Upload
fabiola-rivett
View
214
Download
0
Embed Size (px)
Citation preview
NORTH AMERICAN REGIONAL CONFERENCE, IACE/AIECMAY/MAI 3-5, 2002, UQAM
Facteurs de risque chez les familles d'enfants présentant
un trouble déficitaire de l'attention/hyperactivité (TDA/H): Données québécoises
Risk Factors in Families of Children with ADHD: Data from Quebec
H. Poissant, (1); C. Montgomery, (2)C. Sylvestre (3)S. Lecomte (1); J. Delisle (1)UQAM (1), University of Alberta (2), PANDA (3)
Most common psychiatric disorders encountered by pediatricians
• Attention Deficit and Hyperactivity Disorder (ADHD)
• Anxiety disorders (ANX)
• Depression (DEP)
• Substance-use Disorders (SD)
• Conduct Disorder (CD)
• Oppositional Defiant Disorder (ODD)
• Learning Disorders (LD)
Comorbidity often occurs between disordersHigh rates of comordid disorders among ADHD
Statistics on ADHD
- 1% - 3% American school-aged population
- 5% - 10 % other problems/ psychiatric disorder :comorbidity
- Boys are about 3X more likely than girls to develop ADHD
- 30% - 50% still manifest symptoms in adulthood
- 25 % fathers and 17 -25% mothers of ADHD children have this condition
Objectives
• Determine potential Risk Factors in Etiology of ADHD in French Canadian population
• Draw comparison with English Canadian population
• 2 Main types of Risk Factors:– Genetic– Environment
Etiology
• Twin studies
• First-degree relatives: siblings and parents
• Comorbidity
• Pre and Perinatal events
• Socioeconomic
• Family problems
Genetic Environment
Barkley, R. (1997)
Research
Souza et al. (2001)
Butler (1995)
Breton (1994)
Chang (2000)
Cotugno (1995)
Number/Age
34/6 -16 years
76/children-adolescent
235*/6-14 years
40/ high school
40/ children
Comorbidity in Proband
ODD (20,6%); CD (39,2%);MD & ANX (34,3%)
MD (36%); BDP (22%)
CD & ODD (30 %)ANX & DEP (46.7%)
General psychopathology & DEP
DEP “vulnerability”
* estimated n.
From Poissant, H. (submitted)
Positive Correlation: “Adversity Factors” & ADHD6 Adversity Indicators (Rutter, et al. 1975; 1977)• severe marital discord• low social class• large family size• paternal criminality• maternal mental disorder• foster care placement& Associated Psychiatric Impairments: DEP, LD, etc.
Biederman, J., Milberger, S., Faraone, S. V. et al. (1995)Pediatric Psychopharmacology Unit (PPU), Massachusetts General Hospital
Family Environment& Developmental Disorders
Genetic studiesMeta-analysis
(% explained variance)
• Identical Twins (MZ)
• N-Ident. Twins (DZ)
• MZ + DZ
• 40-79%
• 30-32%
• 61-75%
Lecomte, J., Poissant, H., Delisle, J. (2001)
Genetic studiesMeta-analysis
(% explained variance)
• Comorbidity in ADHD Proband– DEP– ANX– ODD– CD– BPD
• 4-25%• 15-57%• 23-47%• 11-44%• 5%
Lecomte, S., Poissant, H., Delisle, J. (2001)
Genetic studiesMeta-analysis
(% explained variance)
• ADHD in Siblings & Parents
• Comorbidity in Siblings & Parents– DEP
– ANX
– ODD
– CD
– Mental Disorder
• 4-10%
• 1-4%
• 1%
• 0-1%
• 1%
• 0-11%Lecomte, S., Poissant, H., Delisle, J. (2001)
Environment studiesMeta-analysis
(% explained variance)
• Accident during Pregnancy
• Cigarettes Smoking• Problems in Family• Low Family Income• Adversity Factors• Surgery in Newborn
• 2%
• 4%• 2%• 1-7%• 9%• 2%
Lecomte, S., Poissant, H., Delisle, J. (2001)
Method
• Questionnaire distributed to both Parents
• Age of Probands: 6-21; Mean = 10
• N. of Probands: 60
- Control: no ADHD (N= 19: 8 M; 11 F)
(Left hand = 5%; Right hand = 95%)
- ADHD: ADD/ HY/ADHD (N= 41: 33 M; 8 F)
(Left hand = 73%; Right hand = 17%; Ambi = 10%)
School levels of Probands: 0-14 years
Relationship with Probands
N BioMother BioFather NBioMother Total
Cont. 15 2 2 19
ADHD 37 3 1 41
Total 52 5 3 60
Mostly Biological Mothers (N= 52)
Gender of Probands(% Probands)
0
10
20
30
40
50
60
70
80
Boys Girls
ControlADHD
1 ADHD Girl : 4 ADHD Boys (*)
Hand dominance(Pct of probands)
0
10
20
30
40
50
60
70
80
90
100
Right Left Ambi
ControlADHD
More Left and Ambidextrous in ADHD
School levels(n. of probands)
0
1
2
3
4
5
6
7
8
9
10
0 1 2 3 4 5 6 7 8 9 10 11 14
ContADHD
ADH/D (Attention Deficit Disorder with or without Hyperactivity)RISK FACTOR QUESTIONNAIREEpidemiological Study - UQAM© Poissant, Lecomte, Sylvestre 2001
Proband current Health Status (Comorbidity)Diagnosis (Unique or Multi?)Attention Deficit Disorder and Hyperactivity / Impulsiveness (ADHD)Attention Deficit Disorder only (ADD)Hyperactivity and impulsiveness disorder only (HY)Conduct Disorder (CD)Etc.Treatment (Unique or Uulti?)Ritalin, etc.
Questionnaire
SiblingsRelationship with ProbandBiological brother/sisterHalf brother/ half sisterNo biological relationship with Proband
Diagnosis in Siblings (Comorbidity)Attention Deficit Disorder and Hyperactivity / Impulsiveness (AD/HD)Attention Deficit Disorder only (ADD)Hyperactivity and Impulsiveness Disorder only (HY)Conduct Disorder (CD)Etc.
Pregnancy (Pre/ Perinatal, Baby at Birth)Substances consumedEtc.
Questionnaire
Parent(s) :Relationship with Proband: Biological Non-biologicalMotherFather Other (e.g. grand-parent)
Family Socio-EconomicEducation completed EmploymentFamily Income Etc.
Questionnaire
Adversity Factors (Stress) in FamilyHistory of criminal activity (criminal record)Domestic violenceEtc.
Questionnaire
Comorbidity in Parents (based on Diagnosis)Attention Deficit Disorder and Hyperactivity / Impulsiveness (AD/HD)Attention deficit disorder only (ADD)Hyperactivity and impulsiveness disorder only (HY)Conduct Disorder (CD)Bipolar disorder (manic-depression) (BPD)Etc.Medication in ParentsSSRIs (e.g. Prozac)
Family Income
0
5
10
15
20
25
30
35
40
45
50
<20,000 20-40,000 40-60,000 >60,000
ControlADHD
Family Income = Lower in Control (*0.03)
Level of Education &Family Income
0
0,5
1
1,5
2
2,5
3
School Income
ControlADHD
min = 1; max = 4
* 0.03
Particular program(Pct of Probands)
0
10
20
30
40
50
60
70
80
90
100
no yes
ControlADHD
School achievement(Pct of Probands)
0
10
20
30
40
50
60
70
>Average Average <Average Variable
ControlADHD
Types of ADHD(pct of Probands)
0
10
20
30
40
50
60
ADD Hyper ADHD
ControlADHD
Comorbidity in Proband(Pct of proband)
0
5
10
15
20
25
30
35
40
45
ANX DEP CD
ControlADHD
* 0.05
ns
ns
Comorbidity in Probands(Pct of probands)
0
10
20
30
40
50
60
ODD Phobia LD
ControlADHD
** 0.01
***0.001
ns
Comorbidity in Probands(Pct of Probands)
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
BPD TS O-CD
ControlADHD
ns
ns ns
Medication in Probands(Pct of Probands)
0
10
20
30
40
50
60
70
80
Ritalin Dex Well Cloni Tofra
ControlADHD
***0.001
Length of Pregnancy(Pct of mothers)
0
10
20
30
40
50
60
32 35 36 37 38 39 40 41 42
ControlADHD
Mean = 39 weeks, ns
Difficulties during Pregnancy(Pct of Mothers)
0
10
20
30
40
50
60
70
Bleed. bed rest Naus.>3m +11kgWG
ControlADHD
Difficulties during Pregnancy(Pct of mothers)
0
2
4
6
8
10
12
-7kgWG HighBloodP Anemia Toxemia
ControlADHD
Difficulties during Pregnancy(Pct of mothers)
0
10
20
30
40
50
60
70
80
90
Infection Accidents Family prob. Cumul (1 +)
ControlADHD
**0.02
S. C. during Pregnancy: Alcohol
0
10
20
30
40
50
60
never 1-10month 11-20month
ControlADHD
S. C. during Pregnancy: Cigarettes
0
10
20
30
40
50
60
70
never 1-10month 11-20month daily
ControlADHD
S. C. during Pregnancy: Medication
0
10
20
30
40
50
60
70
80
never 1-10month 11-20month daily
ControlADHD
S. C. during Pregnancy: Marijuana, hashish
0
10
20
30
40
50
60
70
80
90
100
never 1-10month
ControlADHD
S. C. during Pregnancy: LDS, mescaline, Extasy, PCP
0
10
20
30
40
50
60
70
80
90
100
never 21-30month
ControlADHD
Cumul S.C. during Pregnancy
60
61
62
63
64
65
66
67
68
1 or more
ControlADHD
ns
N.s in overall
Delivery
0
10
20
30
40
50
60
70
80
90
Natural Caesarian Anesthesia
ControlADHD
n.s in overall
Delivery
0
5
10
15
20
25
30
35
40
45
Suction Forceps Compl. Cumul
ControlADHD
n.s
n.s in overall
Baby at Birth
0
5
10
15
20
25
30
Cord injuries breathing jaundice
ControlADHD
n.s in overall
Baby at Birth
0
2
4
6
8
10
12
14
16
Oxygen Cyanosis Fetal distr. 7days+hosp.
ControlADHD
n.s in overall
Baby at Birth
42
44
46
48
50
52
54
CumulDiff. (1 or +)
ControlADHD
n.s
Adversity Factors(Pct of Parents: mostly mothers)
• Chi-Squares: n.s.
• Learning Difficulties Undiagnosed
• Stress Factors0
10
20
30
40
50
60
70
L.DUndiag.
Stress
ControlADHD
N.s.
N.s
Comorbidity in Parents(Cont = 17 Mothers; 2 Fathers; ADHD = 38 Mothers; 3 Fathers)
0
5
10
15
20
25
30
35
Dep Anx O_CD phobia
ControlADHD
0.07
Dep. marginally significant
Comorbidity in Parents (Cont = 17 Mothers; 2 Fathers; ADHD = 38 Mothers; 3 Fathers)
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
ADHD ADD HY
ControlADHD
n.s in overall
Comorbidity in Parents (Cont = 17 Mothers; 2 Fathers; ADHD = 38 Mothers; 3 Fathers)
0
1
2
3
4
5
6
7
CD BPD Alcohol Drug
ControlADHD
n.s in overall
Medication in Parents (Cont = 17 Mothers; 2 Fathers; ADHD = 38 Mothers; 3 Fathers)
0
5
10
15
20
25
30
SSRIs Tricycl Anxiol Buproprion
ControlADHD
*0.04
Medication in Parents (Cont = 17 Mothers; 2 Fathers; ADHD = 38 Mothers; 3 Fathers)
0
1
2
3
4
5
6
7
8
9
10
Psychostim Thymoregul Venlafax.
ControlADHD
Cumul Medication = 0.07
Main FindingsComorbidity in Probands
Chi-Squares:
•Conduct Disorders (CD): 3.85; df=1; p= 0.05*
•Oppositional Defiant Disorder (ODD): 6.01, df=1; p= 0.01**
•Learning Disorder (LD): 15.15; df=1; p= 0.001***
•Health Status (except CD, ODD, LD): 1.06; df=1; p= 0.3, ns
•Ritalin: 31.78; df= 1; p= 0.001***
•Cumul Medication (except Ritalin); 0.70; df= 1; p= 0.41, ns
Main FindingsPrenatal
T-test•Length of Pregnancy (ns)Control: Mean= 39.05 weeksADHD: Mean= 39.00 weeks
Chi- Squares:•Difficulties during Pregnancy : Cumul (1 +), *0.02Control: 58%ADHD: 85%
•Substances Consumed (S.C) during Pregnancy: Cumul (1 +), ns•Control: 68.4%•ADHD: 62.5%
Main FindingsPerinatal
Chi- Squares:•Difficulty in Delivery: Cumul (1 +), nsControl: 37%ADHD: 44%
•Difficulty Baby at Birth: Cumul (1 +), nsControl: 47%ADHD: 54%
•Weight at Birth (< or = 2.5 kg.), nsControl: 17%ADHD: 15%
Main FindingsPerinatal
T-Test:•Length of labor: n.sControl: Mean= 12.6 hoursADHD: Mean= 12 hours
•Length of delivery: nsControl: 2.4 hoursADHD: 1.1 hour
•Weight at Birth: nsControl: 6.5 poundsADHD: 6.8 pounds
Main Findings« Adversity & Socioeconomic »
Chi-Squares:
•Learning Difficulties Undiagnosed n.s
•Stress Factors in Family: n.s
• Level of Education n.s
•Family Income 0.03 (in unexpected way)
Conclusion Etiology
• Comorbidity Proband:
CD*, ODD*; LD*
• Comorbitiy Parents:
DEP (Mothers)
Fathers ?
• Comorbidity Siblings ?
• Pre and Perinatal:
Cumul Difficulties Pregnancy*
• Socioeconomic (ns or unexpected)
• Adversity (ns)
Genetic Environment
Future Research
• Comparison between Mothers and Fathers on Comorbidity and Medication
• Comparison between Mothers and Fathers on Adversity : Undiagnosed L.D (e.g. excessively agitated) and Stress Factors (e.g. Criminal activity, domestic violence)
1. Levy, F., Hay, D. A., McStephen, M., Wood, C. & Waldman, I. (1997). Attention-deficit Hyperactivity Disorder : A Category or a Continuum ? Genetic Analysis of a large scale Twin Study. Journal of American of Child and Adolescent Psychiatry, 36 (6), p.737-744.
2. Biederman, J., Faraone, S.V., Keenan, K., Benjamin, J., Krifcher, B. et al. (1992). Further Evidence for Family-Genetic Risk Factors in Attention Deficit Hyperactivity Disorder : Patterns of Comorbidity in Probands and Relatives in Psychichiatrically and Pediatrically Referred Samples. Archives of Genetics Psychiatry, 49, p. 728-738.
3. Biederman, J., Milberger, S., Faraone, S. V., Kiely, K., Guite, J., et al. (1995). Family-Environment Risk Factors for Attention-Deficit Hyperactivity Disorder : A test of Rutter’s Indicator of Advesity. Archives of Genetics Psychiatry, 52, 464-470.
4. Milberger, S., Biederman, J., Faraone, S.V., Guite, J. & Tsuang, M. T. (1997). Pregnancy, Delivery and Infancy Complications and ADHD : Issues of Gene-Environment interaction. Biological Psychiatry, 41, 65-75.
.5. Sherman, D. K., Iacono, W. G. & McGue, M. K. (1997). Attention Deficit Hyperactivity disorder dimensions : a twin study of inattention and impulsivity-Hyperactive. Journal of the American Academy of Child and Adolescent Psychiatry, 36 (6), 745-753
6. Stevenson, J. (1992). Evidence for a Genetic Etiology in Hyperactivity inChildren. Behavior Genetics, 22 (3), 337-344.
7. Willicutt, E. G., Pennington, B. F., Chhabildas, N. A., Friedman, M. C. & Alexander, J. (1999). Psychiatry Comorbidity Associated With DSM-IV ADHD in a Nonreferred Sample of Twins. Journal of the American Academy of Child and Adolescent Psychiatry, 38 (11), 1355-1362.
8. Gillis, J. J., Gilger, J. W., Pennington, B. F. & DeFries, J. C. (1992). Attention Deficit Disorder in Reading-Disabled Twins : Evidence for a Genetic Etiology. Journal of Abdnormal Child Psychology, 20 (3), 303-315.
9. Mick, E., Santangelo, S. L., Wypil, D. & Biederman, J. (2000). Impact of Maternal Depression on Ratings of comorbid Depression in Alolescents With Attention-Deficit/ Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39 (3), 314-319.
10. Mick, E., Biederman, J. & Faraone, S. V. (1996). Is Season of Birth a Risk Factor for Attention-Deficit Hyperactivity Disorder? Journal of the Amarican Academy of Cild ans Adolescent Psychiatry, 35 (11), 1470-1476.
11. Nadder, T. S., Silberg, J. L., Eaves, L. J. Maes, H. H. & Meyer, J. M. (1998). Genetic Effects on ADHD Syptomatology in 7-13 years old Twins : Resuls from a Telephone Survey. Behavior Genetics, 28 (2). 83-99. 12. Milberger, S., Faraone, S. V., Biderman, J., Chum, M. P. & Wilens, T. (1998). Familial Risk Analisis of the association Between Attention-Deficit/Hyperactivit Disorder ans Psychoactive Substance Use Disorders. Achives of Pediatrics Adolescent Medecine, 152 (10), 945-951.
13. Milberger, S., Biederman, J., Faraone, S. V., Chen L. & Jones, J. (1996). Is Materanl Smoking during Pregnancy a Risk Factor for Attention Deficit Hyperacvity Disorder in Children ? American Journal of Psychiatry, 153 (9), 1138-1142.
14. Willcutt, E. G., Pennigton, B. F. & DeFries, J. C. (2000). Etiology of Inattention and Hyperactivity/Implusitivy in a Community Sample of Twins with Learning Difficulties. Journal af Abdnormal Child Psychology, 28 (2), 149-159.
15. Eaves, L. J., Silberg, J. L., Meyer, J. M. & Maes, H. H. (1997). Genetics and developmental Psychopathology : 2. The Main Effects of Genes ans Environment on Behavioral Problems in the Virginia Twin Study of Adolescent Behavioral Development. Journal of Child Psychology and Psychiatry, 38 (8), 965-980.