Clinician’s Guide to ADHD Comorbidities in Children and Adolescents (eBook)

Dr. Joseph Sadek is an Associate Professor of Psychiatry at Dalhousie University and the Atlantic Canada Director for Canadian ADHD Resource alliance (CADDRA). He completed his psychiatry residency training at Dalhousie University and his psychopharmacology training at Harvard University. In addition to his medical degree, Dr. Sadek also holds a pharmacy degree (BSc Pharm) and an MBA from St. Mary's University in Halifax. Dr. Sadek is the head of the Neurosciences professional competency unit at Dalhousie University and the chair of the suicide task force for the Capital health District Authority and the IWK hospital. He started the first public adult ADHD clinic in Nova Scotia and is the Clinical and academic leader of the Mayflower Unit at The Nova Scotia Hospital. He is heavily involved in both the undergraduate and postgraduate teaching and has several peer reviewed articles. Dr. Sadek was a member of the CDHA research ethics board from 2002 to 2010, Dalhousie University Senate and he is currently the chair of the investigation committee for the Capital District health Authority. Dr. Sadek received 2 quality awards in 2012.

Foreword 6
Contents 8
About the Author and Reviewers 15
Introduction 18
1: ADHD and Epilepsy 19
1.1 Objectives 19
1.2 The Case 19
1.2.1 Emerson English 20
1.2.2 Questions 21
References 24
2: ADHD and Borderline Personality Disorder (BPD) in Adolescence 26
2.1 Objectives 26
2.2 The Case 26
2.3 Barbara B 27
2.3.1 History of Present Illness and Review of Systems 27
2.3.1.1 Collateral History 28
2.3.2 Summary of the Findings and Management of This Patient 29
2.4 Literature Review Questions 29
2.4.1 Discuss the Challenges Around the Diagnosis of Borderline Personality Disorder (BPD) in Adolescents? 29
2.4.2 Discuss the Epidemiology and Comorbidity of ADHD and Borderline Personality Disorder (BPD)? 30
2.4.3 List Some of the Different Hypothesis That Are Proposed to Account for the Comorbidity Between ADHD and BPD? 31
2.4.4 What Are the Diagnostic Symptoms Criteria of Borderline Personality Disorder? 31
2.4.5 What Are Some of the Warning Signs That May Point to Presence of BPD in Adolescence? 32
2.4.6 Describe Some of the Key Similarities and Differences Between Borderline Personality Disorder and ADHD? 32
2.4.7 What Are the Management Difficulties in Patients with Comorbid ADHD and BPD That Are Related to BPD? 32
2.4.8 Why Is It Important to Recognize a Comorbid Personality Disorder in Patients with ADHD? 33
2.4.9 What Are the Potential Advantages of a Dimensional Model over a Categorical Model in Diagnosing BPD? 33
2.4.10 What Are Some of the Helpful Tips for Managing Borderline Patients in Primary Care Setting? 33
2.4.11 What Are the Key Clinical Treatment Recommendations in Patients with BPD and ADHD? 34
2.4.12 Give Examples of Psychotherapeutic Approaches for Patients with BPD? 34
2.4.13 Is There Any Evidence for Mindfulness Based Interventions in ADHD and BPD? 35
2.4.14 What Is the General Approach to Pharmacotherapy for BPD? 35
2.4.15 What Are the Literature Recommendations for Pharmacological Therapy for Patients with ADHD and BPD? 36
References 36
3: ADHD and Anxiety 39
3.1 Objectives 39
3.2 The Case 39
3.2.1 Amanda Austin 39
3.2.2 History of Present Illness 39
3.2.2.1 Medical History 40
3.2.2.2 Family History 40
3.2.2.3 Personal and Developmental History 40
3.2.2.4 Case Outcome 41
3.3 Literature Review Questions on ADHD and Anxiety 41
3.3.1 Describe the Prevalence Rates and Epidemiological Data of ADHD and Anxiety? 41
3.3.2 What Are the Overlapping and Differentiating Symptoms Between ADHD and Anxiety? 41
3.3.3 Describe Some of the Difficulties in Conducting Meta-Analysis on the Effect of Stimulant Medications on Comorbid Anxiety in ADHD Patients in the Current Literature? 42
3.3.4 List Some of the Instruments That Would Assist Clinicians in Identifying Different Anxiety Disorders? 42
3.3.5 What Is the Role of Parental Anxiety in Patients with ADHD and Anxiety? 43
3.3.6 Describe Some of the Literature Findings on the Relationship Between Trauma and ADHD? 43
3.3.7 What Are the Treatment Considerations in Comorbid ADHD and Anxiety Disorders? 44
3.3.8 What Are the Dosing Recommendations for Atomexetine (ATX) in Children and Adolescents? 45
3.3.9 What Are the Specific Tapering Recommendations to Stop Atomoxetine and What Are the Withdrawal Symptoms? 45
3.3.10 What Are the Dosing Reduction Requirements in Adolescents with Hepatic Impairment When Prescribing Atomoxetine? 45
3.3.11 Does the Literature Recommends Fast Dose Titration or Slow Dose Titration When Starting Atomoxetine? 45
References 46
4: ADHD and Obesity 48
4.1 Objectives 48
4.2 ADHD and Obesity Literature Review Questions 48
4.2.1 Describe the Possible Relationship Between ADHD and Obesity? 48
4.2.2 What Are Some of the Different Hypothesis That May Explain the Association Between ADHD and Obesity? 49
4.2.3 What Is the Impact of ADHD on Weight Loss Effort? 49
4.2.4 What Are the Principals of Management of Adolescent Patients with ADHD and Obesity? 49
4.2.5 Describe Some of the Research Findings of the Mental Health Related Problems Associated with Obesity in Children and Adolescents? 50
References 50
5: ADHD and Oppositional Defiant Disorder (ODD) 52
5.1 Objectives 52
5.2 The Case 52
5.2.1 Owen Oland 53
5.2.2 History of Present Illness 53
5.2.2.1 Medical History 53
5.2.2.2 Family History 54
5.2.2.3 Personal and Developmental History 54
5.2.2.4 Behavior in the Office 54
5.2.2.5 Case Outcome 54
5.3 Literature Review Questions 54
5.3.1 How Was the Diagnosis of ODD Made in This Case? 54
5.3.2 Comment on the Epidemiology of ODD and the Comorbidity with ADHD? 55
5.3.3 What Is the Natural Course of ODD? 55
5.3.4 Give Examples of Tools That Can be Used to Identify ADHD, Oppositional Defiant Disorder, and Other Behavioral Disorders? 55
5.3.5 Mention Some of the Risk Factors Associated with ODD and ADHD? 56
5.3.6 What Are the General Treatment Recommendations for ODD? 57
5.3.7 What Are the Psychosocial Management Recommendations for ODD? 57
5.3.8 What Are the Treatment Considerations in Comorbid ADHD and ODD? 58
5.3.8.1 For ADHD with Behavioural Problems 58
5.3.8.2 For Treatment of Aggression 58
5.3.9 List Some of the Parent Training Programs That Are Supported by Randomized Controlled Trials? 58
References 59
6: ADHD and Conduct Disorder (CD) 61
6.1 Objectives 61
6.2 The Case 61
6.3 Alex Alexander 62
6.3.1 Identifying Information 62
6.3.2 Charges Related to the Incident 62
6.3.3 History of Present Illness 62
6.3.3.1 Substance Use 63
6.3.3.2 Mood Symptoms 63
6.3.3.3 Anxiety Symptoms 63
6.3.4 Medical History 64
6.3.4.1 Past Psychiatric History 64
6.3.4.2 Family History 64
6.3.5 Personal and Developmental History 65
6.3.5.1 Interpersonal Relationships 65
6.3.5.2 School Information 65
6.3.5.3 Mental Status Examination 66
6.3.5.4 Impression 66
6.4 Literature Review Questions 66
6.4.1 How Was the Diagnosis of Conduct Disorder Made in This Case? 66
6.4.2 Describe Some of the Findings of Epidemiological Studies of Conduct Disorder? 67
6.4.3 What Are Some of the Risk Factors for Developing Conduct Disorder? 67
6.4.4 List Some of the Instruments Measuring Externalizing Mental Health Problems in Young People? 67
6.4.5 What Are the Associated Features of Early Versus Late Onset Conduct Disorder? 69
6.4.6 List Some Psychiatric Disorders That Can Be Included in the Differential Diagnosis of Conduct Disorder? 70
6.4.7 What Are Some of the Factors Predicting Poor Outcome in Conduct Disorder? 70
6.4.8 What Are the Comorbidity Rates of ADHD and Conduct Disorder (CD)? 70
6.4.9 What Are Some of the Research Findings on Long-Term Outcomes of ADHD and Conduct Disorder? 70
6.4.10 What Are the Selective Prevention Interventions for at Risk Children and Adolescents That May Reduce the Likelihood of Developing a Conduct Disorder? 71
6.4.11 What Are the Psychosocial and Pharmacological Treatment Recommendations for Conduct Disorder and ADHD? 71
6.4.11.1 Psychosocial Interventions 71
6.4.11.2 Pharmacological Treatment 72
References 72
7: ADHD and Substance Abuse in Children and Adolescents 74
7.1 Objectives 74
7.2 The Case 74
7.3 Substance Use Literature Review Questions 76
7.3.1 Describe the Prevalence and Epidemiology of ADHD and Substance/Alcohol Use Disorder? 76
7.3.2 Explain the Possible Link Between ADHD and SUD? 77
7.3.3 Describe Some of the Challenges in the Diagnostic Assessment of ADHD and SUD? 77
7.3.4 What Psychiatric Disorders Should Be Considered and Included in the Differential Diagnosis When Assessing Individuals with Substance Use Disorders? 78
7.3.5 What Are Some of the Barriers to Seeking Addiction Treatment? 78
7.3.6 What Models of Care Are Used to Treat Concurrent Disorders in Patients with Substance Abuse? What Are the Strengths and Weaknesses of These Models? 79
7.3.7 Suggest a Screening Tool for Adolescent Substance/Alcohol Use Disorder? 80
7.3.8 What Are the National Institute of Drug Abuse Principals of Treatment of Substance Use Disorders in Adolescents? 80
7.3.9 Describe Some on the Controversial Management Considerations That Clinicians Face When Using ADHD Medications in Individuals with ADHD and Addictions? 81
7.3.10 Describe Some of the Factors That Help Make the Decision of How Long to Wait for SUD to Be Under Control Before Initiating Pharmacological Treatment of ADHD 82
7.3.11 Is There an Association Between Stimulant Medication and Substance Use Disorder? 82
7.3.12 What Are the Unique Needs of Adolescents with Substance Use Disorders? 83
7.3.13 What Are the Treatment Recommendations for Substance Abusing Patients with ADHD? 83
7.3.14 Suggest Some Web Resources for Adolescents with Substance Use Disorder? 84
7.3.15 Describe Some of the Concepts Related to Stimulant Medications Abuse and Misuse? 84
7.3.16 What Is the Rate of Stimulants Misuse or Abuse in Young People? 85
7.3.17 What Are the Correlates of Diversion and Misuse? 85
7.3.18 Describe Some of the Research Findings on Stimulant Medications Diversion? 85
7.3.19 What Are the Reasons of Abuse or Misuse of Stimulant Medications? 86
7.3.20 What Are the Clinical Implications of Stimulants Abuse or Diversion? 86
References 86
8: ADHD and Specific Learning Disorders 89
8.1 Objectives 89
8.2 Case Vignette 89
8.3 Review Questions 90
8.3.1 What Are the Rates of Comorbidities Between ADHD and Specific Learning Disorders? 90
8.3.2 Discuss the Possible Risk Factors of ADHD and Specific Learning Disorders? 90
8.3.3 Discuss the Complexity in the Assessment and Diagnosis of SLD? 91
8.3.4 What Are the Management Approaches of ADHD and SLD? 93
8.3.5 Example of Worksheets That Are Used in Schools to Check and Document That Appropriate Instruction in Reading Are Provided 94
8.3.5.1 Reading Worksheet 94
8.3.6 Example of Worksheets That Are Used in Schools to Check and Document That Appropriate Instruction in Mathematics Are Provided 95
8.3.6.1 Mathematics Worksheet 95
8.3.7 Example of Worksheets That Are Used in Schools to Check and Document That Appropriate Instruction in Written Expression Are Provided 96
8.3.7.1 Written Expression Worksheet 96
8.3.8 List Some Helpful Websites That Could Be Used to Educate Parents on Specific Learning Disorders? 98
References 98
9: ADHD and Depression 100
9.1 Objectives 100
9.2 What Are the Prevalence and Morbidity of ADHD and Depression? 100
9.3 What Are Some of the Findings of the Epidemiological Data on ADHD and Suicide? 101
9.4 What Is the Relationship Between ADHD and Suicide? 101
9.5 What Are the Possible Explanations of the Increased Suicide Risk in Patients with ADHD? 101
9.5.1 Comorbid Disorders 101
9.5.2 Cognitive Impairment and Personality Traits 102
9.5.3 Neurobiology 102
9.6 What Are Some of the Challenges in Diagnosis of ADHD in Presence of Depression or Vice Versa? 103
9.7 What Are the Management Approaches of ADHD and Depression? 103
9.8 What Is the Relationship Between ADHD Medication and Suicide? 104
9.8.1 Atomoxetine 104
9.8.2 Stimulant Medications 104
9.9 What Do I Tell Patients and Families When Asked About Suicide and ADHD Medication? 104
9.10 Give Examples of Questions That Can Be Asked to Screen for Suicide? 105
9.11 How Should I Manage Suicidal Thoughts/Behaviour During Treatment with ADHD Medications? 105
References on Depression and Suicide 106
10: ADHD and Bipolar Disorder 109
10.1 Objectives 109
10.2 Questions 109
10.2.1 What Is the Prevalence Rate of ADHD Versus Bipolar Disorder in Late Adolescence? 109
10.2.2 What Are Some of the Challenges in Differentiating Bipolar Disorder from ADHD? 110
10.2.3 List Some of the Medical Conditions That Imitate Bipolar Disorder? 110
10.2.4 What Are the Clinical Features That May Help in Clarifying the Diagnosis of ADHD and Bipolar Disorder? 110
10.2.5 What Are the Management Approaches to Comorbid Bipolar Disorder and ADHD in Late Adolescence? 112
10.2.5.1 Pharmacological Treatment 112
10.2.5.2 Psychosocial Treatment 113
References 113
Bipolar Disorders 113
Bibliography 114
Other Suggested Readings 115
11: ADHD and Tic Disorders 118
11.1 Objectives 118
11.2 Describe the Prevalence and Morbidity of TS and ADHD? 118
11.3 Give Examples of Simple and Complex Tics? 119
11.4 Give Example of Rating Scales Used in Diagnosis or Follow Up in Patients with Tics or TS? 119
11.5 What Disorders Would You Include in the Differential Diagnosis of Motor and Vocal Tics? 120
11.6 What Are the Considerations That Are Taken into Account When Clinicians Decide to Treat Tics? 120
11.7 What Are the Principals of Management of TS, Tics and When Comorbid with ADHD? 120
11.8 Describe Some of the Nonpharmacological Treatment for Tics? 121
11.8.1 Habit-Reversal Therapy (HRT) 121
11.8.2 Comprehensive Behavioural Intervention for Tics (CBIT) 122
11.8.3 Exposure and Response Prevention (ERP) 122
11.9 Describe Some of the Pharmacological Treatments for Tics? 122
11.9.1 Alpha-Adrenergic Agonists 122
11.9.2 Neuroleptics 122
11.9.3 Other Pharmacological Treatments 123
References 123
Bibliography 124
Appendices 125
Appendix A: How to Diagnose ADHD in Children and Adolescents 125
Appendix B: List of Scales: Children 127
Other Tests 128
Appendix C: Sadek ADHD Checklist (SAC) © 130
Appendix D: Key Diagnostic Symptoms of ADHD 132
Inattentive Symptoms 132
Hyperactivity or Impulsivity Symptoms 132
Appendix E: ADHD Differential Diagnosis 133
Appendix F: Monitoring of Children and Adolescents with ADHD 135
Appendix G: ADHD Medications 136
Appendix H: Management of Adverse Events of ADHD Medications 138
Management of Side Effects 138
Common Side Effects and Contraindications: Atomoxetine 142
Appendix I: ADHD Medication Contraindications and Drug Interactions 142
Contraindications to Stimulants 142
Contraindications to Atomoxetine (Strattera) 143
Contraindications to Guanfacine XR (Intuniv XR) 143
Main Potential Drug Interactions for Psychostimulants 143
Main Potential Drug Interactions for Atomoxetine (Strattera) 143
Main Potential Drug Interactions for Guanfacine XR (Intuniv XR) 143
Appendix J: Selective Serotonin Reuptake Inhibitors (SSRIs) Dosing for Children and Adolescents 145
Appendix K: Assessment Measures Available in Public Domain Free of Charge 146
Depression and Bipolar Disorders 146
Center for Epidemiological Studies Depression Scale for Children (CES-DC) 146
Depression Self-Rating Scale for Children (DSRS) 146
Patient Health Questionnaire-9 (PHQ-9) 146
Child Mania Rating Scale-Parent Version (CMRS-P) New! 146
Anxiety 146
Self-Report for Childhood Anxiety Related Disorders (SCARED) 146
Revised Children’s Anxiety and Depression Scale (RCADS) 147
Spence Children’s Anxiety Scale (SCAS) 147
Penn State Worry Questionnaire for Children (PSWQ-C) New! 147
Generalized Anxiety Disorder-7 (GAD-7) 147
Appendix L: Helpful Websites 148