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

This informative article explores the causes and models of ADHD, the rising prevalence of the disorder, and the implications for policies. It addresses common myths and facts about ADHD and discusses the impact of impairment on academic, social, and family domains. The article also examines the differences between DSM-5 and RDoC criteria for ADHD and explores cross-cultural variations in diagnosis and treatment. Additionally, it delves into the neural profiles and potential causes of ADHD, including genetics, epigenetics, and other risk factors.

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

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  1. 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

  2. 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)

  3. 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 outcomes—if it’s a gift, in the words of Ned Hallowell, it’s hard to unwrap

  4. 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

  5. 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 comorbidity…AND key comorbidities don’t respond optimally to ADHD tx • E.g., LD, delinquency, depression

  6. 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

  7. 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

  8. 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

  9. (Motivation) (Attention) (Motivation) (Attention)

  10. Transporter PET Image (Motivation) (Attention)

  11. 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

  12. 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 S’s not ‘doing anything’; more ‘intrusions’ into task performance in ADHD

  13. 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

  14. 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

  15. Other Risk Factors • Low birthweight • Predicts ADHD, LD, Tourette’s, 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

  16. 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

  17. 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!

  18. 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 • It’s not all in the genes!

  19. 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 it’s true that achievement pressure “reveals” ADHD, is it also true that current high rates of pressure are fueling the recent explosion?

  20. 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) “he’ll 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 child’s ADHD

  21. Parenting Influences on Positive Peer StatusHinshaw, 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”

  22. 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

  23. Explained Variance in Positive Nominations

  24. Moderation and Implications • Prediction applies only to ADHD group (beta = .30); for comparisons, beta = .00. • Key theme: “firm yet affirming” parenting style

  25. Sex Differences/Female PresentationMore 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

  26. 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

  27. BGALS Follow-up: Self-harm10-year follow-up (M age = 20)Hinshaw et al. (2012), Journal of Consulting and Clinical Psychology

  28. 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

  29. 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

  30. Tidal Wave/ADHD ExplosionNational Survey of Children’s 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

  31. 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

  32. 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

  33. 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

  34. **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 accountability—districts get ‘noted’ or even cut off from funds, unless test scores go up • 30 states implement such laws <2000 • Then, becomes law of the land for all states with No Child Left Behind (takes effect 2002-3)

  35. 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

  36. FindingsFrom “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 Obama’s dismantling of NCLB

  37. 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 N=24,982 (2003), 22,467 (2007), 24,426 (2011) Sources: 2003, 2007, and 2011 National Survey of Children’s Health

  38. “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 district’s average test score! • Gaming the system, although NCLB eventually outlaws this • Why poorest kids? NCLB targets Title I schools

  39. 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. > 50% RISE IN OTHER STATES

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

  41. 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

  42. 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

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

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