Coexisting Disorders
s 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. 1-800-233-4050
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 5 adhd and coexisting disorders 2
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 5 adhd and coexisting disorders 3
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 5 adhd and coexisting disorders 4
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.
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.
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