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AD/HD Co-Morbidity: What's Under the Tip of the Iceberg?
by Carol Watkins, MD
Many children and adults with AD/HD also experience other difficulties. It seems that having AD/HD makes it more likely that an individual will also have other difficulties. If a child meets criteria for AD/HD, it may not be enough to prescribe a stimulant get a few checklists and do follow up twice a year.
There has been increasing awareness that many adults and children with AD/HD may also meet criteria for one or more other psychiatric diagnoses. (Comorbidity means having two or more diagnosable conditions at the same time) There is some evidence that the incidence of comorbidity is somewhat higher in adults than in children. However, many of the studies looking at the issue of comorbidity are difficult to compare. Studies used different criteria for AD/HD and bipolar disorder, and sometimes got their subjects from different populations. For example, one might expect to see more complex types of AD/HD in specialized hospital clinics than one would see in a door-to-door survey or in a primary care physician’s office. Despite the differing criteria across studies, and the lack of large general population studies of adult AD/HD, there still convincing data that several other psychiatric diagnoses are common among children and adults with AD/HD.
Dr. Genel in Attention Magazine said that research studies showed that as much as 65 percent of children with AD/HD will have one or more comorbid condition at some point in their lives. Dr. Genel’s review of follow-up studies of children with AD/HD and studies of adults who were later diagnosed with AD/HD indicated that the disorder often persists into adulthood.
Common Conditions that often Co-exist with AD/HD
- Oppositional Defiant Disorder (and Conduct Disorder)
- Learning and communication differences
- Anxiety (state or trait)
- Obsessive-Compulsive Disorder
- Drug abuse
- Bipolar Disorder
- Sleep Problems
- Tourettes Disorder
- Pervasive Developmental Disorder
- Many forms of physical illness (such as asthma)
- Accidental injury
Does the individual have AD/HD plus another condition or it is just another condition masquerading as ADHD? This can be a difficult call. Often a thorough initial individual and family history can help clarify this. Anxiety or OCD can look like AD/HD. Drug abuse, especially when it occurs in the school setting, can also make an individual appear inattentive and impulsive. It may be wise to perform a drug screen on some adults and adolescents who present with symptoms of inattention, irritability and impulsivity. Onset of symptoms may help differentiate AD/HD from some other disorders. AD/HD generally begins before age seven. However, a bright child, especially one who is not hyperactive, may escape notice until later when the demands of academia or of life exceed the individual's coping mechanisms. Usually in such individuals, one can take a careful history and elicit stories of how the individual used unique of stressful coping mechanisms or stories of how the individual performed well below an excellent intellectual potential.
How can treatment of the other conditions be different if ADHD is also present?
First, we try to determine whether the anxiety is situational—the individual may be anxious because the AD/HD is making it difficult to succeed academically, vocationally or socially. If this is the case, treating the AD/HD may reduce the anxiety. If the anxiety is a separate entity, one must be more cautious about the use of stimulants because they can sometimes exacerbate anxiety. One may elect to may treat the anxiety first, or treat the anxiety and the AD/HD at the same time. If the individual is capable of using cognitive techniques, to handle the anxiety, he or she can take an active part in controlling his or her anxiety.
Oppositional Defiant Disorder and Conduct Disorder:
These conditions are some of the most commonly associated with AD/HD. These individuals defy rules and, in some cases, engage in violent acting-out behavior. Family work and early behavioral intervention are often useful. It is important to address them early because they may lead to a poorer long-term outcome. One must be on the look out for substance abuse and sexual acting out.
This disorder involves multiple vocal (throat clearing or compulsive use of certain words) and motor tics (twitches or more complex movements.) The tics are often preceded by symptoms of inattention and hyperactivity. Tics often wax and wane over time. They may peak in adolescence and be milder in adulthood. (Not always) There has been a controversy about the use of stimulants in individuals with tics. It was once thought that stimulants would exacerbate or even cause tic disorders. Recent data has suggested that many individuals with Tourettes can safely take stimulant medication. It is important to proceed with more caution. There may be some individuals for whom the stimulants make tics worse. Others benefit from the medication and do not have a worsening of their tics. When treating Tourettes, it is important to determine which symptoms are the most troublesome: The tics, the inattention or other behavioral problems. Often the tics are not the main thing that bothers the individual.
Individuals with both AD/HD and depression may be at increased risk of impulsive acting out. I usually ask early on whether there are any guns in the household and whether they are safely locked up. This may sound extreme, but safety should come first. Some feel that inattentive, less hyperactive individuals are more likely to have co-morbid depression. If the depression is severe, I often treat it before I treat the AD/HD. Once the depression is at least partially better, I may re-evaluate for AD/HD and then treat. Depression in prepubertal children does not show as much of the female preponderance as does the depression that occurs during or after puberty. Children who show depression at an early age have a higher incidence of bipolar disorder. Sometimes the depression seems to occur during the fall and winter. If the depression is seasonal, one must determine whether the depression is related to school difficulties or whether the depression truly linked to the seasons.
Individuals with AD/HD have several characteristics that make them more vulnerable to substance abuse: These may include: self-medication, impulsivity, tendency to associate with other individuals who are not doing well in school, and social skills problems. Appropriately prescribed stimulant medication does not seem to increase the chance of later substance abuse. Parents of a child with AD/HD should start talking about drug abuse and risky behavior early and maintain an open dialogue. If an individual seems to have both AD/HD and a substance abuse problem, how do we treat him or her? I often encourage group therapy in a setting the deals with drugs and encourages abstinence. Family therapy is also a good idea. The individual may benefit from 12-step groups. Family members may benefit from Alanon or Naranon. Should we prescribe Schedule II medications to individuals who are actively abusing drugs? I prefer not to do so, especially if the individual refuses to participate in other forms of treatment. I may consider using a Schedule II stimulant if the individual is a minor, and the parents can tightly monitor the medication, and get regular drug screens. In other cases, we may start with non-Schedule II medications such as Wellbutrin. If the drug abuse is more than a small amount, or if close parental monitoring is not possible, it may not be safe to prescribe medication at all. In some cases, the individual may need intensive out patient or even residential treatment to break through denial and to get treatment started in a safe environment. It may be more difficult to treat substance abuse in an individual with AD/HD than in a non-AD/HD individual. I do not feel comfortable treating an individual who has both AD/HD and substance abuse with medications alone. If the individual refuses treatment, we may start by bringing the family into treatment so that they can learn to understand the situation and set limits.
Diagnosis and treatment for LD often requires a team approach. Psycho-educational testing, school involvement, tutoring and medical involvement may need to be coordinated. Treating just the ADHD does not solve the LD, but it may make the treatment of the LD easier. A child may need to concentrate more in order to learn compensatory skills. Such intense concentration may not be necessary in the child's areas of great strength. I tend to have a lower threshold for using medication in a child with both conditions because this child has a greater need to focus well while learning compensatory skills. I also have a lower threshold for recommending academic help for a child with both because the AD/HD may necessitate more individualized help for the LD.
For years, clinicians have anecdotally noted an increased incidence of enuresis in children with AD/HD. Others have observed that their patients with enuresis have an increased incidence of AD/HD. Because both conditions are fairly common, it would be important to have more systematic studies that looked at the relationship between enuresis and AD/HD.
An article in the Southern Medical Journal published in 1997compared a fairly large group of 6-year-old children with AD/HD to a non-AD/HD control group selected from a pediatric clinic population. They found that the 6-year-olds with AD/HD had 2.7 times higher incidence of enuresis and a 4.5 times higher incidence of diurnal (daytime) enuresis as compared to a control group Other authors have cited higher rates of enuresis in children with ADHD. However, these studies did not have control groups or were not selected randomly.
Sometimes enuresis may be more upsetting for a child with AD/HD. A non-AD/HD child, who is successful in most spheres, may be able to accept his bedwetting more easily. Later, such a child may find it easier to cooperate with behavioral interventions. However the child with ADHD already feels different from his peers. His disorganization and impulsivity may lead to peer rejection and shame. Such a child may cover his shame with a false appearance of bravado. And although he may be more ashamed of his bedwetting, his inattention and disorganization may make it more difficult for him to cooperate with some behavioral treatments. Individuals with AD/HD are more likely to have sleep problems. Some of them sleep deeply and have difficulty waking up to go to the bathroom when their bladder is full.
Treating the child with both AD/HD and enuresis:
This child should have a complete physical exam. It is important to always ask an individual with AD/HD about current and past bedwetting problems. Don’t neglect to ask adolescents about this too. They will rarely volunteer this information on their own. Ask what they and their parents have tried in the past. Some children and teens with AD/HD are veterans of many types of therapy. They may already expect the treatment to fail. The behavioral techniques listed earlier in the article are still useful for these children and teens. Since these children have often experienced teasing and criticism, one should be especially careful to avoid punitive behavioral techniques. One may have to modify behavioral interventions to accommodate the child’s shorter attention span. You may need to prioritize symptoms. If the child has a myriad of behavior difficulties, the family cannot address all of them at once. Which ones are the most important to the child and the parent? Some children and families opt to wait a while longer before starting behavioral or medical interventions. When the family decides that this is the time to treat the enuresis, they may have to back off with some of their other behavioral goals to avoid being overwhelmed. The child and family should be made aware that there are several ways to treat the enuresis. If one does not work, you are not a failure. You still have plan B, plan C, etc.
Physical problems and accidental injury:
It is important to continue childproofing until the child has gone off to college. Parents need to make extra sure that safety precautions are being followed when the child or adolescent is engaged in physical activity or driving. It is a good idea to have a regular primary care practitioner who knows the individual and his family. If this individual makes more than the average number of trips to the ER, make sure that you and your doctor have agreed on the best ER. Not all emergency rooms are well equipped to handle a child with AD/HD.
Some of these comorbid disorders present later than the AD/HD. When I diagnose a child with AD/HD, I often discuss this with parents. Is this just scaring them or causing a self-fulfilling prophesy? I do not think so. Knowledge is strength. If parents, individuals and spouses are on the alert, and know the early warning signs of other disorders, they are more likely to bring the individual back before the situation becomes severe. Families that have a strong history of a particular disorder often feel empowered, instead of living with a vague dread that the individual will develop a disorder and not knowing what to do about it. Sometimes the "early warning signals" turn out to be a physical illness, or just an adolescent moody spell. However, if the re-evaluation is handled in a matter of fact way, it can work well.
Illustration from Joseph Biederman and Stephen Faraone, Harvard Mahoney Neuroscience Institute Letter Winter 1996 Volume 5 Number 1
Cantwell, Dennis, http://www.netacc.net/~gradda/sp99como.html Spring 1999 Greater Rochester Attention Deficit Disorder Newsletter.
Genel in Attention! ® Magazine Volume 5, Number 1, Page 20
Attention Deficit Disorder, Perspectives and Treatment http://www.ncpamd.com/adhd.htm
by Carol Watkins, M.D.