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Conditions That Complicate Management

Attention deficit/hyperactivity disorder is a specific developmental condition with a defined set of characteristics. Although a varied spectrum of severity exists, children with ADHD demonstrate a consistent and typical pattern of behavior and neurological function.

 
However, this “pure”@ picture is often complicated by the presence of other developmental or emotional dysfunctions. Several co-morbid conditions are described by professionals working with A DHD children.

 
Common Co-Morbid Conditions
Let’s look at some of the more common co-morbid conditions which may exist with ADHD:

 
Language-based learning disabilities. Central language processing disorders can mimic, and certainly complicate, the expression of attention disorders. For decades clinicians and educators have observed a significant overlap between children with ADHD and various language-based learning disabilities. As recently as two decades ago, professionals in the field tended to lump children with these related developmental disabilities together into the diagnostic category of minimal brain dysfunction. Attention, hyperactivity, and language-processing disorders were thought to be different ends of the continuum within this diagnosis. Recently the trend is to define the various diagnostic categories more precisely.

 
While many children with ADHD have no evidence of language-based learning disability, there are many children in which ADHD and a learning disability co-exist. I have seen children who have gone for years without treatment for their ADHD because all their academic problems were blamed on their language dysfunction. The attention problems and poor organization were thought to be secondary. On the other hand, I know of children who have not received serious evaluation of their reading and spelling under-achievement because their poor grades were blamed on their attention deficit disorder. When a child has been diagnosed with either ADHD or language processing dysfunction, the child should be carefully observe for evidence of the other condition.

 
Oppositional Defiant Disorder. While children with ADHD may disobey and at times seems to resist discipline, they are not typically defiant. Their lack of compliance is most likely due to impulsiveness and failure to think before they act. They also have difficulty associating their behaviors with consequences. But they want to please and tend to be unhappy with their failure to live up to expectations.

 
Oppositional defiant disorder (ODD) is characterized by a pattern of negative, hostile, and defiant behavior. Children with this disorder easily lose their temper, purposely annoy others, openly defy authority, refuse to comply with rules, and argue often. They may be resentful, angry, spiteful, and vindictive. ODD is defined by a pattern of such behavior over a long period which is not due to temporary stresses or provocations. Oppositional defiant disorder is more common in males. Over time ODD is likely to be associated with low self-esteem, low frustration tolerance, temper outbursts, poor peer relationships, and school underachievement.

 
Conduct Disorder. Children with conduct disorder exhibit a basic disregard for the rights of others and ignore age-appropriate norms of behavior. They may be cruel to other people and animals, fail to respect others rights (i.e., steal, misuse property), and ignore common rules of conduct. This pattern of behavior exists over a long period of time. It significantly disrupts the child’s relationships and adjustments to common life situations such as home and school.

 
Poor school performance, a greater frequency of school suspensions, and incidence of substance abuse are seen in children and adolescents with conduct disorders. These dysfunctional behaviors may begin in middle childhood but become more prominent in adolescence.

 
! Tourette’s Syndrome. Tourette’s syndrome (or Tourette’s disorder as it is sometimes called today) is characterized by the onset during childhood of multiple tics of various kinds (both motor tics and vocal tics) which may fluctuate in severity. The currently accepted essential diagnostic criteria include onset before the age of 21 years, multiple involuntary motor tics, one or more vocal tics, the waxing and waning of the tics, the gradual replacement of old tics with new ones, the absence of other medical explanations for the tics, and the presence of tics for more than one year.

 
Along with the tics, there may be obsessive compulsive tendencies, excessive anxiety, sleep disorders, learning difficulties, and impulsive behaviors. A variety of behavior/emotional problems have been identified in children with Tourette’s syndrome. Whether these behavioral problems are related to tic severity, a direct consequence of having a stigmatizing condition or an underlying part of the developmental condition is not clearly delineated.
ADHD has been reported to occur in 35% to 65% of children with Tourette’s syndrome. The treatment of children with attention deficit/hyperactivity disorder with co-morbid Tourette’s syndrome is controversial. The major confounding factor is that stimulant medications may provoke or intensify the tics. The stimulants do not cause the tics but if a child is predisposed to tics, the use of the stimulants may hasten the expression of tics, or aggravate them when they are present. While the stimulants may help the child with ADHD and Tourette’s, they should be used with caution.

 
If behavior and educational approaches are not successful for the child with Tourette’s and ADHD, then a trial with other types of medication should be considered.

 
Depression. It is well know that psychological depression is the most common emotional disorder affecting adults. The fact that depression is also very common in children and adolescents is less well known. Pre-teens and adolescents are particularly vulnerable to some degree of depression even under the best of circumstances. The child living with the stresses of ADHD are even more vulnerable. The frustration due to having to work harder to keep up academically, the constant negative feedback that is all too common and the difficulty getting along with peers sets the child up for depression. The usual low self-esteem experienced by many children with ADHD underlies their vulnerability.

 
Signs that suggest depression are a sudden drop in grades and performance in other activities such as sports or music. The depressed child or adolescent will tend to be moody and easily frustrated. They seem sad and have more trouble enjoying things they have enjoyed in the past. They often will withdraw and be less able to cope socially.

 
Depression in children and adolescents is likely to be a reaction to circumstances and come on over a short period of time. Chronic, long-term depression is less common.

 
This reactive depression is probably the most common co-morbid condition seen in children with ADHD. Fortunately, depression is also the most effectively treated of all the co-morbid conditions. Recognition, counseling, and sometimes short-term antidepressant medication will usually overcome the depression fairly quickly.

 
These are some of the more common co-morbid disorders. If is important to look for such conditions as a child is evaluated for ADHD. When they exist, success depends on managing the ADHD and co-morbid condition together.

ADHD Associated With Early Death

Individuals diagnosed with attention deficit disorder (ADHD) are at a higher risk of dying young, usually as the result of automobile crashes and other accidents. This is the conclusion from the largest study to date on the relationship of ADHD and mortality. This study, an analysis of nearly 2 million Danish medical records, The presence of related disorders such as drug abuse, or oppositional disorder the odds of early death. The study also noted that the risk of early death is even higher in those diagnosed after age 18.

 

While increased morbidity and mortality due to trauma has been known for many years, this new study gives a more precise picture of the risks due to its large size.

 
Most experts feel that this increase vulnerability is due to the impulsiveness and perceptual deficiencies along with general delayed maturity seen in individuals with ADHD

 
The findings of this study should not cause panic in parents and caretakers of children with ADHD, it does point out the importance of early diagnosis and effective treatment of children and teens with ADHD .

 
Other studies furnish evidence that treatment with behavioral intervention, academic support and medication has the highest rate of success. (Seem previous editions of this blog for management and treatment recommendations.)

When the ADHD Medication Does Not Seem To Be Working

Most children and adults with ADHD have a positive response with few side effects to stimulant medication. It is estimated that up to 85 to 90% of properly diagnosed children with ADHD experience significant improvement in most areas of function with the stimulants. But there are times when the physician or therapist will hear the complaint that the “Medicine is just not working!”

Dr. David Rettew, associate professor of psychiatry and pediatrics at University of Vermont, responds to this concern of medication failure in an article published in Pediatric News. In the article Dr Rettew reviews several reasons why medication may seem to be not working. Some potential causes are listed below in order of there frequency of occurrence:

1. The dose is too low. There is caution on the part of parents and clinicians when prescribing the stimulants. They wisely start off with a modest dose and push it up slowly or not at all. In fact the dose required for optimum effect varies from person to person. If the patient does not have side effects at the low dose, the dose can be increased gradually to the recommended range per weight. Many doctors and parents give up on a specific medicine before the appropriate dose is reached.

2. The medication is working but wears off early. Again, when the dose is too low, the meds might have an early beneficial effect but this positive response wears off by noon or early afternoon. This does not mean that the medicine is ineffective. It means that the doctor, parent, and patient need to modify the dose and method of taking it. First of all, it is important to make sure that the dose is at the optimal level. If the dose is adequate but the medicine effect still wears off early, it probably means that the patient metabolizes the medication more rapidly than the average person. One way of dealing with this is to have the patient take a small dose of short-acting meds after lunch.

3. Symptoms are caused by some condition other than ADHD. If the medicine is given at the proper dose with the proper timing and the patient still does not have improvement, it could mean that some other condition is causing the ADHD-like symptoms. Such conditions could be chronic sleep problems, anxiety, or other mental health disorder.

4. There is psychiatric co-morbidity. Conditions like anxiety disorder, oppositional disorder, or bipolar disorder can mimic ADHD or accompany ADHD. In this case, a thorough evaluation by a psychiatrist and/or psychologist is in order.

5. There is non-compliance. If the medicine is not working, it is important to consider that the patient is not taking the medicine as prescribed. This is often an issue with teens who are given the responsibility of taking their meds on their own without supervision.

6. There is substance abuse. If other psychoactive drugs are being abused by the patient, the benefit of the ADHD medication may be compromised.

7. The expectations of medication are too great. Some parents, even some therapists, expect the medication to be a miracle worker solving all the patient’s, and the family’s problems. While medication can at times be highly effect, it is never sufficient by itself. Issues like learning disability, anxiety, and low self-esteem will need ongoing attention to help the child reach his full potential. Although medication is helping a given patient, counseling for parents and the patient is highly recommended.

Successful medical treatment for ADHD requires openness and honesty and clear communication between parent, patient, and clinician in order to evaluate and deal with these complicating issues.

ADHD Can Persist Into Adulthood

Investigators in Rochester, Minnesota studied a large group of children born between 1976 and 1982. This group was followed from early childhood into adulthood (mean age 27 years at time of study). In this group, 232 subjects had been diagnosed with childhood ADHD. These 232 children were compared with 335 children without ADHD who served as controls. At the time of the study, the now adults were administered a variety of standardized neuro-psychiatric tests and interviews.

It was observed that ADHD persisted into adulthood in 29.3% of the individuals who had been diagnosed with childhood ADHD.

The participants who had childhood ADHD were more likely than controls (56% compared to 29%) to have one or more psychiatric disorders as adults. The most common co-morbid condition was alcohol dependence/abuse (26%). Additional diagnoses were other substance dependence/abuse conditions, anxiety disorders, mood disorders, and major depression. Those with ADHD persisting into adulthood were much more likely to have one or more psychiatric disorder (80% vs. 47%).

Several take home lesions from this study:

First of all, most children with ADHD will have resolution by adulthood.

However, ADHD does persist in a significant number of individuals (30%).

ADHD does leave significant emotional scars in a high percentage of individuals who were diagnosed with childhood ADHD. This points out the need for those diagnosed with ADHD to have ongoing mental health care into adulthood with special attention paid to potential psychiatric disorders.

Those adults with persistent ADHD (30% of those with childhood ADHD) will need to have ongoing ADHD treatment and monitoring as adults for other mental health needs.

ADHD and Handwriting

Even in this day of thumb-driven Twitter shorthand, handwriting continues to be a critical and needed skill. Legible, coherent handwriting is a signal measure of academic success and still plays an important role in formal and informal communication.

 

Educators and other professionals working with children with Attention Deficit Hyperactivity Disorder (ADHD) have observed that many of these children have significant problems with handwriting.

 

A recent study coming out of the Centers for Disease Control and Prevention (CDC) documents the relevance of these observations. This research, led by Slavica Katusic of the Mayo Clinic was published in Pediatrics (September, 2011). The study included 6,000 children—all those born in Rochester Minnesota between 1976 and 1982 and who was still living there after age 5.

 

Katusic and her co-workers evaluated school and medical records to see which children showed signs of ADHD, as well as how well they performed on writing, reading and general intelligence tests over their school career. A total of 379 children fit the criteria for ADHD. About 800 children scored poorly on tests of writing abilities, and most with writing problems had reading difficulties as well.

 

Writing problems were much more common in both boys and girls with ADHD, with close to two-thirds of boys with ADHD having problems with writing. That compared to one in six of their peers without ADHD. In girls, 57 percent with ADHD had a writing problem, compared to less than 10 percent without ADHD.

 

There are several reasons why children with ADHD may have problems in writing. Handwriting is a very complex task that involves cognitive activity and motor activity at the same time. A high level of mental coordination and sequencing is required—tasks that individuals with ADHD have difficulty with. Also, memory and planning problems may affect the writing process. The impairment in sustained attention experienced by children with ADHD causes them to loose track of what they are doing and they will tend to make careless errors and get confused about what is to come next in the phrase or sentence.t is my observation that when kids with ADHD are appropriately treated with medication, improvement in handwriting can be dramatic. In fact, improvement in handwriting can be one of the more objective, observable markers of effective treatment.

 

Kids who have problems with handwriting sufficient to interfere with their ability to express what they are learning can be allowed, even encouraged, to use other means of communicating what they are learning. For instance, a student may be allowed to give a report orally rather than in writing. Certainly in middle and high school the student can be encouraged to develop word processing skills and permitted to prepare homework and even classwork using the word processer. At the same time the student will need ongoing instruction and practice in handwriting. For some ADHD students, their handwriting will never be optimal but should be functional by high school.

At the same time, intentional instruction in handwriting skills is needed. The ADHD child may not develop perfect handwriting but writing skills can be enhanced with intervention. It is appropriate to help them be the best they an be in this area while compensating in other subjects. For instance their grade in science or math should not be knocked down due to messy or slow handwriting.

 

Long term observation does suggest that the writing problems do get a little better with increasing maturity. Individual education plans that address some of those related difficulties can help especially if they’re started early.

ADHD and Handwriting

Even in this day of thumb-driven Twitter shorthand, handwriting continues to be a critical skill. Legible, coherent handwriting is a signal measure of academic success. And it still plays an important role in formal and informal communication.

Educators and other professionals working with children with Attention Deficit Hyperactivity Disorder (ADHD) have observed that many of these children have significant problems with handwriting.

A recent study coming out of the Centers for Disease Control and Prevention (CDC) documents the relevance of these observations. This research, led by Slavica Katusic of the Mayo Clinic was published in Pediatrics (September, 2011).  The study included 6,000 children: all those born in Rochester Minnesota between 1976 and 1982 and who was still living there after age 5.

Katusic and her co-workers evaluated school and medical records to see which children showed signs of ADHD, as well as how well they performed on writing, reading and general intelligence tests over their school career. A total of 379 children fit the criteria for ADHD. About 800 children scored poorly on tests of writing abilities, and most with writing problems had reading difficulties as well.

Writing problems were much more common in both boys and girls with ADHD, with close to two-thirds of boys with ADHD having problems with writing. That compared to one in six of their peers without ADHD. In girls, 57 percent with ADHD had a writing problem, compared to less than 10 percent without ADHD.

There are several reasons why children with ADHD may have problems in writing. Writing is a very complex task that involves cognitive activity and motor activity at the same time. A high level of mental coordination and sequencing is required—tasks that individuals with ADHD have difficulty with. Also, memory and planning problems may affect the writing process. The impairment in sustained attention experienced by children with ADHD causes them to loose track of what they are doing and they will tend to make careless errors and get confused about what is to come next in the phrase or sentence.

Long term observation does suggest that the writing problems do get better with increasing maturity. Individual education plans that address some of those related difficulties can help especially if they’re started early.

It is my observation that when kids with ADHD are appropriately treated with medication, improvement in handwriting can be dramatic. In fact, improvement is often noted immediately

Non-Stimulant Medication Approved for Treatment of ADHD

The FDA has approved a new medication for the treatment of ADHD (Attention Deficit Hyperactivity Disorder). Kapvay is the first non-stimulant approved to treat ADHD in children and adolescents. It can be used either with or one of the traditional stimulant medications or can be used alone in the treatment of ADHD.

Clonidine extended-release tablets (Kapvay) acts on the brain in a different way, and acts in a different part of the brain, than the stimulants. Taken twice a day, Clonidine, in these early studies, improved core ADHD symptoms. In clinical trials, the most common adverse effects were sleepiness and sedation.

We will need more experience with this medication in order to know its long term usefulness. Clonidine in its original form has been around for years. It is used primarily in adults as a treatment for high blood pressure. This older form has been used off label by some psychiatrists to treat oppositional behavior and certain types of sleep problems in children with ADHD.

Most likely, the primarily use of Kapvay will be as an adjunct medication used along with stimulants when the involved child has more impulsive behavior and or/has sleep problems. Those of us treating children with ADHD are pleased to have an additional option available in the management of children with various forms of ADHD.

ADHD and Reading Disability

It is well-known that boys and girls with ADHD (Attention Deficit Hyperactivity Disorder) often underachieve in school. While the symptoms of short attention span and impulsiveness, and disorganization will affect academic performance, it has also been suspected that there is an increase incidence of true learning disability, especially in the area of reading, in children with ADHD. Now a study reported in the October issue of Pediatrics provides evidence that ADHD and reading disability often do exist together.

In this report from the Mayo Clinic, the medical and school histories of over 5000 boys and girls were evaluated. Three hundred and seventy-nine of these children fulfilled the criteria for ADHD. Compared to boys and girls without ADHD, those with ADHD were significantly more likely to be male. The incidence of reading disability was twice as high in children with ADHD as in those without ADHD symptoms. Girls with ADHD were more likely than boys with ADHD to have reading problems.

This large study confirms that there is an increased risk of reading problems in children with ADHD. In light of this, the study authors point out the importance of evaluating children with ADHD for reading disability and providing remedial help to those who need it.

In the ADHD Strategies for Success Book, we point out that the Number 3 step in effective management is Educational Intervention. We state, “Most children with attention deficits will usually have specific educational needs—needs which will require varying levels of evaluation and individualized instruction and/or classroom modification.

While many children with ADHD have no evidence of language-based learning disability, there are many in which ADHD and a learning disability co-exist. I have seen children who have gone for years without treatment for their ADHD because all their academic problems were blamed on their language dysfunction. The attention problems and poor organization were thought to be secondary. On the other hand, I know of children who have not received serious evaluation of their reading and spelling under-achievement because their poor grades were blamed on their attention deficit disorder.  When a child has been diagnosed with either ADHD or language processing dysfunction, the child should be carefully observe for evidence of the other condition.