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Emotional disorders
in ADHD
Eric Taylor
King’s College London, Institute of Psychiatry
Stress, anxiety, depression, anger, hypomania,
dysregulation No competing financial
interests
Stress,
anxiety,
depression,
anger,
brain syndromes,
hypomania,
dysregulation
For people with ADHD, emotional problems are common, can be disabling and need recognition and treatment
Families ADHD
Sources of stress
Guilt
Anger
On-going strain of management
Impact on and experiences of siblings
Relationships within the family
Distressed
Distorted
Poor attachment
Strengths and resilience
From the mother’s perspective Whalen et al., 2008
O Mothers of children with ADHD saw more:
O impatience, restlessness, loudness, talking,
boredom (at weekends), bad moods in the
morning, disagreements with their child
O … and less:
O concentration (in children)
O “competence” (in themselves)
O When mothers were feeling angry:
O ADHD – 3x as likely to be angry with their
child
From the child’s perspective (Whalen et al., 2008)
All children reported:
stress during the week
but children with ADHD also stressed at
weekend (10x more likely!)
Children with ADHD reported more:
restlessness
feelings of sadness and discouragement
(especially at weekends)
disagreements with their mothers
What is it like to have ADHD?
“My thoughts are in a muddle” (usually only after treatment shows the difference)
“I get into trouble a lot, I don’t know why”
“Other kids pick on me”
“Ive got a bad temper”, “I cant concentrate”, “Ive got
ADHD”
(usually repeating what they have been told)
Anxiety disorders in ADHD
ADHD
27% with >1 disorder
5-15%
Controls
5% with >1 disorder
15-35%
Spencer et al. (1999).. Ped
Clin N A, 46, 915-927
Pliszka et al (1999)
ADHD with comorbid
disorders)
Why?
More stress; linked striatal; genetic subtype; emotion dysregulation;
dysfunctional attending; phenocopy; via externalising complications
Associations of coexisting anxiety
ADHD alone
Working memory
better
Reactions quicker
ADHD + anxiety
Inhibition better
Less off-task .
More complications
More –ve life events
Smaller response
Cognition
Pregnancy
Postnatal
Medication
Summaries of Brown (2000, Attention-deficit disorders and comorbidities)
Pliszka et al (1999; ADHD with comorbid disorders)
Fig. 3. Adjusted odds ratios (and 95% confidence intervals) for comorbid DSM-IV disorders. ADHD = attention-deficit/hyperactivity
disorder.
TAMSIN FORD, ROBERT GOODMAN, HOWARD MELTZER
The British Child and Adolescent Mental Health Survey 1999: The Prevalence of DSM-IV Disorders
Journal of the American Academy of Child & Adolescent Psychiatry, Volume 42, Issue 10, 2003, 1203–1211
http://dx.doi.org/10.1097/00004583-200310000-00011
Effect of reactions from others
Not just genetic: The Environmental Risk Longitudinal
Twin Study interviewed the mothers of 565 five-year-old
monozygotic (MZ) twin pairs : the twin receiving more
maternal negativity and less warmth had more antisocial
behavior problems. (Moffitt et al 2008)
Not just bad parents: Medication of child reduces parental EE
Not just complications:
In never-medicated adults:
low striatal dopamine
persisting striatal
hypoactivation
Clinical implications for ADHD
Screen/ ask about anxiety and depression
Support/ education for child & family
Expect controlling ADHD to help Stimulants NOT contraindicated
If anx/dep persist, assess for autism
spectrum, emotional dysregulation, bipolar;
treat if needed
Longitudinal research finds
dimensions rather than diagnoses
ADHD
Inattentive education failure
Impulsive
Oppositional antisocial
Headstrong
Irritable mood disorder
… be clear about the goals
Anger, irritability, rage
Irritability
Excessive anger; in:
frequency
duration
intensity
ease of elicitation
uncontrollability
Emotional Dysregulation
Anxiety Depression Irritability Elation
overlap from shared G; E distinguishes
positive negative
withdrawal approach
Development I: infancy
2-3 months reaction to frustration
or violation of expectancy
5-6 months differentiated anger
eg hand restraint, still-face
gaze preference for joy > anger
regulation by soothing
12 months distress or anger after witnessing discord
regulation by self-stimulation, attention direction
Development II: preschool to school
Overt: tantrums
monthly in 80%, daily in 8-10%
yelling, shaking, autonomic discharge;
then distress
regulation by instrumental, social action
Covert: resentment, hostility
unfairness, coercion, humiliation
regulation by representation, inhibition, language
Emotion Processing
Wessa & Linke, International Review Psych,2009
Emotion processing is a multi-stage process
involving higher-order top-down control and automatic bottom-up processes
19
Emotion Processing
Neural Circuits
Davidson et al., Science 2000 Everitt & Robbins, Nat Rev Neurosci 2005
oPFC vmPFC dlPFC
AMG ACC
Functional connection: executive
Children with ADHD had weaker functional connections between the left
dorsolateral prefrontal cortex and the left anterior operculum (AO), left
supplemental motor area (SMA), left dorsal caudate (DC), left precentral gyrus (PC)
Posner et al (2013) Psych Res 213:24
Functional connection: emotional
Children with ADHD had weaker functional connections between the
left ventral striatum and the left orbitofrontal cortex (OFC) and right
hippocampus (Hippo). Posner et al (2013) Psych Res 213:24
Disruptive mood dysregulation disorder
Severe tempers, > 3/week
Persistent irritability, most of day, nearly every day
Present >12 months, with no remissions lasting 3
months
Onset before age 10
First diagnosis > 6 years and <18 years
No mania, etc
But most irritability is in the context of other disorders: ADHD, ASD, BP (I & II), MDD, ABI, chronic brain disorders
Mood lability in young people
ADHD with comorbid emotional disturbance
Disruptive mood dysregulation disorder
Bipolar disorder, schizo-affective
Depression, PTSD, Substance misuse
Child abuse
Autism spectrum
Organic brain disease (inc.thyroid)
Food-induced behaviour change
Iatrogenic
“Irritability” is commonest symptom at Maudsley: 32%
Neural Circuits Implicated in Emotion
Dysregulation in ADHD
24
Shaw P, et al., Am J Psych 2014
Emotion Dysregulation leads to:
misdiagnosis (esp bipolar)
relationship problems
mood disorders in adult life
risk for suicidal ideation and action
Manage for SAFETY
Treat depression
Emotional education
Suicide in childhood & adolescence
ADHD : 32 per 100,000 international
Population: 11 per 100,000 USA
James, A., Lai, F.H. and Dahl, C., 2004. Acta Psychiatrica
Scandinavica, 110(6), pp.408-415.
• Suicidal ideation • ADHD v population: OR 2.7 – 6.7
Impey, M. and Heun, R., 2012.. Acta Psychiatrica Scandinavica, 125(2),
pp.93-102.
Anger and ADHD:
Mechanisms of association Evocative transactions
assess EE, frustrations; psychoeducation
Dyscontrol
frontal and ventrostriatal
stimulant medication; anger control?
Risks in common
cosegregation and cross-twin cross-trait
Comorbid states
identify and treat depression, bipolar
Emotional lability in parents
affects delivery of treatment
Pharmacological treatment of
emotional dysregulation/irritabiity Stimulants
MPH, DA, Lis-DA
caution in mania
SSRIs (no trials yet)
Atomoxetine, clonidine
Valproate
one small trial (Blader et al 2009)
Risperidone , (aripiprazole)
(Aman et al 2004)
Anger and autism spectrum
SED in 24/91 (Simonoff et al 2012)
Not associated with core ASD severity or IQ
Transactions with caregivers
Comorbidity and FH of depression
Misinterpretations
Inflexibility
Low cortisol and HR reactions to stress
Pain
Treating anger in ASD
Positive behaviour support
functional analysis, adaptive skills
RCT in 124 medicated 9-13 year olds*
Environmental change
structure, order, calmness, predictability
Risperidone
6 RCTs, and 3 longer-term (50% response)
AERs frequent
Aripiprazole
2 RCTs
Valproex and N-acetylcysteine: 1 trial each
* Aman et al 2009
Acquired brain injury
Confusional states
Loss of discipline
Personality change
Propranolol*
(Carbamazepine, lamotrigine)
* meta-analysis by Fleminger et al 2006 for adults
Chronic brain syndromes
Challenging behaviours: irritability associated with
low adaptive function
ABA, risperidone, aripiprazole
Control seizures, but ictal anger is rare
NB Tourette, pseudobulbar palsy, Smith-Magenis
Episode
length
Terminology Medication
seconds gelastic epilepsy anticonvulsants
minutes ‘pseudobulbar affect’
‘emotional incontinence’
drugs, esp. cannabis
dextromethorphan
/quinidine ?
abstain
hours ‘severe dysregulation’
‘DMDD’
ADHD
stimulants
days bipolar II mood stabilisers,
antipsychotics
weeks bipolar I intensive
Bipolar disorder in young people
Excessive and impairing mood changes are very common presentations
Episodes of mania
+/- depression
Chronic lability of mood
especially irritability
Comorbidity frequent, especially ADHD. Careful diagnosis is needed.
Traditional distinction
Bipolar ADHD
Cause Episodic Trait
Mood Euphoric, grandiose Not specified
NICE: recognise only bipolar I; irritability is
not a sufficient affective change for mania
DSM5: rejected “pediatric bipolar disorder”
Controversial re-description of
“paediatric bipolar disorder”
PBPD ADHD
Rapid cycles, maybe
ultradian
Trait, but frequent mood
changes
Mood often irritable, not
euphoric
Not specified, but often
irritable
ADHD in 80 - 90% PBPD in approx 20%
PBPD has led to an epidemic in USA of antipsychotic
prescribing for young children
Databases on antipsychotics
Source Year1 Year 2
Medicaid 1987 1996
1.5/1,000 8.0/1,000
NAMCS 1995 2001
8.6/1,000 39.4/1,000
GPRD 1992 2005
0.39/1,000 0.77/1,000
USA
UK
What are the signs of mania in
children?
EPISODES of:
Irritability
Elated mood
Grandiosity
Hypersexuality
Racing thoughts
Insomnia
Overtalkative, distractible, increased activity
Are these symptoms – reliable? specific? discriminating?
Cardinal features of mania
Symptom Frequency Specificity Impairing Look for
Euphoric ++ +++ ( +) - Substance
use; medicn;
epilepsy
Irritable +++ (+) +++ Episodicity; mood context;
-provocation
Grandiose + ++ ++ Fluctuations;
inappropriate
- arrogance
Associated features of mania
Symptom Frequency Specificity Impairing Look for
Activity +++ - ( +) CHANGE of
activity
Hypersex
uality
+ (+) +++ - Abuse
Insomnia +++ + ++ Change; no
daytime
fatigue
Cycles and episodes
DAYS 1 5 10 15 20 25 30 35 40 45 50 55 60
Mood high
Mood low
Cycles and episodes
DAYS 1 5 10 15 20 25 30 35 40 45 50 55 60
Mood high
Mood low
Bipolar I = 7 days
Bipolar II = 4 days
Bipolar NOS = less (or
fewer symptoms)
What phenomenology is useful in
diagnosing mania in children?
Irritability
Elated mood
Grandiosity
Hypersexuality
Racing thoughts
Insomnia
Overtalkative, distractible, increased activity
Episodicity
How long must an episode be?
Birmaher B, et al. Arch Gen Psychiatry 2006
20% of bipolar NOS
converted to bipolar I or II
after 2 years.
1-2 days recommended as
minimum length of episode;
otherwise regard as
emotional dysregulation
until better evidence comes
“Bipolar disorder” in young people:
is usually Chronic emotional
dysregulation
Excessive and impairing mood changes are very common presentations
Episodes of mania
+/- depression
Chronic lability of mood
especially irritability
Comorbidity frequent, especially ADHD. Careful diagnosis is needed.
Clinical Implications
Important to recognise bipolar disorder in childhood
- predicts a poor outcome
- delayed treatment worsens prognosis (?)
- guide to therapy
- caution with antidepressants
- caution with stimulants
Important not to over-recognise - require episodes of more than 1-2 days - avoid nonspecific use of neuroleptics
Differential diagnosis required
- consider alternative diagnoses - bipolar disorder may co-exist with other problems
Adding mood dysregulation to the
affective disorders of young people
MANIA Explain; ensure safety; ?admit
Lithium, divalproate, neuroleptics; +#2 at 8 weeks
DEPRESSION CBT; stabiliser or SSRI
Quetiapine in bipolar depression
MOOD DYSREGULATION Control ADHD; social interventions; ?risperidone
FURTHER READING: Taylor, E. (2009) Managing bipolar disorders in children and
adolescents. Nat Rev Neurol, 5(9), 484-491.
Stress,
anxiety,
depression,
anger,
brain syndromes,
hypomania,
dysregulation
For people with ADHD, emotional problems
are common and can be disabling