adhd mood disorder

adhd mood disorder - Transcript

ADHD and Mood Disorders

Running Head ADHD and Mood disorders

Are you sure it s ADHD Geetika Agarwal University of Missouri Columbia

ADHD and Mood Disorder

Introduction With all the attention on attention deficit disorder it is very easy to overlook the differences in symptoms that indicate bipolar illnesses or other mood disorders A child that exhibits high levels of energy reduced need for sleep poor impulse control and has trouble paying attention can be easily diagnosed as having ADHD However these symptoms can also be present in a child is struggling with a mood disorder Ninety eight percent of children with diagnose of Bipolar Disorder also qualify for the diagnosis of AD HD because of the presence of inattention impulsivity and hyperactivity seen in the attention deficit population Beiderman 2000 Conversely twenty two percent of those children diagnosed with AD HD for the criteria for Bipolar Disorder Butler 1995 It is extremely important that this second group of kids with the dual diagnosis be identified so that they may receive proper treatment Many children diagnosed with Bipolar disorder after puberty were diagnosed as AD HD in the elementary school years For these kids the symptoms of impulsivity and craving for stimulation that they experienced before high school now take on the more troubling forms of hypomania and depression as Bipolar Disorder emerges These children may have been Bipolar all along or they may have developed Bipolar Disorder at age eight or nine but were undetected as suffering from an affective disorder until later Lynn 2000 Some percentage of children and teens with the diagnosis of AD HD experience challenges that are difficult to distinguish from those seen in Bipolar Disorder The predilection for dangerous destructive and risky behavior the abuse of substances and

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other addictive behavior characterizes some teenagers with AD HD Or these behaviors may indicate the presence of Bipolar Disorder in its mania phase It may be unclear where the simple disinhibited behavior of AD HD leaves off and where the cyclic mania phase of BD picks up Although a diagnosis of BD in children and adolescents has long been a subject of controversy there has been considerable interest in the possibility of a relationship between AD HD and BD in the last decade A review of literature suggests that the evidence supporting a relationship between ADHD and BD comes from several sources Jaideep Reddy Srinath 2006 First some studies have reported a very high rate of co morbid ADHD in juvenile BD patients These rates range from eighty six percent to ninety eight percent in children Geller et al 1998 Faraone et al 1997 Geller et al 2002 Woznaik et al 2002 and from twenty percent to sixty nine percent in adolescents Faraone et al 1997 Geller et al 1995 West et al 1995a West et al 1996 West et al 1995b Second a few family studies of ADHD and BD have contributed to the idea that ADHD and BD could share common familial risk factors Third neuro pharmacological neurological and neuro imaging studies have reported somewhat similar although not specific findings in both ADHD and BD subjects suggesting either a shared patho physiology or a common underlying deficit Kent Craddock 2003 Lastly a follow up study of children with ADHD reported a high rate of BD but in another longitudinal study there was no increased risk of BD Gittelman Mannuzza Shenker Bonagure 1985

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ADHD and Mood Disorder

CBCL as a diagnostic instrument In ADHD research a range of diagnostic instruments are in use How to best characterize these children using rating scales Child Behavior Checklist CBCL Achenbach 1991 in particular and whether to identify them as a pediatric bipolar disorder has been a focus of considerable study Biederman et al 1991 Biederman et al 1996 Biederman et al 2000 addressed this issue of diagnostic uncertainty by describing a profile on the Child Behavior Checklist According to him the CBCL profile in children with BD is discrete from the CBCL profiles in children without either AD HD or BD and more importantly it is also different from children with ADHD alone Mick Biederman Pandina Faraone 2003 This profile on the CBCL is characterized by deviance on the Attention Problems Aggressive Behavior and Anxious Depressed syndrome scales In contrast ADHD children without bipolar disorder show deviance largely limited to the Attention Problems scale alone Kahana et al 2003 extended the analysis of the CBCL BP profile further by using a multi informant approach of investigating the relationship between the CBCL the Teacher Report Form and the Youth Self Report forms of the Achenbach scales They concluded that BD children were significantly different from their any category of controls on the CBCL on all subscales and differed from children with other disruptive behavior disorders on all scales except Social Problems an Attention Problems The highest T scores in BD children were in the Aggressive Attention Anxious Depressed and Delinquent subscales Faraone et al 2005 also tested the potential of using CBCL as a screening instrument for BP in children and suggested that the elevations in the Attention Problems Aggressive

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ADHD and Mood Disorder

Behavior and Anxious Depressed subscales can be used to create a subscale that is highly heritable and predictive of BD diagnosis They also suggested that the efficiency of the measure to predict BD is somewhat increased if symptoms of BD are current rather than lifetime and if the subject had been referred for a psychiatric disorder Wozniak et al unpublished compared the clinically referred children meeting the diagnostic criteria of mania with the children with ADHD but not mania and concluded that manic children had significantly higher rates of major depression psychosis multiple anxiety disorders conduct disorder and oppositional defiant disorder In addition manic children had significantly more impaired psychosocial functioning Further Weinstein et al 1990 found an excellent agreement between the CBCL Attention problems scale and the diagnosis of ADHD between the Delinquent Behavior scale and the diagnosis of conduct disorder and between the Anxiety Depression scale and the diagnosis of anxiety disorders Their study was consistent with prior studies showing the CBCL to be sensitive to internalizing psychopathology As an addendum to a previous research Geller Warner Williams Zimerman 1998 suggested that CBCL and TRF Teacher Rating Form separated BP from ADHD cases largely by non specific externalizing dimensions e g hyperactivity aggressivity Clinically relevant differentiation by categorical mania specific criteria e g elated mood grandiosity racing thoughts occurred with the WASH U KSADS Washington University at St Louis Kiddie Schedule for Affective Disorders and Schizophrenia The results of the discussion so far clearly illustrate that the CBCL can discriminate children with mania from those with ADHD and that the CBCL serves as a

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ADHD and Mood Disorder

rapid and useful screening instrument not only to identify cases likely to meet criteria for mania but also to identify co morbid characteristics of these children to distinguish these children from those with ADHD Another methodological issue relates to the overlap of operational diagnostic criteria As a result mania may be mistaken for ADHD and ADHD may be mistakenly diagnosed as BP Continuing their research on differential diagnosis Geller et al 2002 suggested five symptoms that provided the best discrimination of BP subjects from ADHD subjects These symptoms are Elation Grandiosity Flight of ideas racing thoughts Decreased need for sleep and Hyper sexuality

The above are the mania specific and do not overlap with DSM IV symptoms for ADHD Irritability hyperactivity accelerated speech and distractibility was very frequent in both BP and ADHD groups and was not useful for differentiating between these two diagnoses Lynn 2000 gave seven criteria for differentiating the two conditions Presence of mood shift or mixed state of aggressive depression

Though the moods of children with ADHD may be mercurial especially when these kids hit their teens they do not show the severe highs and lows of Bipolar disorder or the

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violent expression that can occur in the mixed state rapid cycling variety which afflicts younger children A family history of affective illness

Children with Bipolar Disorder often have the condition in their immediate family siblings parents grandparents especially if they are diagnosed at an early age This is an indication that affective disorder may exist in the family line Goodwin and Jamison 1990 Pressured speech or hypomania are present

Pressured speech seen in BD is known by its outpouring of words in continually shifting topics that may have little relationship to each other ADHD rs may talk too much and too loudly but they can be redirected and their verbal delivery can be slowed by a request from the listener such as You are going too fact for me and I am getting breathless just listening to you Dangerous behavior occurs in hypomanic phase

The dysinhibition of ADHD is most often seen as a random search for stimulation in any form be it through danger sports drugs gambling sex or illegal behavior For the BD teen dysinhibition and stimulus craving can take over the child s personality and be directed with a purposeful energy in which he does not seen to need sleep and can power himself energetically toward a goal for several days Presence of rage Bipolar Disorder or anger AD HD

In BP rage is present from an early age It may come up at the drop of a hat Once it s engages it is unstoppable Popper 1989 ADHD children will get engaged because of

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frustration or simple hot temperedness Also they do not rage on a consistent basis as do children in the missed state of aggressive depression seen in BD Presence of hallucinations severe thought distortions and tyrannical behavior The children with ADHD may demonstrate extreme silliness and show a profound lack of common sense because of his ability to focus on things and make good decision The child with affective illness on the other hand may experience visual hallucinations that are very disturbing to him Hendren 2000 Other Bipolar challenges are present such as anempathy and Conduct disorder

Many Bipolar children are anempathetic They do not understand the feelings of others and may show shallow affect themselves ADHD children tend to be supersensitive to the feelings of others when they can stop long enough to pay attention to them

The research further suggests that children with ADHD get angry but their outburst are different from the ones in Bipolar When a child with ADHD tantrums s he usually calms down within 20 or 30 minutes and an adult could imitate the amount of energy generated But when a bipolar child has a tantrum the amount of energy unleashed seems almost super human The reasons for tantrum too differ A child with ADHD usually melts down because of overstimulation The stimulation may be sensory or affective Children with bipolar disorder may more often tantrum in response to limit setting yet may actually seek out conflict with authority figures

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ADHD and Mood Disorder

Implications for School Psychology The discussion above hits upon some very important research findings which has direct implications for the school psychologists A child who has been diagnosed with ADHD is entitled for special services in the school setting These services come in the form of various accommodation and modifications translated into the classroom setting once curriculum goals and expectation etc As these services are driven by the nature of disability and associated difficulties presented by the student any misdiagnosis of either ADHD or mood disorder will have direct implication on the case conceptualization and associated recommendations It hence becomes pivotal for a school psychologist to understand the grey area between an ADHD diagnosis and mood disorder The above research also highlights strengths in various assessment measures which are frequently used in a school setting to assess a presenting behavioral concern CBCL and TRF originate as a favorite among researchers to distinguish ADHD from bipolar disorder are an integral part of a standardized battery for assessing behavioral and socio emotional concern of a child By knowing the built in clinical relevance of these standardized measures and rating scales school psychologist can complement the formal training and make a better and more accurate data driven decision giving them an edge over the other mental health professional This will also help the school psychologists to serve both the parents and the child better Along with the assessment knowing some of the key distinguishing features related to the age of onset familial background cardinal symptoms a school psychologist would be able to provide services that is a close match a child s needs This

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ADHD and Mood Disorder

means that although bipolar and ADHD can be categorized under one common label of Other Health Impaired following the IDEA diagnostic criterion the associated interventions will be markedly different It is also important to understand that the pharmacological interventions associated with the two disorders are markedly different and by knowing the similarities and differences between the two categories school psychologists can be better problem solve and be a better resource to the parents than they have been in the past Biederman 2000 maintains that mania symptoms in ADHD children are often viewed as bad ADHD by ADHD experts and commonly treated with high doses of stimulants along In contrast ADHD symptoms in manic children may be viewed as a part of juvenile mania by Bipolar experts and such children are likely to be treated with mood stabilizers only Although mania and ADHD are known to respond to different treatment there is no literature to guide the treatment of children with co morbid mania plus ADHD Although school psychologists are not training to prescribe medication or even make an ADHD or BP diagnosis knowing the literature about the same can t the emphasized enough Misdiagnosis of the child with Bipolar disorder or ADHD can do him great damage because it not only cuts him off from help appropriate to his illness but it sets the stage for his isolation from his community It is this sense of being in an uncaring universe that drives a child to consider ending his own life This is a tragedy preventable with the right diagnosis at the right time which only underscores the important of knowing the differences between the two

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ADHD and Mood Disorder

It should also be stated that no screening test can substitute for the judgment of a well trained clinicians mental health professional school psychologists while making either a clinical or an educational diagnosis and knowing the relevant research is of utmost important for best practices

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ADHD and Mood Disorder

References Achenbach T M 1991 Manual for the Child Behavior Checklist 4 18 and1991 profile Burlington VT University of Vermont Biederman J 2000 Meeting Highlights Satellite Symposium n Bipolar Disorder in Children and Adolescents Rotterdam The Netherlands Bipolar Network News 6 3 5 6 Biderman J 1998 Debate between Joseph Biderman M D and Pachek G Klein Ph D Resolve for debate Mania is taken for ADHD in Prepubertal Children Journal of American Academy of Child and Adolescent Psychiatry Biederman J et al 1995 CBCL Clinical Scales Discriminate Prepubertal Children with Structured Interview Derived Diagnosis of Mania from those with ADHD Journal of American Academy of Child and Adolescent Psychiatry 94 96 Biederman J Faraone S V Keenan K Tsuang M T 1991 Evidence of familial association between attention deficit disorder and major affective disorders Archives of General Psychiatry 48 633 642 Biederman J Faraone S V Mick E et al 1996 Attention deficit hyperactivity disorder and juvenile mania an overlooked comorbidity Journal of American Academy of Child and Adolescent Psychiatry 35 997 1008 Butler S et al 1995 Affective conorbidity of Children and Adolescents with Attention Deficit Hyperactivity disorder Journal of American Academy of Child and Adolescent Psychiatry 34 6 51 55

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Chang K D Steiner H Ketter T A 2000 Psychiatric phenomenology of child and adolescent bipolar offspring Journal of American Academy of Child and Adolescent Psychiatry 39 453 460 Faraone S V Biederman J Wozniak J Mundy E Mennin D O Donnell D 1997 Is co morbidity with ADHD a marker for juvenile onset mania Journal of American Academy of Child and Adolescent Psychiatry Geller B Cooper T B Zimerman B et al 1998 Lithium for prepubertal depressed children with family history predictors of future bipolarity a double blind placebo controlled study Journal of Affective Disorder 51 165 175 Geller B Craney J L Bolhofner K Nickelsburg M J Williams M Zimerman B 2002 Two year prospective follow up of children with a prepubertal and early adolescent bipolar disorder phenotype American Journal of Psychiatry 159 192 933 Geller B Sun K Zimerman B Luby J Frazier J Williams M 1995 Complex and rapid cycling in bipolar children and adolescents a preliminary study Journal of Affective Disorders 34 259 268 Geller B Warner K Williams Marlene Zimerman B 1998 Prepubertal and young adolescent bipolarity versus ADHD assessment and validity using WASHU KSADS CBCL and TRF Journal of Affective Disorders 51 93 100 Gittelman R Mannuzza S Senkar R Bonagure N 1985 Hyperactive boys almost grow up I Psychiatric status Archives of General Psychiatry 42 937947

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Goodwin F and Jamison K R 1990 Manic depressive Illness Oxford University Press New York Hendren R L 2000 New Research Findings in Bipolar Disorders an Pervasive Developmental Disorder in Youth CME tape from Recent Breakthroughs in Child and Adolescent Psychiatry 42 76 Jaideep T Reddy Y C J Srinath S 2006 Comorbidity of attention deficit hyperactivity disorder in juvenile bipolar disorder Bipolar Disorders 8 182 187 Kahana S Y Youngstrim E A Finding R L Calabress J R 2003 Employing parent teacher and youth self report checklists in identifying pediatric bipolar spectrum disorders an examination of diagnostic accuracy and clinical utility Journal of Child Adolescent Psychopharmacology 13 471 488 Kent L Craddock N 2003 Is the relationship between attention deficit hyperactivity disorder and bipolar disorder Journal of Affective Disorders 73 211 221 Klein D N Depue R A Slater J F 1985 Cyclothymia in the adolescent offspring of parents with bipolar affective disorder Journal of Abnormal Psychology 94 115 127 Konacs M Pollock M 1995 Bipolar Disorder and Co morbid Conduct Disorder in Childhood and Adolescent Journal of the American Academy of Child and Adolescent Psychiatry 34 6 715 723 Lynn G 2000 Survival Strategies for Parenting Children with Bipolar Disorder Jessica Kingsley Publishers London UK

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Mick E Biederman J Pandina G Faraone S V 2003 A preliminary metaanalysis of child behavior checklist in pediatric bipolar disorder Biological Psychiatry 53 1021 1027 Soutullo C A DelBell M P Ochsner J E et al 2002 Severity of bipolarity in hospitalized adolescents with history of stimulant or antidepressant treatment Journal of Affective Disorder 70 323 327 Weinstein S R Noam G G Grime K Stone K Schwan Stone M 1990 Convergence of DSM III diagnoses and self reported symptoms in chid and adolescent inpatients Journal of American Academy of Child and Adolescent Psychiatry 29 627 634 West S A Strakowski S M Sax K W Minner K L McElroy S L Keck P E 1996 Phenomenology and co morbidity of adolescents hospitalized for the treatment of acute mania Biological Psychiatry 39 458 460 West S A McElroy S L Strakowski S M Keck P E Jr Mcconville B J 1995a Attention deficit hyperactivity disorder in adolescent mania American Journal of Psychiatry 152 271 273 West S A Strakowski S M Sax K W Minner K L McElroy S L Keck P E Jr 1995b The comorbidity of attention deficit hyperactivity disorder in adolescent mania potential diagnostic and treatment implications Psychopharmacoloy Bulletin 31 323 351

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Woznaik J Beiderman J Kiely k et al 1995 Mania like symptoms suggestive of childhood onset bipolar disorder in clinically referred children Journal of American Academy of Child and Adolescent Psychiatry 34 867 876

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