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Characteristics of Attention Deficit Disorder, Juvenile Onset Bipolar Disorder, and Reactive Attachment Disorder

30752 Southview Drive, Suite 100
Evergreen, Colorado 80439

Phone: (303) 670-0926
Fax: (303) 670-1191
Email: drjohn@JohnAlstonMD.com

John F. Alston, M.D., P.C.
Attention Deficit Disorder
Juvenile Onset Bipolar Disorder
Reactive Attachment Disorder
Age of Onset
Infancy to toddler, 6 years, 13 years
2 to 3 years, 6 years, 13 to 25 years
Birth to 3 years
Family History ADHD, academic difficulties (based on task incompletion), alcohol and substance abuse. Any mood disorder (depression or bipolar), academic difficulties (based on motivation problems or opposition or defiance), alcohol and substance abuse, adoption, ADHD. Abuse and neglect, severe emotional and behavioral disorders, alcohol and substance abuse. Abuse and neglect in parents’ own early life.
Lifelong Prevalance
3 to 6% of general population
3 to 5% of general population
Uncommon to common.
Etiology Genetic, neurochemical, fetal developmental, brain traumas, nutritional deficiencies, exacerbated by stress. Genetic, exacerbated by stress and hormones. Psychoneurophysiologic secondary to neglect, abuse, mistreatment, abandonment.
Duration Chronic and unremittingly continuous, tending toward improvement. May or may not show clear emotional and behavioral episodes or cycles; worsens over years with increased severity of symptoms. Dependent on extent of abuse, age of relinquishment, including innate temperament and treatment. Worsens over years without treatment to develop antisocial character disorders.
Attention Span Short, leading to a lack of productivity, task performance and completion Entirely dependent on interest and motivation. Distractibility is commonly mistaken for inattention. Hyperarousal influences hypervigilance, distractibility and shortened periods of focus. Shortens with stress.
Impulsivity Secondary to inattention or obliviousness, regret and remorse. “Driven,” “Irresistible,” grandiosity, thrill seeking, counterphobia, little regret or remorse. Pressured speech. "Disinhibition Syndrome" Poor cause and effect. No remorse. Can range from overreactive to highly controlled, self-protective.
Hyperactivity 50% are hyperactive. Disorganized, fidgety, jittery. Wide ranges, with hyperactivity common in children. Common.
Self Esteem Low, rooted in ongoing performance difficulties. Low, rooted in inherent unpredictability of mood. Grandiose or expansive mood could mask low esteem. Low, rooted in abandonment, feel worthless and unlovable, masked by anger or indifference.
Mood Usually friendly in a genuine manner. Some irritability. Unpredictable, oversensitive, overreactive, irritable, grandiose, hard to please or satisfy, negativistic. Superficially charming, phoney, distrusting, emotionally distant, nonintimate.
Control Issues Desire to seek approval – get into trouble by inability to complete tasks. Intermittently desire to please but tend to push limits and relish power struggles. Expert hasslers, persuasive. Controlled and controlling, only self-gain, underhanded, sneaky and covert.
Opposition & Defiance Demonstrate argumentativeness but will relent with show of authority, and are redirectable. Short attention span allows them to “let go” more easily. Usually overtly and prominently defiant, at times passive aggressive, often not relenting to authority. Tend to insist on getting own way. Conning and cunning. Covertly defiant, passive aggressive.
Blaming Self-protective mechanism to avoid immediate adverse consequences. Grandiosity contributes to disbelief and denial they caused something to go wrong. Rejecting of responsibility. Victim position.
Lying Avoid immediate adverse consequences. Enjoys “getting away with it.” “Crazy lying,” stuck in perceptual self-centered “primary process” distortions to be self protective and attempt to gain control.
Fire Setting Play with matches out of curiosity, nonmalicious intent. Intrigued with matches/fire setting and can have malicious intent. Revenge motive. Revenge motivated, malicious. Danger seeking secondary to despair.
Anger, Irritability, Temper and Rage Situational, in response to over-stimulation, poor frustration tolerance and need for immediate gratification. Rage reaction is usually short-lived. Secondary to limit setting or attempts to control their excessive behavior. Rage can last for extended periods of time, at other times may be explosive and over quickly. Overt, aggressive even assaultive. Chronic, revenge “get even” oriented. Eternal “victim” position, with rationalizations for destructive retaliation. Hurtful to innocent others and pets.
Entitlement (Deserving of Special Benefits) Overwhelming need for immediate gratification. (Not a prominent symptom). Expansive and grandiose mood creates belief they deserve special treatment. Infrequent compensation for abandonment and deprivation. (Not a prominent symptom.)
Conscience Development Capable of demonstrating remorse when things calm down. Conscience is close to developmental age. Limited conscience development, dependent on mood and parenting ability. Very “street smart,” good survival skills, con artists, calculating, devious.
Sensitivity Oblivious to detailed circumstances they are in, and inappropriateness shows as result. Do get “big picture.” Acutely aware of circumstances and are “hot reactors.” Detail oriented. Hassle for self-gain. Hypervigilant, compensating for past helplessness. Resistant and insensitive, rarely ill. Limited emotional repertoire.
Perception Flooded by sensory over-stimulation, become distractible, hyperactive, or shut down. Self-absorbed, preoccupied with internal need fulfillment, appear narcissistic. Dissociation possible. Inappropriate affect. Self-centered primary process primitive distortions. Dissociation possible.
Peer Relationships Make friends easily but often not able to keep them. Immature. Can be charismatic or depressed, depending on mood – conflicts are common due to controlling nature. Very poor, secondary to lack of intimacy and control issues. Target others to get angry. No long-term friends.
Sleep Patterns Occasional trouble getting to sleep due to physical over-stimulation. Once asleep, “sleep like a rock.” Fidget in sleep. Nightmares uncommon. Inability to relax, wind down, to fall asleep because of racing thoughts or emotional intensity. Nightmares common. Hypervigilance creates light sleepers. Tends to need little sleep, arise early in the morning. Nightmares common.
Motivation Less resourceful – more adult dependent. Fair starters, poor finishers. Grandiose – believe they are resourceful, gifted, creative. Self-directed, highly variable energy and enthusiasm. Consistently poor initiative, limited industriousness, and intentional inefficiency. Motivation for short term only.
Learning Characteristics “Right brained”. Learning disabilities at 50% incidence. Most commonly coexistent auditory perceptual difficulties and fine motor incoordination. Non-sequential, non-linear learners. Verbally articulate, used in shrewd and manipulative ways. Brain maturational delays secondary to maternal drug/alcohol effects, early life abuse/neglect can create diverse learning problems.
Anxiety Uncommon, unless performance- related. Emotionally wired. High potentials for anxiety, fears and phobias. Somatic symptoms common, needle phobic. Dissociation. Appear invulnerable. Poor recognition, awareness or admission of fears. Dissociation.
Sexuality Emotionally immature and sexually naïve. Average judgment regarding birth control. Sexual hyperawareness, pseudo-maturity, high interest and activity level. Poor judgment in birth control. Uses sex as means of power, control or infliction of pain, sadism.
Alcohol and Substance Abuse Moderate tendencies as coping mechanisms for low self-esteem. Very strong tendencies (60%!) in attempt to enhance or reduce hypomanic/ dysphoric moods. A huge problem. Sporadic and uncommon, not likely to lose too much control. We need more knowledge of correlation.
Parenting Techniques Support, encouragement, redirection. Nothing works long term until correctly diagnosed and medically treated. Understanding child’s vulnerabilities and resistances aids child in becoming workable and establish security.
Optimal Environment Low stimulation and stress. Support and structure. Identify learning disability components or psychological factors. Clear and assertive, balance of limits with encouragement, negotiation. Helpful if all members of treatment team work together. Challenging balance of security, stability, clarity of expectations, nurturance, encouragement and love.
Psychopharmacology Medications helpful include Adderall, Atomoxetine, Methylphenidate, Dexedrine, Modanafil, Bupropion. Clonidine and Guanfacine may be useful as additive medications. Medications helpful to stabilize mood include Lamotrigine, Valproate, Lithium, Verapamil, Carbamazepine, Oxcarbazepine. Medications helpful for opposition and rage include Aripiprazole, Olanzapine, Quetiapine, Risperidone and Ziprasidone. Bupropion helpful for mood and motivational enhancement. Antidepressants, Clonidine, Guanfacine may help decrease hypervigilance. Medications do not help characterological traits.
Prognosis Good to excellent with appropriate medical treatment, ancillary therapies and educational accommodations. Fair to good with times of regression/relapse even with appropriate treatment. Highly variable, dependent upon recognition of comorbid mood disorders, degree of abuse/neglect, age of relinquishment, innate temperament and effects of treatment.
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