Treatment Implications for ADHD Youth with Mood and Anxiety Comorbidity
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Purpose of Review
There are multiple pharmacological and psychosocial interventions that are tolerable and efficacious for the treatment of attention deficit hyperactivity disorder (ADHD). However, many youth with ADHD have elevated levels of mood and anxiety symptoms that can complicate treatment. In this review, we summarize the relevant treatment studies on the treatment of youth with ADHD and comorbid anxiety or mood disorders.
Treatment of ADHD, specifically CNS stimulants, often translates to reduced irritability in youth with ADHD, but appears to have limited impact on other mood or anxiety symptoms. The presence of ADHD does not appear to reduce the efficacy of pharmacological treatments of mood and anxiety disorders. There is less data on the impact of ADHD on psychosocial treatments for internalizing disorders.
In children with elevated levels of mood or anxiety, ADHD can be safely and effectively treated with either evidence-based pharmacological or psychosocial interventions. However, additional treatments are often needed to achieve significant improvements in other mood or anxiety symptoms.
KeywordsAttention deficit hyperactivity disorder Mood disorder Anxiety disorder Comorbidity Treatment
Compliance with Ethical Standards
Conflict of Interest
Dr. R. Baweja declares that he has no conflict of interest. Dr. Waxmonsky, in the past 3 years, received research funds from NIH and Pfizer and served as a consultant for Noven Pharmaceuticals, IronShore, Purdue Pharma, and NLS Pharma.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as follows: • Of importance
- 2.Visser SN, Bitsko RH, Danielson ML, Ghandour RM, Blumberg SJ, Schieve LA, et al. Treatment of attention deficit/hyperactivity disorder among children with special health care needs. J Pediatr. 2015;166(6):1423–30 e2. https://doi.org/10.1016/j.jpeds.2015.02.018.PubMedPubMedCentralCrossRefGoogle Scholar
- 7.Treatment for Adolescents with Depression Study Team. The Treatment for Adolescents With Depression Study (TADS): demographic and clinical characteristics. J Am Acad Child Adolesc Psychiatry. 2005;44(1):28–40. https://doi.org/10.1097/01.chi.0000145807.09027.82.CrossRefGoogle Scholar
- 8.Meinzer MC, Pettit JW, Waxmonsky JG, Gnagy E, Molina BSG, Pelham WE. Does childhood attention-deficit/hyperactivity disorder (ADHD) predict levels of depressive symptoms during emerging adulthood? J Abnorm Child Psychol. 2016;44(4):787–97. https://doi.org/10.1007/s10802-015-0065-0.PubMedPubMedCentralCrossRefGoogle Scholar
- 9.Chronis-Tuscano A, Molina BS, Pelham WE, et al. Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2010;67(10):1044–51. https://doi.org/10.1001/archgenpsychiatry.2010.127.PubMedPubMedCentralCrossRefGoogle Scholar
- 11.Kovacs M, Akiskal HS, Gatsonis C, Parrone PL. Childhood-onset dysthymic disorder. Clinical features and prospective naturalistic outcome. Arch Gen Psychiatry. 1994;51(5):365–74. https://doi.org/10.1001/archpsyc.1994.03950050025003.PubMedCrossRefGoogle Scholar
- 18.Mayes SD, Waxmonsky JD, Calhoun SL, Bixler EO. Disruptive mood dysregulation disorder symptoms and association with oppositional defiant and other disorders in a general population child sample. J Child Adolesc Psychopharmacol. 2016;26(2):101–6. https://doi.org/10.1089/cap.2015.0074.PubMedPubMedCentralCrossRefGoogle Scholar
- 32.Spencer AE, Faraone SV, Bogucki OE, Pope AL, Uchida M, Milad MR, et al. Examining the association between posttraumatic stress disorder and attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. J Clin Psychiatry. 2016;77(1):72–83. https://doi.org/10.4088/JCP.14r09479.PubMedCrossRefGoogle Scholar
- 33.Adams Z, Adams T, Stauffacher K, Mandel H, Wang Z. The effects of inattentiveness and hyperactivity on posttraumatic stress symptoms: does a diagnosis of posttraumatic stress disorder matter? J Atten Disord. 2015:108705471558084. https://doi.org/10.1177/1087054715580846.
- 36.Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128:1007–22.CrossRefGoogle Scholar
- 38.Powers RL, Marks DJ, Miller CJ, Newcorn JH, Halperin JM. Stimulant treatment in children with attention-deficit/hyperactivity disorder moderates adolescent academic outcome. J Child Adolesc Psychopharmacol. 2008;18(5):449–59. https://doi.org/10.1089/cap.2008.021.PubMedPubMedCentralCrossRefGoogle Scholar
- 45.Findling RL. Open-label treatment of comorbid depression and attentional disorders with co-administration of serotonin reuptake inhibitors and psychostimulants in children, adolescents, and adults: a case series. J Child Adolesc Psychopharmacol. 1996;6(3):165–75. https://doi.org/10.1089/cap.1996.6.165.PubMedCrossRefGoogle Scholar
- 48.Kratochvil CJ, Newcorn JH, Arnold LE, Duesenberg D, Emslie GJ, Quintana H, et al. Atomoxetine alone or combined with fluoxetine for treating ADHD with comorbid depressive or anxiety symptoms. J Am Acad Child Adolesc Psychiatry. 2005;44(9):915–24. https://doi.org/10.1097/01.chi.0000169012.81536.38.PubMedCrossRefGoogle Scholar
- 49.Chang K, Nayar D, Howe M, Rana M. Atomoxetine as an adjunct therapy in the treatment of co-morbid attention-deficit/hyperactivity disorder in children and adolescents with bipolar I or II disorder. J Child Adolesc Psychopharmacol. 2009;19(5):547–51. https://doi.org/10.1089/cap.2009.0030.PubMedCrossRefGoogle Scholar
- 50.Findling RL, Short EJ, McNamara NK, et al. Methylphenidate in the treatment of children and adolescents with bipolar disorder and attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1445–53. https://doi.org/10.1097/chi.0b013e31814b8d3b.PubMedCrossRefGoogle Scholar
- 52.Scheffer RE, Kowatch RA, Carmody T, Rush AJ. Randomized, placebo-controlled trial of mixed amphetamine salts for symptoms of comorbid ADHD in pediatric bipolar disorder after mood stabilization with divalproex sodium. Am J Psychiatry. 2005;162(1):58–64. https://doi.org/10.1176/appi.ajp.162.1.58.PubMedCrossRefGoogle Scholar
- 54.Baweja R, Belin PJ, Humphrey HH, Babocsai L, Pariseau ME, Waschbusch DA, et al. The effectiveness and tolerability of central nervous system stimulants in school-age children with attention-deficit/hyperactivity disorder and disruptive mood dysregulation disorder across home and school. J Child Adolesc Psychopharmacol. 2016;26(2):154–63. https://doi.org/10.1089/cap.2015.0053.PubMedPubMedCentralCrossRefGoogle Scholar
- 55.Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, et al. Randomized double-blind placebo-controlled trial of lithium in youths with severe mood dysregulation. J Child Adolesc Psychopharmacol. 2009;19(1):61–73. https://doi.org/10.1089/cap.2008.044.PubMedPubMedCentralCrossRefGoogle Scholar
- 56.• Fernandez de la Cruz L, Simonoff E, McGough JJ, et al. Treatment of children with attention-deficit/hyperactivity disorder (ADHD) and irritability: results from the multimodal treatment study of children with ADHD (MTA). J Am Acad Child Adolesc Psychiatry. 2015;54(1):62–70 e3. This study used data from the Multimodal Treatment Study of Children with ADHD (MTA) to examine whether ADHD treatment is effective in treating irritability and to examine how irritability influences ADHD treatment outcomes. https://doi.org/10.1016/j.jaac.2014.10.006.PubMedPubMedCentralCrossRefGoogle Scholar
- 57.Aman MG, Bukstein OG, Gadow KD, Arnold LE, Molina BSG, McNamara NK, et al. What does risperidone add to parent training and stimulant for severe aggression in child attention-deficit/hyperactivity disorder? J Am Acad Child Adolesc Psychiatry. 2014;53(1):47–60 e1. https://doi.org/10.1016/j.jaac.2013.09.022.PubMedCrossRefGoogle Scholar
- 58.Gadow KD, Arnold LE, Molina BS, et al. Risperidone added to parent training and stimulant medication: effects on attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and peer aggression. J Am Acad Child Adolesc Psychiatry. 2014;53(9):948–59 e1. https://doi.org/10.1016/j.jaac.2014.05.008.PubMedPubMedCentralCrossRefGoogle Scholar
- 59.• Farmer CA, Brown NV, Gadow KD, Arnold LE, Kolko DG, Findling RL, et al. Comorbid symptomatology moderates response to risperidone, stimulant, and parent training in children with severe aggression, disruptive behavior disorder, and attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2015;25(3):213–224. This study examines the parent and child characteristics as predictors and moderators of response in the four-site Treatment of Severe Childhood Aggression (TOSCA) study. https://doi.org/10.1089/cap.2014.0109.PubMedPubMedCentralCrossRefGoogle Scholar
- 60.Waxmonsky J, Pelham WE, Gnagy E, Cummings MR, O'Connor B, Majumdar A, et al. The efficacy and tolerability of methylphenidate and behavior modification in children with attention-deficit/hyperactivity disorder and severe mood dysregulation. J Child Adolesc Psychopharmacol. 2008;18(6):573–88. https://doi.org/10.1089/cap.2008.065.PubMedPubMedCentralCrossRefGoogle Scholar
- 61.Waxmonsky JG, Waschbusch DA, Belin P, Li T, Babocsai L, Humphery H, et al. A randomized clinical trial of an integrative group therapy for children with severe mood dysregulation. J Am Acad Child Adolesc Psychiatry. 2016;55(3):196–207. https://doi.org/10.1016/j.jaac.2015.12.011.PubMedCrossRefGoogle Scholar
- 62.Abikoff H, McGough J, Vitiello B, McCracken J, Davies M, Walkup J, et al. Sequential pharmacotherapy for children with comorbid attention-deficit/hyperactivity and anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2005;44(5):418–27. https://doi.org/10.1097/01.chi.0000155320.52322.37.PubMedCrossRefGoogle Scholar
- 65.Gadow KD, Nolan EE, Sverd J, Sprafkin J, Schwartz J. Anxiety and depression symptoms and response to methylphenidate in children with attention-deficit hyperactivity disorder and tic disorder. J Clin Psychopharmacol. 2002;22(3):267–74. https://doi.org/10.1097/00004714-200206000-00007.PubMedCrossRefGoogle Scholar
- 72.• Halldorsdottir T, Ollendick TH, Ginsburg G, Sherrill J, Kendall PC, Walkup J, et al. Treatment outcomes in anxious youth with and without comorbid ADHD in the CAMS. J Clin Child Adolesc Psychol. 2015;44(6):985–991. This study examines the influence of ADHD on acute treatment response, remission rates, and maintenance of gains at 6-month follow-up in children with anxiety who received CBT alone, pharmacotherapy alone, the combination of CBT, and pharmacotherapy or placebo in the Child Adolescent Multimodal Study (CAMS). https://doi.org/10.1080/15374416.2014.952008.PubMedCrossRefGoogle Scholar
- 74.• Maric M, van Steensel FJ, Bogels SM. Parental involvement in CBT for anxiety-disordered youth revisited: family CBT outperforms child CBT in the long term for children with comorbid ADHD symptoms. J Atten Disord. 2015:108705471557399. https://doi.org/10.1177/1087054715573991. This study describes the efficacy of child cognitive-behavioral therapy (CCBT) versus family CBT (FCBT) in anxiety-disordered youth with high and low comorbid ADHD symptoms.
- 75.Bangs ME, Wietecha LA, Wang S, Buchanan AS, Kelsey DK. Meta-analysis of suicide-related behavior or ideation in child, adolescent, and adult patients treated with atomoxetine. J Child Adolesc Psychopharmacol. 2014;24(8):426–34. https://doi.org/10.1089/cap.2014.0005.PubMedPubMedCentralCrossRefGoogle Scholar
- 80.Kratochvil CJ, May DE, Silva SG, Madaan V, Puumala SE, Curry JF, et al. Treatment response in depressed adolescents with and without co-morbid attention-deficit/hyperactivity disorder in the Treatment for Adolescents with Depression Study. J Child Adolesc Psychopharmacol. 2009;19(5):519–27. https://doi.org/10.1089/cap.2008.0143.PubMedPubMedCentralCrossRefGoogle Scholar
- 83.Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007;297(15):1683–96. https://doi.org/10.1001/jama.297.15.1683.PubMedCrossRefGoogle Scholar
- 89.Pliszka SR, Greenhill LL, Crismon ML, et al. The Texas Children’s Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part I. Attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2000;39(7):908–19. https://doi.org/10.1097/00004583-200007000-00021.PubMedCrossRefGoogle Scholar
- 92.West AE, Henry DB, Pavuluri MN. Maintenance model of integrated psychosocial treatment in pediatric bipolar disorder: a pilot feasibility study. J Am Acad Child Adolesc Psychiatry. 2007;46(2):205–12. https://doi.org/10.1097/01.chi.0000246068.85577.d7.PubMedCrossRefGoogle Scholar
- 93.Stringaris A. National Institute of Mental Health (NIMH). A controlled trial of serotonin reuptake inhibitors added to stimulant medication in youth with severe mood dysregulation. ClinicalTrials.gov [Internet]. [Internet]. Bethesda, MD: National Library of Medicine (US); 2000 Available from: https://clinicaltrials.gov/ct/show/NCT00794040. Accessed Oct 29 2017.
- 94.Coughlin CG, Cohen SC, Mulqueen JM, Ferracioli-Oda E, Stuckelman ZD, Bloch MH. Meta-analysis: reduced risk of anxiety with psychostimulant treatment in children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2015;25(8):611–7. https://doi.org/10.1089/cap.2015.0075.PubMedPubMedCentralCrossRefGoogle Scholar
- 95.Schwartz S, Correll CU. Efficacy and safety of atomoxetine in children and adolescents with attention-deficit/hyperactivity disorder: results from a comprehensive meta-analysis and metaregression. J Am Acad Child Adolesc Psychiatry. 2014;53(2):174–87. https://doi.org/10.1016/j.jaac.2013.11.005.PubMedCrossRefGoogle Scholar
- 101.NextWave Pharmaceuticals. Product information: QUILLIVANT (TM) XR oral extended release suspension mHoersC, CA, 2012.Google Scholar
- 102.United States Product Information. ADDERALL XR(R) oral capsules dsdsaamasocW, PA, 2013.Google Scholar
- 104.Pelham W. Pharmacotherapy for children with ADHD. School Psychol Rev. 1993:199–227.Google Scholar
- 106.Cohen SC, Mulqueen JM, Ferracioli-Oda E, Stuckelman ZD, Coughlin CG, Leckman JF, et al. Meta-analysis: risk of tics associated with psychostimulant use in randomized, placebo-controlled trials. J Am Acad Child Adolesc Psychiatry. 2015;54(9):728–36. https://doi.org/10.1016/j.jaac.2015.06.011.PubMedCrossRefGoogle Scholar
- 107.Childress AC, Arnold V, Adeyi B, Dirks B, Babcock T, Scheckner B, et al. The effects of lisdexamfetamine dimesylate on emotional lability in children 6 to 12 years of age with ADHD in a double-blind placebo-controlled trial. J Atten Disord. 2014;18(2):123–32. https://doi.org/10.1177/1087054712448252.PubMedCrossRefGoogle Scholar
- 108.Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–93. https://doi.org/10.1097/01.chi.0000235077.32661.61.PubMedCrossRefGoogle Scholar