This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014. The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.

1. ADHD and Co-Morbidity
ADHD Attention
 Deficit
 Hyperactivity
 Disorder
Yasir Hameed (MRCPsych)
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Date: 2014-03-31 22:19+01:00

2. ADHD and Co-Morbidity
Proposed outline:
 What is ADHD – and some concepts to
consider
 Co-morbidity
 Stats
 Selected Highlights:
 ASD
 Personality/?bipolar
 Risk
 Case vignettes with discussion on how you
might manage and treat
 (Including medication)

3. ADHD: what is it?
The 3 musketeers:
 Inattention/concentration
 Impulsivity
 Hyperactivity

4. ADHD: what is it?
The 3 musketeers:
 Inattention/concentration
 Impulsivity
 Hyperactivity
And then there is the 4th one:
 Emotional Dysregulation

5. ADHD: the Child Psychiatrist’s View
Growth and Development
 ‘Developmental Tasks’ (Neuro-) Developmental Disorders
 Family Interaction
 Schooling
 Social Interaction
 Disruptions Attachment’
Oppositional Defiant Disorder
Others?
The Whole of Psychiatry?

6. ADHD and Co-Morbidity: Concepts 1

7. ADHD and Co-Morbidity: Concepts 2

8. ADHD and Co--Morbidity:
‘All you ever wanted to know...’
Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution

9. ADHD and Co--Morbidity:
‘All you ever wanted to know...’
Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution

10. ADHD and Co--Morbidity:
‘All you ever wanted to know...’
Adapted from G D Kewley 1999: ADHD – Recognition, Reality and Resolution

11. What happens when ADHD grows up even
more?
Criminal behaviour Personality Disorders
Oppositional School exclusion
Defiant Mood Disorders
Disruptive Disorder
Behaviour Substance Bipolar??
Low Abuse
ADHD only Self-esteem Poor Social Conduct
Skills Disorder Drug & Alcohol Problems
Learning Lack of
Delay Challenging Motivation Criminality
Behaviour
Complex Relationships failures
Learning
Difficulties Underachieving
Study /work problems
6y 10y 14-16y 17-35
Adapted and extended from G D Kewley 1999: ADHD – Recognition, Reality and Resolution

12. ADHD and Co-Morbidity: concepts 3
It is not :
Can’t focus
But:
Can’t control the
focus of attention
- Executive Functions
- Filtering Information
- Signal Noise Ratio

13. ADHD and Co-Morbidity: concepts 4
Comorbidity:
‘Development related’
 Autistic spectrum disorders
 Tics and Tourette’s disorders
 Developmental delay
 Learning disabilities
 Specific learning disabilities (reading, coordination)
‘Ordinary’
 Sleep
 Mood disorders (depression, ?bipolar)
 Anxiety disorders
 Substance abuse disorders (substance and alcohol)
 Personality disorder (dissocial, borderline)

14. ADHD and Co-Morbidity: concepts 5
Underlying processing problems ‘push’ potential
comorbidities towards clinical significance
(E.g. John J. Ratey’s ‘Shadow Syndrome’ idea)

15. ADHD and Co-Morbidity: concepts 6
Utah Criteria for Adult ADHD
A. Inattentiveness
B. Hyperactivity
With at least two of the following:
1. Mood fluctuations
2. Irritability and hot temper
3. Impaired stress tolerance
4. Disorganisation
5. Impulsivity

16. Is Adult ADHD
Plain Vanilla ADHD,
where ….
hyperactivity has gone
underground,
but ….
emotional dysregulation
and co-morbidities
have come to the fore?

17. Comorbidities: stats and a few selected
highlights
 ASD
 Personality disorder, and what
about Bipolar
 Risk
 DSH & Suicide
 The Road

19. ADHD and Autistic Spectrum
Disorders (ASD)
• 41 % of the children with autistic spectrum disorders
also had many ADHD characteristics, and 22 % of
those with ADHD characteristics also had the
diagnosis autistic spectrum disorder.
• Suggested a joint genetic influence in both
disorders (Ronald et al. 2008 ) .

20. ADHD and personality disorder:
Miller, Nigg and Faranoe (2007) studies 363 adults with
ADHD and compared them to non-ADHD controls in
relationship to personality disorder. Adults with ADHD had
a higher incidence of both cluster B and C.
Controls % ADHD %
Cluster A No difference
Cluster B 9.5 24.4
Cluster C 4.3 21.0
The most frequent Cluster B personality disorder in ADHD
was Borderline PD
In Cluster C, the most common type was OC PD

21. In the differential diagnostic assessment, the
following criteria are used:
1. The frequency of the mood swing (4–5 times a
day in ADHD and cluster B personality
disorders, a minimum of 2–3 days in a
hypomanic episode)
2. The course (chronic in ADHD and cluster B
personality disorder, episodic in bipolar disorder)
3. The age of onset (childhood in ADHD, usually
later in the bipolar and personality disorders)

23. The incidence of death from suicide is nearly 5 times higher
among adults who had had childhood ADHD compared with
control participants (N = 367).
Barbaresi et al. Mortality, ADHD, and Psychosocial Adversity in Adults With Childhood
ADHD: A Prospective Study. PEDIATRICS Volume 131,Number 4, April 2013.
The chance of suicidal tendencies in adolescents and adults with
ADHD compared to controls is elevated mainly in the presence of
hyperactivity/impulsivity, depression or dysthymia, and the
antisocial behavioural disorder.
Barkley and Fischer 2005 ; Semiz et al. 2008
In research, among adolescents 36 % of the patients with ADHD
had suicidal thoughts before the age of 18, versus 22 % of a
control group.
For suicide attempts, these numbers were 16 % versus 3 %.
Barkley and Fischer 2005
ADHD: DSH and Suicide

24. Young women diagnosed with ADHD, were three to four
times more likely to attempt suicide and two to three
times more likely to report injuring themselves than
comparable young women in a control group.
Hinshaw et al. Prospective Follow-Up of Girls With Attention-
Deficit/Hyperactivity Disorder Into Early Adulthood: Continuing Impairment
Includes Elevated Risk for Suicide Attempts and Self-Injury. Journal of
Consulting and Clinical Psychology. American Psychological Association.
2012, Vol. 80, No. 6, 1041–105.
This knowledge ought to change our thinking about
DSH drivers, and also our working practices in
trying to deal with this client group!!
ADHD and (Female) DSH

25. Some Cases for Discussion

26. Case 1; Billy
41 years old, living on the street since age 15/16,
multiple drug user, including iv heroin, Hep c
positive. On methadone
Now living in his own flat and finding it very
difficult to cope
When living on the street nobody cared about his
hyper-activtiy, now he is driving everybody
mad
Diagnosis of ADHD, OCD, drug use on
substitution therapy
Physical health, slow pulse low BP

27. Case 2; Phillip
• 63 year old man, initially diagnosed with
bipolar disorder. Marked mood lability,
anger/temper outbursts leading to loss of
job ASDA, very low self-esteem, difficulties
verbalising his problems
• Diagnosis ADHD, sleep disturbance,
emotional lability, anger
• Mood very low at times.
• Treated with stimulants + clonidine

28. Case 3; Ricky
• Presented with OCD, ODD, ADHD, Ticks and
substance misuse
• Treated OCD with SSRIs and ADHD with
atomoxetine, little effect, added risperidone.
Severe sweating
• Relationship difficulties, alcohol abuse leading to
pacreatitis
• Difficult to engage
• Suicidal ideation; started on methylphenidate,
good effect on suicidality and sweating, but not
sustained.

29. Case 4; Susan
• Multiple diagnosis including; bipolar,
depression, BPD, anxiety
• Antidepressants not working
• Marked suicidality and DSH
• Mum believed may have ADHD,
assessment confirmed this
• Stimulant medication marked
improvement on suicidality.