adhd caregiver day - comorbidities

ADHD AND COMORBIDITIESDr. Paul Soper MD FRCPC

Child and Adolescent PsychiatristGlenrose ADHD Program

1Saturday, 21 September, 13

Objectives

Review what is a comorbidity.

Review the different comorbidities frequently found with childhood ADHD.

Review the treatment options for these comorbidities.


WHAT IS A COMORBIDITY?


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.”


Comorbidities1. 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.


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


Comorbidities - TreatmentThe 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.


SPECIFIC COMORBITITIES


OPPOSITIONAL DEFIANT

DISORDER(ODD)


ADHD + ODDRate: 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 Spiteful10Saturday, 21 September, 13

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.


ANXIETY


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


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


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!).


LEARNING DISABILITY (LD)


ADHD + LDRate: 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!)


CONDUCT DISORDER (CD)


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,


ADHD + CD Treatment


Multisystemic:

Includes: Family & Individual Therapy, Mentors, Programming to remove from negative peer groups, Addictions counselling


DEPRESSION


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.


ADHD + Depression Treatment


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.


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!).


BIPOLAR AFFECTIVE DISORDER (BAD)


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.


ADHD + BAD Treatment


Bipolar disorder must be stabilized first.

Usually includes treatment with a mood stabilizer

ADHD medication can be added to mood stabilizer.


ADHD AND AUTISM/ASPERGER’S (ASD)


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


ADHD + ASD Treatment


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.


TOURETTE’S SYNDROME (TS)


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.


ADHD + TS Treatment


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.


SUBSTANCE USE DISORDERS (SUD)


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


ADHD + SUDs Treatment


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


SLEEP DISORDERS (SD)


ADHD + SDsPrevalence: 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)


ADHD + SDsManagement 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


OTHER DEVELOPMENTAL

DELAYS


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.


ADHD +Speech Delays

Rate: ?

Definition: The scores obtained from standardized individually administered measures


The child should receive speech therapy.


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


Occupational/Physical therapy should be involved to develop a program to address delays.


CONCLUSIONS


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
