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Comorbidities extremely common in children with ADHD; effective patient management requires treating these illnesses as well, experts report

Wednesday, December 12 2007 | Comments
Evidence Grade 0 What's This?
Comorbidities may be present in as many as two-thirds of children with attention-deficit/hyperactivity disorder, and treating these comorbidities should be considered an integral part of effectively managing these children, a pair of experts in the field indicated.

"Psychiatric comorbidity [in children with ADHD] is common," said Dr. Robert Findling, director of the division of child and adolescent psychiatry at University Hospitals Case Medical Center. "It is the rule and not the exception. These youngsters have a comorbid psychiatric illness until proven otherwise."

Common comorbidities among children with ADHD include oppositional defiant disorder--which occurs in as many as 40% of children with ADHD--language disorder, anxiety disorders, learning difficulties, conduct disorder, and pervasive development disorder.

"One of the real challenges of ADHD, and especially when thinking about comorbidity, has to do with normal symptom overlap," Dr. Findling said. "Lots of things cause youngsters to be hyperactive; lots of things cause them to be distracted ... including normal development and nonsyndromal conditions ...."

For this reason, physicians must determine whether any comorbid disorders are the primary illness, whether the ADHD symptoms could be caused by the comorbidity, and whether the comorbid symptoms are the result of ADHD.

"So, ultimately, when patients with ADHD meet DSM-IV criteria for a second disorder, the clinician should develop a treatment plan to address each," Dr. Findling said, referring to the American Academy of Child and Adolescent Psychiatry's recommendation for managing comorbidity in children with ADHD.

"Fortunately, evidence-based pharmacological treatment regimens are actually available for these youngsters ...," Dr. Findling said.

Stimulant drugs form the cornerstone of pharmacologic management of children with ADHD with or without comorbid illnesses. Dr. Findling noted that management of ADHD using stimulant drugs appears to significantly reduce the patient's risk of developing substance abuse disorder, it can reduce symptoms of both ADHD and oppositional defiant disorder, and it can reduce comorbid aggression symptoms. Stimulant drugs can also be safe and generally beneficial among stable patients with comorbid bipolar disorder who are being treated with thymoleptics.

In children with comorbid depression, however, clinicians should identify which illness is more severe and treat it first, according to Dr. Findling.

"If symptoms of either of those 2 primary conditions get worse, then treat the other disorder first," he recommended. "Once you've got one of the conditions treated ... and you're still having a problem with the other, add a second medication ...; generally that involves a selective serotonin reuptake inhibitor and a stimulant."

Among children with comorbid hypertension, clinicians should try to control blood pressure before attempting to treat ADHD because all standard treatments increase heart rate and blood pressure, according to Dr. Adelaide Robb, medical director of inpatient psychiatry services at Children's National Medical Center-Children's Hospital in Washington, DC.

Data from an MTA Cooperative Group study conducted in 2001 showed that although behavioral or medical interventions alone provided some efficacy in treating ADHD with comorbid psychiatric disorders, the most noticeable benefits were consistently derived from a combination of the 2 approaches, Dr. Findling noted.

When implementing nonpharmacologic or combination management of children with ADHD, parents play an important role in effective treatment, Dr. Robb said.

It is up to parents to ensure that consistent rules and structure are present throughout adolescence; to monitor their children for substance abuse, including cigarettes; and to maintain close contact with teachers to ensure that they recognize the needs of children with ADHD, according to Dr. Robb.

To improve patient outcomes, individualized treatment for ADHD should have the goal of remission rather than just symptom reduction. Clinicians should recognize that pharmacologic dosing is dependent on weight and that growing children may need higher doses as their weight increases, Dr. Robb noted, adding that drug doses and formulations should be adjusted to minimize side effects while meeting the patient's needs. Additionally, clinicians should reassess the patient's progress every 6 to 12 months in terms of academic and social function; if any comorbid illnesses have been resolved at that time, treatment for that illness may potentially be discontinued.

"Careful clinical assessment is pivotal in order to develop appropriate treatment planning," Dr. Findling concluded. "Fortunately, evidence-based pharmacological treatment regimens are actually available for these youngsters that can help [clinicians] help [their] patients better."

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