Discussing Comorbid Disorders and Complex ADHD

In the final part of this series, Ann Childress, MD, President of the Center for Psychiatry and Behavioral Medicine Inc in Las Vegas, Nevada and Vladimir Maletic, MD, MS, Clinical Professor of Psychiatry, University of South Carolina School of Medicine, Grenville, South Carolina finish their discussion on pediatric attention-deficit/hyperactivity disorder (ADHD).

Dr Childress and Dr Maletic discuss treatment techniques for complex ADHD and diagnosis of comorbid ADHD.

In the previous part 1, part 2, and part 3, Dr Childress and Dr Maletic discussed the pandemic’s effects on relationships, daily lives, nutrition, and school for children with pediatric ADHD.

Read the Transcript:

Dr Maletic: I've heard you on several occasions also discuss complex ADHD,  ADHD where there are comorbid conditions. Sometimes that is the reason that function and quality of life can be compromised. Sometimes that is the reason that these children may have a harder time of fitting in the school environment, and frankly, even in their family environment. 

Would you have any thoughts for our colleagues? How do you screen? If current treatment is not working, what do we do to ameliorate it? 

Dr Childress:  One of the things that we can do is go back to the drawing board. If things aren't getting better where we are, are we on an optimal dose of medication, are we on the right medication? If we've really maxed out our medication, as far as efficacy versus tolerability, then do we need to switch to something else? If we make a switch, are there other things that I'm missing? 

I'm teaching all the time, I have students, which is great. They'll say, "Hey Dr. Childress, what about this?" "What about that?"

In my clinical trials, I'm trying to find those kids that just have ADHD. That's only about 25% of the kids that we see, because 75% have another comorbid disorder, and probably 60% have at least 2. We want to look and see, and also look and see, if there's anxiety and depression, is it because I'm not optimally treating their ADHD?

We may need to make a change, we may need to add on medications, we may need to get them into psychotherapy, and we want to deal with those school issues too, because a good percentage of patients with ADHD have learning disabilities. Let's get them set up for tutoring. 

When I was in high school, I tutored kids on the football team, it was a great job for a nerd, right? 

What I talk with parents about, especially with the younger kids, the middle schoolers, and the elementary school kids, "Do you have somebody in your neighborhood? Do you have somebody who's really smart in high school and is doing really well?" and, "Maybe they can do some after school tutoring," to try to get the parents out of the homework business if they can. 

If there's somebody that they can look up to up here, they may want to work harder for that. Of course, getting a professional tutor is always an option, but sometimes, that's an option that's too expensive for parents. I can vouch that high schoolers will work for a reasonable wage.

Dr Maletic:  These are all great recommendations. So, be careful, if a patient is not responding to the treatment, revisit. Is this the right treatment? Is this the sufficient dosage? Is this the sufficient duration of treatment? What are some alternatives?

At the same time, let us now more carefully examine the diagnosis; are there some comorbidities that we're missing? Are we missing a learning disability that can be associated with ADHD? Are we missing a mood disorder?

In adolescence, frankly, substance use has increased during COVID19 quite a bit, and something that's curious, "Are we missing anxiety?" The reason I'm saying curious, there have been large scale genetic studies recently. They look at the number of risk genes for ADHD, and here's something that they have found. 

The greater number of risk genes for ADHD in males translate into more severe ADHD symptoms. In young women and girls, having higher number of risks for ADHD is associated with greater likelihood of anxiety disorder being diagnosed. Not ADHD, anxiety disorder being diagnosed. Again, you're a very experienced clinician, what are your thoughts about that? 

Dr Childress:  I can think of a patient that came in to see me for an anxiety study that we're doing for GAD, and I would think that she's 12. I started saying, "You're making a good case for ADHD here." 

Yes, she had anxiety, but her anxiety was secondary to her struggles in school. She was going to a private school where there was a heavy academic load even during lockdown. I started talking with her mother about this, and her mother's a nurse. 

She's an instructor at one of the universities, and she said, "It's funny. For several years, I was treated," mom said, "for depression, and none of the antidepressants helped me. Then I got treatment with a stimulant for my ADHD, and I'm doing so much better. Isn't that interesting?" 

She said, "I thought more her brother has ADHD. He's coming in for an evaluation soon, but we got...It's a whole family affair."

If you're doing clinical research, ADHD is great because it's as inheritable as height. So, the kids come in, you get a parent. A parent comes in, you get a couple of kids. It's because of the genetics, so you need to look. 

We started her on a medication for her ADHD, and things are getting better. There's still some oppositional symptoms and still some anxiety because she's not getting her work turned in as much as possible, so we just upped her medicine. 

It's important when people come in for one thing to do a good evaluation. Because I do the mini kit a lot, I've got all those questions in my mind. I can run through DSM pretty quickly with some screening questions to make sure we're going to rule out or rule in other diagnoses. 

Dr Maletic:  It's again a wonderful pearl of wisdom. If there are girls who have a lot of anxiety about transitioning back to live education/instruction, yes, let's take this symptom's face value, but also let us not exclude the possibility that ADHD is there.

You have particularly emphasized how important it is to get a good family history. That can provide a lot of clues.

Ann, as usual, having a conversation with you makes the time just fly by. 

We are close to the conclusion of our time. I do want to thank you and all our audience members for sharing their time with us. Would you have any concluding remarks? Any last thoughts for all of us in our audience? 

Dr Childress:  I would encourage people to be excited about the future. We're going to have some little ups and downs, but hopefully, we are through the worst of the pandemic. Look toward the future, plan fun things to do, and get the kids excited about going back to school. 

 Ann C. Childress, MD, is in private practice in Las Vegas, Nevada. She has adjunct faculty appointments at the University of Nevada Las Vegas, School of Medicine and Touro University Nevada College of Osteopathic Medicine. She is board certified in psychiatry, with a subspecialty in child and adolescent psychiatry. Her current research focuses on the treatment of children, adolescents, and adults with ADHD. Dr. Childress is a Distinguished Fellow of the American Psychiatric Association, President-elect of The American Professional Society of ADHD and Related Disorders, a member of the American Academy of Child and Adolescent Psychiatry and is Education Director for the Nevada Psychiatric Association.

Vladimir Maletic, MD, MS, is a clinical professor of psychiatry and behavioral science at the University of South Carolina School of Medicine in Greenville, and a consulting associate in the Division of Child and Adolescent Psychiatry, Department of Psychiatry, at Duke University in Durham, North Carolina. Dr. Maletic received his medical degree in 1981 and his master’s degree in neurobiology in 1985, both from the University of Belgrade in Yugoslavia. He went on to complete a residency in psychiatry at the Medical College of Wisconsin in Milwaukee, followed by a residency in child and adolescent psychiatry at Duke University.