Professional Documents
Culture Documents
What ADHD is
ADHD is a heterogeneous, clinical condition If appropriately defined (with symptoms, pervasiveness and impairment) it may constitute a difference of degree and possibly kind from normal Deficit does not mean None. It means that attention cannot be sustained when the child or adult is not interested.
H-I-D-E (ADHD)
Developmentally inappropriate levels of: Hyperactivity (6/9 sx): fidgets with hands or feet or squirms in seat;
leaves seat in classroom inappropriately; runs about or climbs excessively; has difficulty playing quietly; is on the go or driven by a motor; talks excessively Impulsivity: blurts out answers before questions are completed; has difficulty awaiting turn; interrupts or intrudes on others Distractibility (6/9 sx): fails to give close attention to details; difficulty sustaining attention; does not seem to listen; does not follow through on instructions; difficulty organizing tasks or activities; avoids tasks requiring sustained mental effort; loses things necessary for tasks; easily distracted; forgetful in daily activities Emotionality (associated symptom): Low frustration tolerance; sensitive to criticism; over-reactive
G. Carlson, 2009
ADHD alone
31%
Tic 11% Dis. Dis . Conduct Disorder
40%
14%
Inattentio n
Though less than in childhood, it is still greater than In non-ADHD peers; verbal > physical
Less than in childhood; more often verbal and cognitive than non-AADHD same age peers
Age
Outcome of ADHD
"Developmental Delay" - about 30% outgrow the disorder by young adulthood (symptoms minimal; Ability to compensate)* milder disorder
"Continual Display" - about 40% remain symptomatic with functional impairment *Worse hyperactivity/inattention---> poor academics "Developmental Decay" - development of more serious antisocial and/or substance use disorders
* * * *
Irritable temperament----> AGGRESSION Worse executive function-------> WORSE IMPULSIVITY Worse social adjustment----> WORSE PEERS More family psychopathology---> higher gene load + Less involvement and poorer communication; high level of fighting/domestic violence; poor supervision and monitoring.
Meta-analysis of 29 controlled studies over 25 years, encompassing 4465 children, adolescents) with some added information (
0.32 0.2
Faraone SV, Spencer TJ: Presented at: American Psychiatric Association Annual Meeting, Toronto, Canada, May 2006. * Connor et al., JAACAP, 1999
Moderate
preschool
School -class and playground; Home-except computer Disorganization and defiance; worse in secondary school underachievement LD, ODD, anxiety,depression
Severe
Age <3
Everywhere and anywhere aggression; peer problems; drugs, underachievement LD, ODD/CD, other disorders
Elementary school
Unstimulating situations; homework time Worsens in secondary school underachievement Often uncomplicated
comorbidity
80%
68% 56%
60%
40%
34%
25%
20%
= ?
% of all
For office-based visits with a mental disorder, rates went from .42% (n=25) in 1994 to 6.7% (n=1003)
Hyperactivity (goal directed), Irritability, Psychosis (grandiosity), Elated/expansive mood, Rapid speech/Racing thoughts, Sleep (doesnt need it or want it) Definite personality change, Undeniable drop in grades, Morbid/suidical, Pessimistic, Somatic
Depression: D*U*M*P*S
Illness, drugs mania, called 2o Superimposed on other conditions Symptoms occur concurrently in episodes lasting at least a week for mania and 2 weeks for depression.
Carlson & Meyer, ADHD with Mood Disorders, In Brown TE, ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults, 2009
wearing sexy clothes, talking to complete strangers, meeting boys on internet chat rooms; up all night; vulgar language.
Mood changes throughout the day from laughing hysterically, to being irritable, swearing and smashing things to becoming tearful and crying uncontrollably. Sleep patterns had changed; up late talking in chat rooms, sleep for a few hours but would wake early and rearrange room, waking the neighbours by usingGCarlson, the vacuum cleaner at 6 am. MD
Nicola continued Mental status: Nicola loud, intrusive, talked fast and laughed loudly. Hard to follow her train of thoughtshe rapidly changed the subject to seemingly unrelated topics. Convinced a TV actor whom she had been trying to contact, would call her and shed have a relationship with him. She used her cell phone to try to call him.
Became suspicious and hostile when asked about drug use which she adamantly denied; She would not allow the interviewer to see her parents alone, likewise, didnt want to be interviewed alone. She expressed a fear that her food may have been poisoned and that her brain had been damaged.
GCarlson, MD
Steve
8 year old, 3rd grade boy in regular education with explosive outbursts (throws chairs, sweeps stuff off of desks, attacks staff)
Chronically hyperactive and impulsive at home and school Symptoms evident in preschool had SEIT who did good behavioral treatment at home and school. No episodes. IQ and achievement testing normal. Steve said what makes him mad: when my mom tells me to do stuff I dont want to do; too much work in school [which is too hard]; I need help and the teacher said wait.
Abnormal mood (anger or sadness) : most days severe enough to be noticeable by parents, teachers, or peers Markedly increased reactivity to negative emotional stimuli. at least three times/ week for the past 4 weeks. Hyperarousal (ADHD sx): Insomnia; Physical restlessness; Distractibility; racing thoughts or flight of ideas; pressured speech;intrusiveness Onset under age 12 Bottom Line: SMD encompasses severe ADHD+ODD
TDDD
X
3 2 1 0
An xi e Co nd OD D AD HD De p. BP rd e r SM D CB CL CB CL
ty
uc t
Di so
att
JB P
Costello et al. AGP 1996, N=1,015 youth; 9, 11, 13 years Brotman et al. Bio Psych 2006, N=1,420 youth; 9, 11, 13 years Hudziak et al., Bio Psych 2005 SMD= Severe Mood Dysregulation
Significance
Any mental disorder Affective disorders Bipolar disorder Unipolar depression Non-affective disorder
n=973, P < .00001 n=614, P < .00001 n=795, P < .0005 n=350, n.s. n=505, n.s.
2 types of families
Parents with complex mood and behavior problems have offspring who carry similar diagnoses; that appears to be different from classic manic depression. Offspring of classic manic depressives (e.g.Amish; parents who are lithium responsive) still have a greater chance of developing bipolar disorder but their course is more benign.
1. Faraone SV, et al. Am J Med Genet. 1998;81(1):108-116. 2. Meyer S, et al. In press. 3. Duffy A, et al. Am J Psychiatry. 1998;155(3):431-433. 4. Grof P. J Clin Psychiatry. 2003;64(suppl 5):53-61.
Bottom line: Many kids referred for treatment; many fewer get the right treatment
Status of Double Blind, Placebo Controlled trials and FDA approval of drugs for acute mania
Drug lithium divalproex Age <18 Approved in teens FDA required study (-); another study (+) olanzapine + Approved down to age 13 carbamazepine ER + Being studied risperidone + Approved to age 10 quetiapine + Approved to age 10 ziprasidone + positive aripiprazole + Approved to age 10 topiramate negative negative Not studied oxcarbazepine negative For dep lamotrigine Being studied
recurrence
Age >18 + +
mania
Lithium Divalproex .31 .28
Zip .48 to Ris .81
aggression
mania
.5 .23 to .62
Atypicals
Haloperidol
Ris .9
.8 but many AEs
Thioridizine
Stimulants atomoxetine
.35
.78 .18
a agonists
.5
NNH
child sleepy Wt gain 7.0 akath eps 30.3 9.8 n/a sleepy adult Wt gain 84 akath eps 11.9 8.0 33.3 ns n/a
SGAs
4.6
7.1
Lithium n/a
n/a
A-Cs
19.1 ns
n/a
n/a
Treatment implications
Mania/BP Lithium Depakote Antipsychotics antidepressants ADHD meds Specific I.E.P. Language rx psychotherapy FFT psychoed CBT ? X X X X X X X X MDD PDD abuse aggression X X X X X ADHD
X
X Soc skills CBT therapy X If comorbid Beh mod Beh mod
CPS
It matters if ADHD or anxiety or PDD or learning disability or something else is underlying the rages
Medication management
ADHD treatment Anti-aggressive/anti Psychotic medications mood stabilizers Understand triggers Keep situation CALM
62.62%
-8.56%
Adolescents
Discharges per 10,000 persons ... Length of Stay (Mean)............... 58.97 8.18 67.65 7.52 85.97 7.25 83.33 7.14
41.31%
-12.66%
Adults
Discharges per 10,000 persons ... Length of Stay (Mean)............... 112.90 8.11 109.62 7.34 118.94 7.17 129.63 7.11
14.82%
-12.28%
2002-3
11.70 per 10,000 4.51 per 10,000 1.19 per 10,000
% Change
+174% +2% +146%
Children
25
20
15
10
BIPOLAR DX
1998-9 Depression
2002-3 Developmental
Irritability
51.7%
n/a
Explosiveness
Temper Dysregulation Disorder (TDDD) % manic symptoms from CMRS-P (Score >20)
51.7%
31% 51.7%
n/a
n/a 55.6%
emotional lability
52.4%
100%
TEMPER DYSREGULATION WITH DYSPHORIA ON A CHILDRENS INPATIENT UNIT BE diagnosis N=29 % of TDDD sample
ODD
ADHD Comorbid ADHD and ODD:
61.9%
76.2%
88.9%
88.9%
6.9%
31.0% 6.9%
0
11.1% 11.1
55.2%
20.7% 41.4% 13.8% 6.9%
77.8%
33.3% 22.2% 0 0
% language disorder
62.1%
77.8%
CONCLUSION SO FAR
If you attribute the rages that prompt admission to acute mania, you should see symptoms of mania during hospitalization Such symptoms were rarely seen However, of the 97% of children whose parents described what may be called temper dysregulation disorder with dysphoria