the complexities of co-morbidities
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The complexities of co-morbidities. Professor Maurice Place [email protected]. Copies of this Presentation can be found at: www.tinyurl.com/7hc2se. Disclosure: Currently member of the speakers panel of AstraZeneca, - PowerPoint PPT PresentationTRANSCRIPT
The complexities of co-morbidities
Professor Maurice Place
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)
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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
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Guess what Guess what
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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
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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
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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
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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
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Depression
Mania an extreme sense of well-being, energy and optimismaffecting thinking and judgmentbelieve strange thingsmake bad decisionsbehave in embarrassing, harmful ways
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bipolar disorder is controversial in childhood
Follow-up studies no significant increase in risk (Fischer et al 2002; Weiss & Hechtman, 2009).
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Diagnostic Challenge Diagnostic Challenge
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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
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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
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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).
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10% to 40% in children with ADHD (Tannock, 2000; Barkley, 2006).
Anxiety Anxiety
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Guess what Guess what
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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)
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2% of population
No gender predominance men and women equally
NOT drinking and gambling (or ? sexual)
compulsions in OCD never give pleasure – unpleasant burden.
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marked elevation in risk for children with ADHD -
prevalence up to 48%
(Comings, 2000).
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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)
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Diagnostic Challenge Diagnostic Challenge
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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
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0
2
4
6
8
10
12
6 7 8 9 10 11 12 13 14 15 16Moffitt 1993
Age of onset
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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)
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45% of childhood conduct disorder continue
into adulthood (Robins 1966)
Disruptive Conduct Disorders
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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).
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Into adulthood
30 - 50% of the prison population30 - 50% of the prison population ((Eyestone & Howell 1994; Retz et al 2004; Rosler et al 2004)
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Guess what Guess what
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Substance Misuse Substance Misuse
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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)
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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).
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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
Copies of this Presentation can be found at:Copies of this Presentation can be found at:
www.tinyurl.com/7hc2sewww.tinyurl.com/7hc2se