ADHDADHD(vs. Bipolar or “Neuro”)(vs. Bipolar or “Neuro”)

Larry Fisher, Ph.D.Larry Fisher, Ph.D.

UHS Neurobehavioral SystemsUHS Neurobehavioral Systems

For More Information:For More Information:

Larry Fisher, Ph.D.Larry Fisher, Ph.D. UHS Neurobehavioral SystemsUHS Neurobehavioral Systems 12710 Research Blvd, Suite 32012710 Research Blvd, Suite 320 Austin, TX 78759Austin, TX 78759 512-257-3468; fax 512-257-3478512-257-3468; fax 512-257-3478 Email: Email:

• c n s g r o u p @ s w b e l l .n e tc n s g r o u p @ s w b e l l .n e t www.ragebehavior.comwww.ragebehavior.com

ADHD, Pediatric Bipolar,ADHD, Pediatric Bipolar, & “Neuro” Kids & “Neuro” Kids

ALL START IN CHILDHOODALL START IN CHILDHOOD• Attention Deficit Hyperactivity DisorderAttention Deficit Hyperactivity Disorder

ADHD starts before age sevenADHD starts before age seven

• Pediatric Bipolar DisorderPediatric Bipolar Disorder Starts before pubertyStarts before puberty

• Neurobehavioral DisordersNeurobehavioral Disorders ““Neuro” often prenatal or perinatal in originNeuro” often prenatal or perinatal in origin Initial symptoms start in early childhoodInitial symptoms start in early childhood

ADHDADHD

First identified in1917First identified in1917• pandemic of von Economo’s encephalitispandemic of von Economo’s encephalitis• Called “Hyperkinesis” Called “Hyperkinesis”

Later renamedLater renamed• “ “Minimal Brain Dysfunction”Minimal Brain Dysfunction”

Renamed againRenamed again• ““Attention Deficit Disorder (ADD)Attention Deficit Disorder (ADD)

Now: “ADHD” (Inattentive type, Now: “ADHD” (Inattentive type, hyperactive impulsive type, combined)hyperactive impulsive type, combined)

ADHDADHD

Affects 3-9 percent of school age kidsAffects 3-9 percent of school age kids Symptoms persist into adulthood (40%)Symptoms persist into adulthood (40%) ADHD kids spend less time immobile:ADHD kids spend less time immobile:

• 66% less than normal kids66% less than normal kids• (Teicher, et al., 1996)(Teicher, et al., 1996)

Hyperactivity is only apparent:Hyperactivity is only apparent:• When ADHD kids are asked to sit stillWhen ADHD kids are asked to sit still• Or during sleep (Porrino, et al., 1983)Or during sleep (Porrino, et al., 1983)

ADHDADHD

Symptoms must emerge before age 7Symptoms must emerge before age 7 Severe enough to cause impairmentsSevere enough to cause impairments Not due to other known mental disorderNot due to other known mental disorder Not due to PDD or Psychotic disorderNot due to PDD or Psychotic disorder For at least six months:For at least six months:

• At least six symptoms of inattentionAt least six symptoms of inattention• Or six symptoms of hyperactive-impulsiveOr six symptoms of hyperactive-impulsive• Or both (for combined type)Or both (for combined type)

ADHDADHD

ADHD kids are NOT more active in playADHD kids are NOT more active in play ONLY when asked to stop and sit stillONLY when asked to stop and sit still Therefore, we see a diminished:Therefore, we see a diminished:

• (1) ability to INHIBIT activity(1) ability to INHIBIT activity Therefore: impulsive, hyperactive (immature)Therefore: impulsive, hyperactive (immature)

• (2) ability to INHIBIT response to distractions(2) ability to INHIBIT response to distractions Therefore: inattentive (not age appropriate)Therefore: inattentive (not age appropriate)

The brain’s “brake” is not working well The brain’s “brake” is not working well

Pediatric Bipolar DisorderPediatric Bipolar Disorder

Bipolar (Manic Depressive) DisorderBipolar (Manic Depressive) Disorder• Pediatric Mania (Geller et al., 2002)Pediatric Mania (Geller et al., 2002)

Hyperactive even in play Hyperactive even in play • ADHD normal during playADHD normal during play

Racing thoughts, rapid speechRacing thoughts, rapid speech• ADHD shows normal rate of cognition and speechADHD shows normal rate of cognition and speech

Little need to sleepLittle need to sleep• ADHD kids may be too hyper to fall asleepADHD kids may be too hyper to fall asleep• But their need for sleep is otherwise normalBut their need for sleep is otherwise normal

Euphoria, grandiosity - unique to ManiaEuphoria, grandiosity - unique to Mania

ADHD versus ManiaADHD versus Mania

ADHD = poor “brakes” ADHD = poor “brakes” • can’t stop - in age appropriate mannercan’t stop - in age appropriate manner

Mania = too much “acceleration”Mania = too much “acceleration”• Brain is racing too fastBrain is racing too fast

Both may show:Both may show:• Hyperactivity, distractibility, irritabilityHyperactivity, distractibility, irritability

Mania shows severe mood swings:Mania shows severe mood swings:• Elation, grandiosity, racing Elation, grandiosity, racing

thoughts/speechthoughts/speech

Irritable “Neuro” KidsIrritable “Neuro” Kids

Irritability may be based on disorders of Irritability may be based on disorders of brain chemistry:brain chemistry:• ADHD, Bipolar Disorder, Schizophrenia, etc.ADHD, Bipolar Disorder, Schizophrenia, etc.

Or it may be a “Neuro” kid with early brain Or it may be a “Neuro” kid with early brain damage from:damage from:• Drugs or alcohol used in pregnancyDrugs or alcohol used in pregnancy• Difficult or premature deliveryDifficult or premature delivery• Very early traumatic brain injuryVery early traumatic brain injury• Genetic diseasesGenetic diseases• Brain electrical d/o’sBrain electrical d/o’s

Impulsive/IrritableImpulsive/Irritable

Irritability = short fuse.Irritability = short fuse.• Early onset/persistent tantrumsEarly onset/persistent tantrums• Impulsive behaviorImpulsive behavior• Impulsive aggressionImpulsive aggression

These behaviors are NOT premeditated.These behaviors are NOT premeditated.• Irritable behaviors are not planned Irritable behaviors are not planned • Quick temper, hot temper, too much emotionQuick temper, hot temper, too much emotion

Differs from Conduct D/O, Psychopathy:Differs from Conduct D/O, Psychopathy:• in cold blood, premeditated, too little emotionin cold blood, premeditated, too little emotion

InterventionsInterventions ““GET TOUGH” approach does NOT workGET TOUGH” approach does NOT work Boot Camp is not effective, early relapseBoot Camp is not effective, early relapse Group therapy does not work eitherGroup therapy does not work either Early interventions for at-risk kids workEarly interventions for at-risk kids work For irritable/hyper kid, medication may workFor irritable/hyper kid, medication may work Family support also effectiveFamily support also effective MST (Multi Systemic Therapy)MST (Multi Systemic Therapy)

• support parent & provide wrap-aroundsupport parent & provide wrap-around Identify psychiatric – ADHD or BIPOLARIdentify psychiatric – ADHD or BIPOLAR Identify brain disorders Identify brain disorders Treat comorbid PTSD, Substance Abuse, etc.Treat comorbid PTSD, Substance Abuse, etc.

ADHD & Life ImpairmentsADHD & Life Impairments

Childhood Childhood • Academic and social issuesAcademic and social issues

AdolescenceAdolescence• Substance abuse, driving accidentsSubstance abuse, driving accidents• Teen pregnancies, don’t finish schoolTeen pregnancies, don’t finish school

Young AdultsYoung Adults• Poor job stability, disrupted marriagesPoor job stability, disrupted marriages• Financial difficulties, impulsive crimes Financial difficulties, impulsive crimes

Other Psychiatric Disorders?Other Psychiatric Disorders?

Disorders often comorbid with ADHDDisorders often comorbid with ADHD• Substance or Alcohol AbuseSubstance or Alcohol Abuse• Oppositional Defiant DisorderOppositional Defiant Disorder• Conduct DisorderConduct Disorder• Mood Disorders (Bipolar or Depression)Mood Disorders (Bipolar or Depression)• Anxiety Disorders:Anxiety Disorders:• Obsessive Compulsive Disorder Obsessive Compulsive Disorder • Learning DisordersLearning Disorders

Stimulants and othersStimulants and others

Methylphenidate-RitalinMethylphenidate-Ritalin

Dextroamphetamine-DexidrineDextroamphetamine-Dexidrine

AdderallAdderall

Pemoline (Cylert)Pemoline (Cylert)

Amoxitine-Strattera (non-stim)Amoxitine-Strattera (non-stim)

Other: Wellbutrin, ClonidineOther: Wellbutrin, Clonidine

Treatment TypesTreatment Types

MedicationsMedications• Stimulants, Non-stimulantsStimulants, Non-stimulants• Antidepressants, Alpha-2-AgonistsAntidepressants, Alpha-2-Agonists

Parent Training – Positive DisciplineParent Training – Positive Discipline• BIP (Behavior Intervention Plan)BIP (Behavior Intervention Plan)

Structure – routines, schedulesStructure – routines, schedules School supportsSchool supports (IEP) (IEP)

AssessmentsAssessments

Comprehensive evaluation is bestComprehensive evaluation is best• Check for IQ, learning disabilitiesCheck for IQ, learning disabilities• Check for other diagnosesCheck for other diagnoses• Rule out Bipolar, “Neuro”, otherRule out Bipolar, “Neuro”, other

ADHD rating scalesADHD rating scales Conners Scales for TeachersConners Scales for Teachers Neuropsychological testingNeuropsychological testing Continuous Performance Test (CPTContinuous Performance Test (CPT

SummarySummary

ADHD ADHD • A common childhood disorderA common childhood disorder• With many causesWith many causes• Often genetic (DAT-1, DRD2, D4 genes)Often genetic (DAT-1, DRD2, D4 genes)

Can produce serious life distressCan produce serious life distress• Learning, behavior, social, teen safetyLearning, behavior, social, teen safety

Goal is resilience: Goal is resilience: • Positive discipline, structure, medsPositive discipline, structure, meds