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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.

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