2. Efforts to Usefully Subtype ADHD
DSM-IV has proven to be relatively useless except for
the Inattentive Type in which a subset of cases appear
to have Sluggish Cognitive Tempo (SCT)
Using etiology (acquired vs. familial) may eventually be
useful but as yet is not well-researched
Acquired cases can arise at any time, though often result from
pregnancy factors
Acquired cases may not respond to stimulants as well as familial cases
Molecular genetics may eventually offer ways of creating
more homogeneous clinically useful subsets
Certain gene variants may predict drug and behavioral treatment
response as well as adverse life course risks
Comorbidity offers the most useful and best established
means for deriving clinically useful subtypes currently*
*Ostrander, R. (2008). Journal of Clinical Child and Adolescent Psychology, 37(4), 833-847.
3. Oppositional Defiant Disorder (40-80%)
A pattern of hostility, anger, defiance, stubbornness,
low frustration tolerance and resistance to authority
(usually parental)
Comprises a two-dimensional disorder
Social conflict and emotion dysregulation*
ADHD cases are 11x more likely to have ODD**
ADHD contributes to and likely causes ODD
This likely occurs through the impact of the hyperactive-
impulsive dimension of ADHD and its strong association
with emotional dysregulation (executive dysfunction)***
This can account for the well-established findings that
ADHD medications reduce ODD symptoms nearly as much
as they do ADHD symptoms
*Hoffenaar, P. J. & Hoeksma, J. B. (2002). Journal of Child Psychology and Psychiatry, 43(3), 375-385.
** Angold, A. et al. (1999). Journal of Child Psychology and Psychiatry, 40, 57-88.
***Burns, G. L. & Walsh, J. A. (2002). Journal of Abnormal Child Psychology, 30(3), 245-256.
4. More on ODD
Some variance in ODD severity is also related to
disrupted parenting
Inconsistent, indiscriminate, emotional, and episodically vacillating
between harsh and permissive (lax) consequences teaches social
coercion as a means of social interaction.
But timid parenting is the most important factor contributing to
ODD which feeds back to make parents more reluctant to discipline
Poor parenting can partly arise from parental ADHD and other high
risk parental disorders in ADHD families (e.g., depression, ASP,
SUDS)
Early ODD predicts persistence of ADHD and
increases risk for enuresis, CD/MDD and anxiety
Emotional dysregulation component predicts later MDD; conflict
component predicts later CD
5. 4-Factor Model of Defiance
Parental
Psychopathology
Child ODD:
Disrupted Parenting Social Conflict
Anger-Frustration
Family Stressors
Child Factors:
Negative Temperament
ADHD Emotional Dysregulation
Mood Disorder
6. Treatment Impact of ODD
Both stimulants and ATX reduce it when it is comorbid with
ADHD; not when ODD is alone
Higher doses may be needed for comorbid cases
Requires adjunctive parent training in behavior
management methods; response is age-related:
60-75% successful for children; 25-35% treatment response after 13+ yrs.
of age
May need to treat parent’s ADHD first to succeed
May need to add problem-solving communication training of teen and
parents after age 14 years
Severely explosive anger may be a sign of either childhood
Severe Mood Dysregulation (SMD) or Bipolar Disorder (BPD)
Treat SMD with stimulants or other ADHD medications first along with
behavior modification methods. If needed, employ antihypertensives or, as
a last resort, atypical antipsychotics. Mood stabilizers have not been found
to be useful for SMD (or even childhood BPD*
*Child and adolescent psychopharmacology news, Vol. 14 (6), 2009
7. Conduct Disorder (20-56%)
If starts early, represents a more severe disorder
and possibly a unique family subtype
More severe, more persistent antisocial behavior
Worse family psychopathology
Antisocial personality, substance use disorders, major depression
Parent hostility, depression, & low warmth and monitoring interact
reciprocally with child conduct problems over time to adolescence*
Greater association with ADHD (especially inattention symptoms)
Less responsive to behavioral or family interventions
Increased risk of psychopathy (20%)
Father desertion, parent divorce more common
Major depression more likely to precede/co-exist with CD
* Special issue on reciprocal influence across development, Journal of Abnormal Child Psychology (2008), vol. #36 (July) .
8. Conduct Disorder
One pathway to early onset CD is through ADHD and its
impulsivity perhaps when combined with adverse social
environments*
Explains why most ADHD does not get CD but most early CD cases
have ADHD
School drop out, drug use, and teen pregnancy are more
likely in comorbid cases than in ADHD alone**
ODD is not so much a precursor to or predictor of CD
but develops in parallel with it if CD has an early onset.
If CD starts late (>12), it may be related to social
disadvantage, family disruption, & affiliation with deviant
peers. BUT, recent research shows reduced amygdala
and insula volume in both CD types*** so some
neurobiological factors are involved in late onset CD too.
*Beauchaine, T. et al. (2010). Clinical Psychology: Science and Practice, 17, 327-336.
**Barkley, R. A. et al. (2008). ADHD in Adults: What the Science Says. New York: Guilford.
*** Fairchild, G. et al. (2011). American Journal of Psychiatry, 168, 624-633.
9. Treatment Impact of CD
Stimulants and ATX reduce aggressive behavior and antisocial acts but
stimulants may work more rapidly to gain case control
Higher doses often required in comorbid cases
Stimulant effectiveness may deteriorate with duration of treatment (3+ yrs)
in this subset of ADHD cases (MTA study)
Parent and family interventions often required to address family issues
Problem-solving, communication training and parent BMT
Multi-systemic therapy where available
Treatment of parental depression and other psychiatric disorders
Family relocation to better neighborhoods advisable
If psychopathy (callous-unemotional traits) is present there is limited or
no response to behavior therapy alone – medication is necessary first,
then follow up with behavioral treatments*
Avoid group treatment due to deviancy training by aggressive peers
Involvement of social service and juvenile justice agencies is highly
likely – educate them about comorbidity
As in ODD, treat with ADHD medications and behavior modification
first. Then follow-up with antihypertensives or, rarely, atypicals may be
needed for highly aggressive/explosive cases or BPD. Mood stabilizers
are often unhelpful.
*Waschbusch, D. A. et al. (2007). Journal of Clinical Child and Adolescent Psychology, 36(4), 629-644.
10. Anxiety Disorders (10-40%)
Considered a stealth or hidden comorbidity in child ADHD cases if only
parents are interviewed about child anxiety symptoms.
High comorbidity with adult ADHD (30%+)
Related in part to emotional dysregulation in ADHD (& ODD)
This is evident more as negative affectivity rather than fear/worry
Also risk for real anxiety disorders(risk increases with age)
Most common are simple phobias or separation anxiety in early
childhood; GAD becomes more common with age
Risk is related to:
earlier inattention more than to impulsive-hyperactive symptoms*
greater disruptive and stressful life events
presence of autistic spectrum disorders and chronic multiple tics**
parental anxiety disorders
Comorbid cases often show lower levels of impulsiveness but are still
more impaired than ADHD alone cases
Comorbid cases have more sleep problems (bedtime resistance and
night waking); anxiety contributes to these besides ADHD
Anxiety contributes additionally to social impairment besides ADHD
*Reinke, W., & Ostrander, R. (2008). Journal of Abnormal Child Psychology, 36(7), 1109-1122.
** Gadow, K. et al. (2009). Journal of Attention Disorders, 12(5), 474-485.
11. Role of Parent Anxiety Disorders
Anxiety disorders more likely in parents and
family* (18%+ of parents have significant
symptoms of anxiety or depression)**
Child and parental anxiety are associated with
low rates of positive parental behavior, over-
protectiveness of the child, less autonomy for
the child, lower child self-sufficiency, and parent
modeling of anxiety.
This excess parental control may increase child
perceptions of threat, decrease children’s sense
of controlling threats, and decreased opportunity
for experience with managing threats***
*Pfiffner, L. & McBurnett, K. (2006). Journal of Abnormal Child Psychology, 34, 725-735.
*Kepley, H., & Ostrander, R. (2007). Journal of Attention Disorders, 10, 317-323.
** Vidair et al. (2011). J Amer. Acad. Child. Adolesc. Psychiatry, 50(5), 441-450.
*** van der Bruggen, C. O. et al. (2008). (meta-analysis) Journal of Child Psychology
and Psychiatry, 49(12), 1257-1269.
12. Treatment Impact of Anxiety Disorders
Probe more carefully in child cases for child
physical or sexual abuse or bullying at school
Bully-victims have high rates of psychosomatic symptoms*
More responsive to behavioral therapies (MTA Study)
May respond better to social skills training (and
possibly cognitive-behavioral therapies)
But CBT outcomes are poor if parental anxiety remains high and if
paternal rejection and depression are present**
Family counseling may be required to limit family
induction of anxiety by other anxious members
Focus parent BMT on increasing positive parenting
behavior and reducing over-protectiveness and less
so on parent discipline tactics
*Gini, G. & Pozzoli, T. (2009). Pediatrics , 123(3), 1059-1065.
**Liber, J. et al. (2008). Journal of Clinical Child and Adolescent Psychology, 37(4), 747-758.
13. Impact of Anxiety on Med Management
Anxiety (or high internalizing symptoms) has
been associated in some studies with reduced
response to stimulants. 4 issues arise here:
Do stimulants make ADHD worse in mixed cases? No
Do stimulants result in less improvement in ADHD
symptoms in these comorbid cases? Maybe –
findings are conflicting here*
Do stimulants make anxiety worse? Maybe – results
are conflicting here also
Do stimulants make some cognitive abilities worse in
mixed cases? Probably**
*Pliszka, S. (1989). Journal of the American Academy of Child and Adolescent Psychiatry, 28, 882-887. Biutelaar, J. et
al. (1995). Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1025-1032. Abikoff, H. et al.
(2005). Journal of the American Academy of Child and Adolescent Psychiatry, 44(5), 418-427. Pliszka, S. (2003).
Paediatric Drugs, 5(11), 741-750.
**Blouin, B. et al. (2009). Journal of Attention Disorders, 13(4), 414-419. Pliszka, S. (1989) [see above]. Tannock, R.
et al. (1995). Journal of the American Academy of Child and Adolescent Psychiatry, 34 , 886-889. Bedard, A. &
Tannock, R. (2008). Journal of Attention Disorders, 11(5), 546-557.
14. More Impact of Anxiety on Med Mgmt
Atomoxetine (ATX) and guanfacine XR do
not worsen anxiety in comorbid cases.
AACAP and CADDRA Practice Guidelines
recommend both stimulants and ATX as
first choice treatments in comorbid cases
15. Major Depression (0-45%)
Likely genetic linkage to ADHD
Genes create a vulnerability to MDD
MDD expressed upon exposure to repeated social
and emotional distress, physical trauma, etc.
Also related to presence of earlier ODD and CD in
child or adult patient & family
Often manifest low self-esteem in childhood in
contrast to other ADHD cases
Full MDD onset may not be until adolescence or
later
In adults with ADHD, MDD is related to higher GAD
and social phobia but lower SUDS and school
disciplinary actions and grade repetitions in
history*
*Fischer, A. et al. (2007). Journal of Psychiatric Research, 41, 991-996.
16. More on Impact of MDD
Parental depression is elevated in these child cases
(18%+ have elevated depression or anxiety)*
Depressed parents:
show decreased positive parenting and nurturance, greater
irritability and expressed emotion, irritability and open hostility,
erratic use of discipline tactics, child rejection, and poor child
monitoring – these are associated with increased later risk for
child ODD and also internalizing problems**
Parental MDD linked directly to child ODD risk; parental DBD
with MDD increases risk for child ADHD, CD, and mania***
Evaluate carefully for presence of child physical or sexual
abuse or victimization by bullying in child cases
Increased suicidal ideation (4x) and attempts (2x) in
ADHD cases during peak risk years in high school
* Vidair et al. (2011). J Amer. Acad. Child. Adolesc. Psychiatry, 50(5), 441-450.
**Elgar et al. (2007). Journal of Abnormal Child Psychology, 35, 943-955.
**Gerdes, et al. (2007). Journal of Abnormal Child Psychology, 35, 705-714.
*** Hirshfeld-Becker, D. R. et al. (2008). Journal of Affective Disorders, 111, 176-184.
17. Suicidality in Childhood
Follow-up study of 127 ADHD cases from age 8
to 14 years*
8 have seriously considered suicide (6.3%)
One teen went on to try once, but was not treated ; one went on to try
more that once and was treated. The latter teen had self-harmed 5
times.
10 teens had intentionally injured themselves
(7.9%) (self-cutting, etc. 1-6x over 1 year); 5 of
these cases had considered or attempted suicide
• R. Schachar, M.D., Hospital for Sick Children (2009, personal communication)
18. Suicidality in Teens & Adults
ADHD is associated with a greater risk for suicidal
ideation & attempts*
Ideation in high school (33 vs. 22%)
Attempts in high school (16 vs. 3%)
Attempts are worse (46% vs. 11% hospitalized)
Ideation after high school (25% vs. 12%), attempts 6 vs
3%); risks for ideation found even at age 27
Associated with comorbid MDD (4x), CD (somewhat), and
more severe ADHD
Evaluate carefully for child physical or sexual abuse or
victimization by bullying
*Barkley, R. A. & Fischer, M. (2005). The ADHD Report, 13 (6), 1-4.
*Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the
science says. New York:Guilford
19. Treatment Impact of MDD
Use ADHD drug first if:
ADHD is chief complaint
ADHD symptoms are more disabling
MDD is mild: Little or no current functional impairment
from depression; dysthymia or demoralization are present
Neuro-vegetative signs are mild or absent
ADHD symptoms clearly preceded MDD symptoms
Start with Antidepressant first if:
MDD symptoms are chief present complaint
Prominent neuro-vegetative signs or health is compromised
Present of suicidal ideation
ADHD symptoms are mild, have a late onset, or are
coincident with MDD onset.
Clear history that depression was non-responsive to ADHD
drugs
20. More Impact of MDD
May require mixed ADHD/SSRI therapy
Stimulants and atomoxetine do not treat MDD
May need cognitive-behavioral therapy
Assess for parental induction of depression in
children and exaggeration of child ODD symptoms
given higher maternal depression
Parent depression may require separate treatment
In parent training use a “go slow” approach to
punishment so as not to contribute to depressive
cognitive schemas (self-statements) or to already
excessive parental use of criticism and discipline
start with all reward programs initially until MDD
symptoms lift then introduce mild, selective punishments.
21. Child Bipolar Disorder (BPD) (2-6%)
Overlap with ADHD is controversial (2-27% incidence in
ADHD cases across studies)
Prevalence rates differ: ADHD = 5-8%, BPD = 1.2-1.6%
Comorbidity can arise from several problems with DSM
Some cases are misdiagnosed BPD when they are ADHD/ODD
ADHD symptoms overlap with bipolar symptoms in DSM
Irritability could substitute for mania in children in DSM-IV – this is
an error to be corrected in DSM-5 (could be ODD)
No requirement for cycling or periods of remission in children
DSM-V will likely require mixed moods (bipolarity), cycling between
them, grandiosity, mania and other typical cognitive BPD symptoms
SMD is more likely to co-exist with ADHD – irritability with
explosive/aggressive behavior but no mania
Overlap probably represents a one-way comorbidity
2-6% of ADHD cases have BPD; 80-97% of child BPD have ADHD
but only 15-20% of adult onset BPD cases have ADHD.
22. More on BPD
Risk for BPD is not elevated in follow-up studies of ADHD
kids (2-6%) or in studies of clinic referred ADHD adults1,2
Childhood BPD has 7-8x family risk of BPD than does ADHD
or adult onset BPD; BPD not elevated in ADHD families
Parental BPD associated with 8x greater risk for ADHD in
offspring and for subthreshold mood and manic symptoms3
BPD unlikely to be fully evident before age 10 years but can
be prodromal in offspring of BPD adults, especially if ADHD
and ODD develop3
Sequence: Age 4 (hyper); 6 (ADHD), 12-22 (BPD+ADHD); adulthood (BPD,
less ADHD)
Neuro-imaging results differ between ADHD and BPD
Larger caudate in BPD; smaller in ADHD
Anterior cingulate affected in both but subgenua ventral region more
involved in BPD while dorsal ACC is less active in ADHD
1. Barkley, R. A. (2006). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd
ed.). New York: Guilford Press.
2. Barkley, R. A. et a. (2008). ADHD in adults: What the science says. New York: Guilford Press.
3. Birmaher, B. et al. (2010). American Journal of Psychiatry, 167(3), 321-330.
23. Differential diagnosis from ADHD
All ADHD symptoms are more severe in BPD cases but ADHD
cases do not show the typical mood regulation features of
BPD. Focus on mood, thought, and hypersexuality.
Irritability: 95% (BPD) vs. 65% (Disruptives)
Elation: 73% vs. 15%
Grandiosity: 80% vs. 10%
Excessive talking: 92% vs. 38%
Racing thoughts: 30% vs. 5%
Flight of ideas: 69% vs. 14%
Decreased need for sleep: 42% vs. 12% (ADHD kids have
sleep problems)
Pressured speech/motor: 84% vs. 35%
More active: 85% vs. 43%
Uninhibited socializing: 32% vs. 3%
Hypersexual: 53% vs. 3%
From Luby & Belden, 2006, Development and Psychopathology, 18, p. 971
24. C-BPD Diagnostic Keys
Grandiosity, elated mood, psychotic-like thinking
(paranoia, delusions, auditory hallucinations, disjointed
thought) , decreased need for sleep and hyper-sexuality
are involved in C-BPD but not in ADHD.
Inattention, high energy, distractibility are NOT helpful signs for
differential diagnosis
Depressed-irritable mood is also a major problem and
moods are often severe (i.e., rage attacks, violence,
destructive). Classify as SMD if mania is absent
Mood states are not related to immediate environmental
events in a rational sense (irrational and inconsistent)
ADHD kids have rational but somewhat excessive emotions
Disruptive (aggressive) behavior rated as 3+SDs on
rating scales like the CBCL (85 or higher) goes with
CBPD, not with ADHD
BPD is significantly more prevalent in biological relatives
25. Treatment Impact of BPD1
Medical management of bipolarity should be done first
before managing ADHD symptoms with ADHD drugs
But expect mania not to be as responsive to BPD drugs
when ADHD is a comorbidity2
Often requires poly-pharmaceutical management for long-
term (mood stabilizers, atypicals, anticonvulsants likely)
Often requires periodic hospitalization for safety (suicidality
or violence) and stabilization
Special education (ED) programs are likely to be needed
SUDs are likely by adolescence (monitor/manage)
Suicidality is increasingly problematic at adolescence
15-20% completed suicide rate
30x population rate for attempts
1. See special issues of Development and Psychopathology, 2006, 18. Entire issue is on childhood BPD,
diagnosis, and management.
2. Consoli et al. (2007). Canadian Journal of Psychiatry, 52(5), 323-328.
26. More Treatment Impact of BPD
Consider all-reward or non-confrontational
parent training programs (Greene &
Ablon’s Explosive Child)
Interventions also must focus on parental
coping with explosive episodes rather than
expecting remediation of disruptive
behavior
ADHD/BPD have highest rates of physical
abuse/PTSD of all ADHD cases
Counsel parents on stress management;
periodic respite care as needed
27. Autistic Spectrum Disorders
20-25% of ADHD children have autistic
spectrum symptoms or disorder
20-54% of ASD kids have ADHD
Overlap may be partially due to risk genes
shared between the two disorders
Both disorders are highly heritability (70-80%)
Poor inhibition is linked to ADHD not to ASD
symptoms while inattention is shared by both
disorders; ASD is more related to social and
language impairments
ADHD medications can be used to treat ADHD
symptoms effectively in context of ASD
28. Learning Disabilities (24-70%)
Not due to ADHD:
Reading (8-39%); (effect size (ES) = 0.64)
Spelling (12-30%) (ES = 0.87)
Math (12-27%) (ES = 0.89)
Result from ADHD or correlated with it
Handwritingproblems (60%+)
Comprehension deficits
Reading, listening, & viewing deficits
Due to adverse impact of ADHD on working
memory
29. Treatment Impact of LDs
Comorbid Reading, Spelling and Math Disorders do
not improve from stimulants
Reading ability improves on atomoxetine
Additional educational interventions will be needed
for these comorbid disorders
Comorbid handwriting and comprehension deficits
are likely to improve from stimulants if secondary to
ADHD itself
ADHD cases with comorbid math disorder may be
less likely to respond to stimulants (37%) than
those with reading disorder (67%) or no LD (75%)*
*Grizenko et al. (2006). Journal of Psychiatry & Neuroscience, 31(1), 46-51.
30. Conclusions
Comorbidity is very common in both child and
adult ADHD
Comorbidity produces additional impairments in
major life activities
Comorbidity affects life course
Comorbidity may require adjustments to ADHD
treatments
Choice of meds is related to presence of anxiety, sleep
problems, tics/TS and OCD, risk for diversion or abuse, and
urgency of care
Comorbid disorders often require separate
interventions from ADHD treatments
