1. Attention Deficit Hyperactivity Disorder
Larry Gray, MD
Developmental and Behavioral Pediatrics
Department of Pediatrics
University of Chicago
Pritzker School of Medicine

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Introduction
740 % h production
25 fold h in Adderall
USA = 80 % of Ritalin
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
Treatment
Relationship to substance use
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Key Points
Very common: 10 % of boys
Poor attention + impulsivity
Pharmacotherapy improves sxs
Treatment protects from later SUD
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5. Evolving Nomenclature
Moral deficit
Minimal brain disorder
Autopsy studies and crude x-rays
Attention Deficit Disorder (ADD)
Attention Deficit/Hyperactivity D/O
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Epidemiology
Very common in elementary age
Estimates from:
Classroom teachers = 12%
Parents = 7 %
Psychiatrist interview = 2%
National US survey: 2003
4.4 million school age children ( ~ 6% )
Boys 2.5 X’s > girls
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Natural History
Symptoms identified in school
Peak prevalence: 9-12 yrs of age
Symptoms lessen with age
Symptoms persist > 25 yrs in 2/3
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
Treatment
Relationship to substance use
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DSM-IV Diagnosis 1
Impairing inattentive symptoms with 6+ of:
Not listening
Fails to finish tasks
Difficulty organizing
Loses things
Easily distracted
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DSM-IV Diagnosis 2
Impulsive
Blurts out answers
Difficulty waiting turn
Interrupts others
Hyperactive
Fidgets
Unable to stay seated
Inappropriate running
Difficulty engaging in activities quietly
Always “on the go”
Talks excessively
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Symptom Criteria
Persistent pattern > 6 months
Onset < 7 years
Impairments
At school and home
In social, academic, or occupational functioning
Not due to:
Conduct disorder
Depression
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ADHD Differential
Normal high activity
Thyroid disorders
Hearing loss
Sleep disorder
Trauma / severe neglect
Learning disabilities
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ADHD Comorbidty
ADHD
66%
33%
ODD / CD
24%
Anxiety/ Mood D/O
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ADHD Subtypes
Inattentive
+ 6/9 criteria inattention only
27 %
Impulsive / hyperactive
+ 6/9 impulsive/hyperactive criteria only
18 %
Combined
+ 6/9 both inattention and I/H criteria
55%
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15. Presentation in Childhood
6 – 12 year olds:
Too distracted
Too talkative
Parents describe as “immature”
Often need to repeat grades
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Presentation in Teens
Adolescents 12 – 18 years:
Inner sense of restlessness
Disorganization is 10 complaint
Managing skills get overwhelmed
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ADHD and Driving
> 5X’s Speeding tickets
> 3X’s Car accidents
> 12X’s Moving violations
> 3 X’s $ Damages
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
Treatment
Relationship to substance use
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Pathophysiology
Different etiologies at work
No one brain mechanism
→ Behavioral syndrome of:
Brain anatomical differences
Genetic / Molecular differences
Environmental risk factors
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20. Environmental Influences
Prenatal factors (i.e. low birth wt)
Neurotoxin exposure
Prenatal (i.e. alcohol)
Postnatal (i.e. lead)
CNS infections - encephalitis
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Genetic Influences
Twin Studies
Identical twins > fraternal twins
Heritability estimates
7 candidate genes
Dopamine D4 receptor
Dopamine transporter gene (DAT 1)
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Dopamine Synapse
Dopamine Transporter
Dopamine
Dopamine Receptor
from:
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
Treatment
Relationship to substance use
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Treatment of ADHD
Effective:
Behavioral Therapy
Pharmacotherapy
Combination of both
Ineffective:
Family, individual, or cognitive therapy
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Pharmacotherapy
Stimulants mainstay
Methylphenidate (Ritalin)
D-amphetamine salts (Adderall)
Less addictive potential
Same structure and action as cocaine
Enters brain more slowly (less reinforcing)
Success =“normalized” behavior
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26. Multimodal Treatment Study of Children with ADHD (MTA)
ADHD alone:
Success rates approach 90 %
Stimulants > behavioral tx
Comorbid ADHD
Need medication + behavioral therapy
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3 Year MTA Follow-Up
All kids improve
Stimulants lose advantage
Can meds be stopped?
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28. Success or Undertreatment ?20
% dx but no meds % 10
% dx on meds 4
Male Age 17
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
Treatment
Relationship to substance use
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30. Adolescents and Substances
High School seniors report
50% used alcohol
25 % used tobacco
25% “some” illicit drug use
ADHD is ↑ in those with SUD
50% of adolescents
25% of adults
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ADHD, CD and SUD
ADHD
66%
33%
ODD / CD
40%
CD SUD
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ADHD, CD and SUD
Exp. of antisocial behavior
ADHD w/o CD ≠ ↑ risk
ADHD’s role in SUD
Earlier onset (1 year vs 3 years)
Persistence of symptoms across development
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Alcohol Use Disorders
F/U 165 sons of alcoholics
6% with ADHD: no SUD 20 yrs later
CD in childhood 18 X the risk of SUD
CD ↑ ↑ risk of alcohol use D/Os
ADHD sx assoc. much weaker
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34. Predictors of Problems with Alcohol in ADHD
129 with ADHD vs. 96 no ADHD
ADHD persisters w/o CD—2.5 X’s
ADHD persisters with CD—5 X’s
Persistence / quality of symptoms
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Treatment Effects
Unmedicated = ↑ risk for SUD
Use substances to ↑ self- control
Meta-analysis → Tx ≠↑ SUD
Emerging evidence → early Tx protects
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36. Prospective Study of ADHD
Rate of SUD during adolescence
75 % unmedicated developed SUD
25 % medicated developed SUD
SUD in treated ADHD = non-ADHD
Treating ADHD may ↓ risk for SUD
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Lecture Aims
Epidemiology + course
Diagnosis
Etiology
Treatment
Relationship to substance use
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Summary
Very common: boys > girls
Poor attention + impulsivity
Pharmacotherapy improves sxs
Treatment protects from SUD
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