Workshop ADHD and Mania: What should you know? Why should you care? Gabrielle A. Carlson, M.D.
Professor of Psychiatry and Pediatrics Director, Child and Adolescent Psychiatry Stony Brook University School of Medicine
Part 1 of 2
Disclosure – 2011
Company BMS GSK FIU
Research Support/ Honoraria/SAB Research Research This presentation
What I will talk about • ADHD- a quick summary of phenomenology, course and treatment • Bipolar disorder – a quick summary of phenomenology, course and treatment • Why has there been confusion; is mood dysregulation another word for bipolar • What are the treatment implications • What is needed to adequately assess mania/bipolar disorder
What ADHD is • ADHD is a heterogeneous, clinical condition • It comes in mild, moderate, severe forms • “Deficit” does not mean “None”. It means that attention cannot be sustained when the child or adult is not interested. • Think of H-I-D-E; Hyperactivity, Impulsivity, Distractibility/Disorganization-Emotional lability that is Persistent, Pervasive, imPairing • It often co-occurs with oppositional defiant/conduct disorder, mood and anxiety disorders, learning and language disorders
“Hyperkinetic Child Syndrome”Laufer and Denhoff, 1957
SYMPTOM
DESCRIPTOR
DSM IV ADHD
Hyperactivity
Involuntary and constant overactivity that greatly surpasses normal
YES
Poor Concentration
Frequent shifting from one activity to another
YES
Variability
Behavior is unpredictable. "Sometimes he is good, sometimes bad"
NO
Irritability/ Explosiveness
Fits of anger easily provoked ; reactions almost volcanic in intensity
NO
Impulsiveness
Does things on the spur of the moment. Cannot delay gratification
YES
Sleep disturbance
Falls asleep at proper time but wakens after only a few hours "rampaging through the house in hyperactive, noisy, sleepdisturbing play"
NO
G. Carlson, 2009
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, unpredictable shift toward negative emotion
The “E” has been given various names over the years – similar though not the same • • • • • • •
Negative affect Affective aggression Impulsive aggression Emotional or mood lability Emotional Impulsiveness Severe Mood Dysregulation “manic symptoms” [mania criteria without episodes]
Co-Occurring Disorders in MTA Children (n=579)
ADHD alone
Oppositional Defiant Disorder
Tic Dis. Conduct Disorder
Mood Dis. Anxiety Disorder
Course of the Disorder Inattention 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-ADHD 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
Drug Amphetamine Methylphenidate Atomoxetine Guanfacine ER Clonidine Modafinil Bupropion Diet without additives
Effect Size 0.92 0.80 0.73 0.73 0.58* 0.49 0.32 0.2
Faraone SV, Spencer TJ: Presented at: American Psychiatric Association Annual Meeting, Toronto, Canada, May 2006. * Connor et al., JAACAP, 1999
MTA: % “Normalized” at 14 Months 100%
88%
80%
68% 56%
60% 34%
40%
25%
20%
0% Controls
Comb
MedMgt
Beh
CC
Comb = medical management + behavioral treatment; MedMgt = medical management; Beh = behavioral treatment; CC = community comparison group
Jensen PS, et al. J Dev Behav Pediatr. 2001;22:60-73.
Effect of severity on ADHD Mild
Moderate
Severe
When obvious
Elementary school
preschool
Age > mania % manic sample symptoms
measure
% Mania
10
250 teens, Columbia, Mo. 1
DICA
.06
5.7
1700 teens, OADP 2
K-SADS
.1
43
3329 6-12 y.o.s LAMS 3
GBI/KSADS
12.5
25
911 5-18 y.o. SB OPD 4
CMRS