ADHD Comorbidity

When comorbid conditions are present, it can make the diagnosis of ADHD much more difficult to pinpoint and the symptoms harder to treat. Some comorbid disorders that commonly occur alongside ADHD are:

Oppositional Defiant Disorder (ODD)

Symptoms occur in as many as 21% to 60% of children with ADHD. ODD symptoms tend to occur more often with people whom the child is close to or knows well, such as family or caregivers.

Some of the behaviors associated with Oppositional Defiant Disorder include:

Opposing Authority

Oppositionality to authority generally begins to appear well before adolescence and can indicate a true case of ODD, but it may also be a side effect of a child’s difficulty interacting with his or her environment.

• The incredible frustration experienced in response to what the child with ADHD may see as “unreasonable” demands of the environment can trigger angry refusals.
• The child may not continue to behave in ways that are consistent with ODD once an appropriate course of treatment has begun. For more information on ODD, please click here.

Depression

10 to 30% of children with ADHD have a co-occurring mood disorder such as depression. Although many depressed adults move, think and talk slowly, children often demonstrate different symptoms when depressed.

• For example, children may show extreme impulsive and hyperactive behavior as well as irritability.

Causes

• EnvironmentalDepression may be a reaction to environmental stressors associated with having ADHD such as viewing the environment as unpredictable, seeing peers as unfriendly and rejecting, or thinking that school is a negative and overwhelming place.In these cases, a separate diagnosis and treatment strategy is not necessary because the depression is occurring in response to ADHD and will likely decrease when the ADHD symptoms are treated.

• FamilyIn other instances in which depression may run in the family and be more directly linked to biological/genetic causes, a separate diagnosis and specific treatment for symptoms of depression would be more appropriate.

Diagnosing Depression with ADHD

Distinguishing between the emotional complications of attention deficit disorder and a separate depressive disorder may be very difficult. It is critical to:

• Look for indications of whether the depression or the ADHD symptoms came first and whether there is a history of depression or ADHD in the family.
• Conduct an evaluation of the severity of symptoms.

Anxiety Disorders

Approximately 25% of individuals with ADHD also have anxiety disorders.

It is very important to distinguish between true anxiety disorders and those children who are experiencing anxiety in response to ADHD, because the treatment options are very different.

• Stimulant medications, while helpful for ADHD symptoms, may actually worsen the symptoms of true anxiety disorders. For more information on anxiety Disorders, please click here.

Bipolar Disorder

Bipolar disorders may co-occur with ADHD or may mimic its symptoms. About 1/2 of boys and 1/4 of girls with bipolar disorder also meet the criteria for ADHD. Children and adolescents with bipolar disorder often show:

• Impulsive inattention and hyperactive behavior.
• Extremely strong feelings.
• An overbearing manner.
• Irritability.
• Difficulty waking up in the morning.

Children and adolescents with severe bipolar symptoms may have excessive and lengthy temper tantrums that are destructive, and often based on gross distortions of objective events.

• For example, when a friend wants to play a different game, the bipolar child may think that his friend is trying to purposefully be mean.
• The child’s anger at such mistreatment may result in an extreme temper tantrum.

Again, it is critically important to reach an accurate diagnosis.

• The stimulant medication used to treat ADHD is not usually helpful for bipolar disorder and will likely exacerbate the symptoms.
• Lithium (one of the most frequently used medications to treat Bipolar Disorder) is usually much more helpful to children who are truly bipolar. For more information on Bipolar Disorder, please click here.

Conduct Disorder

Conduct disorder involves serious behaviors such as:

• Aggression towards people (including fighting) or animals.
• Destruction of property.
• Deceitfulness or theft.
• Serious violations of rules (e.g., staying out late at night, running away from home, or skipping school).

Learning Disorder

Over 1/2 of all children with ADHD also have a learning disorder. ADHD, though it affects the ability to learn, is not a true learning disability. So, treating the symptoms of ADHD will not correct any learning disorders that a child may have.

Learning disabilities are specific disorders that affect one of the four primary steps needed for learning:

• Recording information
  • Input; e.g., visual or auditory perception problems.
• Understanding information
  • Integration; e.g., sequencing and organizing problems.
• Storing information
  • Placing information into memory.
• Retrieving information
  • Memory; e.g., the immediate recall of recently learned information.

An inability to sustain attention resulting from ADHD, combined with a learning disorder can make school very challenging and frustrating for children.

Autism Spectrum Disorders

Intelligence is often impaired, and the ability to learn and utilize new information is markedly restricted.

Behavioral symptoms may include:

• Hyperactivity.
• Aggressiveness.
• Impulsivity.
• A short attention span.
• Temper tantrums.

Autism and ADHD

Similarities between autism spectrum disorders and ADHD can lead to early childhood diagnoses that suggest both are present. As the child ages, however, differences become more distinct and one disorder or the other often emerges as the true condition.

Problems with Diagnosing ADHD

The high comorbidity rate between ADHD and other disorders has essentially created confusion regarding the definition of a “true” ADHD diagnosis.

• Since most children or adults with ADHD also have a second diagnosis, and both sets of symptoms frequently overlap, critics suggest that the nuances of ADHD have not been adequately described.

Some even suggest that making an early (i.e., when a child is very young) ADHD diagnosis is inappropriate.

For instance, the recently identified condition of “early-onset Bipolar Disorder” (not yet recognized by the DSM) mimics ADHD in the areas of impulsivity, mood inconsistencies, and hyperactivity.

• It may not be clear whether very young children suffer from ADHD, early-onset Bipolar Disorder, or another condition that mimics ADHD symptoms. Obviously, establishing an accurate ADHD diagnosis is very challenging for even the best clinicians!