Emotional disorders in ADHD Eric Taylor King s College London, Institute of Psychiatry Stress, anxiety, depression, anger, hypomania, dysregulation No competing financial interests
For people with ADHD, emotional problems are common, can be disabling and need recognition and treatment Stress, anxiety, depression, anger, brain syndromes, hypomania, dysregulation
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
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
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 Controls 5% with >1 disorder Spencer et al. (1999). Clin N A, 46, 915-927 5-15% 15-35% 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 Cognition Pregnancy Postnatal ADHD alone Working memory better Reactions quicker ADHD + anxiety Inhibition better Less off-task. More complications More ve life events Medication Smaller response 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 bad parents: Medication of child reduces parental EE Not just complications: In never-medicated adults: low striatal dopamine persisting striatal hypoactivation 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)
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 Impulsive Oppositional Headstrong Irritable education failure antisocial mood disorder be clear about the goals
Anger, irritability, rage
Irritability Excessive anger; in: frequency duration intensity ease of elicitation uncontrollability
Emotional Dysregulation negative positive Anxiety Depression Irritability Elation withdrawal approach overlap from shared G; E distinguishes
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 Emotion processing is a multi-stage process involving higher-order top-down control and automatic bottom-up processes Wessa & Linke, International Review Psych,2009
Emotion Processing Neural Circuits opfc vmpfc dlpfc AMG ACC Davidson et al., Science 2000 Everitt & Robbins, Nat Rev Neurosci 2005 19
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 seconds gelastic epilepsy Medication anticonvulsants minutes pseudobulbar affect hours emotional incontinence drugs, esp. cannabis severe dysregulation DMDD ADHD dextromethorphan /quinidine? abstain 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.
DSM5: rejected pediatric bipolar disorder 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
Controversial re-description of paediatric bipolar disorder PBPD ADHD Rapid cycles, maybe ultradian Mood often irritable, not euphoric Trait, but frequent mood changes 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 USA 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 UK GPRD 1992 2005 0.39/1,000 0.77/1,000
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 Mood high 1 5 10 15 20 25 30 35 40 45 50 55 60 DAYS Mood low
Cycles and episodes Mood high 1 5 10 15 20 25 30 35 40 45 50 55 60 DAYS 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? 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 Birmaher B, et al. Arch Gen Psychiatry 2006
Bipolar disorder in young people: is usually Chronic emotional dysregulation Excessive and impairing mood changes are very common presentations Comorbidity frequent, especially ADHD. Careful diagnosis is needed. Episodes of mania Chronic lability of mood +/- depression especially irritability
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.
For people with ADHD, emotional problems are common and can be disabling Stress, anxiety, depression, anger, brain syndromes, hypomania, dysregulation