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Experience a more comprehensive conceptualization of research relevant symptoms related to both ADHD and Bipolar Disorder as well as PTSD that goes beyond the narrow framework of the DSM Improve clinical interviewing skills in order to focus on asking the questions that most likely illicit relevant information Adam Andreassen, Psy.D. Become more familiar with the assets and limitations of inventories and psychological testing results. Executive Director Heart of America Psychology Training Consortium Become more competent in ruling in or ruling out other co morbid conditions. President Midwest Assessment & Psychotherapy Solutions (MAPS)
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Appendicitis Fever Strep Throat
Geller & DelBello, 2008
Irritability and Hyperactivity Mania (elated mood and grandiosity)
Major ADHD Depressive (no Disorder cardinal (low mood symptoms) and anhedonia)
Autism (communication and social deficits) Geller & DelBello, 2008
1% 8%
Barkley, 2006
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Anxiety disorder: 10 50% Around WWI ADHD symptoms were often MDD: 15 75% associated with an outbreak of encephalitis Bipolar I: 6 27%; (BAD I carries a very high risk for Clinicians began to see similar symptoms in comorbid ADHD, even though ADHD carries a low risk for BAD I) other organic based disorders (brain injured child, MBD) ODD: Up to 85% Conduct Disorder: 15 56% (worse prognosis) Also “spoiled child” syndrome PTSD may be circular with ADHD: 1 6% 1930’s began to notice improved effects with Tourette syndrome or tick disorder: 12 34% amphetamine use to control headaches PDD: Up to 26% (Barkley, 2006) Barkley 2006
1950’s movement to hyperkinetic impulse disorder The word “manic” traces back to Ancient Later in the decade more specific learning Greek. problems were identified rather than Mania and melancholia have been tied together generalizing MBD for centuries 1970’s began to focus on impulsivity as well Biphasic Mental Illness causing recurrent 1980’s focus on attention problems oscilliations between mania and depression Later focus on educational needs (1854 Jules Baillarger). 21 st century continues to look at further Emil Kraepelin coined term manic depressiion subtypes (1900’s) Barkley 2006 1952 placed in the Diagnostic Manual
No early differentiation between unipolar and bipolar Cyclicity can range from less than 48 hours to Both were considered manic depressive illness several years More recent research has also noted some differences in the energy components between unipolar and bipolar High degree of inter individual variability depressed patients Bipolar disorder has been seen to have a greater genetic Typical cycle length of Bipolar disorder is less link than unipolar depression than in unipolar major depression However, conflicting results have been found with relatives of “well defined” unipolar depressives rarely 13 20% rapid cycling (≥4 depressed or manic exhibiting bipolar disorder episodes per year) Could occur on a polygenic or continuous spectrum: Adams and Sutker (2001) Unipolar Bipolar Adams and Sutker (2001)
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Rapid cycling is more common among women Approximately 10 15% of adolescents with Initial mood episode is usually depressive Rapid cycling generally develops later recurrent MDE will develop Bipolar, mixed Later age of manic onset may be an indication of secondary mania episodes may be more likely in adolescents and and can be indistinguishable from patients with primary mania Can also occur during schizoaffective disorder young adults Difficulty in distinguishing from Borderline Personality disorder First episode in males more likely to be manic Some view BPD as subsyndromal mood disorder and some assert they can coexist, data is unclear due to overlapping symptom and in females depressed presentation Completed suicide occurs in 10 15%
Adams and Sutker (2001) More likely to occur in mixed or depressive state APA 2000
Onset after 40 should alert that there may be a Theory of kindling general medical condition or substance issue Somewhat controversial Important to assumptions of early psychosocial Bipolar II may be more common in women interventions Cyclothymic disorder usually begins in First applied to seizure disorders adolescence or early adult life Combination of stress and genetic vulnerability leads to greater destabilization until full onset Brain becomes further sensitized with each episode until spontaneous occurrence without stressors Will result in less inter episodic recovery time and APA 2000 treatment resistance Geller & DelBello, 2008
Unipolar depression is more prevalent among women Historically children have been viewed as but Bipolar is more evenly distributed by gender However, a major Amish study found no gender honest reporters differences However, most clinicians have encountered Age and hospitalization trends children who deny disruptive behaviors or 1. First unipolar hospitalization tends to occur between 40 and 49 claim mental illness contrary to findings 2. First bipolar hospitalization tends to occur between 20 and 29 According to NIMH: Rogers (2008) 1. Median age of onset for unipolar depression is 25 2. Median age of onset for bipolar is 19 Adams and Sutker (2001)
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Study of 53 dually diagnosed offenders found Children (and their parents on their behalf) may be motivated malingering to be 15%, similar to adult offenders to malinger symptoms to gain external incentives or deny symptoms to avoid consequences Other studies have found 8% of children have Conduct Disorder adolescents may feign ADHD to obtain engaged in acquiescence and 10% in nay saying medication during psychological assessment May feign symptoms to avoid school work or avoid peer 8% attempted to please the interviewer difficulty 14% provided guarded responses Influence custody decisions Avoid juvenile justice system 12% of 6 to 8 year olds presented a socially desirable set of responses Gain academic accommodations Gain money and services Assessment must discern minimal denial and "white Manage peer status lies” from exaggerated reporting and extreme denial Unintentional parent and child misrepresentation Rogers (2008) Rogers (2008)
Distinct period of abnormally and persistently elevated, expansive, ADHD has a small risk for Bipolar Disorder (6 27%) or irritable mood for 1 week (unless hospitalization is necessary) Children with early onset Bipolar Disorder have a Three or more (4 if just irritable) and PRESENT TO A SIGNIFICANT DEGREE very high probability (91 98%) of meeting the criteria 1. Inflated self esteem or grandiosity for ADHD 2. Decreased NEED for sleep 3. More talkative than USUAL HOWEVER, once subtracting out symptom overlap 4. Flight of ideas or racing thoughts only about ½ of ADHD and Bipolar children 5. Distractibility retained the Bipolar Diagnosis 6. INCREASE in goal directed activity or psychomotor agitation 7. Excessive involvement in pleasurable activities with a high 6 10% of children may have legitimate comorbidity potential for painful consequences Not a MDE Follow up studies have also been inconclusive Marked impairment or hospitalization (Barkley, 2006) Not due to drugs or GMC
Fidgety Phil Hoffman 1865 Still and Tredgold were the first to focus clinical attention on the condition in the turn of the 20 th century Still noticed problems with attention and impulsivity, and noted relationships with defiance and delinquency Believed they were driven by immediate gratification and many were insensitive to punishment “defect in moral control” Considered that some of the problem may be a secondary response to an acute brain disease that may remit, and noted it affected mentally retarded as well as typical intellect (Barkley, 2006)
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In infancy: Elementary school: 1. Exhibit poor and irregular sleep 1. Demanding 2. Colic 2. Oppositional 3. Feeding problems 3. Do not play well with others 4. Dislike being cuddled or held still for long 4. Poor tolerance of frustration, high level of activity, poor Toddler: concentration, and poor self esteem may lead to a referral 1. Driven to run rather than walk Adolescence: 2. Driven to handle everything 1. May be failing school Major problems as adults: 2. 25 50% have encountered legal problems 1. Low self esteem 3. Withdraw from school 2. Poor social skills 4. Fail to develop social relations and maintain steady employment Kolb & Whishaw (2003) Kolb & Whishaw (200)
ADHD, Inattentive Type Often fails to give close attention to details and ADHD, Sluggish Cognitive Tempo make careless mistakes ADHD, Hyperactive Impulsive Type Difficulty sustaining attention Does not listen when spoken to directly ADHD, Combined Type Not following through on instructions Difficulty organizing tasks Often loses things Often forgetful in everyday activities
Inattentive Type plus: Changing culture Fidgets with hands or feet in seat One size fits all? Leaves seat in the classroom Concept called comorbidity Runs or climbs about excessively Relief Factor: “Have a name” Difficulty playing in leisure activity Cultural medication solution Is often “on the go” or appears “driven by a motor Changing parenting styles Often talks excessively Impact of schools Lack of investment in natural treatments Treatment of “spectrums”
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High rates of disruptive disorders Limited data for school based interventions in Low rates of engagement with academic gen ed setting instruction and achievement One size fits all Inconsistent completion/accuracy of school Emphasis on reduction of disruptive behavior work rather than improvement in social behavior or Poor performance on homework, tests & long academic skills term assignments Focus on short term outcomes Difficulties getting along with peers Few studies of adolescents
Concept of Executive Functioning and brain Theory suggesting that ADHD (and Conduct, development Antisocial, etc) individuals seek/require more The ability to plan and organize event in a sequential stimulation to transcend their excessively low manner with sound judgment arousal rate Also involves: In one study ADHD individuals required more noise Nonverbal and verbal working memory levels to establish the same stimulation level (due to less dopamine) Emotional Self Regulation Planning and Problem Solving
See Wikipedia – “Low Arousal Theory”
A disorder of “time blindness” (Barkley) Delayed responding and intrinsic motivation ADHD lives in the moment only Time, delays, and thinking ahead Point of Performance Problem Problem solving strategies, and changing It is a disorder of: cognitive sets. Performance, not skill The compassion and willingness of others to Doing what you know, not knowing what you do make accommodations are vital to success The when and where not the how and what It is a chronic medical/psychological disability It is not a Attention Deficit but rather Inattention Deficit Disorder (Inattention to mental events and future possibilities).
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40% of children in some studies suffer from sleep problems 15% exhibit bedtime resistance 10% or more experience daytime drowsiness Students with C’s, D’s, and F’s went to bed on average 40 minutes later than A students Insufficient sleep leads to many other problems
If he or she can fall asleep within 15 30 minutes Can wake up easily at the time they need to get up Awake and alert all day and do not require a nap Check with his or her teacher; kindergarten teacher survey that nearly 10% of students fall asleep at school
Make bedtime special Think about bedtime do not just do it Bedtime should be a regular routine Keep the ritual simple Sleep habits/rituals should work everywhere and anywhere Keep them physical during the day Be mindful of light It is not about what happens AT bedtime but usually at least one hour before
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AGE Hours During a manic episode there is reduced need 4 11.5 for sleep in 69 99% of patients. 5 11 Prominent feature of Bipolar in youth 6 11 May be the early marker (earliest symptom 7 11 8 10 11 reported by parents) for BAD in youth (Faedda, et al) 9 10 11 10 10 Higher rates of sleep disturbance and 11 10 decreased need for sleep in comparison to 12 13 9.5 10 ADHD children.
Critical for affect regulation Does the child fall asleep often while we are Important for cognitive functioning driving? Impacts health Does the child seem irritable, cranky, over emotional, hyper, or have trouble paying Associated with substance use attention? Contributes to impulsivity and risk taking On some nights does the child crash much earlier than his or her bedtime?
The TOUGHEST ddx in the business Destructiveness: ADHD careless destruction v. BAD Considerable overlap of symptoms occurs in anger Harvard Medical School Study: 94% of children with Temper tantrums: ADHD children calm down in 20 30 mania meet the criteria for ADHD, Hyperactive Type minutes; BAD for hours “When one hears the clatter of hoofbeats on the roof, Regression during outbursts: BAD may lose memory one looks for horses not zebras.” (Anthony & Scott) of tantrum; regression more severe in BAD ADHD should only be considered after ruling out a Triggers: ADHD triggered by sensory and emotional mood disorder overstimulation; BAD react more to limit setting Diagnosis may depend upon your own bias or ADHD does not show depressive as primary conceptualization of childhood disorders (mania predominant symptom merely as a defense, ADHD as an attachment disorder) Arrousal in morning: ADHD arouse quickly and alert Is ADHD an early developmental path to full blown within minutes; BAD fuzzy thinking and irritable Bipolar?
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Sleep disturbances often occur with night terrors of Pre-ads/Young Ads Older Ads/Adults MOR themes MDD Mania BAD children may show some giftedness in specific cognitive abilities (verbal and artistic). Rapid cycling Discrete with sudden Misbx: ADHD accidental due to not paying attention onsets/clear offsets to details; BAD intentionally provoked Risk seeking: ADHD unaware of consequences; BAD Chronic, continuous Weeks is risk seeking cycling Reality testing: ADHD unremarkable; Bipolar oh boy! Nonepisodic Improved functioning
Child: Do not fall neatly into current adult Speech language disorders nosology ADHD, ODD, Conduct Disorder, Sexual Abuse Longitudinal monitoring because diagnoses Ads: ADHD, ODD, CD, Sexual Abuse, are unstable and comorbidities may not be Schizophrenia, SA seen each time, or be developed yet Adults: Psychosis, SA, Antisocial Personality 60% of bipolar adults report first symptoms Disorders as children or adolescents.
Positive family history with early age of onset could signify genetic anticipation and higher genetic loading.
Pediatric mania is easily misdiagnosed – Early age of onset is associated with increased differential diagnosis or comorbidity? family history of the disorder.
ADHD Fewer stressors are seen in early onset cases. Conduct disorder Morbid risk of bipolar disorder in first degree Oppositional defiant disorder relatives is 4 6 times higher than in the general Substance abuse population. Depression/anxiety disorders “Bad child” – delinquent, violent
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Excessively comorbid by adult standards Increased energy: 100% Chronic irritability/mixed – Can be associated with aggression and unpredictable behavior Irritability: 98% Frequent temper outbursts, often aggressive Accelerated speech: 97% Positive family history Elated mood: 89% Comorbid ADHD (more likely in younger children and in males) Rapid cycling: 87% High rates of conduct disorder and delinquency ADHD: 87% in adolescents Grandiosity: 86% 20 30% of adolescents with MDD will have an eventual manic episode. Oppositional defiant, conduct disorder: 76%
Geller, et al.; 2001.
The use of BP, NOS most commonly given Higher genetic component ADHD: 4.9 years 48% of first degree relatives for children verses 25% for adults ODD: 6.1 years Accepting reported bipolar dx in family members Bipolar disorder: 6.7 years Comorbidity is the rule rather than the exception Unipolar depression: 6.7 years The Handle Symptoms Psychosis: 9.2 years Adolescents more likely to be rapid cylcers Anger does not = Bipolar Disorder Two extremes of diagnosing in reaction to diagnostic trends
Frazier, et al.; 2001.
Usually not exacerbated by stimulants Misleading research Kindling effect Definitely can be exacerbated by antidepressants Sensitivity verses specificity The “spectrum” Mood stabilizers and atypical antipsychotics Comorbidity the standards for treatment Grisso ”moving targets.” Mood instability trumps ADHD in priority and sequence of treatment.
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Improved assessment methodology Sleep Apnea Again, “spectrum” assessment trends Asthma Inner Ear Infections Pervasive Development Disorders
#1 6 12 year olds with inattention, hyperactivity, impulsivity, academic underachievement ADHD assessment THE MTA STUDY (largest treatment study of ADHD ever conducted). conducted The study represented the combined efforts of investigators at 6 different sites around the #2 The dx of ADHD must meet DSM criteria country and included 579 children ages 7 to 9.9 years who were diagnosed as having ADHD, Combined #3 The assessment requires evidence directly Type using state of obtained from parents in various settings the art diagnostic procedures. After participants had been identified they were Scales are a clinical option randomly assigned to 1 of 4 different treatment Do not use broadband scales conditions. Fourteen months later, the participants were carefully evaluated so that the impact of the # 4 Assessment information from school different treatments could be evaluated (CT, CC, MO, BTO). #5 Evaluation of co existing Conditions Not a study of what worked but rather a study that #6 Other diagnostic tests measure the effectiveness among treatments
Behavioral psychosocial treatment most A combo of medication/psychosocial treatment when: appropriate when: More severe cases Significant aggression or severe problems in school Milder ADHD are present. Preschool age children Severe family disruption caused by ADHD There is a presence of comorbid social skills deficits symptoms The family prefers psychosocial treatment There is a need for a rapid response. Combined type present For all age groups except preschool With the presence of comorbid externalizing disorders, mental retardation, or central nervous system problems
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Parent Management Training Adequate assessment & diagnosis Organization Skill Enhancement Interface of other medical conditions Sleep debt/apnea Social Skill Development Poor diet Child Interventions Learning problems ADHD Monitoring System Executive Dysfunction interventions Working Memory Training Parent management training School Based Interventions Lifestyle management Daily Report Card Neurofeedback/relaxation Classroom Techniques Chiropractic intervention Teacher Techniques Diet and Nutrition
Interpersonal and Social Rhythm Therapy Research on psychotherapy has been largely ignored It postulates that stressful events, disruptions in with Bipolar patients as compared with Depressed circadian rhythms and personal relationships, and patients due to the large focus on the biological basis conflicts arising out of difficulty in social of the disorder adjustment often lead to relapses. Therapy tends to focus on increasing medication Cognitive Behavioral Therapy (CBT) compliance and managing the consequences of Medication Adherence and Psychoeducation behaviors Is Family Therapy Effective? Some newer focus has surged, particularly with CBT Evidence for Alternative Treatments? focusing on stress management, compliance, and managing manic cognitive distortions Herbal Supplements Adams and Sutker (2001) Systematic Treatment Enhancement Program for Bipolar Disorder (STEP BD)
Lithium (Treatment and maintenance) Clinical triall to study people who are bipolar Tegretol (Treatment and maintenance, experiencing a depressed state. particularly for rapid cycling) Largest federally funded study on Bipolar Depakote (Manic episodes that do not respond Disorder to lithium, up to 20%) Purpose: explore a range of treatment options Wellbutrin (some use with bipolar) for Bipolar Disorder Adams and Sutker, 2001 Assessed long term psychosocial treatments v. Also some use of antipsychotics short term, talk therapy treatment outcomes Geller & DelBello, 2008
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Longer term treatments (30 50 minute Results: sessions): Of 293 patients, 59% recovered from depression CBT The intensive therapies: Interpersonal and Social Rhythm Therapy (SRT) More successful recovery rate (64 percent v. 52%) Family Focused Treatment (FFT) Recovery rate was faster following (113 v. 146 days) Short term aka “collaborative care”: More likely (1 ½ times) to remain well during any 3 50 minutes sessions over six weeks given month of the study. Educational videotape Therapies (77% of FFT recovered, 65% IPSRT, 60% CBT). Other educational workbook activities Developed a treatment contract to prevent episodes
Overview of testing that has traditionally been Intelligence/Achievement: utilized in the assessment of ADHD/Bipolar Evidence is conflicting whether can adequately Disorder discriminate groups of ADHD children from non ADHD. Evidence Based Assessment: IQ/Achievement probably contribute in more Intelligence/Achievement Testing indirect ways particularly in the area of establishing Neuropsychological Testing impairment. Projective Testing Assists in ruling in/ruling out reasons for complaints. Inventories Assist in identification of cogntive factors impacting Performance Tests inattention. Should they be considered in every assessment case?
Neuropsychological Tests: Limited studies demonstrate the predictive Stroop Word Color Test: cannot be used validity of the use of projective methods to accurately discriminate ADHD from non ADHD. Rorschach has some promising research Rey Osterrieth Complex Figure Drawing: cannot be used accurately Observational Measures: Trails Making Test: cannot be used accurately Clinical Observations Continuous Performance Tests: the most Test Observation Form (TOF) evidence based of current tests. Response to medication The petri dish experiment
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Rorschach should never be sole source for diagnosis of Lower WSum6 (7.78); (WSumCog in R PAS) ADHD!!!!!! Tend to narrow stimulus field; simplify more complex Lower P’s situations (High Lambda; 1.53 Comprehensive System; F%/Simplicity in R PAS) CDI significant (No Direct Equivalent in R No significant differences between Adj D or D (No PAS) Equivalent in R PAS) between ADHD, Clinical Group, Control Group Unconventional thought process, but without Fewer Sum C; more shading; lower Afr (R8910% in R the significant distortions seen in clinical PAS); fewer blends population Lower egocentricity scores (No Equivalent in R PAS)/more negative judgments about relationship between self/others Fewer COP’s and fewer AG (AGM in R PAS) Less comfort in interpersonal situations; lower Pure H
More exaggerated Lambda’s First Challenge: PTSD is only ONE outcome of Thinking distortions more related avoid most trauma stimuli Trauma = From a psychological perspective it’s Premature disengagement from stimuli (lower an emotional response to a terrible event Zd/Zf). Appraisal is important indicator All my fault? Totally helpless?
High Arousal will look similar to ADHD even History Helps though ADHD is triggered by a LOW arousal! Age of onset Bipolar is more like organic arousal that will Key events? look like triggered (PTSD) arousal AND low Treatment and Response to Intervention arousal response (ADHD) Caveats? How to differentiate? Sleep influence Sleep History Medical History (Sleep Apnea, Frequent Ear Infections, etc)
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ADHD Bipolar Defer until last Can you identify manic or mixed symptoms? May still be underlying, but need to identify most acute (Required) complaints first How long are outbursts occurring? (more than an Also no CARDINAL symptoms mean even if you hour?) answer all diagnostic questions in the affirmative you How intense are outbursts? have not confirmed ADHD! Can increased energy be confirmed? Where so many fail!!! Remember the brain! (ADHD – Executive Functioning; Bipolar – Emotional Dysregulation; PTSD – Triggering events and external influence)
PTSD Underlying ADHD can increase risk of PTSD Can triggering event be identified? If not, trauma Problems gathering and using information can can still be relevant even if you don’t diagnose PTSD complicate appraisal of events which heavily Attention Problems/Hyperactivity could be in fact influences PTSD factors keyed up OVER ATTENTION (monitoring) Can ADHD be identified prior to traumatic events Any subtle behavioral clues? How do they respond when you give them a focusing task? Many individuals with anxiety/ptsd focus well and actually calm themselves with tasks
ADHD is a performance based issue; may need Let the conceptualization guide the assessment performance based assessment alongside full Don’t jump straight to diagnosis! evaluation Is this patient: Bipolar – many mood factors are easier to identify Anxious and keyed up (as well as avoidant) because they when paired with test data need to avoid certain outcomes Requiring something novel and interesting to further PTSD – Residual effects of trauma also easier to arouse focus and consistency? isolate with testing Prone to “losing it” for extended time periods? (more But sometimes time or resources don’t allow this sustained in duration than is typical for PTSD) approach Shoe Shopping! Try on different diagnoses… If this is ADHD, the following behaviors do/don’t make sense as explained by dx Try to reduce the equation to fewest number of diagnoses
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ADHD – Peeling back layer of the onion (what’s left) IF PTSD, diagnose ADHD primarily if able to Degrees of certainty rather than “confirming” identify underlying premorbid condition Additive: Sleep Problems? Sleep Apnea? Early Ear Infections, Asthma, etc IF Bipolar, ADHD is unlikely PTSD – Don’t rush to it as dx just because a trauma occurred – it’s IF ADHD, Bipolar is unlikely a very specific set of reactions One of the most effective ways of narrowing it down Bipolar – Is affect brain lighting up and flooding person? Genetics, etc Remember age of onset info Assess mood upon awaking! (Cranky/Sluggish v. Good to go!)
Axis I Attention Deficit Hyperactivity D/O Bipolar D/O [email protected]
ITS BOTH :}
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