ADHD and manic symptoms: Diagnostic and treatment implications

Preventing Irritability and Temper Outbursts in Youth by Building Resilience

Severe irritability and temper outbursts are risk factors for the onset of serious and lifelong mood disorders. In treating children and adolescents with severe irritability, clinicians should evaluate and address safety issues before acute stabilization of symptoms. Then, clinicians can initiate interventions to prevent the onset or relapses of the undesired behavior and its functional consequences. This review summarizes primary, secondary, and tertiary relapse prevention strategies, with an emphasis on strategies that build resilience in youth that mitigate the onset, recurrence, and progression of emotion dysregulation.

Temperament in Adulthood Attention Deficit-Hyperactivity Disorder without Bipolar Disorder

OBJECTIVE

We examined whether some temperamental traits would be associated with persistence of attention deficit-hyperacitivty disorder (ADHD) in adulthood independent from bipolar disorder (BD).

METHODS

Eighty-one ADHD patients without a comorbid diagnosis of BD were divided into two groups, those with childhood ADHD (n=46), and those with Adulthood ADHD (n=35). The severity of childhood and adulthood ADHD were assessed by using the Wender Utah Rating Scale (WURS-25) and Turgay's Adult ADD/ADHD Diagnosis and Evaluation Scale (DES). Subjects' temperamental characteristics were examined using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire (TEMPS-A).

RESULTS

The mean scores of WURS-25 were higher in adult ADHD group than in childhood ADHD group (p<0.001). Adult ADHD group had significantly higher scores on cyclothymic (p=0.002), irritable (p<0.0001), and anxious (p=0.042) subscales of TEMPS-A. The scores of WURS-25 in adulthood ADHD group were positively correlated with cyclothymia scores (r=0.366, p=0.033). Total scores of Turgay's Adult ADD/ADHD DES were positively correlated with cyclothymic (r=0.354, p=0.040), hyperthymic (r=0.380, p=0.026), and irritable (r=0.380, p=0.026) subscale scores. Cychlothymic and irritable temperaments were significantly associated with the severity of adulthood symptoms of ADHD.

CONCLUSION

We might suggest that cyclothymic and irritable temperaments would predict the diagnosis of adulthood ADHD independent from BD.

The Effectiveness and Tolerability of Central Nervous System Stimulants in School-Age Children with Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder Across Home and School

OBJECTIVE

This study examines the effectiveness and tolerability of stimulants in children with attention-deficit/hyperactivity disorder (ADHD) and disruptive mood dysregulation disorder (DMDD).

METHODS

To be eligible, participants had to meet Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV) criteria for the combined subtype of ADHD and National Institute of Mental Health (NIMH) severe mood dysregulation criteria. The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V) DMDD criteria were retrospectively assessed after the study was completed. An open-label medication trial lasting up to 6 weeks was completed to optimize the central nervous system (CNS) stimulant dose. Measures of affective symptoms, ADHD symptoms and other disruptive behaviors, impairment, and structured side effect ratings were collected before and after the medication trial.

RESULTS

Optimization of stimulant medication was associated with a significant decline in depressive symptoms on the Childhood Depression Rating Score-Revised Scale (p<0.05, Cohen's d=0.61) and Mood Severity Index score (p<0.05, Cohen's d=0.55), but not in manic-like symptoms on the Young Mania Rating Scale. There was a significant reduction in ADHD (p<0.05, Cohen's d=0.95), oppositional defiant disorder (ODD) (p<0.05, Cohen's d=0.5), and conduct disorder (CD) symptoms (p<0.05, Cohen's d=0.65) as rated by parents. There was also a significant reduction in teacher-rated ADHD (p<0.05, Cohen's d=0.33) but not in ODD symptoms. Medications were well tolerated and there was no increase in side effect ratings seen with dose optimization. Significant improvement in functioning was reported by clinicians and parents (all p's<0.05), but youth still manifested appreciable impairment at end-point.

CONCLUSIONS

CNS simulants were well tolerated by children with ADHD comorbid with a diagnosis of DMDD. CNS stimulants were associated with clinically significant reductions in externalizing symptoms, along with smaller improvements in mood. However, most participants still exhibited significant impairment, suggesting that additional treatments may be needed to optimize functioning.

Delineating ADHD and bipolar disorder: A comparison of clinical profiles in adult women

OBJECTIVE

Overlapping symptoms can make the diagnostic differentiation of attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) challenging in adults using current clinical assessments. This study sought to determine if current clinical measures delineate ADHD from BD in adults, comparing relative levels of ADHD, BD and emotional lability (EL) symptoms.

METHODS

Sixty adult women with ADHD, BD or controls were compared on self-report and interview measures for ADHD symptoms, mania, depression, EL, and impairment.

RESULTS

ADHD interview measures and self-ratings of ADHD symptoms best discriminated between ADHD and BD. Self-report measures of EL and depression showed non-specific enhancement in both clinical groups. BD-specific items may distinguish BD from ADHD if a retrospective time-frame is adopted.

CONCLUSIONS

Using measures which capture specific symptoms of ADHD and chronicity/episodicity of symptoms facilitates the delineation of ADHD from BD in adult women.

Treatment of children with attention-deficit/hyperactivity disorder (ADHD) and irritability: results from the multimodal treatment study of children with ADHD (MTA)

OBJECTIVE

Clinically impairing irritability affects 25% to 45% of children with attention-deficit/hyperactivity disorder (ADHD); yet, we know little about what interventions are effective in treating children with ADHD and co-occurring irritability. We used data from the Multimodal Treatment Study of Children With ADHD (MTA) to address 3 aims: to establish whether irritability in children with ADHD can be distinguished from other symptoms of oppositional defiant disorder (ODD); to examine whether ADHD treatment is effective in treating irritability; and to examine how irritability influences ADHD treatment outcomes.

METHOD

Secondary analyses of data from the MTA included multivariate analyses, and intent-to-treat random-effects regression models were used.

RESULTS

Irritability was separable from other ODD symptoms. For treating irritability, systematic stimulant treatment was superior to behavioral management but not to routine community care; a combination of stimulants and behavioral treatment was superior to community care and to behavioral treatment alone, but not to medication alone. Irritability did not moderate the impact of treatment on parent- and teacher-reported ADHD symptoms in any of the 4 treatment groups.

CONCLUSION

Treatments targeting ADHD symptoms are helpful for improving irritability in children with ADHD. Moreover, irritability does not appear to influence the response to treatment of ADHD.

CLINICAL TRIAL REGISTRATION INFORMATION

Multimodal Treatment Study of Children With Attention Deficit and Hyperactivity Disorder (MTA); http://www.clinicaltrials.gov; NCT00000388.

Neuropsychological Profiles Correlated with Clinical and Behavioral Impairments in a Sample of Brazilian Children with Attention-Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD) is a complex neurodevelopmental disorder that implies several-step process, and there is no single test to diagnose both ADHD and associated comorbidities, such as oppositional-defiant disorder (ODD), anxiety disorder, depression, and certain types of learning disabilities. The purpose of the present study was to examine correlations between behavioral and clinical symptoms by administering an extensive neuropsychological battery to a sample of children and adolescents from a developing country. The sample was divided into three groups: non-ADHD, ADHD-non-comorbid, and ADHD + comorbidity. A full neuropsychological battery and clinical assessment found that 105 children met DSM-5 criteria, of whom 46.6% had the predominantly inattentive presentation, 37.3% had combined presentation, and 16% were predominantly hyperactive/impulsive presentation. The internal correlation between neuropsychological tests did not reach statistical significance in the comparison between ADHD and non-ADHD cases (p < 0.17). Clinical ADHD cases, including both + comorbidity and non-comorbid groups, performed substantially worse on continuous performance test (CPT), working memory. Comparing ADHD-non-comorbid and ADHD + comorbidity groups, the latter did significantly worse on inhibitory control, time processing, and the level of perseveration response on CPT indexes, as well as on working memory performance and child behavior checklist (CBCL) tests particularly the CBCL-deficient emotional self-regulation test in the ADHD + comorbidity group. Children diagnosed as ODD or with conduct disorder showed close correlations between clinical CBCL profiles and externalized symptoms. Our findings suggest that ADHD + comorbidity and ADHD non-comorbid cases may be differentiated by a number of neuropsychological measures, such as processing speed, inhibitory control, and working memory, that may reflect different levels of involvement of the hot and cool executive domains, which are more impaired in cases of severe symptomatic-externalized behavior and emotional regulation problems. Therefore, profiles based on clinical and behavioral findings can help clinicians select better strategies for detecting neuropsychological impairment in Brazilian children with ADHD.

A novel group therapy for children with ADHD and severe mood dysregulation

OBJECTIVE

No psychosocial treatments have been developed for children with ADHD and severe mood dysregulation (SMD) despite the significant prevalence and morbidity of this combination. Therefore, the authors developed a novel treatment program for children with ADHD and SMD.

METHOD

The novel therapy program integrates components of cognitive-behavioral therapies for affect regulation with a parent-training intervention for managing recurrent defiant behaviors. It consists of nine 105-min child and parent groups run in unison. A pilot trial was conducted with seven participants with ADHD and SMD ages 7 to 12 who were on a stable stimulant regimen.

RESULTS

Six of the seven (86%) families completed the program. Participants showed large improvements in depressive symptoms, mood lability, and global functioning. Milder improvements in externalizing behaviors were observed.

CONCLUSION

Results suggest the feasibility and potential efficacy of the therapy program for children with ADHD and SMD and warrant a larger controlled trial.

Temperamental characteristics in adults with attention-deficit hyperactivity disorder: a comparison with bipolar disorder and healthy control groups

OBJECTIVE

To date, the affective temperamental characteristics of adults with attention-deficit hyperactivity disorder (ADHD) have not been studied. The aim of this study is to explore those temperamental characteristics for adults diagnosed with ADHD as measured by the TEMPS-A and then to compare those results with results for individuals diagnosed with bipolar disorder (BD) and with healthy controls.

METHODS

Forty adults with ADHD, 40 patients with BD, and 40 healthy controls were enrolled in this study. The groups were matched by age and gender. All patients were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I), the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Young Mania Rating Scale and the Wender Utah Rating Scale. Subjects' temperamental characteristics were examined using the Turkish version of the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto questionnaire (TEMPS-A).

RESULTS

Ten subjects (25%) in the ADHD group and 15 subjects (30%) in the bipolar group had at least one dominant temperament. There was no identifiable dominant temperament in the control group. Compared to the control group, the ADHD group scored higher than other groups on all domains of the TEMPS-A: depressive cyclothymic, irritable and anxious. However, the hyperthymic domain was not higher for this group. Adults with ADHD scored higher on the irritable temperament scale as compared to the BD group. The ADHD and BD groups had similar mean scores for each of the other four temperaments.

CONCLUSION

The adults diagnosed with ADHD in this study had different temperamental characteristics from the control group, and these temperamental characteristics were similar to those of the bipolar patients. Recognizing the role of temperamental characteristics in adults with ADHD may increase our understanding of ADHD.

An update on the debated association between ADHD and bipolar disorder across the lifespan

Diagnostic formulations for attention deficit hyperactivity disorder (ADHD) and bipolar disorder (BD) both include symptoms of distractibility, psychomotor agitation and talkativeness, alongside associated emotional features (irritability and emotional lability). Treatment studies suggest the importance of accurate delineation of ADHD and BD. However, boundaries between the two disorders are blurred by the introduction of broader conceptualisations of BD. This review attempts to elucidate whether associations between ADHD and BD are likely to be driven by superficial symptomatological similarities or by a more meaningful etiological relationship between the disorders. This is achieved by outlining findings on comorbidity, temporal progression of the disorders, familial co-variation, and neurobiology in ADHD and BD across the lifespan. Longitudinal studies fail to consistently show developmental trajectories between ADHD and BD. Comparative research investigating neurobiology is in its infancy, and although some similarities are seen between ADHD and BD, studies also emphasise differences between the two disorders. However, comorbidity and family studies appear to show that the two disorders occur together and aggregate in families at higher than expected rates. Furthermore close inspection of results from population studies reveals heightened co-occurrence of ADHD and BD even in the context of high comorbidity commonly noted in psychopathology. These results point towards a meaningful association between ADHD and BD, going beyond symptomatic similarities. However, future research needs to account for heterogeneity of BD, making clear distinctions between classical episodic forms of BD, and broader conceptualisations of the disorder characterised by irritability and emotional lability, when evaluating the relationship with ADHD.

Pediatric bipolar spectrum disorder and ADHD: comparison and comorbidity in the LAMS clinical sample

OBJECTIVE

  To compare attention-deficit hyperactivity disorder (ADHD), bipolar spectrum disorders (BPSDs), and comorbidity in the Longitudinal Assessment of Manic Symptoms (LAMS) study.

METHODS

  Children ages 6-12 were recruited at first visit to clinics associated with four universities. A BPSD diagnosis required that the patient exhibit episodes. Four hypotheses were tested: (i) children with BPSD + ADHD would have a younger age of mood symptom onset than those with BPSD but no ADHD; (ii) children with BPSD + ADHD would have more severe ADHD and BPSD symptoms than those with only one disorder; (iii) global functioning would be more impaired in children with ADHD + BPSD than in children with either diagnosis alone; and (iv) the ADHD + BPSD group would have more additional diagnoses.

RESULTS

  Of 707 children, 421 had ADHD alone, 45 had BPSD alone, 117 had both ADHD and BPSD, and 124 had neither. Comorbidity (16.5%) was slightly less than expected by chance (17.5%). Age of mood symptom onset was not different between the BPSD + ADHD group and the BPSD-alone group. Symptom severity increased and global functioning decreased with comorbidity. Comorbidity with other disorders was highest for the ADHD + BPSD group, but higher for the ADHD-alone than the BPSD-alone group. Children with BPSD were four times as likely to be hospitalized (22%) as children with ADHD alone.

CONCLUSIONS

  The high rate of BPSD in ADHD reported by some authors may be better explained as a high rate of both disorders in child outpatient settings rather than ADHD being a risk factor for BPSD. Co-occurrence of the two disorders is associated with poorer global functioning, greater symptom severity, and more additional comorbidity than for either single disorder.

Neuropsychological functioning in adult bipolar disorder and ADHD patients: a comparative study

Bipolar disorder (BD) and adult attention deficit hyperactivity disorder (ADHD) usually manifest with shared clinical symptoms, proving quite challenging to thoroughly differentiate one from another. Previous research has characterized these two disorders independently, but no study compared both pathologies from a neuropsychological perspective. The aim of this study was to compare the neuropsychological profile of adult ADHD and BD with each other and against a control group, in order to understand the way in which comprehensive cognitive assessment can contribute to their discrimination as distinct clinical entities as well as their differential diagnosis. All groups were successfully matched for age, sex, years of education, and premorbid IQ. Participants were assessed with an extensive neuropsychological battery evaluating multiple domains. Compared to controls, BD patients had a poorer performance on immediate verbal memory tasks. Both clinical groups exhibited significantly lower scores than controls on the recognition phase of verbal and non-verbal memory tasks, as well as on a task of executive functioning with high working memory demand. Noticeably, however, ADHD had significantly better performance than BD on the recognition phase of both the Rey list memory task and the Rey Figure. The better performance of ADHD patients over BD may reflect the crucial role of the executive component on their memory deficits and gives empirical support to further differentiate the neuropsychological profile of BD and adult ADHD patients in clinical practice.

Long-term outcomes of youth who manifested the CBCL-Pediatric Bipolar Disorder phenotype during childhood and/or adolescence

OBJECTIVE

Recent studies have identified a Child Behavior Checklist (CBCL) profile that characterizes children with severe aggression, inattention, and mood instability. This profile has been coined the CBCL-Pediatric Bipolar Disorder (PBD) phenotype, because it is commonly seen among children with bipolar disorder. However, mounting evidence suggests that the CBCL-PBD may be a better tool for identifying children with severe functional impairment and broad-ranging psychiatric comorbidities rather than bipolar disorder itself. No studies have followed individuals with the CBCL-PBD profile through adulthood, so its long-term implications remain unclear. The present authors examined diagnostic and functional trajectories of individuals with the CBCL-PBD profile from early childhood through young adulthood using data from a longitudinal high-risk study.

METHOD

Participants (n=101) are part of a 23-year study of youth at risk for major mood disorder who have completed diagnostic and functional assessments at regular intervals.

RESULTS

Across development, participants with the CBCL-PBD phenotype exhibited marked psychosocial impairment, increased rates of suicidal thoughts and behaviors and heightened risk for comorbid anxiety, bipolar disorder, cluster B personality disorders and ADHD in young adulthood, compared to participants without this presentation. However, diagnostic accuracy for any one particular disorder was found to be low.

CONCLUSIONS

Children with the CBCL-PBD profile are at risk for ongoing, severe, psychiatric symptomatology including behavior and emotional comorbidities in general, and bipolar disorder, anxiety, ADHD, cluster B personality disorders in particular. However, the value of this profile may be in predicting ongoing comorbidity and impairment, rather than any one specific DSM-IV diagnosis.

The efficacy and tolerability of methylphenidate and behavior modification in children with attention-deficit/hyperactivity disorder and severe mood dysregulation

OBJECTIVES

This study examines the tolerability and efficacy of methylphenidate (MPH) and behavior modification therapy (BMOD) in children with attention-deficity/hyperactivity disorder (ADHD) and severe mood dysregulation (SMD).

METHODS

Children (ages 5-12) from a summer program for ADHD were screened for SMD and additional manic-like symptoms using structured assessments and direct clinical interview with the Young Mania Rating Scale (YMRS). The SMD group was comprised of 33 subjects with SMD and elevated YMRS scores (mean = 23.7). They underwent weekly mood assessments plus the daily ADHD measures that are part of the program. The comparison group (n = 68) was comprised of the rest of the program participants. Using a crossover design, all subjects in both groups were treated with three varying intensities of BMOD (no, low, high) each lasting 3 weeks, with MPH dose (placebo, 0.15 mg/kg t.i.d., 0.3mg/kg t.i.d., and 0.6 mg/kg t.i.d.) varying daily within each behavioral treatment.

RESULTS

Groups had comparable ADHD symptoms at baseline, with the SMD group manifesting more oppositional defiant disorder/conduct disorder (ODD/CD) symptoms (p < 0.001). Both groups showed robust improvement in externalizing symptoms (p < 0.001). There was no evidence of differential treatment efficacy or tolerability. Treatment produced a 34% reduction in YMRS ratings in SMD subjects (p - 0.001). However, they still exhibited elevated YMRS ratings, more ODD/CD symptoms (p < 0.001), and were more likely to remain significantly impaired at home than non-SMD subjects (p < 0.05).

CONCLUSIONS

MPH and BMOD are tolerable and effective treatments for children with ADHD and SMD, but additional treatments may be needed to optimize their functioning.

Frontiers between attention deficit hyperactivity disorder and bipolar disorder

The co-occurrence of attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received much recent attention in the literature. The authors review the literature examining associations between ADHD and bipolar disorder in children, and data concerning severe irritability in youth with ADHD. This article focuses on (1) population-based studies examining ADHD and bipolar disorder or ADHD and co-occurring irritability, (2) the co-occurrence and prospective relationships of ADHD and bipolar disorder in clinical samples, (3) phenomenology and assessment of bipolar disorder and ADHD, (4) treatment of comorbid ADHD and bipolar disorder, (5) family and genetic studies of ADHD and bipolar disorder, and (6) pathophysiologic comparisons between children with ADHD and irritability and bipolar disorder. We draw on the research to make clinical recommendations and highlight important directions for future research.

Phenomenology and diagnosis of bipolar disorder in children, adolescents, and adults: complexities and developmental issues

This review addresses the phenomenology of mania/bipolar disorder from a developmental psychopathology perspective and uses cases with longitudinal information to illustrate major points. Beginning with a summary of the phenomenology of bipolar illness as it occurs in adults, the authors identify diagnostic complexities unique to children and adolescents. These include the challenges of characterizing elation and grandiosity; differentiating mania from comorbid symptoms, rages, sequelae of maltreatment, and typical developmental phenomena; and the unique manifestations of psychosis. We conclude with the observation that a significant difference between early and later onset bipolar disorder is that, in the former, there appears to be a global delay or arrest in the development of appropriate affect regulation; whereas in adult-onset bipolar illness, emotion dysregulation generally presents as an intermittent phenomenon. At this juncture, the study of childhood bipolar illness would benefit from a developmental psychopathology perspective to move beyond the level of cross-sectional symptom description to begin to study individuals over time, focusing on developmental, environmental, genetic, and neurobiological influences on manifest behavior.