Is there a relationship between attention deficit/hyperactivity disorder and manic symptoms among children with mental retardation of unknown etiology?
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
References (21)
- et al.
Does multimodal treatment of ADHD decrease other diagnoses?
Clin Neurosci Res
(2005) - et al.
Heterogeneity of irritability in attention deficit/hyperactivity disorder subjects with and without mood disorders
Biol Psychiatry
(2005) - et al.
Pediatric bipolar disorder: a review of the past 10 years
J Am Acad Child Adolesc Psychiatry
(2005) - et al.
Discriminative validity of a parent version of the young mania rating scale
J Am Acad Child Adolesc Psychiatry
(2002) - et al.
Psychiatric disorders and behavior problems in people with intellectual disability
Res Dev Disabil
(2008) - et al.
Mental retardation
- et al.
Mental health of children and adolescents with intellectual disabilities
Br J Psychiatry
(2007) - et al.
What symptoms predict the diagnosis of mania in persons with severe/profound intellectual disability in clinical practice?
J Intellect Disabil Res
(2007) - et al.
Attention-deficit/hyperactivity disorder
A 14-Month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder
Arch Gen Psychiatry
(1999)
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Attention-deficit hyperactivity disorder, its pharmacotherapy, and the risk of developing bipolar disorder: A nationwide population-based study in Taiwan
2016, Journal of Psychiatric ResearchCitation Excerpt :In addition to ODD or CD, high rates of comorbid BD were commonly observed in patients with neurodevelopmental disorders. For example, one researcher (Fidan et al., 2011) reported that ADHD and BD rates are higher among children and adolescents with intellectual disabilities than the general population. Furthermore, a clinically significant minority of adolescents with BD also suffers from comorbid ASD (Joshi et al., 2013; Vannucchi et al., 2014), tic disorders (Robertson, 2006) and anxiety disorders (Vazquez et al., 2014).
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