ADHD Comorbidity, Screening and Treatment
ADHD and Comorbidity
ADHD is a pervasive neurodevelopmental disorder characterized by symptom clusters of inattention, hyperactivity, and/or impulsivity and associated impairment in 2 or more settings.[1] It is not uncommon for conditions to overlap. Over half of child and adolescents with ADHD have a co-occurring psychiatric condition including, but not limited to, anxiety, depression, and trauma related disorders.[1,2] It is important to understand this potential and screen and treat common comorbid conditions as this can impact treatment response. While it may be the case that a child solely has ADHD or a different mental health disorder with similar presentation, a majority have both ADHD and a comorbid condition.[1,3] Furthermore, research supports gender differences with girls diagnosed with ADHD more likely to have internalizing disorders (anxiety, depression) in comparison to boys.
In general, to assist with differentiating diagnosis, see bulleted list:
- Vanderbilt (useful for monitoring treatment response; 6-12 y),
- PSC (4-16 y)
- SDQ ( 2+ y)
- CBCL ($; 1.5-18 y)
- Conners 4th Ed ($, with short forms useful for monitoring treatment response; 6-18 y)
Below are some key considerations for clinicians treating conditions comorbid with ADHD:
ADHD and Comorbidity Chart Heading link
Comorbid Condition with ADHD | Symptom overlap | Differences | Diagnosis and Screening | Treatment |
General | Vanderbilt (useful for monitoring treatment response; 6-12 y), PSC (4-16 y) SDQ ( 2+ y) CBCL ($; 1.5-18 y) Conners 4th Ed ($, with short forms useful for monitoring treatment response; 6-18 y) | - Treat most impairing condition first.2 | ||
Trauma related disorder45 (e.g. PTSD) | Inattention, restless, difficulty sleeping | Sentinel event, hyperarousal, hypervigilance | For those below the age of 8 or children with developmental delay, parents/caregivers should be relied on for completing screening tools. CTS (Brief 10 questions, 6-17 y) CATS-C (3-17 y) CPSS (8-18 y) TSCC($, 8-16 y); TSCY ($, 3-12 y) | - Trauma focused therapy. - Stimulants may worsen symptoms of anxiety/hyperarousal - α-agonist medications alone or combined with stimulant may alleviate reactivity/irritability - SSRIs may benefit symptoms of depression and anxiety |
Anxiety disorder | Restlessness, inattention, irritability, racing thoughts | Typically provoked by a stressor or associated fear | GAD7 (11+ y) SCARED Parent/Child (8-18 y) SCAS (2.5-12 y) | - therapy involving graded exposure, modeling Depending on severity of symptoms and treatment planning may consider SSRI in addition to therapy. |
Mood Disorder Depression Mania | Depression: inattention, poor motivation Mania: impulsivity, hyperactivity, racing thoughts, poor judgement | Mood episode proceeds onset or excessive worsening of symptoms of inattention/poor concentration/restlessness | PHQ-A (PHQ-9 modified for teens; 11-17 y), CMRS – Parent Version (5-17 y) MDQ (12+ y) YMRS – Parent Version (5-17 y) | - Depression: Depending on severity of symptoms and treatment planning may consider SSRI in addition to therapy. - Manic disorder: child should be adequately stabilized on a mood stabilizer PRIOR to initiation of most ADHD medications as there is risk of exacerbating manic symptoms or contributing to switch to mania. A stimulant can be resumed with close monitoring (Patient may likely benefit specialty referral). |
Sleep Disorder | Inattention, disruptive behaviors, irritability | Corrects with adequate sleep | BEARS, Sleep diary, ESS-CHAD | - Dependent on underlying sleep condition may benefit from subspecialty referral. |
Learning disorder (i.e. Dyslexia, dyscalculia, dysgraphia among others) or intellectual disability | Poor academic performance, inattention, distractibility | Learning disability – specific to one or more areas Intellectual disability: academic performance does not improve with 1:1 guidance | Diagnosis is typically made through psychological testing | - School-based interventions such as IEP or 504 or additional skills-based training. |
Oppositional Defiant Disorder | Poor task completion, mood lability | As opposed to ODD, those with ADHD may be too distracted to comply with requests, forget, or impulsively react to their own regret | - Focus on directing family to therapeutic interventions (therapies focused on development of problem-solving skills and family-based interventions like PMT or PCIT), mobilizing community and school-based interventions such as IEP or 504 plan. - Medications serves more of a role if evidence of aggression. Would then consider atypical antipsychotic with an attempt to taper after 3 months of sustained symptom improvement. |
Screening Tools Heading link
Screening tools are useful for rapid assessment that may assist with clarifying the differential diagnosis, but the sensitivity and specificity of these tools vary and may result in false positives or negatives. Information obtained through screening tools should be coupled with history (from caregivers and child) and examination to determine a diagnosis based on DSM-5 criteria with focus on core symptoms and associated impairment. Clinicians should proceed with treatment of most impairing condition. If the patient struggles with multiple comorbidities that do not respond to initial treatments, it may be beneficial to seek specialty care.
Illinois DocAssist psychiatric consultants are available to help you sort through the complexities that arise when differentiating a diagnosis or treating comorbidities. Call the consultation line 9am-5pm Monday through Friday at 866-896-2778 or schedule a consultation using our online request form.
Announcement: Getting Consent from DCFS Just Got Easier Heading link
The DCFS Guardian Consent process is changing as a part of the IllinoisConnect system rollout. Gone will be the days of fax and email consent forms. Medical providers and other consent requestors will soon be able to utilize the brand-new Guardian Consent Portal to request consent for the following forms:
- CFS 415 – Consent for Ordinary and Routine Medical and Dental Care
- CFS 431– Consent of Guardian to Medical/Surgical Treatment
- CFS 431-1 – Consent of Guardian to Mental Health Treatment
- CFS 431-A – Request for Psychotropic Medication Request Form
- CFS 432 – Consent for Out of State Travel/Out of Country/Extended Trips
- CFS 600-3 – Consent for Release of Information
- Other Ordinary and Routine Requests
References Heading link
References:
[1] Wolraich ML, Hagan JF Jr, Allan C, et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents [published correction appears in Pediatrics. 2020 Mar;145(3):e20193997. doi: 10.1542/peds.2019-3997]. Pediatrics. 2019;144(4):e20192528. doi:10.1542/peds.2019-2528
[2] Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921. doi:10.1097/chi.0b013e318054e724
[3] Centers for Disease Control and Prevention (CDC). Mental health in the United States: Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder. United States, 2003. MMWR Morb Mortal Wkly Rep. 2005;54(34):842–847
[4] A. Spencer, MD, et al; J Clin Psychiatry. Examining the Association Between Posttraumatic Stress Disorder and Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis. 2016;77(1):72–83
[5] Siegfried CB, Blackshear K. National Child Traumatic Stress Network, with assistance from the National Resource Center on ADHD: A Program of Children and Adults with Attention/Hyperactivity Disorder (CHADD). Is it ADHD or child traumatic stress? A Guide for Clinicians. Sep 2016.
[6] Mental Health Practice Tools and Resources. Mental Health Tools for Pediatrics, 2nd ed. APA. Feb 2021. https://www.aap.org/en/patient-care/mental-health-initiatives/mental-health-practice-tools-and-resources/