Comorbid conditions in

Children with ADHD

ADHD

A) A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, with ≥6 sx in each category

B) Several inattentive or hyperactive-impulsive symptoms were present prior to age 12yrs

C) Several inattentive or hyperactive-impulsive sx are present in two or more settings (e.g. at home, school, or work; with friends or other relatives; in other activities)

D) There is clear evidence that the symptoms interfere with, or reduce the quality of social, academic, or occupational functioning

E) The symptoms do not occur exclusively during the course of another disorder

Symptoms of ADHD

Inattention Often fails to give close attention to

details or makes careless errors

Often has difficulty sustaining attention in tasks or play activities

Often does not seem to listen when spoken to directly

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace

Often has difficulty organizing tasks and activities

Often dislikes, avoids, or is reluctant to engage in tasks that require sustained mental effort

Often loses things necessary for tasks and activities

Is often distracted by extraneous stimuli

Is often forgetful in daily activities

Hyperactivity and Impulsivity Often fidgets with or taps hands or

feet or squirms in seat

Often leaves seat in situations when remaining seated is expected

Often runs about or climbs in situations where it may be inappropriate

Often unable to play or engage in leisure activities quietly

Is often “on the go” acting as if “driven by a motor”

Often talks excessively

Often blurts out an answer before a question has been completed

Often has difficulty waiting their turn

Often interrupts or intrudes on others

Epidemiological estimates vary from 2-18%

Percent of Youth 4-17 Ever Diagnosed with Attention-

Deficit/Hyperactivity Disorder by State: National Survey of Children's

Health

Common conditionsLearning Disabilities: 50%

Anxiety Disorders 25%

Mood Disorders 10-30%

Oppositional Defiant Disorder symptoms 21-60%

Speech Problems 12%

Tic Disorders and Tourette’s 7% and

1%

Coordination Problems and DCD 30-50%

Comorbid conditions in

adultsAnxiety Disorders 47%

Mood Disorders 38%

Impulse Control Disorder 20%

Substance Abuse Disorder 15%

Bipolar Disorder

Main criteria of mania

A) Distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity lasting ≥1 eek and present most of the day nearly every day or any amount of time requiring hospitalizations

B) ≥3 criterion B symptoms (or ≥4 if mood is only irritable) during this time, which represent a change from previous behavior

C) The mood disturbance causes marked impairment in function or requires hospitalization to prevent harm to self or others or psychotic symptoms

D) No better explanation

B criterion symptoms

Inflated self-esteem or grandiosity

Decreased need for sleep

More talkative than usual or pressure to keep talking

Flights of ideas, subjective feeling of racing thoughts

Distractibility

Increased goal-directed activity or psychomotor agitation

Excessive involvement in activities that high high potential for painful/serious consequences

ADHD and Bipolar Disorder:

Not an Artifact of Overlapping Criteria

Hyperactivity and Restlessness

Irritability

Continuous symptoms

Onset at a young age

(<7years)Alternating episodes of

lethargy, sadness, suicidal

thoughts

Increased Energy

Hypersexuality

Talkativeness

Both

Both

ADHD

ADHD

Bipolar Disorder

Both

Bipolar Disorder

Both

Mood is Situation-

AppropriateADHD

ADHD and Bipolar Disorder:Not an Artifact of Overlapping Criteria

ADHD is chronic/continuous while Bipolar Disorder Symptoms are episodic

Intermittent/alternating episodes of depression or are not typically seen in ADHD

Grandiosity, hypersexuality, psychosis, significant (v. mild) mood labiality, uncontrolled anger/aggression are more common in mania than in ADHD and if present in ADHD, comorbid diagnosis of bipolar disorder should be suspected

Children with ADHD may talk a lot, but generally don’t have pressured speech and “gear switching” seen in mania

Bipolar Disorder is extremely unlikely to present at a young age such as those <7years old

Caution is needed because stimulants can worsen symptoms of mania, so always treat Bipolar Disorder first in those with comorbidities

Bipolar Disorder

Comorbidity of Attention Deficit Hyperactivity Disorder in Early-and Late-Onset Bipolar Disorder

Among those with early onset Bipolar Disorder (first episode <19yrs old), 62% met the criteria for ADHD

The mean age of the first affective episode was 12.1 years in those with ADHD v. 20yrs in those without

There is a much lower rate of comorbid ADHD in those with late-onset Bipolar Disorder

Conclusion: Children with a high genetic load of bipolar risk factors are more likely to have ADHD, ADHD should be used to identify which children with genetic risk are most likely to develop ADHD

Depression

A) ≥5 symptoms have been present during the same 2-week period and represent a change from previous functioning, and at least 1 symptom is either depressed mood or anhedonia

Depressed mood most of the day, nearly every day as indicated by subjective mood or observation by others

Marked diminished interest or pleasure in all or almost all activities most of the day nearly every day

Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt nearly every

day

Diminished ability to think or concentrate or indecisiveness nearly every day

Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Depression

B) The symptoms cause clinically significant distress or

impairment in social, occupational, or other important

areas of functioning

C) The episodes are not attributable to the physiological

effects of a substance or to another medical condition

Comorbid Depression and ADHD

Rate of depression in children with ADHD is significantly higher than in those without ADHD. 10-30% of children with ADHD have a mood disorder. 70% experience depression at some point

The course of depression is much more severe in children with co-morbid ADHD than in those with depression alone, with higher risk of suicide and higher risk of long-term impairment.

Assessment can be difficult because of overlap in symptoms and with other disorders common in ADHD

Depression typically occurs several years after ADHD symptoms have started and may result from the difficulties of dealing with the effects of ADHD on functioning in combination with genetic risk factors for depression.

Comorbid DepressionHow does ADHD Contribute to Depression?

Feelings of lack of control over their environment

Repeated failure academically or socially

Peer rejection: In pre-school children, “within five

minutes, children with ADHD are seen as less

desirable, companions than those without ADHD”

Cycles of impairment in social skills, rejection

Poor emotional regulation, disproportionate response

to stressful situations

Overlap with dextro-

amphetaminesDextroamphetamines are used to treat depression and

apathy secondary to dementia, Huntington's disease

However, some side effects of dextroamphetamine can

look like depression

Insomnia

Loss of appetite

Loss of interest in sexual activity or sexual dysfunction

Feeling restless, irritable, or agitated

Social Anxiety Disorder

Marked fear or anxiety about or more social situations in which the individual is exposed to possible scrutiny by others- in children, must occur in peer setting

The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated

The social situations almost always provoke anxiety/fear

The social situations are avoided or endured with intense fear or anxiety

The fear or anxiety is out of proportion to the threat posed by the social situation and to the sociocultural context

The fear, anxiety or avoidance is persistent, ≥6months

Social Anxiety Disorder

Social Anxiety Disorder is one of the more common anxiety disorders associated with ADHD.

People with ADHD with SAD often develop SAD earlier and have more severe anxiety and functional impairment than SAD patients without ADHD.

Those with ADHD-SAD also have a higher rate of lifetime depression and bipolar disorder than those with just SAD

In some studies, treatment of ADHD with traditional drugs such as methylphenidate is associated with an improvement in social phobia, especially school-related SAD

Cognitive Behavioral Training and Social Skills Training can be used for both.

Obsessive Compulsive

DisorderA) Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

2.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

2.The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Obsessive Compulsive

Disorder

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior…

OCD and ADHD

Model of an impulsive to obsessive spectrum, with OCD and ADHD on opposite ends

ADHD and OCD may both be due to dysfunction of the frontostrital system, but with increased activity in OCD and decreased activity in ADHD.

However, they result in similar cognitive impairments such as poor planning, decreased executive function performance

Children having trouble focusing because over-focused on one issue like a stain while child with ADHD switching focus

It’s important to distinguish these because giving stimulants to a child with OCD can make him or her more obsessive by increasing fronto-striatal brain activity even further

Ability to follow obsessive rituals is an important distinguishing factor

However

21% of children and 8.5% of adults with OCD also have ADHD

Those with ADHD who have some OC symptoms do better in tests of executive function than those without any ADHD symptoms