Beyond the Core Symptoms of ADHD in Children: Comorbid Screening and Treatment Guidance
ADHD symptoms stretch far beyond hyperactivity and inattentiveness. Among the condition’s signature features are emotional lability and comorbidity with conditions like anxiety, autism, and behavioral disorders. Weighing these factors is integral when designing an appropriate care plan for a child with ADHD.
While diagnosis hinges on the presence of core symptoms like hyperactivity and inattentiveness, attention deficit hyperactivity disorder (ADHD or ADD) is almost always accompanied by other signature factors and comorbidities – like emotional lability, mood disorders, and behavioral problems – that play a critical role in a patient’s care and trajectory. Improving the quality of care for a child means understanding the full scope of ADHD challenges, the role of a comprehensive evaluation, and the importance of early intervention.
ADHD in Children: Diagnosis as Foundation
ADHD and its common comorbid conditions are best diagnosed through a comprehensive psychological evaluation. These fuller evaluations — in contrast to the lone rating scales many pediatricians use — extract a wealth of information about a patient’s ADHD symptoms and any present comorbidities, like learning and language disabilities, early in the evaluation process.
The components of a full psychological evaluation include:
- Diagnostic interviews
- Rating scales – administered to the child’s parents and teachers
- Direct observation of the child
- Psychological testing – core and extended batteries that test for ADHD symptoms and any comorbid conditions, respectively
- Written report of psychological functioning in regard to ADHD and treatment recommendations. These reports can include specific recommendations for school services, like more time for testing, so that the child can learn to the best of their ability. Reports remain current for three to five years.
Not every child, however, may be able to access a comprehensive psychological battery — or need one. A full history and physical, a Vanderbilt assessment, and communication with the school system on accommodations (oftentimes a letter submitted on behalf of the clinician) can suffice, depending on the child’s needs. Some tests, like speech and language assessments, can be completed more easily than others due to the close relationship between many speech pathologists and pediatricians.
ADHD in Children: Common “Non-Core” Symptoms & Comorbidities
Once ADHD is definitively detected, clinicians must consider whether other conditions may be traveling with the patient. Failing to address comorbid challenges may limit the patient’s improvement in functioning.
ADHD Comorbidities: Behavior Disorders
Oppositional defiant disorder (ODD) is the most common comorbidity among children with ADHD, followed by conduct disorder1. ODD, characterized in part by chronic stubbornness and refusal to follow rules or listen to authority, is present in about half of children with hyperactive-impulsive type ADHD, and in about 25 percent of children with ADHD-inattentive type2. Conduct disorder occurs in about a quarter of children with combined type ADHD2.
Diagnosing these disorders is relatively straightforward given the inclusion of several key symptoms in the Vanderbilt Assessment scales for ADHD used by many pediatricians.
ADHD Comorbidities: Anxiety & Mood Disorders
About one-third of children with ADHD will have a comorbid anxiety disorder3. Multiple pathways have been proposed to explain the ADHD-anxiety connection, but I believe these are two separate disorders traveling together in most patients. That said, you treat the ADHD first, and then address the anxiety.
Anxiety can be easily missed, however, if the clinician and caregivers focus only on the child’s ADHD symptoms, especially if they are mainly hyperactive. Directly asking a child if they feel anxious rarely leads to accurate answers. It works much better to ask a child what worries them – the clinician may return with a list of concerns, which can open a discussion around anxiety. Rating forms, like the Screen for Child Anxiety Related Disorders (SCARED), can also capture signs and symptoms of anxiety.
Depression is another comorbid diagnosis that many clinicians overlook or dismiss when evaluating children for ADHD. A child who’s really active and moving all over the place may not fit the stereotypical picture of a person with depression. But difficulty dealing with ADHD symptoms and the consequences they may cause in academic performance, for instance, often leads to negative self-esteem, which can develop into depression. Recent research estimates that 20 percent in children with ADHD also have depression3. Treating ADHD symptoms first can be very helpful in tamping down the symptoms of depression. Therapy and antidepressant medication may still be needed.
ADHD Comorbidity: Autism Spectrum Disorder
Between 30 to 50 percent of children with autism spectrum disorder (ASD) manifest ADHD symptoms4. Pediatricians screen for autism at around 18 months, but developmental-behavioral pediatricians and other clinicians that primarily treat autism should keep ADHD symptoms in mind as the child develops, as untreated or unrecognized ADHD symptoms may impact the child’s ability to learn. Conversely, about 18 percent of children with ADHD show features of ASD, a figure that ADHD clinicians should keep in mind through development.
ADHD Comorbidity: Emotional Lability
The emotionality that comes with ADHD – irritability, anger, sudden shifts toward negative emotions – can impact both home and social life, as well as learning. The more severe the ADHD, the more severe temperamental issues and other comorbidities may be; this interplay impacts the development and effectiveness of coping skills in the long run.
Emotional lability is also at the center of Disruptive Mood Dysregulation Disorder (DMDD), which impacts about 20 percent of children with ADHD5. The combination of ADHD and DMDD is further associated with increased bullying behavior, diminished self-control, and poorer quality of family activities6.
ADHD Comorbidities: Learning Disabilities & Communication Disorders
A child with ADHD undergoing treatment may see improved focus and ability to pay attention. But continuing struggles in school may point to an undiagnosed comorbid learning or language disability. Up to 40 percent of children with ADHD have dyslexia, a disability in reading. For dyscalculia, a disability in math, this number goes up to 60 percent.
ADHD in Children: Medication Considerations
Stimulant and Nonstimulant Medications
Though stimulant medication, paired with behavioral therapy, is the first-line treatment for ADHD in children age 6 and over, contraindications – some of them common comorbidities – and side effects may limit the use of stimulants. Depression and anxiety can worsen with stimulants, for example. Nonstimulants like atomoxetine (Strattera) can be used instead for children with anxiety or depressive disorders. Alpha agonists (clonidine, guanfacine) can also be used by themselves, but are often used in conjunction with a stimulant, and are helpful for comorbid ODD.
If the child has tried multiple stimulants — both methylphenidate and amphetamine — and nonstimulants and is still not showing improvement, it’s time for the clinician to take a step back and consider whether they missed a comorbidity, the child is simply not adhering to the dosing schedule, or the child may need to exceed labeled medication dosages (this may require a discussion with the patient’s insurance company in the event of any difficulty with filling the prescription).
The Importance of Early Pharmacological Treatment
Clinicians should convey to families the findings from research on ADHD medications – that it improves cognitive, behavioral, and functional deficits in children and decreases ADHD symptoms. These improvements lead to better:
- academic achievement in elementary school
- health-related quality of life
- brain functioning7
One ten-year follow-up study also found that stimulants, especially when taken in early childhood, have protective effects on the rates of developing comorbidities like depression, anxiety, and ODD. And compared to children who took no stimulants, those who did were less likely to repeat a grade in school8.
Clinicians should explain to parents that pharmacological treatment, combined with other therapies, does more than get their child to focus in the classroom. It has real, long-term impacts on areas like higher education and employment, involvement with the law, risky behavior, and overall quality of life through adolescence and adulthood.
ADHD in Children: Next Steps
- Read: When It’s Not Just ADHD – Symptoms of Comorbid Conditions
- Download: Is It More Than Just ADHD?
- Research: The ADHD-Anger Connection – New Insights into Emotional Dysregulation and Treatment Considerations
The content for this article was derived from the ADDitude Expert Webinar “Navigating the Life Stages of ADHD: Key Concerns in Diagnosing and Treating Children” by Adelaide Robb, M.D. (available as ADDitude ADHD Experts Podcast episode #319), which was broadcast live on August 13, 2020.
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3Melissa L. Danielson, Rebecca H. Bitsko, Reem M. Ghandour, Joseph R. Holbrook, Michael D. Kogan & Stephen J. Blumberg. (Jan. 24, 2018). Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016. Journal of Clinical Child & Adolescent Psychology, 47:2, 199-212, DOI: 10.1080/15374416.2017.1417860. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834391/pdf/nihms937906.pdf
4 Leitner Y. (2014). The co-occurrence of autism and attention deficit hyperactivity disorder in children – what do we know?. Frontiers in human neuroscience, 8, 268. https://doi.org/10.3389/fnhum.2014.00268
5 Masi L, et al. ADHD and DMDD comorbidities, similarities and distinctions. Journal of Child and Adolescent Behavior. 2016. https://www.omicsonline.org/open-access/adhd-and-dmdd-comorbidities-similarities-and-distinctions-2375-4494-1000325.php?aid=83936
6 Mulraney, M., Schilpzand, E.J., Hazell, P. et al. Comorbidity and correlates of disruptive mood dysregulation disorder in 6–8-year-old children with ADHD. Eur Child Adolesc Psychiatry 25, 321–330 (2016). https://doi.org/10.1007/s00787-015-0738-9
7 Spencer, T. J., Brown, A., Seidman, L. J., Valera, E. M., Makris, N., Lomedico, A., Faraone, S. V., & Biederman, J. (2013). Effect of psychostimulants on brain structure and function in ADHD: a qualitative literature review of magnetic resonance imaging-based neuroimaging studies. The Journal of clinical psychiatry, 74(9), 902–917. https://doi.org/10.4088/JCP.12r08287
8 Biederman, J., Monuteaux, M. C., Spencer, T., Wilens, T. E., & Faraone, S. V. (2009). Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study. Pediatrics, 124(1), 71–78. https://doi.org/10.1542/peds.2008-3347