ADHD: Strategies for Developing a Further Dialogue - Episode 2
A discussion on the common comorbidities screened for when diagnosing ADHD (attention deficit hyperactivity disorder).
Tim Wilens, MD: One important part of those guidelines is screening, and when we think of the screening, one of the things we need to screen for, in addition to ADHD [attention-deficit/hyperactivity disorder], is comorbidity. I was wondering Bob, if you could dovetail on that and tell us how do you look for comorbidities, and what comorbidities are we looking for?
Robert L. Findling, MD, MBA: In many ways, although a lot of attention is paid to treatment, the hardest part of this is making the diagnosis accurately. The symptoms that characterize ADHD are not specific. There are countless things that could make a youngster appear inattentive. Equally, there are innumerable things that might make a youngster look fidgety. In many ways the real challenge is making sure the patient indeed has ADHD. Again, that’s the first and foremost process, making sure the patient has it, and that can only be done by a careful assessment both cross-sectionally and over time. Pediatricians are particularly well equipped to do such a thing because oftentimes they have the benefit of watching children grow up and seeing how they do over time, which is a privilege that many of us in psychiatry don’t have a chance to do.
Presumably you’ve got the diagnosis right and you’re on top of things. The other thing to remember then if faced with a patient who indeed has ADHD, is that comorbidities are the rule and not the exception. Common comorbidities include disruptive behavior disorders, like oppositional defiant disorder; anxiety disorders, particularly things like separation anxiety and generalized anxiety; mood disorders, particularly depression, which is common in teenagers. Certainly, other mood disorders like bipolarity are also less common, but certainly part of this.
The real trick is to remember that ADHD is frequently associated with many other conditions. When faced with a youngster who has a chronic longstanding—and you used the word chronic, Tim, which was perfect—challenges associated with certain characteristic domains over time longitudinally, oftentimes other things come along as well. And you have to look for them because otherwise you might think you’re not treating the ADHD properly because in fact, there are many things that come along that will not respond to ADHD treatment. You must know the whole child.
-Dr. Findling receives or has received research support, acted as a consultant and/or has received honoraria from Acadia, Adamas, Aevi, Afecta, Akili, Alkermes, Allergan, American Academy of Child & Adolescent Psychiatry, American Psychiatric Press, Arbor, Axsome, Daiichi-Sankyo, Emelex, Gedeon Richter, Genentech, Idorsia, Intra-Cellular Therapies, Kempharm, Luminopia, Lundbeck, MedAvante-ProPhase, Merck, MJH Life Sciences,NIH, Neurim, Otsuka, PaxMedica, PCORI, Pfizer, Physicians Postgraduate Press, Q BioMed, Receptor Life Sciences, Roche, Sage, Signant Health, Sunovion, Supernus Pharmaceuticals, Syneos, Syneurx, Takeda, Teva, Tris, and Validus.
-Dr Gephart is retired from the practice of medicine. He is on the faculty of the REACH Institute for a course entitled “Patient Centered Mental Health in Primary Care.” He receives a stipend for serving as a virtual consultant to Course graduates who call in and present difficult cases. He has no other financial contracts to report.
-Dr Childress reports receipt of research or writing support, participation on advisory boards, and service as a consultant or speaker for Adlon Therapeutics, Aevi Genomic Medicine, Akili Interactive, Allergan, Arbor Pharmaceuticals, Cingulate Therapeutics, Emalex Biosciences, Ironshore Pharmaceuticals, Jazz Pharmaceuticals, KemPharm, Lundbeck, Neos Therapeutics, Neurovance, NLS Pharma, Otsuka, Pearson, Pfizer, Purdue Pharma, Rhodes Pharmaceuticals, Sunovion, Supernus Pharmaceuticals, Takeda, and Tris Pharma.
-Dr Wolraich is professor emeritus from the University of Oklahoma Health Sciences Center. He is on the steering committee and a faculty member of the REACH Institute, a non-profit organization providing CME training on mental health to primary care physicians. He has no affiliations or investments where he receives any compensation, and he is no longer in any clinical practice.
-Dr Wilens is Chief, Division of Child and Adolescent Psychiatry and Co-Director of the Center for Addiction Medicine at Massachusetts General Hospital. He receives or has received grant support from NIH(NIDA). He is or has been a consultant for Arbor, Otsuka, Ironshore, KemPharm and Vallon. He is the author of Straight Talk About Psychiatric Medications for Kids (Guilford Press). He is co-editor of ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier); and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). He is co-owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire) and has a licensing agreement with Ironshore (BSFQ Questionnaire). He serves as a clinical consultant to the US National Football League (ERM Associates), U.S. Minor/Major League Baseball; Gavin Foundation and Bay Cove Human Services.