The complexities of co-morbidities

1. The complexities of co-morbidities Professor Maurice Place maurice.place@northumbria.ac.uk Copies of this Presentation can be found at: www.tinyurl.com/7hc2se

2. Disclosure: Currently member of the speakers panel of AstraZeneca, Eli Lilly, Janssen Cilag, and previously UCB Pharma

3. 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, developemotional 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)

4. Depression 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

5. Guess what

7. Bipolar Disorder Previously known as ‘manic depression’ feelings of intense depression and despair AND periods with high or 'manic' feelings of extreme happiness About 1 in every 100 usually starts around teenage unusual to start after 40. Equal gender ratio. 

8. Type I has 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 II Mostly severe depression only mild manic episodes Rapid cycling

9. Type I has 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 II Mostly severe depression only mild manic episodes Rapid cycling

10. Type I has 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 II Mostly severe depression only mild manic episodes Rapid cycling

11. Depression  Mania an extreme sense of well-being, energy and optimism affecting thinking and judgment believe strange things make bad decisions behave in embarrassing, harmful ways

12. bipolar disorder is controversial in childhood Follow-up studies no significant increase in risk (Fischer et al 2002; Weiss & Hechtman, 2009).

13. Diagnostic Challenge

15. Pervasive Developmental Disorder 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

16. and various behavioural difficulties – repetitive and obsessive about activities stereotyped movements resistance to change in routines unusual responses to sensory experiences

17. 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 inconcepts and diagnostic boundaries rather than by any real substantialincrease (Fombonne, 2003) Autistic traits may be 140 per 10,000 boys and 30 per 10,000 girls (Constantino & Todd, 2003).

18. Traditional belief – at least 75% of autistic children have significant learning disability

19. 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)

20. 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)

21. ……and we found 8% of our ADHD clinic Have PDD symptoms emerging after treatment

23. 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).

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

25. Guess what

27. Obsessional Compulsive Disorder (OCD) Obsession Intrusive and repetitive thoughts - usually recognised as excessive, irrational and/or inappropriate Compulsion Repetitive behaviours or mental acts that the person feels driven to perform

28. 2% of population No gender predominance men and women equally NOT drinking and gambling  (or ? sexual) compulsions in OCD never give pleasure – unpleasant burden.

29. marked elevation in risk for children with ADHD - prevalence up to 48% (Comings, 2000).

30. Guess what

33. “when things went wrong it was like OK this just happened, I have to go hack a piece of my flesh off” “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” “as a teenager I used to burn myself…I was in a lot of emotional pain”

34. Cutting has been viewed as DSH within surveys 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.

35. Cutting has been viewed as DSH within surveys 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)

36. Diagnostic Challenge

38. 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 emerges in adolescence

39. Age of onset Moffitt 1993

40. 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)

41. 45% of childhood conduct disorder continue into adulthood (Robins 1966) Disruptive Conduct Disorders

42. 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).

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

44. Guess what

46. Substance Misuse

47. 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)

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

49. Associated Impairments 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)

50. Medication gives higher scores on neuropsychological measures of attention but differences not found for other measures of executive function. (Biederman et al 2008) SOmedication helps with concentration aspect but not the more central aspects of functioning… especially working memory