ADHD, Injury, and Medication Adherence in Children

1. ADHD, Injury, and Medication Adherence in Children Arianna Ahiagbe ‘12 Human Biology, Sc.B. Thesis Adviser: Bruce Becker, MD, MPH Second Reader: John Marshall, Ph.D.

2. Research question • Is there a relationship between medication for Attention Deficit Hyperactivity Disorder (ADHD) and incidence of injury in children?

3. ADHD • Chronic neuropsychiatric condition • Common childhood behavioral disorder, 10% in U.S., 5% World State-based ADHD Diagnosis Prevalence 2007-2008, Source: CDC

4. ADHD Etiology • unknown, observed genetic relationship • May involve noradrenergic and dopaminergic pathways Three subtypes: • predominantly hyperactive-impulsive • predominantly inattentive • combined hyperactive-impulsive and inattentive

5. ADHD Symptoms According to the American Psychiatric Association, DSM-IV: Three types: • Inattentive • Hyperactive • Impulsive Symptoms should: • Be observed before a child is seven-years old • Occur for more than six months and in more than one setting • Cause problems in social, school, or work functioning

6. ADHD Treatment Psychostimulants • Methylphenidate (MPH): inhibits reuptake of NE and DA Ex. Ritalin • Amphetamines: inhibits reuptake of NE, DA and ST, primarily reverses DA transporter effect and blocks degradation of DA Ex. Adderall Non-stimulant • Atomoxetine: inhibits reuptake of NE only Ex. Strattera Behavioral Therapy: environment modification, relaxation training, aversive therapy and exposure and response prevention

7. TREATMENT: efficacy & Compliance • Multimodal Therapy: behavioral and pharmacological therapy most effective • Pharmacological > Behavioral • Stimulant v. Non-stimulant: Compliance is important! Source: Arch PediatrAdolesc Med. 2005;159:572-578.

8. Treatment: Safety Psychostimulants • Long term effects not well understood • Reinforcing properties similar to cocaine (In the ventral tegmental area in the brainstem, DA neurons are part of the reward pathway.) Nonstimulants • Lower abuse potential

9. Unintentional Injury • leading cause of morbidity & mortality for U.S children • an associated feature of ADHD -Burns-Falls - Fractures - Poisoning - Head injuries - Pedestrian or bicycle related - Motor vehicle related

10. Conclusions • ADHD is a growing issue in the U.S. as well as worldwide. • Unintentional injury causes more incidences of morbidity and mortality in children than any other illness or condition. • Children with ADHD are at greater risk for unintentional injury. • No strong conclusions about the influence of medication on injury in children with ADHD.

11. Further research is needed • To attain a greater understanding of the factors that influence the diagnosis and effective treatment of ADHD in children • To determine whether and under what clinical conditions stimulant as well as non-stimulant treatments help protect children with ADHD from risk of injuries • To prevent injury and improve the welfare of children with ADHD

12. Study Design • Prospective, randomized, case-controlled • Hasbro Children’s Hospital Emergency Department -16-20% ADHD prevalence • Brief interview with patient and parent/guardian • Possible Data - ADHD diagnosis - ADHD medications- Age - Gender - Injury or a non-injury condition - Race/ethnicity - Years of education - Parental education - Insurance status, -Primary care physician status - PCP visit in the last year • Chi-Square & Odds Ratio Analysis

13. Study design Examine the relationship between • Diagnosis of ADD/ADHD • Pharmacological treatment for ADD/ADHD • Adherence to said treatment on day of incident and the incidence of injury in patients presenting for treatment in ED Hypothesis: Children with ADHD who did not take their medication on the day of injury will have higher prevalence than children with ADHD who did take their medication on the day of injury.

14. Thank You!