1. ADHD –Comorbidity Issues Donna Fargason, MD Psychiatrist Child and Adolescent Psychiatrist Family Focus, LLC

2. ADHD: Etiology and Prevalence Etiology No single cause No single cause Many possible etiologies Many possible etiologiesPrevalence 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 populations Girls may be under-represented in clinical populations More prevalent in 1st degree biologic relatives More prevalent in 1st degree biologic relatives Ref: Greenhill 1993; Biederman 1989; Safer 1988; Lambert 1981

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

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

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

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

7. ADHD and the Brain Portions of brain’s frontal lobe are responsible for “Executive” functions: Portions of brain’s frontal lobe are responsible for “Executive” functions: –Consolidating information from other areas of the brain –“Considers” potential consequences and implications of behaviors –Puts “brakes” on (inhibits) impulsive reactions –Initiates appropriate response to environment Research suggests that in in children with ADHD, these “executive” areas of the brain are under-active Research suggests that in in children with ADHD, these “executive” areas of the brain are under-active Increasing the activity level in these areas of the ADHD brain have been shown to decrease behavioral symptoms. This is the logic behind using Stimulant medications as a first line treatment for the disorder. Increasing the activity level in these areas of the ADHD brain have been shown to decrease behavioral symptoms. This is the logic behind using Stimulant medications as a first line treatment for the disorder.

8. ADHD: Overview of Assessment Process 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, and prosocial environment? What are the strengths of the child, family, and prosocial environment? What treatment is indicated? What treatment is indicated?

9. ADHD: Patient Evaluation Procedures 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 testing – are not pathognomonic Ref: Reiff 1993

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

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

12. ADHD: Comorbidities in Children/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

13. ADHD and LD, Communication Disorders Learning and Communication Disorders Learning and Communication Disorders –Diagnosis: Academic problems severe and start early in life Academic problems severe and start early in life Dyslexia is a common issue Dyslexia is a common issue Psychological/Psychoeducational testing is helpful Psychological/Psychoeducational testing is helpful –Treatment Implications: LD/CD children need classroom modifications, ST, and often OT LD/CD children need classroom modifications, ST, and often OT Typical ADHD treatment still quite helpful Typical ADHD treatment still quite helpful

14. ADHD and Autism Spectrum Disorders Autism Spectrum Disorders Autism Spectrum Disorders –Diagnosis: ASD kids have more severe symptoms that present earlier ASD kids have more severe symptoms that present earlier ASD kids are hard to “tease out” due to anxiety, and impulse control symptoms ASD kids are hard to “tease out” due to anxiety, and impulse control symptoms –Treatment implications: ASD kids are often very sensitive to medications and results are not typical ASD kids are often very sensitive to medications and results are not typical Very important to incorporate ASD-specific treatments like Very important to incorporate ASD-specific treatments like Applied Behavioral Analysis (ABA), Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH), and sensory integration

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

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

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

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

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

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

21. ADHD and Tic Disorders Chronic Tics or Tourette’s Disorder 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 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

22. ADHD medications Stimulants – first lineNon-stimulants – second line MethylphenidatesAmphetamine Salts Long-actingShort-actingLong-actingShort-acting Daytrana Quillivant Focalin XR Concerta Ritalin Focalin Vyvanse Adderall XR Adderall Dexedrine Strattera Intuniv Clonidine Tenex Kapvay

23. Case Example “Sarah” presented to the psychiatrist as a 14 year old who had functioned pretty well prior to 8 th grade. Suddenly her grades dropped and she was struggling in her peer relationships. “Sarah” presented to the psychiatrist as a 14 year old who had functioned pretty well prior to 8 th grade. Suddenly her grades dropped and she was struggling in her peer relationships. Sarah’s parents believe she has anxiety and depression because she stays in her room on her phone a great deal. Sarah’s parents believe she has anxiety and depression because she stays in her room on her phone a great deal. Sarah says she is anxious and depressed and feels it’s due to her schoolwork being overwhelming. She says it takes her twice as long as her classmates to do her homework, and she never has free time which makes her angry. She cares about her grades but is starting to wonder why she should bother. Sarah says she is anxious and depressed and feels it’s due to her schoolwork being overwhelming. She says it takes her twice as long as her classmates to do her homework, and she never has free time which makes her angry. She cares about her grades but is starting to wonder why she should bother.

24. “Sarah” food for thought What was Sarah like as a child? Even though she didn’t struggle academically, was she sullen, fearful, impulsive, rageful? What was Sarah like as a child? Even though she didn’t struggle academically, 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 said about her functioning? What have Sarah’s gradeschool teachers said about her functioning? What do Sarah’s room, backpack, planner look like? What do Sarah’s room, backpack, planner look like? Other??? Other???

25. What would you do? Question and answer session Question and answer session

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