ADHD and Co-Morbidity

ADHD Attention Deficit Hyperactivity Disorder

ADHD and Co-MorbidityProposed outline:

What is ADHD – and some concepts toconsider

Co-morbidity Stats Selected Highlights:

ASD Personality/?bipolar Risk

Case vignettes with discussion on how youmight manage and treat (Including medication)

ADHD: what is it?

The 3 musketeers:

Inattention/concentration Impulsivity Hyperactivity

ADHD: what is it?

The 3 musketeers: Inattention/concentration Impulsivity Hyperactivity

And then there is the 4th one: Emotional Dysregulation

ADHD: the Child Psychiatrist’s View

Growth and Development

‘Developmental Tasks’ (Neuro-) Developmental Disorders

Family Interaction Schooling Social Interaction

Disruptions Attachment’Oppositional Defiant DisorderOthers?The Whole of Psychiatry?

ADHD and Co-Morbidity: Concepts 1

ADHD and Co-Morbidity: Concepts 2

ADHD and Co--Morbidity:‘All you ever wanted to know...’

Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution

ADHD and Co--Morbidity:‘All you ever wanted to know...’

Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution

ADHD and Co--Morbidity:‘All you ever wanted to know...’

Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution

What happens when ADHD grows up evenmore?

Criminal behaviour Personality DisordersOppositional School exclusionDefiant Mood Disorders

Disruptive DisorderBehaviour Substance Bipolar??

Low AbuseADHD only Self-esteem Poor Social Conduct

Skills Disorder Drug & Alcohol Problems

Learning Lack ofDelay Challenging Motivation Criminality

BehaviourComplex Relationships failuresLearningDifficulties Underachieving

Study /work problems6y 10y 14-16y 17-35

Adapted and extended from G D Kewley 1999: ADHD – Recognition, Reality and Resolution

ADHD and Co-Morbidity: concepts 3

It is not :Can’t focus

But:Can’t control the

focus of attention

- Executive Functions- Filtering Information- Signal Noise Ratio

ADHD and Co-Morbidity: concepts 4

Comorbidity:‘Development related’

Autistic spectrum disorders Tics and Tourette’s disorders Developmental delay Learning disabilities Specific learning disabilities (reading, coordination)

‘Ordinary’ Sleep Mood disorders (depression, ?bipolar) Anxiety disorders Substance abuse disorders (substance and alcohol) Personality disorder (dissocial, borderline)

ADHD and Co-Morbidity: concepts 5

Underlying processing problems ‘push’ potentialcomorbidities towards clinical significance

(E.g. John J. Ratey’s ‘Shadow Syndrome’ idea)

ADHD and Co-Morbidity: concepts 6Utah Criteria for Adult ADHD

A. InattentivenessB. Hyperactivity

With at least two of the following:1. Mood fluctuations2. Irritability and hot temper3. Impaired stress tolerance4. Disorganisation5. Impulsivity

Is Adult ADHDPlain Vanilla ADHD,where ….

hyperactivity has goneunderground,

but ….emotional dysregulation

and co-morbiditieshave come to the fore?

Comorbidities: stats and a few selectedhighlights

ASD

Personality disorder, and whatabout Bipolar

Risk DSH & Suicide The Road

ADHD and Autistic SpectrumDisorders (ASD)

• 41 % of the children with autistic spectrum disordersalso had many ADHD characteristics, and 22 % ofthose with ADHD characteristics also had thediagnosis autistic spectrum disorder.

• Suggested a joint genetic influence in bothdisorders (Ronald et al. 2008 ) .

ADHD and personality disorder:Miller, Nigg and Faranoe (2007) studies 363 adults withADHD and compared them to non-ADHD controls inrelationship to personality disorder. Adults with ADHD hada higher incidence of both cluster B and C.

Controls % ADHD %Cluster A No differenceCluster B 9.5 24.4Cluster C 4.3 21.0

The most frequent Cluster B personality disorder in ADHDwas Borderline PD

In Cluster C, the most common type was OC PD

In the differential diagnostic assessment, thefollowing criteria are used:

1. The frequency of the mood swing (4–5 times aday in ADHD and cluster B personalitydisorders, a minimum of 2–3 days in ahypomanic episode)

2. The course (chronic in ADHD and cluster Bpersonality disorder, episodic in bipolar disorder)

3. The age of onset (childhood in ADHD, usuallylater in the bipolar and personality disorders)

The incidence of death from suicide is nearly 5 times higheramong adults who had had childhood ADHD compared withcontrol participants (N = 367).Barbaresi et al. Mortality, ADHD, and Psychosocial Adversity in Adults With ChildhoodADHD: A Prospective Study. PEDIATRICS Volume 131,Number 4, April 2013.

The chance of suicidal tendencies in adolescents and adults withADHD compared to controls is elevated mainly in the presence ofhyperactivity/impulsivity, depression or dysthymia, and theantisocial behavioural disorder.

Barkley and Fischer 2005 ; Semiz et al. 2008

In research, among adolescents 36 % of the patients with ADHDhad suicidal thoughts before the age of 18, versus 22 % of acontrol group.For suicide attempts, these numbers were 16 % versus 3 %.

Barkley and Fischer 2005

ADHD: DSH and Suicide

Young women diagnosed with ADHD, were three to fourtimes more likely to attempt suicide and two to threetimes more likely to report injuring themselves thancomparable young women in a control group.

Hinshaw et al. Prospective Follow-Up of Girls With Attention-Deficit/Hyperactivity Disorder Into Early Adulthood: Continuing ImpairmentIncludes Elevated Risk for Suicide Attempts and Self-Injury. Journal ofConsulting and Clinical Psychology. American Psychological Association.2012, Vol. 80, No. 6, 1041–105.

This knowledge ought to change our thinking aboutDSH drivers, and also our working practices intrying to deal with this client group!!

ADHD and (Female) DSH

Some Cases for Discussion

Case 1; Billy

41 years old, living on the street since age 15/16,multiple drug user, including iv heroin, Hep cpositive. On methadone

Now living in his own flat and finding it verydifficult to cope

When living on the street nobody cared about hishyper-activtiy, now he is driving everybodymad

Diagnosis of ADHD, OCD, drug use onsubstitution therapy

Physical health, slow pulse low BP

Case 2; Phillip

• 63 year old man, initially diagnosed withbipolar disorder. Marked mood lability,anger/temper outbursts leading to loss ofjob ASDA, very low self-esteem, difficultiesverbalising his problems

• Diagnosis ADHD, sleep disturbance,emotional lability, anger

• Mood very low at times.• Treated with stimulants + clonidine

Case 3; Ricky

• Presented with OCD, ODD, ADHD, Ticks andsubstance misuse

• Treated OCD with SSRIs and ADHD withatomoxetine, little effect, added risperidone.Severe sweating

• Relationship difficulties, alcohol abuse leading topacreatitis

• Difficult to engage• Suicidal ideation; started on methylphenidate,

good effect on suicidality and sweating, but notsustained.

Case 4; Susan

• Multiple diagnosis including; bipolar,depression, BPD, anxiety

• Antidepressants not working• Marked suicidality and DSH• Mum believed may have ADHD,

assessment confirmed this• Stimulant medication marked

improvement on suicidality.