Many ADHD patients have multiple behavioral disorders1
Disruptive behaviors can mimic ADHD symptoms
Children with ADHD may have a temperament-neuropsychological profile characterized by argumentativeness, irritability, and impulsivity—making differential diagnosis a challenge.1
The table below can be used as a guideline for the differential distinctions between ADHD and behavioral disorders.
“Behavioral disorders in pediatric patients—primarily ADHD—pose a clinical challenge for healthcare providers to accurately assess, diagnose, and treat.”1
-Joseph Austerman, DO
Behavior disorders and ADHD
OPPOSITIONAL DEFIANT DISORDER (ODD)
- Resistance to tasks3
- Difficulty with self-control3
- Executive functioning deficits3
- ADHD: oppositional behaviors are more likely due to forgetfulness and difficulty sustaining attention and focus3
- ODD: defiance may be vindictive, or part of an attempt at dominance1
- A persistent pattern of oppositional behavior that is within the 4 ODD categories and lasts ≥6 months is suggestive of ODD3
- ODD occurs in ~50% of children with combined (inattentive/ hyperactive) ADHD and in ~25% of those with inattentive ADHD3
CONDUCT DISORDER (CD)
- Poor self-control3
- Possible behavioral aggresion3
- Disregard for rules and boundaries3
- ADHD: impulsive behavior typically does not violate societal norms or rights of others3
- CD: purposeful aggression, eg, fire setting, physical cruelty towards others or animals, lack of remorse or empathy, bullying on social media3
- Children with CD may have a pattern of school truancy and running away from home before the age of 133
- ~25% of children/teens with combined ADHD have a comorbid diagnosis of CD3
INTERMITTENT EXPLOSIVE DISORDER (IED)
- Failure to control impulsive behavior1
- Symptoms can manifest as early as 3 or 4 years of age1
- ADHD: impulsive behavior is not typically aggressive3
- IED: patients can show serious aggression towards others, out of proportion to provocation1
- IED is relatively rare in children and adolescents3
- Disruptive movements or vocalizations2
- Symptoms often seen first in childhood, with a higher prevalence in males2
- ADHD: disruptive behavior can be managed with appropriate therapies and treatment2
- TIC DISORDERS: while they may appear purposeful, tics are generally involuntary; however, they may be suppressed for periods of time2
- Impairment caused by comorbid tic disorders may be minimal compared to the impact on academic and social functioning associated with ADHD2
This table is intended as a quick reference guide only. For full diagnostic criteria, please refer to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM–5).
Managing Comorbid Behavioral Disorders and ADHD
A multimodal management approach
In pediatric patients with ADHD, comorbid behavioral problems should be addressed in the treatment plan. A multimodal management approach that involves pharmacologic therapy as well as participation of the child’s parents and school are recommended.1*
- First-line therapy for comorbid ODD or conduct disorder involves use of a stimulant in addition to behavioral therapy interventions that target disruptive behavior1
- If the behavioral comorbidity is severe, alpha agonists and even second-generation antipsychotics may be added to the treatment plan1
You can learn more about the multimodal management of ADHD comorbidities here
*There is no FDA-approved medication for ODD. However, antipsychotic medicators are frequently prescribed if a child is at risk of being removed from school or the home.4
Common Comorbidities in Comorbid Complex ADHD: Prevalence, Age of Onset, Diagnosis, and Clinical Implications
Dr. Cutler, associate clinical professor in the Department of Psychiatry, SUNY Upstate Medical University in Syracuse, NY, discusses comorbid complex ADHD—prevalence, age of onset, diagnosis and clinical implications.
Hello, I'm Dr. Andrew Cutler, associate clinical professor in the Department of Psychiatry, SUNY Upstate Medical University in Syracuse, New York. And I'm pleased to be discussing comorbid complex ADHD – prevalence, age of onset, diagnosis, and clinical implications.
Comorbid complex ADHD is very common — studies show that three- quarters of individuals with ADHD have at least one psychiatric condition, and 80% of those have more than one comorbidity. 1
But why do people with ADHD have comorbidities? It’s possible that one disorder is a precursor to the other (evolving over time), it could be a risk factor for developing the other, or they may have a common genetic basis. Some comorbid disorders (such as depression and anxiety) may develop due to the impact of ADHD, making it a secondary condition. 2,3
The comorbidity profile can change throughout the lifespan. In children and adolescents, studies have shown a high incidence of oppositional defiant disorder, which decreases in adulthood. However, in adults, we see problems with emotional dysregulation, stubbornness, trouble managing anger, and other negative emotions. In addition, those comorbidities that tend to be less common in childhood, such as conduct issues, anxiety, major depressive disorder, and substance use disorder, increase in incidence through adolescence, and into adulthood.
The cumulative burden of comorbid complex ADHD evolves and accumulates throughout the lifespan. For example, although oppositional defiant disorder is the most common comorbidity in children, conduct disorder and anxiety are also seen, with the impact of these, along with ADHD, resulting in low self-esteem in this age group. Moving from childhood into adolescence and adulthood, oppositional defiant disorder and conduct disorder decrease, but criminal behaviors start to show, with antisocial personality disorder becoming more common. In addition, learning delays in childhood develop into complex learning difficulties in adolescence and adulthood. With this progression, people often become demoralized and frustrated, resulting in lack of motivation and under achievement. Substance abuse comes into play as well. 2,4-8Es
The presence of comorbidities in different age groups can complicate the diagnosis of ADHD, as symptoms of these comorbidities often overlap with symptoms of ADHD. For example, ADHD symptoms of restlessness, agitation, difficulty concentrating, and decreased attention are also seen in major depressive disorder, bipolar disorder, anxiety, substance use disorder, and sleep disorders; and the ADHD symptom of impulsivity [activate slide build] is also seen in conduct disorder, bipolar disorder, and substance use disorder. 2,9
So, given the overlap of symptoms of ADHD and its comorbidities, what are the steps to ensure an accurate diagnosis? First, it's important to establish the diagnosis, by confirming that the individual meets DSM-5 criteria for ADHD. Then, you should rule out alternative explanations for the symptoms. Finally, and as we've already talked about, it's important to assess for comorbid conditions, which may affect the treatment of ADHD, as well as the diagnosis. 10
For example, to differentiate ADHD from depression, it is necessary to identify which symptoms of depression overlap with ADHD and which are distinct. Overlapping symptoms include loss of motivation, problems concentrating, and restlessness or irritability. So, if your patient has any of these symptoms, it could be ADHD, depression, or both. However, if your patient has only symptoms of depression that are distinct from ADHD, such as feelings of sadness, thoughts of suicide, or changes in eating or sleeping, it is likely depression. 2
Thank you for being part of this Team ADHD educational presentation.
REFERENCES: 1.Banaschewski T, et al. Attention- Deficit/Hyperactivity Disorder. Dtsch Arztebl Int. 2017;114(9):149-159. 2.CADDRA Canadian ADHD Practice Guidelines 2018. https://www.caddra.ca/wp-content/uploads/CADDRA-Guidelines-4th-Edition_-Feb2018.pdf 3.Pliszka SR. Comorbidity of ADHD with psychiatric disorder: an overview. J Clin Psychiatry. 1998;59:50-58. 4.Turgay A, Ansari R. Major depression with ADHD in children and adolescents. Psychiatry. 2006;3(4)20-37. 5.Goodman DW. ADHD in adults: update for clinicians on diagnosis and assessment. Primary Psychiatry. 2009;16(11):21-30. 6. Faraone SV et al. Attention- deficit/hyperactivity disorder. Nat Rev Dis Primers. 2015;1:1-23. 7.Harpin VA. The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Arch Dis Child. 2005;90(Suppl I):i2–i7. 8. Biederman J, et al. Adult outcome of ADHD: a controlled 16-year follow up study. J Clin Psychiatry. 2012;73(7):941- 950. 9.Kooij S, et al. Distinguishing comorbidity and successful management of adult ADHD. J Atten Disord. 2012;16:3S-19S. 1. 10. American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents Pediatrics. 2011;128:1007–1022.
- Disruptive behaviors can mimic ADHD1
- ODD, CD, IED, and tic disorders are the most common comorbid conditions seen with ADHD1
- A multimodal approach to managing comorbid behavioral disorders and ADHD is recommended1
Stay in the know and access an exclusive ADHD resource
“Unmasking ADHD” can help you differentiate between ADHD and the most common overlapping comorbidities in children.
- Austerman J. ADHD and behavioral disorders: Assessment, management, and an update from DSM-5. Cleve Clin J Med. 2015;82(11 suppl 1):S2-S7.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
- Kahn S, Down J, Aouira N, et al. Current pharmacotherapy options for conduct disorders in adolescents and children. Expert Opin Pharmacother. 2019;20(5):571-583.
- Child Mind Institute. ODD: Treatment.
Accessed May 25, 2021.