View Full Version : ADHD and Mood disorder not otherwise specified


2puzzledparents
05-10-09, 12:01 PM
Have been getting this response ALOT from the docs dx'ing and evalutating our son, Brendan. The wife and I a fairly certain that he may have frontal lobe subtype but cannot get the docs to see this.

Where in these forums can I find a discription of adhd subtypes and could somone point us to more interwebs info? Google keyword are fine , too.

kattsqueen
05-10-09, 02:38 PM
frontal lobe subtype? I havent heard of that. Is that a type of add/adhd?

I thought all add was related to a slower working frontal lobe and thats part of the reason why stimulants help speed up processing or is this old school stuff?

Im sorry no one has answered your inquiry yet have you checked out the main forum page to see if there is a forum that migt be more helpfull to you? wish I could offer more information to you..

katts

2puzzledparents
05-10-09, 02:54 PM
thaks anyway, Katt.. Have been lurking about these forums a while learning all we can..

We discussed prefrontal type with both his normal doctor and the docs at the behavioral center. The 'read' wife and I got from the professionsals was the usual "what do they know". Not directly, of course, but more through bodylanguage and what they didn't say

2puzzledparents
05-10-09, 03:08 PM
I REMBERED!

Not frontal lobe.. Temporal lobe! DUH! Not adhd myself.. just occasional bouts of CRS ( cant rember stuff) LOL

Dizfriz
05-10-09, 05:49 PM
Just for information, these are the diagnostic categories for ADHD from The DSM (the diagnostic manual). This will change in the next edition but for now it is what we have.

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type.

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type:

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

314.9 Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified
This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.

There are currently no other types of ADHD-period.

Some have been proposed for the next DSM but we shall have to wait and see what comes out.

Hope this is of some help.

Dizfriz

2puzzledparents
05-10-09, 06:44 PM
I think I may have been unclear on what the doc had said.. ADHD with (?comorbid?) a mood disorder not otherwise specified. Ummm.. as a self described 'information addict' I have recreationally read through the DSM-4 in the past ( don't have access to one since I have married and inhereted two stepsons) and , to be honest, don't like the phrase "not otherwise specified". IS the mental health equivilant of throwing up thier hands and saying "We're stumped"

Just becasue it isn't "otherwised specified" in the DSM doesn't necessarily mean it doesn't exist.

Perhaps I should have used "Temporal type ADHD" as reconized by Dr. Amen's books ""Healing ADHD:The Breakthrough Program That Allows You to See and Heal the 6 Types of ADD"

better?? :P

And that would explain the blank looks of the psych facility's doc gave. LOL Forgot that mental health professionals seldom look beyond the DSM 'bible' for new ideas on diagnosis and treatment.

mctavish23
05-10-09, 09:02 PM
The DSM-IV TR diagnoses are empirically supported.

For ADHD, 6 of 9 symptoms translates to separated from random chance 93x's / 100.

There are definite shortcomings that will be addressed in the DSM-V,including the need

for age & gender referencing.

IMO, you can also (probably) expect Inattentive Type to be replaced by some reference

to Working Memory, while Hyperactive-Impulsive Type would look something like

Disinhibited Type or Behavioral Inhibition.

That's obviously a guess on my part, but I do expect it to be something along those

lines.

As I've posted before,there's an empirically supported "One WayComobidity" between

Bipolar Disorder and ADHD ( i.e., over 90% ( 94-97%) of children /adolescents with

(Pediatric) Bipolar Disorder also have ADHD, while the opposite isn't true).

(My references are Barbara Gellar's work from 2002-2003).

There are 5 empicially supported characteristics found to differentiate between the 2

groups.

I've posted on those a number of times, as well.

The bottom line is that when I suspect the possibilty of (Pediatric) Bipolar Disorder

in a child/adolescent, in which there's a strongly documented family history of BPD,

and who have some or all of the 5 characteristics, I look at 296.90 Mood Disorder

NOS.

I almost always use that diagnosis, as it helps account for the above stated symptoms,

while allowing for the possibility of late onset BPD.

In some cases, the diagnosis of (Pediatric) Bipolar Disorder is self-evident.

Either way, the comorbidity of ADHD will be a given.

Dr. Amen's nomenclature is used ONLY by him (and his grad students).

Consequently, it is misleading.

I hope this helps.

tc

mctavish23

(Robert)

2puzzledparents
05-11-09, 01:15 AM
and I did not mean this to turn into a debate.

Amen's discriptions are so more SPECIFIC than the DSM discriptions, and from what I have learned over the past six months ( and especially last few weeks ) is that each and every case of add/hd is unique and that each and every child also has the potential for different combinations and/or degree of comorbidities and the more refined the discriptions, the more precisely targeted the treatments.

I also am fully aware of the difficulty involved in DX'ing young children due to the simple fact that their brain structures are still developing and that different regions and neural pathways are developing at different rates at different times due to genetic and enviromental factors

Besides there are always , for any scientific pursuit, medical or otherwise, people who will be wish to maintain the status quo and those who will bew refered to as "such and scuch and his/her students"
Kepler, Copurnicus, Gallelio, Jung, Freud, einstien, Darwin...I could continue. I have Google and not afraid to use it!

Now back OT, 'k? ;)

Brendan had been diagnosed from ages 4-6 with bipolar, however she was 100% convinced becasue the doc that she had been taking her to had a predisposition to diagnose bi-polar 'out of hand' ( they had been living in a communnity of less than 3000. So people discuss thier kids ALOT) and was Rx'd tenex and risperdol (wife knows dosages, Me I suffer CRS ( can't rember squat))

As I may have mentioned earlier, My wife's previous marriage was very very abusive.. lots of verbal and physical fights as well as very controling on the ex's part. (yep PTSD is VERY likely) She decided it was time to leave and about a year later , she and I were settled enough to take custody of Brendan and his older brother, Stephen(planning to have him evaluated later).

Brendan's Rx's were running out and we could NOT get his treating doc to renew the prescriptions. Something to do about us having moved nearly 2 hours away and, of course , without meds Brendan began to 'meltdown'

the Wife and I were concerned and frightened for him, of course, and had to take him to "The Ridge" ( Ridge Behavorial Health), the only pediatric health facility within 200 miles in the hopes that they would get him back on meds.

That is when he was diagnosed ADHD with a mood disorder not otherwise specified ( did I mention how much I dislike that phrase) and was dosed with aderral xr and risperadol. And things were good.. until the hypervigelance and violence (please pardon my spelling.. is midnight local time and my cognative isn't cognating very well LOL) started showing its ugly head. Brendan started taking the mindset that other kids were trying to hurt him or wanted to hurt him and all it took was an innocent look from another kid for him to 'go off'.

Many Many times, while playing, he would come in and make very serious claims that another child ( sibling, neighborhood kid) tried to run him over with their bikes when they were riding by several FEET away from hime ( Wife and I both have observed these incidents.. we keep tight eyes on our children when they are out playing)

The kicker of it is, that every single time he has these incidents, he wholeheartedly denies and denies and denies. First we figgured he was just trying to keep out of trouble by lying ( breaking the single BIGGEST) rule in our house. So we would lecture him on not only the attacks but on the bigger issue of lying and give him timeouts and groundings and all we would get back from him was that he was in trouble for no reason!

A month of this and we decided to take him to the local counciling center for further evaluation and treatment. This is when we met the most wonderful Dr. Douglas.

After a couple sessions with him, he refined Brendan's DX as adhd impulsive with that 'not specified' mood disorder. And changed the Rx's to 20mg Vyvance once a day and risperadol 1mg 2x daily.

A month later, Brendan was still (on good days) being a heavily ADHD impulsive sort without assaulting other children and on bad days still laying hands on others then melting down when the school staff sends him to the 'reflection room' to think about why what he did was wrong.

Poor Brendan honestly thinks he is right to do what he does because in his mind it seems that what he imagined the other child was 'going to do' actually happened and that it is totally and completely unfair (wife and I agree that both boys are overly sensitive to fairness by thier father) that he was getting punished and the other child gets away scott free.

Niether we nor our doctor had considered 'amphetamine rage' or is that more correctly 'amphetamine psychosis'? at this point so we upped the Vyvance to 40mg 1x thinking that these outbreaks were simply insuffeciently dampened impulsivity. Nope.. got a little worse.. Teacher and principal were starting to crack under the strain..Other students verging on edge of stampeding.. So we tried 50mg.. that is when all heck started breaking loose...

in the space of a week, we recieved 4 personal calls from the school from a very distraught principle who, bless her heart, is really really trying to help him out. New IEP was being drawn up, they started giving him even more one-on-one.. really trying.

this is when Dr. Douglass and ourselves made the connection between his aphetamine based treatments and his rages and dropped the dose to 40mg on untill we could follow another course of action.

Brendan had punched a boy in PE class because he said the other kids egged him on to do it, he tried to choke another boy just because the other boy's pencil looked like it was rolling towards brendan's study space.. ect.

(I know this is a long post but I am on a roll, please bear with me)

This leads us to last Wensday.. Brendan had a massive meltdown that started with slapping a girl because he had thought was accusing him of cutting line. ( we talked to the girl later and she honestly told us that she never even spoke to him) . Bren was 'escorted with difficulty' to the focus room and was instructed to write an apology to the girl he had hit. What he wrote was "I apologize for NOTHING!" in huge bold (yet very neat) letters followed by a chair throwing, head butting rage that required 4 staff members to constrain him enough to get him into the 'quiet room' to calm down.

He finally calmed down ( 2 hrs later) and was let out of QR and finally worte that apology.

That night we had to admit him back into The Ridge for further evaluation and , fortunatly, the Doc there agreed that stims were NOT a good idea and have started him on Straterra. Today he has choked two different children on two different occasions ( the last and worst being just after an anger management session ( poetic, huh?) but we are waiting to see how the Straterra works.

BTW he has an uncle on his mother's side that is paranoid schitzophrenic and ( I know it may just be concidal) they look enough to be twins, even down to a shared skin disorder that no one else in family has)

So from talking with Bren's Primary and , of course , lurking about these forums and wearing our google toolbar to a virtual nub, we now know that Brendan DOES have impulsive ADHD, not yet offical PTSD possible ODD and a very high chance of schitzophrenia that hasn't blossomed yet. We know that stim treatments are completely out of the question.

I can now take questions: You there , third row! (LOL)

Dizfriz
05-11-09, 08:17 AM
2puzzledparents

Good and very interesting post.

I wish I had time to address this more but have to stay with just a few points.

First, I encourage you to keep on working to get this child the help he needs. I truly believe one of the best tools is a caregiver who keeps pushing professionals to find out what is going on with the child. Some of the most impressive results I have personally seen has stemmed from caregivers continuing to stress the feeling that something was being missed. Sometimes I have seen it take several years to finally determine the true causes of the behaviors. As you mentioned, sometimes the child has to develop more to really see the true dynamics. As an example, one cannot diagnose a reading disorder with a 2 year old.

So keep on working, asking and pushing. You are the advocate for this child and if you do not do it, then no one else will.

On a couple of less important points: accuracy of information is vital in dealing with kids with ADHD or any other disorder of this type. Inaccurate information can turn a search for help into a disaster. Both mctavish and myself tend to try to present current scientifically accurate information as a means of helping readers to understand what is going on. Not a debate but usually just a note to clarify.

On Dr Amen: the problem is that no one has replicated his work therefore those in the field have no way of knowing if his ideas have merit. He may be right or may be wrong, we simply don't know. This has greatly limited his impact. I stated in another post that I wished someone would try to replicate his work so we could better evaluate his ideas. Some of them are quite interesting.

On another issue, I have difficulty with diagnosing bipolar at "ages 4-6". We simply don't, at this time, have enough information of what characteristics in children will predict bipolar when the child becomes an adult. This is an opinion but most of the child Psychiatrists I have dealt with will not diagnose a child bipolar this young and many will use the NOS term discussed. It is a way of letting others know to be alert for mood disorders without making the more serious dx. The child is then often treated for bipolar but is not given the label. The bipolar diagnosis is serious and can stay with a person for life. In my opinion, it should not be given unless very well justified, seldom the case with young children.

On ADHD, the best advice I can give you is to read the work of Russell Barkley. He is, by far, the top person in the field. A good place to start is this transcript of a workshop by him. Some, including myself, consider it to be the best write up on ADHD available on the internet. It is dated 2000 but most of the data is still basically pretty good. I do warn however that this is forty pages long and Barkley is information dense. It can be a bit of a struggle to work though and you probably will have to read some sections several times but it is, in my opinion and the opinion of many others, very much worth the effort. I am going to suggest you start with this overview and then download or read the article from there. The transcript won't address many of the things you have going on but will help you understand ADHD.

http://www.greatschools.net/cgi-bin/showarticle/2054

On Bipolar, I suggest the book The Bipolar Child by Papolos and Papolos as a good starting point. This is pretty much the standard basic book for caregivers and professionals. It is written at a level to make it accessible to parents. They also have a website and newsletter. This might be worth your while.

Anyway, keep on pushing. It is caregivers like you that make sure that the child gets the help needed. Without that advocacy, so many fall between the cracks and otherwise what might have been productive lives are wasted. I have seen this all too often and I applaud your efforts.

Good luck. Dizfriz

2puzzledparents
05-11-09, 08:45 AM
Ahh.. much thank Dizfriz. I appreciate your support and understanding.. Do watch out, though , for I will pick your brain ( might even let it scab over a bit) and be bouncing ideas off the forums.

BTW- really like your corner.. Booked marked it specially!

Now waiting on mctavishe's reply.

2puzzledparents
05-11-09, 01:44 PM
Or at least mostly correct.
I just this minute 1313 est , finished reading Andi's thread on differentiating BP ADHD .

He has the dysphoric hyperarousal
The maternal familial history of affective disorders (schitzophrenia through maternal uncle)
Does NOT have the BP pressured speech , just inappropriatly loud.
havent seen any much in risk taking behaviour ...yet
Definatly has the bipolar erages and has expressed that raging felt good! with amnesia of majority of the attacks.
Auditory hallucinations ( he says he hears ghosts) but not visual
NMo condct disorder.. too young but postive on ODD

And the kicker --- "If a child presents with a mixed-state, rapid cycling early onset Bipolar Disorder and is misdiagnosed “severe AD/HD” and given stimulants, he may be thrown into a manic frenzy." And it has ...

Time to talk to his primary and The Ridge

thanks Dizfritz

MGDAD
05-11-09, 01:56 PM
Puzzle,

I have struggled with getting a proper diagnosis for my oldest too. In the end I have given up since I think her treatment is effective and appropriate. The purpose of a diagnosis is to help determine appropriate treatment. Besides that, the medications are given to treat the symptoms. It does not matter what the diagnosis is, even if your child was diagnosed with bipolar, there are a bunch of different medications that could be given. Beyond that there is the skill of the physician along with a bit of trial an error.

I read that book "Bipolar Child" and it is really good. OTOH, my childs physician does not like it. Oh well, the meds he prescribes for my daughter are on the list of possible meds in Bipolar Child. The book mainly says that if your child has ADHD and Bipolar, the proper med cocktail must include some sort of mood stabilizer along with the stimulant med. That is what has worked best for my daughter. Strattera does not work that well for many people. My daughter takes Vyvanse with Abilify. Abilify is a similar med to Respirdal, but seems to work better for a lot of people.

As diz says, sometimes it takes quite a bit of pushing to get the doctor to prescribe the appropriate med. Unfortunately it often takes a bit of trial and error too.

This daughter rarely admits that she does anything wrong either. Lectures especially dont work, time outs dont work either. I did recently read a book recommended by someone on this site, and the authors punishment ideas work pretty well. "Dont Yell with Your Mouth Full" by Cary Chugh.

Good luck with everything.

Lady Lark
05-11-09, 02:08 PM
Have you looked into Asperger's at all?

When we first started treating my son for what we thought was "just" ADHD, it didn't work. After nearly a year of treating ADHD, I started looking into co-morbid conditions. I remember feeling very strongly that he probably was bipolar, or Aspie. That bit about "rages" seemed to just send chills down my spine, and there is a family history too.

Long story short, he has ADHD, Asperger's, and is also gifted (which I'm sure adds to the mix). Much of what you describe sounds like my son as well. Physical violence to kids, rages that can last for hours, being convinced that someone did something "on purpose".

I don't know for sure, but it might be something to look into as well.

2puzzledparents
05-11-09, 02:30 PM
MGdad, Thanks for support... Fortunately, Bren's Primary is a 'young gun' and is very very supportive and helpful... Approchable ( and wife thinks he's cute hee hee) and very on top of things considering his workload. Depending on what the psych facility says and after reading more about comorbid BP , I think we will be taking the Vyvanse down alot and boosting Risperadol again.. rapidcycle BP kids and stims are like Nitroglycerine and pogosticks.. not a good mix at all!

2puzzledparents
05-11-09, 02:34 PM
Thanks lady lark... Not certain about the Aspergers... Bren matches , like all but 2 of Bipolar. We are also having to consider the possability of PTSD as well... Being yelled at and held down or apporached rapidly trips his trigger , too. Plust the history of violence and control of his birthdad towards his Mom.

Justtess
05-11-09, 08:18 PM
If you were to just come about from the other angle.... what issues are you specifically trying to target?

We started with an unexplainable academic pattern that seemed to be difficult for my son to manage... and I had originally thought it was his personality and lack of commitment to study habits. I don't I really saw anything medically wrong with him until I saw him trying very hard and not getting anywhere with any type of behavior modification.

I've skimmed throught the prior posts and I'm not sure if there was anything in specific you were trying to resolve.

2puzzledparents
05-11-09, 09:59 PM
tommorrow ( 5-12) we have a family session with the inpatient facility and are going to focus on his 'rages/meltdowns' on his BP issues first. get him back on an even keel with that .. More I reseach and more ( spent all day today at hospital.. granny had esophogial surgery, plenty time to think) certain I become of original pdoc's diagnosis. Primary issue BP(1) comorbid with ADHD

Apologies to Mctavish.

mctavish23
05-11-09, 10:57 PM
There's not a debate here.

Dizfriz's comments were pretty much what I would have said.

It all comes down to "evidence based," in terms of what's been proven to work and

what hasn't. As of today, Amen hasn't.

More importantly though, I wish you much luck in finding the correct diagnosis and

treatment for you child. I'm impressed with how much you read,as I believe Parent

Education is the key to providing the best advocacy for your child.

tc

mctavish23

(Robert)

2puzzledparents
05-12-09, 07:39 AM
point me the way to some Juvenile BP forums and resorces... ??

k' thx bai

MGDAD
05-12-09, 11:30 AM
www.bipolarchild.com (http://www.bipolarchild.com)

There is a newsletter section that I found interesting. One that really hit home was "the irrepressible agendas of the bipolar child." Describes "Mission Mode."

www.jbrf.org (http://www.jbrf.org)

They have a forum on this site, but I have not spent much time there.

www.bpkids.org (http://www.bpkids.org)

Interesting site too.

2puzzledparents
05-12-09, 07:08 PM
Ohhhh! thats good stuff! TY TY TY TY TY! :* MGDAD!

Lady Lark
05-12-09, 10:30 PM
Thanks lady lark... Not certain about the Aspergers... Bren matches , like all but 2 of Bipolar. We are also having to consider the possability of PTSD as well... Being yelled at and held down or apporached rapidly trips his trigger , too. Plust the history of violence and control of his birthdad towards his Mom.

I would just caution that you keep an open mind, and don't convince yourself it must be X. We were so sure Steven had ADD, it took us a year to realize there was more there.

2puzzledparents
05-12-09, 10:34 PM
but are treating now with lithium and risperidol!!
Sill a little disturbed that both primary pdoc and the facility pdoc are both not yet ready to to fess up and call it what it is.. but Bren is now on what we all feel are the right treatments.

Will be about a week before both docs get Bren's Lithium dosage dialed in and maybe one more week to check for adverse reactions...

ACK!!! and I found out today that my wife's first cousin has been diagnosed and is being treated for Bipolar as well! Pity the wife and I hadn't thought to mention that bit of family background to the docs!

2puzzledparents
05-12-09, 11:21 PM
Thanks ladylark.. see my reply / posting at end of this thread... Even though docs are still holding to thier ADHD/ MD NOS Diagnosis.. they have begun treating Bren with BP(1) Meds... He should be home in about two weeks. Vuseted him today and he was much much more calm and focused and settled...

indy
06-05-09, 11:51 PM
As I've posted before,there's an empirically supported "One WayComobidity" between

Bipolar Disorder and ADHD ( i.e., over 90% ( 94-97%) of children /adolescents with

(Pediatric) Bipolar Disorder also have ADHD, while the opposite isn't true).

(My references are Barbara Gellar's work from 2002-2003).


do you know if Gellar has published articles (and what the titles may be) or books on this? i have what is called "early onset bipolar disorder" meaning i became symptomatic before the age of 17. i am now 29 and just 6 months ago was given an adhd-i diagnosis. i'd be very interested to read more about the connection between early onset bp and adhd. if you can point me in the right direction (i have access to a library with databases and of course books) i'd really appreciate it. thanks.

op: i have "bipolar disorder-nos and adhd" the NOS is not a bull**** diagnosis, it means i don't fit ALL the diagnostic criterea for bipolar I but am more severely ill than those with bipolar II. so for me, the NOS is a good thing. it keeps me from being undermedicated/treated.

mctavish23
06-06-09, 11:30 AM
Hi,

The best suggestions I can give you right now,as I'm coming off eye surgery on Tues., is to check out the Child and Adolescent Bipolar Foundation (CABF) site and do a search on Geller.She has a new book within the last year or so,but I haven't had a chance to look at it.Dizfriz's earlier reference of "The Bipolar Child" and MGDAD's references are also excellent places to learn more.

In closing, remember that while meds are always a choice, the reality is that both ADHD & Bipolar Disorder are genetic/neurobiological in nature,i.e.,meaning meds are an essential treatment.

Good luck.

tc

mctavish23

(Robert)

indy
06-06-09, 02:25 PM
thank you robert! i will check out those sources. i did a quick search for geller on my university's article databases and came up with some book reviews but no articles. i'll have to request her book(s) from the library.

yes. at the age of 29, i know that i can't live without my meds... at least not very productively. when i was younger i did the whole "i don't need medication/i'm not bipolar" thing but i've outgrown that. :-)