Clinical and functional implications of a history of childhood ADHD in first-episode psychosis

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Abstract

There is mounting evidence indicating that a childhood history of attention-deficit/hyperactivity disorder (ADHD) is associated with an increased risk for psychotic disorders, including schizophrenia. However, the implications of such a history on the symptomatic and functional outcomes of patients with psychotic disorders are still not well documented. This study examined the prevalence of childhood ADHD in patients with first episode psychosis (FEP) consecutively admitted to a specialized early intervention clinic covering a well-defined catchment area, and compared patients with and without a history of childhood ADHD on socio-demographic, clinical, and functional outcomes over a six to twelve months period. Out of 179 patients with FEP, 27 (15%) were treated for ADHD during childhood, consistent with previous literature indicating an association between childhood ADHD and psychosis. FEP patients with childhood history of ADHD had lower academic achievement, earlier onset of psychosis, and higher rates of childhood conduct and learning disorder. While the two groups had similar scores on psychopathology and functioning at baseline, patients with childhood ADHD showed significantly less improvement in positive and negative symptoms, as well as social and occupational functioning. These results strongly indicate that a history of childhood ADHD in FEP is more frequent than that reported in the general population and predictive of poorer clinical response to treatment. This emphasizes the need for actively screening for a history of ADHD in FEP patients and for treatments that are tailored for these patients.

Introduction

An association between a history of childhood attention-deficit/hyperactivity disorder (ADHD) and schizophrenia-spectrum disorders (SSD) has received increasing support in the recent literature, which has documented an increased risk of developing SSD later in life in children with ADHD (Biederman et al., 2006, Dalsgaard et al., 2014), and high rates of an antecedent history of ADHD in adults with SSD (Gomez et al., 1981, Marsh and Williams, 2006, Dalteg et al., 2014). It has proven a complex task to link a generally younger pool of individuals with ADHD, with typical onset in elementary school (Kieling et al., 2010), with an older pool of people with SSD, the peak onset of which is in the third decade of life (Gogtay et al., 2011). This task is further complicated by the partial developmental overlap between these heterogeneous disorders, as symptoms of ADHD typically persist into adulthood (Faraone et al., 2006), while the first episode of psychosis (FEP) is typically preceded by a prodrome with prominent deficits in attention (Cornblatt et al., 2003).

The exact nature of the association between ADHD and SSD has remained unclear thus far. They are both neurodevelopmental disorders which share some genetic (Williams et al., 2010, Hamshere et al., 2013) and environmental risk factors, in particular obstetric complications and early developmental abnormalities (Peralta et al., 2011, Dalsgaard et al., 2014). They each involve a dysregulation in the dopamine system, and are treated with medications that modify its function (Mehler-Wex et al., 2006). Their association is further driven, but also obscured, by prominent shared symptoms, such as deficits in attention (Barr, 2001, Carter et al., 2010). Additionally, substance abuse may be an important moderator of their relationship, as a history of childhood ADHD increases both the rate of substance use disorders (SUDs) (Charach et al., 2011), and the psychotogenic potential of drugs of abuse (Roncero et al., 2012, Salo et al., 2013). This increased rate of substance use disorders has also been noted in samples with first episode of SSD (Cassidy et al., 2011).

Given the typical persistence of both ADHD symptoms and related impairment beyond adolescence (Faraone et al., 2006, Klein et al., 2012), it is important to understand whether patients with childhood ADHD who develop SSD represent a distinct clinical population that may require a modified approach to treatment (Bellak et al., 1987, Levy et al., in press). Two studies have compared participants with SSD with and without a history of childhood ADHD. Elman et al. (1997) investigating adolescents with early-onset schizophrenia, found that those with a history of childhood ADHD had more neurodevelopmental abnormalities and a more insidious course with poorer medication response and functional outcome. Peralta et al. (2011) on the other hand, concluded that obstetrical complications and neurodevelopmental delay explained much of the association of childhood ADHD with schizophrenia, with no further impact on psychopathology or response to treatment in schizophrenia. Additional data come from studies showing that individuals at high-risk for psychosis with ADHD fare worse compared to those without ADHD in terms of premorbid adjustment, psychotic symptoms, cognition, function, and progression into SSD (Oner and Munir, 2005, De la Serna et al., 2010, Hurtig et al., 2011, Kim et al., 2012).

In the present study, we compared the characteristics of two groups of participants with FEP: one with a history of childhood ADHD (the FEP–ADHD group) and another without such a history (the FEP-alone group), on a broad range of demographical, clinical, and functional measures. We tested the hypothesis that the FEP–ADHD group would have worse clinical and functional status both at baseline and at follow-up. These hypotheses were based on previously cited studies associating higher levels of illness severity in SSD with co-morbid ADHD. Our study builds on this previous work by investigating a relatively large well-characterized FEP sample of 179 participants using rigorously-standardized methodology over a longer duration of follow-up.

Section snippets

Participants

The study was conducted on FEP patients treated at the Prevention and Early intervention Program for Psychoses — Montreal (PEPP), a specialized early intervention clinical research program at the Douglas Mental Health University Institute. PEPP is the sole service for FEP patients living in a catchment area of 400,000 in south-west Montreal. This helps minimize referral bias and increases the generalizability of the study's findings. Following international guidelines for specialized early

Prevalence of childhood ADHD

There were 213 patients in our initial PEPP sample. Out of these, 34 (15.8%) had a history of suspected childhood ADHD or a history of diagnosed but untreated childhood ADHD. This FEP–ADHD group (N = 27) was compared with the FEP-alone group (N = 152).

Baseline demographic characteristics

As seen in Table 1, the two groups did not differ in terms of age, marital status, or SES, but there were significantly more males in the FEP–ADHD group. The FEP–ADHD participants had significantly lower academic achievement (p = 0.007). The median

Summary of findings

We found a higher prevalence of childhood ADHD in our FEP sample than rates in the general population (Faraone et al., 2003), consistent with previous studies of ADHD prevalence in FEP samples (Gomez et al., 1981, Dalteg et al., 2014).

Our comparative analysis generally confirmed the hypothesis that FEP–ADHD individuals have worse outcomes. We found that participants with and without a history of ADHD did not differ at baseline on symptoms. However, the FEP–ADHD group had an earlier onset of

Role of funding source

No funding source.

Contributors

Aldanie Rho, Alexandru Traicu and Ridha Joober designed the study and wrote the protocol. Aldanie Rho and Alexandru Traicu performed the literature search and statistical analyses, and wrote the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

We would like to acknowledge Nicole Pawliuk for the assistance with data access, Serge Gallant for the assistance with the statistical analysis and reviewing the manuscript, as well as the PEPP—Montreal staff for their help with participants' recruitment and evaluation.

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