The ADHD Explosion Part 1: Causes, Models, Rising Prevalence, and Policy Implications

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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

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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)

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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

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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
  

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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

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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 lt 12 years,
  not lt 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

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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

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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-naïve adult sample, PET scans of
  transporters and receptors

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(Motivation)
(Attention)
(Motivation)
(Attention)
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Transporter PET Image
(Motivation)
(Attention)
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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

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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

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ADHD Causes

• Heritability and Genes
• H2 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

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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

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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

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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

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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!

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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!

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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?

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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

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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

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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

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Explained Variance in Positive Nominations
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Moderation and Implications

• Prediction applies only to ADHD group (beta
  .30) for comparisons, beta .00.
• Key theme firm yet affirming parenting style

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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

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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

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BGALS Follow-up Self-harm
10-year follow-up (M age 20)Hinshaw et al.
(2012), Journal of Consulting and Clinical
Psychology
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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 h2 .7/.8
• Systems, health-care, legislative, cultural,
  stigma-related factors related to
  underutilization and disparities in care

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AssessmentFull 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

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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
• gt 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

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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

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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

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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

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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 lt2000
• Then, becomes law of the land for all states with
  No Child Left Behind (takes effect 2002-3)

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Consequential accountability laws prior to NCLB
(but not psychotropic medication laws) In the
South
Sources Investigators' Research, Dee Jacob
2011, Dee Jacob 2006, and Center for Education
Policy
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Findings From triple
difference model

• Between 2003-2007, in the 20 NCLB states,
  poorest children showed huge increases in ADHD
  Dx
• In these states, 59 increase in ADHD dx for kids
  within 200 of FPL
• vs. only 8 in middle- or upper-class kids
• Nothing like that in states with previous
  consequential accountability (all kids in those
  states went up 20 or so)
• Nothing like that in private schools
• This trend reverses by 2012, with Obamas
  dismantling of NCLB

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Consequential accountability introduced via NCLB
was associated with higher ADHD diagnostic
prevalence increases among low-income children
aged 8-13 from 2003-2007, but there was no
association from 2007-2011 (unadjusted results)
District of Columbia is included within the 21 No
Child Left Behind consequential accountability
states. NCLB No Child Left Behind FPL Federal
poverty level N24,982 (2003), 22,467 (2007),
24,426 (2011) Sources 2003, 2007, and 2011
National Survey of Childrens Health
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Unintended effect

• Accountability laws encourage ADHD diagnosis for
  at least two reasons
• 1 Diagnosis may lead to treatment, which may
  help boost achievement test scores
• Scheffler et al. (2009), Zoega et al. (2012)
• 2 In some states/districts, diagnosed youth are
  excluded from the districts average test score!
  
• Gaming the system, although NCLB eventually
  outlaws this
• Why poorest kids? NCLB targets Title I schools

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Psychotropic medication laws

• In 2001, Connecticut passed a law pushing back
  against rising ADHD medication use in students
• By now, 14 states have passed such psychotropic
  medication laws, of one or more of 3 types
• Schools are prohibited from recommending meds
• Schools cannot require meds as a condition of
  enrollment
• Parental refusal to medicate the child cannot, in
  and of itself, be considered neglect
• IN THESE STATES, NO RISE IN ADHD DIAGNOSES FROM
  2003-2012, VS. gt 50 RISE IN OTHER STATES

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Findings

• In the 14 states with these laws, essentially no
  change in ADHD diagnostic prevalence between 2003
  and 2011, versus a gt 50 increase in other
  states!

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Where have we been?

• ADHD requires multi-level thinking
• Genes matter
• Families matter
• Cultural values placed on performance matter
• Educational policies matter
• Pharma matters
• ADHD is too important and too impairing to think
  about it reductionistically
• When kids, learning, schools, productivity, and
  medicating young minds are in play, stakes are
  high

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Diversion (Part 2 tomorrow)

• Define non-prescription use
• Rates extremely high (why??)
• How effective are stimulants as neuroenhancers
  for general population?
• Smith Farah (2011), Psychological Bulletin
• Ilieva et al. (2013), Neuropharmacology
• Rates of abuse/addiction Policy implications

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Thanks

• NIMH and NIDA grants
• Robert Wood Johnson Policy Investigator Award
• Participants in many studies
• The Help Group
• You, the audience