More Than We Bargained For
by Peter W. Welty, M.D., F.A.A.P.
September 27, 2004
A child with a diagnosis of ADHD, Attention Deficit Disorder with Hyperactivity, frequently has other diagnoses as well. Thus, the identity of ADHD often means that treatment of the disorder can be complicated by other factors. The high prevalence of ADHD with other comorbid diagnoses was demonstrated in the important MTA, Multimodal Treatment Study, of children with ADHD. This study was one where 579 children who had the disorder were evaluated.
Only 25 to 30 percent of the children in this important study had ADHD as a sole diagnosis. Of the other psychiatric diagnoses, the most common was ODD, oppositional-defiant disorder, with 40 percent of children affected. A particularly high percentage of these children also had conduct disorder. Therefore, approximately 50 percent of children with ADHD also have another diagnosis of a conduct disorder--either oppositional defiant disorder or conduct disorder.
Youngsters with ADHD and a comorbid disruptive behavior disorder also had slightly higher levels of impulsivity than other ADHD groups. This was also confirmed using a CPT test, computerized continuous performance test. In general, youngsters with ADHD along with ODD or CD have a more severe disorder than those without the comorbid disruptive behaviors. Also, persistent or untreated ADHD is ultimately associated with increased impairment over time. This untreated ADHD has an increased likelihood to develop those other disorders, especially if other risk factors are present.
The treatment of ADHD and its related comorbid conditions of conduct disorder and oppositional defiant disorder depends, first off, on correct and timely diagnosis. Medications such as stimulants should be considered as they are the foundation of ADHD treatment. These medications include Ritalin, Adderall or the newer non-stimulant Strattera. There are also longer-acting stimulants that are quite useful during school.
Medication should be used in the context of a multipronged approach. This would include individual and family therapy, behavioral interventions and consequences, and resources for learning problems, if needed. Findings from the MTA study showed that medications, whether alone or in conjunction with psychosocial treatment, are the most effective of all treatments. Medications aid in reducing the number and severity of behavioral symptoms such as verbal and physical aggression, negative social interactions with peers, and more severe conduct behaviors.
ADHD, conduct disorder and oppositional-defiant disorder are very prevalent and frequent in comorbid disorders. A multimodal treatment strategy that combines medication management along with specific psychosocial and behavioral intervention is the very best approach to management of symptoms in these children.
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