Attention deficit Attention deficit hyperactivity disorder hyperactivity disorder (ADHD) and conduct (ADHD) and conduct disorder/problemsdisorder/problems

Paul McArdlePaul McArdle

The true measure of a nation’s standing ishow well it attends to its children – theirhealth and safety, their material security,their education and socialization, andtheir sense of being loved, valued, andincluded in the families and societies intowhich they are born.

Unicef (2007) Child Well-Being in Rich Countries. Innocenti Research Centre

http://www.unicef.ca/portal/Secure/Community/502/WCM/PRESS/IRC7/RC7.pdf

ADHD historyADHD history

►Moral disorder Moral disorder ►Still 1905Still 1905

►Minimal brain damage - 1950Minimal brain damage - 1950►Hyperkinetic syndrome Hyperkinetic syndrome

►Ounsted 1955Ounsted 1955

►Attention deficit disorder with Attention deficit disorder with hyperactivityhyperactivity

►American Psychiatric Association 1981American Psychiatric Association 1981

Diagnostic symptoms Diagnostic symptoms

► InattentionInattention►Over- or hyper-activityOver- or hyper-activity► impulsivityimpulsivity

symptomssymptoms

► InattentionInattention►Often fails to give close attention to details, Often fails to give close attention to details,

makes careless mistakesmakes careless mistakes►Has difficulty sustaining attention in tasks or Has difficulty sustaining attention in tasks or

playplay►Does not seem to listenDoes not seem to listen►Fails to finish tasksFails to finish tasks►Often avoids… sustained mental effortOften avoids… sustained mental effort►Often forgetful, loses thingsOften forgetful, loses things►Easily distracted by extraneous stimuliEasily distracted by extraneous stimuli►Difficulty organising tasks and activitiesDifficulty organising tasks and activities

Symptoms IISymptoms II

►Hyperactivity/impulsivityHyperactivity/impulsivity►Often fidgets,Often fidgets,►Leaves seat in classroomLeaves seat in classroom►Often runs about or climbs excessively in Often runs about or climbs excessively in

situations in which it is inappropriatesituations in which it is inappropriate►Is on the go as if driven by a motorIs on the go as if driven by a motor►Talks excessivelyTalks excessively

Symptoms IISymptoms II

► Hyperactivity/impulsivityHyperactivity/impulsivity► Often fidgets,Often fidgets,► Leaves seat in classroomLeaves seat in classroom► Often runs about or climbs excessively in situations in Often runs about or climbs excessively in situations in

which it is inappropriatewhich it is inappropriate► Is on the go as if driven by a motorIs on the go as if driven by a motor► Talks excessivelyTalks excessively

Often blurts out answersOften blurts out answers Has difficulty waiting turnHas difficulty waiting turn Often interrupts or intrudes on othersOften interrupts or intrudes on others [Runs out in the street, goes off with strangers] [Runs out in the street, goes off with strangers]

Further criteriaFurther criteria

►Early onset before 7 years of ageEarly onset before 7 years of age►Present in more than one settingPresent in more than one setting►Clear evidence of ...significant Clear evidence of ...significant

impairment in social, academic or impairment in social, academic or occupational functioningoccupational functioning

How common is ADHDHow common is ADHD

►5% is usual US figure5% is usual US figure►More boys than girlsMore boys than girls►But less in non-urban and more But less in non-urban and more

traditional societies.traditional societies.►Of 2048 adolescents interviewed in Goa, Of 2048 adolescents interviewed in Goa,

4 had ADHD!4 had ADHD!►Pillai et al (2008) Non traditional lifestyles and Pillai et al (2008) Non traditional lifestyles and

prevalence of mental disorders in adolescents in prevalence of mental disorders in adolescents in Goa, India. British Journal of Psychiatry 192(1):45 Goa, India. British Journal of Psychiatry 192(1):45 – 51.– 51.

Associated featuresAssociated features

► Rejection by peersRejection by peers► Rigid insistence on requests being met and Rigid insistence on requests being met and

bossinessbossiness► Learning and communication disordersLearning and communication disorders► Tics and Tourette's syndromeTics and Tourette's syndrome► Increased accidents, including driving accidents Increased accidents, including driving accidents

and fatal crashesand fatal crashes► Mood lability, unhappiness, demoralizationMood lability, unhappiness, demoralization► Antisocial behaviour, substance misuse, crime Antisocial behaviour, substance misuse, crime

► Barkley RA. Cox D. A review of driving risks and impairments Barkley RA. Cox D. A review of driving risks and impairments associated with attention-deficit/hyperactivity disorder and associated with attention-deficit/hyperactivity disorder and the effects of stimulant medication on driving performance. the effects of stimulant medication on driving performance. Journal of Safety Research. 38(1):113-28, 2007.Journal of Safety Research. 38(1):113-28, 2007.

Even if IQ is unaffectedEven if IQ is unaffected

►Children with ADHDChildren with ADHD Cannot Cannot

►Concentrate, communicate, read and write, Concentrate, communicate, read and write, self-organize, befriend and play to the same self-organize, befriend and play to the same level as other children of the same agelevel as other children of the same age

►Are often judged by parents to be at greater Are often judged by parents to be at greater risk than others andrisk than others and

►Are typically distressed and unhappy even to Are typically distressed and unhappy even to the degree of 'clinical depression'the degree of 'clinical depression'

What is thought to be the cause What is thought to be the cause of ADHDof ADHD

►Nature – a neurological or brain Nature – a neurological or brain conditioncondition

►Nurture – a product largely of Nurture – a product largely of environment (but perhaps also environment (but perhaps also affecting brain development)affecting brain development)

►Both nature and nurture – both brain Both nature and nurture – both brain and environmentand environment

Further ADHD comorbidityFurther ADHD comorbidity

►With pragmatic language/ social With pragmatic language/ social interaction deficits similar to PDDinteraction deficits similar to PDD

► Geurts et al (2004) Can the Childrens Geurts et al (2004) Can the Childrens Communication Checklist differentiate between Communication Checklist differentiate between children with autism, ADHD and normal controls? children with autism, ADHD and normal controls? JCPP (45) 1437-1453JCPP (45) 1437-1453

► Bishop & Baird (2002) Parent and teacher report Bishop & Baird (2002) Parent and teacher report of pragmatic aspects of communication. Use of of pragmatic aspects of communication. Use of the CCC in a clinical setting. Developmental the CCC in a clinical setting. Developmental Medicine and Child Neurology 43:809-818Medicine and Child Neurology 43:809-818

► Gilmour J. et al (2004) Social communication Gilmour J. et al (2004) Social communication deficits in conduct disorder: a clinical and deficits in conduct disorder: a clinical and community survey. JCPPcommunity survey. JCPP 45(5):967-78. 45(5):967-78.

A neurological/brain A neurological/brain condition condition

►Executive function deficit, deficit of Executive function deficit, deficit of frontal cortical functioningfrontal cortical functioning 'goal directed behaviour''goal directed behaviour'

Barkley et al (1997) ADHD and the Nature of Self Barkley et al (1997) ADHD and the Nature of Self Control New York Guilford PressControl New York Guilford Press

►Working memory deficitsWorking memory deficits Rapport MD. et al (2008) Working memory deficits in Rapport MD. et al (2008) Working memory deficits in

boys with attention-deficit/hyperactivity disorder boys with attention-deficit/hyperactivity disorder (ADHD): the contribution of central executive and (ADHD): the contribution of central executive and subsystem processes. Journal of Abnormal Child subsystem processes. Journal of Abnormal Child Psychology. 36(6):825-37.Psychology. 36(6):825-37.

Trends CD and comorbidityTrends CD and comorbidity

0

0.2

0.4

0.6

0.8

1

1.2

1974 1986 1999

girls

boys

0

2

4

6

8

10

12

14

1974 1986 1999

HA +CD

Increased disturbance: parental Increased disturbance: parental reportreport

0

5

10

15

20

25

1974 1986 1999

boys[ep]

girls[ep]

Collishaw et al (2004) JCPP 45: 1350-1362

0

2

4

6

8

10

12

14

16

18

1974 1986 1999

boys[cp]

girls[cp]

Increased disturbance: self-Increased disturbance: self-reportreport

0

5

10

15

20

25

30

35

40

1987 1999

n/m

III

IV/V

West & Sweeting 2003 JCPP 44:399-411

Trends GHQ scores west of Trends GHQ scores west of scotlandscotland

0

5

10

15

20

25

30

1987 1999 2006

male

female

0

2

4

6

8

10

12

14

16

18

1973 1994

R>10

reading

rejection

isolation

Mortality 15-19 year oldsMortality 15-19 year olds

ADHD and CDADHD and CD

► 'ADHD+CD is a quantitative variant of 'ADHD+CD is a quantitative variant of ADHD-related behaviours’ ADHD-related behaviours’

► Thapar 2001Thapar 2001► Heritability of antisocial behaviour is Heritability of antisocial behaviour is

mediated by a ‘callous unemotional’ trait mediated by a ‘callous unemotional’ trait (Viding et al 2005)(Viding et al 2005)

► Also:Also:► ‘‘Gene environment correlations …gene-Gene environment correlations …gene-

environment interactions…environment interactions…Genetic Genetic influences … are strong and pervasive but influences … are strong and pervasive but rarely determinative” rarely determinative”

► Rutter 2002Rutter 2002

Shaw et al 2008 Proceedings of the National Association of Science

NatureNature

►Brain Brain injury – trauma, anoxia or chemicalinjury – trauma, anoxia or chemical Development affected by genetic factorsDevelopment affected by genetic factors

E.g. Martin et al (2002) Observer effects and E.g. Martin et al (2002) Observer effects and heritability of childhood ADHD symptoms British heritability of childhood ADHD symptoms British Journal of Psychiatry 180:260-265Journal of Psychiatry 180:260-265

NurtureNurture

►Extreme early deprivationExtreme early deprivation 'neurodevelopmental programming''neurodevelopmental programming'

► Stevens et al (2008) inattention/overactivity Stevens et al (2008) inattention/overactivity following severe early institutional deprivation – following severe early institutional deprivation – presentation in early adolescence. Journal of presentation in early adolescence. Journal of Abnormal Child Psychology 36(3):285-293.Abnormal Child Psychology 36(3):285-293.

NurtureNurture

►Extreme early deprivationExtreme early deprivation 'neurodevelopmental programming''neurodevelopmental programming'

► Stevens et al (2008) inattention/overactivity Stevens et al (2008) inattention/overactivity following severe early institutional deprivation – following severe early institutional deprivation – presentation in early adolescence. Journal of presentation in early adolescence. Journal of Abnormal Child Psychology 36(3):285-293.Abnormal Child Psychology 36(3):285-293.

►Subtle deprivationSubtle deprivation

Subtle deprivationSubtle deprivation

►““A major study by Play England, part A major study by Play England, part of the National Children's Bureau, of the National Children's Bureau, found that 51% of children had been found that 51% of children had been stopped from climbing trees, 21% from stopped from climbing trees, 21% from playing conkers and 17% from playing playing conkers and 17% from playing games of tag and chase... 'Children games of tag and chase... 'Children are not allowed the freedoms that are not allowed the freedoms that were taken for granted when we were were taken for granted when we were children'”children'” Observer Aug 3rd 2008Observer Aug 3rd 2008

Subtle deprivationSubtle deprivation

► 'In the West, children are not only 'In the West, children are not only socialized into a system that promotes socialized into a system that promotes individualism, competitiveness, and individualism, competitiveness, and inequality and rejects forms of authority inequality and rejects forms of authority but also have to live in the unstable but also have to live in the unstable family structures such an ideology family structures such an ideology produces (including) ..ambivalence produces (including) ..ambivalence towards children'towards children'

Timimi S (2005) the effect of globalization on Timimi S (2005) the effect of globalization on children's mental health BMJ 331:37-39children's mental health BMJ 331:37-39

Subtle deprivationSubtle deprivation

► 'In the West, children are not only socialized 'In the West, children are not only socialized into a system that promotes individualism, into a system that promotes individualism, competitiveness, and inequality and rejects competitiveness, and inequality and rejects forms of authority but also have to live in forms of authority but also have to live in the unstable family structures such an the unstable family structures such an ideology produces (including) ..ambivalence ideology produces (including) ..ambivalence towards children'towards children'

Timimi S (2005) the effect of globalization on children's Timimi S (2005) the effect of globalization on children's mental health BMJ 331:37-39mental health BMJ 331:37-39

► Highest rates of disorder among those with Highest rates of disorder among those with ‘non-traditional life-styles ‘non-traditional life-styles

► Pillai et al 2008Pillai et al 2008

Later perpetuating or Later perpetuating or aggravating factors: mechanismaggravating factors: mechanism►‘‘social and executive function social and executive function

demands of late adolescence demands of late adolescence overload the late developing overload the late developing prefrontal cortex, giving rise to prefrontal cortex, giving rise to prefrontal dysfunction and a lack of prefrontal dysfunction and a lack of inhibitory control over antisocial, inhibitory control over antisocial, violent behavior that peaks at this violent behavior that peaks at this age’age’

Raine (2002) Raine (2002) The role of prefrontal deficits, low The role of prefrontal deficits, low autonomic arousal, and early health factors in the autonomic arousal, and early health factors in the development of antisocial and aggressive development of antisocial and aggressive behavior in children behavior in children JCPP43:410434JCPP43:410434

ADHD and creativityADHD and creativity

► ‘‘His most extraordinary quality… was his titanic His most extraordinary quality… was his titanic energy. He could not sit still or stay long in the energy. He could not sit still or stay long in the same place. He walked so quickly … that those in same place. He walked so quickly … that those in his company had to trot to keep up with him. When his company had to trot to keep up with him. When forced to do paperwork, he paced around a stand forced to do paperwork, he paced around a stand up desk. Seated at a banquet, he would eat for a up desk. Seated at a banquet, he would eat for a few minutes, then spring up to see what was few minutes, then spring up to see what was happening in the next room or to take a walk happening in the next room or to take a walk outdoors… When he had been in one place for a outdoors… When he had been in one place for a while, he wanted to leave… The most accurate while, he wanted to leave… The most accurate image … is of a man who throughout his life was image … is of a man who throughout his life was perpetually… restless, perpetually in movement.’perpetually… restless, perpetually in movement.’ From Peter the Great by Robert K Massie.From Peter the Great by Robert K Massie.

ADHD and creativityADHD and creativity

► ‘‘His most extraordinary quality… was his titanic His most extraordinary quality… was his titanic energy. He could not sit still or stay long in the energy. He could not sit still or stay long in the same place. He walked so quickly … that those in same place. He walked so quickly … that those in his company had to trot to keep up with him. When his company had to trot to keep up with him. When forced to do paperwork, he paced around a stand forced to do paperwork, he paced around a stand up desk. Seated at a banquet, he would eat for a up desk. Seated at a banquet, he would eat for a few minutes, then spring up to see what was few minutes, then spring up to see what was happening in the next room or to take a walk happening in the next room or to take a walk outdoors… When he had been in one place for a outdoors… When he had been in one place for a while, he wanted to leave… The most accurate while, he wanted to leave… The most accurate image … is of a man who throughout his life was image … is of a man who throughout his life was perpetually… restless, perpetually in movement.’perpetually… restless, perpetually in movement.’ From Peter the Great by Robert K Massie.From Peter the Great by Robert K Massie.

treatmenttreatment

►Structure and support in schoolStructure and support in school►Opportunities for active playOpportunities for active play►MentorsMentors►Parent trainingParent training►Supportive medication Supportive medication