Beyond ADHD:
Treating Children with Co-occurring Conditions
S. Steve Snow. MD
Doug Emch MD
Child Psychiatrists- Nashville, TN
Professional Affiliations
• Private Practice, Child/Adolescent/Adult Psychiatry.
Belle Meade Office Park, 4535 Harding RD
Nashville TN 37205 (Emch and Snow).
• Clinical Professor of Psychiatry, Vanderbilt University (Snow)
• Child/Adolescent Psychiatrist, Centerstone Mental Health
Centers (Emch)
• Child/Adolescent Psychiatrist, Namaste, Inc. (Emch)
• Child Adolescent Psychiatrist, Teambuilders Counseling Services,
Inc. (Emch)
Disclosures
• Speaker’s Bureaus: Eli Lilly and Novartis
Pharmaceutical Companies (Snow)
• Preparation of the presentation received no
commercial support
• Off-label uses of medications, such as lack of
approval for specific diagnosis or certain ages,
as frequently used by psychiatrists, will be
included.
Learning Objectives
• Review diagnostic guidelines for Attention
Deficit Hyperactivity Disorders (DSM-IV-TR)
• Identify common co-occurring conditions with
ADHD, and disorders which mimic ADHD
• Update pharmacotherapy for ADHD and it’s
co-occurring disorders
Presentation Outline
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ADHD
Mimicry
Comorbid Conditions
Pharmacotherapy
Questions?
ADHD
Inattention
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Hyperactivity
• Fidgets
• Out of seat
• Climbs/runs
Impulsivity
• Blurts out
• Impatient
• Interrupts
Careless
Inattentive
Not listening
Poor
instructions
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Disorganized
Avoids
Loses things
Distracted
Forgetful
• Loud
• On the go
• Talkative
ADHD Subtypes
• Predominantly Inattentive (20-30%)
• Predominantly Hyperactive/Impulsive (<15%)
• Combined hyperactive-impulsive and
inattentive (50-75%)
Etiology
• Genetic
– Heritability about 76%
– Complex - Chromosomes 4,5,6,8,11,16,17
• Non-Genetic
– Perinatal stress and low birth-weight
– Traumatic brain injury
– In utero substance exposure
– Trauma
– Society?
Farone, Molecular Genetics of ADHD, Biol Psychiatry 57:1313-1323 (2005)
FCC: All Programming To Be Broadcast in
ADHDTV by 2007
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Prevalence
• 1-20% of child/adolescent population (5-8%)
• Account for 30-50% of child referrals to
mental health services
• 4-5% of adult population
• Males:Females :: 9:1  4:1  2:1
Mimicry
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Learning disorders
Hypoglycemia/Diabetes
Hypo/hyperthyroidism
Allergies
Hearing/vision problems
Toxicity (lead, mercury)
Epilepsy
Nutrient deficiencies
Anemia
Sensory integration
dysfunction
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Anxiety disorders
Bipolar/depression
Trauma/PTSD
Attachment disorders
Sleep disorders
Infections
Pain
Traumatic Brain Injuries
Fetal Alcohol Syndrome
Substance abuse
Family problems
Comorbidity
• Almost 3/4’s of individuals with ADHD have a
psychiatric comorbidity:
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Conduct Disorder (10-20%)
ODD (54-84%)
Substance Abuse (40%)
Anxiety Disorders (30-40%)
Affective Disorders (20-30%)
Learning Disorders (@ 33-60%)
Tic Disorders (34%)
Developmental Disorders (?)
Sleep disorders (25-50%)
Academic Impairment
• Very well documented
– Failure to perform academically is the single most common source of
referral for children and adolescents
• Children with ADHD
– Perform poorly on achievement tests and fail grades / courses
significantly more often than children without ADHD
– Complete 3 fewer years of education than matched controls
– More likely not to graduate from high school (35%)
• Academic impairment more profound when learning
disabilities are present
Weiss & Hechtman Hyperactive Children Grown Up 1993
Manuzza & Klein The Economics of Neuroscience, 2001:47-53
Social Function
• Social problems begin in childhood, persist
into adolescence
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Fewer friends, more limited social skills
Lower self esteem on assessment scores
3X’s as likely to have trouble getting along with peers
½ as likely to have good friends
2Xs as likely to get picked on by peers
3Xs as likely to have problems that limit after school
activities
Suppl. JAACAP Practice Parameters for Use of Stimulant Medications 2002;41:26S-49S
I.M.P.A.C.T. Survey;NYU Child Study Center;2001
Sexual Behaviors
• Longitudinal follow-up of cohort of 160 children with
ADHD shows:
– More unprotected sex & >50% tested for HIV
• 0 in the control group
– Of 43 children born to study participants, 42 were
born to those in the ADHD group
• Limiting their academic and occupational attainment
• 54% of these had lost custody of the children
Barkley. Attention 1996;8-11
Criminality
• ADHD has high comorbidity with ODD and CD
– Coupled with an impulsive, high risk lifestyle
• increases risk for legal problems
• Patients with ADHD more likely to be:
– Arrested (39% vs. 20%)
– Convicted (28% vs. 11%)
– Jailed (9% vs. 1%)
Biederman et. al. Arch Gen Psychiatry 1996;53,437
Manuzza et. al. Arch Gen Psychiatry 1989;46,1073
Oppositional Defiant Disorder
ODD
• Pattern of negative/hostile/defiant behavior
– Loses temper
– Argues with adults
– Defies adults’ requests/rules
– Deliberately annoys others
– Blames others
– Touchy/annoyed easily
– Angry/resentful
– Spiteful/vindictive
Conduct Disorder
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Aggression to people and animals
Destruction of Property
Deceitfulness, lying, stealing
Serious violation of rules
TICs
• Transient Tic
• Chronic Motor or Vocal Tic
• Tourette’s (Motor and Vocal)
Sleep Requirements
per 24 hours
• Infant to 6 months: 16-20 hours
• 6mo to 2 yrs: roughly 15 hours
• 2 to 6 yrs: 10-12 hours
• Grade School (7 to 13 yrs): 9 to 11 hours
• High School (14 to 18 yrs): roughly 9 to 10 hours (may vary
greatly day by day)
Dr. Scott Shannon Please Don’t Label My Child
Anxiety Disorders
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Generalized
Separation
Obsessive-Compulsive
Specific & Social Phobia
Panic
Stress Disorders/PTSD
Affective Disorders
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Depression
Dysthymia
Cyclothymia
Bipolar
Depression
• Prevalence
– 2% Children
– 4-8% Adolescents
– Male:female 1:1  1:2
– 20% cumulative incidence by 18
– 5-10% children/adolescents subsyndromal
JAACAP Practice Parameter 46:11, Nov 2007
Depression
• 2 weeks of (5):
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Depressed mood or irritability, or
Loss of interest/pleasure
Wt change (failure to thrive)
Sleep changes
Psychomotor agitation/retardation
Fatigue
Feeling worthless/guilty
Poor concentration/indecisiveness
Recurrent thoughts of death or suicide
Dysthymia
• Depressed mood or irritability on most days
for most of the day for 1 year
• Plus
– Changes in appetite or weight
– Changes in Sleep
– Problems with decision making or concentration
– Low self-esteem, energy, hope
Juvenile Bipolar Disorder
• Adult criteria in DSM; none for youngsters
• Severe type of mood disorder; manic-depressive illness
• Episodes of mania, major depression, or both, often with
psychosis
• Mania includes hyperactivity, which can mimic ADHD, but
also elation, grandiosity, and flight of ideas; may not sleep
for days
• Irritability and rapid speech seen with both
• Depression often very severe, sometimes mixed with
mania; can be suicidal, psychotic, even look catatonic
• Key is an up and down course, with children and teens
often cycling very rapidly, unlike most adults
Developmental Problems and
Substance Abuse
• Many types of underlying developmental disorder, as
well as external factors such as illicit substance use,
and complicate or mimic ADHD
• Autistic Spectrum Disorder overrides and presumably
includes ADHD, under current DSM guidelines,
although frequently ADHD sx are marked in these pts
and the target of Tx
• Cocaine, methamphetamine and other stimulant
abuse can mimic ADHD sx, but even marijuana and
other CNS-depressant substances can result in
dreamy, off-task school performance
Developmental Disorders
• Co-occurring developmental disorders are the rule with
ADHD, but may not be medication targets and require
specialized learning approaches:
• Mental Retardation, of varying degrees of severity, may be
changed to Intellectual Disability or similar term in DSM-V.
• Learning Disorder include Reading, Math and Written
Language disabilities
• Developmental Coordination Disorder may produce
problems in sports, predispose to minor injuries, but also
be a target of teasing or hazing
Developmental Disorders (cont)
• Communication Disorders include both expressive and receptive language
disabilities, as well as Phonological (Articulation) disorders and Stuttering
• Elimination Disorders include enuresis or encopresis and may require both
medical and behavioral intervention
• Tic Disorder are specified as transient, chronic motor or vocal and
Tourette’s Syndrome; most individuals with Tourette’s have parallel ADHD
sx and often OCD, as well; stimulants may exacerbate tics and RX may be
complex
• Haloperidol (Haldol) and pimozide (Orap) are problematic older drugs, age
12 and older for pimoxide, but atypical agents as will be discussed for
bipolar disorders are used off-label for severe T.S.
Treatment
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Medications for ADHD
• Stimulants
– methylphenidates, amphetamines
• Alpha-agonists
– Clonidine, Tenex, Intuniv, Kapvay
• NE/DA Active Antidepressants
– Wellbutrin
• Strattera
• Provigil/Nuvigil
• Tricyclic Antidepressants
Duration of Action
• 2-5 hours
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methylphenidate (MPH) (Ritalin) (1-4 hrs)
d-MPH (Focalin) (1-4 hrs)
d-amphetamine (Dexedrine) (1-6 hrs)
Amphetamine-dextroamphetamine (Adderall) (4-6hrs)
• 5-8 hours
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methylphenidate SR (Ritalin SR) (3-8 hrs)
methylphenidate ER (Metadate ER, Methylin ER) (3-8 hrs)
d-amphetamine (Dexedrine Spansules) (6-8 hrs)
extended release MPH (Ritalin LA & Metadate CD) (6-8 hrs)
• 10-12 hours
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methylphenidate (Concerta) (10-12 hrs)
dexmethylphenidate (Focalin XR) (10-12hrs)
Methylphenidate transdermal (Daytrana) (9-12)
amphetamine-dextroamphetamine (Adderall XR) (10-12 hrs)
lisdexamfetamine (Vyvanse)- (12-14hrs)
Stimulant Side Effects
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Delay of sleep onset
Reduced appetite
Weight loss
Tics
Stomach ache
Headache
Jitteriness
But not necessarily
• Staring
• Daydreaming
• Irritability
• Anxiety
• Nail biting
Suppl. JAACAP Practice Parameters for Use of Stimulant Medications 2002;41,#2:29S
Diet
• Issues with sugars and dyes
• Citric Acid and Ascorbic Acid
– Citrus fruits, juices
– Coke, Diet Coke, Dr. Pepper, A&W Root Beer
• Not the clear, yellow, or red drinks
– Cereals, MVI
– Anything in foil wrappers
• High fat diets
Medications for ADHD
• Stimulants
– methylphenidates, amphetamines
• Alpha-agonists
– Clonidine, Tenex, Intuniv, Kapvay
• NE/DA Active Antidepressants
– Wellbutrin
• Strattera
• Provigil/Nuvigil
• Tricyclic Antidepressants
Antidepresants
• SSRIs
– Fluxoetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa),
Escitalopram (Lexapro), Paroxetine (Paxil), Fluvoxamine
(Luvox)
• SNRIs
– Venlafaxine (Effexor), Desvenlafaxine (Pristiq), Duloxetine
(Cymbalta)
• NE/DA
– Buproprion (Wellbutrin)
Antidepressants (cont)
• Tricyclics
– Imipramine (Tofranil), Amitriptyline (Elavil),
Clomipramine (Anafranil)
• Other
– Trazodone, Remeron
SSRI Side Effects
• Common
– sleep changes
– restlessness
– headaches
– akathisia
– appetite changes
– sexual dysfunction
• 3-8% youths
– impulsivity
– agitation
– irritability
– silliness
– “behavioral
activation”
Black Box Warning: Suicidality
JAACAP Practice Parameter 46:11, Nov 2007
Anxiolytics
• SSRIs
– Prozac, Zoloft, Celexa
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Buspar
Neurontin
Strattera?
Benzodiazepines
– Valium, Klonopin, Ativan
Pharmacotherapy of Bipolar Disorder
• Lithium carbonate, typically from 150 mg to
450mg, one to two tabs or caps, up to BID often in
controlled-release form
• FDA approval ages 12-17; many side effects,
including tremor, thirst and somnolence; lab
needed to monitor Li levels, electrolytes, renal and
thyroid studies
• Calms mania and helps prevent mood excursions,
but not very effective for depression
• Less likely now to be the first agent prescribed
Bipolar Treatment:
Anticonvulsants
• Anticonvulsant “mood stabilizers”
• Commonly prescribed, approvals for pediatric epilepsy, but
not for mood problems
• Valproic Acid (Depakote) has adult bipolar indication; dose
range 125mg BID to as much as 750mg BID, or more; may
cause drowsiness or ataxia; lab monitoring for serious liver,
pancreatic or heme A.E.’s
• Lamotrigine (Lamictal) also has adult bipolar indication; dose
range 25mg BID to 150mg BID, or more; usually well-tolerated
and no blood monitoring, but rare toxic rashes, and very slow
acclimation
Anticonvulsants (cont)
• Oxcarbamazepine (Trileptal) does not have an indication for mood
disorders, adult or children, but has had considerable clinical use, and
largely replaced carbamazepine (Tegetol); usually tolerated except for
sedation and hyponatremia, though not usually a problem; dosed
150mg BID up to 600mg BID or more
• Topiramate (Topamax) also used off label in doses of 50-100mg BID, up
to 200mg BID or more, but may cause some cognitive difficulties, such
as anomia, and predispose to renal stone formation
• Gabapentine (Neurontin) used off label in doses of 100mg BID or TID,
to as much as 600mg TID or more; some initial fatigue, like other
agents, but generally well-tolerated and does not interact much with
other drugs
Bipolar Treatment:
Atypicals
• Atypical neuroleptics, such as Risperidone, Aripiprazole, and
Olanzepine have mostly replaced older agents, such as Haloperidol and
Thioridazine, so-called “typical neuroleptics”
• Risperidone (Risperdal) in doses from 0.25mg BID, all the way to 4mg
BID, or more, treat mania and stabilize bipolar episodes; approved in
children and adolescents ages 10 and up for mania; can cause
significant weight gain, sedation, prolactin stimulation and other
adverse effects
• Aripiprazole (Abilify) approved ages 10-17 and used in doses of 2mg
daily up to a maximum of 30mg per day, often in divided doses;
generally not as much weight increase, but may cause restlessness and
dystonias; does not elevate prolactin
Atypical Antipsychotics (cont)
• Olanzepine (Zyprexa) is a potent anti-psychotic, with concerns of
weight gain and subsequent metabolic problems, but does have an
approval for bipolar 1 disorder, ages 13-17; dose ranges from 2.5 to
30mg, or more
• Quiatepine (Seroquel) is not approved in children or adolescents, but
used for insomnia of bipolar disorders, and for psychosis and mood
stability in higher doses, range from 25 to 800mg or more, off label.
Sedation and wt gain as S.E.’s
• Ziprasidone (Geodon), also non-approved in kids, but sometimes used
because of wt. gain from other agents, or sedation from other agents;
more concern in children of QT prolongation on EKG; more EPS and
akathisia; does not raise prolactin levels
Parent Medication Guide
• Newly revised guide for Depression in children and
adolescents
• Comprehensive guide to ADHD Rx; nice discussion of
conditions that accompany and/or “show the same
type of sx”
• Joint project of American Psychiatric Association and
American Academy of Child and Adolescent
Psychiatry
• Available at ParentsMedGuide.org
• Slides available at www.emchpsychiatry.com
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Dopamine
• Enhances signal
• Improves attention
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Focus
Vigilance
Acquisition
On-task behavior
On-task cognition
Nigrostriatal Pathway
Mesolimbic Pathway
Substantia nigra
Mesocortical
Pathway
Ventral tegmental area
Solanto. Stimulant Drugs and ADHD. Oxford; 2001.
Norepinephrine
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Dampens noise
Decreases shifting
Executive operations
Increases inhibition
–Behavioral
–Cognitive
–Motoric
Frontal
Limbic
Locus ceruleus
Solanto. Stimulant Drugs and ADHD. Oxford; 2001.