Attention-Deficit/Hyperactivity Disorder vs.
        Bipolar Disease in the Pediatric Population

             Richard G P...
Disclosure
                        Richard G. Petty, MD, MSc, MRCP(UK), MRCPsych
          Consultant
                As...
Attention-Deficit/Hyperactivity Disorder and
                      Bipolar Disorder

           There are four key questi...
History of Attention-Deficit/Hyperactivity
                              Disorder (ADHD)
         •    Mid-1800s: Minimal ...
ADHD Statistics

          • 3-5% of all U.S. school-age children are
            estimated to have this disorder
        ...
Diagnostic Features
           Persistent pattern of:
             Inattention
             Hyperactivity
            ...
Components of Attention

           Arousal and alertness
           External or receptive attention: sensory processing...
Diagnosing ADHD: DSM-IV

             Inattentiveness:

             Has a minimum of 6
             symptoms regularly f...
Diagnosing ADHD: DSM-IV
                                            •   Lacks attention to detail;
                       ...
Diagnosing ADHD: DSM-IV

          •    Hyperactivity/
               Impulsivity:

              Has a minimum of 6
     ...
Diagnosing ADHD: DSM-IV
                                             •   Fidgets or squirms
                              ...
Diagnosing ADHD: DSM-IV

                                 •   Symptoms causing impairment
           Additional          ...
Problems of Diagnosis

              Subjectivity of Criteria
              Inconsistent evaluations--presence of sympto...
ADHD and the Brain
            Diminished arousal of
             some regions of the
             nervous system
       ...
ADHD and the Brain II
        Similarities of ADHD symptoms to those from
         injuries and lesions of frontal lobe a...
What Causes ADHD?
             Underlying cause of these differences is still
              unknown; there is much confli...
Inadequately Treated Attention
              Deficit Hyperactivity Disorder May
                 Have Serious Consequences...
Ch
                                               Academic              ildr
                                             ...
ADHD: Impact of No Treatment or
                          Under-Treatment

                  Health Care
                 ...
Bipolar Disorder in Children




Sunday, July 26, 2009
Difficulties in Diagnosing Pediatric Bipolar
                             Disorder

         Variability in clinical pres...
Developmental Manifestations of Manic Symptoms
                         in Children
     Elation/euphoria
        Giggli...
Developmental Manifestations of Manic
                      Symptoms in Children (continued)
      Grandiosity
         ...
Frequent Prodromal Features Before Onset of BP-I
      Ages 0-6 (n=13)          Ages 7-10 (n=24)       11-12 (n=10)

     ...
ADHD and Bipolar Disorder Are Highly
                    Co-morbid Conditions




Sunday, July 26, 2009
Conditions That May Co-Exist with
           Attention-Deficit/Hyperactivity Disorder




Sunday, July 26, 2009
Reward Deficiency Syndrome or “Salience
                        Disruption Syndrome”




Sunday, July 26, 2009
Reward Deficiency Syndrome or “Salience
                        Disruption Syndrome”
            Addictive                ...
Sunday, July 26, 2009
Bipolar
                        Disorder




Sunday, July 26, 2009
Personality
    Disorders                           Bipolar
                                                              ...
Irritable bowel   Cardio-
                  Pain         Fibromyalgia
                                                    ...
Differentiating Bipolar Disorder and ADHD




Sunday, July 26, 2009
Attention Deficit Disorder, Pediatric Bipolar
                Disorder and Neurobehavioral Disorders

           ALL STAR...
Attention-Deficit/Hyperactivity Disorder

           Children with Attention-Deficit/Hyperactivity
            Disorder a...
AD/HD - Co-existing Conditions:
                                    Depression

       35 % of individuals with AD/HD will...
AD/HD - Co-existing Conditions:
                        Mania or Bipolar Disorder

           20% of individuals with AD/...
AD/HD - Co-existing Conditions: Anxiety
                              Disorders

       35% of individuals with AD/HD will...
Bipolar Disorder - Differential Diagnoses

             Normal moodiness and behaviors
             Recurrent explosive,...
Things That Look Like ADHD

           Depression                   Learning disabilities
           Anxiety           ...
Diagnostic Overlap between Mania & ADHD


   DSM-IV Mania                             ADHD

   Elevated, expansive mood   ...
Pediatric Bipolar Disorder
           Bipolar (Manic Depressive) Disorder
             Pediatric Mania
                 ...
Attention-Deficit/Hyperactivity Disorder
                          versus Mania

           Attention Deficit Hyperactivi...
Keys to Differentiating Bipolar Disorder and Attention Deficit
                                 Disorder
 Bipolar Disorder...
Children with Bipolar Disorder and Elation/
                 Grandiosity (n=93) vs. ADHD (n=81)
        100


           7...
Irritable Neurobehavioral Disordered
                               Children

           Irritability may be based on dis...
Impulsive/Irritable
           Irritability = short fuse
           Early onset/persistent tantrums
              Impul...
Relationship Between Conduct Disorder and
                     Bipolar Disorder
                                 Symptom P...
Relationship Between Conduct Disorder and
                     Bipolar Disorder
                                   Symptom...
Comprehensive Treatment Strategies for
                          ADHD




Sunday, July 26, 2009
Assessments

           Comprehensive clinical evaluation Check for IQ,
            learning disabilities
              ...
The Pharmacological Treatment of ADHD:
                  Stimulants and Others
    Methylphenidate: Ritalin: 5-60mg; Conce...
ADHD: Treatment Types
           Medications: Essential to explain to the child - and adults -
            that treatment...
Treatment of Bipolar Disorder in Young
                             People




Sunday, July 26, 2009
Treatment of Bipolar Disorder in Children

             Acute
             Maintenance (prevention of relapses and
     ...
Bipolar Disorder - Psychoeducation
               •   Symptomatology
               •   Etiology ( e.g., genetics)
       ...
Pharmacological Treatment

             Mood Stabilizers
               Lithium
               Anticonvulsants
        ...
Bipolar Disorder – Pharmacological
                            Treatment (Cont’)
    •   Very few studies in youth - mostl...
Psychosocial Treatments


           Family Focus Therapy (FFT)
           Cognitive Behavior Therapy (CBT)
           ...
Why Treat Adolescent Bipolar Patients with
                 Adjunctive Family Psychoeducation?

           Family psychoe...
Family Expressed Emotion Status as a Predictor of
                 9-Month Clinical Outcome

    15




                  ...
Summary 1: ADHD




Sunday, July 26, 2009
Summary 1: ADHD

          Attention Deficit Hyperactivity Disorder




Sunday, July 26, 2009
Summary 1: ADHD

          Attention Deficit Hyperactivity Disorder
            A common childhood disorder




Sunday, ...
Summary 1: ADHD

          Attention Deficit Hyperactivity Disorder
            A common childhood disorder
           ...
Summary 1: ADHD

          Attention Deficit Hyperactivity Disorder
            A common childhood disorder
           ...
Summary 1: ADHD

          Attention Deficit Hyperactivity Disorder
            A common childhood disorder
           ...
Summary 1: ADHD

          Attention Deficit Hyperactivity Disorder
            A common childhood disorder
           ...
Summary 1: ADHD

          Attention Deficit Hyperactivity Disorder
            A common childhood disorder
           ...
Summary 1: ADHD

          Attention Deficit Hyperactivity Disorder
            A common childhood disorder
           ...
Summary 2: Bipolar Disorder




Sunday, July 26, 2009
Summary 2: Bipolar Disorder

        • BP disorder in youth is a chronic and difficult to treat
          illness that con...
Summary 2: Bipolar Disorder

        • BP disorder in youth is a chronic and difficult to treat
          illness that con...
Summary 2: Bipolar Disorder

        • BP disorder in youth is a chronic and difficult to treat
          illness that con...
Summary 2: Bipolar Disorder

        • BP disorder in youth is a chronic and difficult to treat
          illness that con...
Summary 3

           The treatment of both ADHD and bipolar disorder
            requires four attention to four factors...
Useful Addresses


       
            www.RichardGPettyMD.com

       
            www.RichardGPettyMD.blogs.com

     ...
Upcoming SlideShare
Loading in...5
×

ADHD Bipolar Disorder

5,220

Published on

The slides that accompanied a lecture on the problems of differentiating ADHD and bipolar disorders in young people and adults.

Published in: Health & Medicine
2 Comments
7 Likes
Statistics
Notes
No Downloads
Views
Total Views
5,220
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
275
Comments
2
Likes
7
Embeds 0
No embeds

No notes for slide

ADHD Bipolar Disorder

  1. 1. Attention-Deficit/Hyperactivity Disorder vs. Bipolar Disease in the Pediatric Population Richard G Petty MD, MSc, MRCP(UK), MRCPsych, Promedica Research Center, Georgia State University College of Health Sciences, Loganville, Georgia, USA rpettyus@aol.com Sunday, July 26, 2009
  2. 2. Disclosure Richard G. Petty, MD, MSc, MRCP(UK), MRCPsych  Consultant  AstraZeneca; Bristol Myers Squibb; Eli Lilly and Company; Janssen Pharmaceuticals  Speaker’s Bureau  Abbott Laboratories; AstraZeneca; Avanir Pharmaceuticals; Janssen Pharmaceuticals  Grant Support  British Diabetic Association; Bristol Myers Squibb; British Heart Foundation; Du Pont Merck, Inc.; Eli Lilly and Company; Janssen; Medical Research Council (UK); National Institute of Mental Health; Pfizer  Dr. Petty’s presentation will include the discussion of off- label, experimental, and/or investigational use of drugs or devices Sunday, July 26, 2009
  3. 3. Attention-Deficit/Hyperactivity Disorder and Bipolar Disorder  There are four key questions:  Are they two separate illnesses?  Are they two overlapping syndromes?  Are they sets of coexistent symptoms?  How often is Attention-Deficit/Hyperactivity Disorder an early symptom or warning sign of impending bipolar disorder?  Do these questions matter? Sunday, July 26, 2009
  4. 4. History of Attention-Deficit/Hyperactivity Disorder (ADHD) • Mid-1800s: Minimal Brain Damage • 1902 Defects in moral character • 1934 Organically driven • 1940 Minimal Brain Syndrome • 1957 Hyperkinetic Impulse Disorder • 1960 Minimal Brain Dysfunction (MBD) • 1968 Hyperkinetic Reaction of Childhood (DSM II) • 1980 Attention-Deficit Disorder - ADD (DSM III) with- hyperactivity without-hyperactivity residual type • 1994-present: Attention-Deficit/Hyperactivity Disorder: • 314.01: ADHD, Combined Type 314.00: ADHD, Predominantly Inattentive type 314.01: ADHD, Predominantly Hyperactive-Impulsive Type Sunday, July 26, 2009
  5. 5. ADHD Statistics • 3-5% of all U.S. school-age children are estimated to have this disorder • 5-10% of the entire U.S. population • Males are 3 to 6 times more likely to have diagnosed ADHD than are females • At least 50% of ADHD sufferers have another diagnosable mental disorder Sunday, July 26, 2009
  6. 6. Diagnostic Features  Persistent pattern of:  Inattention  Hyperactivity  Impulsivity Sunday, July 26, 2009
  7. 7. Components of Attention  Arousal and alertness  External or receptive attention: sensory processing and interpretation  Internal or reflective attention  Processing attention or selective attention  Focus  Filtering  Inhibition of sensation  External or expressive attention  Working memory Sunday, July 26, 2009
  8. 8. Diagnosing ADHD: DSM-IV  Inattentiveness: Has a minimum of 6 symptoms regularly for the past six months Symptoms are present at abnormal levels for stage of development Sunday, July 26, 2009
  9. 9. Diagnosing ADHD: DSM-IV • Lacks attention to detail; makes careless mistakes  Inattentiveness: • Has difficulty sustaining attention • Doesn’t seem to listen Has a minimum of 6 • Fails to follow through/fails to symptoms regularly for the finish projects past six months • Has difficulty organizing tasks Symptoms are present at • Avoids tasks requiring abnormal levels for stage of mental effort development • Often loses items necessary for completing a task • Easily distracted • Is forgetful in daily activities Sunday, July 26, 2009
  10. 10. Diagnosing ADHD: DSM-IV • Hyperactivity/ Impulsivity: Has a minimum of 6 symptoms regularly for the past six months. Symptoms are present at abnormal levels for stage of development Sunday, July 26, 2009
  11. 11. Diagnosing ADHD: DSM-IV • Fidgets or squirms excessively • Hyperactivity/ • Leaves seat when Impulsivity: inappropriate • Runs about/climbs extensively when Has a minimum of 6 inappropriate symptoms regularly for the • Has difficulty playing quietly past six months. • Often “on the go” or “driven by a motor” Symptoms are present at • Talks excessively abnormal levels for stage of • Blurts out answers before development question is finished • Cannot await turn • Interrupts or intrudes on others Sunday, July 26, 2009
  12. 12. Diagnosing ADHD: DSM-IV • Symptoms causing impairment  Additional present before age 7 Criteria: • Impairment from symptoms occurs in two or more settings • Clear evidence of significant impairment (social, academic, etc.) • Symptoms not better accounted for by another mental disorder Sunday, July 26, 2009
  13. 13. Problems of Diagnosis  Subjectivity of Criteria  Inconsistent evaluations--presence of symptoms usually given by teacher or parent  Studies have shown that the number of diagnosed cases of ADHD decreased 80% when observations of parent, teacher and physician were used rather than just one source  Symptoms in females more subtle---leads to under-diagnosis Sunday, July 26, 2009
  14. 14. ADHD and the Brain  Diminished arousal of some regions of the nervous system  Decreased blood flow to prefrontal cortex and pathways connecting to limbic system (caudate nucleus and striatum)  PET scan shows decreased glucose metabolism throughout Comparison of normal brain (left) and brain brain of ADHD patient. Sunday, July 26, 2009
  15. 15. ADHD and the Brain II  Similarities of ADHD symptoms to those from injuries and lesions of frontal lobe and prefrontal cortex  MRI scans of ADHD patients consistently show: • Smaller anterior right frontal lobe  abnormal development in the frontal and striatal regions • Significantly smaller splenium of corpus callosum  decreased communication and processing of information between hemispheres • Smaller caudate nucleus Sunday, July 26, 2009
  16. 16. What Causes ADHD?  Underlying cause of these differences is still unknown; there is much conflicting data between studies  Strong evidence of genetic component  Predominant theory: catecholamine neurotransmitter dysfunction or imbalance  Decreased dopamine and/or norepinephrine uptake in brain  Theory supported by positive response to stimulant treatment  Recent study in mice indicates possible lack of serotonin as a factor  Diet  Constant over-stimulation Sunday, July 26, 2009
  17. 17. Inadequately Treated Attention Deficit Hyperactivity Disorder May Have Serious Consequences Sunday, July 26, 2009
  18. 18. Ch Academic ildr en limitations Occupational/ Relationships vocational Adults Legal difficulties ADHD Low self esteem Motor vehicle accidents Injuries Smoking and substance abuse Adolescents Sunday, July 26, 2009
  19. 19. ADHD: Impact of No Treatment or Under-Treatment Health Care System Family 3-5x increase in Parental 50% increased in bicycle accidents1 Patient Divorce or Separation11,12 33% increase in ER visits2 2-4 x increase in Sibling Fights13 2-4 x more motor vehicle accidents3-5 Society Employer School & Occupation Increased Parental Substance Use Disorders: 46% Expelled6 2 X Risk8 Absenteeism14 35% Drop Out6 Earlier Onset9 and reduced Lower Occupational Status7 Less Likely to Quit Productivity14 in Adulthood10 1. DiScala et al., 1998. 6. Barkley, et al., 1990. 9. Pomerleau et al., 1995. 12. Brown & Pacini, 1989. 2. Liebson et al., 2001. 7. Mannuzza et al., 1997. 10. Wilens et al., 1995. 13. Mash & Johnston, 1983. 3. NHTSA, 1997. 8. Biederman et al., 1997. 11. Barkley, Fischer et al., 1991. 14. Noe et al., 1999. 4-5. Barkley et al., 1993; 1996. Sunday, July 26, 2009
  20. 20. Bipolar Disorder in Children Sunday, July 26, 2009
  21. 21. Difficulties in Diagnosing Pediatric Bipolar Disorder  Variability in clinical presentation  Severity, phase of the illness (depressed, manic, mixed, rapid cycling); and subtype of bipolar disorder  Highly comorbid with other psychiatric disorders  Effects of child’s development in symptom expression  Child’s physical and behavioral problems may be expressions of her or his symptoms  Effects of medications  Context where the bipolar disorder is developing Sunday, July 26, 2009
  22. 22. Developmental Manifestations of Manic Symptoms in Children  Elation/euphoria  Giggling uncontrollably in class while peers are calm; laughing hysterically when talking about killing others  Dancing and laughing at home while telling parents’ they are “suspended”  Finds everything funny & they don’t know why  Decreased need for sleep  Up at 2 AM rearranging furniture, cleaning, then awake at 6 AM dressed and ready for school  Child awake at 4 AM during summer vacation Geller et al., American Journal of Psychiatry, 2002; 159: 927-933 Sunday, July 26, 2009
  23. 23. Developmental Manifestations of Manic Symptoms in Children (continued)  Grandiosity  Telling principal to “shut up” and listen because the principal is the child’s “slave”; demanding that teacher be fired for stupidity  Child stealing go-kart because he felt rules did not apply to him (acute onset of conduct d/o)  Child believing he/she is a superhero & tries to fly  Child spends evenings “practicing” when they become president, despite failing in school  Hypersexuality – drawing or preoccupied with pictures of naked people; inappropriate kissing, touching of others breasts/buttocks; 1-900- sex lines; sexually vulgar language; sending notes propositioning peers Sunday, July 26, 2009
  24. 24. Frequent Prodromal Features Before Onset of BP-I Ages 0-6 (n=13) Ages 7-10 (n=24) 11-12 (n=10) Symptoms/Behaviors (%) Cried -23% Irritable mood-29% Depressive Increased Overly sensitive-25% mood-50% energy-23% Cried-21% Low energy/tired-30% Bold/Demanding-23% Bold /Demanding-21% Increased Quick temper-15% energy-30% Quick Temper-21% Anxious-15% Labile/mood Energy-17% changes-30% Anxious-30% Cried-30% Egeland et al., 2000 Sunday, July 26, 2009
  25. 25. ADHD and Bipolar Disorder Are Highly Co-morbid Conditions Sunday, July 26, 2009
  26. 26. Conditions That May Co-Exist with Attention-Deficit/Hyperactivity Disorder Sunday, July 26, 2009
  27. 27. Reward Deficiency Syndrome or “Salience Disruption Syndrome” Sunday, July 26, 2009
  28. 28. Reward Deficiency Syndrome or “Salience Disruption Syndrome” Addictive Impulsive Compulsive Personality behaviour behaviour behaviour disorder Attention deficit Conduct Alcoholism disorder + Aberrant disorder hyperactivity sexual Polysubstance Tourette’s behaviour Antisocial abuse syndrome personality Smoking Pathological Aggressive Autism gambling behaviour Obesity Redrawn and adapted from Blum, K. et al., American Scientist 1996; 1-30 www.sigmaxi.org/amsci/Articles/96Articles/Blum-full.html Sunday, July 26, 2009
  29. 29. Sunday, July 26, 2009
  30. 30. Bipolar Disorder Sunday, July 26, 2009
  31. 31. Personality Disorders Bipolar Tourette’s Disorder syndrome ADHD Autism spectrum disorders Conduct disorders Anxiety Disorders Impulse Sexual Substance Eating Control disorders/ Abuse Disorders Disorders addictions Sunday, July 26, 2009
  32. 32. Irritable bowel Cardio- Pain Fibromyalgia syndrome vascular Disorders Obesity Migraine Diabetes Mellitus Personality Disorders Bipolar Tourette’s Disorder syndrome ADHD Autism spectrum disorders Conduct disorders Anxiety Disorders Impulse Sexual Substance Eating Control disorders/ Abuse Disorders Disorders addictions Sunday, July 26, 2009
  33. 33. Differentiating Bipolar Disorder and ADHD Sunday, July 26, 2009
  34. 34. Attention Deficit Disorder, Pediatric Bipolar Disorder and Neurobehavioral Disorders  ALL START IN CHILDHOOD  Attention Deficit Hyperactivity Disorder  ADHD starts before age seven  Pediatric Bipolar Disorder  Starts before puberty  Neurobehavioral Disorders  Often prenatal or perinatal in origin  Initial symptoms start in early childhood Sunday, July 26, 2009
  35. 35. Attention-Deficit/Hyperactivity Disorder  Children with Attention-Deficit/Hyperactivity Disorder are NOT more active in play  ONLY when they are asked to stop and sit still  Therefore, we see a diminished:  Ability to INHIBIT activity  Therefore: impulsive, hyperactive (immature)  Ability to INHIBIT response to distractions  Therefore: inattentive (not age appropriate)  The brain’s “brake” is not working well Sunday, July 26, 2009
  36. 36. AD/HD - Co-existing Conditions: Depression 35 % of individuals with AD/HD will have depression 50 45 40 35 30 Children 25 20 Adults 15 10 5 0 Sunday, July 26, 2009
  37. 37. AD/HD - Co-existing Conditions: Mania or Bipolar Disorder  20% of individuals with AD/HD may manifest bipolar disorder  May have moods that change very rapidly, seemingly for no reason Sunday, July 26, 2009
  38. 38. AD/HD - Co-existing Conditions: Anxiety Disorders 35% of individuals with AD/HD will have anxiety. 40 35 30 25 Children 20 Adults 15 10 5 0 Sunday, July 26, 2009
  39. 39. Bipolar Disorder - Differential Diagnoses  Normal moodiness and behaviors  Recurrent explosive, aggressive, and irritable behaviors: Bipolar vs. unipolar recurrent agitated MDD vs. ADHD + ODD  Asperger’s Disorder  ADHD vs. Bipolar  Abrupt onset of “ADHD”  Late onset “ADHD”  Intermittent “ADHD”  Intermittent worsening of the ADHD symptoms ( “tolerance” to the stimulants)  In adolescents: Borderline Personality Disorder Sunday, July 26, 2009
  40. 40. Things That Look Like ADHD  Depression  Learning disabilities  Anxiety  Parenting problems  Hearing problems  Substance use  Visual problems  Medication side-effects  Seizure disorder  Lead poisoning  Oppositional defiant disorder  Autism Sunday, July 26, 2009
  41. 41. Diagnostic Overlap between Mania & ADHD DSM-IV Mania ADHD Elevated, expansive mood No Irritability Commonly associated Inflated self-esteem / grandiosity No Decreased need for sleep Can be present More talkative / pressured speech DSM-IV Criteria Flight of Ideas or racing thoughts No Hyperactivity / goal-directed activity DSM-IV Criteria Pleasurable activities with high risk Commonly associated …for painful consequences Distractibility DSM-IV Criteria Sunday, July 26, 2009
  42. 42. Pediatric Bipolar Disorder  Bipolar (Manic Depressive) Disorder  Pediatric Mania  Hyperactive even in play • ADHD normal during play  Racing thoughts, rapid speech • ADHD shows normal rate of cognition and speech  Little need to sleep • ADHD children may be too hyperactive to fall asleep • But their need for sleep is otherwise normal  Euphoria, grandiosity - unique to Mania Geller et al., American Journal of Psychiatry, 2002; 159: 927-933 Sunday, July 26, 2009
  43. 43. Attention-Deficit/Hyperactivity Disorder versus Mania  Attention Deficit Hyperactivity Disorder = Poor “brakes”  Cannot stop - in age appropriate manner  Mania = Too much “acceleration”  Brain is racing too fast  Both may show:  Hyperactivity, distractibility, irritability  Mania shows severe mood swings:  Elation, grandiosity, racing thoughts/speech Sunday, July 26, 2009
  44. 44. Keys to Differentiating Bipolar Disorder and Attention Deficit Disorder Bipolar Disorder ADD/ADHD Most common onset ages 15-19 Present by K/G1 or Earlier Family history of attentional problems but mood Family history of mood disorder disorders less commonly Family history of alcohol or substance abuse Family history of alcohol or substance abuse less common Fluctuating moods Fluctuating attention Discrete mood episodes Chronic condition Seasonality of symptoms No seasonal component Premenstrual exacerbation of attentional Hormonal exacerbation of mood disorders problems Daily variation in mood and activity Relatively fixed mood and activity level in the Flight of Ideas or racing thoughts Accelerated thinking Poor response to antidepressants Equivocal response to antidepressants Symptoms often exacerbated by psychostimulants Symptoms usually improved by psychostimulants Sunday, July 26, 2009
  45. 45. Children with Bipolar Disorder and Elation/ Grandiosity (n=93) vs. ADHD (n=81) 100 75 50 25 0 1 2 3 4 5 6 7 8 9 le ed ed le se nt ctib y ch Ne at tab erg me t dio igh El ee tra ep dg Irri an En Fl Sp Dis g/ Sle Gr Ju cin Ra =BPD Geller et al., American Journal of Psychiatry, 2002; 159: 927-933 Sunday, July 26, 2009
  46. 46. Irritable Neurobehavioral Disordered Children  Irritability may be based on disorders of brain chemistry:  Attention Deficit Hyperactivity Disorder, Bipolar Disorder, Schizophrenia, etc.  Or it may be a child with early brain damage from:  Drugs or alcohol used in pregnancy  Difficult or premature delivery  Very early traumatic brain injury  Genetic diseases  Epileptiform disorders Sunday, July 26, 2009
  47. 47. Impulsive/Irritable  Irritability = short fuse  Early onset/persistent tantrums  Impulsive behavior  Impulsive aggression  These behaviors are NOT premeditated  Irritable behaviors are not planned  Quick/hot temper = Poor impulse control and too much emotion  Differs from conduct disorders, some psychosis and Psychopathy:  In cold blood, premeditated, too little emotion Sunday, July 26, 2009
  48. 48. Relationship Between Conduct Disorder and Bipolar Disorder Symptom Profile of Bipolar Disorder BPD = bipolar disorder; CD = conduct disorder. Reprinted with perminssion, Biederman J et al. Biol Psychiatry. 2003;53:952-960 © 2003 Society of Biological Psychiatry. Sunday, July 26, 2009
  49. 49. Relationship Between Conduct Disorder and Bipolar Disorder Symptom Profile of Conduct Disorder CD BPD + CD Reprinted with perminssion, Biederman J et al. Biol Psychiatry. 2003;53:952-960 © 2003 Society of Biological Psychiatry. Sunday, July 26, 2009
  50. 50. Comprehensive Treatment Strategies for ADHD Sunday, July 26, 2009
  51. 51. Assessments  Comprehensive clinical evaluation Check for IQ, learning disabilities  Check for other diagnoses  Rule out Bipolar disorder, Neurocognitive problems and other disorders  ADHD rating scales  Conners Scales for Teachers  Neuropsychological testing  Continuous Performance Test (CPT) Sunday, July 26, 2009
  52. 52. The Pharmacological Treatment of ADHD: Stimulants and Others Methylphenidate: Ritalin: 5-60mg; Concerta 18-81mg/day Dextroamphetamine: Dexidrine SR: 5-15mg Adderall XR: 4 amphetamine salts: 10-30mg Pemoline: Cylert: 37.5mg/day, increase up to 75mg Atomoxetine: Strattera (non-stimulant): 80-120mg Others: Modafinil: Provigil: 300mg Buproprion: dopamine and norepinephrine reuptake inhibitor Clonidine: α-adrenoceptor agonists: 0.1mg t.i.d. (Guanfacine {Tenex}): α-adrenoceptor agonists: 1-3mg q.d. Sunday, July 26, 2009
  53. 53. ADHD: Treatment Types  Medications: Essential to explain to the child - and adults - that treatment must be year-round  Integrated medical approaches:  Nutrition  Food additives  Herbs and supplements including fish oils  Homeopathy  Acupuncture  Parent Training – Positive Discipline  BIP (Behavior Intervention Plan)  Structure – routines, schedules  School supports Sunday, July 26, 2009
  54. 54. Treatment of Bipolar Disorder in Young People Sunday, July 26, 2009
  55. 55. Treatment of Bipolar Disorder in Children  Acute  Maintenance (prevention of relapses and recurrences)  Treatment of mania, depression, rapid cycling, mixed episodes, and sometimes psychosis  Tools:  Medications  Psychotherapy  Life style management Sunday, July 26, 2009
  56. 56. Bipolar Disorder - Psychoeducation • Symptomatology • Etiology ( e.g., genetics) • Treatment • Prognosis • Prevention (early signs of relapse/recurrence) • Psychosocial Scars • Stigma • Mood and sleep hygiene • Importance of year-long compliance Sunday, July 26, 2009
  57. 57. Pharmacological Treatment  Mood Stabilizers  Lithium  Anticonvulsants  Valproate (Depakote); carbamazepine (Tegretol); oxcarbamazepine (Tryleptal); lamotrigine (Lamictal) etc.  New antipsychotics  Risperidone (Risperdal), olanzapine (Zyprexa); quetiapine (Seroquel), ziprasidone (Geodon), aripripazole (Abilify) etc.  Antidepressants  Selective Serotonin Reuptake Inhibitors  Venlafaxine (Effexor), bupropion (Wellbutrim) etc.  Others: benzodiazepines, fish oils etc. N.B. None is indicated for use in people under the age of 18 Sunday, July 26, 2009
  58. 58. Bipolar Disorder – Pharmacological Treatment (Cont’) • Very few studies in youth - mostly open label • Response to acute treatment with mood stabilizers (lithium, valproate (VPA), carbamazepine (CBZ) approx. 40%-80% • Small study showed that valproate + quetiapine was better than valproate + placebo for children with mania • Open studies suggest that the “atypicals” alone or in combination may be efficacious • May need treatment with multiple medications Sunday, July 26, 2009
  59. 59. Psychosocial Treatments  Family Focus Therapy (FFT)  Cognitive Behavior Therapy (CBT)  Interpersonal Psychotherapy (IPT)  Interpersonal and Social Rhythms Therapy (IPSRT) Sunday, July 26, 2009
  60. 60. Why Treat Adolescent Bipolar Patients with Adjunctive Family Psychoeducation?  Family psychoeducation is a powerful adjunct to pharmacotherapy for adult bipolar patients  Family factors are correlated with the course of recurrent mood disorders in adults and children  Early-onset mood and behavioral disturbances are associated with a high familial loading for major affective disorder  Mood stabilizers can be difficult to dispense safely to adolescents living in chaotic family environments Sunday, July 26, 2009
  61. 61. Family Expressed Emotion Status as a Predictor of 9-Month Clinical Outcome 15 Number of Patients 11 8 4 0 Low EE (7/13) High EE (9/10) No Relapse Relapse North χ2(1) = 3.82, p=.05 Miklowitz DJ , et al. Arch Gen Psychiatry, 1988;45(3):225-231 Sunday, July 26, 2009
  62. 62. Summary 1: ADHD Sunday, July 26, 2009
  63. 63. Summary 1: ADHD  Attention Deficit Hyperactivity Disorder Sunday, July 26, 2009
  64. 64. Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder Sunday, July 26, 2009
  65. 65. Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder  With many causes Sunday, July 26, 2009
  66. 66. Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder  With many causes  Often genetic (e.g. DAT-1, DRD2, D4 genes) Sunday, July 26, 2009
  67. 67. Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder  With many causes  Often genetic (e.g. DAT-1, DRD2, D4 genes)  Can produce serious life distress Sunday, July 26, 2009
  68. 68. Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder  With many causes  Often genetic (e.g. DAT-1, DRD2, D4 genes)  Can produce serious life distress  Learning, behavior, social, teen safety Sunday, July 26, 2009
  69. 69. Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder  With many causes  Often genetic (e.g. DAT-1, DRD2, D4 genes)  Can produce serious life distress  Learning, behavior, social, teen safety  Goal is to create resilience: Sunday, July 26, 2009
  70. 70. Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder  With many causes  Often genetic (e.g. DAT-1, DRD2, D4 genes)  Can produce serious life distress  Learning, behavior, social, teen safety  Goal is to create resilience:  Positive discipline, structure, medications Sunday, July 26, 2009
  71. 71. Summary 2: Bipolar Disorder Sunday, July 26, 2009
  72. 72. Summary 2: Bipolar Disorder • BP disorder in youth is a chronic and difficult to treat illness that conveys high morbidity (e.g., behavior problems, substance abuse), poor psychosocial functioning, psychosis, and risk for suicide Sunday, July 26, 2009
  73. 73. Summary 2: Bipolar Disorder • BP disorder in youth is a chronic and difficult to treat illness that conveys high morbidity (e.g., behavior problems, substance abuse), poor psychosocial functioning, psychosis, and risk for suicide • Youth with BP usually have mixed and rapid cycling patterns that are the types carrying the worst prognosis and are more difficult to treat Sunday, July 26, 2009
  74. 74. Summary 2: Bipolar Disorder • BP disorder in youth is a chronic and difficult to treat illness that conveys high morbidity (e.g., behavior problems, substance abuse), poor psychosocial functioning, psychosis, and risk for suicide • Youth with BP usually have mixed and rapid cycling patterns that are the types carrying the worst prognosis and are more difficult to treat • BP is highly comorbid with other psychiatric disorders that require identification and treatment Sunday, July 26, 2009
  75. 75. Summary 2: Bipolar Disorder • BP disorder in youth is a chronic and difficult to treat illness that conveys high morbidity (e.g., behavior problems, substance abuse), poor psychosocial functioning, psychosis, and risk for suicide • Youth with BP usually have mixed and rapid cycling patterns that are the types carrying the worst prognosis and are more difficult to treat • BP is highly comorbid with other psychiatric disorders that require identification and treatment • The diagnosis of BP may be difficult and requires longitudinal follow-up Sunday, July 26, 2009
  76. 76. Summary 3  The treatment of both ADHD and bipolar disorder requires four attention to four factors:  Physical:  Appropriate medications  Nutrition  Environmental factors  Psychological  Social  Spiritual Sunday, July 26, 2009
  77. 77. Useful Addresses  www.RichardGPettyMD.com  www.RichardGPettyMD.blogs.com  rpettyus@aol.com  www.Healia.com Sunday, July 26, 2009
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×