ADHD –Comorbidity Issues

1. ADHD –Comorbidity Issues Regina Bussing, M.D., M.S.H.S. Chief, Division of Child and Adolescent Psychiatry

2. ADHD: Etiology and Prevalence Etiology • No single cause • Many possible etiologies Prevalence • Estimates in school-age children: 3% to 9% • More commonly diagnosed in boys (4:1 to 9:1) • Girls may be under-represented in clinical populations • More prevalent in 1st degree biologic relatives Ref: Greenhill 1993; Biederman 1989; Safer 1988; Lambert 1981

3. ADHD: Core Symptoms Varying degrees of: • Inattention • Hyperactivity • Impulsivity Symptoms also vary in: • Degree of impairment • Frequency of occurrence • Pervasiveness Ref: Greenhill 1993; Swanson 1992; Cantwell 1985

4. DSM-IV ADHD Criteria:Inattention Symptoms Behaviors manifested often: • Careless mistakes • Difficulty sustaining attention • Seems not to listen • Fails to finish tasks • Difficulty organizing • Avoids tasks requiring sustained attention • Loses things • Easily distracted • Forgetful Ref: APA 1994

5. DSM-IV ADHD Criteria:Hyperactivity/Impulsivity Symptoms Hyperactivity behaviors manifested often: • Difficulty engaging in leisure activities quietly • Fidgeting • Unable to stay seated • Moving excessively (restlessness) • “On the go” • Talking excessively Impulsivity behaviors manifested often: • Blurting out answer before question is completed • Difficulty waiting turn • Interrupting/intruding upon others Ref: APA 1994

6. ADHD: DSM-IV General Criteria and Subtypes Inattention and hyperactivity-impulsivity symptoms: • Onset before age 7 • Present for > 6 months • Present in  2 settings (e.g., home, school, work) Subtypes: • AD/HD, combined type: criteria from both dimensions • 6 of 9 from both symptom lists • AD/HD, predominantly inattentive type: inattentive criteria • 6 of 9 inattentive symptoms • AD/HD, predominantly hyperactive-impulsive type: hyperactive-impulsive criteria • 6 of 9 hyperactive-impulsive symptoms Ref: APA 1994

7. ADHD: Overview of Assessment Process • What is the child’s developmental level? • Does the child meet the criteria for ADHD? • What are the areas of functional impairment? • Is comorbidity present? • What are the strengths of the child, family, and prosocial environment? • What treatment is indicated?

8. ADHD: Patient Evaluation Procedures • Parent/child interviews • Parent-child observation • Behavior rating scales • Physical examination (include neurologic) • Cognitive testing (if indicated?) • Laboratory studies • Check on audiology/vision testing • are not pathognomonic Ref: Reiff 1993

9. ADHD Domains of Impairment • Peer relationships • Adult relationships • Family relationships • School functioning • Leisure activities Ref: Mannuzza 1993; Pelham 1982; Shaywitz 1988

10. Differential Diagnosis of ADHD in Children Ref: Reiff 1993; Barkley 1990

11. ADHD: Comorbidities in Children/Adolescents • Learning disorders • Language and communication disorders • Oppositional defiant disorder • Conduct disorders • Anxiety disorders • Mood disorders • Tourette’s syndrome; chronic tics Ref: Biederman 1991; Hinshaw 1987

12. ADHD and Other Disruptive Disorders • ODD • Diagnosis: • Similar age of onset, course • Likely most frequent comorbidity encountered • Prompts specialty mental health referral (over-represented) • Treatment implications • Family and patient education • Raises caregiver stress more than ADHD or CD • Psychotherapy choices (PCIT; parenting interventions) • Medication implications (stimulants; non-stimulant ADHD treatments)

13. ADHD and Other Disruptive Disorders • CD • Diagnosis: • Variations in age of onset, course • Comorbidity with significant prognostic impact (increased risk of drug abuse; antisocial behaviors) • Treatment implications • Family likely has significant other risk factors • Psychotherapy choices (PCIT; parenting interventions) • Medication implications (stimulants; non-stimulant ADHD treatments; atypical neuroleptics; possibly mood stabilizers for anti-aggressive effects)

14. ADHD and Anxiety Disorders • GAD and SAD • Diagnosis: • Tease out age of onset and course of symptoms • “Shared” symptoms (inattention, hyperactivity; academic performance problems; sleep problems) • Unique features (worry; fears; significant somatic complaints) • Treatment implications • Families may be reinforcing avoidances and fears • Psychotherapy choices • Medication implications (stimulants; non-stimulant ADHD treatments; antidepressant options)

15. ADHD and Anxiety Disorders • PTSD • Diagnosis: • Identify stressor event • Tease out age of onset and course of symptoms • “Shared” symptoms (inattention, hyperactivity; academic performance problems; sleep problems) • Treatment implications • Families often have significant other stressors • Psychotherapy choices • Medication implications (stimulants; non-stimulant ADHD treatments; antidepressant options)

16. ADHD and Mood Disorders • Major Depression/Dysthymia • Diagnosis: • Differentiate age of onset, course • “Shared” symptoms (inattention, academic performance problems; sleep problems) • Treatment implications • Family and patient education • Psychotherapy choices • Medication implications (stimulants; non-stimulant ADHD treatments; antidepressant options)

17. ADHD and Mood Disorders • Bipolar Disorder • Diagnosis: • Differentiate age of onset, course (issues of mixed presentation and of rapid cycling) • “Shared” symptoms (attention problems; hyperactivity; increased speech output; loud; sleep problems; academic performance problems) • Unique symptoms (grandiosity; psychotic symptoms; severe mood lability • Treatment implications • Family and patient education • Medication implications (mood stabilizers; atypical neuroleptic medications; issue of stimulants; non-stimulant ADHD treatments; antidepressant options)

18. ADHD and Tic Disorders • Chronic Tics or Tourette’s Disorder • Onset of ADHD often precedes onset of Tics or TS • Important to inquire about family history and educate parents about stimulants and tics/TS • Treatment • Stimulants were considered “contraindicated” in past • Focus now on improving functioning – ADHD may be more impairing than tics • Complex regimens may be used, combining ADHD medications with alpha-agonists and/or atypical neuroleptic medications

19. A Norepinephrine Reuptake Inhibitor (NRI)

20. Mechanism of Action

21. Strattera: Effects on Dopamine

22. Case Example • XY presented to child psychiatrist for ADHD, SLD, expressive language disorder • Family history + ADHD, depression • Treated with stimulants, school interventions as preadolescent • Developed severe aggression, mood instability, some seasonal variations in mood in early adolescence • Repeated inpatient crisis stabilization, family therapy, medication adjustments • Developed psychotic symptoms with hypomanic component • Residential treatment pursued

23. XY follow-up • Temporarily stopped ADHD medication treatment, used antipsychotic medications • Moved into mood stabilization, resumed ADHD medications once had remained free of psychotic symptoms for 3 months • Continued family intervention (“the explosive child”) • Able to resume regular school attendance, with partial special education services, continued ADHD treatment, ongoing mood stabilization, off all antipsychotic medications • Continues to experience social isolation, but markedly improved overall functioning