Transcript Antisocial Substance Abusers: Intractable or Treatable

Attention Deficit
Hyperactivity Disorder
Larry Gray, MD
Developmental and Behavioral Pediatrics
Department of Pediatrics
University of Chicago
Pritzker School of Medicine
Introduction
 740 % h production
 25 fold h in Adderall
 USA = 80 % of Ritalin
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Lecture Aims
 Epidemiology + course
 Diagnosis
 Etiology
 Treatment
 Relationship to substance use
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Key Points
 Very common: 10 % of boys
 Poor attention + impulsivity
 Pharmacotherapy improves sxs
 Treatment protects from later SUD
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Evolving Nomenclature
 Moral deficit
 Minimal brain disorder
– Autopsy studies and crude x-rays
 Attention Deficit Disorder (ADD)
 Attention Deficit/Hyperactivity D/O
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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
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Natural History
 Symptoms identified in school
 Peak prevalence: 9-12 yrs of age
 Symptoms lessen with age
 Symptoms persist > 25 yrs in 2/3
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Lecture Aims
Epidemiology + course
 Diagnosis
 Etiology
 Treatment
 Relationship to substance use
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DSM-IV Diagnosis 1
 Impairing inattentive symptoms with 6+ of:
- Not listening
- Fails to finish tasks
- Difficulty organizing
- Loses things
- Easily distracted
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DSM-IV Diagnosis 2
 Impulsive
 Hyperactive
- Fidgets
- Blurts out answers
- Unable to stay seated
- Inappropriate running
- Difficulty waiting turn
- Difficulty engaging in
activities quietly
- Interrupts others
- Always “on the go”
- Talks excessively
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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
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ADHD Differential
 Normal high activity
 Thyroid disorders
 Hearing loss
 Sleep disorder
 Trauma / severe neglect
 Learning disabilities
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ADHD Comorbidty
ADHD
66%
33%
ODD / CD
24%
Anxiety/ Mood D/O
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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%
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Presentation in Childhood
6 – 12 year olds:
 Too distracted
 Too talkative
 Parents describe as “immature”
 Often need to repeat grades
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Presentation in Teens
Adolescents 12 – 18 years:
 Inner sense of restlessness
 Disorganization is
0
1 complaint
 Managing skills get overwhelmed
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ADHD and Driving
 > 5X’s Speeding tickets
 > 3X’s Car accidents
 > 12X’s Moving violations
 > 3 X’s $ Damages
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Lecture Aims
Epidemiology + course
Diagnosis
 Etiology
 Treatment
 Relationship to substance use
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Pathophysiology
 Different etiologies at work
 No one brain mechanism
 → Behavioral syndrome of:
– Brain anatomical differences
– Genetic / Molecular differences
– Environmental risk factors
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Environmental Influences
 Prenatal factors (i.e. low birth wt)
 Neurotoxin exposure
Prenatal (i.e. alcohol)
Postnatal (i.e. lead)
 CNS infections - encephalitis
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Genetic Influences
 Twin Studies
– Identical twins > fraternal twins
– Heritability estimates
 7 candidate genes
– Dopamine D4 receptor
– Dopamine transporter gene (DAT 1)
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Dopamine Synapse
Dopamine
Transporter
Dopamine
Dopamine
Receptor
from: www.drugabuse.gov
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
 Treatment
 Relationship to substance use
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Treatment of ADHD
 Effective:
– Behavioral Therapy
– Pharmacotherapy
– Combination of both
 Ineffective:
– Family, individual, or cognitive therapy
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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
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Multimodal Treatment Study of
Children with ADHD (MTA)
 ADHD alone:
– Success rates approach 90 %
– Stimulants > behavioral tx
 Comorbid ADHD
– Need medication + behavioral therapy
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3 Year MTA Follow-Up
 All kids improve
 Stimulants lose advantage
 Can meds be stopped?
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Success or Undertreatment ?
20
%
% dx
but no
meds
10
% dx on
meds
0
4
Male Age
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
Treatment
 Relationship to substance use
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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
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ADHD, CD and SUD
ADHD
33%
66%
CD
ODD / CD
40%
SUD
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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
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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
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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
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Treatment Effects

Unmedicated = ↑ risk for SUD

Use substances to ↑ self- control

Meta-analysis → Tx ≠↑ SUD

Emerging evidence → early Tx
protects
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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
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
Treatment
Relationship to substance use
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Summary
 Very common: boys > girls
 Poor attention + impulsivity
 Pharmacotherapy improves sxs
 Treatment protects from SUD
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