adhd across the lifecycle: definitions and...
TRANSCRIPT
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ADHD Across the Lifecycle: Definitions and Overview
Joseph Biederman, MD Professor of Psychiatry Harvard Medical School
Chief, Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD
Massachusetts General Hospital
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Disclosures
• My spouse/partner and I have the following relevant financial relationship with a commercial interest to disclose: – Research support: DOD, FDA, AACAP , Alcobra, Forest Research
Institute, Ironshore, Lundbeck, Magceutics Inc., Merck, PamLab, Pfizer, Shire Pharmaceuticals Inc., SPRITES, Sunovion, Vaya Pharma/Enzymotec, and NIH.
– Royalties paid to the Department of Psychiatry at MGH, for a copyrighted ADHD rating scale used for ADHD diagnoses: Ingenix, Prophase, Shire, Bracket Global, Sunovion, and Theravance
– US Patent Application (Provisional Number #61/233,686) through MGH corporate licensing, on a method to prevent stimulant abuse.
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0 5 10 15 20 Prevalence of ADHD (%)
Puerto Rico New York City
Pittsburgh Iowa
Tennessee Minnesota
Oregon Missouri Virginia
North Carolina N.Y., Mich., Wis.
India China
Netherlands New Zealand
Japan Brazil
Ukraine Germany
Netherlands/Belgium Switzerland
Israel United Kingdom
Ireland Canada
New Zealand Spain
0 5 10 15 20 Prevalence of ADHD (%)
Worldwide Prevalence of ADHD in Children
Faraone SV et al. (2003), World Psychiatry 2(2):104-113
USA Ex USA
www.mghcme.org Akinbami et al. NCHS Data Brief No. 70, August 2011
www.mghcme.org Zuvekas al. Am J Psychiatry 2012; 169:160-166
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Poor Adherence to Treatment in ADHD
• Despite the well documented morbidity of ADHD and the marked efficacy and safety of stimulants, the failure to adhere to medications after one year is as high as 87%!! (Safren 2007)
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Long Delays in the Initiation of Treatment (n=1498)
3.3
7.8
0
1
2
3
4
5
6
7
8
9
Age of Onset of Diagnosis Age of Onset of Treatment
p < 0.001
MGH Pediatric Psychopharmacology Clinic
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Inattention
Impulsivity/Hyperactivity
ADHD: Core Symptom Areas
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Course of ADHD Symptoms Over Time by Sex: A Growth Curve Model
Age by Sex Interaction: NS
Biederman et al. 2009
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ADHD: Course of the Disorder
Inattention
Time
Hyperactivity
Impulsivity
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Age-Dependent Decline and Persistence of ADHD Throughout the Lifetime
Faraone et al. Nature Reviews Disease Primers 2015
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Persistent Controversy BMJ | 3 april 2010 | Vol 340
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Changes in DSM-V ADHD
• “Neurodevelopmental” - not “disruptive” • ≥ 6/9 inattentive or ≥ 6/9 impulsive/hyperactive
symptoms over last six months (>5 for adults) • Symptoms caused impairment by age 12 (no
longer 7) • ASDs no longer exclusionary • No more “subtypes”; Inattentive / Hyperactive-
impulsive / Combined are now “Presentations” • Restricted inattentive subtype: In Appendix,
worthy of further study
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ADHD as a Brain Disorder: Neuroimaging Findings
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MRI findings in Adult with ADHD
Seidman et al. Biol Psychiatry, 2006; 60: 1071-1080
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Volumetric reductions in light blue (frontal and cerebellar regions)
Superior frontal gyrus
Anterior cingulate gyrus
Cerebellar cortex
Seidman et al. Biol Psychiatry, 2006; 60: 1071-1080
Volume Reductions in Adult ADHD
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•Dorsolateral Frontal Cortex (BA 8, 9)
•Supramarginal Gyrus (BA 40)
•Superior Temporal Gyrus (BA 22)
•Angular Gyrus (BA 39)
•Middle Temporal Gyrus (BA 21)
Makris et al. Cerebral Cortex June 2007; 17:1364-1375
Cortical Thickness Analysis in Adult with ADHD
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•Anterior Cingulate Gyrus (BA 24)
•Orbital Frontal Cortex ((BA 11, 12, 13, 14)
•Orbital Frontal Cortex ((BA 11, 12, 13, 14)
Makris et al. Cerebral Cortex June 2007; 17:1364-1375
Cortical Thickness Analysis in Adult with ADHD
www.mghcme.org Reproduced from Makris N, et al. Cerebral Cortex. 2007; doi:10.1093/cercor/bhm156.
A DTI-MRI Study of Connections in ADHD
Makris et al. Cerebral Cortex 2008 May;18(5):1210-20
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MGH-NMR Center & Harvard- MIT CITP Bush et al, Biological Psychiatry 1999
1 x 10 -3
1 x 10 -2 y = +21 mm
Normal Controls 1 x 10 -2
1 x 10 -3
y = +21 mm
ADHD
Dorsal Anterior Cingulate Cortex (Cognitive Division) Fails to Activate in ADHD
www.mghcme.org Bush et al. Arch Gen Psychiatry. 2008:65:102-114.
0
0.5
1
1.5
2
2.5
Baseline 6 Weeks
OROS MPHPlacebo
• fMRI at baseline and again at week 6 • OROS MPH group showed higher daMCC activation at 6 weeks vs placebo • N=21 adults with ADHD; dosing to 1.3 mg/kg/day OROS MPH or placebo
P = 0.02 vs PBO
Methylphenidate Activates Dorsal Anterior Midcingulate Cortex
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www.mghcme.org Nakao et al. Am J Psychiatry 2011
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www.mghcme.org Faraone et al. Nature Reviews Disease Primers 2015
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Brain Mechanisms in ADHD Faraone et al. Nature Reviews Disease Primers 2015
The executive control and cortico-cerebellar networks coordinate EFs
The DLPC is linked to WM, the VMPFC to complex decision making and strategic planning, and the parietal cortex to attention
The VMPFC, OFC & ventral striatum are the brain network associated with anticipation and reward
The frontal and parietal cortices and the thalamus support attentional functioning
Negative correlations between the DMN and the frontoparietal control network are weaker in patients with ADHD
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Resting-State Functional Connectivity in a Longitudinal
Sample of ADHD Children Grown Up
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Adult ADHD: Decreased Positive Correlations Between PCC-MPFC
• 20 ADHD participants (mean age = 34.9; 16 male) – Ascertained retrospectively
• 20 Controls (mean age = 31.2; 14 male)
Castellanos et al., 2008
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Reduced MPFC-PCC Coupling Reflects Current Diagnostic State of ADHD
Mattfeld et al. Brain: A Journal of Neurology 2014, epub: June 10, 2014
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Neural Basis of Persistent ADHD
• Persistent ADHD alters intrinsic functional organization of the brain
• Findings supports the idea that adult ADHD diagnosis reflects a true brain difference (vs. controls & vs. remitting ADHD)
Mattfeld et al. Brain: A Journal of Neurology 2014, epub: June 10, 2014
www.mghcme.org Mattfeld et al. Brain: A Journal of Neurology 2014, epub: June 10, 2014
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ADHD Imaging Studies Summary
• Neuroimaging studies confirm that brain abnormalities in fronto-subcortical networks are associated with ADHD
• Neuroimaging techniques are not valid tools for ADHD diagnosis; imaging measures are not sensitive or specific enough to be used for diagnostic purposes
• Treatment attenuate neural deficits
Spencer et al. J Clin Psychiatry 2013 Sep;74(9):902-17.
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ADHD as a Neurobiological Disorder: Catecholamine Dysregulation
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Frontosubcortical Networks and Catecholamines
• Dopaminergic and noradrenergic dysregulation abnormalities in fronto subcortical pathways
• Medications that are effective in ADHD are either dopaminergic or noradrenergic
Zametkin. J Am Acad Child Adolesc Psychiatry. 1987;26(5):676-686.
Zametkin. J Am Acad Child Adolesc Psychiatry. 1987;26(5):676-686
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MESENCEPHALON
PONS
MEDULLA Raphe nuclei (serotonin)
Substantia nigra tegmentum (dopamine)
Locus ceruleus (norepinephrine)
to cerebellum
to cord
to diencephalon and cerebrum
Brain Stem
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ADHD as a Neurobiological Disorder: Genetic Findings
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Genetic Basis
of ADHD
ADHD: Genetics
Twin Studies Family Studies
Adoption Studies Molecular Genetics
www.mghcme.org Mean heritability of ADHD = .75 Faraone et al. Biol Psychiatry. 2005;57:1313-23.
ADHD
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Matheny 1971
Willerman 1973
Goodman 1989
Gillis 1992
Edelbrock 1992
Stevenson 1992
Schmitz 1995
Thapar 1995
Gjone 1996
Silberg 1996
Sherman 1997
Levy 1997
Nadder 1998
Hudziak 2000
Willcutt 2000
Thapar 2000
Coolidge 2000
Kuntsi 2001
Martin 2002
Rietveld 2003
Laarson 2004
Heritability
Panic Disorder Schizophrenia Height
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Genetics of ADHD
Faraone et al. Nature Reviews Disease Primers 2015
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Dopamine Transporter (DAT)
Dopamine Receptor (DRD4)
Presynaptic Neuron
Methylphenidate (MPH)
Dopamine
The Dopamine Story...
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Measuring Changes in Dopamine
T Y R O S I N E
D A
D O P A
D A
D A
D A
M A O
D O P A C
D A
T Y R O S I N E
D A
D O P A
D A
D A
D A
M A O
D O P A C
D A
D A D A D A D A
D A D A D A
m e t h y l p h e n i d a t e
C O N H C H 2
C l C l
O 1 1 C H 3 H O N C 2 H 5
H
[ 1 1 C ] r a c l o p r i d e
C O N H C H 2
C l C l
O 1 1 C H 3 H O N C 2 H 5
H
[ 1 1 C ] r a c l o p r i d e
R R R R R R
Dopamine Stress Test
Volkow, Swanson. Am J Psychiatry. 2003 Nov;160(11):1909-18
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After Oral MPH Baseline
DAT PET Imaging (Altropane) with and without oral MPH
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DAT Binding (age-corrected) in Right Caudate by Diagnosis
2.7
2.8
2.9
3
3.1
3.2
3.3
3.4
3.5
ADHD Controls
DAT
Bind
ing p <0.008
N=21 N=26
15 %
Spencer et al Biol Psychiatry 2007
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New Results from Genomewide Association Studies (GWAS)
010
,000
20,0
0030
,000
40,0
00
Y2012 Y2014 Q4_2015 Q1_2019
Number of ADHD GWAS Samples
Faraone et al, 2015
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Preliminary ADHD meta-analysis 18,284 cases 33,836 controls
Preliminary analyses suggest eight genome-wide significant loci Faraone et al, 2015
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FOXP2 association
Faraone et al, 2015
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Maternal Smoking During Pregnancy: Results in Children
22%
8%
0%
5%
10%
15%
20%
25%
ADHD Controls
* P=0.04, controlling for SES, parental ADHD, and parental IQ
P=0.002
N=140 N=120
Hist
ory
of M
ater
nal
Smok
ing
(%)
Milberger et al. Am J Psychiatry 1996;153:1138.
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1.5
1.7
1.9
2.1
Nicotine (6) Control (6)
Volu
me
(x10
9 µm
3 )
(14% reduction, P<0.001)
Cingulate Cortex
Prenatal nicotine exposure reduces the volume of the cingulate cortex
*
Bhide et al 2009
Prenatal Nicotine Exposure: Effects on Brain Structure
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Prenatal Exposure (PNE (F1) Mice Have Increased Spontaneous Locomotor Activity
F1 - Female
F1 - Male
www.mghcme.org Zhu et al. J Neuroscience 2012; 32(27):9410-9418
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ADHD Diagnostic Considerations
Inattention
Impulsivity/Hyperactivity
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00.10.20.30.40.50.60.70.80.9
1
Cum
ulat
ive
Mor
bidi
ty R
isk
Control ADHD
P ≤ .009 for all categories
Biederman et al. Psychological Medicine, 2006, 36, 167–179.
Cumulative Morbidity Risks for Psychiatric Disorders in ADHD and Control Probands
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Biederman et al. AJP. April 2010
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Parental Support at the 16-Year Follow-Up
13.3% 15.9%
26.6%
38.0%
0%5%
10%15%20%25%30%35%40%
Financially Dependent on Parents Lives with Parents
Controls ADHD
z=2.13 p=0.03
z=2.45 p=0.01
Biederman et al. JCP 2012
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84.6%
37.9%
0%10%20%30%40%50%60%70%80%90%
100%
Controls ADHD
z=-4.78 p<0.001
Biederman et al. JCP 2012
College Graduate at the 16-Year Follow-Up
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1.9
2.5
0.0
1.0
2.0
3.0
4.0
5.0
Controls ADHD
z=3.47 p=0.001
Biederman et al. JCP 2012
Holli
ngsh
ead
Mea
n Sc
ore
(Hig
her S
core
= H
ighe
r SES
Overall SES at the 16-Year Follow-Up
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Biederman et al. JCP 2012
6.1 6.6
5.1 5.2
0.01.02.03.04.05.06.07.08.09.0
Educational Level (1 to 7) Occupational Level (1 to 9)
Controls ADHD
Holli
ngsh
ead
Mea
n Sc
ore
(Hig
her S
core
= H
ighe
r SES
z=-5.36 p<0.001
z=-3.12 p=0.002
Educational and Occupational Level at the 16-Year Follow-Up
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Biederman et al. Pediatrics 2009 Jul;124(1):71-8.
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Protective Effect of Stimulants on Comorbidity
Biederman et al. Pediatrics 2009
χ2(1) =19.7, p<0.001 χ2
(1) =17.8, p<0.001
χ2(1) =3.5, p=0.063
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Protective Effect of Stimulants on Comorbidity
χ2(1) =21.4, p<0.001
χ2(1) =19.9, p<0.001
χ2(1) =1.3, p=0.258
Biederman et al. Pediatrics 2009
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Protective Effect of Stimulants
χ2(1) =18.4, p<0.001
Biederman et al. Pediatrics 2009
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67
ADHD and Substance Abuse
Wilens et al. J Nerv Ment Dis. 1997;185(8): 475-482.
Risk for Substance Use Disorder (SUD) Onset in Adults With Untreated ADHD
Control ADHD
P ≤0.05, ADHD vs control at end point
Risk
for S
UD
(%)
0 10 20 30 40 50 60 70 80 90
100
Age at onset (years) 0 10 20 30 40 50 60
Earlier onset
Higher risk
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SUD in ADHD Youth Growing Up: Overall Rate of Substance Use Disorder
0
5
10
15
20
25
30
35
Control (n=344)
Medicated (n=117)
Unmedicated (n = 45)
Perc
ent o
f Gro
up
p < 0.001
Biederman, Wilens, Mick et al., Pediatric 1999
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0 10 30 20
25
50
75
100
Age
*p<0.05 vs. Controls
%
Biederman et al. Am J Psychiatry. 2008 Mar 3
No Stimulant Therapy*
Controls
Stimulant Therapy*
*p<0.05 vs. Controls
Stimulant Therapy and Subsequent Risk for Substance Dependence Disorders
www.mghcme.org Humphreys et al. JAMA Psychiatry 2013
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0 4 8 12 16 20
0
0.1
0.3
0.4
0.5
0.6
Age (years)
Su
rviv
al P
rob
abil
ity
Milberger S, et al. J Am Acad Child Adolesc Psychiatry. 1997:36;37-44.
P<.003
Onset of Nicotine Use in Children and Adolescents with ADHD
ADHD
Control
0.2
2 6 10 14 18 22
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Hammerness et al. J Pediatr 2012
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Prospective Study of OROS MPH vs. non-ADHD and ADHD
Omnibus test, chi-squared(1)=8.44, p=0.04
8.6 7.1 8.3
20.8
0
5
10
15
20
25
Non-ADHD (n=177)
OROS MPH (n=154)
ADHD Current Meds (n=36)
ADHD Not Current Meds
(n=49)
% current smoking according to Fagerstrom Tolerance Questionnaire
p=0.02
p=0.007
Not significant (all p>0.60)
Hammerness and Biederman, Jounal of Pediatrics 2012
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Lichtenstein et al. New Eng J Med 2012;367(21):2006-14.
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Novel Comorbidities
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Emotional Dysregulation
www.mghcme.org (Kim 2011 Behavioral Brain Research)
Amgydala-Prefrontal Circuitry Amygdala: Red Ventromedial prefrontal cortex: Blue Dorsomedial prefrontal cortex: Green
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Deficient Emotional Self Regulation in Youth with ADHD
2%
44%
0
10
20
30
40
50
60
Controls ADHD
χ2(1)=108.4, p<0.001 %
% subjects with ADHD-associated severe impairment
32%
50%
0
10
20
30
40
50
60
ADHD ADHD+DESR
z=2.49, p=0.01
%
Spencer et al. Postgrad Med. 2011
Sep;123(5):50-9.
Rates of DESR
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Autistic Traits
www.mghcme.org Clinical and Research Programs in Pediatric Psychopharmacology
Autism
From Autism to Autistic Traits
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Autistic Traits in ADHD Children
18.0%
1.0% 0%
5%
10%
15%
20%
25%
ADHD Probands Control Probands
p <0.001
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PTSD and TBI
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•For each comparison, the dot gives the relative risk and the horizontal line gives the 95% confidence interval
•The center of the diamond at the bottom gives the weighted relative risk across all studies and the width of the diamond gives its 95% confidence interval
NORMAL CONTROLS Antshel 2013 Ruhl 2009 Kessler 2006 Bernardi 2012 Park 2010 Biederman 2012 Hurtig 2007 Smalley 2007 Wozniak 1999 Subtotal
PSYCHIATRIC CONTROLS McLeer 1994 (PSY) Ford 2000 Subtotal
TRAUMA CONTROLS Daud 2009 (non-TP) Daud 2009 (TP) McLeer 1994 (SA) Husain 2008 Subtotal
Citation
Adult Adult Adult Adult Adult Adult Child Child Child
Child Child
Child Child Child Child
Age
ADHD Population Population Population Population ADHD ADHD ADHD ADHD
Population ADHD
Population Population Population Population
Sample
1 .01 .5 1 10 100
Relative Risk for PTSD
Spencer-Kimchi et al. 2014 submitted
Forest Plot of Studies Examining the ORs of PTSD in ADHD
PSY=psychiatric sample. SA=Sexually abused sample. TP=Sample of refugee children with tortured parents. Non-TP=Sample of refugee children with non-traumatized parents.
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Forest Plot of Studies Examining the ORs of ADHD after mTBI
www.mghcme.org Man et al. Pediatrics. 2014 Dec 15.
www.mghcme.org Mikolajczyk et al. JAMA Pediatr. 2015; doi: 10.1001/jamapediatrics.2014.3275
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Functional Impairments
Results of A Survey of 1000 Subjects with and without ADHD
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Educational Impairment in High School
*
*
*
*
* p ≤.001
Percentage of Those Who Attended High School
52% 27%
37% 13%
37% 10%
30% 8%
"C" average or lower
Had a tutor
Had special classes
Had to repeat a grade
ADHD (N=464)
Non-ADHD (N=487)
Biederman et al. J Clin Psychiatry. 2006 Apr; 67(4):524-40
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Current Employment Status
*
*
*
*
* p ≤.001
Percentage of Each Group
52% 72%
34% 57%
48% 27%
14% 5%
Currently employed
Employed full time
Not currently employed
Looking for work ADHD (N=500)
Non-ADHD (N=501)
Biederman et al. J Clin Psychiatry. 2006 Apr; 67(4):524-40
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Average Household Income by Education Level Attained
$23,859
$46,471
$66,683
$91,316
$29,577 $38,733
$63,086
$52,404
$0$10,000$20,000$30,000$40,000$50,000$60,000$70,000$80,000$90,000
$100,000
Less than HighSchool
High School/SomeCollege
College/Some Post-Grad
Post-graduateDegree
Control ADHD
Education (Highest Degree Obtained) Biederman and Faraone. Medscape General Medicine 2006; 8:12.
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Accidents and Near Misses
0%
10%
20%
30%
40%
50%
60%
70%
80%
Accident Accident and Near Misses
Prob
abili
ty o
f Acc
iden
t
P<0.05*
P<0.05*
*Indicates P<0.05 after controlling for gender, age, time of day and the age*ADHD interaction
(Reimer et al., submitted)
ADHD ADHD
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Percent of Subjects Involved in Collisions During Surprise Events
LDX = lisdexamfetamine dimesylate
Biederman et al. 2011 submitted
*
During the five surprise events, drivers in the medication group were 67% less likely to have a collision than drivers in the placebo group
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Mean Number of Impaired Health Risk Indicators
Spencer et al. 2013 submitted
Impaired Health Risk indicators: cutoffs defined by values outside the normal range
P=0.003
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Dalsgaard, S., Østergaard, S. D., Leckman, J. F., Mortensen, P. B., & Pedersen, M. G. The Lancet. 2015; http://dx.doi.org/10.1016/S0140-6736(14)61684-6
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Assessment Guides Management
Faraone et al. Nature Reviews Disease Primers 2015
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Management Decision Tree
Faraone et al. Nature Reviews Disease Primers
2015
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Summary
• ADHD is a neurobehavioral disorder with a: – Complex etiology – Neurobiologic basis – Strong genetic component
• ADHD – Affects millions of people of both genders – Persists through adolescence and adulthood in a high
percentage of cases – Can have negative impact on multiple areas of
functioning