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

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adhd comorbidity issues

ADHD –Comorbidity Issues

Regina Bussing, M.D., M.S.H.S.

Chief, Division of Child and Adolescent Psychiatry

adhd etiology and prevalence
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

adhd core symptoms
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

dsm iv adhd criteria inattention symptoms
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

dsm iv adhd criteria hyperactivity impulsivity symptoms
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

adhd dsm iv general criteria and subtypes
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

adhd overview of assessment process
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?
adhd patient evaluation procedures
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

adhd domains of impairment
ADHD Domains of Impairment
  • Peer relationships
  • Adult relationships
  • Family relationships
  • School functioning
  • Leisure activities

Ref: Mannuzza 1993; Pelham 1982; Shaywitz 1988

differential diagnosis of adhd in children
Differential Diagnosis of ADHD in Children

Ref: Reiff 1993; Barkley 1990

adhd comorbidities in children adolescents
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

adhd and other disruptive disorders
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)
adhd and other disruptive disorders13
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)
adhd and anxiety disorders
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)
adhd and anxiety disorders15
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)
adhd and mood disorders
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)
adhd and mood disorders17
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)
adhd and tic disorders
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
case example
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
xy follow up
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
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