ADHD AND
COMORBIDITIES
Dr. Paul Soper MD FRCPC
Child and Adolescent Psychiatrist
Glenrose ADHD Program
1Saturday, 21 Septe...
Objectives
Review what is a comorbidity.
Review the different comorbidities frequently found
with childhood ADHD.
Review th...
WHAT IS A
COMORBIDITY?
3Saturday, 21 September, 13
Comorbidities
Definition:
The presence of a second disorder
Feinstein “Any distinct additional entity that has
existed or m...
Comorbidities
1. Chance
2. Direct Causation - Having ADHD causes the other
disorder
3. Associated Risk Factors - Risk fact...
Comorbidities
Comorbidity often complicates the diagnosis and
treatment of childhood ADHD:
87 % of ADHD children have at l...
Comorbidities - Treatment
The treatment of ADHD should involve many
different types of interventions at the same time
(mult...
SPECIFIC
COMORBITITIES
8Saturday, 21 September, 13
OPPOSITIONAL
DEFIANT
DISORDER(ODD)
9Saturday, 21 September, 13
ADHD + ODD
Rate: By far the most common: up to 60% of kids
Definition: A pattern of negativistic, hostile, and defiant behav...
ADHD + ODD
Treatment should be multimodal (of course!). The
following principles apply:
1. Stimulants found to be the most...
ANXIETY
12Saturday, 21 September, 13
ADHD + Anxiety
Rate: 20-30% of children with ADHD
Definition:
Generalized Anxiety Disorder: Excessive anxiety and
worry (ap...
ADHD + Anxiety
Treatment
Should be multimodal (of course!!)
Cognitive behavior therapy should be the first line
treatment f...
ADHD + Anxiety
Treatment
How to find a therapist trained in CBT:
1. Usually the fastest and easiest way to find a CBT
practi...
LEARNING DISABILITY
(LD)
16Saturday, 21 September, 13
ADHD + LD
Rate: 20-30% of children with ADHD
Definition: “Abilities are below expectations”
Reading Disorder
Mathematics Di...
CONDUCT DISORDER
(CD)
18Saturday, 21 September, 13
ADHD + CD
Rate: 14% of children with ADHD
Definition:
A repetitive and persistent pattern of behavior in
which the basic ri...
ADHD + CD
Treatment
Should be multimodal (of course!!)
Multisystemic:
Includes: Family & Individual Therapy, Mentors,
Prog...
DEPRESSION
21Saturday, 21 September, 13
ADHD + Depression
Rate: 4 % of children with ADHD
Definition:
Five (or more) of the following symptoms have been
present du...
ADHD + Depression
Treatment
Should be multimodal (of course!!)
The most impairing difficulty should be the focus of
treatmen...
ADHD + Depression
Treatment
How to find a therapist trained in CBT:
1. Usually the fastest and easiest way to find a CBT
pra...
BIPOLAR AFFECTIVE
DISORDER (BAD)
25Saturday, 21 September, 13
ADHD + BAD
Rate: 6-7 % of people with ADHD from all ages (rare
in childhood)
Definition:
A distinct period of abnormally an...
ADHD + BAD
Treatment
Should be multimodal (of course!!)
Bipolar disorder must be stabilized first.
Usually includes treatme...
ADHD AND AUTISM/
ASPERGER’S (ASD)
28Saturday, 21 September, 13
ADHD + ASD
Rate: 30% of kids with Autism, 18% of children with
ADHD have Autistic Traits
Definition:
Severe and pervasive i...
ADHD + ASD
Treatment
Should be multimodal (of course!!)
Some form of social skills training should be added to
the treatme...
TOURETTE’S
SYNDROME (TS)
31Saturday, 21 September, 13
ADHD + Tourette’s
Rate: 11% of children with ADHD have a tic disorder
(less than one percent meet criteria for Tourette’s)...
ADHD + TS
Treatment
Should be multimodal (of course!!)
Treat the tics only if they are a problem.
The bigger issue is usua...
SUBSTANCE USE
DISORDERS (SUD)
34Saturday, 21 September, 13
ADHD + SUDs
Rate: 47% of 27 year olds with ADHD report a
substance use problem during their lifetime
Definition:
A maladapt...
ADHD + SUDs
Treatment
Should be multimodal (of course!!)
Addictions counseling should be involved.
My experience is that A...
SLEEP DISORDERS (SD)
37Saturday, 21 September, 13
ADHD + SDs
Prevalence: 25%-55% of children with ADHD
experience sleep problems
These sleep problems include:
Sleep Onset I...
ADHD + SDs
Management of insomnia usually includes the following
steps:
1. Ensure appropriate diagnosis
2. Sleep Hygiene
3...
OTHER
DEVELOPMENTAL
DELAYS
40Saturday, 21 September, 13
ADHD +
Intellectual Disability
Rate: 8-39% of those with Borderline or Mild ID
Definition: Having a measured IQ that is gre...
ADHD +
Speech Delays
Rate: ?
Definition: The scores obtained from standardized
individually administered measures
Treatment...
ADHD +
Motor Delays
Rate:?
Definition:Performance in daily activities that require
motor coordination is substantially belo...
CONCLUSIONS
44Saturday, 21 September, 13
Conclusions
Having another diagnosis with the diagnosis of ADHD
is the norm.
Assessment for the presence of another disord...
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ADHD Caregiver Day - Comorbidities

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This PDF is a copy of the slides that Dr. Soper presented on September 20, 2013 for that CAMH ADHD Caregiver Day.

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ADHD Caregiver Day - Comorbidities

  1. 1. ADHD AND COMORBIDITIES Dr. Paul Soper MD FRCPC Child and Adolescent Psychiatrist Glenrose ADHD Program 1Saturday, 21 September, 13
  2. 2. Objectives Review what is a comorbidity. Review the different comorbidities frequently found with childhood ADHD. Review the treatment options for these comorbidities. 2Saturday, 21 September, 13
  3. 3. WHAT IS A COMORBIDITY? 3Saturday, 21 September, 13
  4. 4. Comorbidities Definition: The presence of a second disorder Feinstein “Any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study.” 4Saturday, 21 September, 13
  5. 5. Comorbidities 1. Chance 2. Direct Causation - Having ADHD causes the other disorder 3. Associated Risk Factors - Risk factors for both disorder are correlated. 4. Heterogeneity - Whatever puts you at risk for ADHD also puts you at risk for the other disorder. 5. Independence - The combination of the two diseases is actually because of a third disease. 5Saturday, 21 September, 13
  6. 6. Comorbidities Comorbidity often complicates the diagnosis and treatment of childhood ADHD: 87 % of ADHD children have at least one comorbid condition 67 % of ADHD children have at least two co- morbidities 77 % of ADHD adults meet criteria for a comorbid condition 6Saturday, 21 September, 13
  7. 7. Comorbidities - Treatment The treatment of ADHD should involve many different types of interventions at the same time (multimodal). These include: Parent/Patient Education (e.g. Today!) Appropriate Lifestyle Changes (Diet, Sleep, Exercise) Therapy Specific to the ADHD and Comorbidities The disorder causing the most difficulties for the child/ adolescent should be the priority for treatment. 7Saturday, 21 September, 13
  8. 8. SPECIFIC COMORBITITIES 8Saturday, 21 September, 13
  9. 9. OPPOSITIONAL DEFIANT DISORDER(ODD) 9Saturday, 21 September, 13
  10. 10. ADHD + ODD Rate: By far the most common: up to 60% of kids Definition: A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present 1. Being defiant 2. Arguing with people 3. Losing temper 4. Annoys people 5. Blames others 6. Touchy 7. Angry 8. Mean or Spiteful 10Saturday, 21 September, 13
  11. 11. ADHD + ODD Treatment should be multimodal (of course!). The following principles apply: 1. Stimulants found to be the most effective treatment. 2. Behavioral Therapy/Parent Training should be added. 3. Collaborative Problem Solving may be an effective alternative to Parent Training. 11Saturday, 21 September, 13
  12. 12. ANXIETY 12Saturday, 21 September, 13
  13. 13. ADHD + Anxiety Rate: 20-30% of children with ADHD Definition: Generalized Anxiety Disorder: Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). Can also refer to Panic Disorder, OCD, PTSD, social phobia 13Saturday, 21 September, 13
  14. 14. ADHD + Anxiety Treatment Should be multimodal (of course!!) Cognitive behavior therapy should be the first line treatment for anxiety. Relapse rates are lower with therapy Can usually be accessed quicker than a psychiatric assessment for anxiety. Don’t have to worry about interactions. Frequently Zoloft or other SSRIs are added safely to other ADHD medications 14Saturday, 21 September, 13
  15. 15. ADHD + Anxiety Treatment How to find a therapist trained in CBT: 1. Usually the fastest and easiest way to find a CBT practitioner is through your private insurance plan. (Watch for limits on the amount/duration that is covered!) 2. Schools frequently have therapists/counsellors but they may not be trained in this treatment. 3. AHS usually has practitioners skilled in this treatment. Group treatment is also available. (Watch for wait times!). 15Saturday, 21 September, 13
  16. 16. LEARNING DISABILITY (LD) 16Saturday, 21 September, 13
  17. 17. ADHD + LD Rate: 20-30% of children with ADHD Definition: “Abilities are below expectations” Reading Disorder Mathematics Disorder Disorder of Written Expression Treatment: Accomodations/programming through the school. Optimize management of ADHD (multimodal!) 17Saturday, 21 September, 13
  18. 18. CONDUCT DISORDER (CD) 18Saturday, 21 September, 13
  19. 19. ADHD + CD Rate: 14% of children with ADHD Definition: A repetitive and persistent pattern of behavior in which the basic rights of others or major age- appropriate societal norms or rules are violated, 19Saturday, 21 September, 13
  20. 20. ADHD + CD Treatment Should be multimodal (of course!!) Multisystemic: Includes: Family & Individual Therapy, Mentors, Programming to remove from negative peer groups, Addictions counselling 20Saturday, 21 September, 13
  21. 21. DEPRESSION 21Saturday, 21 September, 13
  22. 22. ADHD + Depression Rate: 4 % of children with ADHD Definition: Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 22Saturday, 21 September, 13
  23. 23. ADHD + Depression Treatment Should be multimodal (of course!!) The most impairing difficulty should be the focus of treatment: If depression mild, focus on ADHD Symptoms and depression may improve. If depression severe, focus on the treatment of depression. If both are severe, focus on the treatment of depression. 23Saturday, 21 September, 13
  24. 24. ADHD + Depression Treatment How to find a therapist trained in CBT: 1. Usually the fastest and easiest way to find a CBT practitioner is through your private insurance plan. (Watch for limits on the amount/duration that is covered!) 2. Schools frequently have therapists/counsellors but they may not be trained in this treatment. 3. AHS usually has practitioners skilled in this treatment. Group treatment is also available. (Watch for wait times!). 24Saturday, 21 September, 13
  25. 25. BIPOLAR AFFECTIVE DISORDER (BAD) 25Saturday, 21 September, 13
  26. 26. ADHD + BAD Rate: 6-7 % of people with ADHD from all ages (rare in childhood) Definition: A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). This is different for your already high energy child. 26Saturday, 21 September, 13
  27. 27. ADHD + BAD Treatment Should be multimodal (of course!!) Bipolar disorder must be stabilized first. Usually includes treatment with a mood stabilizer ADHD medication can be added to mood stabilizer. 27Saturday, 21 September, 13
  28. 28. ADHD AND AUTISM/ ASPERGER’S (ASD) 28Saturday, 21 September, 13
  29. 29. ADHD + ASD Rate: 30% of kids with Autism, 18% of children with ADHD have Autistic Traits Definition: Severe and pervasive impairment in several areas of development: reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests, and activities 29Saturday, 21 September, 13
  30. 30. ADHD + ASD Treatment Should be multimodal (of course!!) Some form of social skills training should be added to the treatment. Warning: Children with this co-morbidity other have more side effects for ADHD treatment. 30Saturday, 21 September, 13
  31. 31. TOURETTE’S SYNDROME (TS) 31Saturday, 21 September, 13
  32. 32. ADHD + Tourette’s Rate: 11% of children with ADHD have a tic disorder (less than one percent meet criteria for Tourette’s) Definition: A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization. For Tourette’s, there must be the presence of multiple motor and a vocal tic. 32Saturday, 21 September, 13
  33. 33. ADHD + TS Treatment Should be multimodal (of course!!) Treat the tics only if they are a problem. The bigger issue is usually with symptoms of OCD, cognitive rigidity and explosive tempers. Warning: Children with this co-morbidity other have more side effects for ADHD treatment. 33Saturday, 21 September, 13
  34. 34. SUBSTANCE USE DISORDERS (SUD) 34Saturday, 21 September, 13
  35. 35. ADHD + SUDs Rate: 47% of 27 year olds with ADHD report a substance use problem during their lifetime Definition: A maladaptive pattern of substance use, leading to clinically significant impairment or distress, There is specific criteria for substance abuse and substance dependence 35Saturday, 21 September, 13
  36. 36. ADHD + SUDs Treatment Should be multimodal (of course!!) Addictions counseling should be involved. My experience is that ADHD medications are rarely abused. There are usually two options: 1. Treat the ADHD aggressively and hope that the SUD improves. 2. Treat the ADHD aggressively only following resolution of the SUD 36Saturday, 21 September, 13
  37. 37. SLEEP DISORDERS (SD) 37Saturday, 21 September, 13
  38. 38. ADHD + SDs Prevalence: 25%-55% of children with ADHD experience sleep problems These sleep problems include: Sleep Onset Insomnia (SOI)/Circadian Rhythm Disorders Sleep-Related Breathing Disorder (SRBD)/ Obstructive Sleep Apnea (OSA) Periodic Limb Movement Disorder (PLMD)/Restless Leg Syndrome (RLS) 38Saturday, 21 September, 13
  39. 39. ADHD + SDs Management of insomnia usually includes the following steps: 1. Ensure appropriate diagnosis 2. Sleep Hygiene 3. Melatonin 1. Immediate release melatonin for initial insomnia 2. Delayed Release Melatonin for Middle/Late insomnia 39Saturday, 21 September, 13
  40. 40. OTHER DEVELOPMENTAL DELAYS 40Saturday, 21 September, 13
  41. 41. ADHD + Intellectual Disability Rate: 8-39% of those with Borderline or Mild ID Definition: Having a measured IQ that is greater than 2 standard deviations below the average (roughly the bottom 1.5%) Treatment: Should be multimodal (of course!!) Responses to treatment tend to be less robust. 41Saturday, 21 September, 13
  42. 42. ADHD + Speech Delays Rate: ? Definition: The scores obtained from standardized individually administered measures Treatment: Should be multimodal (of course!!) The child should receive speech therapy. 42Saturday, 21 September, 13
  43. 43. ADHD + Motor Delays Rate:? Definition:Performance in daily activities that require motor coordination is substantially below that expected given the person's chronological age and measured intelligence Treatment: Should be multimodal (of course!!) Occupational/Physical therapy should be involved to develop a program to address delays. 43Saturday, 21 September, 13
  44. 44. CONCLUSIONS 44Saturday, 21 September, 13
  45. 45. Conclusions Having another diagnosis with the diagnosis of ADHD is the norm. Assessment for the presence of another disorder is essential for the optimal management of ADHD. While keeping comorbidities in mind, treatment should be individualized to the child/family with ADHD 45Saturday, 21 September, 13
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