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Comorbid adhd conditions


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psychiatric comorbid conditions in children with ADHD
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Comorbid adhd conditions

  1. 1. Comorbid conditions in Children with ADHD
  2. 2. ADHD A) A persistent pattern of inattention and/or hyperactivity- impulsivity that interferes with functioning or development, with ≥6 sx in each category B) Several inattentive or hyperactive-impulsive symptoms were present prior to age 12yrs C) Several inattentive or hyperactive-impulsive sx are present in two or more settings (e.g. at home, school, or work; with friends or other relatives; in other activities) D) There is clear evidence that the symptoms interfere with, or reduce the quality of social, academic, or occupational functioning E) The symptoms do not occur exclusively during the course of another disorder
  3. 3. Symptoms of ADHD Inattention  Often fails to give close attention to details or makes careless errors  Often has difficulty sustaining attention in tasks or play activities  Often does not seem to listen when spoken to directly  Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace  Often has difficulty organizing tasks and activities  Often dislikes, avoids, or is reluctant to engage in tasks that require sustained mental effort  Often loses things necessary for tasks and activities  Is often distracted by extraneous stimuli  Is often forgetful in daily activities Hyperactivity and Impulsivity  Often fidgets with or taps hands or feet or squirms in seat  Often leaves seat in situations when remaining seated is expected  Often runs about or climbs in situations where it may be inappropriate  Often unable to play or engage in leisure activities quietly  Is often “on the go” acting as if “driven by a motor”  Often talks excessively  Often blurts out an answer before a question has been completed  Often has difficulty waiting their turn  Often interrupts or intrudes on
  4. 4. Epidemiological estimates vary from 2-18% Percent of Youth 4-17 Ever Diagnosed with Attention- Deficit/Hyperactivity Disorder by State: National Survey of Children's Health
  5. 5. Common conditions Learning Disabilities: 50% Anxiety Disorders 25% Mood Disorders 10-30% Oppositional Defiant Disorder symptoms 21-60% Speech Problems 12% Tic Disorders and Tourette’s 7% and 1% Coordination Problems and DCD 30-50%
  6. 6. Comorbid conditions in adults Anxiety Disorders 47% Mood Disorders 38% Impulse Control Disorder 20% Substance Abuse Disorder 15%
  7. 7. Bipolar Disorder Main criteria of mania A) Distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity lasting ≥1 eek and present most of the day nearly every day or any amount of time requiring hospitalizations B) ≥3 criterion B symptoms (or ≥4 if mood is only irritable) during this time, which represent a change from previous behavior C) The mood disturbance causes marked impairment in function or requires hospitalization to prevent harm to self or others or psychotic symptoms D) No better explanation B criterion symptoms  Inflated self-esteem or grandiosity  Decreased need for sleep  More talkative than usual or pressure to keep talking  Flights of ideas, subjective feeling of racing thoughts  Distractibility  Increased goal-directed activity or psychomotor agitation  Excessive involvement in activities that high high potential for painful/serious consequences
  8. 8. ADHD and Bipolar Disorder: Not an Artifact of Overlapping Criteria Hyperactivity and Restlessness Irritability Continuous symptoms Onset at a young age (<7years) Alternating episodes of lethargy, sadness, suicidal thoughts Increased Energy Hypersexuality Talkativeness Both Both ADHD ADHD Bipolar Disorder Both Bipolar Disorder Both Mood is Situation- Appropriate ADHD
  9. 9. ADHD and Bipolar Disorder: Not an Artifact of Overlapping Criteria  ADHD is chronic/continuous while Bipolar Disorder Symptoms are episodic  Intermittent/alternating episodes of depression or are not typically seen in ADHD  Grandiosity, hypersexuality, psychosis, significant (v. mild) mood labiality, uncontrolled anger/aggression are more common in mania than in ADHD and if present in ADHD, comorbid diagnosis of bipolar disorder should be suspected  Children with ADHD may talk a lot, but generally don’t have pressured speech and “gear switching” seen in mania  Bipolar Disorder is extremely unlikely to present at a young age such as those <7years old  Caution is needed because stimulants can worsen symptoms of mania, so always treat Bipolar Disorder first in those with comorbidities
  10. 10. Bipolar Disorder Comorbidity of Attention Deficit Hyperactivity Disorder in Early- and Late-Onset Bipolar Disorder  Among those with early onset Bipolar Disorder (first episode <19yrs old), 62% met the criteria for ADHD  The mean age of the first affective episode was 12.1 years in those with ADHD v. 20yrs in those without  There is a much lower rate of comorbid ADHD in those with late-onset Bipolar Disorder  Conclusion: Children with a high genetic load of bipolar risk factors are more likely to have ADHD, ADHD should be used to identify which children with genetic risk are most likely to develop ADHD
  11. 11. Depression A) ≥5 symptoms have been present during the same 2- week period and represent a change from previous functioning, and at least 1 symptom is either depressed mood or anhedonia  Depressed mood most of the day, nearly every day as indicated by subjective mood or observation by others  Marked diminished interest or pleasure in all or almost all activities most of the day nearly every day  Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day  Insomnia or hypersomnia nearly every day  Psychomotor agitation or retardation nearly every day  Fatigue or loss of energy nearly every day  Feelings of worthlessness or excessive or inappropriate guilt nearly every day  Diminished ability to think or concentrate or indecisiveness nearly every day  Recurrent thoughts of death, recurrent suicidal ideation without a specific
  12. 12. Depression B) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C) The episodes are not attributable to the physiological effects of a substance or to another medical condition
  13. 13. Comorbid Depression and ADHD  Rate of depression in children with ADHD is significantly higher than in those without ADHD. 10-30% of children with ADHD have a mood disorder. 70% experience depression at some point  The course of depression is much more severe in children with co-morbid ADHD than in those with depression alone, with higher risk of suicide and higher risk of long-term impairment.  Assessment can be difficult because of overlap in symptoms and with other disorders common in ADHD  Depression typically occurs several years after ADHD symptoms have started and may result from the difficulties of dealing with the effects of ADHD on functioning in combination with genetic risk factors for depression.
  14. 14. Comorbid Depression How does ADHD Contribute to Depression?  Feelings of lack of control over their environment  Repeated failure academically or socially  Peer rejection: In pre-school children, “within five minutes, children with ADHD are seen as less desirable, companions than those without ADHD”  Cycles of impairment in social skills, rejection  Poor emotional regulation, disproportionate response to stressful situations
  15. 15. Overlap with dextro- amphetamines Dextroamphetamines are used to treat depression and apathy secondary to dementia, Huntington's disease However, some side effects of dextroamphetamine can look like depression  Insomnia  Loss of appetite  Loss of interest in sexual activity or sexual dysfunction  Feeling restless, irritable, or agitated
  16. 16. Social Anxiety Disorder  Marked fear or anxiety about or more social situations in which the individual is exposed to possible scrutiny by others- in children, must occur in peer setting  The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated  The social situations almost always provoke anxiety/fear  The social situations are avoided or endured with intense fear or anxiety  The fear or anxiety is out of proportion to the threat posed by the social situation and to the sociocultural context  The fear, anxiety or avoidance is persistent, ≥6months
  17. 17. Social Anxiety Disorder  Social Anxiety Disorder is one of the more common anxiety disorders associated with ADHD.  People with ADHD with SAD often develop SAD earlier and have more severe anxiety and functional impairment than SAD patients without ADHD.  Those with ADHD-SAD also have a higher rate of lifetime depression and bipolar disorder than those with just SAD  In some studies, treatment of ADHD with traditional drugs such as methylphenidate is associated with an improvement in social phobia, especially school-related SAD  Cognitive Behavioral Training and Social Skills Training can be used for both.
  18. 18. Obsessive Compulsive Disorder A) Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2):  1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.  2.The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
  19. 19. Obsessive Compulsive Disorder B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior…
  20. 20. OCD and ADHD  Model of an impulsive to obsessive spectrum, with OCD and ADHD on opposite ends  ADHD and OCD may both be due to dysfunction of the frontostrital system, but with increased activity in OCD and decreased activity in ADHD.  However, they result in similar cognitive impairments such as poor planning, decreased executive function performance  Children having trouble focusing because over-focused on one issue like a stain while child with ADHD switching focus  It’s important to distinguish these because giving stimulants to a child with OCD can make him or her more obsessive by increasing fronto-striatal brain activity even further  Ability to follow obsessive rituals is an important distinguishing factor However  21% of children and 8.5% of adults with OCD also have ADHD  Those with ADHD who have some OC symptoms do better in tests of executive function than those without any ADHD symptoms