That s Interesting Doc but my. ADHD and its Comorbidities. Jonathan E. Romain, Ph.D., ABPP-CN

Transcription

1 That s Interesting Doc but my Kid ADHD and its Comorbidities Jonathan E. Romain, Ph.D., ABPP-CN

2 Rationale Children with one diagnosis are more likely to have additional challenges (comorbidities) Children with more than one diagnosis (comorbidity) are at greater risk for struggles Support communication and collaboration among families Decrease stigma In Neuropsychology, we see it all

3 Overview Who are you and what are you doing here? Brief refresher on ADHD ADHD and its Comorbidities ADHD and Tourette Syndrome ADHD and Epilepsy ADHD and High Functioning Autism (Asperger s) Seeking additional assessment References and Discussion

4 Neuropsychology Doctorate in Clinical Psychology Residency and Fellowship Trained in Neuropsychology Medical setting Mental health expertise Knowledge of Special Education Board Certification To protect the public by examining and certifying psychologists who demonstrate competence in approved specialty areas.

5 Neuropsychology Whole Picture and Case Managers Referrals Include: Difficulty in learning Attention Behavior Socialization Neurological Disorders Expertise in Brain and Behavior Relationships

6 Neuropsychology Thorough history Carefully chosen test battery Attention Language Memory Executive functions Planning, problems solving, flexibility, Inhibition, working memory Motor skills Academics Detailed feedback Useful report written for parents, teachers, and pediatricians

7 What is ADHD? my child doesn t listen. my child can t finish assigned tasks. my son can t get the work done on his own. he goes from one thing to another. she can t follow any lengthy commands. she just doesn t learn from her mistakes. 7

8 Inattention Inability to sustain attention and follow through on rules and instructions Disorganized, distracted, and forgetful Off task - poor concentration, easily distracted, failure to finish assignments Poor listening skills Less likely to return to an activity once interrupted A problem with the deferred gratification? 8

9 Impulse Control Deficits Behavioral dysregulation Risk taking Impulsive thinking Sometimes hyperactivity but not the defining feature 9

10 ADHD is a developmental disorder of self-control. Russell Barkley, Ph.D. (1997) Impacts attention span, impulse control, and activity level Impacts the capacity to control behavior relative to the passage of time The inability to keep future goals and consequences in mind It is a disorder of self-control 10

11 What is ADHD Not? It is not a normal phase of childhood It is not caused by parental failure to discipline or failure to control the child It is not an abnormality or defect in the badness gene 11

12 Consensus Definition A developmental disorder of: inattention and/or hyperactivity-impulsivity Developmentally inappropriate levels of symptoms Childhood onset (symptoms-impairment) Cross-setting occurrence of symptoms Significant impact in major life activities Exclusion of other developmental disorders (ID, ASD, Neurologic, Psychiatric) 12

13 Comorbidities Symptoms of ADHD overlap with other disorders ODD (35-65%) Conduct D/O (20-56% children, 44-50% adolescents) LD (~8-39%) Communicative disorders (10-54%) MDD (25%) Bipolar D/O (6%) Anxiety (25%) Tourette Syndrome (54%) Epilepsy (25-50%) High Functioning Autism (20%) 13

14 Isn t one Diagnosis Enough? Identifying a second diagnosis (if one exists) can lead to better, more effective treatment There are medications and therapies proven to work for multiple diagnoses A clear second diagnosis can help teachers manage complex behaviors and develop more appropriate school supports. For some parents, the pursuit of another diagnosis can lead to new insights into their child's challenges.

15 Three Common Co-Occurring Syndromes Tourette Epilepsy Autism (ASD)

16 Tourette Syndrome Two or more motor tics (for example, blinking or shrugging the shoulders) and at least one vocal tic (for example, humming, clearing the throat, or yelling out a word or phrase). Tics for at least a year. The tics can occur many times a day (usually in bouts) nearly every day, or off and on. Onset before age 18. Symptoms not due to medications or another medical condition. Coprolalia is not common or necessary for Dx. Diagnosis is made by history and observation.

17 Tourette Syndrome 19% of children in regular education classes have tics. 23% of children in special education classes have tics. 4% of children in regular education meet diagnostic criteria for Tourette s. 7% of children in special education have Tourette s.

18 Tourette Syndrome Comorbidities Any psychiatric comorbidity among individuals with TS was 85.7% 57.7% of individuals with TS had 2 or more psychiatric disorders. 72.1% of individuals with TS met DSM-IV-TR diagnostic criteria for OCD or ADHD. Other disorders, including mood, anxiety, and disruptive behavior, each occurred in approximately 30% of the participants. Parental history of ADHD was associated with a higher burden of non-ocd, non-adhd comorbid psychiatric disorders. Genetic correlations between TS and mood, anxiety, and disruptive behavior disorders may be accounted for by ADHD and, for mood disorders, by OCD. Hirschtritt, M.E., et al. (2015)

19 Tourette Syndrome and ADHD Symptoms of ADHD often predate tics. More often problems with impulse control. Distraction by the tics themselves as well as by internal distractions.

20 Tourette Syndrome and ADHD Greater functional and quality-of-life impairment than do those solely with tic disorders or ADHD. Dual-affected children are more prone to have anxiety and depression and to display greater maladaptive behaviors. Greater risk for obsessive-compulsive disorder (OCD) and related anxiety disorders and depression. Greater risk of social problems and bullying.

21 Tourette Syndrome and ADHD Behavioral Management Treatment needs to be multi-factorial. Treating tics can improve ADHD symptoms. Treating anxiety can improve tics and ADHD symptoms. Period screening for the development of additional syndromes. Increased emphasis on strategies for emotional outbursts.

22 Tourette Syndrome ADHD Rx Management Psychostimulants are equally effective in improving ADHD symptoms whether the disorder is associated with tics or not. Group data suggests no significant increase in tics when psychostimulants are used in patients with tics. Individual patients, however, may experience an increase in tics. Level A evidence support for the use of noradrenergic agents. Rizzo, R. (2013) Erenberg, G. (2005)

23 Epilepsy Seizure - A solitary event that occurs when an excessive, uncontrolled, synchronous discharge of cortical neurons results in a clinical expression and is accompanied by electrographic (EEG) changes. Epilepsy - Recurrent seizures.

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25 Epilepsy Risk with Special Populations 25.8% of children with Intellectual Disabilities 13% of children with cerebral palsy 8.7% of children of mothers with epilepsy 2.4% of children of fathers with epilepsy 20-25% of children with epilepsy also have ADHD 3% of children with ADHD have epilepsy 33% of people who have had a single, unprovoked seizure 25

26 Epilepsy and ADHD Common genetic propensity. Common neurological pathways (e.g., frontal lobe, striatal pathway). Cognitive changes and uncontrolled seizures. Subclinical epileptiform discharges. Clinical seizures (Absence, BECTS, and Simple Partial). Antiepileptic drug effects.

27 Epilepsy and ADHD Treatment Find a professional who knows both! Comprehensive neuropsychological evaluation especially for epilepsy Treat the seizures Consider the cause of the ADHD.

28 Epilepsy and ADHD Treatment Primarily Inattentive type of ADHD is most common. Place greater emphasis on working with/around potential cognitive deficits. Be mindful of memory and executive dysfunction.

29 Epilepsy and ADHD Rx Management Talk with treating neurologist about concerns as alterations in AED s may be possible. Stimulant medications are not explicitly contraindicated in epilepsy. It s complicated

30 Autistic Spectrum Disorder (ASD) Criterion A: Persistent deficits in social communication and interaction Can include social-emotional reciprocity, nonverbal communicative behaviors, developing/maintaining relationships Criterion B: Restricted, repetitive patterns of behavior Repetitive motor movements (rocking), ecolalia, insistence on sameness and a routine, highly restricted, fixated interests, unusual interest in sensory aspects of the environment Symptoms must be present in early developmental period and cannot be better explained by intellectual disability or global developmental disability 3 levels of severity Viewed as a dimensional disorder

31 Social Problems Most universal, specific characteristic of ASD Consistent and replicated across studies Lack joint attention, theory of mind Cannot correctly assign motives, understand someone s goals, difficulty participating in spontaneous symbolic play Other groups show problems with theory of mind but may not show same deficits in joint attention Down Syndrome, severe hearing impairment Pay proportionately less attention to people than objects Spend less time than NT kids doing something that shows intent Children are attached to mothers as much as age- and IQ-matched NT kids (Rogers et al., 1991) Tend not to point, show objects attention-sharing behaviors (Sigman et al., 1986) Do not seem to recognize emotions (facial expression, gesture, nonverbal vocalizations of emotion)

32 Restricted Repetitive Behaviors Verbal and nonverbal repetitive, stereotyped behaviors More heterogeneous and context-dependent than social deficits Including them on diagnostic instruments increases specificity with little change in sensitivity One study showed only 9 of 2700 children with ASD diagnosis did not show any RRB s (Lord et al., 2012)

33 Restricted Repetitive Behaviors Four subdomains: Motor stereotypies lining things up, flipping things, step counting, unusual responses to sensory input, rocking Some of these may be common in young children clinicians must look at the number and intensity of behaviors to discriminate TD from ASD Tend to emerge early in life but are somewhat malleable Most common subdomain Rituals and sameness Prevalent in about 25% of ASD population Develop later than motor type, stable throughout life Circumscribed interests highly fixated or unusual interests A particular movie, cartoon character, topic, the phone book, shoe size Self-injurious behavior hand flapping, hitting Present in other disorders More common in ASD than general population Subdomains show different trajectories

34 Prevalence In 1990 s ASD was 1 per 2,000; including Asperger s Syndrome 1 per 1,000 Prevalence rates in 2000 were 1/166 and in 2008 were 1/88 for ASDs Increases in milder cases Increases of all case types More awareness Problems with diagnostic instruments Incorrect diagnoses Studies differ in screening methods, diagnostic instruments, diagnostic criteria Diagnosed 4x as often in males than females

35 CDC Prevalence Statistics for ASD

36 Typical Behavior Characteristics of High- Functioning Individuals with Autism Adapted from C. Bees (1998). The GOLD Program: a program for gifted learning disabled adolescents. Roeper Review, 21, p. 160.

37 Myths about ASD Caused by cold refrigerator mothers Children with eye contact do not have Autism Children who are social do not have Autism All people with Autism have extraordinary skills

38 Myths about ASD (con.) People with Autism just need love to get better People with Autism just need more discipline to get better Autism can be outgrown There is a cure for Autism

39 Common Comorbidities 70% of ASD individuals have one comorbid disorder, up to 40% may have 2 or more (DSM-V) Medical conditions such as epilepsy and sleep problems somewhat common Comorbid diagnoses of ADHD, anxiety and depressive disorders, and developmental coordination disorder seen First degree relatives have higher incidence of major depression and social phobia than the rest of the population (Bolton et al., 1998) Relatives have 20% frequency of social phobia (Smalley et al., 1995) 10 times higher than controls Over half (64%) had first episode before the birth of autistic child

40 Common Comorbidities Behavioral disorders (44%) Anxiety (42%) Tic Disorder (26%) ADHD (30%)

41 ASD and ADHD 20% of Children with ADHD have Autism Traits 30% of Children with Autism also have ADHD Traits The Combination of Autism and ADHD in boys is higher than in girls

42 ASD and ADHD Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the APA states that the two conditions can cooccur. Autistic symptoms are not common in ADHD. Because of the high frequency of ADHD symptoms in autism, children with autism may initially be misdiagnosed with ADHD.

43 ADHD ASD Easily distracted Switching attention from one thing to another Difficulty focusing Difficulty concentrating on one task Easily bored Talking nonstop Trouble sitting still Blurting out Interrupting Not showing concern for other people s emotions or feelings Unresponsive to common stimuli Impaired social interaction Intense focus on a one item withdrawn behaviors avoiding eye contact an inability to react to others emotions or feelings repetitive movement, such as rocking or twisting delayed developmental benchmarks

44 Treatment Strategies for ADHD and ASD Behavioral is first line but medication may help to get to this point Medication may be an adjunct to improve receptivity to behavioral strategies Medication may improve aggression and acting out It is important that psychopharmacological treatment of ADHD symptoms in individuals with autism is carefully considered, and that these individuals are not treated identically to those with ADHD only.

45 Treatment Strategies for ADHD and ASD Anxiety reduction and regulation strategies (e.g., How s your engine running?) are particularly helpful Social skills support should be a high priority Modeling Pro-social Behavior Prepare in advance for difficult situations Be mindful of situations that may increase ASD symptoms Choose your battles

46 Why make a Comorbid Diagnosis? Making a correct co-occurring diagnosis is invaluable in guiding treatment Similarly, ruling out a co-occurring diagnosis can be equally valuable Kids are moving targets and diagnosis may be an ongoing process for complex children Work with professionals familiar with: Medical Neurodevelopmental Psychiatric disorders

47 Potential Struggles on the Road to Correct Diagnosis Clinicians that don t take enough time. Clinicians that diagnose symptoms, not the underlying problem. Reflexively blame school and social struggles on ADHD. Reflexively not considering ADHD when grades are good. Failure to understand that children are always developing Working with a clinician who has a narrow focus Working with a clinician, who by degree wouldn t be expected to have expertise in the area of interest. Wasting resources (time and money) on alternative avenues that are not supported by research. Sticking with a doctor you don t like.

48 Signs you are on the right Path A comprehensive evaluation (Tests alone are not enough) Thorough history More than observation of child Aimed to define the child's strengths and weaknesses Various measures to assess for attention, executive functions, social and communication, anxiety/depression, and a host of other symptoms. As a general rule, clinicians affiliated with Academic Medical Centers have experience with collaboration A diagnosis or explanation that rings true to you as a parent

49 References Gerald Erenberg, The Relationship Between Tourette Syndrome, Attention Deficit Hyperactivity Disorder, and Stimulant Medication: A Critical Review, Seminars in Pediatric Neurology, Volume 12, Issue 4, December 2005, Pages Tourette Syndrome and comorbid ADHD: current pharmacological treatment options. Rizzo R 1, Gulisano M, Calì PV, Curatolo P.

50 References for Parents (Tourette)

51 References for Parents (epilepsy)

52 References for Parents (ASD)

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54 Questions? Comments?