ADHD COMMON COMORBID DISORDERS Lynn Hugger Ph D

ADHD: COMMON CO-MORBID DISORDERS Lynn Hugger, Ph. D. 333 East Shore Road Manhasset, NY 516 -829 -8930

ADHD Defined A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Occurs before age 12 Occurs across 2 or more settings (e. g. home, school/work, peers) Symptoms are not caused by another problem – such as psychosis, depression, PTSD, another neurological problem

Symptoms of inattention: Fails to close attention to detail – makes careless mistakes Difficulty sustaining attention Does not seem to listen when spoken to Often does not follow through on instructions or fails to finish schoolwork, chores or duties in the workplace Avoids or dislikes tasks that require sustained mental effort Often loses things Easily distracted Forgetful in daily activities

Symptoms of Hyperactivity/Impulsivity Often fidgets with or taps hands, feet or squirms in seat Leaves seat in situations when remaining in seat is expected Runs about or climbs in situations where it is inappropriate Often unable to play or engage in leisure activities quietly Often “on the go, ” unable to be still for extended periods of time Often talks excessively Often blurts out an answer before a question has been completed Often has difficulty waiting his/her turn Often interrupts or intrudes on others

Developmental Considerations Problems with hyperactivity are often seen in early childhood – They activity level is excessive relative to children of the same age Predominantly Inattentive Type is often noticed until later elementary school or even later (especially with girls). Middle school and the higher grades are more complex worlds academically and socially – resulting in greater demand for strong executive functions.

Inhibit Impulsivity Initiate Working Emotion Regulation Memory Attention Executive Functions Monitor Social skills Shift Transitions Effort Speed Plan Organize

Co-Morbid Disorders More than 50% of children & adolescents with AD/HD meet criteria for another psychiatric disorder as well. (Brown, 2001) 25% of children with ADHD meet criteria for an anxiety disorder 27% have a reading disorder 31% have a math disorder 65% have a disorder of written expression Depression Oppositional defiant disorder/conduct disorder Disruptive Mood Dysregulation Disorder Obsessive Compulsive Disorder Tic Disorders Autism Spectrum Disorder Substance Abuse

Additional Ways to Think About ADHD Daniel Amen (& others) identify 7 types of ADHD In addition to 1. ADHD-Inattentive Type 2. ADHD-Hyperactive, Impulsive Type 3. ADHD-Combined Type Daniel Amen adds: 4. Overfocused ADD – excessive worrying, argumentative, tends to get stuck in negative thoughts. 5. Temporal Lobe ADD – temper, rage, mild paranoia 6. Limbic ADD – moody & low energy 7. ‘Ring of Fire’ ADD- angry, aggressive, periods of mean aggressive behavior & grandiose thinking

Importance of a Comprehensive Psychological Testing Assessment This is the only way to fully understand what is impacting your child or teenager. Once you understand your child’s unique profile you can begin to create realistic expectations at school and at home within your family life. As you will see there are many overlapping disorders that require different kinds of interventions.

Parent/Child Relationship Challenges Your understanding helps: You to obtain the necessary supports at school. Have realistic expectations at home. Help extended family support your child and you. Through your understanding, your child/teen can understand themselves Helps you to shift from criticism and punishment to support and realistic expectations. These changes decrease anxiety, depression, OCD These changes decrease risk for substance abuse

Overlap between ADHD & Reading disorders have various facets – Problems with decoding or phonetics are separate from ADHD but your child can have both. Children & teens often have the following reading challenges: Weakness in sustained concentration Slow reader due to processing weakness Misunderstanding main ideas or inferences due to weakness in organizing information efficiently or tendency to make atypical connections Low frustration tolerance causing decreased patience needed for reading

Helping With Weakness in Reading If your child has been assessed to have a weakness in phonetic decoding Pick short books School needs to modify quantity of reading Some people benefit from an audio book Sparks notes help distill important information – this should not be seen as cheating. Teens with ADHD need to be taught how to identify important information. work with a certified reading teacher is very important.

Anxiety It is very common for people with ADHD to experience anxiety. Processing rapid, complex information is often experienced as an overwhelming feeling. Modifications in school and in your parenting style can decrease this overwhelmed feeling. People with ADHD (just like other people) can have anxiety for other reasons that have less to do with having ADHD – that is two co-existing conditions.

Modifications at School & Decrease in Anxiety Look for ways to decrease pressure Modified homework requirements Extended deadlines without penalty Tutors Lighter course load and increased study halls

Changes at home that decrease anxiety Help at home with organization Parents understanding that help with homework is needed & not due to being “irresponsible” or “immature” Consider medication Consider psychotherapy Modify your own expectations and help your child modify their expections

Obsessive-Compulsive Disorder Obsessions are recurrent & persistent thoughts, urges, or images that are experienced as intrusive or unwanted Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rigid rules. OCD, Tic Disorders and ADHD can often be seen in combination in children

Helping Your Child with OCD The disorder typically has a neurobiological basis The more you give in to an obsession or compulsion the larger and stronger it gets Your child can not be asked to stop all at once but understanding this idea will help make them a partner in gradually reducing the process in a slow, step-by-step manner Work with a therapist will be important in this It is often driven by some other conflict, worry or concern and addressing this in psychotherapy is very important When needed, medication can be of help.

Depression can have many causes – people with ADHD have conflicts just like everyone else. Living with ADHD - at times - can contribute to different levels of depression because of all the challenges and failure experiences. Symptoms of depression: apparent sadness, change in sleep patterns, withdrawal, lack of pleasure, self-harm, substance abuse, suicidal thinking

Oppositional Defiant Disorder Your child begins to act atypically angry and defiant Easily loses temper Often touchy or easily annoyed Argumentative Defies rules and requests from people in authority Often blames others for his/her misbehavior Spiteful or vindictive With someone who has ADHD – want to be sure that these symptoms do not only occur in situations that demand sustained effort and attention

Disruptive Mood Regulation Disorder Severe, recurrent temper outbursts manifested verbally (verbal rages) &/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation. Temper outbursts are inconsistent with the chld’s developmental level. Temper outbursts occur, on average, 3 or more times per week. Mood between temper outbursts is persistently irritable or angry most of the day & is observable by others. Symptoms present for 12 or more months Symptoms occur in at least 2 or 3 settings. Onset is before 10 years old.

Autism Spectrum Disorder Children can have Autism Spectrum Disorder & ADHD Autism Spectrum Disorder includes: Persistent deficits in social communication and social interaction across multiple contexts: Problems with social-emotional reciprocity Weakness in nonverbal communication behaviors (eye contact, reading social cues & body language) Weakness in understanding relationships Restricted, repetitive patterns of behavior, interests, or activities: Repetitive motor movements, use of objects, or types of speech Inflexible, insistence on sameness Restricted, fixated interests – “special interest” Hyper or Hypo sensitivity to sensory aspects of the environment (pain, temperature, smell, visual fascination with lights or movement Ranges from level 1 – requires support to level 3 requires very substantial support

Bipolar Disorder This is a mood disorder with cycles of highs (mania) and lows (depression) It can at times be hard to distinguish from ADHD Some people with Bipolar Disorder also have ADHD Emotion regulation problems can go with both disorders Impulsivity can go with both disorders Depression can be co-morbid with ADHD and is one of the cycles of Bipolar In young children severe temper tantrums instead of typical mania can be a symptom of Bi. Polar disorder

Sources Amen, Daniel (2001). Healing ADD: the breakthrough program that allows you to see & heal the 6 types of ADD. NY: The Berkley Publishing Group. Brown, Thomas (2001). Brown Attention-Deficit Disorder Scales for Children & Adolescents. Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition March, John (2007). Talking Back to OCD. NY: Guilford Press. Papolos, Demitri (2007). The Bipolar Child: the definitive and reassuring guide to childhood’s most misunderstood disorder, 3 rd Edition. NY: Broadway.