ADHD & Mania: Distinctions, Evolution & Executive Functions

• I need help on a paper, is anyone able to give me suggestion about linking ADHD, conduct disorder and antisocial personality? jholsinf@mato.com by (No author), 3/17/97
  
  

Mania and ADHD: Benefits of Acknowledging the Elephant (1)

Gabrielle Carlson (1997) commented that when the same child is reviewed, Paul Wender sees emotionally labile ADHD, Joseph Biederman bipolar disorder, and a third from NIMH "multiply dimensionally impaired." As in her essay, the "elephant" can be a creature examined by different, blindfolded experts. "Elephant" also applies to a large animal in the middle of the room that people in the room do not discuss with each other. This latter danger occurs whenever parallel specialities - that for bipolar disorder and that for ADHD - evolve. It seems more likely given that information about bipolar children derived from adult treatment and research; ADHD research started with children and has included adults only within the past decade.

My setting is a rural evolving into suburban practice. Thus, I see a lot of things in moderate severity and in small volumes but I've pondered for several years the possible distinctions between ADHD and mania.

In most aspects of diagnosis and treatment the word "maybe" applies as do the words "mild, moderate, or severe." Within that context, I offer the following:

1) The diagnosis of ADHD could change so there is clearer distinction when compared with mania. Barkley (1996) has built a coherent model that focuses more on deficits in neuropsychological Executive Functions (EFs) than on the traditional external one of fidgeting and calling out in class. EFs are behaviors that control other behaviors and include memory formation and retrieval, planning and implementing plans, emotional regulation (inhibition, dissociation from motor sequences and kindling), and the skills of analyzing events into component parts as well as assembling those components into more useful sequences. There are accompanying deficits in the child's sense of time as well as his sense of himself. Barkley's contribution is substantial given the ambiguous meaning of ADHD/mania signs such as talkativeness, interrupting, fidgeting and restlessness, and distractibility. It also lets us focus on the more significant impairments of ADHD; I don't care if the child fidgets, I do care if he doesn't know on Wednesday the family plans for Saturday. I do care if he repeatedly makes the same mistake in his conduct with other people because he's not analyzing events, developing a plan, and implementing it.

2) I belong to the group that sees things in patterns and percentages of differing severities. "Subclinical mania" is a useful construct when understanding the behavior of some children and explaining it to their families. Gardner's (1982) evolutionary concept of dominance seems particularly useful for describing the essentials of mania and allows us to detach somewhat from externals of energy level, distractibility, and talkativeness. Excessive concern with winning is perhaps a workable clue. "Excessive" can be measured by disproportionate emotionality and power struggles with authority (as well as by cheating and lying in order to win), access to resources (friends, the phone, the car keys), and demands for special treatment (slacker curfews, being excused from routine assignments, getting expensive toys and clothing) Cantwell (1996) mentioned that hypersexuality can be expected with manic children; thus, constantly having a girl or boyfriend is less surprising in some 3rd graders.

3) Mood shifts can also occur in varying intensities and be elicited by social events, changes in sleep patterns (the child who's up late on Friday night may still be irritable on Monday morning), and gains or losses in material resources.

There are several implications from these shifts in definition.

1) Family impact can be severe with either disorder; parents can be infuriated when their child displays both. "He remembers his friend's phone numbers and his party schedule but not his math assignment." Identifying similar determination and manipulativeness in parents or grandparents usually removes some of the emotionality and blaming that occurs.

2) Just as ADHD children seem to require shorter tasks and more frequent reinforcement or changes in reinforcers, manic children may well lock in on delayed goals when they cannot manipulate more rapid success. Manic children should respond better to goals that involve their achieving something outrageous. Finding a special talent and helping them to be the "first girl wrestler" or the best debater could relieve a lot of aggravation more thoroughly than medications and in ways more acceptable to parents.

3) Parents of manic children might be reminded that mania is often associated with higher intelligence, somewhat greater creativity, and greater economic success whereas ADHD often has a negative impact on I.Q., an impairment in creativity, and a reduction in longterm economic achievement. Neither child will always be fun to have around; one because she is trying to take over, the other because of social immaturity.

4) ADHD children may require one type of intervention with schools, children with mania another. Reminders, seating nearer the teacher, shorter tasks seem good things to do with ADHD children. Having a few, more-consistent-than-gravity rules is likely helpful with highly determined children. There will be times when parental siding with their child has destructive longterm outcomes. Manic children may need to learn earlier that managing their teacher is their own responsibility and to the extent the child ignores family standards for honesty and respect, he sacrifices their protection.

5) Medication becomes an array of options, with the possibility of adjusting strategies as the child matures. I suspect there are many children with manic traits who are considerably less irritable and less domineering for several hours after they take a stimulant. Parents might also be less surprised at the negative moods that occur as stimulants leave the child's bloodstream. They can also view sleep disruption that sometimes accompanies stimulants as an aspect of mania rather than ADHD and a problem they would periodically encounter even if stimulants were not used. Stimulants may leave some major problems unresolved in some children, particularly as they get older but mood stabilizers, antidepressants, alpha2-adrenergic agonists, or neuroleptics can still be considered in combination with psychotherapy and behavioral programs.

This model helps me understand more the child who has many difficulties with sustained attention but his mind remembers, kindles emotional displays, plans, and shows considerable creativity in getting his way. It expecially helps when that same child has parents and grandparents with similar willfulness.

NOTE & REFERENCES:

1) This essay was also sent to "Child & Adolescent Psychopharmacology News."

Barkley R (1996) Attention deficit/hyperactivity disorder. In Mash E & Barkley (eds), Child Psychopathology, NY: Guilford

Carlson G (1997) Mania and ADHD, "Child & Adolescent Psychopharmacology News," 2(4), pp 9-10. Gardner R (1982) Mechanisms in manic depressive disorder: An evolutionary model. "Archives of General Psychiatry," 39, 1436-1441.

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