Diagnosing and Differentiating ADHD and The Bipolar (and some other stuff)
ADAM ANDREASSEN, PSY.D. Objectives of Presentation
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 Become more familiar with the assets and limitations of inventories and psychological testing results. Become more competent in ruling in or ruling out other co-morbid conditions.
May I have fries with that Ritalin? 700% increase of Ritalin prescribed in the US since 1995 Everyone Thinks They Are Knowledgeable About Each Disorder Common Overlapping Symptoms in Medical Field
Appendicitis Fever Strep Throat
Geller & DelBello, 2008 Common Overlapping Symptoms in Psychological Symptoms
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
A 2012 New York Times Article Suggested:
An estimated 3 Million children in the U.S. take drugs for problems focusing. Twentyfold increase in use of ADHD drugs over last 30 years Where are we heading? Prevalence Rates
1% 8%
Barkley, 2006 Comorbidity with ADHD
Anxiety disorder: 10-50% MDD: 15-75% Bipolar I: 6-27%; (BAD I carries a very high risk for comorbid ADHD, even though ADHD carries a low risk for BAD I) ODD: Up to 85% Conduct Disorder: 15-56% (worse prognosis) PTSD may be circular with ADHD: 1-6% Tourette syndrome or tick disorder: 12-34% PDD: Up to 26% (Barkley, 2006) History and Features of ADHD
Around WWI ADHD symptoms were often associated with an outbreak of encephalitis Clinicians began to see similar symptoms in other organic based disorders (brain injured child, MBD) Also “spoiled child” syndrome 1930’s began to notice improved effects with amphetamine use to control headaches
Barkley 2006 History and Features of ADHD 1950’s movement to hyperkinetic impulse disorder Later in the decade more specific learning problems were identified rather than generalizing MBD 1970’s began to focus on impulsivity as well 1980’s focus on attention problems Later focus on educational needs 21st century continues to look at further subtypes Barkley 2006 The word “manic” traces back to Ancient Greek. Mania and melancholia have been tied together for centuries Biphasic Mental Illness causing recurrent oscilliations between mania and depression (1854 Jules Baillarger). Emil Kraepelin coined term manic depressiion (1900’s) 1952 placed in the Diagnostic Manual History and Features of Bipolar Disorder
No early differentiation between unipolar and bipolar Both were considered manic-depressive illness More recent research has also noted some differences in the energy components between unipolar and bipolar depressed patients Bipolar disorder has been seen to have a greater genetic link than unipolar depression However, conflicting results have been found with relatives of “well- defined” unipolar depressives rarely exhibiting bipolar disorder Could occur on a polygenic or continuous spectrum: Unipolar Bipolar Adams and Sutker (2001) History and Features of Bipolar Disorder
Cyclicity can range from less than 48 hours to several years High degree of inter-individual variability Typical cycle length of Bipolar disorder is less than in unipolar major depression 13-20% rapid cycling (≥4 depressed or manic episodes per year) Adams and Sutker (2001) History and Features of Bipolar Disorder
Rapid cycling is more common among women Initial mood episode is usually depressive Rapid cycling generally develops later Later age of manic onset may be an indication of secondary mania and can be indistinguishable from patients with primary mania Can also occur during schizoaffective disorder Difficulty in distinguishing from Borderline Personality disorder Some view BPD as subsyndromal mood disorder and some assert they can coexist, data is unclear due to overlapping symptom presentation
Adams and Sutker (2001) Features of Bipolar I Disorder
Approximately 10-15% of adolescents with recurrent MDE will develop Bipolar, mixed episodes may be more likely in adolescents and young adults First episode in males more likely to be manic and in females depressed Completed suicide occurs in 10-15% More likely to occur in mixed or depressive state APA 2000 Features of Bipolar
Onset after 40 should alert that there may be a general medical condition or substance issue Bipolar II may be more common in women Cyclothymic disorder usually begins in adolescence or early adult life
APA 2000 Neurobiological Aspects of Bipolar Disorder
Theory of kindling Somewhat controversial Important to assumptions of early psychosocial interventions First applied to seizure disorders 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 treatment resistance Geller & DelBello, 2008 History and Features of Bipolar Disorder
Unipolar depression is more prevalent among women but Bipolar is more evenly distributed by gender However, a major Amish study found no gender differences Age and hospitalization trends 1. First unipolar hospitalization tends to occur between 40 and 49 2. First bipolar hospitalization tends to occur between 20 and 29 According to NIMH: 1. Median age of onset for unipolar depression is 25 2. Median age of onset for bipolar is 19 Adams and Sutker (2001) Deception in Assessing Children and Adolescents
Historically children have been viewed as honest reporters However, most clinicians have encountered children who deny disruptive behaviors or claim mental illness contrary to findings
Rogers (2008) Prevalence of Child and Adolescent Deception
Study of 53 dually diagnosed offenders found malingering to be 15%, similar to adult offenders Other studies have found 8% of children have engaged in acquiescence and 10% in nay-saying during psychological assessment 8% attempted to please the interviewer 14% provided guarded responses 12% of 6 to 8-year-olds presented a socially desirable set of responses Assessment must discern minimal denial and "white lies” from exaggerated reporting and extreme denial Rogers (2008) Reasons for Types of Deception in Children and Adolescents
Children (and their parents on their behalf) may be motivated to malinger symptoms to gain external incentives or deny symptoms to avoid consequences Conduct Disorder adolescents may feign ADHD to obtain medication May feign symptoms to avoid school work or avoid peer difficulty Influence custody decisions Avoid juvenile justice system Gain academic accommodations Gain money and services Manage peer status Unintentional parent and child misrepresentation Rogers (2008) ADHD and Bipolar
ADHD has a small risk for Bipolar Disorder (6-27%) Children with early-onset Bipolar Disorder have a very high probability (91-98%) of meeting the criteria for ADHD HOWEVER, once subtracting out symptom overlap only about ½ of ADHD and Bipolar children retained the Bipolar Diagnosis 6-10% of children may have legitimate comorbidity Follow-up studies have also been inconclusive (Barkley, 2006) Manic Episode
Distinct period of abnormally and persistently elevated, expansive, or irritable mood for 1 week (unless hospitalization is necessary) Three or more (4 if just irritable) and PRESENT TO A SIGNIFICANT DEGREE 1. Inflated self-esteem or grandiosity 2. Decreased NEED for sleep 3. More talkative than USUAL 4. Flight of ideas or racing thoughts 5. Distractibility 6. INCREASE in goal-directed activity or psychomotor agitation 7. Excessive involvement in pleasurable activities with a high potential for painful consequences Not a MDE Marked impairment or hospitalization Not due to drugs or GMC Where are we heading? Conceptual Features of ADHD
Fidgety Phil- Hoffman 1865 Still and Tredgold were the first to focus clinical attention on the condition in the turn of the 20th 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) Conceptualizing ADHD
In infancy: 1. Exhibit poor and irregular sleep 2. Colic 3. Feeding problems 4. Dislike being cuddled or held still for long Toddler: 1. Driven to run rather than walk 2. Driven to handle everything Major problems as adults: 1. Low self-esteem 2. Poor social skills
Kolb & Whishaw (2003) Distinctive ADHD Features
Elementary school: 1. Demanding 2. Oppositional 3. Do not play well with others 4. Poor tolerance of frustration, high level of activity, poor concentration, and poor self-esteem may lead to a referral Adolescence: 1. May be failing school 2. 25-50% have encountered legal problems 3. Withdraw from school 4. Fail to develop social relations and maintain steady employment
Kolb & Whishaw (200) Different Types of ADHD
ADHD, Inattentive Type
ADHD, Sluggish Cognitive Tempo ADHD, Hyperactive-Impulsive Type ADHD, Combined Type ADHD, Inattentive Type
Often fails to give close attention to details and make careless mistakes Difficulty sustaining attention Does not listen when spoken to directly Not following through on instructions Difficulty organizing tasks Often loses things Often forgetful in everyday activities ADHD, H-I Type
Inattentive Type plus:
Fidgets with hands or feet in seat
Leaves seat in the classroom
Runs or climbs about excessively
Difficulty playing in leisure activity
Is often “on the go” or appears “driven by a motor
Often talks excessively Why is it over diagnosed?
Changing culture
One size fits all? Concept called comorbidity Relief Factor: “Have a name” Cultural medication solution Changing parenting styles Impact of schools Lack of investment in natural treatments Treatment of “spectrums” Most Common School Problems & ADHD
High rates of disruptive disorders Low rates of engagement with academic instruction and achievement Inconsistent completion/accuracy of school work Poor performance on homework, tests & long-term assignments Difficulties getting along with peers Problems with Current Research
Limited data for school based interventions in gen ed setting One size fits all Emphasis on reduction of disruptive behavior rather than improvement in social behavior or academic skills Focus on short-term outcomes Few studies of adolescents Legitimate Behavioral Problem or Medical Condition
Concept of Executive Functioning and brain development
The ability to plan and organize event in a sequential manner with sound judgment Also involves:
Nonverbal and verbal working memory
Emotional Self-Regulation
Planning and Problem-Solving ADHD & Low Arousal Theory
Theory suggesting that ADHD (and Conduct, Antisocial, etc) individuals seek/require more stimulation to transcend their excessively low arousal rate
In one study ADHD individuals required more noise levels to establish the same stimulation level (due to less dopamine)
-See Wikipedia – “Low Arousal Theory” ADHD
A disorder of “time blindness” (Barkley) ADHD lives in the moment only Point of Performance Problem It is a disorder of:
Performance, not skill
Doing what you know, not knowing what you do
The when and where not the how and what
It is not a Attention-Deficit but rather Inattention Deficit Disorder (Inattention to mental events and future possibilities). ADHD Struggles in Children
Delayed responding and intrinsic motivation Time, delays, and thinking ahead Problem-solving strategies, and changing cognitive sets. The compassion and willingness of others to make accommodations are vital to success It is a chronic medical/psychological disability Sleep problems are some of the most common problems parents face with their kids Some Staggering Statistics
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
How can you tell if your child gets the right amount of sleep?
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 Good Sleep Hygiene
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
How Much Sleep is Enough?
AGE Hours 4 11.5 511 611 711 8 10-11 9 10-11 10 10 11 10 12-13 9.5-10 During a manic episode there is reduced need for sleep in 69-99% of patients. Prominent feature of Bipolar in youth May be the early marker (earliest symptom reported by parents) for BAD in youth (Faedda, et al) Higher rates of sleep disturbance and decreased need for sleep in comparison to ADHD children. Critical for affect regulation Important for cognitive functioning Impacts health Associated with substance use Contributes to impulsivity and risk taking Other Important Q’s to Ask:
Does the child fall asleep often while we are driving? Does the child seem irritable, cranky, over-emotional, hyper, or have trouble paying attention? On some nights does the child crash much earlier than his or her bedtime? An Overview
The TOUGHEST ddx in the business Considerable overlap of symptoms Harvard Medical School Study: 94% of children with mania meet the criteria for ADHD, Hyperactive Type “When one hears the clatter of hoofbeats on the roof, one looks for horses not zebras.” (Anthony & Scott) ADHD should only be considered after ruling out a mood disorder Diagnosis may depend upon your own bias or conceptualization of childhood disorders (mania merely as a defense, ADHD as an attachment disorder) Is ADHD an early developmental path to full-blown Bipolar? Important Distinctions (Papolos & Papolos)
Destructiveness: ADHD careless destruction v. BAD occurs in anger Temper-tantrums: ADHD children calm down in 20-30 minutes; BAD for hours Regression during outbursts: BAD may lose memory of tantrum; regression more severe in BAD Triggers: ADHD-triggered by sensory and emotional overstimulation; BAD-react more to limit setting ADHD does not show depressive as primary predominant symptom Arrousal in morning: ADHD- arouse quickly and alert within minutes; BAD-fuzzy thinking and irritable Important Distinctions cont.
Sleep disturbances often occur with night terrors of MOR themes BAD children may show some giftedness in specific cognitive abilities (verbal and artistic). Misbx: ADHD-accidental due to not paying attention to details; BAD-intentionally provoked Risk-seeking: ADHD-unaware of consequences; BAD is risk-seeking Reality testing: ADHD unremarkable; Bipolar -oh boy! Clinical Course
Pre-ads/Young Ads Older Ads/Adults Mania MDD Discrete with sudden Rapid-cycling onsets/clear offsets
Weeks
Chronic, continuous Improved functioning cycling Nonepisodic Common Differentials
Child: Speech-language disorders ADHD, ODD, Conduct Disorder, Sexual Abuse Ads: ADHD, ODD, CD, Sexual Abuse, Schizophrenia, SA Adults: Psychosis, SA, Antisocial Personality Disorders Mood Disorders in Children
Do not fall neatly into current adult nosology
Longitudinal monitoring because diagnoses are unstable and comorbidities may not be seen each time, or be developed yet
60% of bipolar adults report first symptoms as children or adolescents.
Positive family history with early age of onset could signify genetic anticipation and higher genetic loading. The Bipolar Bandwagon: Is Every Behavioral Problem Indicative of Bipolar Disorder? Pediatric mania is easily misdiagnosed – differential diagnosis or comorbidity? ADHD Conduct disorder Oppositional defiant disorder Substance abuse Depression/anxiety disorders “Bad child” – delinquent, violent Genetics of Pediatric Bipolar Disorder
Early age of onset is associated with increased family history of the disorder.
Fewer stressors are seen in early onset cases.
Morbid risk of bipolar disorder in first-degree relatives is 4-6 times higher than in the general population. Presentation of Pediatric Bipolar Disorder
Excessively comorbid by adult standards Chronic irritability/mixed – Can be associated with aggression and unpredictable behavior Frequent temper outbursts, often aggressive Positive family history Comorbid ADHD (more likely in younger children and in males) High rates of conduct disorder and delinquency in adolescents 20-30% of adolescents with MDD will have an eventual manic episode. Presentation of Pediatric Bipolar Disorder
Increased energy: 100% Irritability: 98% Accelerated speech: 97% Elated mood: 89% Rapid cycling: 87% ADHD: 87% Grandiosity: 86% Oppositional defiant, conduct disorder: 76%
Geller, et al.; 2001. The use of BP, NOS most commonly given Higher genetic component- 48% of first degree relatives for children verses 25% for adults Accepting reported bipolar dx in family members Comorbidity is the rule rather than the exception The Handle Symptoms Adolescents more likely to be rapid cylcers Anger does not = Bipolar Disorder Two extremes of diagnosing in reaction to diagnostic trends Developmental Course of Pediatric Bipolar Disorder: Mean Age of Onset
ADHD: 4.9 years ODD: 6.1 years Bipolar disorder: 6.7 years Unipolar depression: 6.7 years Psychosis: 9.2 years
Frazier, et al.; 2001. Treatment of Pediatric Bipolar Disorder
Usually not exacerbated by stimulants
Definitely can be exacerbated by antidepressants
Mood stabilizers and atypical antipsychotics the standards for treatment
Mood instability trumps ADHD in priority and sequence of treatment. Difficulty in differentiation-why?
Misleading research Kindling effect Sensitivity verses specificity The “spectrum” Comorbidity Grisso-”moving targets.” Over-diagnosis or not?
Improved assessment methodology Again, “spectrum” assessment trends Interfacing Medical Issues
Sleep Apnea Asthma Inner Ear Infections Pervasive Development Disorders Clinical Practice Guidelines
#1 6-12 year olds with inattention, hyperactivity, impulsivity, academic underachievement ADHD assessment conducted #2 The dx of ADHD must meet DSM criteria #3 The assessment requires evidence directly obtained from parents in various settings Scales are a clinical option Do not use broadband scales # 4 Assessment information from school #5 Evaluation of co-existing Conditions #6 Other diagnostic tests THE MTA STUDY (largest treatment study of ADHD ever conducted). The study represented the combined efforts of investigators at 6 different sites around the country and included 579 children ages 7 to 9.9 years who were diagnosed as having ADHD, Combined Type using state-of- the-art diagnostic procedures. After participants had been identified they were randomly assigned to 1 of 4 different treatment conditions. Fourteen months later, the participants were carefully evaluated so that the impact of the different treatments could be evaluated (CT, CC, MO, BTO). Not a study of what worked but rather a study that measure the effectiveness among treatments Behavioral-psychosocial treatment most appropriate when:
Milder ADHD
Preschool-age children
There is a presence of comorbid social skills deficits
The family prefers psychosocial treatment A combo of medication/psychosocial treatment when: More severe cases Significant aggression or severe problems in school are present. Severe family disruption caused by ADHD symptoms 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 Parent Management Training Organization Skill Enhancement Social Skill Development Child Interventions ADHD Monitoring System Working Memory Training School Based Interventions Daily Report Card Classroom Techniques Teacher Techniques What else works?
Adequate assessment & diagnosis Interface of other medical conditions Sleep debt/apnea Poor diet Learning problems Executive Dysfunction interventions Parent management training Lifestyle management Neurofeedback/relaxation Chiropractic intervention? Diet and Nutrition The Kitchen Sink Treatment of Bipolar Disorder
Research on psychotherapy has been largely ignored with Bipolar patients as compared with Depressed patients due to the large focus on the biological basis of the disorder Therapy tends to focus on increasing medication compliance and managing the consequences of behaviors Some newer focus has surged, particularly with CBT focusing on stress management, compliance, and managing manic cognitive distortions Adams and Sutker (2001) Interpersonal and Social Rhythm Therapy
It postulates that stressful events, disruptions in circadian rhythms and personal relationships, and conflicts arising out of difficulty in social adjustment often lead to relapses. Cognitive Behavioral Therapy (CBT) Medication Adherence and Psychoeducation Is Family Therapy Effective? Evidence for Alternative Treatments? Herbal Supplements Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) Medication Treatment for Bipolar Disorder
Lithium (Treatment and maintenance) Tegretol (Treatment and maintenance, particularly for rapid cycling) Depakote (Manic episodes that do not respond to lithium, up to 20%) Wellbutrin (some use with bipolar) Adams and Sutker, 2001 Also some use of antipsychotics Geller & DelBello, 2008 Clinical triall to study people who are bipolar experiencing a depressed state. Largest federally funded study on Bipolar Disorder Purpose: explore a range of treatment options for Bipolar Disorder Assessed long-term psychosocial treatments v. short-term, talk therapy treatment outcomes Longer-term treatments (30 50 minute sessions):
CBT
Interpersonal and Social Rhythm Therapy (SRT)
Family Focused Treatment (FFT) Short-term aka “collaborative care”:
3 50 minutes sessions over six weeks
Educational videotape
Other educational workbook activities
Developed a treatment contract to prevent episodes Results:
Of 293 patients, 59% recovered from depression
The intensive therapies:
More successful recovery rate (64 percent v. 52%)
Recovery rate was faster following (113 v. 146 days)
More likely (1 ½ times) to remain well during any given month of the study.
Therapies (77% of FFT recovered, 65% IPSRT, 60% CBT). Psychological Testing, Inventories, and Checklists
Overview of testing that has traditionally been utilized in the assessment of ADHD/Bipolar Disorder
Evidence-Based Assessment:
Intelligence/Achievement Testing
Neuropsychological Testing
Projective Testing
Inventories
Performance Tests Intelligence/Achievement: Evidence is conflicting whether can adequately discriminate groups of ADHD children from non-ADHD. IQ/Achievement probably contribute in more indirect ways particularly in the area of establishing impairment. Assists in ruling-in/ruling-out reasons for complaints. Assist in identification of cogntive factors impacting inattention. Should they be considered in every assessment case? Neuropsychological Tests: Stroop Word-Color Test: cannot be used accurately Rey-Osterrieth Complex Figure Drawing: cannot be used accurately Trails Making Test: cannot be used accurately Continuous Performance Tests: the most evidence-based of current tests. Limited studies demonstrate the predictive validity of the use of projective methods to discriminate ADHD from non-ADHD.
Rorschach has some promising research
Observational Measures:
Clinical Observations
Test Observation Form (TOF)
Response to medication
The petri dish experiment Rorschach/ADHD (Cotugno) Rorschach should never be sole source for diagnosis of ADHD!!!!!! Tend to narrow stimulus field; simplify more complex situations (High Lambda; 1.53 Comprehensive System; F%/Simplicity in R-PAS) No significant differences between Adj D or D (No Equivalent in R-PAS) between ADHD, Clinical Group, Control Group Fewer Sum C; more shading; lower Afr (R8910% in R- PAS); fewer blends 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 ADHD cont.
Lower WSum6 (7.78); (WSumCog in R-PAS) Lower P’s CDI significant (No Direct Equivalent in R-PAS) Unconventional thought process, but without the significant distortions seen in clinical population Summary ADHD/Rorschach
More exaggerated Lambda’s Thinking distortions more related avoid most stimuli Premature disengagement from stimuli (lower Zd/Zf). Important Differentials & Considerations Disruptive mood dysregulation disorder A. Severe recurrent temper outbursts (verbal or physical) B. Outbursts inconsistent with developmental level C. Occur 3+ times per week (on average) D. Mood at other times is largely irritable or angry most of the time E. A-D have been present for 12 or more months with no 3 month remittance F. A & D present in 2 of 3 settings G. Don’t diagnose before age 6 or after 18 H. A-e onset prior to age 10 I. No mania or hypomania criteria for longer than a day J. Not part of MDE K. Not something else Disruptive mood dysregulation disorder
Can’t coexist with:
ODD (only dx DMDD if both criteria met)
IED or Bipolar (don’t dx dmdd if mania or hypomania ever met) Can coexist with:
MDD
ADHD
Conduct
Substance Use Disorders Disruptive mood dysregulation disorder
Diagnosis invented to account for non-episodic mood problems
Also to reduce number of children receiving bipolar dx due to chronic but not episodic mood disruptions Prevalence
Unknown (Brand new)
Guess: 2% - 5%
Rates expected to be higher in males and school-age children Disruptive mood dysregulation disorder
Development & course
Before age 10 but after age 6. Validity established 7-18.
Rates of conversion to full Bipolar low – high conversion to unipolar and/or anxiety by adulthood Risk & Prognostic
Temperamental (chronic irritability)
Genetic & Physiological: Still a bit muddy
Related to anxiety, depression, Bipolar, and problems with facial recognition in family history Disruptive mood dysregulation disorder
Marked by low frustration tolerance – lots of functional implications at school and elsewhere Disruptive mood dysregulation disorder Differential Bipolar – Longitudinal & episodic differentiation Oppositional defiant disorder – large overlap. Dx DMDD if both met ADHD, Anxiety, MDD, & Autism: But dx MDD first Intermittent explosive disorder: iED less likely to include persistent mood complaints when not exploding (thus “intermittent”
High comorbidity – rare to see dmdd alone Disruptive Mood Dysregulation Disorder
Study: Will it replace pediatric bipolar? Reviewed 82 hospitalized children 5 to 12 years old 30.5% of inpatient children met criteria for DMDD by parent report 15.9% by unit observation 56% had parent-reported manic symptoms Of those, 45.7% met criteria for DMDD by parent-report
But only 17.4% did when observed on unit Conclusion: DMDD decreased the rate of diagnosis of Bipolar in Children but how much depends on whether history or observation was used Disruptive Mood Dysregulation Disorder
Problem with dx of bipolar: Adult bipolar I with impairment occurs about 0.5% but Bipolar spectrum about 10 times that! Broad vs. narrow approach advised?
Narrow: Look for discrete episodes – telltale
Broad: mania can be less discrete
Problem: Episodes are less discrete in children/Adolescents anyway
In juveniles is it actually mood regulation problems Disruptive Mood Dysregulation Disorder
Problem: At least one study failed to demonstrate that Mood dysregulation is not on a bipolar spectrum Disruptive Mood Dysregulation Disorder
Will DMdD replace Bipolar in Children (Study Con’t)
Four questions in current study.
1. How often children with parent-report irritability and explosiveness to require hospitalization met criteria for dmdd
2. Would direct hospitalization confirm?
3. What other conditions were affecting children
4. How often would Bipolar dx children be dx with dmdd? Disruptive Mood Dysregulation Disorder
Discussion of study (con’t) DMDD as a concept is reasonable but will not account for the majority of children with explosive behaviors who get hospitalized
Exclusionary dx’s account for more than half of the irritable, explosive children Unclear whether DMDD is a distinct condition: Much overlap with individuals who carried comorbid dx’s of ADHD & ODD
BUT only ¼ of children with comorbid ADHD/ODD met DMDD criteria
Is DMDD a more severe form of adhd/Odd?
Separate entity adding a mood component
Appears to include anxiety/depressive component Disruptive Mood Dysregulation Disorder
But did dmdd prevent pediatric bipolar dx?
45.7% of the time it did
But when rigorously dx with observation only 17.4% would have received it
Likely to also be over diagnosed
Is that better?
May limit mood stabilizers but could also cause treatable conditions like adhd to be overlooked Posttraumatic Stress Disorder
First Challenge: PTSD is only ONE outcome of trauma Trauma = From a psychological perspective it’s an emotional response to a terrible event
Appraisal is important indicator
All my fault?
Totally helpless? PTSD & Arousal
High Arousal will look similar to ADHD even though ADHD is triggered by a LOW arousal! Bipolar is more like organic arousal that will look like triggered (PTSD) arousal AND low arousal response (ADHD) How to differentiate? Differential Wrap-up Suggested Strategy
History Helps
Age of onset
Key events?
Treatment and Response to Intervention Caveats?
Sleep influence
Sleep History
Medical History (Sleep Apnea, Frequent Ear Infections, etc) Profiling the Diagnosis
ADHD
Defer until last
May still be underlying, but need to identify most acute complaints first
Also no CARDINAL symptoms mean even if you answer all diagnostic questions in the affirmative you have not confirmed ADHD!
Where so many fail!!! Profiling the Diagnosis
Bipolar
Can you identify manic or mixed symptoms? (Required)
How long are outbursts occurring? (more than an hour?)
How intense are outbursts?
Can increased energy be confirmed?
Remember the brain! (ADHD – Executive Functioning; Bipolar – Emotional Dysregulation; PTSD – Triggering events and external influence) Profiling the Diagnosis
PTSD
Can triggering event be identified? If not, trauma can still be relevant even if you don’t diagnose PTSD
Attention Problems/Hyperactivity could be in fact keyed-up OVER- ATTENTION (monitoring)
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 & PTSD
Underlying ADHD can increase risk of PTSD
Problems gathering and using information can complicate appraisal of events which heavily influences PTSD factors
Can ADHD be identified prior to traumatic events Testing & Formal Evaluation
ADHD is a performance-based issue; may need performance-based assessment alongside full evaluation
Bipolar – many mood factors are easier to identify when paired with test data
PTSD – Residual effects of trauma also easier to isolate with testing
But sometimes time or resources don’t allow this approach Simplifying further
Let the conceptualization guide the assessment
Don’t jump straight to diagnosis!
Is this patient:
Anxious and keyed up (as well as avoidant) because they need to avoid certain outcomes
Requiring something novel and interesting to further arouse focus and consistency?
Prone to “losing it” for extended time periods? (more sustained in duration than is typical for PTSD)
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 Simplifying Further
ADHD – Peeling back layer of the onion (what’s left) Degrees of certainty rather than “confirming” Additive: Sleep Problems? Sleep Apnea? Early Ear Infections, Asthma, etc PTSD – Don’t rush to it as dx just because a trauma occurred – it’s 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!) Both/And?
IF PTSD, diagnose ADHD primarily if able to identify underlying premorbid condition IF Bipolar, ADHD is unlikely IF ADHD, Bipolar is unlikely Axis I Attention-Deficit Hyperactivity D/O Bipolar D/O
ITS BOTH :} [email protected]