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