2/5/2014 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) 1 2/5/2014 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 2 2/5/2014 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 1320% 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) 3 2/5/2014 Rapid cycling is more common among women Approximately 1015% 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 1015% 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) 4 2/5/2014 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) 5 2/5/2014 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. 2550% 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” 6 2/5/2014 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