Medical Comorbidities and Complicated ADHD
There are a number of medical conditions that can coexist with ADHD and complicate the disorder. These conditions include disruptive behavior disorders, like oppositional defiant disorder and conduct disorder; anxiety disorders; tics; mood disorders, including depression and bipolar disorder; developmental coordination disorder; learning disorders that result in difficulties with math and writing; and substance use disorders. Mental health issues are also prevalent in incarcerated populations.
In this podcast, Dr. L. Eugene Arnold discusses the prevalence of these conditions that can coexist with ADHD, how ADHD symptoms by themselves negatively affect functioning, and the negative impacts added to functioning when comorbid conditions are present. He provides diagnostic questions to ask when seeking to identify the presence of these co-occurring conditions, and gives advice on treatment for complicated ADHD.
L. Eugene Arnold, MD, MEd
L. Eugene Arnold, MD, MEd, is CHADD’s resident expert and professor emeritus of psychiatry at Ohio State University, where he was formerly director of the division of child and adolescent psychiatry and vice-chair of psychiatry. He is a co-investigator in the OSU research unit on pediatric psychopharmacology. He has over 38 years of experience in child psychiatric research, including the multi-site NIMH Multimodal Treatment Study of Children with ADHD (“the MTA”), for which he continues as executive secretary and current chair of the steering committee.
Listeners will be able to:
- Describe complexities of ADHD.
- Describe the importance of interprofessional collaboration in treatment of ADHD.
Announcer: You're listening to Pocket MD, training on ADHD in children and adults.
Dr. Max Wiznitzer: This is Dr. Max Wiznitzer. I'm a child neurologist at Rainbow Babies and Children's Hospital and moderator for this session on ADHD comorbidities and complicated ADHD. Our guest today is Dr. Eugene Arnold. Dr. Arnold, please tell the listener about yourself.
Dr. Eugene Arnold: I'm a professor emeritus of psychiatry at Ohio State University and CHADD’'s resident expert. I've had 40 some years of experience with ADHD, including treatment research studies.
Dr. Max Wiznitzer: Well, let's get to the topic about ADHD comorbidities and we can split some of these comorbidities in little sections. So, for the listener, tell us what are the common psychiatric comorbidities that can occur with ADHD?
Dr. Eugene Arnold: Well, first of all, the most common is oppositional defiant disorder, which is simply argumentativeness, refusal to comply with instructions. Not because they weren't paying attention, but because they refuse to do it, and irritability is often part of that. Then, if it gets a little more serious, they could develop conduct disorder, which involves breaking rules, the age-appropriate rules like truancy, but also some that would be inappropriate for anybody of any age like stealing or setting fires or lying. Those are the things that are called disruptive behavior disorders. There's often a blend of those in a youngster who has that problem, but that's not everybody with ADHD. Some kind of go the other direction, being very anxious, and about a third of children with ADHD have anxiety that tends to remain with adults also.
And comorbid anxiety is one of the things the Multimodal Treatment Study of ADHD, the MTA, found to predict a poor adult outcome. Then there's also things like tics, that's involuntary motor movements, eye blinks, or coughs, barks, rapid twitches, or movements of the limbs. About half of children with a tic disorder, chronic tic disorder, also have ADHD, but it's only a minority of those with ADHD because the tic disorder is not as common.
Then we have mood disorders, and there's a big symptom overlap between mood disorders and ADHD. For instance, difficulty concentrating is one of the cardinal symptoms of depression. Things like psychomotor agitation, which would be like hyperactivity. There can be impulsiveness with manic-type mood problems. The motivation to do things to finish projects can also result from depression because of the lack of energy. We also have things like a developmental coordination disorder, which is more of a neurological problem, and at one time was considered an essential part of the ADHD syndrome, back when it was called minimal brain dysfunction. It still is a complication that's a problem for many children with both ADHD and developmental disorders. Sometimes the comorbidity is actually the primary problem that maybe needs to be treated even before ADHD. For example, someone with bipolar disorder needs to have that treated as a primary problem; not to ignore the ADHD, but just noting the seriousness of that particular comorbid disorder.
Then we have things like learning disorders, which a high proportion of children with ADHD have—learning disorders maybe 20, 25%. And that complicates things, and their academic problems result then from both disorders. They have trouble paying attention, but they also have trouble remembering things, they have trouble deciphering words in reading, or trouble adding and subtracting, multiplying, dyscalculia sometimes called, and of course, expressive writing disorder, where they have trouble getting the words out in an essay-type production.
Dr. Max Wiznitzer: When we look at some of these learning problems, we know that if you don't develop good foundations for learning, such as in math, and don't develop the fundamentals of math, that they may not be able to progress to more complicated areas, such as multiplication, division, or higher order math issues. How often would you say that ADHD itself can interfere with that learning process?
Dr. Eugene Arnold: I think it's a particular problem for math, because if you don't learn how to add and subtract, then you have trouble with multiplication and division. And if you don't learn the times tables, then when you get on further up and try to do algebra or some other more complicated function, you're really hamstrung. The reading you can catch up on, but the math, if you don't have the foundation, the whole thing collapses. It is a particular problem in math.
Dr. Max Wiznitzer: One of the areas that people are concerned about when we're talking about comorbidities or coexisting conditions is substance use. And whether it's occasional substance use or rising to the level of substance use disorder, how is that associated with ADHD and with its treatment?
Dr. Eugene Arnold: There is a high risk, about double the risk, for substance use disorders. If someone has ADHD, now that doesn't mean the majority become addicted or dependent on drugs, but it's about double the risk in the general population. And there are a number of things with ADHD that tend to predispose to that. One of course is impulsiveness, acting without thinking, not thinking through the dangers of experimenting and trying. Also, the seeking of novelty. They're more likely to look for something exciting, get involved in drugs in that way or alcohol for that matter.
One of the problems that people worry about is whether the medications that we give for ADHD, the stimulant drugs, whether that can be a problem; can they get dependent or addicted to that? And those are drugs of abuse, which is why they're controlled substances controlled by the DEA. The data indicate that what the substance use problems that people with ADHD have are not with stimulants. They tend to become dependent or addicted—or at least abusing—alcohol, tobacco, and marijuana. In some cases, they may be using this as self-medication either to calm their anxiety, or in the case of tobacco, there's some evidence that nicotine actually does help ADHD symptoms, but the problem is it's hard on your lungs. So, it's not the best way to self-medicate.
A lot of people are claiming lately that marijuana can be useful for ADHD, but there's no good evidence for that at this point, partly because it hasn't really been adequately studied. The symptoms of marijuana dependence mimic some of the symptoms of ADHD—so it doesn't appear likely—things like lack of motivation and not paying attention to duties and responsibilities. So, it's not likely that straight marijuana will be helpful. However, there is another, cannabidiol, a derivative of hemp that is supposed to not be addicting, may have some possibilities, but it hasn't been adequately studied yet.
But the bottom line is there's no evidence that being treated with stimulant drugs predisposes to substance abuse, or use, or dependence. What little evidence there is one way or the other seems to favor slightly that it may prevent the substance use. Being treated with the FDA-approved medications, the stimulants, may actually prevent substance use.
Dr. Max Wiznitzer: People report that for individuals who are incarcerated in jail there is a high rate of mental health issues, including ADHD, in that population. Is this true?
Dr. Eugene Arnold: The data that I've seen indicate that there is, and people joke the ones who ended up in jail are the ones who don't plan things out well enough to make their escape. Having ADHD may handicap a criminal as much as it handicaps anybody else. There is the impulsiveness and the seeking of excitement and novelty that put a person at greater risk for some sort of act that would get them in jail. Once in jail, unfortunately, they're not usually treated well, and they're left to kind of their own devices. So, it's a bad combination to be in jail with ADHD and other mental disorders that make a person more vulnerable, more susceptible.
Dr. Max Wiznitzer: With these comorbid or coexisting conditions, what is a general provider to do? And when seeing an individual with ADHD, what kind of questions should they ask in order to identify whether some of these conditions are or are not present?
Dr. Eugene Arnold: Well, one of the things is to ask them how they feel, what they generally feel, and if they are genuinely sad or depressed or anxious or nervous, that indicates that they probably have one of these comorbidities. Also, to ask some observers about symptoms of rule breaking, defiance, and so forth. Usually the person themselves, particularly children, will deny it. They don't see that they have a problem. It's the teacher's mean, or the parents are too strict, or whatever. So, you need to ask another observer about those disruptive behavior symptoms, the so-called externalizing behavior. But for the internal things like anxiety, depression, manic symptoms, you can ask the individual themselves, whether a child or adult.
Dr. Max Wiznitzer: There are other conditions that can be associated with ADHD. Does ADHD only occur in, we'll say, individuals who have normal intelligence and no other possible medical problems?
Dr. Eugene Arnold: Yeah. It can occur at any level of intelligence from genius level down. For example, Leonardo da Vinci, lot of us suspect that he had ADHD. But it can occur at any intelligence level, including intellectual disability and in autism, about half of people with autism have ADHD also. And in neurological, neurodevelopmental problems like Fragile X syndrome or Angelman syndrome, or there's a fancy one called Velo-cardio-facial syndrome. But the point is that anything that interferes with brain function can also result in ADHD.
Dr. Max Wiznitzer: There are some, I will call it acquired neurodevelopmental problems that can result with ADHD symptoms, including some that actually have ADHD as part of their diagnostic criteria. For instance, fetal alcohol spectrum disorders are that way. Can you count up perhaps about the impacts of other conditions that can be acquired, such as prematurity or cerebral palsy and their association with ADHD?
Dr. Eugene Arnold: Yeah. Anything that interferes with development of the fetus in the womb— things like maternal smoking, maternal alcohol use, vitamin deficiency, mineral deficiencies, the recent study, first trimester anemia during pregnancy has an effect later on the child at four or five or six years of age. With symptoms, it sounds like ADHD. Or infection, intrauterine infection. Rubella used to be—was then called minimal brain dysfunction—would now be called ADHD. So, anything that affects the development of the brain could result in ADHD symptoms, and if they are chronic and impairing, then that could be diagnosed as ADHD. ADHD is a phenomenological diagnosis; in other words, it's based on behavior and function, not necessarily on causes.
Dr. Max Wiznitzer: Assuming that these comorbidities or coexisting disorders are present, how does that impact the management by the medical practitioner?
Dr. Eugene Arnold: Well, you can't just treat the ADHD. If they also have a lot of anxiety, if they're depressed, you have to also treat that. Sometimes the same treatment could be good for both. For example, cognitive behavioral treatment can help both depression and anxiety and has recently been shown to be useful in ADHD. There are some medications that will help both depression, and some antidepressants, for example, would help both depression and ADHD symptoms as has been shown in controlled studies.
Dr. Max Wiznitzer: As a final message to our listeners, what would you tell them about the individual who comes in, where they suspect either it's a comorbidity is present or they have complicated ADHD? What should they do?
Dr. Eugene Arnold: Well, it would probably be good to get at least psychiatric consultation, if not referral to a psychiatrist, to manage these more complicated cases that have psychiatric comorbidity along with their ADHD. And I should mention that the symptoms of ADHD are very broad. They occur across many, many disorders. And so you might think of ADHD as a kind of naked executive function deficit without the trappings of mood disorder, anxiety, PTSD, all the other things that can also cause the same symptoms.
Dr. Max Wiznitzer: Thank you, Dr. Arnold
Announcer: Pocket MD is brought to you by CHADD with funding from the US Centers for Disease Control and Prevention and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.
- Society for Developmental and Behavioral Pediatrics (SDBP), Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder, Journal of Developmental & Behavioral Pediatrics, January 30, 2020.
- Society for Developmental and Behavioral Pediatrics (SDBP) Complex ADHD Guidelines Executive Summary.
- American Academy of Pediatrics (AAP). Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, Pediatrics, October 2019
- CHADD National Resource Center on ADHD. ADHD and Coexisting Conditions (fact sheet)
- CHADD National Resource Center on ADHD. ADHD and Coexisting Conditions (infographic). February 2020.
- CHADD National Resource Center on ADHD. ADHD Medications Approved by the US FDA (infographic). January 2020.
CDC, our planners, presenters, and their spouses/partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. L. Eugene Arnold, MD, MEd, Dr. Craig Surman and Dr. Margaret Sibley and the wish to disclose research funding from commercial interests.
Planning committee discussed conflict of interest with Dr. Arnold, Dr. Surman and Dr. Sibley to ensure there is no bias.
Content will not include any discussion of the unlabeled use of a product or a product under investigational use.
CDC did not accept commercial support for this continuing education activity.