ADHD CME Module 3


    Recognition and Consideration of
    Comorbid Conditions of ADHD




               VERMONT CHILD ...
ADHD CME Module 3 Objectives:
After completing this educational activity, participants
   should be able to:

• Recognize ...
ADHD CME Module 3 Content:

Comorbidities in ADHD
• Conditions confused with ADHD
• Behavioral co-morbidities
• Psychiatri...
ADHD CME Module 3 Content:

Strategies for initial treatment of the child with ADHD and co-
   morbid conditions
• Behavio...
Comorbidities in ADHD

• The diagnosis of ADHD can be difficult as there are many
  conditions that may share the symptoms...
Common Conditions Coexisting with ADHD
Medical               Psychiatric            Development- Environmental/
diagnoses ...
Comorbidities in ADHD

• Studies of children diagnosed with ADHD consistently
  document high rates of comorbid psychiatri...
Comorbidities in ADHD:
Commonly Coexisting Axis I Disorders


     Comorbidities       Prevalence range

 Anxiety disorder...
Comorbidities in ADHD:
    Commonly Coexisting Axis II Disorders


• Learning Disabilities
• Mental retardation
• Autism s...
Comorbidities in ADHD:
                  Behavioral Conditions

• Children with ADHD may not comply with requests secondar...
Comorbidities in ADHD:
                 Behavioral Disorders

• Approximately 35-40% of children with ADHD will meet crite...
Comorbidities in ADHD:
                  Behavioral Disorders
• Studies suggest that ADHD and comorbid CD may represent a
...
Behavioral Comorbidities of ADHD

• It is often not difficult to detect the symptoms of ODD or CD as
  these behaviors are...
Oppositional Defiant Disorder
• Children with ODD exhibit a pattern of negativistic, hostile and
  defiant behavior

• Opp...
Oppositional Defiant Disorder:
               DSM-IV Criteria

• Often loses temper
• Often argues with adults
• Often act...
Conduct Disorder:
                    DSM-IV Criteria

Children with CD exhibit:
• A repetitive and persistent pattern of ...
Conduct Disorder:
                    DSM-IV Criteria
• Aggression to people and animals
   – Often bullies, threatens or ...
Conduct Disorder:
                    DSM-IV Criteria
• Deceitfulness or theft
   – Has broken into someone else's propert...
Comorbidities in ADHD:
                 Depression
• Prevalence estimates of depression in children with ADHD
  range from...
Comorbidities in ADHD:
                   Depression

• Children with comorbid ADHD and depression appear to have
  poorer...
Major Depressive Disorder:
                DSM-IV Criteria

• Symptoms must be present for more than 2 weeks
• Symptoms le...
Major Depressive Disorder:
                   DSM-IV Criteria

5 or more symptoms should be present nearly every day
     ...
Comorbidities in ADHD:
                Bipolar Disorder

• There is a great deal of symptom overlap between ADHD and
  the...
Comorbidities in ADHD:
                Bipolar Disorder
• A recent study compared prevalence of DSM-IV mania
  symptoms in...
Bipolar Disorder:
           Children and Adolescents


• A number of studies have suggested that depression in
  children...
Bipolar Disorder:
                    DSM-IV Criteria

• Bipolar disorder is a mood disorder characterized by the
  presen...
Bipolar Disorder:
                    DSM-IV Criteria
• During the period of mood disturbance at least 3 of the
  followin...
Comorbidities in ADHD:
               Learning Disorders

• Children with ADHD and comorbid learning disorders do not
  ha...
Comorbidities in ADHD:
               Learning Disorders

Learning disorders occur in 2-10% of the general population
  As...
Learning Disorders:
                    DSM-IV Criteria

• The child’s achievement and ability in reading, math or writing...
ADHD and Comorbid Anxiety Disorders

• 25-30% of children with ADHD have comorbid symptoms of an
  anxiety disorder
• Anxi...
ADHD and Comorbid Anxiety Disorders


• Children with comorbid anxiety may describe subjective
  feelings of: stress, tire...
DSM-IV Criteria:
        Generalized Anxiety Disorder

Excessive worry and anxiety about a number of events or
  activitie...
DSM-IV Criteria:
           Generalized Anxiety Disorder*

• The anxiety, worry or physical symptoms cause significant
  d...
ADHD and Comorbid Tic Disorders
• Approximately 7% of children with ADHD have a tic disorder
• Approximately 60% of childr...
ADHD and Comorbid Tic Disorders


• Children with tic disorders often are not aware when they are
  exhibiting a tic and u...
DSM-IV Criteria:
                 Tourette’s Disorder

• Both multiple motor and at least one vocal tic have been
  presen...
ADHD and Developmental Delays

Symptoms of ADHD can coexist with the behavioral
  symptoms seen in children with developme...
Achenbach Child Behavior Check List
                 (CBCL)

• This broad band symptom check list has components that
  pa...
Strategies for the Initial Treatment of
   Children with ADHD and Comorbidities

• The issue of frequently occurring comor...
Strategies for the Initial Treatment of
   Children with ADHD and Comorbidities

• If ADHD is the primary disorder, approp...
Strategies for the Initial Treatment of Children
  with ADHD and Behavioral Comorbidities

• Research has consistently sho...
Strategies for the Initial Treatment of Children
  with ADHD and Behavioral Comorbidities

  • The child and parents often...
Strategies for the Initial Treatment of Children
         with ADHD and Depression

The behavioral/psychosocial treatment ...
Strategies for the Initial Treatment of Children
         with ADHD and Depression

• The clinician must determine which s...
Strategies for the Initial Treatment of Children
         with ADHD and Depression

 • If symptoms of depression are mild ...
Strategies for the Initial Treatment of Children
         with ADHD and Depression
• Stimulant therapy is more rapidly eff...
Strategies for the Initial Treatment of Children
       with ADHD and Bipolar Disorder

• This clinical situation is parti...
Strategies for the Initial Treatment of Children
           with ADHD and Anxiety

• Children with primary ADHD and comorb...
Strategies for the Initial Treatment of Children
           with ADHD and Anxiety

Psychosocial treatment of children with...
Strategies for the Initial Treatment of Children with
             ADHD and Learning Disorders
• If children with ADHD con...
Strategies for the Initial Treatment of
    Children with ADHD and Tic Disorders

• Evidence from double-blind, placebo-co...
Strategies for the Initial Treatment of
   Children with ADHD and Tic Disorders

An initial decision should be made as to ...
Strategies for the Initial Treatment of Children
  with ADHD and Developmental Disorders
• Children with developmental dis...
ADHD and Substance Use

• It is not necessary for the individual to be “substance free”
  before being treated for ADHD.
•...
References
1)   American Psychiatric Association (1994). Diagnostic and
     Statistical Manual of Mental Disorders 4th ed...
References

7) Kim EY, Miklowitz DJ. Childhood mania, attention deficit
     hyperactivity disorder and conduct disorder: ...
References

11) Tourette’s syndrome Study Group. Treatment of ADHD in
     children with tics:a randomized controlled tria...
ADHD Module 3
                      CME Post Test
Question 1:
Studies of children diagnosed with ADHD consistently documen...
ADHD Module 3
                     CME Post Test

Question 3:
Indicate which of the following statements are true for
    ...
ADHD Module 3
                   CME Post Test
Question 4:
When beginning treatment for a child with ADHD and
   comorbid ...
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Transcript of "ADHD CME Module 3"

  1. 1. ADHD CME Module 3 Recognition and Consideration of Comorbid Conditions of ADHD VERMONT CHILD HEALTH IMPROVEMENT PROGRAM
  2. 2. ADHD CME Module 3 Objectives: After completing this educational activity, participants should be able to: • Recognize and describe frequently occurring comorbid conditions of ADHD • Understand the use of the Achenbach Child Behavior Check List (CBCL) to assist in identifying possible comorbid conditions of ADHD • Discuss the initial management of the school-aged child with ADHD and comorbid conditions
  3. 3. ADHD CME Module 3 Content: Comorbidities in ADHD • Conditions confused with ADHD • Behavioral co-morbidities • Psychiatric co-morbidities • Learning/academic problems • Developmental problems Use of the Achenbach Child Behavior Check List (CBCL) to assess presence of possible co morbid conditions
  4. 4. ADHD CME Module 3 Content: Strategies for initial treatment of the child with ADHD and co- morbid conditions • Behavioral problems • Depression • Bipolar disorder • Anxiety disorders • Tic disorders • Learning/academic difficulties • Developmental problems
  5. 5. Comorbidities in ADHD • The diagnosis of ADHD can be difficult as there are many conditions that may share the symptoms of or can coexist with ADHD. • Symptoms of ADHD may also obscure coexisting symptoms. • A clinician’s ability to consider, recognize and identify the comorbid disorders of ADHD is an essential part of the ADHD diagnostic process. • The DSM-IV states that comorbid conditions may overlap with ADHD. In order to make a diagnosis of ADHD, however, symptoms should not be better explained by another disorder (1).
  6. 6. Common Conditions Coexisting with ADHD Medical Psychiatric Development- Environmental/ diagnoses disorders al issues family issues Hearing/vision Oppositional defiant Learning disabilities family dysfunction problems disorder or Conduct (separation, divorce, disorder domestic violence) Complications of Anxiety Mental retardation Environmental or chronic disorders/OCD and developmental family stressors illness/meds delays Seizure disorders Mood disorders – Autism spectrum Physical, sexual or other neurological depression and disorders psychological abuse disorders /bipolar disorder or neglect toxins Substance Parenting use/abuse dysfunction Syndromes (e.g. Tourette’s disorder fetal alcohol, fragile / tic disorders X)
  7. 7. Comorbidities in ADHD • Studies of children diagnosed with ADHD consistently document high rates of comorbid psychiatric symptoms • Approximately 2/3 of children with ADHD also have at least one other Axis I psychiatric disorder (2). • It is essential to look carefully for comorbid disorders and not assume that co-occurring symptoms are secondary to ADHD. • The presence of comorbid disorders in a child with ADHD often plays a significant role in treatment decisions and also may influence the child’s future outcome.
  8. 8. Comorbidities in ADHD: Commonly Coexisting Axis I Disorders Comorbidities Prevalence range Anxiety disorders 8-30% Conduct disorder 8-25% ODD 45-64% Depression /dysthymia 15-75% Tic disorders 8-34% Mania/hypomania 0-22%
  9. 9. Comorbidities in ADHD: Commonly Coexisting Axis II Disorders • Learning Disabilities • Mental retardation • Autism spectrum disorders – Autism – PDD- NOS – Asperger’s Disorder, • Developmental language delays (2,3)
  10. 10. Comorbidities in ADHD: Behavioral Conditions • Children with ADHD may not comply with requests secondary to distractibility, low frustration tolerance and impulsivity • In school, non-compliance with academic tasks may be also secondary to learning difficulties, lack of organizational skills or anticipation of failure • ADHD in and of itself, however, does not lead to antisocial behavior or behavior that violates social norms
  11. 11. Comorbidities in ADHD: Behavioral Disorders • Approximately 35-40% of children with ADHD will meet criteria for a diagnosis of either Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) • CD and ODD are characterized by impulsive, oppositional and disruptive behaviors – which can appear similar to symptoms of ADHD. This can make it difficult at times to distinguish ODD and CD from ADHD (4)
  12. 12. Comorbidities in ADHD: Behavioral Disorders • Studies suggest that ADHD and comorbid CD may represent a distinct subtype of ADHD as this comorbidity is often found in multiple members within families • Longitudinal data indicate that children with ADHD and comorbid CD have poorer long-term outcomes than children with ADHD alone • One study reported a rate of police contact of: – 30.8% for children with ADHD and CD – 20.7 % for children with CD only – 3.4% for children with ADHD only (5)
  13. 13. Behavioral Comorbidities of ADHD • It is often not difficult to detect the symptoms of ODD or CD as these behaviors are usually readily described by upset and angry parents and teachers • ODD is characterized by persistent patterns of oppositional, irritable behavior toward adults in several settings • CD, which is a more severe behavioral disorder, presents with a repetitive, persistent pattern of behavior which violates social norms and rules and the basic rights of others.
  14. 14. Oppositional Defiant Disorder • Children with ODD exhibit a pattern of negativistic, hostile and defiant behavior • Oppositional or defiant behavior lasts at least 6 months at a frequency greater than that seen in children of similar age and developmental level • These behaviors cause significant impairment in social, academic or occupational functioning. • The oppositional/defiant behavior also cannot occur exclusively during the course of a mood or psychotic disorder
  15. 15. Oppositional Defiant Disorder: DSM-IV Criteria • Often loses temper • Often argues with adults • Often actively defies/refuses to comply with requests/rules of adults • Often deliberately annoys people • Often blames others for his/her mistakes or behavior • Often touchy or easily annoyed by others • Often angry or resentful • Often spiteful or vindictive
  16. 16. Conduct Disorder: DSM-IV Criteria Children with CD exhibit: • A repetitive and persistent pattern of behavior that violates the basic rights of others and/or major age-appropriate societal norms and rules • At least 3 behavioral criterion have occurred over the last 12 months • At least one criterion must have occurred in the past 6 months • These behaviors must cause clinically significant impairment in social, academic or occupational function
  17. 17. Conduct Disorder: DSM-IV Criteria • Aggression to people and animals – Often bullies, threatens or intimidates others – Often initiates fights – Has used a weapon that can cause serious harm – Has been physically cruel to people – Has been physically cruel to animals – Has stolen while confronting a victim – Has forced someone into sexual activity • Destruction of property – Has deliberately engaged in fire setting with intention of causing damage – Has deliberately destroyed others property
  18. 18. Conduct Disorder: DSM-IV Criteria • Deceitfulness or theft – Has broken into someone else's property – Often lies to obtain goods, favors or to avoid obligations – Has stolen nontrivial items without confronting a victim • Serious violations of rules – Stays out at night despite parental prohibitions before age 13 – Run away from home overnight while living in caregiver home – Often truant from school beginning before age 13
  19. 19. Comorbidities in ADHD: Depression • Prevalence estimates of depression in children with ADHD range from 9-38% • In most cases ADHD precedes symptoms of depression • Environmental and genetic factors contribute to etiology of depression – Children with ADHD often experience ongoing social rejection and negative feedback from peers and adults. – This often leads to poor self-esteem and may contribute to the development of depression. – Genetic research suggests possibility of a genetic link between depression and ADHD, as families with members with ADHD have a higher than average prevalence of depression (6)
  20. 20. Comorbidities in ADHD: Depression • Children with comorbid ADHD and depression appear to have poorer outcomes during adolescence than children with ADHD alone • The presence of ADHD and baseline depression may predict recurrent depression as well as an increased risk for social dysfunction and family conflict • Adolescents with ADHD and depression are at an increased risk for suicide attempts, thus, the identification, diagnosis and treatment of comorbid depression is crucial (2)
  21. 21. Major Depressive Disorder: DSM-IV Criteria • Symptoms must be present for more than 2 weeks • Symptoms lead to significant impairment in function. • Symptoms cannot be due to medication side effects, substance abuse or a general medical condition • Symptoms cannot be better explained as acute bereavement. • If manic or hypomanic symptoms are also present, than a diagnosis of bipolar disorder ( not major depression) should be made.
  22. 22. Major Depressive Disorder: DSM-IV Criteria 5 or more symptoms should be present nearly every day including depressed/irritable mood or anhedonia • Depressed or irritable mood most of the day (irritability is more common than depressed mood in children and adolescents) • Anhedonia (markedly decreased interest or pleasure in activities) • Increase or decrease in appetite and/or significant weight loss or gain (or in children failure to make expected weight gains) • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or inappropriate guilt • Decreased ability to think, concentrate or make decisions Recurrent thoughts of death or suicidal ideation
  23. 23. Comorbidities in ADHD: Bipolar Disorder • There is a great deal of symptom overlap between ADHD and the current description of early onset bipolar disorder • Controversy exists as to whether early onset pediatric bipolar disorder is often misdiagnosed as either ADHD or conduct disorder • There is also significant debate as to whether ADHD is often misdiagnosed as bipolar disorder • Research suggests that children with bipolar disorder and ADHD may have a distinct familial subtype of bipolar disorder. • Some findings suggest that manic symptoms may be a sign which indicates severity of psychopathology in a child or adolescent (7)
  24. 24. Comorbidities in ADHD: Bipolar Disorder • A recent study compared prevalence of DSM-IV mania symptoms in a sample with early onset bipolar disorder to groups with ADHD only and controls. • Symptoms of irritability, hyperactivity, accelerated speech, and distractibility were very frequent in both groups with bipolar disorder and ADHD and were not useful for differential diagnosis. • Symptoms of elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep, and hypersexuality provided the best discrimination of subjects with bipolar disorder from subjects with ADHD and controls. • Concurrent symptoms of elation and irritability occurred > 87% of subjects with early onset bipolar disorder • Subjects diagnosed with early onset bipolar disorder with symptoms of mania had high rates of comorbid DSM-IV ADHD (8)
  25. 25. Bipolar Disorder: Children and Adolescents • A number of studies have suggested that depression in children may convert to bipolarity over time (9) • Among children with ADHD the risk of developing symptoms of bipolar disorder increases in adolescence. • Symptoms of prepubertal and adolescent bipolararity often differs from symptoms seen in adults and can be characterized by: (4) – “Affective storms” – Prolonged or aggressive temper outbursts
  26. 26. Bipolar Disorder: DSM-IV Criteria • Bipolar disorder is a mood disorder characterized by the presence of co-occurring depressed episodes and manic episodes, hypomanic episodes or mixed mood episodes • The DSM-IV defines a manic episode as: – a distinct period of abnormally and persistently elevated, expansive or irritable mood – lasting at least a week
  27. 27. Bipolar Disorder: DSM-IV Criteria • During the period of mood disturbance at least 3 of the following symptoms are present – Inflated self-esteem or grandiosity – Decreased need for sleep – Pressured speech or more talkative than usual – Flight or ideas or subjective racing thoughts – Distractibility – Psychomotor agitation or increase in goal-directed activity – Excessive involvement in pleasurable activities with a high risk for poor outcomes • These mood symptoms affect functioning, social relationships or can cause harm to self or others • These symptoms are not the direct result of substance use or a medical condition (e.g. hyperthyroidism)
  28. 28. Comorbidities in ADHD: Learning Disorders • Children with ADHD and comorbid learning disorders do not have lower cognitive levels than children without these diagnoses. • Children with ADHD and comorbid learning disorders are not significantly more anxious, hyperactive or aggressive than children with ADHD alone • Children with ADHD and comorbid learning disorders can have poor academic function and this may negatively impact on their self-esteem and their relationships with family and peers (10)
  29. 29. Comorbidities in ADHD: Learning Disorders Learning disorders occur in 2-10% of the general population As many as 50% of children with ADHD may have learning disorders. • Learning disorders and academic problems are identified and diagnosed by formal psychological and educational testing • Formal learning disabilities are defined by a a significant discrepancy (usually 2 standard deviations) between an individual’s IQ score and their performance on standardized achievement tests. • Learning disabilities are categorized by whether they are specific to reading, math or written expression.
  30. 30. Learning Disorders: DSM-IV Criteria • The child’s achievement and ability in reading, math or writing skills as measured by individually administered standardized tests, is substantially below those expected given the child’s chronological age, measured intelligence and age-appropriate education • The learning disturbance significantly interferes with academic achievement or activities of daily living that require the ability in question • If a sensory deficit is present, the difficulties are in excess of those usually associated with it
  31. 31. ADHD and Comorbid Anxiety Disorders • 25-30% of children with ADHD have comorbid symptoms of an anxiety disorder • Anxiety disorders appear more often in children with inattentive or combined type ADHD than with hyperactive/impulsive ADHD • Children with comorbid ADHD and anxiety are less likely than those without anxiety to exhibit disruptive behavior and are more likely to appear tired, listless and unmotivated • Anxiety in children with ADHD may go unrecognized unless the clinician looks for symptoms • Approximately ½ of children who subjectively describe significant anxiety symptoms are not described as anxious by their parents (2)
  32. 32. ADHD and Comorbid Anxiety Disorders • Children with comorbid anxiety may describe subjective feelings of: stress, tiredness, tension or excessive worry about things in their life • Children with comorbid anxiety may describe poor sleep, somatic complaints such as stomach aches, nausea, lightheadedness, sweatiness, difficulty breathing, headaches and flushing, or symptoms consistent with panic • Children with anxiety may often be mistakenly perceived by parents or other adults as oppositional as they may respond to anxiety provoking situations by using avoidant or resistant behavior
  33. 33. DSM-IV Criteria: Generalized Anxiety Disorder Excessive worry and anxiety about a number of events or activities that occur more often than not for at least 6 months • The child is not able to control the worry • The anxiety and worry is associated with at least 1 of the following symptoms: – Restlessness or edginess – easy fatigue – Difficulty with concentration – Irritability – Muscle tension – Sleep disturbance
  34. 34. DSM-IV Criteria: Generalized Anxiety Disorder* • The anxiety, worry or physical symptoms cause significant distress or impairment in home, school or academic function • The anxiety and worry are not confined to the symptoms of another Axis I disorder ( e.g. OCD, social phobia, separation anxiety…) • The anxiety or worry is not due to the direct physiological effects of a substance or a general medical condition * please see the DSM-IV for the specific criteria for separation anxiety, social phobia and panic disorder
  35. 35. ADHD and Comorbid Tic Disorders • Approximately 7% of children with ADHD have a tic disorder • Approximately 60% of children with Tourette’s disorder have ADHD (11) • Tics are sudden, rapid, recurrent nonrhythmic stereotyped motor movements or vocalizations • Tourette’s disorder is characterized by multiple motor tics and at least 1 vocal tic which occur nearly every day for more than a year • Tics can be simple or complex – Common simple motor tics include blinking, shrugging, grimacing and neck turning – Common simple vocal tics include throat clearing, sniffing, grunting and snorting – Common complex motor tics include facial gestures, touching, smelling objects and jumping – Common complex vocal tics include repeating one’s own sounds, echolalia and use of socially unacceptable words (coprolalia)
  36. 36. ADHD and Comorbid Tic Disorders • Children with tic disorders often are not aware when they are exhibiting a tic and usually find tics very difficult to resist • Tics can usually be suppressed for short periods of time although this process can be tiring to the child • Tics generally are exacerbated by fatigue, stress or any strong positive or negative emotion • Tics are usually diminished when the child’s attention is focused on an activity and during sleep.
  37. 37. DSM-IV Criteria: Tourette’s Disorder • Both multiple motor and at least one vocal tic have been present at least some time during the illness. They do not need to have occurred concurrently • Tics occur many times a day, nearly every day or intermittently for more than a year. During this period there was never a tic- free period of more than 3 months • Onset of tics was prior to age 18 • Symptoms cause marked distress or impairment in social, academic or occupational functioning • Symptoms are not due to the direct physiological effects of a substance or a general medical condition
  38. 38. ADHD and Developmental Delays Symptoms of ADHD can coexist with the behavioral symptoms seen in children with developmental delays. • It is essential to recognize that a child with developmental delays should function at a level consistent with the child’s developmental age. • It is very important not to attribute all of the child’s symptoms of distractibility, hyperactivity and impulsivity to their developmental delays. • If child has significant distractibility, hyperactivity and/or impulsivity that is not typical for their developmental age and it interferes with their function in 2 or more settings than a diagnosis of ADHD should be explored
  39. 39. Achenbach Child Behavior Check List (CBCL) • This broad band symptom check list has components that parents, teachers and children (12 years and older) complete • Once scored and analyzed, the CBCL can assist the clinician in systematically identifying the child’s areas of social and academic strength and weakness and comorbid symptoms that may warrant further clinical evaluation • In combination with a focused ADHD checklist the CBCL can provide the clinical with a tool to thoroughly identify a broad range of psychiatric and behavioral symptoms from multiple sources (12)
  40. 40. Strategies for the Initial Treatment of Children with ADHD and Comorbidities • The issue of frequently occurring comorbidities of ADHD often leads to questions that are essential to address in developing an appropriate treatment plan for patients. • The initial decision that needs to be made is whether the child’s ADHD symptoms or the symptoms of the comorbid disorders are the primary symptoms affecting the child’s function • As a general rule, the primary disorder should always be addressed and treated first
  41. 41. Strategies for the Initial Treatment of Children with ADHD and Comorbidities • If ADHD is the primary disorder, appropriate ADHD treatment should be initiated • If the comorbid disorders are primary they should be addressed and treated first. – If primary comorbid symptoms are adequately treated and ADHD symptoms are still present and impacting significantly on the child's function; then adding treatment for ADHD should be considered • Although simultaneous treatment for ADHD and comorbid disorders is often indicated, the clinician needs to be vigilant to the potential for drug interactions and increased medication side effects.
  42. 42. Strategies for the Initial Treatment of Children with ADHD and Behavioral Comorbidities • Research has consistently shown that treatment with stimulant medication can benefit the symptoms of ADHD and can often attenuate oppositional and defiant behaviors • It is essential that children with comorbid ADHD and ODD or CD be provided with: – clear, structured behavioral expectations – reinforcement of appropriate behavior – consistent consequences for negative, inappropriate behavior • The development of a behavioral plan designed to extinguish negative and antisocial behaviors is a central part of treatment.
  43. 43. Strategies for the Initial Treatment of Children with ADHD and Behavioral Comorbidities • The child and parents often will require assistance from a behavioral therapist • The child’s parents may also benefit from working with a counselor who can provide parent guidance to assist them in developing skills and strategies for managing their child’s behavior • If stimulant medication and behavioral therapy assists in treating ADHD symptoms, but persistent, significant aggressive behavior continues; then a reevaluation is warranted. • This reevaluation should rule out additional disorders and determine if additional medication treatment may assist in decreasing aggressive behavior.
  44. 44. Strategies for the Initial Treatment of Children with ADHD and Depression The behavioral/psychosocial treatment of children with mild- moderate depression involves: • minimizing the child's experience of ongoing negative feedback about their function and/or behavior • Develop the child’s opportunities for positive social experiences and social success • If academic difficulties are present – an evaluation to rule out learning disabilities is essential • Referral to therapist/counselor, if indicated, to assist child/ family with issues related to self-esteem, social difficulties, behavior and coping strategies
  45. 45. Strategies for the Initial Treatment of Children with ADHD and Depression • The clinician must determine which symptoms: ADHD or Major Depression, are primary or more severe. • If the child’s symptoms of depression are primary or significant, than depression should be the focus of treatment – including the consideration of pharmacotherapy for depression • ADHD medication and antidepressants can be used together, if indicated
  46. 46. Strategies for the Initial Treatment of Children with ADHD and Depression • If symptoms of depression are mild to moderate and ADHD symptoms are primary, then treatment with a stimulant medication should be initiated • • Modification of ADHD symptoms secondary to effective ADHD treatment may decrease depressed symptoms • The use of an antidepressant alone when treating primary ADHD with comorbid mild-moderate depression should be considered, at best, a second-line treatment
  47. 47. Strategies for the Initial Treatment of Children with ADHD and Depression • Stimulant therapy is more rapidly effective than antidepressant medication treatment. • The clinician can reassess symptoms of ADHD and depression after an adequate stimulant trial – If symptoms of ADHD and depression have both significantly improved than no further adjustments to the treatment plan may be needed – If symptoms of ADHD are significantly improved but symptoms of depression are still present, than the clinician should consider referring the child for therapy/counseling or adding antidepressant therapy (or initiating both treatments)
  48. 48. Strategies for the Initial Treatment of Children with ADHD and Bipolar Disorder • This clinical situation is particularly difficult to diagnose and treat • A recent analysis of the efficacy of medications given to children with comorbid ADHD and bipolar disorder indicated that the use of mood stabilizers was most associated with significant symptom improvement while the use of antidepressants, antipsychotic and stimulant medication was not as likely to lead to significant improvement in symptoms (13)
  49. 49. Strategies for the Initial Treatment of Children with ADHD and Anxiety • Children with primary ADHD and comorbid anxiety should be initially treated with stimulant medication • Psychosocial interventions are recommended in the situation where the ADHD symptoms improve but the anxiety symptoms do not • If psychosocial interventions are not effective, or the anxiety symptoms worsen, then treatment with a selective serotonin reuptake inhibitor (SSRI) or other anti-anxiety medication should be considered • For children whose anxiety symptoms are primary, psychosocial interventions and treatment of anxiety should occur prior to the treatment of ADHD symptoms
  50. 50. Strategies for the Initial Treatment of Children with ADHD and Anxiety Psychosocial treatment of children with comorbid ADHD and anxiety involves: • educating the child about anxiety • helping the child recognize how anxiety affects them individually • Assisting the child to identify anxiety provoking stressors • The child should also receive targeted anxiety management training to assist them with developing skills and strategies for coping with anxiety provoking situations. This involves learning techniques for: • Relaxation • Deep breathing • Imaging These interventions should ideally be provided by a cognitive behavioral therapist
  51. 51. Strategies for the Initial Treatment of Children with ADHD and Learning Disorders • If children with ADHD continue to have academic problems after their ADHD symptoms have been effectively treated. They should undergo an educational and psychological evaluation • The clinician should advise the parent to contact the child’s school in order to request this evaluation. Clinician contact with the school may also be needed to assist with this process • If learning disorders or academic problems are identified, then a 504 plan or IEP needs to be developed which addresses both the child’s learning disorders and the issues related to ADHD • The clinician can assist the child and family over time with insuring that the child's 504 plan or IEP is targeting the areas of concern and is appropriately implemented
  52. 52. Strategies for the Initial Treatment of Children with ADHD and Tic Disorders • Evidence from double-blind, placebo-controlled studies indicate that stimulants are very effective for the treatment of ADHD in children with comorbid tic disorders • Stimulant treatment may lead to transient flare-ups of tics • Research indicates that the frequency and severity of tics is not significantly different in children with comorbid ADHD and tics treated with stimulants compared with children with the same disorders who are not treated with stimulants (11) • After providing appropriate informed consent stimulants can be tried in children with ADHD and comorbid tic disorders
  53. 53. Strategies for the Initial Treatment of Children with ADHD and Tic Disorders An initial decision should be made as to whether the child's ADHD symptoms or tics are causing the greatest impairment in function • If the tic symptoms are primary, then treatment with an alpha- agonist (guanfacine or clonidine) should be initiated • If ADHD symptoms are primary then stimulant medication or Strattera should be started – If tics increase in severity, a different ADHD medication should be tried – If ADHD symptoms improve and tics persist and are affecting the child's function then combining the ADHD medication with an alpha-agonist should be considered
  54. 54. Strategies for the Initial Treatment of Children with ADHD and Developmental Disorders • Children with developmental disorders and comorbid ADHD can significantly benefit from treatment of their ADHD symptoms – this may lead to improvements in academic and social function • ADHD treatment decisions should be similar to decisions made for children without developmental disorders • Important to recognize that children with developmental disorders may be more likely to experience medication side effects • Children with developmental delays may be more likely to have a transient period of irritability when starting stimulant medication. – Irritability, if it occurs typically lasts only a few days – Important to prepare parents for this when starting treatment • In general, initial starting doses of medication should be low, dose adjustments should be done slowly and the child’s response to medication should be monitored closely
  55. 55. ADHD and Substance Use • It is not necessary for the individual to be “substance free” before being treated for ADHD. • Close follow up is necessary, as always. • Research demonstrates that an individual who is properly treated for symptoms of ADHD is less likely to abuse substances than an individual who is untreated. Resources: • Wilens, TE. ADHD and alcohol or drug use. Program and abstract of the 154th Annual Meeting of the American Psychiatric Association; May 5-10, 2001; New Orleans, Louisiana. Symposium 25C • Biederman J, Wilens, T, Mick E, et al. Pharmacotherapy of ADHD reduces risk for substance use disorder. Pediatrics, Aug 1999, 104 (2) pe20
  56. 56. References 1) American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV). Washington D.C. 2) Spencer T, Biederman J, Wilens T. Attention deficit hyperactivity disorder and comorbidity. Pediatric Clin North Am. 1999;46:915-927. 3) Biederman J, Faraone S et al. . A prospective 4-year follow-up study of attention deficit hyperactivity and related disorders. Arch Gen Psychiatry. 1996; 53(5); 437-446. 4) Pliszka SR. Co-morbidity with attention deficit hyperactivity disorder: an overview. 1998; Jour of Clin Psychiatry, 59(supp7):S50-S58 5) Barkley, RA, Fischer M, Smallish L, Fletcher K. Young adult follow-up of hyperactive children: antisocial activities and drug use. J Child Psychol Psychiatry. 2004, 45:195-211. 6) Pliszka SR. Patterns of psychiatric comorbidities with attention deficit hyperactivity disorder. Child and Adol Psychiatric Clin of North Am., July 2000. 525.540.
  57. 57. References 7) Kim EY, Miklowitz DJ. Childhood mania, attention deficit hyperactivity disorder and conduct disorder: a critical review of diagnostic dilemmas. Bipolar Disord 2002 Aug;4(4):215- 25 8) Geller B; Zimerman B; Williams M et al. .DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls. J Child Adolesc Psychopharmacol 2002 Spring;12(1):11-25. 9) Geller, B, Zimmerman B et al. Bipolar disorder a prospective follow-up of adults who had prepubertal major depressive disorder. Am J of Psychiatry. 2001;158:125-127. 10) Faraone SV, Beiderman J, Weber W et al. Psychiatric, neuropsychological and psychosocial features of DSM-IV subtypes of Attention Deficit Hyperactivity Disorder: results from a clinically referred sample. J Am Acad Child and Adolesc Psychiatry 1998.37:185-193.
  58. 58. References 11) Tourette’s syndrome Study Group. Treatment of ADHD in children with tics:a randomized controlled trial. Neurology 2002;58:527-36 12) Achenbach TM (1991) , Manual for the Child Behavior Checklist/ 4-18 . University of Vermont , Department of Psychiatry 13) Biederman J, Mick E, Bostic JQ. The naturalistic course of pharmacologic treatment of children with manic like symptoms: a systematic chart review. J Clin Psychiatry. 1998; 59: 628-637.
  59. 59. ADHD Module 3 CME Post Test Question 1: Studies of children diagnosed with ADHD consistently document high rates of comorbid psychiatric symptoms (True or False) Question 2: A recent analysis of the efficacy of medications given to children with comorbid ADHD and bipolar disorder indicated that the following medication was most associated with significant symptom improvement 1. Mood stabilizers 2. Antidepressant medication 3. Antipsychotic medication 4. Stimulant medication
  60. 60. ADHD Module 3 CME Post Test Question 3: Indicate which of the following statements are true for children with developmental delays: 1. Symptoms of ADHD can coexist with the behavioral symptoms seen in children with developmental delays. 2. The child’s symptoms of distractibility, hyperactivity and impulsivity are almost always related only to their developmental delays.
  61. 61. ADHD Module 3 CME Post Test Question 4: When beginning treatment for a child with ADHD and comorbid depression: 1. If symptoms of depression are mild to moderate and ADHD symptoms are primary, then treatment with a stimulant medication should be initiated 2. Modification of ADHD symptoms secondary to effective ADHD treatment may decrease depressed symptoms 3. The use of an antidepressant alone when treating primary ADHD with comorbid mild-moderate depression should be considered, at best, a second-line treatment 4. All of the above
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