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The ADHD Explosion Part 1: Causes, Models, Rising Prevalence, and Policy Implications Stephen P. Hinshaw University of California, Berkeley Help Group Summit 10/17/14 Slide 2 Slide 3 ADHD: Key Themes Newsworthy Cause of ADHD is SpongeBob Square Pants Cause of ADHD is starting kindergarten at age 4 Stimulants lead to heart attacks New York Times 2012/2013 opinion pieces: Sroufe, Kureishi, Friedman, Brooks: Back to the past Too much of the news and opinion is mythical (see subtitle of book) Slide 4 4 Slide 5 Facts ADHD is a neurodevelopmental disorder with high genetic liability ADHD incurs huge costs to those with high levels of symptoms All too few people with ADHD have excellent life outcomesif its a gift, in the words of Ned Hallowell, its hard to unwrap Slide 6 Myths Medications are poisons, destroying developing brains Meds help in 80% of cases May actually be neuroprotective for youth with ADHD Medication alone is a sufficient treatment Need family/school intervention for skill building SEE PART 2 TOMORROW! ADHD can be assessed and diagnosed in a 10 office visit Yet this, far too often, is the national standard Results in both overdiagnosis and underdiagnosis Slide 7 Impairment Academic (school failure)/Vocational $100 billion/year (youth) indirect costs (justice, sp. ed, SUD) $200 billion annually (adults) indirect costs (job problems) Social/peer (most peer-rejected condition) Family (reciprocal chains of bidirectional influences) Accidental injury (across the age span) Impairment often independent of comorbidityAND key comorbidities dont respond optimally to ADHD tx E.g., LD, delinquency, depression Slide 8 DSM-5 vs. RDoC DSM-5 changes: Neurodevelopmental disorder Types (Inattentive, HI, Combined) now presentations Adult examples of most symptoms Age of onset of impairing symptoms: < 12 years, not < 7 **Each successive edition of DSM has loosened criteria somewhat, which is one reason for ADHD explosion Research Domains Criteria Dimensional, multiple levels (genes to culture) Search for underlying mechanisms Slide 9 ADHD Cross Culturally Appears in nearly all cultures (that feature compulsory education) Polanczyk et al. (2007), AJP: Diagnostic prevalence strikingly similar across world regions: 5% Disparities linked to dx practices (ICD vs. DSM; informants; etc Hinshaw et al. (2011) Within-country variation high in many nations However, treatments and systems of care vary radically across regions and cultures MANY NATIONS CATCHING UP WITH U.S. MEDICATION TRENDS But some not: politics, history, penetration of Big Pharma Slide 10 Nature of ADHD: Models Cognitive models: Attention deficit, EF Inhibitory models: Barkley (1997) Motivation models: Reward undersensitivity E.g., Volkow et al. (2009): large medication-nave adult sample, PET scans of transporters and receptors Slide 11 (Attention) (Motivation) (Attention) (Motivation) Slide 12 (Attention) (Motivation) Transporter PET Image Slide 13 Combination Models Sonuga-Barke et al. (2010): Top-down executive control Bottom-up delay aversion Time management ADHD clearly implicates multiple brain regions and paths for different facets of symptomatology Slide 14 Neural profiles Structural/anatomical: Overall lowered cerebral volume; caudate, cerebellum Key research: Shaw et al. (2006, 2007, 2009, 2012) Delayed patterns of cortical thickening/thinning in ADHD vs. comparison samples, longitudinally Roughly 3 year delay for ADHD groups: Immaturity come to life Immaturity persists; thickness correlated with symptoms Functional: Frontal-striatal paths Until recently: must scan during active cognitive performance Default mode: reliable differences when Ss not doing anything; more intrusions into task performance in ADHD Slide 15 ADHD: Causes Heritability and Genes: H 2 of ADHD near.8 **What is heritability? genetic liability, but not inevitability Too often, assumption is that ADHD is fixed and largely immutable PKU example Height example IQ example Slide 16 Which genes? Seemed a simple question 10-15 years ago: Genes related to dopamine systems and pathways in brain But any single gene variant explains only a tiny fraction of ADHD-ness Dark matter of genetics: missing heritability! Recent discoveries: genes conferring risk for ADHD are SAME as those conferring risk for schizophrenia, mood disorders, and autism MUST BE that early influences are epigenetic Slide 17 Other Risk Factors Low birthweight Predicts ADHD, LD, Tourettes, CP, retardation Teratogenic effects FAE: Many are nearly identical to ADHD symptoms Smoking/nicotine: genetic mediation, too Early parenting: No consistent evidence as causal Middle-class; few prospective studies from early years Insecure attachment? Does NOT predict later ADHD, independent of comorbid aggression Slide 18 Risk Factors: Equifinality Carlson et al. (1995): In low-income sample, early maternal insensitivity predictive of ADHD symptoms to a greater extent than early temperament Need genetically informative design Institutional deprivation (Kreppner et al., 2001) English and Romanian Adoptive Study Team: Inattention/overactivity associated with length of severe institutional deprivation in first 4 years Specific effect: Conduct problems and internalizing symptoms not similarly associated with deprivation Yet, different feel from typical ADHD presentation AND, EF deficits may be distinct from typical ADHD presentation Hence, equifinality apparent Slide 19 Slide 20 Role of Parenting Maintaining cause, if not primary cause Parents tend to fight fire with fire Coercive discipline (too lax, too harsh) Cycles of dysregulated emotion Given heritability of ADHD, parents likely to have ADHD symptoms themselves Parent management: PART 2, TOMORROW! Slide 21 Important New Findings Harold et al. (2013a, 2013b) Adoption study in UK Controls for biological relatedness Even in adoptive families, kids levels of ADHD elicit overcontrolling parenting from parents AND, levels of harshness predict further ADHD symptoms, over time Its not all in the genes! Slide 22 Ultimate cause? The real cause of ADHD has to be compulsory education (same as for LD) Certainly, attention or impulse control genes have been around for the history of our species, but extremes not salient until we made children sit and learn to read If its true that achievement pressure reveals ADHD, is it also true that current high rates of pressure are fueling the recent explosion? Slide 23 Developmental Paths Infancy/temperament: Activity level vs. effortful control Preschool Manifestations (S. Campbell) Careful evaluations of 3 and 4 year olds See AAP Guidelines (2011) Prospective predictions to mid-late childhood: PPP =.5! Hence, multifinality apparent That is, suggestions of (a) hell grow out of it and (b) medicate today are each fraught with error Predictors of continuation: (a) severity of early ADHD (b) negativity of early parent/child interaction, controlling for severity of childs ADHD Slide 24 Parenting Influences on Positive Peer Status Hinshaw, Zupan, et al. (1997) Aim: Predict peer acceptance from parenting Ideas About Parenting (Heming et al., 1989) 3 factors = Authoritarian, Authoritative, Permissive Authoritative Factor: 15 items Warmth, Limits, Autonomy Encouragement--e.g., I encourage my child to be independent of me I expect a great deal of my child I have clear, definite ideas about childrearing Raising a child is more pleasure than work When I am angry with my child, I let him know I reason with my child regarding misbehavior Slide 25 Slide 26 Results Mothers of ADHD boys: lower on Authoritative ES =.75 Yet variance in ADHD group equivalent to comparisons Tested predictive power of parenting factors, observed overt and covert behavior, and internalizing score (CDI, observed withdrawal) via hierarchical regressions Neither Authoritarian nor Permissive beliefs predicted peer nominations, but Authoritative beliefs did so (beta =.3), even with diagnostic group controlled Slide 27 Explained Variance in Positive Nominations Slide 28 Moderation and Implications Prediction applies only to ADHD group (beta =.30); for comparisons, beta =.00. Key theme: firm yet affirming parenting style Slide 29 Sex Differences/Female Presentation More in Part 2, tomorrow Another myth: ADHD effects only boys! Our sample (BGALS): Largest in existence of preadolescent girls with ADHD (140, with 88 matched comparison girls) Baseline: marked impairments across symptoms, impairments, neuropsych measures Impairments maintained at 5-year follow-up 11/11 domains, with widening gap in math Sources: Hinshaw (2002); Hinshaw et al. (2006), Journal of Consulting and Clinical Psychology Slide 30 10-year follow-up 95% retention rate (vs. 92% at 5 year) How? Facebook, relentless staff Despite losing ADHD status majority of time, impairments maintain in academics, comorbidities, social functioning. Yet, self-harm findings: Different adolescent path for girls?? Suicide attempts: 22% ADHD-C 8% ADHD-I 6% comparisons NSSI: 51% ADHD-C 29% ADHD-I 19% comparisons Slide 31 BGALS Follow-up: Self-harm 10-year follow-up (M age = 20) Hinshaw et al. (2012), Journal of Consulting and Clinical Psychology Slide 32 Conclusions ADHD not a static entity Different pathways lead to ADHD: Equifinality Differential outcomes from early ADHD symptoms: Multifinality What predicts, moderates, mediates differential outcomes? Peer deficits and social skills; EF deficits; Motivation Developmental, contextual factors crucial Parenting styles, which may not be causal, are important determinants of outcome, even for a condition with h 2 =.7/.8 Systems, health-care, legislative, cultural, stigma-related factors related to underutilization and disparities in care Slide 33 Assessment Full coverage requires a day-long workshop Brief visit: false positives and false negatives Must get informant ratings, for kids, teens, or adults Brief/narrow vs. broader scales Ideal to get info from past as well as present teacher Must get full developmental history Must appraise rule-out and comorbid conditions LD, Anxiety, Depression, etc. require different interventions Slide 34 Tidal Wave/ADHD Explosion National Survey of Childrens Health (Visser et al., 2013) Tidal Wave/ADHD Explosion National Survey of Childrens Health (Visser et al., 2013) Parent-reported ADHD ever diagnosed For all 4-17 year olds in U.S.: 2003: 7.8% 2007: 9.5% 2012: 11.0% > 40% INCREASE IN 9 YEARS! Low income rates now = middle class; Black = White Hispanic lower (but fast growing) Medication higher, too: Just under 70% of those currently diagnosed now receive medication From other sources: Largest medication increases: adolescents, adults Slide 35 Earlier Explosions: 1990s Policy shifts: IDEA: ADHD as OHI Medicaid: authorizes ADHD SSI: ADHD (with other impairment) can qualify Late 1990s: FDA changes regs on DTC ads 2000: Concerta (first effective long-acting form) More and more LBW babies survive Slide 36 Huge Regional Variation Now Rise across entire nation, but major-league state-by-state variation, too 2011-12: Arkansas now #1, Indiana #2, NC #3 NC had been #1 in 2007 Medication trends similar to 2007, but slightly higher overall Slide 37 37 Slide 38 38 Slide 39 What does not explain variation Demographics Hispanic population clearly higher in California, and traditionally the lowest rates of diagnosis Eliminated a little of the CA-NC difference but not most **Hispanic rates growing FAST, esp. in California Rates of health-care providers Explains other disorders, but not here State culture May explain regional differences within state -- but not state-by-state per se Slide 40 ** Consequential accountability 1970s-80s: public school reforms input focused Reduce class size, pay teachers more, etc. Results not consistent; shift in 1990s to output focused I.e., incentivize test score improvements per se Consequential accountabilitydistricts get noted or even cut off from funds, unless test scores go up 30 states implement such laws