1. ADHD: COMMON CO-MORBID DISORDERS Lynn Hugger, Ph.D.
333 East Shore Road
Manhasset, NY

2. ADHD Defined
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.
Occurs before age 12
Occurs across 2 or more settings (e.g. home, school/work, peers)
Symptoms are not caused by another problem – such as psychosis, depression, PTSD, another neurological problem

3. Symptoms of inattention:
Fails to close attention to detail – makes careless mistakes
Difficulty sustaining attention
Does not seem to listen when spoken to
Often does not follow through on instructions or fails to finish schoolwork, chores or duties in the workplace
Avoids or dislikes tasks that require sustained mental effort
Often loses things
Easily distracted
Forgetful in daily activities

4. Symptoms of Hyperactivity/Impulsivity
Often fidgets with or taps hands, feet or squirms in seat
Leaves seat in situations when remaining in seat is expected
Runs about or climbs in situations where it is inappropriate
Often unable to play or engage in leisure activities quietly
Often “on the go,” unable to be still for extended periods of time
Often talks excessively
Often blurts out an answer before a question has been completed
Often has difficulty waiting his/her turn
Often interrupts or intrudes on others

5. Developmental Considerations
Problems with hyperactivity are often seen in early childhood –
They activity level is excessive relative to children of the same age
Predominantly Inattentive Type is often not noticed until later elementary school or even later (especially with girls).
Middle school and the higher grades are more complex worlds academically and socially – resulting in greater demand for strong executive functions.

6. Executive Functions Initiate Speed Effort Working Memory Inhibit Shift
Attention
Shift
Transitions
Plan
Organize
Monitor
Social skills
Emotion Regulation
Inhibit
Impulsivity
Initiate
Speed
Effort
Working
Memory

7. Co-Morbid Disorders
More than 50% of children & adolescents with AD/HD meet criteria for another psychiatric disorder as well. (Brown, 2001)
25% of children with ADHD meet criteria for an anxiety disorder
27% have a reading disorder
31% have a math disorder
65% have a disorder of written expression
Depression
Oppositional defiant disorder/conduct disorder
Disruptive Mood Dysregulation Disorder
Obsessive Compulsive Disorder
Tic Disorders
Autism Spectrum Disorder
Substance Abuse

8. Additional Ways to Think About ADHD
Daniel Amen (& others) identify 7 types of ADHD
In addition to 1. ADHD-Inattentive Type
2. ADHD-Hyperactive, Impulsive Type
3. ADHD-Combined Type
Daniel Amen adds:
4. Overfocused ADD – excessive worrying, argumentative, tends to get stuck in negative thoughts.
5. Temporal Lobe ADD – temper, rage, mild paranoia
6. Limbic ADD – moody & low energy
7. ‘Ring of Fire’ ADD- angry, aggressive, periods of mean aggressive behavior & grandiose thinking

9. Importance of a Comprehensive Psychological Testing Assessment
This is the only way to fully understand what is impacting your child or teenager.
Once you understand your child’s unique profile you can begin to create realistic expectations at school and at home within your family life.
As you will see there are many overlapping disorders that require different kinds of interventions.

10. Parent/Child Relationship Challenges
Your understanding helps:
You to obtain the necessary supports at school.
Have realistic expectations at home.
Help extended family support your child and you.
Through your understanding, your child/teen can understand themselves
Helps you to shift from criticism and punishment to support and realistic expectations.
These changes decrease anxiety, depression, OCD
These changes decrease risk for substance abuse

11. Overlap between ADHD & Reading
Reading disorders have various facets –
Problems with decoding or phonetics are separate from ADHD but your child can have both.
Children & teens often have the following reading challenges:
Weakness in sustained concentration
Slow reader due to processing weakness
Misunderstanding main ideas or inferences due to weakness in organizing information efficiently or tendency to make atypical connections
Low frustration tolerance causing decreased patience needed for reading

12. Helping With Weakness in Reading
If your child has been assessed to have a weakness in phonetic decoding work with a certified reading teacher is very important.
Pick short books
School needs to modify quantity of reading
Some people benefit from an audio book
Sparks notes help distill important information – this should not be seen as cheating.
Teens with ADHD need to be taught how to identify important information.

13. Anxiety
It is very common for people with ADHD to experience anxiety. Processing rapid, complex information is often experienced as an overwhelming feeling.
Modifications in school and in your parenting style can decrease this overwhelmed feeling.
People with ADHD (just like other people) can have anxiety for other reasons that have less to do with having ADHD – that is two co-existing conditions.

14. Modifications at School & Decrease in Anxiety
Look for ways to decrease pressure
Modified homework requirements
Extended deadlines without penalty
Tutors
Lighter course load and increased study halls

15. Changes at home that decrease anxiety
Help at home with organization
Parents understanding that help with homework is needed & not due to being “irresponsible” or “immature”
Consider medication
Consider psychotherapy
Modify your own expectations and help your child modify their expections

16. Obsessive-Compulsive Disorder
Obsessions are recurrent & persistent thoughts, urges, or images that are experienced as intrusive or unwanted
Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rigid rules.
OCD, Tic Disorders and ADHD can often be seen in combination in children

17. Helping Your Child with OCD
The disorder typically has a neurobiological basis
The more you give in to an obsession or compulsion the larger and stronger it gets
Your child can not be asked to stop all at once but understanding this idea will help make them a partner in gradually reducing the process in a slow, step-by-step manner
Work with a therapist will be important in this
It is often driven by some other conflict, worry or concern and addressing this in psychotherapy is very important
When needed, medication can be of help.

18. Depression
Depression can have many causes – people with ADHD have conflicts just like everyone else.
Living with ADHD - at times - can contribute to different levels of depression because of all the challenges and failure experiences.
Symptoms of depression: apparent sadness, change in sleep patterns, withdrawal, lack of pleasure, self-harm, substance abuse, suicidal thinking

19. Oppositional Defiant Disorder
Your child begins to act atypically angry and defiant
Easily loses temper
Often touchy or easily annoyed
Argumentative
Defies rules and requests from people in authority
Often blames others for his/her misbehavior
Spiteful or vindictive
With someone who has ADHD – want to be sure that these symptoms do not only occur in situations that demand sustained effort and attention

20. Disruptive Mood Regulation Disorder
Severe, recurrent temper outbursts manifested verbally (verbal rages) &/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation.
Temper outbursts are inconsistent with the chld’s developmental level.
Temper outbursts occur, on average, 3 or more times per week.
Mood between temper outbursts is persistently irritable or angry most of the day & is observable by others.
Symptoms present for 12 or more months
Symptoms occur in at least 2 or 3 settings.
Onset is before 10 years old.

21. Autism Spectrum Disorder
Children can have Autism Spectrum Disorder & ADHD
Autism Spectrum Disorder includes:
Persistent deficits in social communication and social interaction across multiple contexts:
Problems with social-emotional reciprocity
Weakness in nonverbal communication behaviors (eye contact, reading social cues & body language)
Weakness in understanding relationships
Restricted, repetitive patterns of behavior, interests, or activities:
Repetitive motor movements, use of objects, or types of speech
Inflexible, insistence on sameness
Restricted, fixated interests – “special interest”
Hyper or Hypo sensitivity to sensory aspects of the environment (pain, temperature, smell, visual fascination with lights or movement
Ranges from level 1 – requires support to level 3 requires very substantial support

22. Bipolar Disorder
This is a mood disorder with cycles of highs (mania) and lows (depression)
It can at times be hard to distinguish from ADHD
Some people with Bipolar Disorder also have ADHD
Emotion regulation problems can go with both disorders
Impulsivity can go with both disorders
Depression can be co-morbid with ADHD and is one of the cycles of Bipolar
In young children severe temper tantrums instead of typical mania can be a symptom of BiPolar disorder

23. Sources
Amen, Daniel (2001). Healing ADD: the breakthrough program that allows you to see & heal the 6 types of ADD. NY: The Berkley Publishing Group.
Brown, Thomas (2001). Brown Attention-Deficit Disorder Scales for Children & Adolescents.
Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition
March, John (2007). Talking Back to OCD. NY: Guilford Press.
Papolos, Demitri (2007). The Bipolar Child: the definitive and reassuring guide to childhood’s most misunderstood disorder, 3rd Edition. NY: Broadway.