Counseling Points - Family/Pediatric Nurse 11/08 - (Page 8)

(Table 3). These conditions include but are not limited to learning disabilities, sensory deficits (e.g., hearing or vision problems), Tourette syndrome, insufficient sleep syndromes (e.g., too few hours of sleep or obstructive sleep apnea), poor nutrition resulting in hypoglycemia (e.g., skipped breakfast), allergies (e.g., pruritus), depression, anxiety, conduct disorder (CD), and oppositional defiant disorder (ODD).14,18,22 In addition, the side effects of many medications (e.g., first-generation antihistamines, anti-epileptics) may be mistaken for symptoms of ADHD.15 ADHD and Co-morbid Conditions in Children and Adolescents The lifetime prevalence of co-morbid psychiatric and/or lear ning disorders with ADHD may be as high as 84%.8,18,22 The incidence of co-morbid conditions with ADHD increases with the individual’s age.23 Recent studies support the early identification and treatment of ADHD to help prevent the subsequent development of co-morbid disorders.23 Psychotherapy, in additional to pharmacotherapy, is useful in children with co-morbid ADHD and other psychiatric disorders. Co-morbid Anxiety Disorders. Children with significant anxiety may have co-morbid ADHD, or they may have symptoms that merely mimic ADHD. Patients with severe anxiety will often internalize their anxiety and appear distracted or disorganized. In addition, their anxiety may drive externalizing behaviors, such as tantrums, agitation, and sleep dysregulation. Findings from both clinical and epidemiologic studies have concluded that concomitant ADHD and anxiety disorders are present in approximately 25% of children.24 If the clinician does not detect the co-morbid anxiety and treat it first, stimulant therapy may worsen the person’s anxiety, panic (if present), and agitation. For example, in clinical practice it has sometimes been observed that people with obsessivecompulsive disorder (OCD) may experience increased obsessive thoughts and compulsive behaviors from stimulant therapy. Co-morbid Depression. ADHD and depression have common symptoms that include psychomotor agitation and distractability. The lifetime rate of major depressive disorder among children with ADHD is estimated to be about 26%.24,25 Co-morbid Tic Disorders. Recent research indicates that most children with co-morbid ADHD and tic disorCOUNSELING POINTS™ 8 ders either do not experience an exacerbation of tic symptoms with methylphenidate; others may find that the benefits of treatment outweigh any minor increase in tics.8,26 It is important to evaluate the severity and functional impairment from the individual’s tics prior to treating ADHD symptoms. Stimulant therapy has been shown to improve ADHD behaviors, social skill deficits, and aggression in children with chronic tics or Tourette syndrome.23 Many children with ADHD and a co-morbid tic disorder do tolerate stimulant therapy, but it is important to use stimulants with caution and monitor the individual closely.23 Co-morbid Conduct Disorder and Oppositional Defiant Disorder. ADHD can be co-morbid with both CD and ODD.18 In children with severe oppositional behavior, it is important to determine if there is an underlying, untreated, mood disorder. In many children, once the mood is stabilized, oppositional behavior improves. Individuals with ADHD and co-morbid CD are at an increased risk to develop antisocial behavior as well as substance abuse disorders.18,23 Table 3. Differential Diagnosis of ADHD • Organic disorder • Sensory integration disorders • Medication-induced effects (e.g., antihistamines, phenobarbital, beta-agonists) • Seizure disorder (e.g., absence seizures) • Learning disabilities • Thyroid abnormality (e.g., hyperthyroidism) • Mental retardation • Brain neoplasm or frontal lobe abscess • Lead intoxication (e.g., neurocognitive deficits) • Pervasive developmental disorder • Anxiety disorder (e.g., generalized anxiety disorder, obsessive-compulsive disorder) • Juvenile bipolar disorder—manic presentation • Post-traumatic stress disorder (e.g., from abuse or neglect) • Adjustment disorder • Tourette syndrome/multiple tic disorder • Age-appropriate hyperactivity • Multiple life stressors and transitions (e.g., divorce, move, chronic illness in family member) • Inappropriate school or work placement • Family conflict or psychopathology • Inconsistent limit-setting and disciplining by parents

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Counseling Points - Family/Pediatric Nurse 11/08

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