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ADHD AND COMORBIDITIES – MANAGEMENT PRINCIPLES

Posted on:January 12, 2022

Last Updated: February 25, 2022
Time to read: 22–26 minutes

ADHD is a chronic neurodevelopmental condition that has a comorbidity prevalence
estimated to be as high as 90% of patients [Kessler et al., 2006]; [Sobanski,
2006]; [Jacob et al., 2007]

This review describes the common ADHD comorbidities and how their symptoms
overlap with ADHD [Canadian ADHD Practice Guidelines]

If a patient is suspected of having ADHD, then during a medical review, the
clinician should determine whether other medical and psychiatric disorders could
mimic the symptoms of ADHD.

In some cases, ADHD may co-exist with another psychiatric comorbidity that
influences the diagnosis and management.

You can go to the  following links for a refresher on ADHD:

 1. Diagnosis and Management of ADHD
 2. Diagnosis of ADHD in Females
 3. Clinical Evaluation of ADHD (Video)

GENERAL PRINCIPLES IN MANAGEMENT OF ADHD COMORBIDITIES


Click here to zoom image

1. BEHAVIOURAL PROBLEMS


Oppositional defiant disorder (ODD)

 * ODD is the most common comorbid disorder in children that can persist into
   adulthood. ODD is characterised by wilfully oppositional or defiant
   behaviours, i.e. deliberately refusing to comply with the rules and
   exhibiting spiteful and vindictive characteristics towards others. [Canadian
   ADHD Practice Guidelines]
 * ODD symptoms that overlap with ADHD include reactive, irritable, and
   aggressive symptoms; however, according to the DSM-5, mood-related,
   provocative or vindictive symptom clusters can differentiate ODD from ADHD.
 * The combination is associated with greater symptom severity, daily
   impairment, and a more at-risk prognosis than either disorder alone.
 * As the symptoms of ADHD can progress to ODD, ADHD treatment should be
   optimised to prevent the reactive and irritable dimensions of ODD from
   developing later. [Harvey et al., 2016]

Management of ADHD and ODD: 

 * Address core symptoms of ADHD and augmentation with other treatments to
   address the ODD.
 * Psychostimulants, alpha-2 agonists, and atomoxetine can be beneficial for
   disruptive and aggressive behaviours in addition to core ADHD symptoms;
   however, psychostimulants generally provide the most benefit. [Pringsheim et
   al., 2015]
 * Methylphenidate has the best evidence, followed by atomoxetine, guanfacine SR
   and clonidine for ADHD with behaviour problems. [Ghosh et al., 2017]
 * Psychosocial management via parental management training, functional family
   therapy, cognitive behaviour therapy either in individual or group format are
   treatment approaches that can be used with pharmacotherapy options. [Ghosh et
   al., 2017]

Mild:

 * May respond to behaviour management alone
 * Monotherapy with stimulant medication or atomoxetine.

Moderate to severe:

 * Combination pharmacotherapy (e.g. stimulant and clonidine) and behaviour
   management.

Severe or refractory cases

 * May require the introduction of an atypical antipsychotic such as
   risperidone. [Hazell, 2010]

Conduct disorder/aggression (CD)

 * CD is often preceded by ODD but is characterised as a more severe and
   persistent form of ODD whereby the patient exhibits higher levels of
   callousness and cruelty and an absence of remorse or empathy towards others.
   [Harpold et al., 2007]
 * It is characterised by symptoms of aggression toward people or animals,
   destruction of property, deceitfulness or theft, and serious violations of
   rules.
 * Aggressive behaviour, lying, stealing, fire-setting, and running away from
   home and school are the most frequent manifestations of CD. They are often
   accompanied by hyperactivity, impulsive behaviour, explosiveness, cognitive
   and learning problems, and poor social skills.
 * Moreover, patients with CD are more than likely to develop antisocial
   personality disorder in adulthood and substance abuse disorders and
   depression. [Barkley et al., 2004]

Management of Comorbid Conduct Disorder and ADHD: 

 * The most effective approach to treatment requires a multimodal strategy that
   incorporates stimulant/non-stimulant pharmacotherapies in conjunction with
   individual and family psychosocial interventions. [Canadian ADHD Practice
   Guidelines]
 * Psychostimulants are highly recommended. [Lillig, 2018]
 * Other drugs that may be useful include atomoxetine antidepressants
   (imipramine, desipramine, Selective Serotonin Reuptake Inhibitors (SSRIs),
   atypical antipsychotics such as risperidone, or mood stabilisers including
   lithium.  [Turgay, 2005]
 * Risperidone may benefit patients with conduct disorder who have severe
   aggression or explosive anger after comorbid ADHD is treated.
 * Some ADHD medications could increase irritability and aggressive symptoms;
   hence monitoring is needed.

2. PERSONALITY DISORDERS


Antisocial personality disorder (ASPD)

 * ASPD symptoms are characterised by deceitfulness and disrespectful,
   manipulative or reckless behaviour without regard for oneself or others. The
   patient is often irritable and aggressive with confrontation and physical
   fights, a persistent and repeated characteristic.[Canadian ADHD Practice
   Guidelines]
 * Patients with CD are more likely to develop ASPD; however, patients with ADHD
   are unlikely to develop ASPD. [Storebø and Simonsen, 2013]
 * Therefore, the development of ASPD with ADHD is a complex issue that may
   require specialised interventions.
 * Interventions include stimulants; however, ASPD is often associated with
   drug-seeking behaviours, and therefore clinicians should be wary of
   considering these treatments. [Biederman et al., 1995]
 * The provision of non-stimulant therapies has not been adequately researched
   at present.

Borderline personality disorder (BPD)

 * ADHD and BPD are common comorbid disorders with a lifetime prevalence of 34%
   in ADHD patients. [Dowson et al., 2004]
 * ADHD and BPD also share similar core symptoms, including impulsivity, mood
   lability, and emotional dysregulation.

The relationship between ADHD and BPD is multifaceted. [Storebø et al, 2014],
[Ditrich et al, 2021]

 * ADHD may be an early developmental stage of BPD
 * The same genes lead to two distinct disorders (genetic pleiotropy)
 * BPD and ADHD are overlapping, e.g. they are different presentations of the
   same underlying disorder
 * ADHD is associated with a higher risk of developing BPD.
 * They may be separate disorders co-occurring.

To distinguish patients with BPD from those with ADHD, BPD patients have rapid
changes to self-identity and self-image and an elevated risk of heightened
rejection sensitivity, suicidal threats, self-injury, depression, and anxiety.
[Canadian ADHD Practice Guidelines]

Management of ADHD and BPD: 

 * Psychotherapy is the primary treatment option for BPD, with dialectical
   behavioural therapy the most common. [van den Bosch et al., 2005]
 * Medications that target specific core symptoms such as impulsivity, which
   both ADHD and BPD share, are helpful.
 * Treatment of ADHD should always be considered when treating comorbid
   personality disorders as patients are more likely to engage and benefit from
   psychological treatment programs for BPD when comorbid ADHD is treated.
   [Asherson et al., 2014]
 * Systematic reviews and meta-analyses have shown Methylphenidate (MPH) as
   beneficial in treating emotional dysregulation in adult ADHD alone.
 * BPD-ADHD patients receiving MPH treatment showed a significantly improved
   response to DBT treatment for Trait-State Anger scores, motor impulsiveness,
   depression severity, and ADHD severity compared with those without stimulant
   medication. [Prada et al., 2015]
 * MPH may improve decision making in patients with BPD by addressing ADHD
   symptomatology. [Gvirts et al., 2018]

3. ADDICTION


Substance use disorder (SUD)

 * Substance abuse is a significant risk factor in patients with ADHD, and vice
   versa, with 50% of patients with SUD also diagnosed with ADHD. [Wilens et
   al., 2005]; [Molina et al., 2007]
 * Patients with ADHD-SUD comorbidity show more complex and chronic patterns of
   substance use, including more polysubstance use, than adults with SUD without
   comorbid ADHD and, have more difficulties remaining abstinent and report a
   reduced quality of life. [Crunelle et al., 2018]
 * They have more significant psychiatric comorbidity, such as antisocial
   personality disorder, borderline personality disorder, anxiety disorders,
   bipolar disorders and/or post-traumatic stress disorders.
 * The Conners’ Adult ADHD, Diagnostic Interview for the DSM-IV (CAADID) is
   often used as the gold standard for diagnosing adult ADHD in patients with
   SUD.

Management of Comorbid SUD and ADHD: 

 * Management should integrate the treatment of ADHD and SUD due to the
   bi-directional relationship between ADHD and SUD.
 * First start SUD treatment, followed by ADHD treatment as soon as possible
   after that.
 * Combined pharmacotherapy and psychotherapy is efficacious.
 * In SUD patients, treatment of ADHD can be helpful to reduce ADHD symptoms
   without worsening the SUD and should not be avoided.
 * From a pharmacological perspective, standard-dose pharmacotherapy for
   treating ADHD in patients with ADHD-SUD comorbidity shows lower efficacy and
   higher doses may be needed if patients do not respond. Higher doses, however,
   require close monitoring. [Crunelle et al., 2018]
 * Long-term drug use may down-regulate brain dopamine systems in chronic
   drug-dependent individuals necessitating higher stimulant doses.
 * At the same time, ADHD pharmacotherapy on its own is generally not effective
   in reducing substance use and is associated with a higher frequency of
   adverse effects and treatment discontinuation.
 * Although psychostimulants are prescribed, the potential abuse requires
   careful monitoring during follow-up.
 * Long-acting formulations, osmotic-release oral system formulations of
   methylphenidate (OROS-MPH) and lisdexamphetamine, have lower misuse and
   diversion rates than immediate-release preparations.
 * Stimulant treatment for ADHD does not precipitate the onset of SUD in adults
   without previous SUD.
 * Patients treated with MPH have better retention rates in treatment, and
   higher doses of MPH are also associated with more significant long term
   treatment adherence.

Alcohol Use Disorder and ADHD:

 * Atomoxetine is associated with reducing ADHD symptoms and decreasing alcohol
   craving and consumption.
 * In comorbid alcohol use disorder, Atomoxetine can also be used with
   naltrexone, nalmefene, acamprosate or topiramate. [Crunelle et al., 2018]

Stimulant Use Disorder (Cocaine, amphetamines) and ADHD:  

 * Higher doses of MPH (up to 180 mg/day) have shown a decrease in ADHD symptoms
   and the reinforcing effects and the use of cocaine and amphetamines (and
   other drugs) in adult stimulant-dependent ADHD patients. [Konstenius et al.,
   2014]
 * Extended-release mixed amphetamine (60 and 80 mg/day) with CBT showed
   substantial reductions in both ADHD and drug use in cocaine-dependent
   patients with ADHD. [Levin et al., 2015 ]
 * Psychotherapeutic options for this population has not been extensively
   studied.
 * Integrated CBT (iCBT) addressing ADHD and SUD resulted in significant extra
   improvement in ADHD symptoms in SUD + ADHD patients. [van Emmerik-van
   Oortmerssen et al., 2019]
 * Other options are individual coaching, structured skills training, dialectic
   behavioural therapy, and mindfulness-based therapy.

4. EATING DISORDERS


Eating Disorders (EDs)

 * The prevalence of ADHD in EDs ranges between 1.6% and 18%. Comorbid ADHD was
   more often reported in the AN-binge eating/purging subtype and BN than in the
   AN restrictive subtype. ADHD is also closely associated with Binge Eating
   Disorder (BED) with overlapping clinical (impulsivity) and neurobiological
   correlates. [Nickel et al., 2019]
 * Females with ADHD are 3.6x more likely to develop an eating disorder than
   females without ADHD. [Canadian ADHD Practice Guidelines] Eating disorders
   such as bulimia nervosa and anorexia nervosa (purging subtype) are the most
   commonly diagnosed.
 * ADHD and EDs may share common neurobiological mechanisms with dopamine
   dysregulation in frontostriatal areas underpinning both disorders. [Levin et
   al.,2016] 
 * ADHD is also a risk factor for obesity unless the patient has compensatory
   behaviours such as excessive exercise, purging, fasting, or misuse of
   laxatives, diet pills or other medications. [Cortese et al., 2016]
 * ADHD symptoms are inversely correlated with recovery in ED. [Svedlund et al.,
   2018]
 * Lisdexamfetamine (LDX) is FDA approved to treat moderate to severe Binge
   Eating disorder (BED) in adults.
 * Clinicians also need to be aware that some patients may feign ADHD to acquire
   stimulant medications to aid their weight loss. [Canadian ADHD Practice
   Guidelines]

5. ANXIETY AND AFFECTIVE DISORDERS


Anxiety disorder

 * Individuals with ADHD have higher rates of anxiety (up to 50%) than the
   general population. [Katzman et al., 2017]
 * Patients with ADHD are often forgetful, which can cause excessive
   over-compensatory mechanisms (e.g. checking and rechecking) that can induce a
   state of anxiety about forgetting something important. [Canadian ADHD
   Practice Guidelines]. This can give the impression of a primary anxiety
   disorder.
 * In childhood, the presence of generalised anxiety disorder (GAD) could
   prevent the typical inhibitory dysfunction present in ADHD. In adolescence it
   may increase the deficit of working memory. In adulthood it may enhance the
   presence of sleep problems.
 * Individuals with anxiety disorders who have comorbid ADHD tend to have more
   severe anxiety symptoms, earlier age of onset of anxiety, and more frequent
   additional comorbid psychiatric diagnoses and substance use than those who do
   not have ADHD. [Katzman et al., 2017]
 * The combination of ADHD and anxiety is associated with a very high risk of
   bipolar disorder. [Meier et al., 2018]
 * However, some signs and symptoms are distinct to ADHD that differentiate from
   anxiety. For example, ADHD symptoms such as inattention and restlessness
   occur in the absence of an emotional state, unlike what that with an anxiety
   disorder. Patients with anxiety will also exhibit physical symptoms such as
   elevated heart rate, nausea, and shortness of breath, all of which are
   usually absent in patients with ADHD. [Canadian ADHD Practice Guidelines]

Management of Anxiety and ADHD:

 * Treatment of anxiety and ADHD requires a strategy that treats the most
   impairing condition.
 * Individuals with comorbid ADHD and anxiety disorders would benefit from
   adjunctive psychosocial or adjunctive pharmacotherapy interventions to
   cognitive behavioural treatment. [D’Agati et al., 2019]
 * Individuals with ADHD can experience distress and state anxiety during
   cognitive tasks. MPH can reduce state anxiety and improve cognitive
   performance. [Bloch et al., 2017]
 * Psychostimulants can also increase anxiety and should be titrated upward
   slowly until symptoms are stabilised.
 * Some studies that evaluated MPH in anxiety showed that patients could respond
   less well and get more unpleasant arousal side-effects.
 * Low dose aripiprazole treatment in adolescents and adults may also provide
   benefits. [D’Agati et al., 2019]

Management of Anxiety and ADHD in children. 

 * Treating ADHD with stimulants can lead to improvement in ADHD-related anxiety
   symptoms.
 * Treating anxiety can reduce anxiety-related attentional problems and
   executive functioning.
 * Atomoxetine and alpha agonists may be suitable treatments that address both
   ADHD and anxiety.
 * Behavioural treatment should be part of the plan for ADHD co-occurring with
   anxiety disorders. [Janiczak et al.,2020] 

Major depressive disorder (MDD)

 * Patients with ADHD are at an increased risk of developing MDD with ADHD-MDD
   comorbidity, also increasing illness severity and functional impairments.
   [Miller et al., 2007]
 * Loss of motivation, restlessness, and irritability are common symptoms of
   both MDD and ADHD; however, feelings of sadness, hopelessness, tiredness and
   suicide indicate MDD rather than ADHD.
 * A clinician is encouraged to ask “since when?” if MDD-specific symptoms are
   reported. [Canadian ADHD Practice Guidelines]

ADHD and Comorbid MDD in children: 

True comorbid MDD is differentiated by :

 * Depressive cognitions (e.g., guilt, worthlessness, hopelessness, morbid or
   suicidal thoughts)
 * Severe anhedonia
 * Psychomotor retardation.

Symptoms such as irritability, poor concentration, anergia, sleep problems, and
psychomotor or appetite changes have overlap with ADHD and other frequent
comorbidities. They may be associated with the side effects of ADHD medications.
[Daviss, 2016]

Management of ADHD and Comorbid MDD.

 * Treat the most severe or functionally impairing condition first. [Daviss,
   2016].[McIntosh et al., 2009]

Click here to zoom image

If Depression more severe:

 * If moderate-severe MDD is the most pressing clinical issue, then treatment
   for Depression should be initiated first. [McIntosh et al., 2009]
 * Option to add a stimulant if the depressive but not the ADHD symptoms respond
   to the antidepressant. [Daviss, 2016]
 * Once the Depression has improved, the patient should be re-evaluated for
   symptoms of ADHD, and if necessary, treatment for ADHD should be initiated.
 * If the patient does not respond adequately to antidepressant medication,
   consideration should be given to re-evaluating both the Depression and ADHD
   diagnosis and, if appropriate, initiating ADHD treatment.
 * Consider concomitant psychotherapy.

If ADHD is the primary condition

 * Treat ADHD first with long-acting psychostimulant as first-line treatment
 * Atomoxetine and bupropion are indicated if a stimulant trial is
   contraindicated or has failed, or when a non-stimulant is preferred
 * Reassess if depressive symptoms are present and if AD is required.
 * Antidepressants may not always be needed.
 * Consider concomitant psychotherapy.

Management of ADHD and Comorbid MDD in Children and adolescents: [Turgay et al.,
2006]

ADHD symptoms more prominent: 

 * Treatment with psychostimulants for at least two weeks
 * If depressive symptoms do not improve, add SSRI.
 * Continue stimulant medication if the ADHD and depressive symptoms improve.
 * If the ADHD and/or depressive symptoms worsen, the stimulant should be
   discontinued.
 * Combining SSRI with psychostimulants can be considered when the risk of
   suicide and/or serious self-injurious behaviour is high. [Hughes et al.,
   1999]
 * Atomoxetine is also effective in treating ADHD in pediatric patients with
   ADHD and comorbid symptoms of depression or anxiety.

Depressive symptoms more prominent: 

 * Start with AD
 * If no response, switch to a different class of antidepressants.
 * Add psychostimulants if depressive symptoms improve with antidepressants, but
   ADHD symptoms do not respond.
 * Bupropion is a recommended antidepressant as it addresses both symptoms of
   Depression and ADHD.

Important Tips in Management

 * Antidepressants such as SSRIs can be combined with stimulant or non-stimulant
   medications for ADHD.
 * However, fluoxetine and paroxetine are potent inhibitors of the CYP450/2D6
   liver isoenzyme, and caution is advised when co-administering amphetamines or
   atomoxetine for ADHD as they can increase levels.
 * Children and adolescents, and patients should be monitored for indicators of
   potential suicidal ideation

Bipolar disorder (BD): 

 * ADHD often co-occurs with BD and BPD, characterised by symptoms that overlap
   with ADHD. [Asherson et al., 2014]
 * Approximately 20% of patients with BD or BPD will have comorbid ADHD, with
   research suggesting that this is true comorbidity that goes beyond the
   complexity of just symptom overlap. [Milberger et al., 1995]

The following table can help differentiate ADHD from Bipolar disorder:

Click here to zoom image

Management of ADHD and Comorbid Bipolar Disorder: 

 * The first goal of ADHD–BD treatment is mood stabilisation. In some cases,
   after mood is stabilised, some ADHD/BD patients may not fulfil diagnostic
   criteria for ADHD. [Salvi et al., 2021]
 * In patients who complain of residual cognitive symptoms, clinicians can add
   ADHD medications such as MPH, atomoxetine or amphetamine salts.
 * The use of stimulants in BPAD has been controversial, with the main concern
   being the risk of mania.
 * A large study of 145000 children with ADHD showed that MPH treatment for more
   than one year reduced the risk of new-onset BPAD compared to those not
   treated. [Wang et al., 2016]
 * Another study found no evidence for a positive association between MPH and
   treatment-emergent mania among those on concomitant mood stabilisers.
   However, those treated with MPH alone had a 6.7-times increased risk of manic
   episodes within three months of medication initiation. [Viktorin et al.,
   2017]
 * Lisdexamfetamine also showed benefits on ADHD and depressive symptoms in a
   4-week trial in adults with bipolar I/II disorder without inducing any
   treatment-emergent hypomanic or manic episode. [McIntyre et al., 2013]
 * Lisdexamphetamine is also evidence-based as an add on treatment in the
   treatment of treatment-resistant Bipolar Depression. [McElroy et al., 2015]
 * Bupropion SR may also be effective in ADHD/BD comorbidity without significant
   activation of mania. [Wilens et al., 2003]
 * Atomoxetine has been associated with mania and hypomania or mood
   dysregulation or irritability in 33% of children with ADHD. Atomoxetine
   carries the risk of induction of (hypo) mania even in stabilised patients
   with BD. Caution is therefore warranted when using atomoxetine in ADHD/BD
   comorbidity. [Kumar et al., 2017]
 * Alpha-2 agonists, such as clonidine and guanfacine, are useful agents in ADHD
   / BD comorbidity. Clonidine is also effective in the treatment of manic
   episodes. [Girard et al., 2017]

Disruptive mood dysregulation (DMDD)

 * DMDD is characterised by chronic and severe irritability with frequent
   out-of-proportion outbursts of temper. [Canadian ADHD Practice Guidelines]
 * There are many differential diagnoses, including BD, ODD, ADHD, and CD
   [Axelson et al., 2012]; however, patients with DMDD have an inter-episode
   mood that is still characterised as irritable/dysphoric. [Leibenluft et al.,
   2006]
 * DMDD is a relatively new DSM-5 diagnosis, and therefore only approximate
   pharmacological and psychosocial treatments can be recommended.
 * MPH treatment significantly improved mood and emotional symptoms associated
   with DMDD comorbid with ADHD. [Winters et al., 2018 ]

6. COMPULSIVE DISORDERS


Obsessive-compulsive disorder (OCD)

 * ADHD and OCD are both developmental disorders, and the comorbidity between
   these diagnoses are common despite inconsistent prevalence reports and their
   directly opposing neurobiology and clinical features. [Abramovitch et al.,
   2015]
 * For example, impulsivity and disinhibition are core symptoms of ADHD (which
   can be treated with stimulants). In contrast, obsessiveness and compulsivity
   are the core symptoms of OCD (which can be treated with SSRIs and
   neuroleptics).

> There has been increasing awareness of the cross-cutting nature of the symptom
> domains of impulsivity and compulsivity.  Impulsivity is characterised by an
> inability to resist impulses and urges, delaying gratification deficits,
> unreflective decision making and premature behaviour.  Compulsivity is
> characterised by perseverative and repetitive action and is ruminative and
> ridged in nature.  There is an overlap between the two conditions with
> features such as impulsivity observed in both groups but at markedly levels in
> those with ADHD.  A degree of frontostriatal hyperactivity or hypoactivity
> also appears to underpin symptoms in both OCD and ADHD. [Cabarkapa et al.,
> 2019]

Management of ADHD and Comorbid OCD: 

 * Treating OCD with SSRIs and cognitive behaviour therapy with exposure
   response prevention (CBT+ERP) improves attentional symptoms.
 * Treating ADHD with stimulants improves comorbid obsessive-compulsive
   symptoms.
 * Untreated comorbid ADHD diminishes treatment response on the OCD
 * Clinicians can start with SSRIs for OCD and psychostimulants such as
   methylphenidate and dexamphetamine for ADHD.
 * Medication should be introduced one at a time to assess response and improve
   tolerability. In addition, clinicians should be aware of the possibility of
   worsening OC symptoms with stimulants.
 * TMS is also an effective option for treating comorbid ADHD and OCD [Cabarkapa
   et al., 2019] 

Tourette’s syndrome

 * In a cohort study of Tourette syndrome patients, there were four subtypes
   identified: ‘pure’ Tourette syndrome (49.8%), Tourette syndrome and ADHD
   (22.2%), Tourette syndrome and OCD (21.5%), and Tourette syndrome, ADHD and
   OCD (6.5%). Rizzo et al., 2013]
 * Tourette syndrome and Tourette syndrome with comorbid ADHD are distinct from
   both a neurobiologically perspective and a neurobehaviourally perspective.
   For instance, patients with Tourette syndrome have prolonged prosaccade
   latencies, whereas patients with ADHD have impaired antisaccade accuracy.
   However, there are overlaps, including emotional lability.

Management of ADHD and Comorbid Tourette’s Syndrome 

 * Start with a non-stimulant agent such as guanfacine (long-acting preparations
   may be preferred) or clonidine as they effectively alleviate both symptoms of
   TS and ADHD. Rizzo et al., 2013]
 * If the TS is not severe, but the ADHD is disabling, one should consider
   treating the ADHD with a stimulant. Monitor for worsening tics with a
   reliable TS rating scale, such as The Yale Global Tic Severity Scale (YGTSS).
   Oluwabusi et al., 2016]
 * According to the Tourette’s Syndrome Study Group, the combination of
   methylphenidate and clonidine is effective for ADHD in children with comorbid
   tics. Prior recommendations to avoid methylphenidate because of concerns of
   worsening tics are unsupported [Tourette’s Syndrome Study Group, 2002]
 * Atomoxetine and Aripiprazole are useful in some cases. [Rizzo et al., 2013]

7. DEVELOPMENTAL DISORDERS


Autism spectrum disorder (ASD)

 * ASD was an exclusion criterion in the DSM-IV for ADHD; however, in the DSM-V,
   there is the possibility of a dual diagnosis. Analysis of the prevalence of
   ASD co-occurring with ADHD varies from 37% to 85%. [Gadow et al., 2006]; [Lee
   and Ousleey, 2006]
 * ASD is characterised by social dysfunction and restrictive-repetitive
   behaviours, although these psychosocial issues can be exacerbated by comorbid
   ADHD. Both ADHD and ASD include a spectrum of difficulties associated with
   attention, communication, impulsivity, restlessness, and/or hyperactivity.
 * Risperidone and aripiprazole are approved for the treatment of ASD, and both
   drugs effectively reduce irritability. Methylphenidate and atomoxetine are
   commonly administered for ADHD-related symptoms. However, there may only be
   an improvement in symptoms such as hyperactivity and impulsivity, which may
   not be associated with the patient’s ASD diagnosis. [Arnold et al., 2006];
   [Arnold et al., 2012]
 * ADHD and ASD are thought to be associated with (or defined by) executive
   dysfunction, although the specific executive domains that are negatively
   impacted may differ. For example, children with ASD have more planning, and
   cognitive flexibility difficulties and children with ADHD have more
   inhibition difficulties.
 * Atomoxetine and methylphenidate show evidence for treating ADHD symptoms
   within individuals with ASD. However, effect sizes from the ASD population
   are somewhat smaller than the non-ASD population, and side effects are more
   common in the ASD population. [Antshel et al., 2013]

SUMMARY


ADHD is associated with a high degree of comorbidity across the lifespan.

Comorbidities may make the diagnosis of ADHD challenging, and as a result, may
delay diagnosis for some patients.



Comorbidities also confound treatment and may require other therapies beyond
treatments for ADHD.  The presence of comorbidities is not a contraindication
for the use of stimulants, even in conditions such as anxiety, SUD and Bipolar
disorder.

In general, the more severe disorder should be addressed first.

Treating ADHD and comorbidities tends to have better outcomes than treating
either disorder alone.


REFERENCES

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the National Comorbidity Survey Replication
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States: results from the National Comorbidity Survey Replication. Am J
Psychiatry. 2006;163(4):716-723.
Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder
(ADHD)
Sobanski E. Psychiatric comorbidity in adults with attention-deficit/
hyperactivity disorder (ADHD). Eur Arch Psychiatry Clin Neurosci. 2006;256(1
Suppl 1):i26–i31.
Co-morbidity of adult attention-deficit/hyperactivity disorder with focus on
personality traits and related disorders in a tertiary referral center
Jacob C, et al. Co-morbidity of adult attention-deficit/hyperactivity disorder
with focus on personality traits and related disorders in a tertiary referral
center. Eur Arch Psychiatry Clin Neurosci. 2007;257:309–317. 
Canadian ADHD Practice Guidelines
Canadian ADHD Practice Guidelines, 4th edition. 
Early development of comorbidity between symptoms of
attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant
disorder (ODD)

Harvey E et al., Early development of comorbidity between symptoms of
attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant
disorder (ODD). J Abnorm Psychol. 2016;125(2):154-167.

The pharmacological management of oppositional behaviour, conduct problems, and
aggression in children and adolescents with attention-deficit hyperactivity
disorder, oppositional defiant disorder, and conduct disorder: a systematic
review and meta-analysis. Part 1: psychostimulants, alpha-2 agonists, and
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Pringsheim, T., Hirsch, L., Gardner, D., & Gorman, D. A. (2015). The
pharmacological management of oppositional behaviour, conduct problems, and
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disorder, oppositional defiant disorder, and conduct disorder: a systematic
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   Dr. Sanil Rege is a Consultant Psychiatrist and founder of Psych Scene and
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