DIVA 2.0. Sandra Kooij MD PhD. Psychiatrist Program Adult ADHD PsyQ, psycho-medical programs The Hague, The Netherlands.

Transcription

1 DIVA 2.0 Sandra Kooij MD PhD Psychiatrist Program Adult ADHD PsyQ, psycho-medical programs The Hague, The Netherlands

2 Conflict of interest JJS Kooij Pharmaceutical industry: Speaker for Janssen, Shire, Eli Lilly, HB Pharma Unrestricted research grants Shire, Janssen Unrestricted educational grants Shire, Janssen, Eli Lilly, Eurocept Non - profit: Chair DIVA Foundation Chair European Network Adult ADHD Member Dutch ADHD Network Royalties Springer, book Adult ADHD

3 Topics Development of DIVA 2.0 Translations and DIVA 2.0 App DIVA Foundation & Board members Validation DIVA Training

4 Clinical picture of ADHD Lifetime symptoms of Attention-Deficit/Hyperactivity Disorder: Inattention: distracted, chaotic, forgetful, late, difficulty making decisions, organising and planning, no sense of time, procrastination Hyperactive: (inner) restlessness, tense, talkative, busy; coping by: excessive sporting/alcohol abuse/avoiding meetings Impulsive: acting before thinking, impatient, difficulty awaiting turn, jobhopping, binge eating, sensation seeking In addition in 90% of adults, lifetime: Moodswings (5x/day) and Anger outbursts APA 1994; Kooij 2001; Conners 1996

5 Decrease of hyperactivity Hyperactivity is adjusted, compensated for, or experienced as more inner restlessness : Avoiding meetings where you have to sit stil Excessive sporting Hectic job full of change Cannabis / alcohol / tranquillisers against restlessness Talkativeness, inner restlessness The decrease in marked outward visible hyperactivity has presumably been the reason why we mistakenly have thought that ADHD was outgrown

6 Inattention most invalidating symptom in adults Adults need more attention than children: Procrastination Chaos Difficulty organising Being late Difficulty reading and remembering Forgetting things or appointments Using no watch or agenda!

7 ADHD in DSM-IV Attention-deficit/hyperactivity disorder 18 criteria: 9 attention problems (A) and 9 hyperactive/impulsive criteria (HI) Diagnosis in childhood from 6/9 of one or both domains 3 subtypes: ADHD, inattentive type (also ADD) (10-15%) ADHD, hyperactive/impulsive type (3%) ADHD, combined type (85%)

8 Impairment in adult ADHD In clinical as well as epidemiological samples compared to NCs: Learning problems (60%) Less graduated Lower education Lower income Less employed, more sickness leave More job changes (longest job 5 yrs) More often arrested, divorced and more social problems More driving accidents, teenage pregnancies, suicide attempts Higher (mental) health care costs Biederman 2006; Kooij 2001, 2005; Barkley 2002; Manor, in prep 2008

9 ADHD is a clinical diagnosis Interview patient and partner: lifetime symptoms and impairment of ADHD and comorbid disorders Schoolreports if available If possible, parents/sibs about childhood onset Patient is best informant, though tends to underreport severity No neuropsychological diagnostic test (battery) No validated instruments in Europe Kooij 2003, 2008; Ferdinand 2004

10 Dilemmas using childhood DSM-IV criteria in adults Formulation not applicable to adults Self report in stead of informant report (parent) Cutoff may be lower in adults Age of onset criterium (< age 7) never validated in children and unreliable in adults Current criteria lead to under-identification of adults Age referenced criteria have to be developed and validated DSM-V will use broader age of onset (before age 12 or 16) and probably different criteria for different age groups Barkley 2002; Kooij 2005; Faraone 2000, 2004, 2006;

11 Outline Diagnostic Assessment Early onset in life Chronic persistent course Chronic impairment or compensation/coping causing secondary impairment Mainstay of ADHD diagnosis is: CHRONICITY The period that ADHD symptoms are remembered will be longest in older adults

12 Comorbidity in adults with ADHD ADHD comes seldom alone: 75% at least one other disorder 33% two or more Mean: 3 comorbid disorders Biederman 1993; Kooij 2001, 2004

13 Comorbidity in ADHD? Depression (60% SAD) 20-55% Bipolar Disorder (88% BP II) 10% Anxiety Disorders 20-30% SUD 25-45% Smoking 40% Cluster B Pers. Disorders 6-25% Sleeping Problems (DSPS) 75% Muscle, joint, neck- and backpain?? Biederman 1991,1993, 2002; Weiss 1985; Wilens 1994; Kooij 2001, 2004; van Veen 2010; Amons 2006

14 The other way round: ADHD is comorbid in 20% of psychiatric patients SUD: 20% (Trimbos Institute) Anxiety disorders: 20% (PsyQ) Bipolar II: 20% (PsyQ) Borderline PD: 35% (Radboud University) And in accordance to epidemiological data USA: 20% vd Glind 2005; Rops 2010 in prep; Roodbergen 2010 in prep; Fones 2004; van Dijk 2010 in prep; Kessler APA 2007; Fayyad 2007

15 Semi-structured Diagnostic Interviews for Adult ADHD Only 2 Semi-structured Diagnostic Interviews based on DSM-IV: CAADID and DIVA 2.0 CAADID: expensive in use and the editor requires validation studies by the translator of other languages We wanted to lower the thresholds for proper diagnostic assessment of ADHD in adults DIVA 2.0 is online available free of charge, now in Dutch, Danish, English, Finnish, French, German, Norwegian, Spanish and Swedish Another 14 translations are underway New: DIVA 2.0 App available in App store and Google Play store (price 7.99 euro for extended use)

16 Ultrashort screening of adult ADHD 1. Are you usually restless? 2. Are you usually easily distracted or chaotic? 3. Do you usually do things before thinking? If 1 of 3 answers = yes: 4. Did you have this symptom all your life? If yes, further diagnostic assessment of ADHD Kooij 2006

17 Development of DIVA 2.0 The DIVA was first developed in Dutch by J.J.S. Kooij and M.H. Francken in 2007 October 2010: slightly adjusted version with an improved introduction of the DIVA available (DIVA 2.0) in Dutch and English The DIVA was developed because there is a need for a structured diagnostic instrument in the field that is easily available for free, in many different languages, for research and clinical assessment purposes.

18 What does DIVA 2.0 look for? The DIVA investigates the DSM-IV criteria of ADHD in childhood and adulthood, as well as impairment in five areas of functioning in both life periods. In order to facilitate understanding of the criteria in daily life in both childhood and adulthood, every DSM-IV criterion is accompanied by several examples that can be probed. The same is true for the five areas of impairment: education, work, social relationships, social activities/leisure time, partner/family relationships and self-esteem.

19 Translation of DIVA 2.0 in 23 languages supported by the European Network Adult ADHD Now available in 9 languages: Danish, Dutch, English, Finnish, French, German, Norwegian, Spanish, and Swedish Almost ready: Portugese Hebrew Turkish

20 DIVA 2.0 App The DIVA 2.0 App is now available in 8 languages in both App store as at Google Play, for Iphone, Android and Ipad! The DIVA 2.0 App adds the total number of DSM-IV criteria for ADHD in both child- and adulthood, and the number or areas of impairment. Data are not stored, but sent via , both as text and as SPSS file. Costs: 7.99 euro for extended use.

21 Adult ADHD Diagnostic Assessment and Treatment Formal reference of DIVA 2.0 JJS Kooij, 3rd edition December Search for Adult ADHD

22 DIVA Foundation The DIVA foundation is the responsible legal body taking charge of the quality, coordination and distribution of the translations of DIVA 2.0 The DIVA Foundation is a non-profit organization that is independent from pharmaceutical industry. Every representative of a language pays an entrance fee for the set up of the DIVA Foundation and website Commercial companies and industry pay royalties for use of DIVA 2.0

23 DIVA Board 2011

24 Process of translations In 2009, clinicians and researchers asked for translations of DIVA 2.0. All were made from the original Dutch version in order to prevent bias. We are grateful for the support by Janssen for the first translations from Dutch into English, German, Swedish, and Spanish. Translations into other languages were supported by mental health organisations or individual professionals. For proper wording and formulations used in clinical psychiatric practice, experienced clinicians are asked to check and improve the first translations of the DIVA. After verification of the back translations into Dutch, the final translations are authorised by the authors of the DIVA.

25 Future of DIVA 2.0 DSM5 is expected May 2013 ADHD criteria for adults will change Age of onset will change to < 12 years Number of symptoms needed in adulthood will be 4 or more (?) Examples of the criteria that apply to all age groups will be given There will be a need for DIVA 3.0

26 Validation studies Validation studies of DIVA 2.0 are necessary and are performed in Spain first, because they have a formal validated and translated CAADID in Spanish to compare with DIVA 2.0

27 DIVA 2.0 DIVA 2.0 has been developed to facilitate appropriate and careful diagnostic assessment of ADHD in adults This semi-structured diagnostic instrument still needs interpretation by a (trained) clinician DIVA 2.0 should therefore not be used by patients for self report

28 Set-up of DIVA 2.0 DSM-IV Criterion A Part 1) The 9 criteria for Attention Deficit (A1) Part 2) The 9 criteria for Hyperactivity-Impulsivity (A2) DSM-IV Criteria B, C and D Part 3) The Age of Onset and Impairment accounted for by the ADHD symptoms Summary form Score form

29 Order of questioning Part 1 and 2 Always first read the full DSM-IV criterion aloud, ask if it is recognised in adulthood, and if yes to give (an) example(s) The frequency of behaviour has to be often The duration of current symptoms needs to be at least 6 months Often is not operationalised, but refers to a symptom being more severe and/or frequent compared to an age and IQ matched group, or to be closely linked to impairment Tick the examples mentioned

30 Order of questioning II If no examples are given, read the examples that belong to the criterion and tick those that apply Start always with the adult symptom (> 6 months), continue with the childhood presentation of the same symptom (between 5-12 yrs) It is not necessary to have many examples per criterion, also one convincing example may be enough for the investigator to be able to decide about the absence or presence of the criterion

31 Order of questionning III If spouse and/or parent/sibs are present, ask them after the patient about the same symptom in resp. adulthood and childhood In case of disagreement, the patient usually is the best informant in clinical settings The more outward visible hyperactive behaviour is i.e. better remembered than inattention by family members Collateral information serves as additional information about severity, chronicity and impairment The investigator weighs all information and decides per criterion whether it applies Kooij ea, 2008

32 No collateral information The patient can be the sole informant to make the diagnosis Collateral information serves only to get a more complete picture, but may as well induce doubt in case of disagreement Disagreement about the symptoms is common in ADHD families School reports may be helpful if the behaviour is described, but cannot be used to reject the diagnosis if no remark was made Former reports of diagnostic assessments may be useful regarding descriptions of the same symptoms earlier in time

33 Part 3: Criterion B Criterion B: Age of onset Have you always had these symptoms of attention deficit and/or hyperactivity/impulsivity? Yes (a number of symptoms were present prior to the 7th year of age) No If no is answered above, starting as from. year of age.

34 Part 3: Criterion C and D Criterion C: Clinical significant impairment of which many examples are given in 5 specified areas in adulthood as well as childhood: Work/ education Relationship/ family Social contacts Free time/ hobby Self-confidence/ self-image Conclude if there is clinical significant impairment in 2 or more areas

35 Summary form Count the total number of criteria met for inattention (A) and hyperactivity/impulsivity (HI), in both adulthood and childhood

36 Score form Answer the questions on the Score form on: 1. Sufficient number of symptoms in adulthood ( 4) and childhood ( 6)* 2. A lifetime pattern of symptoms and limitations (rather than a strict age of onset!) 3. Symptoms and impairment manifest in 2 or more areas 4. No better explanation of the symptoms by other psychiatric disorders 5. Level of support for the diagnosis by collateral information 6. Diagnosis and subtype***

37 Trying to find the adult cutoff * Composite measure of impairment by number of symptoms with GHQ-28 as covariate (5,4,3,2,1,0) 0.25 (3,2,1,0) (2,1,0) (2,1,0) 0.20 (3,2,1,0) (3,2,1,0) >= number of inattentive symptoms 0.06 >= number of hyperactive/impulsive symptoms Kooij 2005

38 Cutoff current DSM-IV criteria in adults? Epidemiological study (n=1800): adults were significantly more impaired starting from 4/9 current ADHD criteria: of inattention as well as hyperactivity/impulsivity in both genders, and in young and old people effect remained significant after controlling for impairment due to comorbidity (GHQ) ADHD proved to have its own contribution to impairment, independent of comorbidity C/ 6/9 symptoms in childhood and 4 or more current DSM-IV symptoms may lead to diagnosis of ADHD in adulthood Kooij 2005; Barkley 1997;

39 Different subtypes in child- and adulthood*** Score Form: *** If the established sub-types differ in childhood and adulthood, the current adult sub-type prevails for the diagnosis

40 Training DIVA 2.0 yourself You are now a certified DIVA 2.0 trainer! To train those who want to use DIVA 2.0 in your language These slides can be used for trainings and can be send to you all (please write your address)