ADHD –Comorbidity IssuesADHD –Comorbidity Issues

Donna Fargason, MDDonna Fargason, MDPsychiatristPsychiatrist

Child and Adolescent PsychiatristChild and Adolescent Psychiatrist

Family Focus, LLCFamily Focus, LLC

ADHD: Etiology and PrevalenceADHD: Etiology and Prevalence

EtiologyEtiology

• No single causeNo single cause

• Many possible etiologiesMany possible etiologies

PrevalencePrevalence

• Estimates in school-age children: 3% to 9%Estimates in school-age children: 3% to 9%

• More commonly diagnosed in boys (4:1 to 9:1)More commonly diagnosed in boys (4:1 to 9:1)

• Girls may be under-represented in clinical Girls may be under-represented in clinical populationspopulations

• More prevalent in 1st degree biologic relativesMore prevalent in 1st degree biologic relatives

Ref: Greenhill 1993; Biederman 1989; Safer 1988; Lambert 1981Ref: Greenhill 1993; Biederman 1989; Safer 1988; Lambert 1981

ADHD: Core SymptomsADHD: Core Symptoms

Varying degrees of:Varying degrees of:• InattentionInattention•HyperactivityHyperactivity• ImpulsivityImpulsivity

Symptoms also vary in:Symptoms also vary in:•Degree of impairmentDegree of impairment•Frequency of occurrenceFrequency of occurrence•PervasivenessPervasiveness

Ref: Greenhill 1993; Swanson 1992; Cantwell 1985Ref: Greenhill 1993; Swanson 1992; Cantwell 1985

DSM-IV ADHD Criteria:DSM-IV ADHD Criteria:Inattention SymptomsInattention Symptoms

Behaviors manifested Behaviors manifested often:often:

• Careless mistakesCareless mistakes

• Difficulty sustaining attentionDifficulty sustaining attention

• Seems not to listenSeems not to listen

• Fails to finish tasksFails to finish tasks

• Difficulty organizingDifficulty organizing

• Avoids tasks requiring sustained attentionAvoids tasks requiring sustained attention

• Loses thingsLoses things

• Easily distractedEasily distracted

• ForgetfulForgetfulRef: APA 1994Ref: APA 1994

DSM-IV ADHD Criteria:DSM-IV ADHD Criteria:Hyperactivity/Impulsivity Hyperactivity/Impulsivity SymptomsSymptoms

Hyperactivity behaviors manifested Hyperactivity behaviors manifested often:often:• Difficulty engaging in leisure activities quietlyDifficulty engaging in leisure activities quietly• FidgetingFidgeting• Unable to stay seatedUnable to stay seated• Moving excessively (restlessness)Moving excessively (restlessness)• ““On the go”On the go”• Talking excessivelyTalking excessively

Impulsivity behaviors manifested Impulsivity behaviors manifested often:often:• Blurting out answer before question is completedBlurting out answer before question is completed• Difficulty waiting turnDifficulty waiting turn• Interrupting/intruding upon othersInterrupting/intruding upon others

Ref: APA 1994Ref: APA 1994

ADHD: DSM-IV General Criteria and ADHD: DSM-IV General Criteria and SubtypesSubtypes

Inattention and hyperactivity-impulsivity symptomsInattention and hyperactivity-impulsivity symptoms::• Onset before age 7Onset before age 7• Present for > 6 monthsPresent for > 6 months• Present in Present in 2 settings (e.g., home, school, work) 2 settings (e.g., home, school, work)

Subtypes:Subtypes:• ADHD, combined type: criteria from both dimensionsADHD, combined type: criteria from both dimensions

– 6 of 9 from both symptom lists6 of 9 from both symptom lists

• ADHD, predominantly inattentive type: inattentive criteriaADHD, predominantly inattentive type: inattentive criteria– 6 of 9 inattentive symptoms6 of 9 inattentive symptoms

• ADHD, predominantly hyperactive-impulsive type: ADHD, predominantly hyperactive-impulsive type: hyperactive-impulsive criteriahyperactive-impulsive criteria

– 6 of 9 hyperactive-impulsive symptoms6 of 9 hyperactive-impulsive symptomsRef: APA 1994Ref: APA 1994

ADHD and the BrainADHD and the Brain• Portions of brain’s frontal lobe are responsible for Portions of brain’s frontal lobe are responsible for

“Executive” functions:“Executive” functions:– Consolidating information from other areas of the brainConsolidating information from other areas of the brain– ““Considers” potential consequences and implications of Considers” potential consequences and implications of

behaviorsbehaviors– Puts “brakes” on (Puts “brakes” on (inhibitsinhibits) impulsive reactions) impulsive reactions– Initiates appropriate response to environmentInitiates appropriate response to environment

• Research suggests that in in children with ADHD, these Research suggests that in in children with ADHD, these “executive” areas of the brain are “executive” areas of the brain are under-activeunder-active

• Increasing the activity level in these areas of the ADHD Increasing the activity level in these areas of the ADHD brain have been shown to decrease behavioral symptoms. brain have been shown to decrease behavioral symptoms. This is the logic behind using Stimulant medications as a This is the logic behind using Stimulant medications as a first line treatment for the disorder.first line treatment for the disorder.

ADHD: Overview of Assessment ADHD: Overview of Assessment ProcessProcess

•What is the child’s developmental level?What is the child’s developmental level?

•Does the child meet the criteria for ADHD?Does the child meet the criteria for ADHD?

•What are the areas of functional impairment?What are the areas of functional impairment?

• Is comorbidity present?Is comorbidity present?

•What are the strengths of the child, family, What are the strengths of the child, family,

and prosocial environment?and prosocial environment?

•What treatment is indicated?What treatment is indicated?

ADHD: Patient Evaluation ADHD: Patient Evaluation ProceduresProcedures

• Parent/child interviewsParent/child interviews• Parent-child observationParent-child observation• Behavior rating scalesBehavior rating scales• Physical examination (include neurologic)Physical examination (include neurologic)• Cognitive testing (if indicated?)Cognitive testing (if indicated?)• Laboratory studiesLaboratory studies

– Check on audiology/vision testingCheck on audiology/vision testing– are not pathognomonicare not pathognomonic

Ref: Reiff 1993Ref: Reiff 1993

ADHD Domains of ImpairmentADHD Domains of Impairment

•Peer relationshipsPeer relationships

•Adult relationshipsAdult relationships

•Family relationshipsFamily relationships

•School functioningSchool functioning

•Leisure activitiesLeisure activitiesRef: Mannuzza 1993; Pelham 1982; Shaywitz 1988Ref: Mannuzza 1993; Pelham 1982; Shaywitz 1988

Differential Diagnosis Differential Diagnosis of ADHD in Childrenof ADHD in Children

Developmental Disorders

Psychiatric Disorders

Medical Disorders

Learning disorders Conduct Post traumatic encephalopathy

Anxiety Seizures (e.g., absence)

Mental Retardation

Mood Drug-induced change

Environmental Chronic Illness (e.g., hypo/hyperthyroid)

Stress Sensory Deficits (e.g., hearing loss)

Ref: Reiff 1993; Barkley 1990

ADHD: Comorbidities in ADHD: Comorbidities in Children/AdolescentsChildren/Adolescents

• Learning and Communication DisordersLearning and Communication Disorders• Autism Spectrum DisordersAutism Spectrum Disorders• Oppositional defiant disorderOppositional defiant disorder• Conduct disordersConduct disorders• Anxiety disordersAnxiety disorders• Mood disordersMood disorders• Tourette’s syndrome; chronic ticsTourette’s syndrome; chronic tics

ADHD and LD, ADHD and LD, Communication DisordersCommunication Disorders

• Learning and Communication DisordersLearning and Communication Disorders– Diagnosis:Diagnosis:

•Academic problems severe and start early in lifeAcademic problems severe and start early in life

•Dyslexia is a common issueDyslexia is a common issue

•Psychological/Psychoeducational testing is Psychological/Psychoeducational testing is helpfulhelpful

– Treatment Implications:Treatment Implications:•LD/CD children need classroom modifications, LD/CD children need classroom modifications,

ST, and often OTST, and often OT

•Typical ADHD treatment still quite helpfulTypical ADHD treatment still quite helpful

ADHD and Autism Spectrum ADHD and Autism Spectrum DisordersDisorders• Autism Spectrum DisordersAutism Spectrum Disorders

– Diagnosis:Diagnosis:• ASD kids have more severe symptoms that present ASD kids have more severe symptoms that present

earlierearlier

• ASD kids are hard to “tease out” due to anxiety, and ASD kids are hard to “tease out” due to anxiety, and impulse control symptomsimpulse control symptoms

– Treatment implications:Treatment implications:• ASD kids are often very sensitive to medications and ASD kids are often very sensitive to medications and

results are not typicalresults are not typical

• Very important to incorporate ASD-specific treatments Very important to incorporate ASD-specific treatments like like Applied Behavioral Analysis (ABA), Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH), and sensory integration

ADHD and Other Disruptive ADHD and Other Disruptive DisordersDisorders• ODDODD

– Diagnosis:Diagnosis:• Similar age of onset, courseSimilar age of onset, course• Likely most frequent comorbidity encounteredLikely most frequent comorbidity encountered• Prompts specialty mental health referral (over-Prompts specialty mental health referral (over-

represented)represented)

– Treatment implicationsTreatment implications• Family and patient educationFamily and patient education• Raises caregiver stress more than ADHD or CDRaises caregiver stress more than ADHD or CD• Psychotherapy choices (PCIT; parenting interventions)Psychotherapy choices (PCIT; parenting interventions)• Medication implications (stimulants; non-stimulant Medication implications (stimulants; non-stimulant

ADHD treatments)ADHD treatments)

ADHD and Other Disruptive ADHD and Other Disruptive DisordersDisorders• CDCD

– Diagnosis:Diagnosis:• Variations in age of onset, courseVariations in age of onset, course• Comorbidity with significant prognostic impact Comorbidity with significant prognostic impact

(increased risk of drug abuse; antisocial behaviors)(increased risk of drug abuse; antisocial behaviors)

– Treatment implicationsTreatment implications• Family likely has significant other risk factorsFamily likely has significant other risk factors• Psychotherapy choices (PCIT; parenting Psychotherapy choices (PCIT; parenting

interventions)interventions)• Medication implications (stimulants; non-stimulant Medication implications (stimulants; non-stimulant

ADHD treatments; atypical neuroleptics; possibly ADHD treatments; atypical neuroleptics; possibly mood stabilizers for anti-aggressive effects)mood stabilizers for anti-aggressive effects)

ADHD and Anxiety ADHD and Anxiety DisordersDisorders• GAD and SADGAD and SAD

– Diagnosis:Diagnosis:• Tease out age of onset and course of symptomsTease out age of onset and course of symptoms• ““Shared” symptoms (inattention, hyperactivity; Shared” symptoms (inattention, hyperactivity;

academic performance problems; sleep problems)academic performance problems; sleep problems)• Unique features (worry; fears; significant somatic Unique features (worry; fears; significant somatic

complaints)complaints)

– Treatment implicationsTreatment implications• Families may be reinforcing avoidances and fearsFamilies may be reinforcing avoidances and fears• Psychotherapy choicesPsychotherapy choices• Medication implications (stimulants; non-stimulant Medication implications (stimulants; non-stimulant

ADHD treatments; antidepressant options)ADHD treatments; antidepressant options)

ADHD and Anxiety DisordersADHD and Anxiety Disorders

• PTSDPTSD– Diagnosis:Diagnosis:

• Identify stressor eventIdentify stressor event• Tease out age of onset and course of symptomsTease out age of onset and course of symptoms• ““Shared” symptoms (inattention, hyperactivity; Shared” symptoms (inattention, hyperactivity;

academic performance problems; sleep problems)academic performance problems; sleep problems)

– Treatment implicationsTreatment implications• Families often have significant other stressorsFamilies often have significant other stressors• Psychotherapy choicesPsychotherapy choices• Medication implications (stimulants; non-stimulant Medication implications (stimulants; non-stimulant

ADHD treatments; antidepressant options)ADHD treatments; antidepressant options)

ADHD and Mood DisordersADHD and Mood Disorders

• Major Depression/DysthymiaMajor Depression/Dysthymia– Diagnosis:Diagnosis:

• Differentiate age of onset, courseDifferentiate age of onset, course

• ““Shared” symptoms (inattention, academic Shared” symptoms (inattention, academic performance problems; sleep problems)performance problems; sleep problems)

– Treatment implicationsTreatment implications• Family and patient educationFamily and patient education

• Psychotherapy choicesPsychotherapy choices

• Medication implications (stimulants; non-stimulant Medication implications (stimulants; non-stimulant ADHD treatments; antidepressant options)ADHD treatments; antidepressant options)

ADHD and Mood ADHD and Mood DisordersDisorders• Bipolar DisorderBipolar Disorder

– Diagnosis:Diagnosis:• Differentiate age of onset, course (issues of mixed Differentiate age of onset, course (issues of mixed

presentation and of rapid cycling)presentation and of rapid cycling)• ““Shared” symptoms (attention problems; hyperactivity; Shared” symptoms (attention problems; hyperactivity;

increased speech output; loud; sleep problems; academic increased speech output; loud; sleep problems; academic performance problems)performance problems)

• Unique symptoms (grandiosity; psychotic symptoms; Unique symptoms (grandiosity; psychotic symptoms; severe mood labilitysevere mood lability

– Treatment implicationsTreatment implications• Family and patient educationFamily and patient education• Medication implications (mood stabilizers; atypical Medication implications (mood stabilizers; atypical

neuroleptic medications; issue of stimulants; non-stimulant neuroleptic medications; issue of stimulants; non-stimulant ADHD treatments; antidepressant options)ADHD treatments; antidepressant options)

ADHD and Tic DisordersADHD and Tic Disorders

• Chronic Tics or Tourette’s DisorderChronic Tics or Tourette’s Disorder– Onset of ADHD often precedes onset of Tics or TSOnset of ADHD often precedes onset of Tics or TS– Important to inquire about family history and Important to inquire about family history and

educate parents about stimulants and tics/TSeducate parents about stimulants and tics/TS

• TreatmentTreatment– Stimulants were considered “contraindicated” in Stimulants were considered “contraindicated” in

pastpast– Focus now on improving functioning – ADHD may be Focus now on improving functioning – ADHD may be

more impairing than ticsmore impairing than tics– Complex regimens may be used, combining ADHD Complex regimens may be used, combining ADHD

medications with alpha-agonists and/or atypical medications with alpha-agonists and/or atypical neuroleptic medicationsneuroleptic medications

ADHD medicationsADHD medications

Stimulants – first line Non-stimulants – second line

Methylphenidates Amphetamine Salts

Long-acting

Short-acting Long-acting

Short-acting

DaytranaQuillivantFocalin XRConcerta

RitalinFocalin

VyvanseAdderall XR

AdderallDexedrine

• Strattera• Intuniv• Clonidine• Tenex• Kapvay

Case ExampleCase Example• ““Sarah” presented to the psychiatrist as a 14 year Sarah” presented to the psychiatrist as a 14 year

old who had functioned pretty well prior to 8old who had functioned pretty well prior to 8thth grade. Suddenly her grades dropped and she was grade. Suddenly her grades dropped and she was struggling in her peer relationships.struggling in her peer relationships.

• Sarah’s parents believe she has anxiety and Sarah’s parents believe she has anxiety and depression because she stays in her room on her depression because she stays in her room on her phone a great deal.phone a great deal.

• Sarah says she is anxious and depressed and feels Sarah says she is anxious and depressed and feels it’s due to her schoolwork being overwhelming. it’s due to her schoolwork being overwhelming. She says it takes her twice as long as her She says it takes her twice as long as her classmates to do her homework, and she never classmates to do her homework, and she never has free time which makes her angry. She cares has free time which makes her angry. She cares about her grades but is starting to wonder why she about her grades but is starting to wonder why she should bother.should bother.

““Sarah” food for thoughtSarah” food for thought• What was Sarah like as a child? Even What was Sarah like as a child? Even

though she didn’t struggle academically, though she didn’t struggle academically, was she sullen, fearful, impulsive, rageful?was she sullen, fearful, impulsive, rageful?

• What is the family psychiatric history?What is the family psychiatric history?• Has Sarah has psychological testing?Has Sarah has psychological testing?• What have Sarah’s gradeschool teachers What have Sarah’s gradeschool teachers

said about her functioning?said about her functioning?• What do Sarah’s room, backpack, planner What do Sarah’s room, backpack, planner

look like?look like?• Other???Other???

What would you do?What would you do?

• Question and answer sessionQuestion and answer session

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