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Help4adhd.org
W H AT W E K N O W Coexisting Disorders As many as two thirds of children with ADHD have at
least one other coexisting condition.1 The constant
motion and fidgetiness, interrupting and blurting out, difficulty waiting in lines or sitting in
restaurants, and need for constant reminders may overshadow these other
disorders. But just as untreated ADHD can leave lasting scars, so too can other
untreated disorders cause unnecessary suffering in individuals with ADHD and
their families. Any disorder can coexist with ADHD, but certain disorders seem
HOW ArE THEsE COExisTiNg CONDiTiONs iDENTifiED? As the diagnosis of ADHD is considered, the clinician or mental health
professional must also determine whether there are any other psychiatric
disorders affecting the child that could be responsible for presenting symptoms.
Often, the symptoms of ADHD may overlap with other disorders. The challenge
for the clinician is to discern whether a symptom belongs to ADHD, to a
different disorder, or to both disorders at the same time. For some children, the
overlap of symptoms among the various disorders makes multiple diagnoses
necessary. By conducting a complete evaluation, a clinician or mental health professional
familiar with ADHD and other psychiatric disorders will be able to diagnose
both the ADHD and related conditions. Interviews and questionnaires are often
used to obtain information about symptoms from the patient, the patient’s family,
and his or her teachers to screen for these other disorders.
www.help4adhd.org 1-800-233-4050 WHiCH CONDiTiONs mOsT COmmONly
Treatment of the person with ADHD and ODD/CD
COExisT WiTH ADHD?
requires efforts to discourage delinquent behaviors
ADHD may coexist with one or more disorders. The
so that the person will increasingly choose pro-social
most common disorders to occur with ADHD are (1)
behaviors. ODD and CD usual y require strong, clear
disruptive behavior disorders; (2) mood disorders; (3)
structure with reinforcement of appropriate behaviors
anxiety disorders; (4) tics and Tourette Syndrome; and
as well as a positive behavior management plan to
extinguish antisocial behaviors. Medication remains important. Research has shown
that ADHD and CD students treated with stimulant
DisrupTivE BEHAviOr DisOrDErs
medicines are not only more attentive, but also less
(OppOsiTiONAl-DEfiANT DisOrDEr
antisocial and aggressive. In addition, medication
AND CONDuCT DisOrDEr)
combinations, such as a psychostimulant with an
About 40 percent of individuals with ADHD have
antidepressant, appear to be very effective for these
oppositional defiant disorder (ODD). Among individuals
with ADHD, conduct disorder (CD) is also common,
occurring in 25 percent of children, 45-50 percent of
adolescents and 20-25 percent of adults. ODD involves
mOOD DisOrDErs
a pattern of arguing with multiple adults, losing one’s
Some children, in addition to being hyperactive,
temper, refusing to follow rules, blaming others,
impulsive, and/or inattentive, may also seem to always be
deliberately annoying others, and being angry, resentful,
in a bad mood. They may cry daily, out of the blue, for no
reason, and they may frequently be irritable with others
CD is associated with efforts to break rules without
for no apparent reason. Both sad, depressive moods and
getting caught. Such children may be aggressive to
persisting elevated or irritable moods (mania) occur with
people or animals, destroy property, lie or steal things
ADHD more than would be expected by chance.
from others, run away, skip school, or break curfews.
DEprEssiON “The most common disorders to
The most careful studies suggest that between 10-30
percent of children with ADHD, and 47 percent of
occur with AD/D are disruptive
adults with ADHD, also have depression. Typical y,
ADHD occurs first and depression occurs later. Both
behavior disorders, mood disorders,
environmental and genetic factors may contribute.
anxiety disorders, tics and Tourette
Environmental y, as children with ADHD get older, they
may feel left out. Too often they are forgotten on birthday
Syndrome, and learning disabilities.”
party lists, playdates, and sleepovers. These children may
not be invited to play at other children’s homes because
of past difficulties with accidents or may not be chosen
CD is often described as delinquency and children who
to be on sports teams or to participate in games. This
have ADHD and conduct disorder may have lives that
takes a heavy toll on the child’s self-esteem. As these
are more difficult than those of children with ADHD
episodes pile up, the child with ADHD can become
alone. Academical y, students with both ADHD and
discouraged and about one in four may become clinical y
CD are twice as likely to have difficulty reading as other
depressed. While all children have bad days where they
ADHD children. Children with both ADHD and CD,
feel down, depressed children may be down or irritable
but not other children with ADHD, are at greater risk for
most days. Children with ADHD and depression may
social and emotional failure. Studies now suggest that
also withdraw from others, stop doing things they once
ADHD and CD may be a particular subtype of ADHD,
enjoyed, have trouble sleeping or sleep the day away, lose
since multiple family members often have both of these
their appetite, criticize themselves excessively (“I never
do anything right!”), and talk about dying (“I wish I were
What We KnoW 5adhd and coexisting disorders2
dead”). Fortunately, ADHD by itself is not associated
children with ADHD will go on to develop mania. The
with increased risk of suicidal behavior. Current studies
combination of ADHD and mania often leads to severe
suggest that both ADHD and depression may share
difficulty functioning. The overlap of mania and ADHD
a common underlying genetic link, since families
is being actively studied. As patients with ADHD-mania
with ADHD also seem to have more members with
are followed over time, it will become clearer what their
depression than would be expected by chance.
Treatment of children with ADHD and depression
From a treatment standpoint, mood must be stabilized
involves minimizing environmental traumas and
on medications before treatment for ADHD is likely
different medication regimens. To minimize the child
to be successful. Patients with ADHD-mania now are
with ADHD’s difficulty in playing with others, parents
treated with mood stabilizers such as lithium, valproate
and teachers can arrange small group play experiences
(Depakote), or carbamazepine (Tegretol). Because these
(sometimes just two people). In addition, it is vital that
agents usual y do not improve the ADHD symptoms,
the parent monitor the school setting. Even children with
stimulants or antidepressants are often added to improve
careful y constructed educational plans may continue to
struggle if the plan is inadequate. A number of studies
have shown that certain antidepressant medications
improve ADHD alone, or with depression. The
antidepressant desipramine (Norpramin) has improved
Up to 30 percent of children and 25-40 percent of adults
both ADHD and ADHD and depression. Researchers
with ADHD will also have an anxiety disorder. Anxiety
have also found that stimulants (such as Ritalin) can be
disorders are often not apparent, and research has
combined safely with antidepressants such as fluoxetine
shown that half of the children who describe prominent
(Prozac) — these children not only feel better but also
anxiety symptoms are not described by their parents
function better at school. Newer antidepressants such as
as anxious. As with depression, the child’s internal
bupropion (Wel butrin) and venlafaxine (Effexor) have
feelings may not stand out to parents or teachers.
been found effective in some individuals with ADHD
Patients with anxiety disorders often worry excessively
alone and may additional y benefit those individuals
about a number of things (school, work, etc.), and may
feel edgy, stressed out or tired, tense, and have trouble
getting restful sleep. A small number of patients may
report brief episodes of severe anxiety (panic attacks),
mANiA/BipOlAr DisOrDEr
which intensify over about 10 minutes with complaints
Up to 20 percent of individuals with ADHD also may
of pounding heart, sweating, shaking, choking, difficulty
manifest bipolar disorder. This condition involves
breathing, nausea or stomach pain, dizziness, and fears
periods of abnormal y elevated mood contrasted by
of going crazy or dying. These episodes may occur for
episodes of clinical depression. Adults with mania may
no reason, and sometimes awaken patients. Students
have long (days to weeks) episodes of being ridiculously
with ADHD and anxiety report more school, family,
happy, and even believe they have special powers or
and social/peer problems than student who only have
receive messages from God, the radio, or celebrities.
ADHD. Students with ADHD accompanied by anxiety
With this expansive mood, they may also talk incessantly
are less likely to appear hyperactive and disruptive, but
and rapidly, go days without sleeping, and engage in
instead appear more slowed down or inefficient. Genetic
tasks that ultimately get them into trouble. While manic,
research thus far suggests that ADHD and anxiety are
they may go on spending sprees which get them into
separate disorders inherited independently of each other.
debt, become hypersexual, or contact people at all hours
Treatment of ADHD and anxiety requires attention
to precipitating stressors, and training in methods
In younger people, mania may show up differently.
of contending with fear-provoking circumstances.
Children may have moods that change very rapidly,
Relaxation techniques and alternative ways to think
seemingly for no reason, be pervasively irritable, exhibit
through stressful situations may be helpful. ADHD
unpremeditated aggression, and sometimes hear voices
and anxiety appear less responsive to conventional
or see things the rest of us don’t. ADHD is much more
ADHD medication treatments. Specifical y, children
common than mania, and while many children with
with ADHD and anxiety only showed a 30 percent
mania may first exhibit ADHD symptoms, very few
response to methylphenidate (Ritalin), versus a 70-80
What We KnoW 5adhd and coexisting disorders3
percent response observed in ADHD-only children.
anxious, hyperactive, or aggressive than student with
Moreover, at least one study has shown that children
ADHD only. However, the learning disorder does impact
with ADHD and anxiety are more sensitive to negative
school performance, which may subsequently impact
side effects of stimulant medications. Accordingly,
alternative medication regimens may be necessary.
Tricyclic antidepressants (e.g., desipramine [Norpramin],
Treatment requires careful attention to the student’s
nortriptyline [Pamelor], imipramine [Tofranil]),
unique strengths and weaknesses. If academic difficulties
benzodiazepines (lorazapam [Ativan], clonazepam
occur despite beneficial treatment (with psychosocial
[Klonopin], alprazolam [Xanax], etc.) and more recently
interventions and medication), then it is necessary to
buspirone (BusPar) may benefit these patients.
pursue an educational evaluation that assesses learning
disabilities. Usual y this requires that family members
contact the school principal, teacher, or guidance
department to initiate the process, which culminates
TiCs AND TOurETTE syNDrOmE
with devising — when necessary — an individual
Only about seven percent of those with ADHD have
tics or Tourette Syndrome, but 60 percent of those with
Tourette Syndrome have ADHD. Tics (sudden, rapid,
“Individuals with ADHD frequently
recurrent, involuntary movements or vocalizations) or
Tourette Syndrome (both movements and vocalizations)
have difficulty learning in school.up
can occur with ADHD in two ways. First, mannerisms
or movements such as excessive eye blinking or throat
to 50 percent of children with ADHD
clearing often occur between the ages of 10-12 years.
have a coexisting learning disorder.”
When children are nervous or tired, these tics may
appear worse or more conspicuous. These temporary tics
usual y go away gradual y over one-to-two years, and are
just as likely to happen in children with ADHD as others.
educational plan (IEP) or Section 504 plan for the
Tourette Syndrome is a much rarer, but more severe tic
student. The IEP is reviewed at least annual y by school
disorder, where patients may make noises (e.g., barking a
personnel to ensure that educational planning is helping
word or sound) and movements (e.g., repetitive flinching
the student make academic progress. Medications do not
or eye blinking) on an almost daily basis for years.
specifical y improve learning disorders, but may improve
ADHD symptoms so that learning can accelerate.
ADHD, although the opposite is not true. Tics can also become more noticeable when patients
are treated with stimulants or — much less likely —
WHAT ABOuT suBsTANCE ABusE?
bupropion. While these medicines no longer appear
Recent work suggests that youths with ADHD are at
to cause tics, they may unmask or exaggerate tics.
increased risk for very early cigarette use, followed
Accordingly, sometimes lowering the dose can decrease
by alcohol and then drug abuse. Cigarette smoking is
the tics. Other medicines such as nortriptyline (Pamelor
more common in adolescents with ADHD, and adults
or Aventyl), clonidine (Catapres), or guanfacine (Tenex)
with ADHD have elevated rates of smoking and report
may be used to decrease tics while treating ADHD.
particular difficulty in quitting. Youths with ADHD
are twice as likely to become addicted to nicotine as
lEArNiNg DisABiliTiEs
As documented by current research, cocaine and
Individuals with ADHD frequently have difficulty
stimulant abuse is not more common among individuals
learning in school. Depending on how learning disorders
with ADHD who were previously treated with
are defined, up to 50 percent of children with ADHD
stimulants: growing up taking stimulant medicines does
have a coexisting learning disorder. Individuals with
not lead to substance abuse as these children become
learning disabilities may have a specific problem reading
teenagers and adults. Indeed, those adolescents with
or calculating, but they are not less intelligent than their
ADHD prescribed stimulant medication are less likely
peers are. Research indicates that students with both
to subsequently use illegal drugs than are those not
ADHD and reading disorder (dyslexia) are no more
What We KnoW 5adhd and coexisting disorders4 suggEsTED rEADiNg The information provided in this sheet is supported by Grant/
Biederman, J. (1998). Attention-deficit/ hyperactivity disorder:
Cooperative Agreement Number 5U38DD000335-05 from the
A life-span perspective. Journal of Clinical Psychiatry 59
Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. This fact sheet was approved
Biederman, J, et al. (1999). Pharmacotherapy of attention-
by CHADD’s Professional Advisory Board in 2003.
deficit/hyperactivity disorder reduces risk for substance use
disorder. Pediatrics 104:e20. Hechunan, L., Ed. (1996). Do they grow out of it? Long-Term Outcomes of Childhood Disorders. Washington, DC: American
Psychiatric Association. Pliszka, S.R. (1998). Comorbidity of attention-deficit/
hyperactivity disorder with psychiatric disorder: An overview.
Permission is granted to photocopy and freely distribute
Journal of Clinical Psychiatry 59 (Supplement 7): 50-5B.
this What We Know sheet for non-commercial,
Gregg, S. (1996). Preventing antisocial behavior in disabled
educational purposes only, provided that this document
and at-risk students. Appalachia Educational Laboratory Policy
is reproduced in its entirety, including the CHADD
and NRC names, logos, and all contact information.
Wachtel, A. (1998). The attention deficit answer book. New
Permission to distribute this material electronical y
without express written permission is denied. rEfErENCEs
For further information about ADHD or CHADD,
1. MTA Cooperative Group. (1999). A 14-month randomized
clinical trial of treatment strategies for attention deficit
hyperactivity disorder. Archives of General Psychiatry, 56, 12. national resource center on adhd children and adults with attention-deficit/hyperactivity disorder 8181 Professional Place, Suite 150 Landover, MD 20785 800-233-4050 www.help4adhd.org www.chadd.org.
What We KnoW 5adhd and coexisting disorders5
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Case: 07-2271 Document: 00318362723 Page: 1 Date Filed: 03/31/2009 PRECEDENTIAL by the United States Nuclear Regulatory CommissionBefore: McKEE, SMITH and ROTH, Circuit JudgesCase: 07-2271 Document: 00318362723 Page: 2 Date Filed: 03/31/2009Anne Milgram, Esquire Attorney General of New Jersey Nancy Kaplen, Esquire Assistant Attorney General of Counsel Ellen B. Balint, Esquire Eileen P. Kell