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AD/HD and Co-Existing Disorders
AD/HD and Co-Existing Disorders - CHADD Fact Sheet #5
As many as two thirds of children with AD/HD have at least one other coexisting
condition.1 The constant motion and fidgetiness, interrupting and blurting out,
difficulty waiting in lines or sitting in restaurants, and need for constant
reminders may overshadow these other disorders. But just as untreated AD/HD can
leave lasting scars, so too can other untreated disorders cause unnecessary
suffering in individuals with AD/HD and their families. Any disorder can coexist
with AD/HD, but certain disorders seem to occur more commonly with AD/HD.
How are These Co-Existing Conditions Identified?
First and foremost, diagnostic precision is essential for any person suspected
of having AD/HD. Currently, people cannot be “tested” with paper-pencil or blood
tests to “prove” they have AD/HD (or other psychiatric disorders). Instead, a
careful evaluation by a trained physician or a mental health clinician is the
most appropriate way to determine whether a person has one or more disorders.
These evaluations require time and effort, and include many screening questions
about multiple disorders, as well as questions about the person’s functioning at
home, with others, and at school or work. Since parents and teachers are usually
effective at describing observed behaviors, while the patient is usually more
effective at explaining internal feelings such as sadness or worry, the
clinician ordinarily interviews both the patient and family members. It is
helpful to view these evaluations as an ongoing process. Careful diagnosis
periodically revisited improves the detection and treatment of other co-existing
conditions as they arise or impair the patient.
Which Conditions most Commonly Co-Exist with AD/HD?
AD/HD may co-exist with one or more disorders. The most common disorders to
occur with AD/HD are (1) Disruptive Behavior Disorders; (2) Mood Disorders; (3)
Anxiety Disorders; (4) Tics and Tourette’s Syndrome; and (5) Learning
Disabilities.
Disruptive Behavior Disorders
(Oppositional-Defiant Disorder and Conduct Disorder)
About 40 percent of individuals with AD/HD have oppositional defiant disorder
(ODD). Among individuals with AD/HD, conduct disorder (CD) is also common,
occurring in 25 percent of children, 45-50 percent of adolescents and 20-25
percent of adults. ODD involves a pattern of arguing with multiple adults,
losing one’s temper, refusing to follow rules, blaming others, deliberately
annoying others, and being angry, resentful, spiteful, and vindictive.
CD is associated with efforts to break rules without getting caught. Such
children may be aggressive to people or animals, destroy property, lie or steal
things from others, run away, skip school, or break curfews. CD is often
described as delinquency and children who have AD/HD and conduct disorder may
have lives that are more difficult than those of children with AD/HD alone.
Academically, students with both AD/HD and CD are twice as likely to have
difficulty reading as other AD/HD children. Children with both AD/HD and CD, but
not other children with AD/HD, are at greater risk for social and emotional
failure. Studies now suggest that AD/HD and CD may be a particular subtype of
AD/HD, since multiple family members often have both of these disorders
together.
Treatment of the person with AD/HD and ODD/CD requires efforts to discourage
delinquent behaviors so that the person will increasingly choose pro-social
behaviors. ODD and CD usually require strong, clear structure with reinforcement
of appropriate behaviors as well as a positive behavior management plan to
extinguish antisocial behaviors.
Medication remains important. Research has shown that AD/HD and CD students
treated with stimulant medicines are not only more attentive, but also less
antisocial and aggressive. In addition, medication combinations, such as a
psychostimulant with an antidepressant, appear to be very effective for these
patients.
Mood Disorders
Some children, in addition to being hyperactive, impulsive, and/or inattentive,
may also seem to always be in a bad mood. They may cry daily, out of the blue,
for no reason, and they may frequently be irritable with others for no apparent
reason. Both sad, depressive moods and persisting elevated or irritable moods
(mania) occur with AD/HD more than would be expected by chance.
Depression
The most careful studies suggest that between 10-30 percent of children with
AD/HD, and 47 percent of adults with AD/HD, also have depression. Typically,
AD/HD occurs first and depression occurs later. Both environmental and genetic
factors may contribute.
Environmentally, as children with AD/HD get older, they may feel left out. Too
often they are forgotten on birthday party lists, playdates, and sleepovers.
These children may not be invited to play at other children’s homes because of
past difficulties with accidents or may not be chosen to be on sports teams or
to participate in games. This takes a heavy toll on the child’s self-esteem. As
these episodes pile up, the child with AD/HD can become discouraged and about
one in four may become clinically depressed. While all children have bad days
where they feel down, depressed children may be down or irritable most days.
Children with AD/HD and depression may also withdraw from others, stop doing
things they once enjoyed, have trouble sleeping or sleep the day away, lose
their appetite, criticize themselves excessively (“I never do anything right!”),
and talk about dying (“I wish I were dead”). Fortunately, AD/HD by itself is not
associated with increased risk of suicidal behavior. Current studies suggest
that both AD/HD and depression may share a common underlying genetic link, since
families with AD/HD also seem to have more members with depression than would be
expected by chance.
Treatment of children with AD/HD and depression involves minimizing
environmental traumas and different medication regimens. To minimize the child
with AD/HD’s difficulty in playing with others, parents and teachers can arrange
small group play experiences (sometimes just two people). In addition, it is
vital that the parent monitor the school setting. Even children with carefully
constructed educational plans may continue to struggle if the plan is
inadequate. A number of studies have shown that certain antidepressant
medications improve AD/HD alone, or with depression. The antidepressant
desipramine (Norpramin) has improved both AD/HD and AD/HD and depression.
Researchers have also found that stimulants (such as Ritalin) can be combined
safely with antidepressants such as fluoxetine (Prozac) ¾ these children not
only feel better but also function better at school. Newer antidepressants such
as bupropion (Wellbutrin) and venlafaxine (Effexor) have been found effective in
some individuals with AD/HD alone and may additionally benefit those individuals
with both AD/HD and depression.
Mania/Bipolar Disorder
Up to 20 percent of individuals with AD/HD also may manifest bipolar disorder.
This condition involves periods of abnormally elevated mood contrasted by
episodes of clinical depression. Adults with mania may have long (days to weeks)
episodes of being ridiculously happy, and even believe they have special powers
or receive messages from God, the radio, or celebrities. With this expansive
mood, they may also talk incessantly and rapidly, go days without sleeping, and
engage in tasks that ultimately get them into trouble. While manic, they may go
on spending sprees which get them into debt, become hypersexual, or contact
people at all hours of the night.
In younger people, mania may show up differently. Children may have moods that
change very rapidly, seemingly for no reason, be pervasively irritable, exhibit
unpremeditated aggression, and sometimes hear voices or see things the rest of
us don’t. AD/HD is much more common than mania, and while many children with
mania may first exhibit AD/HD symptoms, very few children with AD/HD will go on
to develop mania. The combination of AD/HD and mania often leads to severe
difficulty functioning. The overlap of mania and AD/HD is being actively
studied. As patients with AD/HD-mania are followed over time, it will become
clearer what their symptoms look like in adulthood.
From a treatment standpoint, mood must be stabilized on medications before
treatment for AD/HD is likely to be successful. Patients with AD/HD-mania now
are treated with mood stabilizers such as lithium, valproate (Depakote), or
carbamazepine (Tegretol). Because these agents usually do not improve the AD/HD
symptoms, stimulants or antidepressants are often added to improve the AD/HD
symptoms.
Anxiety
Up to 30 percent of children and 25-40 percent of adults with AD/HD will also
have an anxiety disorder. Anxiety disorders are often not apparent, and research
has shown that half of the children who describe prominent anxiety symptoms are
not described by their parents as anxious. As with depression, the child’s
internal feelings may not stand out to parents or teachers. Patients with
anxiety disorders often worry excessively about a number of things (school,
work, etc.), and may feel edgy, stressed out or tired, tense, and have trouble
getting restful sleep. A small number of patients may report brief episodes of
severe anxiety (panic attacks) which intensify over about 10 minutes with
complaints of pounding heart, sweating, shaking, choking, difficulty breathing,
nausea or stomach pain, dizziness, and fears of going crazy or dying. These
episodes may occur for no reason, and sometimes awaken patients. Students with
AD/HD and anxiety report more school, family, and social/peer problems than
student who only have AD/HD. Students with AD/HD accompanied by anxiety are less
likely to appear hyperactive and disruptive, but instead appear more slowed down
or inefficient. Genetic research thus far suggests that AD/HD and anxiety are
separate disorders inherited independently of each other.
Treatment of AD/HD and anxiety requires attention to precipitating stressors,
and training in methods of contending with fear-provoking circumstances.
Relaxation techniques and alternative ways to think through stressful situations
may be helpful. AD/HD and anxiety appear less responsive to conventional AD/HD
medication treatments. Specifically, children with AD/HD and anxiety only showed
a 30 percent response to methylphenidate (Ritalin), versus a 70-80 percent
response observed in AD/HD-only children. Moreover, at least one study has shown
that children with AD/HD and anxiety are more sensitive to negative side effects
of stimulant medications. Accordingly, alternative medication regimens may be
necessary. Tricyclic antidepressants (e.g., desipramine [Norpramin],
nortriptyline [Pamelor], imipramine [Tofranil]), benzodiazepines (lorazapam [Ativan],
clonazepam [Klonopin], alprazolam [Xanax], etc.) and more recently buspirone (BusPar)
may benefit these patients.
Tics and Tourette’s Syndrome
Only about seven percent of those with AD/HD have tics or Tourette’s syndrome,
but 60 percent of those with Tourette’s syndrome have AD/HD. Tics (sudden,
rapid, recurrent, nonrhythmic movements or vocalizations) or Tourette’s syndrome
(both movements and vocalizations) can occur with AD/HD in two ways. First,
mannerisms or movements such as excessive eye blinking or throat clearing often
occur between the ages of 10-12 years. When children are nervous or tired, these
tics may appear worse or more conspicuous. These transient tics usually go away
gradually over one-to-two years, and are just as likely to happen in children
with AD/HD as others. Tourette’s is a much rarer, but more severe tic disorder,
where patients may make noises (e.g., barking a word or sound) and movements
(e.g., repetitive flinching or eye blinking) on an almost daily basis for years.
Tourette’s often includes AD/HD, although the opposite is not true.
Tics can also become more noticeable when patients are treated with stimulants
or ¾ much less likely ¾ bupropion. While these medicines no longer appear to
cause tics, they may unmask or exaggerate tics. Accordingly, sometimes lowering
the dose can decrease the tics. Other medicines such as nortriptyline (Pamelor
or Aventyl), clonidine (Catapres), or guanfacine (Tenex) may be used to decrease
tics while treating AD/HD.
Learning Disabilities
Individuals with AD/HD frequently have difficulty learning in school. Depending
on how learning disorders are defined, up to 50 percent of children with AD/HD
have a co-existing learning disorder. Individuals with learning disabilities may
have a specific problem reading or calculating, but they are not less
intelligent than their peers are. Research indicates that students with both
AD/HD and reading disorder (dyslexia) are no more anxious, hyperactive, or
aggressive than student with AD/HD only. However, the learning disorder does
impact school performance, which may subsequently impact family and peer
relationships.
Treatment requires careful attention to the student’s unique strengths and
weaknesses. If academic difficulties occur despite beneficial treatment (with
psychosocial interventions and medication), then it is necessary to pursue an
educational evaluation that assesses learning disabilities. Usually this
requires that family members contact the school principal, teacher, or guidance
department to initiate the process, which culminates with devising ¾ when
necessary ¾ an individual educational plan (IEP) or Section 504 plan for the
student. The IEP is reviewed at least annually by school personnel to ensure
that educational planning is helping the student make academic progress.
Medications do not specifically improve learning disorders, but may improve
AD/HD symptoms so that learning can accelerate.
What about Substance Abuse?
Recent work suggests that youths with AD/HD are at increased risk for very early
cigarette use, followed by alcohol and then drug abuse. Cigarette smoking is
more common in adolescents with AD/HD, and adults with AD/HD have elevated rates
of smoking and report particular difficulty in quitting. Youths with AD/HD are
twice as likely to become addicted to nicotine as individuals without AD/HD..
As documented by current research, cocaine and stimulant abuse is not more
common among individuals with AD/HD who were previously treated with stimulants:
growing up taking stimulant medicines does not lead to substance abuse as these
children become teenagers and adults. Indeed, those adolescents with AD/HD
prescribed stimulant medication are less likely to subsequently use illegal
drugs than are those not prescribed medication.
This article first appeared as CHADD Fact Sheet No. 5, Spring 2000.
Suggested Reading
Biederman, J. (1998). Attention-deficit/ hyperactivity disorder: A life-span
perspective. Journal of Clinical Psychiatry 59 (Supplement 7): 4-16.
Biederman, J, et al. (1999). Pharmacotherapy of attention-deficit/hyperactivity
disorder reduces risk for substance use disorder. Pediatrics 104:e20.
Hechunan, L., Ed. (1996). Do they grow out of it? Long-Term Outcomes of
Childhood Disorders. Washington, DC: American Psychiatric Association.
Pliszka, S.R. (1998). Comorbidity of attention-deficit/ hyperactivity disorder
with psychiatric disorder: An overview. Journal of Clinical Psychiatry 59
(Supplement 7): 50-5B.
Gregg, S. (1996). Preventing antisocial behavior in disabled and at-risk
students. Appalachia Educational Laboratory Policy Brief. Pgs. 1-12.
Wachtel, A. (1998). The attention deficit answer book. New York: Plume
(Penguin).
References
1. MTA Cooperative Group. (1999). A 14-month randomized clinical trial of
treatment strategies for attention deficit hyperactivity disorder. Archives of
General Psychiatry, 56, 12.
Need more information about AD/HD or the national organization dedicated to
helping children and adults with AD/HD succeed?
Call Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
at 800-233-4050,
fax (301) 306-7090
write CHADD at 8181 Professional Place, Suite 201, Landover, MD 20785
or visit our website at www.chadd.org
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