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

1. ADHD AND
COMORBIDITIES
Dr. Paul Soper MD FRCPC
Child and Adolescent Psychiatrist
Glenrose ADHD Program
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2. Objectives
Review what is a comorbidity.
Review the different comorbidities frequently found
with childhood ADHD.
Review the treatment options for these comorbidities.
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3. WHAT IS A
COMORBIDITY?
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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.”
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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.
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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
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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.
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8. SPECIFIC
COMORBITITIES
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9. OPPOSITIONAL
DEFIANT
DISORDER(ODD)
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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
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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.
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12. ANXIETY
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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
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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
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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!).
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16. LEARNING DISABILITY
(LD)
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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!)
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18. CONDUCT DISORDER
(CD)
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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,
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20. ADHD + CD
Treatment
Should be multimodal (of course!!)
Multisystemic:
Includes: Family & Individual Therapy, Mentors,
Programming to remove from negative peer groups,
Addictions counselling
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21. DEPRESSION
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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.
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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.
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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!).
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25. BIPOLAR AFFECTIVE
DISORDER (BAD)
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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.
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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.
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28. ADHD AND AUTISM/
ASPERGER’S (ASD)
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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
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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.
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31. TOURETTE’S
SYNDROME (TS)
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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.
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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.
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34. SUBSTANCE USE
DISORDERS (SUD)
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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
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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
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37. SLEEP DISORDERS (SD)
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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)
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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
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40. OTHER
DEVELOPMENTAL
DELAYS
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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.
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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.
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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.
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44. CONCLUSIONS
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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
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