Treatment of Complex ADHD
Complex ADHD is ADHD that co-occurs with one or more conditions that can complicate the symptoms of ADHD. Two-thirds of children with ADHD have at least one coexisting condition. These coexisting conditions may include oppositional defiant disorder (ODD), anxiety disorders, depression, learning disorders, autism spectrum disorders, intellectual disability, and tics (Tourette Syndrome).
Treatment of complex ADHD begins with treating the condition that is most prominent, and may involve behavior therapy, parent training, or medication. When medication is used, stimulants are the first line of treatment. Nonstimulant medications may be considered when stimulants do not work. If learning disorders coexist with ADHD, academic interventions are needed.
In this ADHD 365 podcast, Dr. Tanya Froehlich offers expert information on complex ADHD, focusing on the conditions that often coexist with ADHD. She discusses the recommended treatments based on research for each of the conditions, and the options available when first line treatments don't work.
Tanya Froehlich, MD, MS
Dr. Tanya Froehlich is a professor of pediatrics at Cincinnati Children’s Hospital Medical Center in the division of developmental and behavioral pediatrics. She is a developmental-behavioral pediatrician and an ADHD clinical specialist. Dr. Froehlich serves on the national ADHD clinical practice guideline development committees for both the American Academy of Pediatrics and the Society for Development and Behavioral Pediatrics.
Listeners will be able to:
- Identify ADHD symptoms throughout the lifespan.
- Describe the importance of interprofessional collaboration in treatment of ADHD.
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Dr. Gene Arnold: Hello, I'm Dr. Gene Arnold, professor emeritus of psychiatry and behavioral health at Ohio State University and CHADD's resident expert. Today we will be talking about complex ADHD. And to elaborate on that, we have…
Dr. Tanya Froehlich: Dr. Tanya Froehlich and I'm professor of pediatrics at Cincinnati Children's Hospital Medical Center in the division of developmental and behavioral pediatrics.
Dr. Gene Arnold: Now, the topic is complex ADHD, but what exactly is meant by that term?
Dr. Tanya Froehlich: So, “complex ADHD” refers to ADHD that is complicated by having another condition, a condition that's neurobehavioral traveling along with it. Now some of these conditions that can come along with ADHD include things like oppositional defiant disorder, anxiety disorder, depression, learning disorders, autism spectrum disorders, intellectual disability, tics or Tourette syndrome, to name just a few, so as we go through each one of them, I'll explain a little bit more.
Dr. Gene Arnold: Okay, before we get into that, why did the Society for Developmental and Behavioral Pediatrics develop a guideline especially for assessment and treatment of complex ADHD?
Dr. Tanya Froehlich: The fact is that existing pediatric ADHD guidelines largely focused on treatment and assessment of ADHD in isolation, even though ADHD in fact usually doesn't travel alone. In fact, two thirds of children with ADHD have a coexisting condition.
Dr. Gene Arnold: What's the most common of those?
Dr. Tanya Froehlich: Really high on our list would have to be oppositional defiant disorder. So, more than half of kids with ADHD have coexisting oppositional defiant disorder or ODD. Now, children with ODD, they're much more uncooperative, defiant, and hostile toward their peers, toward parents, teachers, and other authority figures, than are other children.
Dr. Gene Arnold: When you described oppositional defiant disorder or ODD, as it's popularly called, it reminded me a little bit of kind of a bratty behavior. So what's the difference between ODD and just bad child behavior?
Dr. Tanya Froehlich: Well, ODD or oppositional defiant disorder is basically a description when a child is having a lot of temper outbursts, when kids are not listening to parents or teachers, they're openly defiant. So, there's a lot of overlap, and sometimes when parents are describing behavior as just being bratty or bad behavior, the doctor really needs to dig into it a little more and think about it. And it could be oppositional defiant disorder, which needs a specific parent behavior training to address.
Dr. Gene Arnold: Okay, does it help to find out how they behave with other people, like peers, teachers, coaches, and so forth, whether it's only occurring with the parents or if it's with everybody. Does that help?
Dr. Tanya Froehlich: That definitely does help, but one thing to note is that even if it's just happening with the parents and it's not happening with any other authority figures, the family still could benefit from the parents doing the parent behavior training classes to address those difficulties and to reduce family stress to help everyone in the family have more harmony and to get along better.
Dr. Gene Arnold: How will that affect the treatment plan?
Dr. Tanya Froehlich: All children with ADHD, whether or not they have a coexisting neurobehavioral condition, are going to benefit if their parents participate in a parent behavior training program. And this is even more true and even more important when kids have coexisting oppositional defiant disorder. This is because inconsistent and overly harsh parenting practices really make oppositional behaviors flourish. And to combat this, the parent behavior training programs teach parents how to set up rules and consistent routines, how to reward and reinforce appropriate behaviors, and how to put the lid on inappropriate behaviors in ways that are not overly harsh or severe, and therefore, likely to backfire on them.
So, behavior therapy that focuses on parent training is the number one treatment that we should employ when kids have coexisting ADHD and oppositional defiant disorder. And I really want to make sure that everyone understands that when we talk about parent behavior training, we do not mean play therapy or talk therapy with the kids. We know that these are not effective for ADHD or for oppositional defiant disorder. So it really has to be working with the parents and not just the kid by themselves with the therapist.
Dr. Gene Arnold: So power to the parents? Okay.
Dr. Tanya Froehlich: Absolutely. I also want to say a few words about how medication treatments for ADHD, how things work if kids have oppositional defiant disorder, too. So, stimulant medications, those are things like, the generic names will be methylphenidate or amphetamine, dextroamphetamine, they're the first line or first choice medication treatment for coexisting ADHD and oppositional defiant disorder, since stimulants have been shown to help with oppositional and aggressive symptoms in addition to helping with ADHD symptoms.
I think this is because oppositional symptoms are often a form of emotional impulsivity. However, I feel like, I'm out with it. I don't have good frustration tolerance. I can't hold myself back when upset. So when the stimulants treat that emotional impulsivity, they can also help with some of these oppositional behaviors.
Dr. Gene Arnold: Oppositional defiant disorder though is not the only co-occurring problem that some children with ADHD have, is it?
Dr. Tanya Froehlich: Absolutely not. Another one that frequently comes up is anxiety disorders. And, in fact, we think that 25% to 35% of kids with ADHD have a coexisting anxiety disorder. And so, people often want to know how's that going to affect ADHD treatment if there's anxiety present too? So, the first order of business is really to determine which of these disorders is driving the bus. So, which one is causing more problems and more impairment? And then we want to lead with treatment of the disorder that seems to be more prominent.
This is because treating that more prominent condition can often improve the other. For instance, once anxiety is treated, the kid is not consumed with anxiety and worry taking over all their thoughts. They're not in a frenzy of worried activity, so then they're able to attend better and they seem less hyperactive. On the flip side, if ADHD is the bigger factor, if we treat it, then the kids feel more comfortable, they feel more successful, and that can make their anxiety go down. But one thing we definitely don't want to do is to start anxiety and ADHD medication treatments at the same time, because this could be subjecting kids to unnecessary extra medication treatment. So, we really want to be going in a stepwise rather than a shotgun fashion.
So, let's take the example where anxiety seems to be driving the bus. So, the first thing we would recommend is cognitive behavioral therapy. And in cognitive behavioral therapy, a lot of times people wonder like what is that? It can be hard to figure out if your therapist is offering the right behavior for your child. So, in cognitive behavioral therapy, the child and the therapist work together on changing patterns of thinking that drive the anxiety. Of note, kids do need to be old enough to understand their thought patterns to do cognitive behavioral therapy. Some kids will be able to do this at around age six or seven, other kids will need to be older. But we want to be really clear: it's not for very young kids and wouldn't work for a four-year-old.
So, assuming a child is old enough to participate in cognitive behavioral therapy, they're first going to learn to recognize the triggers, how their body feels when they're becoming more anxious, they'll learn self-calming techniques, and by experiencing exposure to their triggers, they'll learn how to change the way they think about these triggers and therefore, respond to them. Now, if the cognitive behavior exposure sessions don't help a child's anxiety enough, then they'll need to try an anxiety medication, and we would choose, we would recommend first a medication from the selective serotonin reuptake inhibitor group.
Let's take the case of a child who has ADHD and anxiety, and ADHD seems to be the more prominent condition. We'd recommend first starting with evidence-based ADHD behavior treatments. And we do have some evidence that kids who have coexisting ADHD and anxiety may respond even better to behavioral treatments than kids who have ADHD in isolation. Again, being mindful that when we say ADHD behavioral treatments, we mean that parent behavior training. But if those behavior treatments don't fully address ADHD symptoms, then we want to consider adding an ADHD medication, and stimulant medications are what we would recommend first when kids have both ADHD and anxiety, with atomoxetine also being shown to be effective. Clinicians and families can get worried about this because they've often heard that anxiety is a side effect of methylphenidate, but a number of studies, including meta-analysis which combine the results of individual studies, have actually shown that at least in groups of kids, methylphenidate can improve anxiety rather than worsen it. So, even when kids have ADHD and anxiety traveling together, we would recommend to go with stimulant medications first if we are going to try medication.
Dr. Gene Arnold: And of course, both ODD and anxiety can travel together with ADHD.
Dr. Tanya Froehlich: Absolutely.
Dr. Gene Arnold: A secondary analysis of the MTA (Multimodal Treatment Study of Children with ADHD) showed that those who have the double co-occurring disorders, both anxiety and ODD, get a terrifically better response to the combination of behavioral treatment and medication more so than any other group.
Dr. Tanya Froehlich: That behavior parent training is so important, and not just medications when kids have these coexisting conditions like anxiety or oppositional defiant disorder.
Dr. Gene Arnold: Well, let's talk about another possible co-occurring disorder: learning disorders, which are usually thought of as more educational diagnoses than psychiatric or pediatric diagnoses. What about those? Is that included in complex ADHD?
Dr. Tanya Froehlich: Absolutely, because, the fact of the matter is learning disorders are brain-based and they are surprisingly common in children who have ADHD. Early studies suggested that around 30% of kids with ADHD have a coexisting learning disorder or learning disability, but more recent studies suggest that it could be even higher. It may be as many as more than 50% of kids. That's when we think about not just ADHD plus reading disorders, but also think about math disorders or written expression disorders. So, it's extremely common, and it's important for pediatricians, psychiatrists, other psychologists who are working with kids to recognize.
Dr. Gene Arnold: Learning problems seem like they might get confused with ADHD symptoms, because in both cases, the child is having trouble completing their work and it could be because they have expressive writing disorder or it could be because they are inattentive and disorganized and can't finish things. So could you talk a little bit more about that?
Dr. Tanya Froehlich: One thing we want to think about is—are the problems with grades just because the kids aren't completing their work, that they lost points on all their homework assignments, they didn't turn things in, or is it because parents and teachers perceive that they have a problem with understanding? Another thing that can be a useful indicator is, how are the kids doing on their standardized testing? Now, we can run into problems where we have a kid who is markedly below grade level on their standardized testing, and the teachers also tell the family, "I think Johnny is below grade level and is really struggling with reading or math." And sometimes parents say, "My doctor thinks that he has ADHD. So I want to wait to think about the learning issues. Let's go with ADHD treatment. I think that maybe if we treat the attention, then everything will come up. The skills will come up and look better." And I really want to caution parents about that.
We know that children with ADHD perform differently in different situations, and we know that they tend to perform better in one-on-one situations or when they perceive that a situation has high stakes. Now, they generally do know that standardized testing situations are high stakes. The rooms are also usually very quiet and there are a few distractions when they're doing the tests. So they actually tend to do best or better in that case, more overperformance on the standardized tests, unlike regular classroom tests, doesn't depend on whether they study the night before or they did particular homework sets in preparation. So, kids with ADHD who don't have a coexisting learning disorder can often actually do better on the standardized test than their general grades or their day-to-day school performance would suggest. Not worse.
So, when kids are performing a markedly below grade level on standardized tests and the teachers think that they really have an understanding problem, it really needs to be looked into. In addition, studies have shown that ADHD medications, they have not shown that ADHD medications can markedly improve reading skills in kids who have ADHD plus a coexisting reading disorder. And we don't really have studies to look at how math skills or written expression skills would be affected by ADHD medications for kids who have math disorders or written expression disorders. So, we really don't want to depend on just ADHD treatments to address the learning problems.
Dr. Gene Arnold: In fact, I think there was a study done at your institution on this very issue. The ICARD Study.
Dr. Tanya Froehlich: Yup.
Dr. Gene Arnold: Could you summarize the results of that very quickly?
Dr. Tanya Froehlich: Yeah, so the ICARD Study showed that the ADHD medications improved the ADHD symptoms, but they really didn't improve the reading. So, for kids with reading disorders, they really needed that ongoing reading intervention which the study also provided to help their reading skills to come up.
Dr. Gene Arnold: So, both disorders need to be treated?
Dr. Tanya Froehlich: Absolutely; so, parents should not delay. If kids have ADHD and a suspected learning disorder, they should make a written request to the schools for the schools to provide academic interventions specifically for the learning issue. Or they could do an outside evaluation and get tutoring, but the kids need some academic specific intervention. Regarding ADHD treatments, we know that if we're just wanting to improve ADHD symptoms, that when kids have a coexisting learning disorder, then stimulant medications would be the first-line treatment. And then there's some additional information that atomoxetine could also be helpful, but that evidence is less strong than what we have for stimulant medications when there's a coexisting learning disorder.
Dr. Gene Arnold: How about autism? We're hearing a lot lately about the overlap of those disorders. And, in fact, half of children with autism also have ADHD. So, how does that affect the diagnosis and treatment?
Dr. Tanya Froehlich: In terms of making the diagnosis, right now, we need more information about this, but we're really in a position where we would just do the parent and teacher ADHD rating scales, as we would do for another child. Where we think about treatment, that's where things diverge a bit. So, one thing, it's important to emphasize that there aren't any medications that can treat the core problems of autism in terms of communication and social functioning. But if we want to think about improving ADHD symptoms, then we can think about medications to help with those even when kids have coexisting autism spectrum disorder.
Now, methylphenidate is considered to be the first-line treatment for ADHD and autism spectrum disorder, but things work a little differently than they do with typically developing children. Their rate of response, the percentage of kids who benefit from methylphenidate if they have coexisting autism spectrum disorder, is lower than what we see with typically developing children. The amount of change in their ADHD symptoms, the amount of decrease is also less for kids who have coexisting autism spectrum disorder, and they also have higher rates of side effects, particularly the side effect of irritability with methylphenidate than kids who are typically developing.
People often think about and ask about the other medications for treating ADHD and autism spectrum disorder. Unfortunately, we don't have a lot of information about how amphetamine or dextroamphetamine will work in kids with ADHD plus autism spectrum disorder. So it's hard to make definitive statements. We do have some really good studies, though, to look at how atomoxetine works (that medication is also known as Strattera), and how alpha-agonist medications such as guanfacine work, although we have much less data than we have with methylphenidate. So for treatment of ADHD symptoms and autism spectrum disorder, experts recommend that you first try a stimulant medication first, with most data behind methylphenidate, and then think about trying atomoxetine or guanfacine if the stimulant doesn't work.
Dr. Gene Arnold: How are the actions different from atomoxetine, for example, from stimulants? With stimulants, you tend to see the effect of the given dose right away within a day or two. How about atomoxetine?
Dr. Tanya Froehlich: Yeah, so atomoxetine will take three to four weeks to get up and running in the system and for you to see maximum benefit from it. So, that's one thing when thinking about trying atomoxetine that families need to be cautioned that they have to be patient and they have to give it a good month to see how things are going before they decide that it isn't working. And in some cases, there may need to be some dose adjustments made, just as with stimulant medications.
Dr. Gene Arnold: ADHD is kind of an equal opportunity problem. It affects all social classes; it affects all levels of intellectual function from genius—some people suspect that Leonardo da Vinci, for example, had ADHD—all the way from genius down to intellectual disability. And if we think of intellectual disability as another co-occurring problem, how would it affect treatment?
Dr. Tanya Froehlich: For treating ADHD in the setting of intellectual disability has many parallels and similarities to what we see for coexisting autism spectrum disorder. So, most studies of ADHD medications in kids who have coexisting ADHD and intellectual disability focused on stimulant medications, and especially methylphenidate. And we see, again, a lower percentage of kids who have intellectual disability responding to methylphenidate compared to what we see with typically developing children. In addition, we see higher rates of side effects when kids have coexisting intellectual disability, just like we see with coexisting autism spectrum disorder. And, in particular, some of the studies have noted more prominent social withdrawal with methylphenidate treatment for intellectual disability compared to typically developing kids.
Now, researchers have attempted to figure out which of the kids with intellectual disability are going to benefit more from methylphenidate and stimulant medications. Can we predict who's going to benefit so we know do we have a good shot or not in undertaking this medication? And so one thing that has been shown is that the kids who are higher functioning seem to respond a little better. So, those kids who have IQs greater than 50 seem to be more likely in the good response groups, whereas the kids who have IQs less than 50 had more risk for not getting benefit.
Dr. Gene Arnold: Any final thoughts that we haven't touched on that you think would be important for people to hear?
Dr. Tanya Froehlich: Well, I did want to talk a little bit about ADHD treatment when kids have tics or Tourette syndrome. This is another situation that can happen with some frequency. Now, people often wonder, "What exactly is a tic? Does my child have tics?" So I just want to take a few minutes to talk about that for a few seconds. So, tics are short-acting sudden or repeated muscle movements. Those are called motor tics or short-acting sudden or repeated sounds that kids make like grunting, sniffing, or throat clearing, and these are called vocal tics. Tourette syndrome is diagnosed when kids have both motor and vocal tics for least a year. Now, among children with ADHD—
Dr. Gene Arnold: Does that have to be continuous over the whole year?
Dr. Tanya Froehlich: It doesn't have to be every single day, but it can't be big breaks in time in which there's absolutely nothing going on.
Dr. Gene Arnold: They can get better and worse over time.
Dr. Tanya Froehlich: Yeah, exactly. And tics are, by their nature, they really are waxing and waning, which means sometimes they'll go up and sometimes they just fade away and then come back later at a different time. So, that's a good point. They don't need to be continuous for the yearto meet that diagnosis.
Now, among children with ADHD, the rate of tic disorders is about 20%, although sometimes parents just aren't aware of them because they can be very mild. So, first thing we need to talk about is the widespread concern that stimulants can bring on or worsen tics. Many people will be surprised to hear that research studies have shown that it's not the case for the majority of children who try stimulant medications, rather families can simply notice motor tics that were already there when the kids are taking stimulant medications because they're afraid this will be a side effect, or typically start around the same time kids are starting taking ADHD medications. So, the medications and the tics can coincide and appear to be related, even if the medication is not actually causing the tics.
So, what do we recommend for treating ADHD when kids have coexisting tics? Well, ADHD behavioral therapies are certainly recommended, parent behavior training, as they are for all kids with ADHD. But if behavior treatments don't help enough to treat the ADHD symptoms, stimulant medications are considered first line, even in the setting of coexisting tics due to the lack of evidence that for most kids, they worsen or cause tics, which I mentioned, although there are of course exceptions to every rule. So, if you have a child where tics do seem to start or increase with stimulant medications, what doctors will first do is try to determine if the tics are actually causing problems in a kid's daily life. This means, is it stopping the kid from doing typical activities? Is it causing social problems or the child to be embarrassed? Because if tics aren't causing any concrete problems for the child, the doctors actually don't recommend doing anything about them.
However, if they are causing concrete problems for the child, we have several options. We can try stopping the stimulants to see if the tic stops, and if so, we can later rechallenge with the stimulant to see if the tics come back. And if they do, we can think about changing medications. Surprisingly, sometimes, even if one stimulant medication can be associated with worsening tics, other stimulant medications could be tolerated okay, or we could try a nonstimulant ADHD medication. We can also try adding a behavioral intervention to address tics. One evidence-based one is called CBIT or cognitive behavioral intervention for tics, or we could try a tic-reducing medication. And interestingly, guanfacine is a medication that can reduce tics in addition to treating ADHD symptoms, although it's usually not as good for ADHD symptoms as a stimulant, which is why we don't recommend it right off the bat.
Dr. Gene Arnold: I wonder if you would summarize what you think are the key points in what we've talked about here.
Dr. Tanya Froehlich: Parents should remember that it is common, and it's in fact the rule rather than the exception, for ADHD to come with another behavioral disorder on top of it. So, if parents suspect this, don't hesitate to tell your doctor. Make sure that your child has a comprehensive evaluation. And this is particularly important because in some cases, having that other condition will affect the treatment plan or how well the treatment plan will work.
Dr. Gene Arnold: Okay, thank you.
Dr. Tanya Froehlich: Thank you, Dr. Arnold. It's been a pleasure.
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- 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.
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