What causes ADHD? Can science improve treatment? ACAMH ADHD - PDF document

18/09/2019 What causes ADHD? Can science improve treatment? ACAMH ADHD Masterclass 2019 Edmund Sonuga‐Barke 1 RUNNING ORDER • Why we …..treat? …..research? …..label? • Medical v Bio‐psycho‐social models as a basis for translational science? • The state of ADHD science • Aetiology  Genes  Environments  GE interaction and correlation. • Pathophysiology  Heterogeneity & complexity 2 1

18/09/2019 WHY WE …..TREAT? 3 WHY WE …..TREAT? 4 2

18/09/2019 CHARACTERISING ADHD DEVELOPMENTAL CONTINUITIES AND ESCALATIONS NASCENT Early Acting Risk Processes Genetic, Environmental & Biological Markers 5 CHARACTERISING ADHD DEVELOPMENTAL CONTINUITIES AND ESCALATIONS PRODROME High Activity, Speech/Motor Early Sub‐clinical Signs in Preschool Delay, Difficult Temperament NASCENT Early Acting Risk Processes Genetic, Environmental & Biological Markers 6 3

18/09/2019 CHARACTERISING ADHD DEVELOPMENTAL CONTINUITIES AND ESCALATIONS FULL Clinical Condition in Diagnostic Criteria Met Middle Childhood PRODROME High Activity, Speech/Motor Early Sub‐clinical Signs in Preschool Delay, Difficult Temperament NASCENT Early Acting Risk Processes Genetic, Environmental & Biological Markers 7 CHARACTERISING ADHD DEVELOPMENTAL CONTINUITIES AND ESCALATIONS COMPLEX Conduct Disorder, Depression, Emergence of Comorbidity Anxiety in Later Adolescence FULL Clinical Condition in Diagnostic Criteria Met Middle Childhood PRODROME High Activity, Speech/Motor Early Sub‐clinical Signs in Preschool Delay, Difficult Temperament NASCENT Early Acting Risk Processes Genetic, Environmental & Biological Markers 8 4

18/09/2019 CHARACTERISING ADHD DEVELOPMENTAL CONTINUITIES AND ESCALATIONS ESCAL’TING Spirals of Dysfunction Personality Disorders, in Adulthood Substance Abuse COMPLEX Conduct Disorder, Depression, Emergence of Comorbidity Anxiety in Later Adolescence FULL Clinical Condition in Diagnostic Criteria Met Middle Childhood PRODROME High Activity, Speech/Motor Early Sub‐clinical Signs in Preschool Delay, Difficult Temperament NASCENT Early Acting Risk Processes Genetic, Environmental & Biological Markers 9 ILLUSTRATING THE INCREMENTAL DEVELOPMENTAL BURDEN OF ADHD ESCAL’TING COMPLEX FULL PRODROME NASCENT 10 5

18/09/2019 IMPAIRMENT ESCAL’TING COMPLEX FULL PRODROME NASCENT 11 IMPAIRMENT ESCAL’TING COMPLEX FULL PRODROME NASCENT 12 6

18/09/2019 IMPAIRMENT ESCAL’TING COMPLEX FULL PRODROME NASCENT 13 IMPAIRMENT ESCAL’TING COMPLEX FULL PRODROME NASCENT 14 7

18/09/2019 IMPAIRMENT IMPAIRMENT ESCAL’TING ESCAL’TING COMPLEX COMPLEX FULL FULL PRODROME PRODROME NASCENT NASCENT 15 IMPACT ON FAMILY & COMMUNITY IMPAIRMENT ESCAL’TING COMPLEX FULL PRODROME NASCENT 16 8

18/09/2019 ECONOMIC BURDEN HEALTH, EDUCATION & JUSTICE IMPACT ON FAMILY & COMMUNITY IMPAIRMENT ESCAL’TING COMPLEX FULL PRODROME NASCENT 17 WHY WE……RESEARCH? 18 9

18/09/2019 WHY WE……RESEARCH? 19 MEDICATION – EFFICACIOUS BUT LIMITED o Medication is a pragmatic short‐term solution to a serious problem. o Its efficacy is proven by countless RCTs ‐ but it has limitations – normalization – rare – Key functional outcomes untouched – long term effects ‐ uncertain – side effects – frequent – resistance from parents, clinicians and governments – common – societal concern about the increasing prescribing rates o For all these reasons the development of effective non‐pharma treatments is an urgent priority. o Especially as current approaches such a parent training, neurofeedback and cognitive training appear to lack solid evidence of efficacy. 20 10

18/09/2019 A translational model holds out the promise that therapeutic innovation builds on scientific understanding about ADHD pathogenesis. ‐‐‐‐‐‐‐‐‐‐‐ If we can understand the causes of ADHD we can target them with new and improved treatments. 21 BENCH TO BEDSIDE IN ADHD – MYTH OR REALITY We wax lyrical about the reciprocal relationship between science and practice… Clinic Lab …but identifying the ways in basic science has affected clinical practice in relation to ADHD is a challenge! We have evidence‐based medicine. Where is the science‐driven medicine? 22 11

18/09/2019 WHY WE …….LABEL 23 WHY WE …….LABEL 24 12

18/09/2019 ADHD ‐ A(N UNNECESSARILY) POLARISING AND CONTROVERSIAL CONCEPT THE REASONABLE DEBATE……. Listen old chap ‐ the ADHD label is damaging ‐ it stigmatises, undermines agency, distracts from socio‐economic reality –it’s big pharma driven. Dear old thing ‐ these kids are suffering. If we are going to help them then we need to clearly identify them. 25 ….TYPICALLY DESCENDS INTO THE UNREASONABLE SCRAP! Sonuga‐Barke 26 13

18/09/2019 WHAT DO WE MEAN BY SAYING SOMEONE SUFFERS A DISORDER? o Boundaries and underlying structure of construct need to be characterised. o Do problems of attention, impulse control and activity form a syndrome? o Inattention, overactivity and impulsive behaviours do cluster and can be differentiated statistically and prognostically from other clusters of problems despite a degree of overlap between and heterogeneity within. o Is the syndrome associated with suffering through distress/disability? o developmentally inappropriate levels of severe/pervasive disorder can be greatly impairing, in both the short and long term – predictive of school failure, unemployment, criminality, mental health, addictions and relationships problems. We will use the term “disorder” as a shorthand for this impairing cluster 27 LABELS ESSENTIAL BUT ALSO POTENTIALLY LIMITING o Clinical science can only proceed if there is effective communication between scientists (& clinicians). o Need precisely defined terms giving common reference points. o Terms used systematically & consistently are essential for progress. o But philosophers of science also warn us that shared terms have an insidious effect on science ‐ introducing non‐scientific assumptions to shape hypotheses. o Unpacking these assumptions turns diagnoses into “working models” – an approximation of reality ‐ to be tested, updated and refined. 28 14

18/09/2019 MEDICAL V BIO‐PSYCHO‐SOCIAL MODELS AS A BASIS FOR TRANSLATIONAL SCIENCE? 29 THE WAY YOU THINK ABOUT ADHD WILL AFFECT THE WAY YOU RESEARCH IT AND DISORDER IN THE MEDICAL MODEL TREAT IT! o The original concept of ADHD has its roots in the medical model and still carries a set of implicit assumptions o ADHD as a discrete disease category o qualitatively different from normality o impairment inherent to the condition o Resulting wholey from bio‐genetically determined dysfunction within brain o This has led researchers to focus on its genetic origins and to search for a single core deficit in the minds or brains of the affected child. o This has hampered progress in the field and led to a focus on meds. So much data now challenges these core assumptions – this has led to the beginning of a reconceptualization of ADHD. 30 15

18/09/2019 A BIO‐PSYCHO‐SOCIAL ALTERNATIVE o A bio‐psycho‐social perspective holds out considerable hope for translational progress. o It assumes. o ADHD is a mismatch between extreme expression of continuous temperamental traits and the social environment. o Impairment depends on social context o Results from complex developmental interplay between genes and the social environment mediated by brain alterations. o In principle this offers diverse possibilities for intervention. 31 EARLY OPERATING GENE AND PRE‐ AND PER‐NATAL RISK INTERACT TO CREATE A CHILDREN’S WELLBEING IS INFLUENCED BY THE EMOTIONAL ATMOSPHERE CREATE DEVELOPMENTAL PATHWAYS MEDIATED BY NEURO‐COGNITIVE TOGETHER MAKE A CRITICAL AND UNDERMINING ENVIRONMENT POSTNATAL ENVIRONMENT MAY MODERATE PATHWAYS THESE SECONDARY EFFECTS MEDIATED BY NEUROBIOLOGICAL ALTERATIONS AND EVOKED BY THE CHILD’S BEHAVIOR AND CHARACTERISTICS THAT ENVIRONMENT IS LIKELY CORRELATED WITH GENES SPECTRUM OF BIOLOGICAL RISK WITHIN THEIR FAMILY ALTERATIONS. ENVIRONMENT SOCIAL neuro‐cognitive impairment ADHD DLPFC secondary sense of self VMFC neuro‐cognitive who I am – Amyg TP impairment what can I do? O O F F Emo & Beh C C problems 32 16

18/09/2019 NON‐PHARMA TREATMENTS COULD TARGET MULTIPLE LEVELS pre‐ perinatal originating Public Parenting G, E, GE, GxE causes Health Training & Education Family Therapy ENVIRONMENT SOCIAL neuro‐cognitive impairment ADHD DLPFC sense of self secondary VMFC neuro‐cognitive who I am – Amyg TP Psycho‐ Cognitive impairment what can I do? O O therapy Training F F Emo & Beh C C problems 33 ADHD AS AN EVOLVING CONCEPT o The concept of ADHD is evolving rapidly as the shift from a medical model to a bio‐psycho‐social perspective gathers pace ‐ promoted by scientific progress. o This is creating new opportunities for non‐pharmacological intervention innovation. o The evolving concept of ADHD has provided coherence and continuity that has made this body of work possible and will in the future promote improvements in clinical practice. o While we should not underestimate some of the negative aspects of labelling and stigma ADHD itself is far more stigmatizing and harmful than the label. 34 17