Richard G. Petty, profile picture
Uploaded byRichard G. Petty
5,812 views

ADHD Bipolar Disorder

This document discusses differentiating between attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder in children. It poses four key questions about whether they are separate illnesses, overlapping syndromes, coexistent symptoms, or if ADHD is a warning sign of bipolar disorder. It then provides background on the history and diagnostic criteria of ADHD, as well as statistics on its prevalence. It also discusses the challenges of diagnosing pediatric bipolar disorder and lists common developmental manifestations of manic symptoms in children. The document notes that ADHD and bipolar disorder are highly comorbid conditions and explores some ways to differentiate between the two.

Embed presentation

Downloaded 364 times
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
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
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
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
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
Diagnostic Features  Persistent pattern of:  Inattention  Hyperactivity  Impulsivity Sunday, July 26, 2009
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
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
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
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
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
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
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
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
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
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
Inadequately Treated Attention Deficit Hyperactivity Disorder May Have Serious Consequences Sunday, July 26, 2009
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
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
Bipolar Disorder in Children Sunday, July 26, 2009
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
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
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
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
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 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
Sunday, July 26, 2009
Bipolar Disorder Sunday, July 26, 2009
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
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
Differentiating Bipolar Disorder and ADHD Sunday, July 26, 2009
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Comprehensive Treatment Strategies for ADHD Sunday, July 26, 2009
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
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
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
Treatment of Bipolar Disorder in Young People Sunday, July 26, 2009
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
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
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
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
Psychosocial Treatments  Family Focus Therapy (FFT)  Cognitive Behavior Therapy (CBT)  Interpersonal Psychotherapy (IPT)  Interpersonal and Social Rhythms Therapy (IPSRT) Sunday, July 26, 2009
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
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
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, July 26, 2009
Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder  With many causes Sunday, July 26, 2009
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
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
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
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
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
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 conveys high morbidity (e.g., behavior problems, substance abuse), poor psychosocial functioning, psychosis, and risk for suicide Sunday, July 26, 2009
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
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
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
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
Useful Addresses  www.RichardGPettyMD.com  www.RichardGPettyMD.blogs.com  rpettyus@aol.com  www.Healia.com Sunday, July 26, 2009

More Related Content

PPTX
Complete Psychological Disorders List
byAvigail Gabaleo Maximo
 
PPT
Elimination disorders
byNilesh Kucha
 
PPTX
Assessment of ADHD
byTataInteractive
 
PPTX
Website audit for SEO
byDignitas Digital Pvt. Ltd.
 
PPTX
addictive disorder (abnormal psychology)
byVershul Jain
 
PPTX
The Science of Motivation - Marta Loveguard
byMartaLoveguard
 
PPTX
Anger management
byPriya Verma
 
PPT
Adhd
byAbdo_452
 
Complete Psychological Disorders List
byAvigail Gabaleo Maximo
 
Elimination disorders
byNilesh Kucha
 
Assessment of ADHD
byTataInteractive
 
Website audit for SEO
byDignitas Digital Pvt. Ltd.
 
addictive disorder (abnormal psychology)
byVershul Jain
 
The Science of Motivation - Marta Loveguard
byMartaLoveguard
 
Anger management
byPriya Verma
 
Adhd
byAbdo_452
 

Viewers also liked

PPTX
The adhd brain
byCMoondog
 
PPT
Adhd and the_brain
byCMoondog
 
PPT
ADHD powerpoint
bymicalg
 
PPT
Pediatric Bipolar (against)
bypsych493
 
PDF
Final PPP Slides by Ali Fossell
byAli Fossell
 
PPTX
EOCCS Teaching Strategies K-4
byJudith Champion
 
PPTX
Adhd Presentation
bypsych493
 
PPT
Understanding ADHD
byTeenMentalHealth.org
 
PPT
Adhd
byCMoondog
 
PPTX
Pediatric Bipolar Disorder
bypsych493
 
PPTX
Iacapap workshop on PRESCRIBING FOR CHILDREN AND ADOLESCENTS: PERSPECTIVE FR...
byDevashish Konar
 
PPTX
Juvenile bipolar disorder
bySalman Kareem
 
PPTX
Workshop on child and adolescent psychopharmacology
byDevashish Konar
 
PPTX
Differentiating Intellectual Disability, Autism Spectrum Disorder, & Specific...
byConsulting Psychologists
 
PPTX
Pediatric Psychopharmacology
byPallav Pareek
 
PPTX
Ritalin: Ending the Abuse for Non-ADHD Patients
bykallovesdior
 
ODP
Atomoxetine Hydrochloride Capsules (Attentrol)
byClearsky Pharmacy
 
PPTX
Comorbid adhd conditions
byAbigail Mae
 
PPTX
Hanipsych, bipolar
byHani Hamed
 
The adhd brain
byCMoondog
 
Adhd and the_brain
byCMoondog
 
ADHD powerpoint
bymicalg
 
Pediatric Bipolar (against)
bypsych493
 
Final PPP Slides by Ali Fossell
byAli Fossell
 
EOCCS Teaching Strategies K-4
byJudith Champion
 
Adhd Presentation
bypsych493
 
Understanding ADHD
byTeenMentalHealth.org
 
Adhd
byCMoondog
 
Pediatric Bipolar Disorder
bypsych493
 
Iacapap workshop on PRESCRIBING FOR CHILDREN AND ADOLESCENTS: PERSPECTIVE FR...
byDevashish Konar
 
Juvenile bipolar disorder
bySalman Kareem
 
Workshop on child and adolescent psychopharmacology
byDevashish Konar
 
Differentiating Intellectual Disability, Autism Spectrum Disorder, & Specific...
byConsulting Psychologists
 
Pediatric Psychopharmacology
byPallav Pareek
 
Ritalin: Ending the Abuse for Non-ADHD Patients
bykallovesdior
 
Atomoxetine Hydrochloride Capsules (Attentrol)
byClearsky Pharmacy
 
Comorbid adhd conditions
byAbigail Mae
 
Hanipsych, bipolar
byHani Hamed
 

Similar to ADHD Bipolar Disorder

PPTX
ADHD (2). Definition , diagnostic criteria
byChAli93
 
DOCX
Dsim
byackerkri
 
PPTX
Attention-Deficit-13032023-105959am.pptx
byRajaFahad8
 
PPTX
Adhd Attention Deficit Hyperactivity Disorder
byLAMAEZULFIQAR
 
PDF
Adult Adhdv Criteria Comorbidities Considerations
bystevehughesphd
 
PDF
Illinois Doc Assist ADHD Presentation
bydocassist
 
PPT
Attention Deficit Hyperactice Disorder
byDr. Saad Saleh Al Ani
 
PPTX
Au Psy492 M7 A2 Acevedo,Janisse.Docx
byjea074
 
PPT
Diagnosis slides
byTbilkey
 
PPT
Attention deficit hyperactivity disorder (adhd)
byMermaidtail
 
PPT
ADHD topic in nurse
byMermaidtail
 
KEY
ADD/ ADHD in Children
byTammy Baker
 
PPT
ADHD_session_one
bycindyyew
 
PPT
ADHD
bySantanu Ghosh
 
PPTX
What Teachers Need to Know About ADHD Medications
byTeenMentalHealth.org
 
PPT
ADHD PRACTICAL POINTS
byHussein Abdeldayem
 
PPT
Adhd new developments
bysagedayschool
 
PPTX
KIPP ADHD presentation Kurtz
bysteven_kurtz
 
PPT
Topic 2 - ADHD and Hyperkinetic Disorder 2010
bySimon Bignell
 
PDF
Attention Deficit Hyperactivity Disorder: Valid Medical Condition or Cultural...
byworldwideww
 
ADHD (2). Definition , diagnostic criteria
byChAli93
 
Dsim
byackerkri
 
Attention-Deficit-13032023-105959am.pptx
byRajaFahad8
 
Adhd Attention Deficit Hyperactivity Disorder
byLAMAEZULFIQAR
 
Adult Adhdv Criteria Comorbidities Considerations
bystevehughesphd
 
Illinois Doc Assist ADHD Presentation
bydocassist
 
Attention Deficit Hyperactice Disorder
byDr. Saad Saleh Al Ani
 
Au Psy492 M7 A2 Acevedo,Janisse.Docx
byjea074
 
Diagnosis slides
byTbilkey
 
Attention deficit hyperactivity disorder (adhd)
byMermaidtail
 
ADHD topic in nurse
byMermaidtail
 
ADD/ ADHD in Children
byTammy Baker
 
ADHD_session_one
bycindyyew
 
ADHD
bySantanu Ghosh
 
What Teachers Need to Know About ADHD Medications
byTeenMentalHealth.org
 
ADHD PRACTICAL POINTS
byHussein Abdeldayem
 
Adhd new developments
bysagedayschool
 
KIPP ADHD presentation Kurtz
bysteven_kurtz
 
Topic 2 - ADHD and Hyperkinetic Disorder 2010
bySimon Bignell
 
Attention Deficit Hyperactivity Disorder: Valid Medical Condition or Cultural...
byworldwideww
 

Recently uploaded

PPTX
Updated PALS slides 2025 guidelines.pptx
bydrabrehman121
 
PPT
Menin Masters for AML Care: Guidance on Integrating Menin Inhibitor Regimens ...
byPVI, PeerView Institute for Medical Education
 
PPT
Elevating NMIBC Care: Putting the Latest Innovations for Intravesical Therapi...
byPVI, PeerView Institute for Medical Education
 
PPTX
Types of Communication Disorders SLP lecture 3.pptx
byDr Zonera Khalid PT
 
PPTX
Historical background and development of profession of pharmacy pptx
byGulam Muheyuddeen
 
PPTX
Organization, Premises, Equipment & Raw Materials The Pillars of Pharmaceutic...
byDr. Smita Kumbhar
 
PPTX
Seminar on Ebola virus , سیمینارێکی ئامادەکراو لەسەر Ebola virus
bydanaShalal2
 
PDF
Regal Best Kidney Multispecialty Hospital
bysekhardigitalmarketi
 
PPTX
case control study for Community Medicine.pptx
byDr.Bharti Koria
 
PPTX
EYELID TUMOURS . CLINICAL FEATURES . DIAGNOSIS . SURGICAL MANAGEMENT
byDr Aarushi Choudhary
 
PPT
Forging New Paths With Earlier Use of ADCs in Breast Cancer: From Clinical Br...
byPVI, PeerView Institute for Medical Education
 
PPTX
Drug Distribution Explained | Pharmacokinetics, Barriers, Vd & Redistribution...
byWasim Akram Rajoor
 
PPTX
Antigen ppt .pptx by Dr. Rakesh Prasad Sah
byDr. Rakesh Prasad Sah
 
PPTX
CRITICAL APPRAISAL_.pptx for practical pharmacology
bySAMYUKTHAKANDULA
 
PPT
The Challenges of Choice in First-Line EGFRm NSCLC: Practical Guidance on Opt...
byPVI, PeerView Institute for Medical Education
 
PPTX
WCPCCS 2025 Intelligent Digital Agents Final.pptx
byJAI NAHAR, MD MBA
 
PPTX
RHINOSINUSITIS: Etiology, Classification, Diagnosis and Treatment.pptx
byProf Sangita Bhandary
 
PPTX
Liver failure in children -PEDIATRIC.pptx
byDr Ndayisaba Corneille
 
PPTX
Unit- II (Bioavaliability & Bioequivalence).pptx
byUditiHanda
 
PPTX
Slenderiiz Dual Drops: Slenderiix & Xceler8 Insider Guide
byDualDrops.com
 
Updated PALS slides 2025 guidelines.pptx
bydrabrehman121
 
Menin Masters for AML Care: Guidance on Integrating Menin Inhibitor Regimens ...
byPVI, PeerView Institute for Medical Education
 
Elevating NMIBC Care: Putting the Latest Innovations for Intravesical Therapi...
byPVI, PeerView Institute for Medical Education
 
Types of Communication Disorders SLP lecture 3.pptx
byDr Zonera Khalid PT
 
Historical background and development of profession of pharmacy pptx
byGulam Muheyuddeen
 
Organization, Premises, Equipment & Raw Materials The Pillars of Pharmaceutic...
byDr. Smita Kumbhar
 
Seminar on Ebola virus , سیمینارێکی ئامادەکراو لەسەر Ebola virus
bydanaShalal2
 
Regal Best Kidney Multispecialty Hospital
bysekhardigitalmarketi
 
case control study for Community Medicine.pptx
byDr.Bharti Koria
 
EYELID TUMOURS . CLINICAL FEATURES . DIAGNOSIS . SURGICAL MANAGEMENT
byDr Aarushi Choudhary
 
Forging New Paths With Earlier Use of ADCs in Breast Cancer: From Clinical Br...
byPVI, PeerView Institute for Medical Education
 
Drug Distribution Explained | Pharmacokinetics, Barriers, Vd & Redistribution...
byWasim Akram Rajoor
 
Antigen ppt .pptx by Dr. Rakesh Prasad Sah
byDr. Rakesh Prasad Sah
 
CRITICAL APPRAISAL_.pptx for practical pharmacology
bySAMYUKTHAKANDULA
 
The Challenges of Choice in First-Line EGFRm NSCLC: Practical Guidance on Opt...
byPVI, PeerView Institute for Medical Education
 
WCPCCS 2025 Intelligent Digital Agents Final.pptx
byJAI NAHAR, MD MBA
 
RHINOSINUSITIS: Etiology, Classification, Diagnosis and Treatment.pptx
byProf Sangita Bhandary
 
Liver failure in children -PEDIATRIC.pptx
byDr Ndayisaba Corneille
 
Unit- II (Bioavaliability & Bioequivalence).pptx
byUditiHanda
 
Slenderiiz Dual Drops: Slenderiix & Xceler8 Insider Guide
byDualDrops.com
 

ADHD Bipolar Disorder

  • 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.
    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.
    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.
    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.
    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.
    Diagnostic Features  Persistent pattern of:  Inattention  Hyperactivity  Impulsivity Sunday, July 26, 2009
  • 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.
    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.
    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.
    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.
    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.
    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.
    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.
    ADHD and theBrain  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.
    ADHD and theBrain 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.
    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.
    Inadequately Treated Attention Deficit Hyperactivity Disorder May Have Serious Consequences Sunday, July 26, 2009
  • 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.
    ADHD: Impact ofNo 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.
    Bipolar Disorder inChildren Sunday, July 26, 2009
  • 21.
    Difficulties in DiagnosingPediatric 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.
    Developmental Manifestations ofManic 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.
    Developmental Manifestations ofManic 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.
    Frequent Prodromal FeaturesBefore 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.
    ADHD and BipolarDisorder Are Highly Co-morbid Conditions Sunday, July 26, 2009
  • 26.
    Conditions That MayCo-Exist with Attention-Deficit/Hyperactivity Disorder Sunday, July 26, 2009
  • 27.
    Reward Deficiency Syndromeor “Salience Disruption Syndrome” Sunday, July 26, 2009
  • 28.
    Reward Deficiency Syndromeor “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.
  • 30.
    Bipolar Disorder Sunday, July 26, 2009
  • 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.
    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.
    Differentiating Bipolar Disorderand ADHD Sunday, July 26, 2009
  • 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.
    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.
    AD/HD - Co-existingConditions: 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.
    AD/HD - Co-existingConditions: 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.
    AD/HD - Co-existingConditions: 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.
    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.
    Things That LookLike 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.
    Diagnostic Overlap betweenMania & 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.
    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.
    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.
    Keys to DifferentiatingBipolar 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.
    Children with BipolarDisorder 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.
    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.
    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.
    Relationship Between ConductDisorder 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.
    Relationship Between ConductDisorder 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.
    Comprehensive Treatment Strategiesfor ADHD Sunday, July 26, 2009
  • 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.
    The Pharmacological Treatmentof 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.
    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.
    Treatment of BipolarDisorder in Young People Sunday, July 26, 2009
  • 55.
    Treatment of BipolarDisorder 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.
    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.
    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.
    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.
    Psychosocial Treatments  Family Focus Therapy (FFT)  Cognitive Behavior Therapy (CBT)  Interpersonal Psychotherapy (IPT)  Interpersonal and Social Rhythms Therapy (IPSRT) Sunday, July 26, 2009
  • 60.
    Why Treat AdolescentBipolar 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.
    Family Expressed EmotionStatus 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.
  • 63.
    Summary 1: ADHD  Attention Deficit Hyperactivity Disorder Sunday, July 26, 2009
  • 64.
    Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder Sunday, July 26, 2009
  • 65.
    Summary 1: ADHD  Attention Deficit Hyperactivity Disorder  A common childhood disorder  With many causes Sunday, July 26, 2009
  • 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.
    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.
    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.
    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.
    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.
    Summary 2: BipolarDisorder Sunday, July 26, 2009
  • 72.
    Summary 2: BipolarDisorder • 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.
    Summary 2: BipolarDisorder • 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.
    Summary 2: BipolarDisorder • 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.
    Summary 2: BipolarDisorder • 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.
    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.
    Useful Addresses  www.RichardGPettyMD.com  www.RichardGPettyMD.blogs.com  rpettyus@aol.com  www.Healia.com Sunday, July 26, 2009