ADHD Causes Course through life

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ADHD Causes
Course through life

• Dr Adri van der Walt

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Disclosures

• Janssens Cilag Advisory Board
• Lecturer
• Previously meds
  research
• Novartis Advisory Board
• Lecturer
• Eli Lilly Advisory board
• Lecturer
• Previously meds
  research

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CAUSES

• Definition of ADHD
• DSM IV criteria
• ICD 10 criteria
• History of the condition
• Comorbidity
• Nature vs Nurture

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Primary Problem

• Dysfunction in Dopaminergic system
• Prefrontal /
  striatal
• Noradrenergic
  system Post
• White matter abnormalities Diffusion tensor
  imaging studies left fronto temporal
• right parieto
  occipital Silk 2008
• Fronto parietal tracts parents/ children Casey
  2007
• cognitive control go/ no-go
  task

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Neurobiology today
Bush et al., Biol Psychiatry 1999 451542-1552
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Functional MRI Scan
MPH Increases Activity in the Dorsal
Anterior Cingulate Cortex In patients with ADHD
dACC Low Activity
Vaidya et al, PNAS 1998
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Proposed Norepinephrine Roles in ADHD
Insufficient DA inhibition and stimulation,
mediated by NE DA
Central NE dysregulation in the posterior
attention system
Excessive NE tone (noise) at level of locus
ceruleus
Peripheral EPI NE insufficiency affecting NE in
the locus ceruleus
Pliszka SR, et al. J Am Acad Child Adolesc
Psychiatry. 199635(3)264-72
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Differences identified

• Decrease total cerebral volume gt7
• Decrease in total cortical volume gt8
• Decreased folding and surface area
• No differences in cortical thickness
• Wolosin Hum Brain Mapp
  2009
• Reduced activation ventrolateral prefrontal
• attention vs interference inhibition R
  temp/par
• comparison CD patients Silk Hum
  Brain Mapp 2008

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Genetics ?

• Family studies 80
• Twin studies
• Adoption Studies
• Heritability 0.77
• Importance of identifying the genes
• progress of condition
• treatment responses
• comorbidity patterns

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• 8 genes 7 has association
• dopamine D4 receptor gene DRD4
• dopamine D5 receptor gene DRD5
• dopamine transporter gene DAT
• dopamine beta-hydroxylase DBH
• serotonin transporter / receptor 1B genes
• synaptosomal prot 25 gene SNAP25

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• Genetic architecture is complex
• DAT regulated by DA /Amphet DAT 1 MPH
  inactivate
• inhibitor cocaine
• Thus altered transporter trafficking ..
  surface expression
• DRD4 VTRN variant
• DRD5 microsatelite marker Thapar 2007
• DRD5 Adults ?effect other genes
  Johansson 2008
• Steroid sulfatase ? Davies 2009

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Gender differences

• Ratio boys to girls
• Within the ADHD spectrumsubtypes
• Does it make a difference in adolescence?
• Spectrum of comorbidity?
• Adulthood?

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Environment

• In utero impact of prematurity
• SFD babies
• alcohol
• nicotine
• drugs
• stress
• Neurological diseases

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• Syndromes
• Parenting issues
• Social deprivation / emotional neglect
• Drugs later in life?

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Different ages Different faces

• 4 basic problems
• inattention /organisational problems
• hyperactivity
• impulsivity
• Areas of impact school
• social
• home and
  family

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Modifiers

• Age
• Intelligence
• Temperament
• Comorbid conditions
• Physical
• Neurological
• Environment

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Preschooler

• Diagnostic criteria ?
• Presentation.
• behavior issues impulsivity
• seen as aggressive
  /oppositional
  hearing
  problems
• inability to adapt socially
  in group
• inability to wait / learn
  from experience

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• Concentration cannot shift attention
• interest
  levels
• listen to
  stories
• Immature
• Problem Developmental issues
• other diagnoses ASD etc
• Primary problem / comorbidity ?

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Primary school

• HA vs inattentive
• Why at school structured environment
• task completion
• no interest in
  work
• Impact academics
• praxis problems
• impairment in
  fundamental skills

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• social skills
• homework
• time management
• Emotional problems
• Poor academic performance
• Behavior
• Self esteem issues

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Adolescents

• Changes in symptomatology
• Comorbidity often more visible
• What brings them to our attention
• Academic Failure
• Parental frustration

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• Behavior issues
• Drug Abuse / alcohol /smoking
• Psycho social dysfunction
• often comorbid problems bring them to
  attention
• 4-7 has ADHD
• 50-70 has continuation of symptoms

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Academic

• Poor verbal learning / vigilance / maths
• More suspensions
• More failures to complete fulltime schooling
• Chronic underachievement
• Disorganised schoolwork /poor follow through
• Failure to do independent school work
• Inconsistent marks

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Behavior

• Smoking / drinking
• Drugs
• ODD /CD
• Teenage pregnancies
• Impulsive behavior issues driving etc
• Family issues /distrust vs need for autonomy

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• Bloemfontein study
• Girls and positive adjustment 40-60 vs 80/90
• Emotionally immature
• Sleep disturbances
• Problems diagnosis
• details school functioning
• interaction with therapist
• view on medication

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Family Life

• Effect on parents
• changes mood/ behavior
• mother bear brunt
• reaction other people / family
• stressed marriages
• parenting skills/ inadequacy /
  discipline
• trust issues
• concerns future

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• Effect on sibs
• victimization
• their friendships
• their behavior copy / attention
• feel neglected
• viewed as perfect by ADHD sibs
• Caretaker responsibility

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2 Socialization

• Negative feedback
• Inattentive picked upon single
• more time alone
• Combined quick reactions/ forgotten
• accepting responsibility
• lack self control
• ostracism
  ridicule
• Boys less empathy

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• Frustration tolerance Temper
• Group activities
• Verbal impulsivity
• Long-term relationships

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Adults

• Major diagnostic issue
• Full syndrome symptomatic vs subsyndromal
• 50 still functional problems
• Problems access to medical care
• health insurance
• Anticipatory guidance?

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Problem areas

• Education
• Social // relationships
• Divorces
• Driving //accidents
• Organising skills // responsibility
• Suicide attempts
• Drugs // alcohol

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Quality of life issues

• May seem minor but major impact
• Affects wide range of people not only ADHD
• Consistent within studies
• Patients needs should be fully evaluated and
  addressed in all areas

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Good feedback

• Selfs die deftige kinders speel nou met my
• For the first time in my life I have a mother
• Ek weet nou ek kan
• Ek is nie meer op my wolkie nie
• I go to bed knowing I have done things not only
  thought about doing them.

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The final story

• But remember the positive side of ADHD