In children with ADHD, its common that difficulties go beyond attentional deficits, hyperactivity, and impulsivity. Commonly, parents and teachers report problematic behavior, struggles with frustration, learning disorders, tics disorders, and more. Below, we provide a brief overview of ADHD and some of the most common comorbidities.
Disruptive Behavior Disorders
While many times children with ADHD have difficulty paying attention, following rules, listening to adults, and controlling impulses. In many children these behaviors are a result of inattention or overactivity, and are not willful behaviors. However, many children with ADHD often demonstrate behavioral difficulties above and beyond what would be expected from ADHD alone. In fact, studies show that between 50-65% of children with ADHD meet criteria for a disruptive behavior diagnosis such as Oppositional Defiant Disorder or Conduct Disorder. Disruptive behaviors commonly seen in children with ADHD and co-occurring behavior disorders include:
Willful defiance of rules
Refusal to comply with adults
Yelling and screaming
Verbal and physical aggression
Lying, stealing, and other "sneaky" behaviors
While these behaviors occur in both males and females, higher rates of co-occurring disruptive behavior disorders are seen in children with males with the Combined presentation of ADHD. This comorbidity is typically associated with more severe social, behavioral, emotional, and academic problems than children with ADHD alone.
Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)
Disruptive behavior disorders include ODD and CD. The difference between ODD and CD is in the severity of symptoms. Symptoms can get worse with age, thus causing ODD to progress into CD. However, not all children with ODD will develop CD, particularly if treatment is sought early. Oppositional defiant disorder occurs when a child behaves in a negative, disobedient and defiant manner consistently for at least six months. To be diagnosed with ODD a child exhibit four of the following symptoms "often" (i.e. more frequently than peers). The behavior must also cause impairment in the child’s social, academic or occupational functioning.
Often loses temper
Often argues with adults
Often defies rules or requests
Often annoys people on purpose
Often blames others for his or her mistakes or misbehaviors
Is often annoyed easily
Is often angry
Is often spiteful
Conduct disorder is a more severe pattern of antisocial behaviors. 25% of children with ADHD may have CD, which is diagnosed when a child or adolescent:
Exhibits more serious deviant behaviors and actions
Is physically cruel to animals or people
Treatment of ADHD and a Disruptive Behavior Disorder
Both ADHD and ODD as well as ADHD and CD can be treated
Behavioral support at school can help with academic and social problems at school
Many children with ADHD and ODD or ADHD and CD benefit from use of a behavior plan in the classroom.
Parent training can teach parents how to work with their child or adolescent
ADHD and Frustration Tolerance
Children with ADHD often have poor frustration tolerance and difficulty managing frustration. Therefore, they become frustrated more quickly than other children and have difficulty handling distress when frustration occurs. Children with ADHD express frustration in many different ways. When frustrated, children with ADHD may:
Refuse to complete assignments/activities or give up easily
Become "hyper-focused" on completing a task
Become irritated or angry with others
Make negative comments about themselves (i.e., "I'm stupid," "I'm no good, etc."
Experience temper tantrums or "meltdowns."
In severe cases, children may become aggressive, destructive, self-injurious, or violent as a result of frustration.
This diminished frustration tolerance is the product of many issues. The symptoms of ADHD often make tasks more difficult for children with ADHD, therefore there are more instances in which frustration may occur. For example, children with ADHD, have difficulty transitioning between activities. Additionally, children with ADHD often have stronger emotional reactions, and have difficulty controlling their emotions when upset. Finally, some children with ADHD also have difficulty with mood/depression problems. About 30% of children with ADHD also qualify for a diagnosis of anxiety or depression.
Treatment of Children with ADHD and Frustration Difficulties
Structure and predictability are very important for children with ADHD. When children with ADHD have sufficient structure, they are better able to manage frustration.
Make sure that children with ADHD have plenty of breaks when completing challenging or difficult activities. At school, this can take place as water breaks, taking notes to the office, or getting a drink of water.
Set up a quiet, safe "cool down" place in the house or classroom to give the child a place to calm themselves down when they get frustrated. It is important that the "cool down" place is different than the time-out location!
If a child is demonstrating aggressive, destructive, or self-injurious behavior, the child should be referred to a mental health professional to see if additional treatment is necessary.
ADHD and Learning Disorders
Between 10-50% of children with ADHD also have a learning disorder (LD), making it very likely that children and students with ADHD may have an LD as well. Children with ADHD and an LD often show particular difficulty with a specific academic skill or subject. As such, there are a number of learning disorders that can occur. For example, children may have:
Non-verbal Learning Disorders
Although ADHD and LD can both affect a child’s ability to learn, they are very different disorders. Despite different presentations and etiology, it can be difficult to distinguish between ADHD and LD. Children with this combination may experience academic difficulty due to attention and behavior problems, as well as misbehave in the classroom due to frustration. Other common difficulties include:
Difficulty paying/sustaining attention
Increased activity levels
Difficulty completing assignments
Sloppy or poor classwork
Power struggles with authority
ADHD and Tics
What are Simple Tics and Tourettes Disorder?
A simple tic is an involuntary body movement or vocal sound that can be temporary or chronic. Behaviors are repeated, such as eye blinking, throat clearing, head rolling, licking lips, shoulder shrugging, picking at skin, and others. Many children will demonstrate transient simple tics at some point in childhood, with up to 20% demonstrating at least one tic at some point in childhood. It is important to know that tics are not willful behavior, and often the child is not aware that they are engaging in these behaviors. Therefore, children should not be punished for these tics due to their involuntary nature. Tourette's Disorder is a chronic psychological disorder characterized by the presence of frequent motor and vocal tics over a period lasting at least a year. eIn addition to simple motor tics, children with Tourette's Disorder may demonstrate complex motor or vocal tics.
Complex motor tics may include hand gestures, jumping, stomping, physical routines, unusual physical postures, or other combinations.
Complex vocal tics may include combinations of vocal sounds or repeated uttering of specific words or combinations of words. Only in very rare cases do vocal tics include obscenities.
Tourette's Disorder and obsessive-compulsive behaviors often co-occur
ADHD and Tics
While ADHD and tics may be highly comorbid, Studies do not show a strong relationship between ADHD and tics or Tourette's Disorder. Some studies have shown slightly higher evidence of tics in children with ADHD, but studies do not show any evidence of higher rates of Tourette's Disorder in children with ADHD. Additonally, the development of simple motor tics appears to be a somewhat rare side effect of stimulant medication. However, most studies indicate that stimulant tics stop when stimulant medications are used, except in cases where the child has a preexisting tic disorder. Development of tics should be monitored in all children using psychostimulant medications. If tics become severe or impairing, appropriate action should be taken.