…Pills don’t build skills!

MYTHS that still surface these days

 School grades are good indicators for ADHD-

associated impairments and represent an
effective measure for medical treatment
response.

 Specific clinical or genetic profile can help

predict which ADHD medication will be better.

 One can predict optimal dosage based on a

mg/kg rule for ADHD medication.
 ADHD Medications
Active Ingredients LA Delivery System

Psychostimulants (IR and LA) • Pills, tablets or Capsules:

• Methylphénidate – Unscored
– Breakable
• Amphetamines
– Sprinkable
Non stimulants
– Pro-drug (content of the capsule can be diluted)
• Atomoxetine – Fast-dissolving
• Guanfacine XL – Delayed onset of action ( eg.: 8h post-dose)
• Clonidine XL • Liquid Formulation
• Transdermic patch
LA Delivery system and proportions of immediate/delayed release of active ingredient
influence onset and duration of action

ADHD medications may have different names, indications , reimbursement and availability
in different parts of the world
ADHD Meds : HOW to Choose?

CADDRA Expert Consensus

Each product is unique and different, including generics

 Different molecules
 Different liberation modes
 Preferential responders

Treatment should be individualized

caddra.ca
 ADHD Medication Selection TIPS

Patient-related factors

• Age and individual variation

• Duration of effect required by timing of symptoms
• Concurrent psychiatric and medical issues
• Physician, family and patient attitudes

caddra.ca
 ADHD + Comorbid Disorders
A step-by-step approach

Psychosis
Substance Use
and Abuse
Mood
Disorders*
Anxiety
Disorders*
ADHD

Bipolar Disorder: Treat first

ADHD + Anxiety or Depressive Disorder
Treat first the more invalidating problem
*
Adapted from:
Goodman D. Treatment and assessment of ADHD in adults.Biederman J, éd.
ADHD Across the Life Span: From Research to Clinical Practice—An Evidence-Based
Understanding. Hasbrouck Heights, NJ: Veritas Institute for Medical Education, Inc. 2005.
 ADHD & Substance Use and Abuse
Risk to developp Substance Abuse
- Increases if ADHD is comorbid with :
 Early Smoking
 Personnality Disorder
 Conduct Disorder
- Could decrease if ADHD is treated ?

Promote Combine treatments Consider ADHD medication and risk

Abstinence of abuse
of Illicit Reduce Substance abuse
Drugs Select LA psychostimulants non
and treat ADHD easily crushable or Pro-drug or
Nonstimulants
Avoid IR psychostimulants
 ADHD Medication Selection TIPS

Medication-related factors
• Active ingredient /mode of action/drug interactions
• Delivery system / onset of action / duration of action
• Available doses
• Canadian clinical indications
• Affordability, accessibility and reimbursement (public/private)

Special considerations:
• Combining medication for adjunct effects
• Potential of abuse, misuse and diversion
• Generic formulations
caddra.ca
What are your treatment targets ?

How do you measure change?

Follow-up Tools (Questionnaires)
-Explore-

Therapeutic effects:
ADHD symptoms
Impairment

Side effects

Look at as many angles as you can:

Patient
Family-Spouse
Teacher-coach-other
ADHD : Pharmacologic Treatment Steps

ADHD diagnosis confirmed

Impacts and Compensatory Burden identified
Treatment targets selected

Start with a long-acting psychostimulant

(Amphetamine-based or Methylphenidate-based)
 Consider onset and duration of action, liberation mode
and active ingredient
 If needed, consider adding a short acting psychostimulant
to top-up the clinical effect at a specific time

caddra.ca
Illustration from Vincent A, My Brain Still Needs Glasses. 2017, Montréal: Juniper Publishings
Other Tips: attentiondeficit-info.com
ADHD : Pharmacologic Treatment Steps

Sub-optimal response or too much side effects

Try another long acting psychostimulant
(Amphetamine-based or Methylphenidate-based)

 Consider duration of action, liberation mode and active

ingredient
 If needed, add a short acting psychostimulant in the evening

caddra.ca
ADHD : Pharmacologic Treatment Steps

After a trial of both types of psychostimulants

(Amphetamine-based and Methylphenidate-based)

-Sub-optimal response :
Consider adding a non stimulant (adjunct treatment)

-No response :
Consider a non-stimulant (monotherapy)

caddra.ca
 ADHD Treatment Optimization caddra.ca

Problem Suggestion
Positive effects but peaks and
valleys or inadequate Keep same molecule but change
duration of action liberation pattern
Positive effects but rebound (add short acting or change for another
phenomenon LA psychostimulant)

Side effects
Partial response at maximum Change psychostimulant : different
dosage liberation mode or different molecule
No response
+ Review diagnosis and look for
comorbid disorders
 Psychostimulant Switch
Actual Product Switched to Comments
MPH IR Oros MPH
MPH multilayers Calculate equivalent dose taking
Oros MPH MPH multilayers into account delivery modes
MPH multilayers-12h 40% IR
MPH multilayers-16h 20% IR
MPH multilayers Oros MPH Oros MPH-12h 22% IR

D-AMP IR AMP mixt salts or

LDX
AMP mixt salts LDX
No direct equivalency
LDX AMP mixt salts
Begin at the usual starting dose
Amphetamines MPH

MPH Amphetamines

caddra.ca
ADHD Medication Interruption

Asymptomatic patient

Re-evaluate ponctually medication necessity :

Reduce dosage then stop

Continue follow-up even if medication is stopped

caddra.ca
ADHD Medication Interruption

Persistent side effects

Reduce dosage vs stop during target times
(WE, school breaks)

Consider swithching to another medication

If cessation is needed, plan the right time, continue follow-

up and re-evaluate need for treatment.
caddra.ca
 Increased Prescription Rate of ADHD
Medications: Hypothesis
• Lifesyle issues?
• Misdiagnosis?
• Better screening for ADHD? (particularly for Adult ADHD)
• Treatment Optimization ?
– Better response rate, so more decide to maintain Rx?
– Better adhesion?
– Combined therapy?
• LA psychostimulant + IR psychostimulant in the evening
• Psychostimulant + Nonstimulant
ADHD
A quick dip in the Alternatives Approaches waters
Free fatty acid supplementation
 Small but significant reductions in ADHD symptoms
 Clinical significance remains to be determined.

Neurofeedback
Cognitive training
Restricted elimination diets
 NOT recommended as treatments for core ADHD symptoms
 Better evidence is required for efficacy from blinded assessments

Sonuga-Barke EJ et al. Am J Psychiatry. 2013 Mar;170(3):275-89

Nonpharmacological interventions for ADHD: systematic review and meta-
analyses of randomized controlled trials of dietary and psychological
treatments.
ADHD - IN SUMMARY -

 Individualized and often multimodal approach

 Clarify diagnosis
 Identify impacts
 Target treatment strategies
• Psychoeducation
• Healthy life style
• Adaptative strategies adaptatives
• Coaching and/or Specific Psychotherapy
• Consider medication when :
 Compensatory Burden costs are too high
 Persistant functional impacts
 Follow-up
Every ADHD expedition has its challenges
Dive, enjoy and uncover great treasures
Guide the way 