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

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: AD/HD, combined type: criteria from both dimensions AD/HD, combined type: criteria from both dimensions –6 of 9 from both symptom lists AD/HD, predominantly inattentive type: inattentive criteria AD/HD, predominantly inattentive type: inattentive criteria –6 of 9 inattentive symptoms AD/HD, predominantly hyperactive-impulsive type: hyperactive-impulsive criteria AD/HD, predominantly hyperactive-impulsive type: hyperactive-impulsive criteria –6 of 9 hyperactive-impulsive symptoms Ref: APA 1994

7. 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?

8. 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

9. 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

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

11. ADHD: Comorbidities in Children/Adolescents Learning disordersLearning disorders Language and communication disordersLanguage and communication disorders Oppositional defiant disorderOppositional defiant disorder Conduct disordersConduct disorders Anxiety disordersAnxiety disorders Mood disordersMood disorders Tourette’s syndrome; chronic ticsTourette’s syndrome; chronic tics Ref: Biederman 1991; Hinshaw 1987

12. 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)

13. 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)

14. 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)

15. 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)

16. 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)

17. 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)

18. 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

19. A Norepinephrine Reuptake Inhibitor (NRI)

20. Mechanism of Action

21. Strattera: Effects on Dopamine

22. Case Example XY presented to child psychiatrist for ADHD, SLD, expressive language disorder XY presented to child psychiatrist for ADHD, SLD, expressive language disorder Family history + ADHD, depression Family history + ADHD, depression Treated with stimulants, school interventions as preadolescent Treated with stimulants, school interventions as preadolescent Developed severe aggression, mood instability, some seasonal variations in mood in early adolescence Developed severe aggression, mood instability, some seasonal variations in mood in early adolescence Repeated inpatient crisis stabilization, family therapy, medication adjustments Repeated inpatient crisis stabilization, family therapy, medication adjustments Developed psychotic symptoms with hypomanic component Developed psychotic symptoms with hypomanic component Residential treatment pursued Residential treatment pursued

23. XY follow-up Temporarily stopped ADHD medication treatment, used antipsychotic medications 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 Moved into mood stabilization, resumed ADHD medications once had remained free of psychotic symptoms for 3 months Continued family intervention (“the explosive child”) 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 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 Continues to experience social isolation, but markedly improved overall functioning