ADHD:

1. ADHD: COMMON CO-MORBID DISORDERS Lynn Hugger, Ph.D. 333 East Shore Road Manhasset, NY 516-829-8930

2. ADHD Defined • A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. • Occurs before age 12 • Occurs across 2 or more settings (e.g. home, school/work, peers) • Symptoms are not caused by another problem – such as psychosis, depression, PTSD, another neurological problem

3. Symptoms of inattention: • Fails to close attention to detail – makes careless mistakes • Difficulty sustaining attention • Does not seem to listen when spoken to • Often does not follow through on instructions or fails to finish schoolwork, chores or duties in the workplace • Avoids or dislikes tasks that require sustained mental effort • Often loses things • Easily distracted • Forgetful in daily activities

4. Symptoms of Hyperactivity/Impulsivity • Often fidgets with or taps hands, feet or squirms in seat • Leaves seat in situations when remaining in seat is expected • Runs about or climbs in situations where it is inappropriate • Often unable to play or engage in leisure activities quietly • Often “on the go,” unable to be still for extended periods of time • Often talks excessively • Often blurts out an answer before a question has been completed • Often has difficulty waiting his/her turn • Often interrupts or intrudes on others

5. Developmental Considerations • Problems with hyperactivity are often seen in early childhood – • They activity level is excessive relative to children of the same age • Predominantly Inattentive Type is often not noticed until later elementary school or even later (especially with girls). • Middle school and the higher grades are more complex worlds academically and socially – resulting in greater demand for strong executive functions.

6. Effort Initiate Speed Working Memory

7. Co-Morbid Disorders • More than 50% of children & adolescents with AD/HD meet criteria for another psychiatric disorder as well. (Brown, 2001) • 25% of children with ADHD meet criteria for an anxiety disorder • 27% have a reading disorder • 31% have a math disorder • 65% have a disorder of written expression • Depression • Oppositional defiant disorder/conduct disorder • Disruptive Mood Dysregulation Disorder • Obsessive Compulsive Disorder • Tic Disorders • Autism Spectrum Disorder • Substance Abuse

8. Additional Ways to Think About ADHD • Daniel Amen (& others) identify 7 types of ADHD • In addition to 1. ADHD-Inattentive Type 2. ADHD-Hyperactive, Impulsive Type 3. ADHD-Combined Type Daniel Amen adds: 4. Overfocused ADD – excessive worrying, argumentative, tends to get stuck in negative thoughts. 5. Temporal Lobe ADD – temper, rage, mild paranoia 6. Limbic ADD – moody & low energy 7. ‘Ring of Fire’ ADD- angry, aggressive, periods of mean aggressive behavior & grandiose thinking

9. Importance of a Comprehensive Psychological Testing Assessment • This is the only way to fully understand what is impacting your child or teenager. • Once you understand your child’s unique profile you can begin to create realistic expectations at school and at home within your family life. • As you will see there are many overlapping disorders that require different kinds of interventions.

10. Parent/Child Relationship Challenges • Your understanding helps: • You to obtain the necessary supports at school. • Have realistic expectations at home. • Help extended family support your child and you. • Through your understanding, your child/teen can understand themselves • Helps you to shift from criticism and punishment to support and realistic expectations. • These changes decrease anxiety, depression, OCD • These changes decrease risk for substance abuse

11. Overlap between ADHD & Reading • Reading disorders have various facets – • Problems with decoding or phonetics are separate from ADHD but your child can have both. • Children & teens often have the following reading challenges: • Weakness in sustained concentration • Slow reader due to processing weakness • Misunderstanding main ideas or inferences due to weakness in organizing information efficiently or tendency to make atypical connections • Low frustration tolerance causing decreased patience needed for reading

12. Helping With Weakness in Reading • If your child has been assessed to have a weakness in phonetic decoding work with a certified reading teacher is very important. • Pick short books • School needs to modify quantity of reading • Some people benefit from an audio book • Sparks notes help distill important information – this should not be seen as cheating. • Teens with ADHD need to be taught how to identify important information.

13. Anxiety • It is very common for people with ADHD to experience anxiety. Processing rapid, complex information is often experienced as an overwhelming feeling. • Modifications in school and in your parenting style can decrease this overwhelmed feeling. • People with ADHD (just like other people) can have anxiety for other reasons that have less to do with having ADHD – that is two co-existing conditions.

14. Modifications at School & Decrease in Anxiety • Look for ways to decrease pressure • Modified homework requirements • Extended deadlines without penalty • Tutors • Lighter course load and increased study halls

15. Changes at home that decrease anxiety • Help at home with organization • Parents understanding that help with homework is needed & not due to being “irresponsible” or “immature” • Consider medication • Consider psychotherapy • Modify your own expectations and help your child modify their expections

16. Obsessive-Compulsive Disorder • Obsessions are recurrent & persistent thoughts, urges, or images that are experienced as intrusive or unwanted • Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rigid rules. • OCD, Tic Disorders and ADHD can often be seen in combination in children

17. Helping Your Child with OCD • The disorder typically has a neurobiological basis • The more you give in to an obsession or compulsion the larger and stronger it gets • Your child can not be asked to stop all at once but understanding this idea will help make them a partner in gradually reducing the process in a slow, step-by-step manner • Work with a therapist will be important in this • It is often driven by some other conflict, worry or concern and addressing this in psychotherapy is very important • When needed, medication can be of help.

18. Depression • Depression can have many causes – people with ADHD have conflicts just like everyone else. • Living with ADHD - at times - can contribute to different levels of depression because of all the challenges and failure experiences. • Symptoms of depression: apparent sadness, change in sleep patterns, withdrawal, lack of pleasure, self-harm, substance abuse, suicidal thinking

19. Oppositional Defiant Disorder • Your child begins to act atypically angry and defiant • Easily loses temper • Often touchy or easily annoyed • Argumentative • Defies rules and requests from people in authority • Often blames others for his/her misbehavior • Spiteful or vindictive • With someone who has ADHD – want to be sure that these symptoms do not only occur in situations that demand sustained effort and attention

20. Disruptive Mood Regulation Disorder • Severe, recurrent temper outbursts manifested verbally (verbal rages) &/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation. • Temper outbursts are inconsistent with the chld’s developmental level. • Temper outbursts occur, on average, 3 or more times per week. • Mood between temper outbursts is persistently irritable or angry most of the day & is observable by others. • Symptoms present for 12 or more months • Symptoms occur in at least 2 or 3 settings. • Onset is before 10 years old.

21. Autism Spectrum Disorder • Children can have Autism Spectrum Disorder & ADHD • Autism Spectrum Disorder includes: • Persistent deficits in social communication and social interaction across multiple contexts: • Problems with social-emotional reciprocity • Weakness in nonverbal communication behaviors (eye contact, reading social cues & body language) • Weakness in understanding relationships • Restricted, repetitive patterns of behavior, interests, or activities: • Repetitive motor movements, use of objects, or types of speech • Inflexible, insistence on sameness • Restricted, fixated interests – “special interest” • Hyper or Hypo sensitivity to sensory aspects of the environment (pain, temperature, smell, visual fascination with lights or movement • Ranges from level 1 – requires support to level 3 requires very substantial support

22. Bipolar Disorder • This is a mood disorder with cycles of highs (mania) and lows (depression) • It can at times be hard to distinguish from ADHD • Some people with Bipolar Disorder also have ADHD • Emotion regulation problems can go with both disorders • Impulsivity can go with both disorders • Depression can be co-morbid with ADHD and is one of the cycles of Bipolar • In young children severe temper tantrums instead of typical mania can be a symptom of BiPolar disorder

23. Sources • Amen, Daniel (2001). Healing ADD: the breakthrough program that allows you to see & heal the 6 types of ADD. NY: The Berkley Publishing Group. • Brown, Thomas (2001). Brown Attention-Deficit Disorder Scales for Children & Adolescents. • Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition • March, John (2007). Talking Back to OCD. NY: Guilford Press. • Papolos, Demitri (2007). The Bipolar Child: the definitive and reassuring guide to childhood’s most misunderstood disorder, 3rd Edition. NY: Broadway.