BHIPP Bulletin

Volume 8, Issue 4

October 2022

This month's BHIPP Bulletin is a contribution from

Rick Ostrander, EdD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine,

Founder of Pediatric Medical Psychology Program at Johns Hopkins Children's Center and BHIPP Consultant.

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common psychiatric disorders displayed during the childhood and adolescent years. A diagnosis of ADHD is often a life changing event in a child’s life. It is often diagnosed in early childhood and is associated with a wide range of negative outcomes.  Luckily, there are several effective treatments for the core ADHD symptoms of inattention, hyperactivity, and impulsivity. Various types of medications, most prominently stimulants, often achieve a dramatic improvement in the symptoms of ADHD. On their own, stimulants are often sufficient to treat the manifest symptoms of ADHD without the need of additional treatments. However, behavioral modification can also achieve improvement in these symptoms; in some cases, the combination of behavioral and pharmacological treatment achieves better results than either alone. 

However, some children with ADHD experience other psychiatric and neurodevelopmental disorders. For example, it is not uncommon for children with ADHD to experience problems in learning, deep sadness, extreme anxiety, and oppositional or other conduct problems. In some cases, these other disorders may be misdiagnosed as ADHD; however, most children with ADHD experience additional problems that affect their learning, emotional, and behavioral functioning. 

ADHD was once considered a standalone disorder. However, people with ADHD typically exhibit one or more additional conditions. The co-occurrence of two or more disorders is typically referred to as a comorbidity. There have been several studies that have illustrated the extent of comorbid conditions associated with children and adolescents diagnosed with ADHD. Initially the studies focused on clinically referred youth; therefore, the relatively high levels of cooccurring conditions were attributed to the referral bias associated with clinical settings. While clinical complexity could be expected in young people seen in clinical settings, several studies have illustrated that high levels of co-occurring conditions have also been found in community settings. This would suggest that the elevated levels of comorbidity are not just because of referral bias (Blackman, Ostrander, Herman, 2005; Ostrander Crystal & August, 2006). For example, the following table was derived from National Center for Health Statistics (including children 6-17 years of age) and reported that two-thirds of children with ADHD experienced at least one additional mental health or neurodevelopmental disorder (Larson, et. al., 2011). By comparison, the rates of similar problems in the non-ADHD group were much lower (11.5%).

Nearly half of all young people with ADHD were identified with a specific learning disability; however, there were also high rates of conduct, anxiety, and depressive disorders. Moreover, almost a third of those diagnosed with ADHD had more than one comorbid condition, and nearly one in five (18 percent) had three or more co-occurring diagnoses.

These findings dovetail with other studies and support the conclusion that ADHD is less likely to occur in isolation; as a result, a diagnosis of ADHD should result in a broader examination. For example, the schools should be encouraged to examine whether a child with ADHD has a Specific Learning disability. In addition, a diagnosis of ADHD should routinely lead to further screening for whether mood, conduct, anxiety, or other neurodevelopmental considerations are also evident.

In addition to the complexity associated with the clinical presentation, comorbidity in young people with ADHD has clear implications for their day-to-day functioning. While multiple comorbidities are not uncommon in children with ADHD, most of the research have been limited to children and adolescents displaying ADHD and one other disorder. For example, children with ADHD and LD were found to have a lower academic self-concept and academic self-efficacy. They are also more likely to experience more peer rejections than typically developing children (Hooper & Williams, 2005). Youth diagnosed with both ADHD and depression have incrementally greater impairment in their social interactions and family functioning (Blackman, Ostrander & Herman, 2005; Borden & Ostrander, 2020); moreover, they are three times more likely to have completed suicide than those diagnosed with either disorder alone (Chronis et.al., 2010; James et al. 2004). Similarly, co-occurrence of ADHD and anxiety has been associated with higher severity of inattentive symptoms, negative affect, social and family difficulties, decreased self-esteem, and incremental impairment in working memory (Borden & Ostrander, 2020; Pliszka, 2000). While a diagnosis of ADHD and other externalizing disorders (i.e., Oppositional or Conduct disorders) have consistently been associated with relatively high levels of delinquency, individuals with comorbid ADHD and Conduct disorders are at a particularly high risk for a negative outcome (Sibley et. al., 2011). 

Increasing evidence suggests that comorbidity in youth with ADHD results from both environmental and genetic factors. ADHD has a particularly strong genetic basis and there is also evidence that comorbidity may be linked to shared genetic influences (Azeredo, Moreira, & Barbosa, 2018; Daviss, 2018). However, the relationship between genetic considerations and the occurrence of comorbidity in children probably involves a complex interplay between genetic and environmental considerations (Rutter, 2010). For example, the high levels of hyperactive, impulsive and/or inattentive behaviors of children with ADHD often evokes negative and inconsistent reactions from peers, parents, and other caregivers. Overtime, these negative exchanges are likely to escalate and contribute to children increasingly experiencing maladaptive behaviors and negative beliefs. Without effective treatment, these functional impairments can eventually lead to conduct disorders, academic failure, mood disturbances and/or increasing anxiety (Barkley, 2022; Ostrander et. al., 2006; Humphreys et. al., 2013). 

While ADHD commonly co-occurs with other disorders, surprisingly few studies have examined how to simultaneously treat children diagnosed with ADHD and their comorbid disorders. Most of the studies that have provided some insight concerning the treatment of comorbid disorders are often retrospective and/or limited by methodological considerations. Still, when considered together the available evidence has several important implications for clinical practice. Specifically: For example, there is considerable empirical support for the notion that treatment that includes stimulants can improve academic, mood and conduct related problems in children with ADHD; however, stimulants alone are often insufficient to optimally treat both ADHD and these cooccurring symptoms (Daviss, 2018; Jenson, et.al., 2001). For example, in the case of ADHD with comorbid conduct and/or academic problems, the combination of stimulants and psychosocial interventions have consistently been found to achieve the broadest effect on overall functioning (Barkley, 2022; Jenson, et.al., 2001; Sibley, et.al., 2011). As it relates to ADHD and co-occurring internalizing disorders (i.e., anxiety and depression), there is preliminary evidence supporting use of pharmacological treatments such as stimulants, SSRIs, bupropion, and atomoxetine for treating either or both disorders (Daviss, 2018).

There is also support for the use of psychosocial interventions for the treatment of internalizing symptoms in children with ADHD and these treatments often achieve the broadest impact when combined with pharmacological treatments. Accordingly, behavioral therapies such as Behavioral Parent Training, Cognitive Behavioral Therapy, or Interpersonal Therapy can be effective approaches to treat the functional deficits associated with internalizing disorders while also addressing contributing environmental factors and moderating the risk of suicidal behaviors (Daviss, 2018; Webster-Stratton & Herman, 2008). Including these psychosocial treatments may be especially important in more severe and highly comorbid cases (Daviss, 2018). 

Final conclusions:

• ADHD often occurs along with other psychiatric and/or neurodevelopmental disorders.
• A diagnosis of ADHD should routinely lead to screening for other disorders.
• The occurrence of comorbidity in ADHD is probably related to a complex interplay between genetic and environmental considerations.
• Optimal treatment of comorbidity in children with ADHD often includes the use of stimulants; however, implementing other pharmacological and behavioral treatments is often necessary to achieve the broadest clinical improvement. 

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

REFERENCES

Azeredo, A., Moreira, D., & Barbosa, F. (2018). ADHD, CD, and ODD: Systematic review of genetic and environmental risk factors. Research in developmental disabilities, 82, 10-19.

Barkley, R. A. (2020). Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. Guilford Publications.

Blackman, G. L., Ostrander, R., & Herman, K. C. (2005). Children with ADHD and Depression: A Multisource, Multimethod Assessment of Clinical, Social, and Academic Functioning. Journal of Attention Disorders, 8(4), 195-207.

Borden, L. A., Hankinson, J., Perry-Parrish, C., Reynolds, E. K., Specht, M. W., & Ostrander, R. (2020). Family and Maternal Characteristics of Children With Co-Occurring ADHD and Depression. Journal of Attention Disorders, 24(7), 963-972.

Bryant, A., Schlesinger, H., Sideri, A., Holmes, J., Buitelaar, J., & Meiser-Stedman, R. (2022). A meta-analytic review of the impact of ADHD medications on anxiety and depression in children and adolescents. European Child & Adolescent Psychiatry, 1-14.

Chronis-Tuscano, A., Molina, B. G., Pelham, W. E., Applegate, B., Dahlke, A., Overmyer, M., & Lahey, B. B. (2010). Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 67(10), 1044–1051. 

Daviss, W. B. (2018). Depressive disorders and ADHD. Moodiness in ADHD, 91-109.

Hooper, S. R., & Williams, E. A. (2005). Attention deficit hyperactivity disorder and learning disabilities. In Attention Deficit Hyperactivity Disorder (pp. 215-254). Humana Press.

Humphreys, K. L., Katz, S. J., Lee, S. S., Hammen, C., Brennan, P. A., & Najman, J. M. (2013). The association of ADHD and depression: Mediation by peer problems and parent–child difficulties in two complementary samples. Journal of abnormal psychology, 122(3), 854.

James, A., Lai, F., & Dahl, C. (2004). Attention deficit hyperactivity disorder and suicide: a review of possible associations. Acta Psychiatrica Scandinavica, 110(6), 408–415. 

Jensen, P. S., Hinshaw, S. P., & Kraemer, H. C. (2001). ADHD comorbidity findings from the MTA study: comparing comorbid subgroups. Journal of the American Academy of Child and Adolescent Psychiatry, 40(2), 147-158.

Larson, K., Russ, S. A., Kahn, R. S., & Halfon, N. (2011). Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics, 127(3), 462-470.

Ostrander, R., Crystal, D. S., & August, G. (2006). Attention deficit-hyperactivity disorder, depression, and self-and other-assessments of social competence: a developmental study. J Abnorm Child Psychol, 34(6), 773-87.

Pliszka S. R. (2000). Patterns of psychiatric comorbidity with attention- deficit/hyperactivity disorder. Child and Adolescent Psychiatric Clinics of North America, 9(3), 525–540. 

Rutter, M. (2010). Gene-Environment Interplay. Depression and Anxiety, 27(1), 1-4.

Sibley, M. H., Pelham, W. E., Molina, B. S., Gnagy, E. M., Waschbusch, D. A., Biswas, A., ... & Karch, K. M. (2011). The delinquency outcomes of boys with ADHD with and without comorbidity. Journal of abnormal child psychology, 39(1), 21-32.

Swanson, J. M., Kraemer, H. C., Hinshaw, S. P., Arnold, L. E., Conners, C. K., Abikoff, H. B., ... & Wu, M. (2001). Clinical relevance of the primary findings of the MTA: success rates based on severity of ADHD and ODD symptoms at the end of treatment.

Webster-Stratton, C., & Herman, K. C. (2008). The impact of parent behavior-management training on child depressive symptoms. Journal of Counseling Psychology, 55(4), 473.

Sign up for the BHIPP Resilience Break this Thursday, 10/26

Mark your calendar for the BHIPP ECHO^TM Clinic

on 10/27 12:30-1:30pm

Sign up for the upcoming BHIPP Mental Health Crisis Training on 11/3. There is still time to register for this session and all others in the series through the link below!

Health Resources and Services Administration Survey

Have you found BHIPP effective in helping you address your patients’ behavioral health? Let us know what you think in the Health Resources and Services Administration surveys!

MOM's Self-Referral Tool for patients

The Maryland Department of Health (the Department) is one of a cohort of states selected to implement the Maternal Opioid Misuse (MOM) model, with funding from the federal Center for Medicare and Medicaid Innovation. The MOM model, which provides enhanced case management services to pregnant Medicaid participants with opioid use disorder, recently developed an online Self-Referral Tool for potential participants to refer themselves into the model. This tool was created as part of an upcoming MOM model social media marketing campaign to spread awareness of the model and to encourage members to enroll. The tool can be accessed at: http://health.maryland.gov/EnrollMOM



Maryland Department of Health and PsychArmor Institute invites you to join them for a one hour live webinar on November 9th from 12-1 PM to learn more about the military veteran community and culture. Led by Dr. Heidi Kraft, chief clinical psychologist at PsychArmor and Navy combat veteran, they aim to empower attendees to better facilitate conversations and understanding within the military connected community.