ADHD and Coexisting Conditions

Over one-half of children living with ADHD live with at least one other major mental health condition. Any condition can coexist with ADHD, but certain conditions are seen more often, including:

• oppositional defiant disorder;
• conduct disorder;
• depression;
• anxiety; and
• learning disorders.

The combination of ADHD with other mental health conditions often presents extra challenges for youth and their families. The key to positive treatment outcomes for children living with ADHD is the early identification of any coexisting conditions with ADHD, followed by a treatment plan that uses the most effective interventions, including home and school-based interventions. Coexisting conditions must be considered simultaneously to broaden understanding of the child’s symptoms and to maximize treatment outcomes. Sometimes it may be necessary to identify the symptoms that are having the biggest impact on the child’s life and to treat them in order of priority.

Disruptive Behavior Disorders: Oppositional Defiant Disorder and Conduct Disorder

Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is one of the most common conditions coexisting with ADHD. NIMH’s (Multimodal Treatment Study of Children with ADHD (MTA) ) reveals that 40 percent of children living with ADHD also live with ODD. ODD usually starts before age 8, but no later than early adolescence. Symptoms of ODD include:

• negative, hostile and defiant behavior;
• persistent arguing with adults;
• refusal to comply with requests from adults;
• intense rigidity and inflexibility;
• feeling entitled to make unreasonable demands; and
• acting touchy, resentful and spiteful.

Parents of children living with ODD often express anger or exasperation over their child’s refusal to obey or cooperate. The behaviors of ODD often result in significant difficulties for children in school, at home and with peers.

Conduct Disorder

Conduct disorder (CD) is less common than ODD, but it is severe and highly disruptive to youth and their families. Treatment for CD should be implemented as early as possible. According to the latest data from the American Academy of Child and Adolescent Psychiatry (AACAP), almost half of those diagnosed with ADHD are also diagnosed with ODD or CD. Symptoms of CD include:

• aggression and cruelty toward people and animals;
• bullying with bats, pipes and other weapons;
• destructiveness (e.g., setting fires or destroying property);
• deceitfulness (e.g., lying, stealing or “conning”); and
• lack of remorse for behaviors.

Parents of children living with ADHD and CD often feel frightened and intimidated by their child’s behaviors and worry about danger or injury to other family members. Parents are also shocked or embarrassed by their child’s sadistic behaviors.

Adolescents living with ADHD and coexisting conduct disorder and/or oppositional defiant disorder are at higher risk for antisocial behavior and suspension from school. The school dropout rate for this group is 12 times greater than the rate among adolescents who are not affected by ADHD. These outcomes underline the importance of early identification and treatment of ADHD, ODD and CD.

Treatment of Oppositional Defiant Disorder and Conduct Disorder

There are several effective psychosocial interventions for the treatment of ODD and CD:

• Parent Training helps parents develop effective child-behavior management skills, including limit setting, enforcing consequences, reinforcing positive behaviors and enhancing behaviors at home and in school.
• Anger Coping Therapy is a school-based group intervention that reduces future conduct problems, delinquency and substance abuse by promoting self-instruction and awareness and building social cognitive skills
• Brief Strategic Family Therapy focuses on improving interactions between the family and child by developing and implementing strategies that build on family strengths to improve problems.
• Functional Family Therapy engages the family in skills training on family communication, positive parenting, problem-solving, conflict management and using community resources.
• Treatment Foster Care places youth with trained treatment parents who provide structure, support, close supervision and monitoring.
• Multisystemic Therapy empowers families by identifying family strengths and natural supports, addressing barriers and developing effective strategies for addressing negative behaviors.
• Mentoring connects a child with an adult to increase his or her healthy activity and involvement in school and the community.
• Cognitive Behavioral Therapy teaches youth how to notice, take account of and ultimately change thinking and behaviors that negatively impact their feelings.

Additionally, behavioral interventions that address negative behaviors and promote positive behaviors should be implemented within the school setting for children living with ADHD, ODD and/or CD.

Stimulants are often effective treatment for aggressive or antisocial behavior in youth living with ADHD. Antipsychotic medications and mood stabilizers have been proven to be effective in treating oppositional defiant disorder and conduct disorder.

Depression

Sometimes, the outcomes associated with living with ADHD—including low self-esteem, difficulty making friends and poor school performance—can lead to persistent feelings of irritability, sadness and frustration. According to data from a 2008 NIMH-supported study, approximately 21 percent of children and adolescents living with ADHD also have depression. Symptoms of depression in children include:

• extreme irritability, aggressiveness and combativeness;
• anxious complaints about headaches or stomachaches;
• feeling mad, sullen or groundless all the time;
• negative self-judgment and believing they are ugly or dumb;
• a drop in grades, feeling anxiety about tests and refusing to go to school;
• thoughts of death;
• inability to have fun and refusal to join in activities;
• overreacting to disappointment and frustration; and
• lethargy and/or apathy.

Symptoms of depression in adolescents include:

• feeling sad, hopeless and empty;
• appearing lethargic, slow-moving and sleepy;
• acting irritated, grouchy;
• withdrawing from family and friends;
• feeling restless and aggressive;
• overreacting to disappointment or failure;
• becoming self-destructive; and
• morbid images or thoughts of death.

Parents of children living with depression may observe that nothing seems to please their child and that their child “puts on a good face” in public but displays the worst of symptoms at home. Parents often express that their child seems to be completely different and unfamiliar to them.

Children and adolescents living with depression are at an increased risk for suicide. However, depression—when identified—is highly treatable.

Treatment of Depression

There are several effective psychosocial interventions for the treatment of depression, including:

• Cognitive Behavioral Therapy teaches youth how to notice, take account of and ultimately change thinking and behaviors that negatively impact their feelings.
• Interpersonal Therapy examines relationships and transitions for adolescents and helps them recognize how they affect their thinking and feelings.
• Family Education and Support focuses on creating an atmosphere of hope and cooperation in a family through relationship building, education, collaboration and problem solving.

The combination of CBT and antidepressant medication (SSRIs) is often the most effective in treating major depression in children and adolescents. Antidepressants may be used in conjunction with stimulants with close supervision to treat major depression and ADHD.

Anxiety

According to a 2008 NIMH-supported study, over 30 percent of children living with ADHD also live with anxiety. In the classroom, students living with both disorders are less likely to appear hyperactive and disruptive and more likely to appear slowed-down or inefficient. The symptoms of anxiety include:

• feelings of discomfort and unease in situations generally regarded as unthreatening;
• missing school;
• being rude and noncompliant when trying to avoid encounters that trigger anxiety;
• shunning the spotlight or “hiding out;”
• excessively worrying about school, how they look or what they are doing; and
• experiencing panic attacks—heart pounding, sweating, shaking, stomach pain, dizziness and fears of dying.

Parents of children living with anxiety often report worry or concern over their child’s repeated absences from school. They often struggle with accommodating their child’s anxious behaviors versus having their child continuously fall apart if they insist he or she do what is causing the anxiety.

Anxiety is an internalizing condition—meaning children and adolescents living with anxiety may not show any outward signs of distress or discomfort. It is important that parents and school personnel are extra vigilant in their observations if they are concerned a child may have anxiety.

Treatment of Anxiety

There are several effective psychosocial interventions for the treatment of anxiety.

• Cognitive behavioral therapy teaches youth how to notice, take account of and ultimately change their thinking and behaviors that impact their feelings.
• Exposure therapy educates and teaches children and adolescents on how to manage fears and worries to reduce their distress.

Youth living with ADHD and anxiety may show greater benefit from psychosocial interventions than those with ADHD alone.

Antidepressant medications (SSRIs) and Benzodiazepines have been shown to be effective in treating anxiety. A child’s response to stimulant medication for the treatment of ADHD is not affected by coexisting anxiety.

Learning Disorders

The CDC reports that roughly one-half of children living with ADHD also have a learning disorder. The combination of attention problems caused by ADHD and a learning disorder can make it especially hard for a child to learn in school. A child in preschool with a learning disability may have difficulty understanding certain sounds or words or have problems expressing him or herself in words. A school-aged child may struggle with reading, spelling, writing and math.

Working with health care professionals to determine a treatment plan that takes into account ADHD, learning disorders and the child’s strengths is the best way to treat a child living with both conditions. Different types of health care providers may need to be involved with the treatment plan to achieve the best outcomes.

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