Elsevier

Comprehensive Psychiatry

Volume 52, Issue 6, November–December 2011, Pages 644-649
Comprehensive Psychiatry

Is there a relationship between attention deficit/hyperactivity disorder and manic symptoms among children with mental retardation of unknown etiology?

https://doi.org/10.1016/j.comppsych.2010.11.007Get rights and content

Abstract

Mental retardation (MR) is common and lifelong. In children and adolescents with MR, the rate of attention deficit/hyperactivity disorder (ADHD) and bipolar disorder is higher than that in the general population. However, there are no previous sufficient data that exist in establishing a relationship between ADHD and manic symptoms. The aim of the present study was to examine the relationship between manic symptoms and ADHD as well as oppositional-defiant disorder (ODD) and conduct disorder (CD) in children with MR of unknown etiology (MR-UE).

A total of 167 children with MR-UE attending a rehabilitation and training school in Erzurum, Turkey, were included in the study. We administered the Child Disruptive Behavior Screening and Rating Scale related to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and the Young Mania Rating Scale–Parent Version (P-YMRS) to parents.

The age range of children and adolescents with MR-UE was between 5 and 21 years, with a mean age of 11.13 ± 3.75 years. In total, 5.8% of children and adolescents with MR-UE showed a border intelligence quotient (IQ), with 58.4% having a mild IQ, 29.2% having a moderate IQ, and 6.6% having severe IQ. According to the Child Disruptive Behavior Screening and Rating Scale related to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 40.1% of children and adolescents with MR-UE had inattention, 19.9% had hyperactivity, 28.7% had ODD, and 13.3% had CD.

A total of 7.2% of the children and adolescents with MR-UE had probable mania, and 1.8% had mania according to Young Mania Rating Scale–Parent Version. A positive correlation existed between the mean scores of Young Mania Rating Scale–Parent Version and the mean scores of inattention, hyperactivity, ODD, and CD (P = .000). Hyperactivity and ODD were predictors of being manic/probably manic.

Diagnosing psychiatric disorders in children and adolescents with MR-UE is difficult but essential for better functioning. Manic symptoms and disruptive behaviors as well as ADHD symptoms were prevalent among children and adolescents with MR-UE and hyperactivity, and oppositional-defiant symptoms were predictors of manic symptoms in these patients.

Introduction

Mental retardation (MR) is characterized by subnormal intellectual functioning, commensurate deficits in adaptive functioning, and onset before 18 years. Levels of MR are classified as border, mild, moderate, severe, and profound. Historically, researchers have used 2 broad categories to classify persons with MR. One group has an organic cause of MR and consists of people with known prenatal, perinatal, and postnatal insults. Estimates suggest that one half of people with MR have a known etiology such as asphyxia or hypoxia, metabolic disorders, chromosomal anomalies/disorders, tuberosclerosis, neurofibromatosis, infections, toxins, and others. The second group has no clearly identifiable organic cause, and this group is postulated to account for most persons with mild MR [1].

Several well-constructed community-based population studies suggest that 35% to 40% of children and adolescents with MR are likely to have a diagnosable psychiatric disorder [2]. In children with MR, the rates of attention deficit hyperactivity disorder and bipolar disorder were found to be higher than the general population [3].

Attention deficit/hyperactivity disorder (ADHD) is characterized by severe, persistent, and early-appearing symptoms of inattention, hyperactivity, and impulsivity [4]. Attention deficit/hyperactivity disorder has a high rate of comorbid psychiatric disorders. Half of clinical samples have oppositional-defiant disorder (ODD) or conduct disorder (CD), 25% to 30% have anxiety disorder, and 20% to 25% have a learning disorder [5], [6]. Conduct disorder and ODD are known as disruptive behavioral disorders (DBDs). Conduct disorder constitutes a constellation of antisocial and aggressive behaviors that may become prominent in early childhood and persist through adolescence even into adulthood, and oppositional disorder is characterized with persistent patterns of resistant and negativistic behavior in children [7]. There is also increased risk for mood disorders (which may develop later). Comorbidity can introduce some diagnostic challenges because the comorbid disorders can mimic ADHD, with overlapping symptoms, so the diagnostician must differentiate between comorbidity and primary diagnosis. The most diagnostically challenging and controversial disorders co-occurring with ADHD is bipolar disorder (BPD). When these occur in combination, they complicate the assessment process, clinical diagnosis, and treatment [8]. Elevation, grandiosity, racing thoughts, decreased need for sleep, and hypersexuality are common in bipolar disorder and can discriminate BPD from ADHD [9], [10]. Both of these mental disorders affect thinking, mood, and/or behavior and are associated with distress and/or impaired functioning in children and adolescents with MR.

Mental retardation is common and lifelong. Children and adolescents with MR have more functional impairment when they are dually diagnosed. In recent years, children and adolescents with MR have often been diagnosed with ADHD and occasionally with bipolar disorder, but the relationship between ADHD and manic symptoms remains unclear. Patients with MR have limitations in verbal ability, and with increasing levels of disability, they may show atypical clinical presentations that overshadow manic or hypomanic episodes of bipolar disorders.

In the present study, we investigated ADHD as well as ODD and CD in an effort to examine the relationship between ADHD and manic symptoms in children with MR-UE.

Section snippets

Methods

This study was carried out in a rehabilitation and training school in Erzurum, Turkey, that comprised a total of 305 children and adolescents having different kinds of disabilities. Only 167 children and adolescents aged 5 to 21 years with MR-UE were included in the study. Participants younger than 5 years and having cerebral palsy, deafness, blindness, and other known etiology of MR were excluded from the study to avoid possible confounding effects. Parents were interviewed by the researchers,

Results

A total of 167 children and adolescents with MR-UE were assessed in this study. All the informants were mothers, and the participation ratio was 95%. Of these, 55 (32.9%) were girls and 112 (67.1%) were boys, and their mean age was 11.13 ± 3.75 years. We grouped MR as border, mild, moderate, and severe based on clinical assessment according to DSM-IV and intelligence tests done by a professional psychologist (Stanford Binet Intelligence test). In total, 8 (5.8%) children with MR-UE had border

Discussion

Children and adolescents with MR are at significantly increased risk for certain forms of psychiatric disorders. In the present study, we assessed children with MR-UE using P-YMRS and T-DSM-IV-S. Estimates of bipolar disorder in the intellectually disabled population range from 0.9% to 4.8%, thus exceeding rates in the general population [3]. The prevalence of mania among MR adult cases reportedly varies between 0% and 8% [1]. In the present study, among children with MR-UE, we found the rate

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