The complexities of co-morbidities

The complexities of co-morbidities

Professor Maurice Place

maurice.place@northumbria.ac.uk

Copies of this Presentation can be found at:Copies of this Presentation can be found at:

www.tinyurl.com/7hc2sewww.tinyurl.com/7hc2se

Hartlepool CAMHS

Disclosure:Disclosure:

Currently member of the speakers panel of Currently member of the speakers panel of AstraZeneca,AstraZeneca,

Eli Lilly, Janssen Cilag, and previously UCB PharmaEli Lilly, Janssen Cilag, and previously UCB Pharma

ADHD affects children and adolescents in different ways and degrees but the consequences of severe ADHD can be serious both for the individual and family

Children with severe ADHD often have low self esteem, develop emotional and social problems, and frequently underachieve at school

ADHD may persist into adolescence and adulthood and is often associated with continuing emotional and social

problems, substance misuse, unemployment and involvement

in crime (NICE

2009)

Hartlepool CAMHS

major depression or dysthymia 20 - 30% (Fischer et al. 2002; Barkley et al 2008)

link between ADHD and depression mediated by Conduct Disorder (Angold et al 1999).

n/retardation

fatigue

feeling worthless

poor concentration

Depression

Hartlepool CAMHS

Guess what Guess what

Hartlepool CAMHS

Previously known as ‘manic depression’

feelings of intense depression and despairAND periods with high or 'manic' feelings of extreme happiness

About 1 in every 100 usually starts around teenageunusual to start after 40. Equal gender ratio. 

Bipolar DisorderBipolar Disorder

Hartlepool CAMHS

Type Ihas been a manic episode, which has lasted for longer than one week.Some people may only have manic episodes Untreated - mania lasts 3 - 6 months. depression last 6 -12 mths.Type IIMostly severe depression only mild manic episodes Rapid cycling

Hartlepool CAMHS

Type Ihas been a manic episode, which has lasted for longer than one week.Some people may only have manic episodes Untreated - mania lasts 3 - 6 months. depression last 6 -12 mths.Type IIMostly severe depression only mild manic episodes Rapid cycling

Hartlepool CAMHS

Type Ihas been a manic episode, which has lasted for longer than one week.Some people may only have manic episodes Untreated - mania lasts 3 - 6 months. depression last 6 -12 mths.Type IIMostly severe depression only mild manic episodes Rapid cycling

Hartlepool CAMHS

Depression  

Mania an extreme sense of well-being, energy and optimismaffecting thinking and judgmentbelieve strange thingsmake bad decisionsbehave in embarrassing, harmful ways 

Hartlepool CAMHS

bipolar disorder is controversial in childhood

Follow-up studies no significant increase in risk (Fischer et al 2002; Weiss & Hechtman, 2009).

Hartlepool CAMHS

Diagnostic Challenge Diagnostic Challenge

Hartlepool CAMHS

a developmental disability

usually evident by age three

they are neurological disorders that affect

the ability to communicate

understand language

demonstrate imaginative play

relate to others

Pervasive Developmental DisorderPervasive Developmental Disorder

Hartlepool CAMHS

and various behavioural difficulties –

repetitive and obsessive about activities

stereotyped movements

resistance to change in routines

unusual responses to sensory experiences

Traditionally - 4 per 10,000 for autism spectrum disorders

More recently - 30 - 60 per 10,000

(Chakrabarti & Fombonne, 2001; Yeargin-Allsopp et al 2003).

Difference explained by change in concepts and diagnostic

boundaries rather than by any real substantial increase

(Fombonne, 2003)

Autistic traits may be 140 per 10,000 boys

and 30 per 10,000 girls

(Constantino & Todd, 2003).

Traditional belief –

at least 75% of autistic children have

significant learning disability

BUT INCREASINGLY FINDING

- at least 75% have IQs in the normal range

(MRC, 2001).

- no clear distinction from specific

language disorders (Bishop & Norbury, 2002; Howlin et al.,2000)

ASD core features present in ADHD

1) Lack of awareness of the feelings of others (Nijmeijer et al 2008)

Poor social skills (Mikami, 2010)

Reduced empathy (Gillberg, 2007)

2) Language delay (Hagberg et al 2010)

Pragmatic language difficulties (Geurts et al 2010)

3) Stereotypic behaviour (Hartley & Sikora, 2009; Santosh & Mijovic, 2004)

Sensory over-responsivity (Ghanizadeh, 2008)

……and we found 8% of our ADHD clinic

Have PDD symptoms emerging after treatment

Hartlepool CAMHS

Gilles de la Tourette Syndrome Gilles de la Tourette Syndrome Probably caused by abnormal functioning

in the dopamine system

0.4% of the population (Peterson et al 2001).

Up to 12% in ADHD clinic sample (Spencer et al 2001).

Hartlepool CAMHS

10% to 40% in children with ADHD (Tannock, 2000; Barkley, 2006).

Anxiety Anxiety

Hartlepool CAMHS

Guess what Guess what

Hartlepool CAMHS

Obsession Intrusive and repetitive thoughts - usually recognised as excessive, irrational and/or inappropriate

CompulsionRepetitive behaviours or mental acts that the person feels driven to perform

Obsessional Compulsive Disorder (OCD)Obsessional Compulsive Disorder (OCD)

Hartlepool CAMHS

 2% of population

No gender predominance men and women equally

NOT drinking and gambling  (or ? sexual)

compulsions in OCD never give pleasure – unpleasant burden.

Hartlepool CAMHS

marked elevation in risk for children with ADHD -

prevalence up to 48%

(Comings, 2000).

Hartlepool CAMHS

Guess what Guess what

“I made one cut for every day that I’d been

injured….with each one I felt that I was

punishing myself, but at the same time, I felt

relief”

“when things went wrong it was like OK

this just happened, I have to go

hack a piece of my flesh off”

“as a teenager I used to burn myself…I was

in a lot of emotional

pain”

Cutting has been viewed as DSH within surveysCutting has been viewed as DSH within surveys

BUT the nature and aetiology makes it distinct BUT the nature and aetiology makes it distinct

Clinically predominantly girls

cut their bodies, often their arms,

as a way of coping with perceived life stresses

This cutting is rarely life threatening,

and often seems to be secretive in nature.

Cutting has been viewed as DSH within surveysCutting has been viewed as DSH within surveys

BUT the nature and aetiology makes it distinct BUT the nature and aetiology makes it distinct

Clinically predominantly girls

cut their bodies, often their arms,

as a way of coping with perceived life stresses

This cutting is rarely life threatening,

and often seems to be secretive in nature.

probably increased risk in ADHD (Izutsu et al 2006)

Hartlepool CAMHS

Diagnostic Challenge Diagnostic Challenge

Hartlepool CAMHS

Conduct Disorder Conduct Disorder Oppositional Defiance elements with -

aggression towards others

destruction of property theft and deceit

If emerge in early years then a distinctly different group from those where emergesin adolescence

Hartlepool CAMHS

0

2

4

6

8

10

12

6 7 8 9 10 11 12 13 14 15 16Moffitt 1993

Age of onset

Hartlepool CAMHS

Severe conduct disorder associated with drug misuse, criminality, affective illness and youth suicide (Loeber et al., 2000)

If emerge in early years then a strong link with development of antisocial personality disorder (Frick, 1998)

 Rates of conduct disorder (adolescent emergence) are increasing quite dramatically (Loeber & Farrington, 1998)

Hartlepool CAMHS

45% of childhood conduct disorder continue

into adulthood (Robins 1966)

Disruptive Conduct Disorders

Hartlepool CAMHS

ODD - x10 more common than general population (Angold et al 1999).

54% - 67% meeting criteria for ODD by 7 yrs age (Loeber et al 2000).

CD with ADHD 20 - 50% in children 44 - 50% in adolescence with ADHD (Barkley, 1998; Waschbusch, 2002).

Hartlepool CAMHS

Into adulthood

30 - 50% of the prison population30 - 50% of the prison population ((Eyestone & Howell 1994; Retz et al 2004; Rosler et al 2004)

Hartlepool CAMHS

Guess what Guess what

Hartlepool CAMHS

Substance Misuse Substance Misuse

Hartlepool CAMHS

risk greater if there is Conduct Disorder (Burke et al 2001; Loeber, & Stouthamer-Loeber 2009)

risk for SUDs 12-24% (Rasmussen & Gillberg 2001; Fischer et al 2002).

stimulant medication has protective effect (Barkley et al 2002; Loney et al 2009)

Hartlepool CAMHS

Into adulthood

ADHD affects between 11 and 35% of "substance-abusing" adults (Kalbag & Levin 2005)

ADHD symptom severity is associated with

magnitude of impairment in executive functions

BUT this relationship can be obscured by the

presence of comorbid disruptive disorders.

(Barnett et al 2009)

Associated Impairments

Medication gives higher scores on neuropsychological measures of attention

but differences not found for other measures

of executive function. (Biederman et al 2008)

SO medication helps with concentration aspect

but not the more central aspects of

functioning… especially working memory

Short-term memoryShort-term memory is the term for

short-term storage of information

with no manipulation or

organizational element

Working memoryWorking memory is

the structures and processes

used for temporarily storing

and manipulating informationmanipulating information.

Professionals use working memory for…

– Getting to work on time

– Meeting deadlines at work

– Multi-tasking and prioritizing

– Working effectively in pressure situations

– Remembering important names and phone numbers

– Interaction with co-workers

– Writing emails, memos, or summaries

Indicators that a working memory needs improving

• Frequently late to work

• Underestimates time required to complete a task

• Problems breaking a project down into manageable

steps or dealing with more than one task at a time

• Can’t concentrate under pressure; prone to panicking

• Can’t remember clients’ names or numbers after

meeting them or hanging up the phone

• Difficulty creating neat and coherent emails,

memos, or summaries

Associated Impairments

Many of these cognitive difficulties appear to be specific to ADHD (Murphy et al 2001 ;Barkley et al 2008).

Hartlepool CAMHS

mothers with ADHD

* poorer at monitoring child behaviour

* less consistent disciplinarians

* less effective at problem solving about

childrearing issues (child oppositional and conduct-disordered

behaviour were controlled for) (Murray & Johnston, 2006)

…and in case you were wondering

QUESTIONSQUESTIONS??

The complexities of co-morbidities

Professor Maurice Place

maurice.place@northumbria.ac.uk

Copies of this Presentation can be found at:Copies of this Presentation can be found at:

www.tinyurl.com/7hc2sewww.tinyurl.com/7hc2se