NORTH AMERICAN REGIONAL CONFERENCE, IACE/AIEC MAY/MAI 3-5, 2002, UQAM Facteurs de risque chez les...

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

poissant.helene@uqam.ca

Risk Factors in Families of Children with ADHD: Data from Quebec

poissant.helene@uqam.ca

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)

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