Doctors refer to the simultaneous presence of two or more chronic conditions as “co-morbidity.” The term sounds scary, but it’s not uncommon for kids to receive a second— or even a third—diagnosis down the road, when they have attention deficit hyperactivity disorder (ADHD).
“If you just look at the tip of the iceberg, you’re maybe going to miss what’s below the surface,” says Peter Nieman, a community-based paediatrician in Calgary.
When Michele Jarvie received a triple co-morbid diagnosis for her son Connor, then eight, she was relieved to finally have answers. But the labels of ADHD, autism spectrum disorder (ASD) and anxiety disorder were just the beginning of a long journey to find the right medications and support for her kid, now 13.
“He was shutting down in school, not listening, getting fixated on what he wanted to do and not transitioning to other things,” says Jarvie. ADHD meds could not fully address Connor's complex symptoms, and Jarvie ultimately moved her son to a private school for kids on the spectrum that had a staff psychologist, a life skills program and a one-to-five teacher-to-student ratio. She also enrolled him in an after-school program run by the Autism Aspergers Friendship Society to help with his social skills. This multi-pronged approach has been a key to Connor’s success and experts say the co-existing strategies are critical when treating complex neuro-developmental conditions.
Doron Almagor, a child and adolescent psychiatrist and the director of The Possibilities Clinic, a multi-disciplinary clinic that specializes in ADHD and its associated disorders says: “You really have to look at all co-morbidities and social contributors, family functioning, school supports and everything else going on in the child’s life.”
Common ADHD co-morbid conditions ADHD is a brain-based disorder characterized by attention problems, disorganization, impulsive behaviour and, in many cases, signs of hyperactivity, such as squirming and fidgeting. About 70 percent of kids with ADHD will have a secondary diagnosis. "It rarely comes on its own,” says Almagor.
One condition that occurs in 40 to 60 percent of kids with ADHD is oppositional defiant disorder (ODD), which is defined by ongoing angry, argumentative and defiant behaviour. Signs often begin in preschool and include frequent temper tantrums, a pattern of refusal to comply with adult requests, behaving in a spiteful way, and purposely provoking parents, siblings or friends on a regular basis.
Anxiety and depression occur in 25 to 48 percent of children with ADHD, and substance abuse problems can crop up, particularly in teens, when their ADHD has gone untreated. Parents of kids of all ages with ADHD should become concerned when a down mood doesn’t lift or excessive worry creeps into everyday functions or interactions.
Tourette’s syndrome, a condition that presents as multiple motor tics and at least one vocal tic, affects just three out of 1,000 children, but nearly half of kids with Tourette’s also have ADHD. Look for motor tics, such as eye blinking, nose twitching or shoulder shrugging, and vocal tics that can range from repetitive throat clearing or grunting to blurting out swear words.
“Up to 50 percent of kids with ADHD have a learning disability, and both of those have to be assessed and treated separately,” says Almagor. The classic signs of dyslexia in early childhood include trouble learning and recognizing letters in the alphabet and difficulty remembering popular childhood nursery rhymes. In elementary school, the condition is marked by difficulty learning how to read. Red flags for dyscalculia, which is a learning disability in math, are problems counting, sorting, grasping simple addition or subtraction, or comprehending the passage of time (for example, your kid asks for lunch right after breakfast).
It can sometimes be hard for parents to know whether a symptom is just part of the ADHD—for example, social awkwardness—or if it’s another condition such as ASD. Suzanne Lewis, vice-chair of Autism Canada and the chief medical officer and vice-president of research for the Pacific Autism Family Network, states that "ADHD is a very common co-occurring condition of ASD—often concurrent or preceding recognition of ASD in up to 50 percent or more cases. ASD is classified as a brain-development disorder that affects communication, social interaction and behaviour. It’s also associated with motor-coordination difficulties, attention deficits, sleep issues and intellectual disability. Though kids with ADHD often struggle socially because of inattentive, annoying or explosive behaviour, those with co-morbid ASD may lack the desire to join in games or seem befuddled by the rules of social engagement.
Parents who are worried that a single diagnosis doesn’t account for some of their kid’s symptoms should catalogue all their kid's symptoms (and their context) and research possible co-morbid conditions. Presenting a compelling case to your family doctor will help ensure that the right testing and follow-up happens with all medical specialists that your child needs.