Attention Deficit Hyperactivity Disorder Larry Gray MD Developmental

Attention Deficit Hyperactivity Disorder Larry Gray, MD Developmental and Behavioral Pediatrics Department of Pediatrics University of Chicago Pritzker School of Medicine Copyright Alcohol Medical Scholars Program

Introduction § 740 % h production § 25 fold h in Adderall § USA = 80 % of Ritalin Copyright Alcohol Medical Scholars Program 2

Lecture Aims § Epidemiology + course § Diagnosis § Etiology § Treatment § Relationship to substance use Copyright Alcohol Medical Scholars Program 3

Key Points § Very common: 10 % of boys § Poor attention + impulsivity § Pharmacotherapy improves sxs § Treatment protects from later SUD Copyright Alcohol Medical Scholars Program 4

Evolving Nomenclature § Moral deficit § Minimal brain disorder – Autopsy studies and crude x-rays § Attention Deficit Disorder (ADD) § Attention Deficit/Hyperactivity D/O Copyright Alcohol Medical Scholars Program 5

Epidemiology § Very common in elementary age § Estimates from: – – – Classroom teachers = 12% Parents = 7 % Psychiatrist interview = 2% § National US survey: 2003 – 4. 4 million school age children ( ~ 6% ) – Boys 2. 5 X’s > girls Copyright Alcohol Medical Scholars Program 6

Natural History § Symptoms identified in school § Peak prevalence: 9 -12 yrs of age § Symptoms lessen with age § Symptoms persist > 25 yrs in 2/3 Copyright Alcohol Medical Scholars Program 7

Lecture Aims üEpidemiology + course § Diagnosis § Etiology § Treatment § Relationship to substance use Copyright Alcohol Medical Scholars Program 8

DSM-IV Diagnosis 1 § Impairing inattentive symptoms with 6+ of: - Not listening - Fails to finish tasks - Difficulty organizing - Loses things - Easily distracted Copyright Alcohol Medical Scholars Program 9

DSM-IV Diagnosis 2 § Impulsive § Hyperactive - Fidgets - Blurts out answers - Difficulty waiting turn - Interrupts others - Unable to stay seated - Inappropriate running - Difficulty engaging in activities quietly - Always “on the go” - Talks excessively Copyright Alcohol Medical Scholars Program 10

Symptom Criteria § Persistent pattern > 6 months § Onset < 7 years § Impairments – At school and home – In social, academic, or occupational functioning § Not due to: – Conduct disorder – Depression Copyright Alcohol Medical Scholars Program 11

ADHD Differential § Normal high activity § Thyroid disorders § Hearing loss § Sleep disorder § Trauma / severe neglect § Learning disabilities Copyright Alcohol Medical Scholars Program 12

ADHD Comorbidty ADHD 66% 33% ODD / CD 24% Anxiety/ Mood D/O Copyright Alcohol Medical Scholars Program 13

ADHD Subtypes § Inattentive – + 6/9 criteria inattention only – 27 % § Impulsive / hyperactive – + 6/9 impulsive/hyperactive criteria only – 18 % § Combined – + 6/9 both inattention and I/H criteria – 55% Copyright Alcohol Medical Scholars Program 14

Presentation in Childhood 6 – 12 year olds: § Too distracted § Too talkative § Parents describe as “immature” § Often need to repeat grades Copyright Alcohol Medical Scholars Program 15

Presentation in Teens Adolescents 12 – 18 years: § Inner sense of restlessness § Disorganization is 0 1 complaint § Managing skills get overwhelmed Copyright Alcohol Medical Scholars Program 16

ADHD and Driving § > 5 X’s Speeding tickets § > 3 X’s Car accidents § > 12 X’s Moving violations § > 3 X’s $ Damages Copyright Alcohol Medical Scholars Program 17

Lecture Aims üEpidemiology + course üDiagnosis § Etiology § Treatment § Relationship to substance use Copyright Alcohol Medical Scholars Program 18

Pathophysiology § Different etiologies at work § No one brain mechanism § → Behavioral syndrome of: – Brain anatomical differences – Genetic / Molecular differences – Environmental risk factors Copyright Alcohol Medical Scholars Program 19

Environmental Influences § Prenatal factors (i. e. low birth wt) § Neurotoxin exposure § Prenatal (i. e. alcohol) § Postnatal (i. e. lead) § CNS infections - encephalitis Copyright Alcohol Medical Scholars Program 20

Genetic Influences § Twin Studies – Identical twins > fraternal twins – Heritability estimates § 7 candidate genes – Dopamine D 4 receptor – Dopamine transporter gene (DAT 1) Copyright Alcohol Medical Scholars Program 21

Dopamine Synapse Dopamine Transporter Dopamine Receptor from: www. drugabuse. gov Copyright Alcohol Medical Scholars Program 22

Lecture Aims üEpidemiology + course üDiagnosis üEtiology § Treatment § Relationship to substance use Copyright Alcohol Medical Scholars Program 23

Treatment of ADHD § Effective: – Behavioral Therapy – Pharmacotherapy – Combination of both § Ineffective: – Family, individual, or cognitive therapy Copyright Alcohol Medical Scholars Program 24

Pharmacotherapy § Stimulants mainstay – Methylphenidate (Ritalin) – D-amphetamine salts (Adderall) § Less addictive potential – Same structure and action as cocaine – Enters brain more slowly (less reinforcing) § Success =“normalized” behavior Copyright Alcohol Medical Scholars Program 25

Multimodal Treatment Study of Children with ADHD (MTA) § ADHD alone: – Success rates approach 90 % – Stimulants > behavioral tx § Comorbid ADHD – Need medication + behavioral therapy Copyright Alcohol Medical Scholars Program 26

3 Year MTA Follow-Up § All kids improve § Stimulants lose advantage § Can meds be stopped? Copyright Alcohol Medical Scholars Program 27

Success or Undertreatment ? 20 % % dx but no meds 10 % dx on meds 0 4 Male Age Copyright Alcohol Medical Scholars Program 17 28

Lecture Aims üEpidemiology + course üDiagnosis üEtiology üTreatment § Relationship to substance use Copyright Alcohol Medical Scholars Program 29

Adolescents and Substances § High School seniors report – 50% used alcohol – 25 % used tobacco – 25% “some” illicit drug use § ADHD is ↑ in those with SUD – 50% of adolescents – 25% of adults Copyright Alcohol Medical Scholars Program 30

ADHD, CD and SUD ADHD 33% 66% CD ODD / CD 40% SUD Copyright Alcohol Medical Scholars Program 31

ADHD, CD and SUD § Exp. of antisocial behavior § ADHD w/o CD ≠ ↑ risk § ADHD’s role in SUD – Earlier onset (1 year vs 3 years) – Persistence of symptoms across development Copyright Alcohol Medical Scholars Program 32

Alcohol Use Disorders § F/U 165 sons of alcoholics – 6% with ADHD: no SUD 20 yrs later – CD in childhood 18 X the risk of SUD § CD ↑ ↑ risk of alcohol use D/Os § ADHD sx assoc. much weaker Copyright Alcohol Medical Scholars Program 33

Predictors of Problems with Alcohol in ADHD § 129 with ADHD vs. 96 no ADHD § ADHD persisters w/o CD— 2. 5 X’s § ADHD persisters with CD— 5 X’s § Persistence / quality of symptoms Copyright Alcohol Medical Scholars Program 34

Treatment Effects § Unmedicated = ↑ risk for SUD § Use substances to ↑ self- control § Meta-analysis → Tx ≠↑ SUD § Emerging evidence → early Tx protects Copyright Alcohol Medical Scholars Program 35

Prospective Study of ADHD § Rate of SUD during adolescence § 75 % unmedicated developed SUD § 25 % medicated developed SUD § SUD in treated ADHD = non-ADHD § Treating ADHD may ↓ risk for SUD Copyright Alcohol Medical Scholars Program 36

Lecture Aims üEpidemiology + course üDiagnosis üEtiology üTreatment üRelationship to substance use Copyright Alcohol Medical Scholars Program 37

Summary § Very common: boys > girls § Poor attention + impulsivity § Pharmacotherapy improves sxs § Treatment protects from SUD Copyright Alcohol Medical Scholars Program 38