Ask the Experts

When It’s Not Just ADHD

“Doctors used to view ADHD as a stand-alone disorder. But research suggests that about half of all individuals with ADHD also suffer from depression, anxiety, or some other emotional or neurological issue.”Here’s what you need to know about differentiating and diagnosing symptoms.

Girls sitting outside

Most individuals with attention deficit disorder (ADHD) experience a dramatic improvement in symptoms after receiving appropriate treatment. The easily distracted are able to focus, the hyperactive are able to sit still and work, and the impulsive are able to take a deep breath and think before they act.

As the daily frustrations associated with their ADHD symptoms fade, most individuals receiving effective treatment gradually overcome their sadness, anxiety, and low self-confidence.

Most — but not all.

Some individuals experience significant emotional problems long after their ADHD symptoms are brought under control. Maybe medication has improved your focus, yet you remain anxious or depressed. Perhaps your son’s hyperactivity has eased — yet he remains defiant and aggressive. Maybe your daughter continues to struggle at school despite improved attention and organization skills. Now you’re asking: Are these ADHD symptoms — or something else?

A Common Problem

Doctors used to view ADHD as a stand-alone disorder. But research now suggests that more than half of all individuals who have ADHD also suffer from depression, anxiety, obsessive-compulsive disorder (OCD), oppositional defiance disorder (ODD), a learning disorder, autism, or some other psychological or neurological problem.

In some cases, these problems are “secondary” to ADHD — that is, they are triggered by the frustration of coping with symptoms of ADHD. For example, a girl’s chronic lack of focus may cause her to experience anxiety in school. Years of disapproval and negative feedback from friends, family members, and teachers may cause a boy to become depressed. Most of the time, secondary problems fade once the child’s ADHD symptoms are brought under control.

ADD vs. ADHD – What’s the Difference, Anyway?

When secondary problems don’t resolve with effective ADHD treatment, it’s time to consider another possibility: Some problems are not secondary to ADHD, but distinct entities known as “comorbid” conditions. Like ADHD, comorbid conditions occur along what doctors call a “continuum of neurologically based disorders.”

Comorbid disorders may be caused by the same factors that trigger ADHD (heredity, exposure to environmental toxins, prenatal trauma, and so on). But unlike secondary problems, comorbid conditions do not go away on their own once ADHD has been treated. They require their own specific treatment in addition to any treatment given for ADHD itself.

In other words, a child who has one or more comorbid conditions might need to get tutoring or school accommodations, undergo psychotherapy, or take medication beyond that which he takes for ADHD.

Three Kinds of Trouble

There are three categories of comorbid conditions commonly found with ADHD.

  • Cortical “wiring” problems.These are conditions caused by structural abnormalities in the cerebral cortex, the brain region responsible for high-level brain functions. Cortical wiring problems include learning disabilities, language disabilities, problems with motor coordination, and/or severe problems with organization and time planning (executive functions).
  • Tic disorders.These include motor and oral tics. These tics may come and go and change form. Children with both motor and vocal tics are often diagnosed with co-existing Tourette’s disorder.
  • Problems regulating emotions.These include depression, anxiety disorders (including panic attacks), anger-control problems (intermittent explosive disorder), OCD, and, probably, bipolar disorder, as well.

Parents should recognize that depression can cause a range of symptoms beyond sadness and thoughts of suicide; these include irritability, reduced interest in activities that used to be pleasurable, sleep disturbances, decreased ability to concentrate, indecisiveness, agitation or slowness of thinking, fatigue or loss of energy, and feelings of worthlessness or inappropriate anger.

A child with intermittent explosive disorder doesn’t just yell and stamp his feet. He’s a “Jekyll and Hyde” child, who explodes so fast that you don’t know what caused it, spending 30 minutes or more screaming, cursing, hitting, throwing, and threatening. During this time, he is irrational. The explosion ends almost as abruptly as it began. Once it is over, he might be tired and not want to discuss what happened. Later, he might feel remorse and say that he is sorry and that he does not know why he did it.

OCD can cause a need to count or repeat behaviors, a need to check over and over to make sure that something was done or that an answer given is correct, a need to collect or hoard objects, a need to arrange and organize things, a need to clean and wash, or a need to bite nails or cuticles, pick at sores or scabs, or twirl or pull out hair. OCD doesn’t always appear with those stereotypical symptoms — sometimes OCD is evident through stuck thoughts, hypervigilance, or extreme anxiety.

In some cases, OCD is confused with inattention, most often when a child is so fearful of making a mistake that he is unable to move on to the next task or activity.

What About Bipolar Disorder?

Although bipolar disorder may not occur along the same continuum as cortical wiring problems, emotional regulatory problems, and tic disorders, individuals with ADHD do face an increased risk for this highly complex disorder.

Bipolar disorder is characterized by mood swings that vacillate between depression and a “super-happy” state called mania. The mind races. It is difficult to stop talking or acting or to relax. Moods may swing from calm to rage and back again. Behavior is driven by neurochemistry and may appear inappropriate.

Unlike the mood shifts that characterize ADHD (which are usually triggered by life events), bipolar mood shifts may appear to come and go without any connection to the outside world, and may be sustained over longer periods of time.

A child or adolescent who appears to be depressed and exhibits severe ADHD-like symptoms, with outbursts and mood changes, should be evaluated by a psychiatrist or psychologist with experience in bipolar disorder, particularly if there is a family history of the illness.

Getting Help for Your Child

Are your child’s symptoms secondary to ADHD (and therefore likely to go away on their own, once treated)? Or are they evidence of a comorbid disorder (which requires additional treatment)? It’s not always easy to tell.

Consider where and when your child’s problems arise. Secondary problems typically start at a certain time or occur only under certain circumstances. Did your daughter start experiencing anxiety only in the third grade? Is she anxious only in school or at home when doing homework? Odds are, her anxiety is secondary to ADHD and not a true comorbid disorder. Ditto if your son became aggressive only upon starting middle school.

In contrast, comorbid disorders are both chronic and pervasive. They are generally apparent from early childhood and occur in every life situation. Rather than occurring just during the school day, for instance, they persist over weekends and holidays and during the summer; they are evident in school, at home, at work, and in social situations. As with ADHD, there is often a family history of similar problems.

Perhaps you feel that your daughter’s ADHD medication is working, but her teacher continues to describe her as inattentive and suggests increasing the dose. Maybe the inattention is because she has an unrecognized learning disability, or she is anxious in class, depressed, or tied up with obsessions.

If you suspect that your child has a comorbid condition, consult a child and adolescent psychiatrist or psychologist. Specific assessments may be needed to identify learning, language, motor, or organization/executive function problems. A clinical evaluation will be needed to see if there is anxiety, depression, anger control, OCD, or a tic disorder.

Regulatory problems — anxiety, depression, anger control, and OCD — often respond to a specific group of medications known as selective serotonin reuptake inhibitors, or SSRIs. These medications, which include Prozac, Paxil, Zoloft, Luvox, and Celexa, can generally be used in conjunction with ADHD meds.

Tic disorders are treated with medications such as Catapres, Haldol, Tenex, and Orap — which can generally be given along with ADHD stimulant medication.

Bipolar disorder is an exceedingly complex condition with many possible treatments. With this disorder especially, it’s important to work with a psychiatrist who understands how to use these medications and, when necessary, use them along with the medications for ADHD.

Ultimately, trust your intuition. If you feel that your child might have one or more of these related neurologically based disorders, take action. Early recognition of the problem and prompt intervention are critical, before the problems become greater or more ingrained.

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